Passpoint Flashcards
Caused by loss of calcium and phosphate from the bones, causing easy fractures
Osteoporosis
Insufficient bone mineralization result of lack Vitamin D, calcium, phosphorous
Softening Bones
Osteomalacia
Phebitis is….
Inflammation of a vein, often related to IV therapy
“______” is a female who has never been pregnant.
A “______” is a female who is pregnant for the first time or has been pregnant once.
A “______” or “______” is a female who has been pregnant more than once.
nulligravