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201 Intro > INTRO FINAL > Flashcards

INTRO FINAL Flashcards

1
Q

GIVEN A CERTAIN AMOUNT OF LIQUID AND A TIME PERIOD, WHAT IS THE NECESSARY IV FLOW RATE IN ML/HR?

A

VOLUME (ML) / TIME (HR) = Y (FLOW RATE IN ML/HR)

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2
Q

WHAT MEASUREMENT IS USED WHEN AN IV IS REGULATED ELECTRONICALLY BY INFUSION PUMP?

A

ML/HR

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3
Q

PATIENT IS ORDERED 1000 ML D5W IV TO INFUSE IN 10 HOURS BY INFUSION PUMP. WHAT IS THE FLOW RATE?

A

100 ML/HR
1000ML/10HR

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4
Q

THE PHYSICIAN ORDERS ANCEF 400 MG IV Q8H FOR A CHILD WEIGHING 32 LBS. YOU HAVE ANCEF 330 MG/ML. THE RECOMMENDED DAILY IV DOSAGE FOR A CHILD IS 100 MG/KG/DAY IN DIVIDED DOSES OF Q6-8H.
A. CHILD’S WEIGHT IN KG
B. WHAT IS THE RECOMMENDED SAFE DOSAGE RANGE FOR THIS CHILD
C. IS THE ORDER SAFE
D. HOW MANY ML WILL YOU PREPARE

A

A. 14.5 KG
B. 1450 MAX
C. YES, ORDER RESULTS IN 1200 MG
D. 1.2 ML 400/330 = 1.21 * 1 = 1.21 = 1.2

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5
Q

S&T

A

SAFE AND THERAPEUTIC

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6
Q

GIVEN A CERTAIN AMOUNT OF LIQUID, A TIME PERIOD, AND A DROP FACTOR, WHAT IS THE NECESSARY IV FLOW RATE IN GTTS/MIN?

A

VOLUME (ML)/ TIME (MIN) * DROP FACTOR (GTTS/ML) = Y (FLOW RATE IN GTTS/MIN)

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7
Q

MEASUREMENT USED WHEN IV IS REGULATED MANUALLY

A

GTTS/ML
*CAN’T GIVE FRACTION SO ROUND TO NEAREST WHOLE NUMBER

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8
Q

CALCULATE THE FLOW RATE FOR 1200 ML OF NS TO BE INFUSED IN 6 HOURS WITH A DROP FACTOR OF 15 GTTS/ML

A

ML/MIN*GTTS/ML=Y
1. CONVERT 6 HOURS TO MINUTES = 360 MINUTES
2. 1200 ML / 360 MIN * 15 GTTS/ML = 50 GTTS/MIN

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9
Q

5 MILLIGRAM = ? MICROGRAM

A

5000 MCG

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10
Q

1 TSP = ? ML

A

5 ML

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11
Q

1 TBSP = ? ML

A

15

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12
Q

2 TBSP = ? OUNCE

A

1

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13
Q

1 OUNCE = ? ML

A

30

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14
Q

1 CUP = ? OUNCES

A

8

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15
Q

1 CUP = ? ML

A

240

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16
Q

1 PINT = ? OUNCES

A

16

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17
Q

1 PINT = ? ML

A

480

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18
Q

1 QUART = ? OUNCES

A

32

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19
Q

1 ML = ? CC

A

1

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20
Q

1 KG = ? LBS

A

2.2

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21
Q

1 INCH = ? CM

A

2.54

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22
Q

a provider’s prescription calls for 10 mL of 250 mg cephalexin liquid by mouth. How many teaspoons should the nurse instruct the client to take?
A. WHAT UNIT OF MEASUREMENT DO WE NEED
B. WHAT DOSE DO WE ADMIN (DESIRED)
C. WHAT IS AVAILABLE (HAVE)
D. SHOULD WE CONVERT
E. WHAT IS THE ANSWER

A

A. TSP
B. 10 ML
C. 5 ML PER 1 TSP
D. YES, ML DOES NOT EQUAL TEASPOON
E. 5ML/1TSP = 10ML/X TSP SO X TSP = 2 TSP

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23
Q

20 MG INTO MCG

A

20000 MCG

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24
Q

60 ML INTO TBSP

A

4 TBSP

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25
Q

RATIO AND PROPORTION METHOD

A

HAVE / QUANTITY = DESIRED / X

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26
Q

A nurse is preparing to administer 174 mg of amoxicillin/clavulanate oral suspension to a client. The amount available is amoxicillin/clavulanate 125 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number.)

A

X ML = 125 MG / 5 ML = 174 MG / X
X ML = 125X = 870
X ML = 125X / 125 = 870 / 125
X ML = 6.96 ML
X ML = 7 ML

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27
Q

DESIRED OVER HAVE METHOD

A

X = DESIRED X QUANTITY / HAVE

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28
Q

A nurse is preparing to administer 174 mg of amoxicillin/clavulanate oral suspension to a client. The amount available is amoxicillin/clavulanate 125 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number.)

DESIRED OVER HAVE

A

X = DESIRED X QUANTITY / HAVE
X ML = 174 MG X 5 ML / 125 MG
X ML = 870 ML / 125
X ML = 6.96 ML
X ML = 7 ML

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29
Q

WHEN CALCULATING MEDICATIONS, WHEN CAN YOU ROUND

A

ONLY AT THE VERY END

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30
Q

SYSTOLE

A

TOP NUMBER OF BP
MAXIMUM PRESSURE EXERTED WHEN THE HEART CONTRACTS

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31
Q

DIASTOLE

A

BOTTOM NUMBER OF BP
MINIMUM PRESSURE WHEN HEART IS RELAXED
*REMEMBER AN SD CARD SO S/D IF YOU GET CONFUSED

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32
Q

CARDIAC OUTPUT

A

VOLUME OF BLOOD EJECTED BY THE HEART IN ONE MINUTE
CO = SV * HR
(SV IS STROKE VOLUME)

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33
Q

STROKE VOLUME

A

VOLUME OF BLOOD EJECTED BY THE LEFT VENTRICLE DURING ONE CONTRACTION
CO = SV * HR

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34
Q

FACTORS INCREASING BP

A

INCREASED CO
INCREASED SV
INCREASED HR
INCREASED VOLUME
INCREASED VISCOSITY
DECREASED BLOOD VESSEL ELASTICITY
ATHEROSCLEROSIS
INCREASED CONTRACTILITY
INCREASED PRELOAD (EXERCISE)
INCREASED AFTERLOAD

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35
Q

ARE MANUAL OR ELECTRONIC BP MORE ACCURATE

A

MANUAL

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36
Q

WHEN SHOULD YOU USE A MANUAL BP

A

BP IS OUTSIDE OF EXPECTED RANGE
CHILDREN
ELDERLY
HISTORY OF ELEVATED OR DECREASED BP
CRITICALLY ILL

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37
Q

CORRECT BP CUFF SIZE

A

CUFF WIDTH SHOULD BE 80%+ OF THE CLIENTS ARM

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38
Q

DO’S AND DONT’S WHILE TAKING BP

A

DON’T CROSS LEGS
FEET FLAT ON FLOOR
SUPPORT ARM BY RESTING ON FURNITURE
ARM PLACED AT HEART LEVEL AND PALM UP
CUFF 1 INCH ABOVE ANTECUBITAL FOSSA
STETHO OVER BRACHIAL ARTERY

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39
Q

WHAT SHOULD YOU INFLATE BP CUFF TO

A

30 MMHG ABOVE EXPECTED OR 200 MMHG

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40
Q

KOROTKOFF SOUNDS AND BP

A

FIRST SOUND IS SYSTOLIC
NO SOUND IS DIASTOLIC

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41
Q

CONTRAINDICATION OF BP IN ARM

A
  1. BREAST SURGERY THAT INVOLVED REMOVAL OF LYMPH NODES
  2. RECENT SURGERY
  3. ACUTE INJURY
  4. SPECIAL MEDICAL EQUIPMENT LIKE A PICC LINE, ARTERIOVENOUS SHUNT FOR HEMODIALYSIS
  5. EXTREMITY WITH PERIPHERAL IV CATHETER
  6. SEVERE EDEMA
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42
Q

ALTERNATIVE BP SITES

A

THIGH AND USE POPLITEAL ARTERY
*WILL BE SEVERAL MMHG HIGHER THAN ARM
CAN ALSO USE WRIST OR LOWER LEG

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43
Q

INACCURATE BP

A
  1. TOO SMALL CUFF- FALSELY HIGH
  2. TOO TIGHT CUFF- FALSELY HIGH
  3. WHITE COAT SYNDROME, ARM NOT SUPPORTED, NOT ALLOWED REST AFTER ACTIVITY
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44
Q

EXTRINSIC FACTORS AFFECTING BP

A

WEIGHT
STIMULANTS
CAFFEINE
NICOTINE
MEDS
Na INTAKE
STRESS
ANXIETY
FEAR

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45
Q

INTRINSIC FACTORS AFFECTING BP

A

PAIN
FEVER
HYPOGLYCEMIA
HEART FAILURE

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46
Q

HYPERTENSION

A

HIGH BP.
INCREASES RISK OF HEART ATTACK OR STROKE.
USUALLY DUE TO THICKENING OF ARTERIAL VESSEL WALLS AND DECREASE IN ELASTICITY WHICH INCREASES PERIPHERAL VASCULAR RESISTANCE

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47
Q

NORMAL BP

A

LESS THAN 120/LESS THAN 80

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48
Q

ELEVATED BP

A

120-129
/
LESS THAN 80

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49
Q

HYPERTENSION STAGE 1

A

130-139
/
80-89

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50
Q

HYPERTENSION STAGE 2

A

140+
/
90+

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51
Q

HYPERTENSIVE CRISIS

A

180+
/
120+

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52
Q

HYPOTENSION

A

LESS THAN 90
/
LESS THAN 60

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53
Q

CAUSES OF HYPOTENSION

A

DEHYDRATION
BLOOD LOSS
SHOCK
SIGNIFICANT ILLNESS
SEPSIS

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54
Q

MANIFESTATIONS OF HYPOTENSION

A

DIZZINESS
NAUSEA
BLURRED VISION
INCREASED HR
FATIGUE

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55
Q

ORTHOSTATIC HYPOTENSION

A

DROP IN BP WHEN A CLIENT RISES TO SITTING OR STANDING
FROM DEHYDRATION, HYPOTENSION, HEART FAILURE, CNS ISSUE
DROP IN SYSTOLIC OF AT LEAST 20
DROP IN DIASTOLIC OF AT LEAST 10
WITHIN 1 MINUTE AFTER MOVING, BUT UP TO 3 MINUTES

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56
Q

INTERVENTIONS FOR ORTHOSTATIC HYPOTENSION

A

INCREASE FLUIDS
COMPRESSION STOCKINGS
CHANGE POSITIONS SLOWLY
SLIGHTLY ELEVATE HOB
AVOID LYING/SITTING FOR EXTENDED TIME
EVALUATE MEDS

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57
Q

SA NODE
SINOATRIAL NODE

A

PACEMAKER OF THE HEART

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58
Q

ADULT HR

A

60-100

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59
Q

INFANT HR

A

90-160

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60
Q

TODDLER HR

A

80-140

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61
Q

PRESCHOOL HR

A

70-120

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62
Q

SCHOOLAGE HR

A

60-110

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63
Q

TEEN HR

A

50-100

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64
Q

TACHYCARDIA

A

HR OVER 100/MIN

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65
Q

VALSALVA MANEUVER

A

TESTS VAGUS NERVE
BEAR DOWN LIKE BM
STIMULATES PARASYMPATHETIC NERVOUS SYSTEM
DROPS HR

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66
Q

BRADYCARDIA

A

HR LESS THAN 60/MIN

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67
Q

WHEN IS BRADYCARDIA EXPECTED

A

CLIENTS WHO ARE VERY PHYSICALLY FIT

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68
Q

APICAL PULSE LOCATION

A

APEX OF THE HEART
5TH INTERCOSTAL SPACE, LEFT SIDE, MIDCLAVICULAR LINE

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69
Q

S1

A

LOW PITCHED
DULL
LUB
EASIER TO HEAR WITH BELL

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70
Q

S2

A

SHORTER
HIGHER PITCHED
DUB
EASIER TO HEAR WITH DIAPHRAGM

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71
Q

HOW LONG TO COUNT APICAL PULSE

A

1 MINUTE

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72
Q

PERIPHERAL PULSE SITES

A

TEMPORAL
CAROTID
BRACHIAL
RADIAL
FEMORAL
POPLITEAL
DORSALIS PEDIS
POSTERIOR TIBIAL

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73
Q

PULSE DEFICIT

A

DIFFERENCE IN APICAL AND PERIPHERAL PULSE IN 1 MINUTE
2 NURSES COUNT AT SAME TIME

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74
Q

DO’S AND DON’T FOR DETERMINING HR

A

CLIENT IS RELAXED
HASN’T EXERCISED OR USED NICOTINE IN LAST FEW MINUTES (WOULD INCREASE)

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75
Q

PULSE RATINGS

A

0 = ABSENT
+1 = WEAK/THREADY
+2 = NORMAL
+3 = INCREASED/BOUNDING

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76
Q

WHAT IF YOU CAN’T PALPATE A PULSE

A

DON’T DOCUMENT NON PALPABLE, GO GET DOPPLER
DUS
DOPPLER ULTRASOUND STETHOSCOPE

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77
Q

IF PULSE OR RR IS IRREGULAR, HOW LONG DO YOU COUNT

A

1 MINUTE

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78
Q

HOW LONG TO COUNT REGULAR RR

A

30 SECONDS

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79
Q

NORMAL TEMP
F

A

96.8-100.4F
average of 98.6 F

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80
Q

normal temp
c

A

36-38 C
AVERAGE 37 C

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81
Q

WHEN IS TEMP LOWEST

A

MORNING, BUT VARIABLE THROUGHOUT DAY

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82
Q

FACTORS AFFECTING TEMP

A

EXERCISE
STRESS
EXTERNAL ENVIRONMENT
TIME OF DAY
ILLNESS

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83
Q

METHODS OF THERMOREGULATION

A

SWEATING
SHIVERING
VASOCONSTRICTION
VASODILATION
METABOLIC PROCESSES
CONDUCTION
CONVECTION
EVAPORATION
RADIATION

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84
Q

WHAT IS CONSIDERED A FEVER

A

OVER 100.4

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85
Q

FEBRILE

A

STATE OF HAVING A FEVER

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86
Q

AFEBRILE

A

FEVER BREAKS

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87
Q

HYPERTHERMIA

A

HYPOTHALAMUS CANNOT MAINTAIN TEMP REGULATION
S/S- DIZZINESS, WEAKNESS, THIRST, NAUSEA, SYNCOPE, TACHYCARDIA, CONFUSION, ORGAN FAILURE, DEATH

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88
Q

INTERVENTIONS FOR HYPERTHERMIA

A

MOVE TO COOLER ENVIRONMENT
REMOVE EXCESS CLOTHING
COLD PACKS TO NECK, AXILLAE, GROIN
FAN
IV FLUIDS

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89
Q

S/S OF HYPOTHERMIA

A

SHIVERING
DECREASED MOTOR SKILLS
IMPAIRED PERIPHERAL PERFUSION
CONFUSION
DILATED PUPILS
LOSS OF CONSCIOUSNESS
LOSS OF DEEP TENDON REFLEXES
COMA
CARDIAC ARREST

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90
Q

INTERVENTIONS FOR HYPOTHERMIA

A

WARMING BLANKET
RADIANT WARMER
INCREASE ROOM TEMP
ADD CLOTHING
PLACE HAT ON HEAD
WARMED IV FLUIDS

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91
Q

ORAL TEMP

A

EASILY ACCESSIBLE
ACCURATE BODY SURFACE TEMP
INACCURATE IF ATE/DRANK/SMOKED IN 30 MINUTES
NOT FOR NEWBORNS, INFANTS, YOUNG CHILDREN

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92
Q

TYMPANIC TEMP

A
  1. EASILY ACCESSIBLE
  2. RAPID RESULT
  3. ACCURATE CORE TEMP
  4. NOT ALTERED BY ENVIRONMENT
  5. NOT ACCURATE WITH CERUMEN OR EAR INFECTION
  6. DIFFICULT IN NEWBORNS/INFANTS/YOUNGER THAN 3
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93
Q

TEMPORAL TEMP

A
  1. EASILY ACCESSIBLE
  2. RAPID RESULT
  3. NO RISK OF INJURY
  4. ALL AGE GROUPS
  5. REFLECTS RAPID CORE CHANGES
  6. AFFECTED BY MOISTURE ON SKIN LIKE SWEAT
  7. INACCURATE WITH HEAD COVERING OR HAIR ON FOREHEAD
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94
Q

AXILLARY TEMP

A
  1. ALL AGE GROUPS
  2. NO RISK OF INJURY
  3. MORE TIME
  4. NOT FOR RAPID CHANGES
  5. POTENTIAL FOR ENVIRONMENTAL ALTERATIONS
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95
Q

RECTAL TEMP

A

RELIABLE TEMP
UNLPLEASANT
RISK FOR RECTAL MUCOSA INJURY
ALTERED WITH STOOL
NOT FOR DIARRHEA, CHEMO, HEMMORRHOIDS, RECTAL SURGERY OR COAGULATION DISORDERS

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96
Q

IMPORTANT INFO FOR RR

A
  1. PRETEND TO CHECK PULSE
  2. MUST ALSO CHECK RATE, RHYTHM, DEPTH, EFFORT
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97
Q

INFANT RR

A

25-60

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98
Q

ADULT RR

A

12-20

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99
Q

TEEN RR

A

16-20

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100
Q

SCHOOL AGE RR

A

20-25

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101
Q

PRESCHOOL RR

A

20-25

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102
Q

TODDLER RR

A

25-30

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103
Q

TACHYPNEA

A

RR OVER 20/MIN

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104
Q

BRADYPNEA

A

RR LOWER THAN 12/MIN

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105
Q

INTERVENTIONS FOR BRADYPNEA

A

NALOXONE
DECREASE ICP
SLIGHTLY ELEVATE HOB

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106
Q

APNEA

A

CESSATION OF RESPIRATIONS

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107
Q

CHEYNE STOKE RESPIRATIONS

A

CYCLING PATTERN
RANGE FROM SHALLOW TO DEEP FOLLOWED BY QUICK BREATHS FOLLOWED BY APNEA
INCREASED ICP, BRAIN TUMOR, STROKE, HEART FAILURE

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108
Q

KUSSMAUL RESPIRATIONS

A

REGULAR RHYTHM
ABNORMALLY DEEP AND RAPID
MAY SHOW LEABORED BREATHING OR RESPIRATORY DISTRESS
METABOLIC ACIDOSIS, SEVERE KIDNEY DISEASE

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109
Q

NORMAL SaO2

A

OVER 95%

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110
Q

ADEQUATE CAPILLARY REFILL

A

LESS THAN 2 SECONDS

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111
Q

CONTRAINDICATIONS OF PULSE OX LOCATIONS

A

MUST BE DRY
FREE OF DARK COLORED POLISH
SKIN PIGMENTATION
ARTIFICIAL NAILS
TAKES 15-30 SECONDS

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112
Q

ALTERNATE SaO2 SITES

A

EARLOBE
FOOT/WRIST OF NEWBORN

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113
Q

DYSPNEA

A

SOB

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114
Q

HYPOXIA

A

NOT ENOUGH OXYGEN IS BEING SUPLIED TO THE TISSUES

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115
Q

HYPOXEMIA

A

DECREASED OXYGEN IN THE BLOOD

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116
Q

HYGIENE

A

handwashing, maintaining oral health by brushing the teeth, and removing pathogens through routine bathing.

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117
Q

ASSESSMENT FOR HYGIENE

A

COLOR, HYDRATION, TURGOR, TEXTURE, LESIONS, FEET, NAILS, CUTICLES, CIRCULATION, DEXTERITY, GAIT, ABILITY, SAFETY CONCERNS, EMOTIONAL STATUS, EDUCATION NEEDS

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118
Q

FLOSSITIS

A

INFLAMED TONGUE

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119
Q

CHELITIS

A

CRACKED LIPS

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120
Q

XEROSTOMIA

A

DRY MOUTH

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121
Q

STOMATITIS

A

INFLAMMATION OF ORAL MUCOUSA

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122
Q

SALIVA

A

BACTERIAL STATIC PROPERTY
RISK OF PNEUMONIA FROM STATIC SECRETIONS IN UNCONSCIOUS PATIENT

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123
Q

EYE HYGIENE

A

INNER TO OUTER CANTHUS
DIFFERENT PART OF CLOTH FOR EACH EYE
MORE FREQUENTLY IF UNCONSCIOUS, NOT BLINKING
ASSESS FOR SECRETIONS, GLASES, DRY EYES, ALLERGIES

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124
Q

EAR HYGIENE

A

OUTER CANAL WITH WASH CLOTH
NO Q TIPS BC COULD DAMAGE TYMPANIC MEMBRANE

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125
Q

CONSIDERATIONS FOR NEONATES- HYGIENE

A

SKIN LOOSLY BOUND
EASILY DAMAGED
LAYERS BIND AS THEY AGE

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126
Q

ADOLESCENT CONSIDERATIONS- HYGIENE

A

SEX HORMONES
SEBACEOUS GLANDS-OIL
SWEAT GLANDS-ODOR

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127
Q

ELDERLY CONSIDERATIONS-HYGIENE

A

DECREASED COLLAGEN-WRINKLES
THINNING
LOSS OF ELASTICITY
DECREASED SWEAT AND OIL
DRIER AND MORE LESIONS
INCREASE FACIAL HAIR
DRY BRITTLE NAILS
DECREASED SALIVA

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128
Q

MALNUTRITION IN ELDERLY

A

SOCIOECONOMIC STATUS
LIMITED ABILITY
DENTAL PROBLEMS

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129
Q

HYGIENE NURSING DIAGNOSIS/PROBLEMS

A

ACTIVITY INTOLERANCE
SELF CARE DEFICIT
IMPAIRED MOBILITY
IMAPIRED SKIN INTEGRITY
IMPAIRED ORAL MUCOUS MEMBRANES
RISK FOR INFECTION

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130
Q

PLANNING HYGIENE

A

WHO IS INVOLVED
COMMUNITY AGENCIES NEEDED
AMOUNT OF HELP REQUIRED
SET PRIORITIES BASED ON ASSISTANCE REQUIRED, EXTENT OF PROBLEMS, NATURE OF DIAGNOSIS

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131
Q

IMPLEMENTATION OF HYGIENE

A

PROVIDE PRIVACY
PROFESSIONALISM
MODESTY
SAFETY
WARMTH OF WATER, ROOM, BLANKET
MITT LOSES LESS HEAT AND REDUCES DRAG

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132
Q

WHY SHOULD WE BATHE DAILY

A

CLEANSE AND REDUCE MICROBE COUNT
REMOVE DEAD SKIN
STIMULATE CIRCULATION
PROVIDE RELAXATION
ENHANCE HEALING

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133
Q

TYPES OF BATHS

A

COMPLETE
PARTIAL- CAN’T TOLERATE
THERAPEUTIC
BED BATH

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134
Q

HOW TO BATHE

A

LONG, FIRM STROKES
DISTAL TO PROXIMAL FOR VENOUS CIRCULATION
DIFFERENT PARTS OF CLOTH
LIGHT STROKES IF Hx OF CLOTS

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135
Q

LOTION-HYGIENE

A

APPLY TO ALL AREAS
NOT BETWEEN TOES- RISK OF IRRITATION AND MACERATION

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136
Q

MACERATION

A

SOFTENING

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137
Q

SUPINE

A

FLAT ON BACK

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138
Q

PRONE

A

FLAT ON STOMACH WITH HEAD TO THE SIDE

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139
Q

LATERAL POSITION

A

LIE ON SIDE
TOP LEG OVER BOTTOM LEG
RELIEVES PRESSURE ON COCCYX

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140
Q

SIMS

A

BETWEEN SUPINE AND PRONE
LEX FLEXED IN FRONT OF PATIENT
ARMS COMFORTABLY BESIDE PATIENT AND NOT UNDERNEATH

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141
Q

FOWLER’S POSITION

A

HOB AT 45 DEGREES
HIPS MAY OR MAY NOT BE FLEXED
COMMON FOR COMFORT AND CARE

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142
Q

SEMI FOWLERS POSITION

A

HOB AT 30 DEGREES
FOR CARDIAC OR RESPIRATORY CONDITIONS
FOR NG TUBE PATIENTS

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143
Q

ORTHOPNEIC OR TRIPOD POSITION

A

PATIENT SITS AT SIDE OF BED
HEAD RESTS OVER TABLE ON SEVERAL PILLOWS
FOR BREATHING DIFFICULTIES

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144
Q

TRENDELENBURG POSITION

A

HOB LOWER THAN FEE
HYPOTENSION AND EMERGENCIES
VENOUS RETURN TO HEAD AND HEART

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145
Q

ORAL CARE

A

EXCESS MUCOUS INCREASES HAI
BRUSH BID
FLOSS 1X/D
IF UNCONCIOUS/VENTILATED/ OR NPO- Q1-2H
SUCTION FOR UNCONSCIOUS
CHECK FOR GAG REFLEX, DIABETES, ARTIFICIAL AIRWAY, CHEMO

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146
Q

CHG

A

ORAL RINSE
PASTE
ANTIMICROBIAL EFFECT
DECREASE HAI
NOT NEAR EYES OR EARS
LEAVE ON FOR MORE EFFECTS
USE IN BASINS

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147
Q

GENERAL IMPLEMENTATION OF HYGIENE

A
  1. DRY WELL TO PREVENT FUNGAL GROWTH
  2. BRUSH HAIR DAILY AND BRAID LONG HAIR
  3. COMBING MOST EFFECTIVE FOR LICE
  4. TRIM NAILS IN LINE WITH TIP OF FINGER AND CLEANS
  5. DIABETIC FOOD CARE DAILY
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148
Q

PERINEAL CARE

A

UNCIRCUMCISED, CATHS, POST RECTAL OR GENITAL SURGERY, CHILDBRITH INCREASE ROI
CONCERNS- BURNING, SORENESS, EXCORIATION, PAIN, DISCHARGE,

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149
Q

EXCORIATION

A

RAW

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150
Q

RISK OF SKIN BREAKDOWN

A

INCONTINENCE
DRESSINGS
CATHETERS
OBESITY

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151
Q

CARE FOR ARTIFICIAL EYE

A

NS
NS OR WATER ON SOFT GAUZE TO CLEAN EYE SOCKET
STORE IN WATER OR NS IN LABELED CONTAINER
OBSERVE FOR INFECTION

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152
Q

DIABETIC FOOT CARE

A

INSPECT FEET AND BETWEEN TOES DAILY
LUKEWARM WATER
NO SOAKING
THOROUGH DRYING
NO LOTION BETWEEN TOES
WE CAN FILE BUT NOT CUT WITHOUT ORDERS
COTTON SOCKS
COMFORTABLE/STURDY SHOES
NO HEATING PAD
ELEVATE FEET
DON’T CROSS LEGS FOR LONG PERIODS
AVOID SMOKING
ROM FOR 5 MINUTES 2-3 TIMES A DAY

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153
Q

HYGIENE EVALUATION

A

WERE PATIENT EXPECTATIONS MET
PATIENT OUTCOME
USE TEACHBACK
BATHED
MOISTUREIZED
TEETH BRUSHED/FLOSSED
EYES, EARS, NOSE WITHOUT REDNESS OR DRAINAGE
FEET HAVE NOT BREAKDOWN
NAILS CLEAN AND TRIMMED

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154
Q

HYGIENE SAFETY

A
  1. ID WITH 2 IDENTIFIERS
  2. MOVE FROM CLEAN TO LESS CLEAN
  3. USE GLOVES
  4. TEST WATER TEMP
  5. GOOD BODY MECHANICS
  6. PROPER DIRECTION TO UAP
  7. SAFE PATIENT HANDLING
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155
Q

SQUALING OF HEARING AIDS

A

WAX

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156
Q

WHICH HEARING AID/ WHICH EAR

A

RED = RIGHT
BLUE = LEFT

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157
Q

HEARING AID BATTERIES

A

STORE WITH DOOR OPEN

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158
Q

STEPS OF THE NURSING PROCESS

A

ASSESSMENT
DIAGNOSIS
PLANNING
IMPLEMENTATION
EVALUATION

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159
Q

SMART GOALS

A

SPECIFIC
MEASURABLE
ATTAINABLE
REASONABLE
TIME CONTRAINT

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160
Q

RESERVOIR

A

HABITAT OF INFECTIOUS AGENT WHERE IT LIVES, GROWS, REPLICATES

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161
Q

CONTACT TRANSMISSION

A

INFECTED PERSON TO INFECTED PERSON

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162
Q

DROPLET TRANSMISSION

A

DOPLETS FROM THE RESPIRATORY TRACT TRAVEL THROUGH AIR AND TO MUCOSA OF A HOST

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163
Q

AIRBORNE TRANSMISSION

A

SMALL PARTICULATES MOVE INTO THE SPACE OF ANOTHER PERSON

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164
Q

DIRECT CONTACT TRANSMISSION

A

MICROORGANISMS MOVE DIRECTLY FROM PERSON TO PERSON WITH NOTHING IN BETWEEN

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165
Q

INDIRECT CONTACT TRANSMISSION

A

MICROORGANISMS MOVE TO ANOTHER PERSON WITH A CONTAMINATED OBJECT OR PERSON BETWEEN

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166
Q

NONSPECIFIC IMMUNITY

A

NEUTROPHILS AND MACROPHAGES AND THEIR WORK AS PHAGOCYTES

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167
Q

SPECIFIC IMMUNITY

A

ANTIBODIES, IMMUNOGLOBULINS AND LYMPHOCYTES

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168
Q

INFLAMMATORY RESPONSE

A
  1. PATTERN RECEPTORS RECOGNIZE HARMFUL STIMULI
  2. INFLAMMATORY PATHWAYS ACTIVATED
  3. INFLAMMATORY MARKERS RELEASED
  4. INFLAMMATORY CELLS RECRUITED
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169
Q

INCUBATION STAGE OF INFECTION

A

INFECTION ENTERS AND BEGINS TO MULTIPLY

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170
Q

PRODROMAL STAGE OF INFECTION

A

CLIENT BEGINS HAVING MILD SYMPTOMS

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171
Q

ACUTE ILLNESS STAGE OF INFECTION

A

SPECIFIC S/S OBVIOUS AND MAYBE SEVERE

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172
Q

DECLINE STAGE OF INFECTION

A

S/S BEGIN TO WANE

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173
Q

CONVALESCENSE STAGE OF INFECTION

A

CLIENT RETURNS TO NORMAL

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174
Q

LOCAL INFECTION

A

CONFINED TO ONE AREA
TREATED WITH TOPICAL OR ORAL ANTIBIOTICS

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175
Q

SYSTEMIC INFECTION

A

START LOCAL AND SPREAD TO THE BLOOD STREAM TO INFECT THE ENTIRE BODY
LIKE SEPSIS

176
Q

HANDWASHING

A

15-20 SECONDS
SOAP AND WATER FOR C DIFF, VISIBLE DEBRIS, SPORE POTENTIAL

177
Q

SANITIZER REQUIREMENTS

A

GREATER THAN 70% ALCOHOL

178
Q

WHEN TO PERFORM HAND HYGIENE

A

HANDS ARE SOILED
BEFORE PT CONTACT
AFTER PATIENT CONTACT
BEFORE STERILE GLOVING
CONTACT WITH BODY FLUIDS
EACH TIME GLOVES REMOVED

179
Q

MEDICAL ASEPSIS

A

CLEAN TECHNIQUE
ELIMINATION OF AND ABSENCE OF DISEASE CAUSING MICROORGANISMS

180
Q

SURGICAL ASEPSIS

A

STERILE TECHNIQUE

181
Q

STERILE FIELD

A
  1. OBJECT IS FREE OF ALL MICROORGANISMS
  2. ALL OBJECTS ON FIELD MUST BE STERILE
  3. OPEN ORDER: AWAY, SIDE, CLOSEST TO YOU
  4. MUST BE AT OR ABOVE WAIST
  5. MOISTURE CONTAMINATES-CAPILLARY ACTION
  6. BOTTLE CAPS FACE UP
  7. OUTER 1 INCH IS UNSTERILE
  8. AVOID TALKING, LAUGHING, SNEEZING OVER FIELD
182
Q

STANDARD PRECAUTIONS

A

INFECTION PREVENTION PRACTICES APPLIED TO ALL WHETHER INFECTIOUS OR NOT

183
Q

DONNING PPE

A

GOWN
MASK
GOGGLES
GLOVES

184
Q

DOFFING PPE

A

GLOVES
GOGGLES
GOWN
MAKS
HAND HYGIENE

185
Q

NEEDS AIRBORNE PRECAUTIONS

A

LESS THAN 5 MICRONS OR ON DUST PARTICLES
N95 RESPIRATOR
NEGATIVE PRESSURE ROOM
TB
CHICKEN POX
COVID
EBOLA

186
Q

DROPLET PRECAUTIONS

A

PARTICLES LARGER THAN 5 MICRONS
DROP TO THE FLOOR WITHIN 3 FEET OF HOST
MASK REQUIRED
INFLUENZA
PERTUSSIS

187
Q

CONTACT PRECAUTIONS

A

DIRECT OR INDIRECT TRANSMISSION
ALL ITEMS CONTAMINATED WITHIN 24 HOURS
ALWAYS: GOWN, GLOVES, HAND HYGIENE, MASK IF SPLASHING
MRSA

188
Q

CONTACT PLUS

A

CONTACT BUT ALSO WIPE ROOM SURFACES ROUTINELY
CDIFF

189
Q

PROTECTIVE ENVIRONMENT

A

PRIVATE ROOM
POSITIVE AIRFLOW
HEPA FILTRATION
MASK OUT OF ROOM
NO LIVE PLANTS
IMMUNOSUPPRESSED
NEUTROPENIC
DOOR CLOSED
LIMIT OUTSIDE MOVEMENT
CLEAN GOWN AND PPE FOR PT IF TRANSPORT

190
Q

CONTACT PRECAUTIONS REQUIRE

A

HAND HYGIENE
GOWN
GLOVES
MASK IF RISK

191
Q

CONTACT PLUS PRECAUTIONS REQUIRE

A

HAND HYGIENE
GOWN
GLOVES
MASK IF SPLASH RISK
TWICE DAILY SURFACE CLEANING

192
Q

DROPLET AND CONTACT PRECAUTIONS

A

HAND HYGIENE
MASK
EYE PROTECTION
GOWN
GLOVES

193
Q

DROPLET PRECAUTIONS REQUIRE

A

HAND HYGIENE
STANDARD PRECAUTIONS
MASK

194
Q

AIRBORNE PRECAUTIONS

A

HAND HYGIENE
N95
STANDARD PRECAUTIONS
NEGATIVE PRESSURE ROOM
DOOR CLOSED

195
Q

PROTECTIVE PRECAUTIONS REQUIRE

A

NOBODY SICK MAY VISIT
HAND HYGIENE
PATIENT WEARS MASK OUT OF ROOM
NO LIVE PLANTS
POSITIVE PRESSURE

196
Q

4 MAJOR HAIs

A

CLASBI- CENTRAL LINE
CAUTI- CATHETER
SSI- SURGICAL SITE
VAP- VENTILATOR PNEUMONIA

197
Q

IATROGENIC HAI

A

FROM A PROCEDURE

198
Q

EXOGENOUS HAI

A

FROM MICROORGANISM OUTSIDE OF INDIVIDUAL

199
Q

ENDOGENOUS HAI

A

PATIENT FLORA BECOMES ALTERED AND OVERGROWN

200
Q

MDRO

A

BENE MUTATION AFTER SURVIVING ANTIBIOTIC THERAPY
MRSA, VRE, CDIFF

201
Q

HAI AND ANTIBIOTIC RESISTANCE

A

INVASIVE PROCEDURES
ALTERED IMMUNE DEFENSES
ELDERLY
ANTIBIOTIC ADMIN
MDRO

202
Q

PREVENTING HAI/MDRO

A

HAND HYGIENE
CONSERVATIVE ANTIBIOTIC USE
UNIVERSAL PRECAUTIONS
TRANSMISSION BASED PRECAUTIONS
PROPER PPE DISPOSAL
NOT SHARING PATIENT ITEMS
ANTIMICROBIAL DRESSINGS
NO ARTIFICIAL FINGERNAILS
LIMIT CATHS
BREAK THE CHAIN

203
Q

STANDARD PRECAUTIONS INCLUDE

A

HANDWASHING
PPE
SAFE SHARP DISPOSAL
NEVER RECAP NEEDLE

204
Q

NORMAL BMI

205
Q

FEVER TREATMENT

A

COOL JUICES/DRINKS
COOL ROOM
LIGHT/NO COVER
SHEET ONLY
ANTYPYRETICS- TYLENOL/ADVIL
ANTIBIOTICS IF WARRANTED
COOL THEM DOWN

206
Q

TJC
THE JOINT COMMISSION

A

ACCREDITS
PERFORMANCE OUTCOMES MEASURED

207
Q

WRONG SURGICAL SITE

A

TIME OUT
SITE IS MARKED, CONSISTENT WITH PERMIT BEFORE ANESTHESIA AND BEFORE SURGERY

208
Q

PASS

A

PULL
AIM
SQUEEZE
SWEEP

209
Q

PATIENT SAFETY GOALS

A

YEARLY SINCE 2002 BY TJC
1. ID PATIENT CORRECTLY
2. IMPROVE STAFF COMMUNICATION
3. MEDICATION SAFETY
4. ALRMS SAFETY
5. PREVENT INFECTIONS
6. REDUCE PATIENT SAFETY RISK
7. IMPROVE EQUITY
8. PREVENT SURGICAL MISTAKES

210
Q

NEAR INJURY OR MEDICATION ERRORS

A

REQUIRE OCCURRENCE REPORT TO IMPROVE

211
Q

SENTINEL EVENT

A

NEVER EVENT
DEATH OR SERIOUS INJURY
ROOT CAUSE ANALYSIS
QUALITY ASSURANCE

212
Q

PATIENT INHERENT ACCIDENT

A

PHYSICAL OR PSYCHOLOGIC ATTRIBUTES
SEIZURES

213
Q

PROCEDURE RELATED ACCIDENT

A

BY HCP
MED ERROR
POOR TECHNIQUE

214
Q

EQUIPMENT RELATED ACCIDENT

A

FAULTY EQUIPMENT
INJURY OR DEATH REPORTABLE TO FDA

215
Q

RACE

A

RESCURE AND REMOVE
ACTIVATE ALARM
CONFINE FIRE
EXTINGUISH

216
Q

ABC CHEMICAL

A

A- TRASH/WOOD/PAPER
B- LQUIDS/GASES
C- ENERGIZED ELECTRICAL SOURCES

217
Q

LATEX PRECAUTION

A

RUBBER TREE PRODUCT
REPEATED USE = HYPERSENSITIVITY
HANDWASHING REMOVES IRRITANTS
LESS LIKELY WITHOUT POWDER

218
Q

HOME OXYGEN

A

NO SMOKING SIGN
PRESCRIBED DRUG AND AMOUNT
LIMIT ITEMS THAT GENERATE STATIC ELECTRICITY
LIMIT WOOL, NYLONG, SYNTHETICS
USE COTTON
SMOKE ALARMS
FIRE EXTINGUISHER
AVOID HEATING OIL AND NAIL POLISH REMOVER

219
Q

FALLS PREVENTION

A

HRF BRACELET
BED OR CHAIR ALARM
NON SKID FOOTWEAR
PATIENT ITEMS IN REACH
FREQUENT ROUNDING

220
Q

RESTRAINT SAFETY

A
  1. REDUCE FALLS OR INTERRUPTION OF THERAPY
  2. REDUCE HARM TO SELF OR OTHERS
  3. NOT P UNISHMENT
  4. LEAST RESTRICTIVE MEASURES FIRST
  5. CAN BE CHEMICAL
  6. MANDATED BY FEDERAL AND STATE LAWS
  7. ASSAULT AND BETTERY OR FALSE IMPRISONMENT
221
Q

RESTRAINT ORDERS

A
  1. REEVALUATED Q24H
  2. CAN’T BE PRN
  3. ASSESS THE TIONS Q2H
  4. YOU ARE DOING THEIR ADLS
  5. MUST MONITOR AND PROVIDE NEDS
  6. RELEASE RESTRAINTS PER POLICY
222
Q

OTHER RETRAINT INFO

A

BEHAVIOR- Q15 MINUTE MONITORING
ALL 4 RAILS IS RESTRAINT UNLESS SEDATED
DON’T ATTACH TO SIDE RAILS
ATTACH TO FRAIM
QUICK RELEASE KNOT
BED IN LOWEST POSITION AND MAT ON FLOOR

223
Q

SEIZURE SAFETY

A

DISORDERLY DISCHARGE OF NEURONS
ALL 4 RAILS UP AND PADDED
POSITION SIDE LYING
HAVE O2,, SUCTION, ORAL AIRWAY AT BEDSIDE
NOTHING IN MOUTH
LOOSEN CLOTHING
STAY WITH PT
TIME SEIZURE
ASSESS FOR INJURY AND COMFORT AFTERWARDS

224
Q

NEAR MISS

A

POTENTIAL ERROR THAT COULD HAVE CAUSED HARM BUT WAS CAUGHT AND AVOIDED

225
Q

PATIENT SAFETY EVENT

A

UNEXPECTED THAT OCCURRED WITHOUT INJURY TO PATIENT

226
Q

SENTINEL EVENT

A

CRITICAL
UNEXPECTED
ADVERSE
SEVERE PHYSICAL/PSYCH HARM

227
Q

SURGICAL/PROCEDURAL

NEVER EVENT

A

WRONG PROCEDURE
WRONG SITE

228
Q

PRODUCT/DEVICE

NEVER EVENT

A

DEATH/INJURY DUE TO CONTAMINATION

229
Q

CLIENT PROTECTION

NEVER EVENT

A

SUICIDE IN CARE

230
Q

CARE MANAGEMENT

NEVER EVENT

A

STAGE3, 4, OR UNSTAGEABLE PI ACQUIRED IN HOSPITAL

231
Q

ENVIRONMENTAL

NEVER EVENT

A

RESTRAINTS CAUSED DEATH/INJURY

232
Q

RADIOLOGIC

NEVER EVENT

A

DEATH/INJURY DUE TO METAL OBJECT LEFT DURING MRI

233
Q

CRIMINAL NEVER EVENT

A

SEXUAL ABUSE OR ASSAULT WHILE IN CARE OR ON GROUNDS

234
Q

PDSA METHOD

A

PLAN- CHOOSE PROBLEM
DO- MAKE CHANGE
STUDY- ANALYZE
ACT- DECIDE IMPLEMENTATION

235
Q

FRICTION

A

FORCE OF RUBBING 2 SOURCES AGAINST ONE ANOTHER
FORCE THAT OCCURS IN DIRECTION OPPOSITE TO MOVEMENT
GREATER SURFACE AREA = MORE FRICTION

236
Q

PREVENT FRICTION

A

HAVE PT CROSS ARMS TO REDUCE SURFACE AREA BEFORE MOVING
HAVE PATIENT BEND KNEES TO HELP THEM MOVE UP
MOVE PILLOWS AND HAVE PT LIFT HEAD OFF BED IF ABLE

237
Q

SHEAR

A

SLIDING RESULT OF GRAVITY PUSHING DOWN ON THE PATIENT’S BODY AND THE RESISTANCE BETWEEN THE PATIENT AND THE CHAIR OR BED. WHEN HOB ELEVATED GREATER THAN 60 DEGREES, SKIN REMAINS STATIONARY ON THE SHEETS AND THE BONY STRUCTURES BENEATH IT MOVE TOWARDS THE FOOT OF THE BED

238
Q

PREVENT SHEARING

A

USE DRAW SHEETS AND SLIDING BOARDS
KEEP HOB 30 DEGREES

239
Q

ISOMETRIC EXERCISE

A

STRETCHING, TIGHTENING OR TENSING OF MUSCLES WITHOUT JOINT MOVEMENT
IMPROVES CIRCULATION
INCREASES MUSCLE MASS, TONE AND STRENGTH
INCREASES OSTEOBLASTIC ACTIVITY
INCREASES RR AND HR
CAN BE A STRESSOR EVEN THOUGH NOT ACTIVE
YOGA, STRETCHING, QUAD AND GLUTE TIGHTENING IF BEDBOUND

240
Q

ISOTONIC EXERCISE

A

AEROBIC/ACTIVE MOVEMENT
CONCENTRIC AND ECCENTRIC TENSIONS OF MUSCLE FIBERS
IMPROVES CIRCULATION, RESPIRATORY FUNCTION,
INCREASES MUSCLE MASS, TONE, STRENGTH
PROMOTES OSTEOBLASTIC ACTIVITY-PREVENTS OSTEOPOROSIS
WALKING, RUNNING, SWIMMING, BIKING

241
Q

BODY MECHANICS

A

COORDINATED EFFORTS OF MUSCULOSKELETAL AND NERVOUS SYSTEMS TO AVOID INJURIES
BACKS ONLY SAFELY LIFE 30-35 LBS
BALANCE AND USE OF THIGH MUSCLES
LIFT DEVICES

242
Q

SCOLIOSIS

A

TEENS
S CURVE OF SPINE

243
Q

KYPHOSIS

A

CONVEX CURVATURE OF SPINE
TOO FAR FORWARD
ROUNDED UPPER BACK
CAN’T STAND UP STRAIGHT
HUNCHBACK-ELDERLY

244
Q

LORDOSIS

A

CONCAVE CURVATURE OF SPINE INWARD AT LOWER BACK, SWAY BACK, PREGNANCY

245
Q

CONGENITAL HIP DYSPLASIA

A

BALL IS LOOSE IN HIP SOCKET AND DISLOCATES EASILY

246
Q

IMMOBILITY AND METABOLISM

A

S/S- DECREASED METABOLIC RATE, SLOW GI, ANOREXIA, NEGATIVE N BALANCE
INTERVENTIONS: HIGH PROTEIN, HIGH CALORIES, VIT B, VIT C, CA, TPN, ENTERAL/GI FEEDINGS,

247
Q

RESPIRATORY AND IMMOBILITY

A

S/S- SNAP/CRACKLE/POP, HYPOSTATIC PNEUMONIA, LUNG INFECTION, HYPOEXPANSION, DECREASED CILIARY ACTION AND MUCUS REMOVAL, ATELECTASIS
INTERVENTIONS- TURN, DEEP BREATH, COUGH Q1-2H, INCENTIVE SPIROMETER, CHEST PHYSIOTHERAPY, RESPIRATORY ASSESSMENT, FLUID INTAKE
MONITOR O2

248
Q

TURN DEEP BREATHE AND COUGH

A

Q 1-2 H
MOBILIZE STATIC MUCUS

249
Q

INCENTIVE SPIROMETER

A

Q1H WHILE AWAKE X 10 INHALES

250
Q

CHEST PHYSIOTHERAPY

A

POSTURAL DRAINAGE

251
Q

RESPIRATORY ASSESSMENT

252
Q

FLUID INTAKE

A

2L PER DAY FOR THIN, WATERY, CLEAR, MUCUS

253
Q

MUSCULOSKELETAL AND IMMOBILITY

A

IF YOU DON’T USE IT, YOU LOSE IT
IMPAIR BALANCE
ALTERED CAL METABOLISM- OSTEOPOROSIS
CONTRACTURES
INTERVENTIONS- ROM, PRONE POSITION, CPM, PREVENT FOOTDROP, ISOMETRIC EXERCISE, SITTING, AMBULATION

254
Q

ROM

A

2-3 X / DAY
Q8H
5 REPS PER JOINT

255
Q

CPM

A

CONTINUOUS PASSIVE MOTION
AFTER KNEE REPLACEMENT
SHOULDERS IN AFFECTED SIDE OF CVA
SPLINTS

256
Q

FOOTDROP

A

FOOT STAYS IN PLANTAR FLEXION
AMBULATION IMPOSSIBLE
HIGH TOP SHOES AND POSITIONINGHELP

257
Q

ISOMETRIC EXERCISE

A

QID WHEN NOT AMBULATION

258
Q

GI/GU AND IMMOBILITY

A

LESS DRAINAGE VIA GRAVITY
INCREASED RISK FOR RENAL CALCULI, URINARY STASIS, UTI
GI SLOWS, CONSTIPATION- 16X MORE LIKELY, GERD, IMPACTION
INTERVENTIONS- 2L FLUIDS, I&O RELATIVELY EQUAL, PROMOTE URINATION, HIGH FIBER, FRESH FRUITS, VEGGIES, ELEVATE HOB AFTER MEALS

259
Q

FLEXION

260
Q

EXTENSION

A

STRAIGHTEN

261
Q

ABDUCTION

262
Q

ADDUCTION

A

MOVE CLOSER

263
Q

PRONATION

A

FACE BACKWARD

264
Q

SUPINATION

A

FACE FORWARD

265
Q

CIRCUMDUCTION

A

CIRCULAR MOTION

266
Q

ROTATION

A

SIDE TO SIDE

267
Q

INVERSION

A

TURN INWARD

268
Q

EVERSION

A

TURN OUTWARD

269
Q

DORSIFLEXION

270
Q

PLANTARFLEXION

271
Q

INTEGUMENTARY AND IMMOVILITY

A

S/S- COMPROMISED CAPILLARY BLOOD FLOW, PI, TISSUE ISCHEMIA
INTERVENTIONS- PROPER POSITION, LIFT DEVICES, RULE OF 30, ASSESSMENT Q2H, SKIN AND PERINEAL CARE, TURN Q1-2H, LIMIT CHAIR TO 1H, SHIFT WEIGHT Q15 MIN, SPECIALTY MATTRESS, FLOAT HEELS

272
Q

CARDIO AND IMMOBILITY

A

S/S- ORTHOSTATIC HYPOTENSION, LESS BLOOD VOLUME, BLOOD POOLING, DECREASED AUTONOMIC RESPONSE, HEART HAS TO WORK HARDER, OXYGEN CONSUMPTION INCREASES
INTERVENTIONS- RAISE HOB TO ENCOURAGE BLOOD FLOW, DANGLING BEFORE AMBULATION, SLOW CHANGES, FALL RISK SAFETY, ANTIEMBOLISM STOCKINGS, MONITOR VS, DISCOURAGE VALSALVA MANEUVER

273
Q

3 MAIN CARDIO COMPLICATIONS

A
  1. BLOOD CLOTS
  2. VIRCHOWS TRIAD
  3. DVT
274
Q

IMMOBILITY AND CARDIO PREVENTION

A

HYDRATION, TEACHING, POSITION CHANGES, ASAP AMBULATION, ROM 2-3 TIMES A DAY, QNTIEMBOLIC EXERCISES Q1-2H WHILE AWAKE, SCD- REMOVE Q8H, LOOSE CLOTHING, DON’T MESSAGE LEGS

275
Q

THROMBUS

A

ACCUMULATION OF PLATELETS, FIBRIN, CLOTTING FACTORS ATTACH INTERIOR LINING OF VEIN OR ARTERY

276
Q

EMBOLUS

A

CLOT THAT DETACHES OR MOVES WITHIN VESSELS

277
Q

DVT

A

OF CALF IS MOST COMMON
IS A NEVER EVENT
CAN LEAD TO PE, MI, OR CVI
ASSESS FOR EDEMA, WARMTH, TENDERNESS IN LE
PROPHYLAXIS IS KEY

278
Q

METABOLIC AND IMMOBILITY BRIEF

A

ENDOCRINE
CALCIUM ABSORPTION
GI FUNCTION

279
Q

CARIO AND IMMOBILITY BRIEF

A

ORTHOSTATIC HYPOTENSION
INCREASED CARDIAC WORKLOAD
THROMBUS

280
Q

MUSCLE AND IMMOBILITY BRIEF

A

LOSS OF MASS
ATROPHY

281
Q

URINARY ELIMINATION AND IMMOBILITY BRIEF

A

URINARY STASIS
RENAL CALCULI

282
Q

BOWELS AND IMMOBILITY BRIEF

A

CONSTIPATION
FECAL IMPATION

283
Q

RESPIRATORY AND IMMOBILITY BRIEF

A

ATELECTASIS
HYPOSTATIC PNEUMONIA

284
Q

SKELETAL AND IMMOBILITY BRIEF

A

IMPAIRED CALCIUM ABSORPTION
JOINT ABNORMALITIES

285
Q

SKIN AND IMMOBILITY BRIEF

A

PI
ISCHEMIA

286
Q

CANE USE

A

ON STRONGER SIDE
6-10 INCHES FORWARD
BODY WEIGHT ON BOTH LEGS
WEAKER LEG IS MOVED FORWARD
DIVIDE WEIGHT BETWEEN CANE AND STRONGER LEG
STRONGER LEG IS ADVANCED PAST CANE
DIVIDE WEIGHT BETWEEN CANE AND WEAKER LEG

287
Q

CRUTCH USE

A

GOING UP STAIRS- LEAD WITH STRONGER
GOING DOWN STAIRS- LEAD WITH WEAKER
DON’T HOP

288
Q

CRUTCH LOCATION

A

1-2 INCHES BETWEEN PAD AND AXILIA
NO WEIGHT ON AXILLA

289
Q

4 POINT ALTERNATING GATE

A

GIVE STABILITY
BOTH LEGS WEIGHT BEARING

290
Q

3 POINT GAIT

A

ALL WEIGHT ON ONE FOOT
WEIGHT ON CRUTCHES
WEIGHT ON GOOD LEG
AFFECTED LEG DOES NOT TOUCH GROUND

291
Q

2 POINT GAIT

A

PARTIAL WEIGHT ON EACH FOOT
LEG AND OPPOSITE CRUTCH MOVE AND THEN OTHER SIDE

292
Q

SWING THROUGH GATE

A

PARAPLEGIA
MOVE LEGS TOGETHER

293
Q

ATELECTASIS

A

ALVEOLAR COLLAPSE
FROM LOW OXYGEN DUE TO LOW SURFACTANT LEVELS

294
Q

HYPOVOLEMIA

A

RESULTS IN HYPOXIA TO TISSUES AND DECREASED PRELOAD
Tx IS IVF

295
Q

CONDITIONS AFFECTING CHEST WALL MOVEMENT

A

PREGNANCY
OBESITY
NEUROMUSCULAR DISEASE
MUSCULOSKELETAL ABNORMALITIES-KYPHOSIS, TRAUMA, CNS, SPINAL CORD

296
Q

INDICATIONS OF HYPOXEMIA

A

CLUBBED FINGERS
BARREL CHEST
RBC INCREASE TRYING TO COMPENSATE
RENAL INSUFFICIENCY DECREASE ERYTHROPOIETIN PRODUCTION CAUSING ANEMIA

297
Q

ORTHOPNEA

A

UPRIGHT POSITION FOR BREATHING
HOW MANY PILLOWS DO THEY USE
SLEEP IN RECLINER

298
Q

EXERCISE GOALS

A

3-4 TIMES A WEEK
30-60 MINUTES

299
Q

INCENTIVE SPIROMETRY

A

5-10 BREATHS
QH WHILE AWAKE

300
Q

COUGH AND DEEP BREATH

A

Q2H WHILE AWAKE

301
Q

TRACH SUCTIONING

A

HYPEROXYGENATE FIRST TO DECREASE SUCTION INDUCED HYPOXEMIA
INTERMITTENT SUCTION NO LONGER THAN 10 SECONDS
NEVER SUCTION DURING INSERTION
LIMIT TO 2 PASSES

302
Q

NASAL CANULA

A

LOW FLOW
1-6 LPM

303
Q

SIMPLE MASK

A

6-10 LPM
5 IS MINIMUM
LOW FLOW

304
Q

PARTIAL REBREATHER MASK

305
Q

NONREBREATHER MASK

306
Q

WHEN DO YOU HUMIDIFY O2

307
Q

PURSED LIP BREATHING

A

DEEP INSPIRATION
PROLONGED EXPIRATION
PREVENTS ALVEOLAR COLLAPSE

308
Q

DIAPHRAGMATIC BREATHING

A

PULMONARY DISEASE
LABOR
RELAX INTERCOSTAL AND ACCESSORY MUSCLES TO DECREASED AIR TRAPPING AND WORK OF BREATHING

309
Q

PNEUMOTHORAX

A

AIR IN PLEURAL SPACE
COLLAPSED LUNG

310
Q

HEMOTHORAX

A

BLOOD IN PLEURAL SPACE
OTHER THAN TRAUMATIC INJURIES

311
Q

CHEST TUBE

A

DRAIN AIR OR BLOOD
KEEP SECURED
BELOW CHEST LEVEL
MONITOR WATER SEAL
MARK LEVEL OF DRAINAGE

312
Q

COPD

A

LOW O2
DECREASES DRIVE TO BREATH
HYPOXIC

313
Q

WHEN YOU GET A YES ANSWEWR….

A

KEEP ASKING QUESTIONS

314
Q

SUBJECTIVE

A

THOUGHTS/FEELINGS

315
Q

OBJECTIVE

316
Q

SMART GOAL

A

SPECIFIC
MEASURABLE
ATTAINABLE
REALISTIC
TIMED

317
Q

NURSE INITIATED INTERVENTION

A

INDEPENDENT
DO NO REQUIRE ORDER OR SUPERVISION

318
Q

HCP INITIATED

A

DEPENDENT-REQUIRES ORDER
REQUIRE SPECIFIC NURSING RESPONSIBILITIES AND NURSING KNOWLEDGE

319
Q

COLLABORATIVE INTERVENTION

A

INTERDEPENDENT
INTERDISCIPLINARY CARE PLAN

320
Q

DIRECT CARE

A

INTERVENTIONS/Tx PERFORMED THROUGH INTERACTIONS WITH PATIENTS

321
Q

INDIRECT CARE

A

INTERVENTIONS/Tx PERFORMED AWAY FROM PT BUT ON THEIR BEHALF LIKE DOCUMENTATION OR COLLABORATION

322
Q

CLINICAL PRACTICE GUIDELINES

A

SYSTEMATICALLY DEVELOPED STATEMENTS THAT HELPS MAKE DECISIONS

323
Q

STANDING ORDERS

A

PREPRINTING DOCUMENTS CONTAINING ORDERS FOR THE CONDUCT OF ROUTINE THERAPIES, MONITORING, GUIDELINE, AND/OR DIAGNOSTIC PROCEDURES

324
Q

STANDARS OF PRACTICE

A

EVIDENCE OF STANDARD OF CARE

325
Q

HYPERNATREMIA

A

WATER DEFICIT

326
Q

HYPERTONIC

A

LOSS OF MORE WATER THAN SALT

327
Q

HYPONATREMIA

A

WATER EXCESS

328
Q

HYPOTONIC

A

WATER INTOXICATION

329
Q

S/S OF FLUID VOLUME EXCESS

A

CONFUSION
EDEMA
INCREASED WEIGHT

330
Q

S/S OF FLUID DEFICIT

A

HYPOTENSION
WEAK PULSE
HIGH OUTPUT
ORIENTATION, VISION, HEARING, REFLEX, MUSCLE CHANGES,
DECREASED WEIGHT
SKIN BREAKDOWN

331
Q

NORMAL PH

332
Q

WHAT ORGANS WORK TOGETHER TO KEEP BALANCE

A

KIDNEYS AND LUNGS

333
Q

RESPIRATORY ALKALOSIS

A

HYPERVENTILATION
PH UP
CO2 DOWN
PULMONARY EMBOLI
FEVER
HYPOXIA
PREGNANCY
ALTITUDE
ANXIETY

334
Q

METABOLIC ALKALOSIS

A

LOW GASTRIC JUICES
OVERUSE OF ANTACIDS
POTASSIUM WASTING DIURETICS
PH UP
HCO3 UP

335
Q

RESPIRATORY ACIDOSIS

A

HYPOVENTILATION
PH DOWN
CO2 UP
AIRWAY OBSTRUCTION
COPD
CHEST TRAUMA
NEUROMUSCULAR DISEASE
DRUG OVERDOSE
PULMONARY EDEMA

336
Q

METABOLIC ACIDOSIS

A

DIABETIC KETOACIDOSIS
SALICYLATE OD
SHOCK
SEPSIS
SEVERE DIARRHEA
RENAL FAILURE
PH DOWN
HCO3 DOWN

337
Q

s/s RESPIRATORY ACIDOSIS

A

HYPOVENTILATION –> HYPOXIA
DROWSINESS
DIZZINESS
DISORIENTATION
MUSCLE WEAKNESS
DYSRHYTHMIAS
HYPERKALEMIA
HEADACHE
DYSPNEA
RAPID/SHALLOW RESPIRATIONS

338
Q

S/S METABOLIC ALKALOSIS

A

RESTLESSNESS–>LETHARGY
DECREASED LOC
IRRITABLE
N&V
DIARRHEA
TREMORS
MUSCLE CRAMPS
HYPOKALEMA
TINGLING
TACHYCARDIA

339
Q

RESPIRATORY ALKALOSIS

A

DYSPNEA
DEEP/RAPID RR
TACHYPNEA
DEHYDRATION

340
Q

METABOLIC ALKALOSIS

A

CARDIAC DYSRHYTHMIAS
HYPOKALEMIA
WEAKNESS
CRAMPING
HYPERACTIVE REFLEXES
TETONY
CONVULSIONS
CONFUSION

341
Q

SODIUM

342
Q

POTASSIUM

343
Q

CALCIUM

344
Q

MAGNESIUM

345
Q

PHOSPHOROUS

346
Q

CHLORIDE

347
Q

PH

348
Q

PACO2

349
Q

PAO2

350
Q

HCO3
BICARB

351
Q

RBC

A

MALES 4.7-6.1
FEMALES 4.2-5.4

352
Q

HGB

A

MALES 14-18
FEMALES 12-16

353
Q

HCT

A

MALE 42-52
FEMALE 37-47

354
Q

WBC

A

5000-10000

355
Q

ESR

A

LESS THAN 20

356
Q

TOTAL CHOLESTEROL

A

LESS THAN 200

357
Q

LDL

A

LESS THAN 130

358
Q

HDL

A

MALES 35-65
FEMALES 35-80

359
Q

ALBUMIN

360
Q

AMMONIA

361
Q

BILIRUBIN

362
Q

PROTEIN

363
Q

UA SPECIFIC GRAVITY

A

1.005-1.025

364
Q

UA PROTEIN

365
Q

UA GLUCOSE

A

LESS THAN 0.5 G/DAY

366
Q

UA KETONES

367
Q

UA PH

368
Q

CREATININE

A

MALE 0.6-1.2
FEMALE 0.5-1.1

369
Q

BUN

370
Q

GLUCOSE

371
Q

HBA1C

A

4-6
GREATER THAN 8 INDICATES POOR DM CONTROL

372
Q

AC

A

BEFORE MEALS

373
Q

PC

A

AFTER MEALS

374
Q

DRUG RIGHTS

A

RIGHT DRUG
RIGHT DOSE
RIGHT PATIENT
RIGHT ROUTE
RIGHT TIME
RIGHT DOCUMENTATION

375
Q

TOPICALLY

A

NO ABBREVIATION

376
Q

FREELY
AS DESIRED

377
Q

OUT OF BED

378
Q

BR

379
Q

PEG

A

PRECUTANEOUS ENDOSCOPIC GASTROSTOMY

380
Q

AKI

A

ACUTE KIDNEY INFECTION

381
Q

CKD

A

CHRONIC KIDNEY DISEASE

382
Q

ARF

A

ACUTE RENAL FAILURE

383
Q

ESRD

A

END STAGE RENAL DISEASE

384
Q

AMA

A

AGAINST MEDICAL ADVICE

385
Q

AMI

A

ACUTE MYOCARDIAL INFARCTION

386
Q

CVD

A

CARDIOVASCULAR DISEASE

387
Q

SHOB

A

SHORTNESS OF BREATH

388
Q

CVA

A

CEREBROVASCULAR ACCIDENT

389
Q

TIA

A

TRANSISCHEMIC ATTACK

390
Q

DJD

A

DEGENERATIVE JOINT DISEASE

391
Q

AKA

A

ABOVE KNEE AMPUTATION

392
Q

Fx

393
Q

Sx

394
Q

IDDM

A

INSULIN DEPENDENT DIABETES MELLITUS

395
Q

C

396
Q

S

397
Q

ACUTE/TRANSIENT PAIN

A

PROTECTIVE MECHANISM
IDENTIFIABLE CAUSE
SHORT DURATION
LIMITED TISSUE DAMAGE

398
Q

CHRONIC EPISODIC PAIN

A

OCCURS OVER TIME
UNPREDICTABLE EPISODES
EX HEADACHES

399
Q

IDIOPATHIC PAIN

A

CHRONIC PAIN
ABSENCE OF IDENTIFIABLE CAUSE

400
Q

CANCER PAIN

A

ACUTE AND CHRONIC NOCICEPTIVE OR NEUROPATHIC REASONS

401
Q

INFERRED PAIN

A

SOMATIC OR VISCERAL OF NOCICEPTIVE OR NEUROPATHIC NATURE FROM ORGANS OR DAMAGED NERVES

402
Q

PHANTOM PAIN

A

RELATED TO AN ABSENT LIM OR ORGAN

403
Q

PQRSTU

A

PALLIATIVE OR PROVOKING FACTORS
QUALITY
REGION/RADIATION
SEVERITY
TIMING
EFFECT ON UR LIFE

404
Q

NON OPIOID PAIN MEDS

A

NSAIDS
ACETAMINOPHEN
ADJUVANT

405
Q

NSAIDS

A

SIDE EFFECTS: GI BLEED, RENAL INSUFFICIENCY, HTN
EX: IBPROFEN, ASA

406
Q

ACETAMINOPHEN

A

SE: HEPATOXACITY
OFTEN IN COMBINED MEDS
4 GM MAX/DAY

407
Q

ADJUVANT

A

USED TO TREAT OTHER CONDITIONS
PAIRS WELL WITH PAIN MEDS
EX: ANTIDEPRESSANTS, CORTICOSTEROIDS, SEDATIVES, ANTIANXIETY

408
Q

OPIOID MEDS

A

MODERATE TO SEVERE PAIN
WORKS ON CNS
MORPHINE IS THE BASIC MEASUREMENT
NARCAN REVERSES- SHORTER HALF LIFE
RESPIRATORY DEPRESSION
S/E: N&V, CONSTIPATION, ITCHING, ALTERED MENTAL STATUS, URINARY RENTENTION

409
Q

TIPS FOR EFFECTIVE PAIN MANAGEMENT

A

PATIENTS ARE THE EXPERTS
ESTABLISH RELATIONSHIP OF TRUST
AVOID LABELING PATIENTS AS DRUG SEEKING
AROUND THE CLOCK DOSING IS MORE EFFECTIVE
CONSTIPATION IS PRIMARY SYMPTOM OF OPIOID USE- STIMULANT LAXATIVE PREFERRED
DOCUMENT PHARM AND NON PHARM INTERVENTIONS

410
Q

PROPHYLAXIS

A

FOR PREVENTION
HEPARIN TO PREVENT THROMBOSIS

411
Q

THERAPEUTIC PURPOSE OF MEDS

A

REPLACE FLUIDS OR VITAMINS
PALLIATION OF PAIN AND CURE- ANTIBIOTICS
SUPPORTIVE- ANESTHESIA

412
Q

GENERIC DRUG NAME

413
Q

DRUG CLASSIFICATION

A

BASED ON DESIRED EFFECT ON BODY SYSTEM

414
Q

PEAK

A

THE MAXIMAL THERAPEUTIC LEVEL
MAX SERUM
DOSE AND TIME VARIES

415
Q

TROUGH/LEVEL

A

LOWEST THERAPEUTIC LEVEL
DRAW 30 MINUTE BEFORE NEXT DOSE

416
Q

OTHER MEDICATION RIGHTS

A

ASSESSMENT
EVALUATION
REFUSAL
EDUCATION

417
Q

STANDING/ROUTINE ORDER

A

ADMIN UNTIL DOSAGE IS CHANGED OR ANOTHER MED IS PRESCRIBED

418
Q

SINGLE- ONE TIME

A

GIVEN ONE TIME FOR A SPECIFIC REASON

419
Q

NOW ORDER

A

NEEDED RIGHT AWAY
NOT STAT

420
Q

PRN ORDER

A

WHEN PATIENT REQUIRES IT

421
Q

STAT ORDER

A

IMMEDIATELY
EMERGENCY

422
Q

PRESCRIPTION ORDER

A

MEDS TAKEN OUTSIDE OF HOSPITAL

423
Q

IV ONSET

A

3-5 MINUTES

424
Q

IM ONSET

A

3-20 MINUTES

425
Q

SC ONSET

A

3-20 MINUTES

426
Q

PO ONSET

A

30-45 MINUTES

427
Q

TOPICAL MEDS

A

SKIN
RECTAL
VAGINAL
OTIC
OPTIC
NASAL

428
Q

SUSTAINED RELEASE OR ENTERIC COATED

A

DO NOT CRUSH

429
Q

SUBLINGUAL ADMIN

A

PATIENT SITTING
DISSOLVE UNDER TONGUE
DON’T EAT DRINK SMOKE UNTIL ABSORBED

430
Q

ADMIN OF INHALED DRUGS

A

AEROSOL, MIS, POWDER VIA INHALERS
BRONCHODILATION
SYSTEMIC EFFECTS LIKE TACHYCARDIA
EXHALE FIRST, INHALE SLOWLY, HOLD 5-10 SECONDS, 30 SECONDS BETWEEN PUFFS
RINSE AND SPIT AFTER STEROIDS TO REDUCE RISK OF THRUSH

431
Q

OPTIC ADMIN

A

DON’T TOUCH CORNEA
PULL DOWN CONJUNCTIVAL SAC
PRESS LACRIMAL DUCT
DON’T SHARE
ONLY ON AFFECTED EYE

432
Q

OTIC ADMIN

A

ALWAYS AT ROOM STEMP
STERILE SOLUTIONS
NEVER OCCLUDE CANAL
DO NOT FORCE MEDS
YOUNG CHILD-EAR DOWN AND BACK
OTHERS- EAR UP AND BACK

433
Q

parenteeral

A

INJECTION INTO TISSUES

434
Q

ID NEEDLE

A

1/4-3/4 INCH
27-25

435
Q

IM NEEDLE

A

1-1.5 INCH
25-18 G

201 Intro (9 decks)

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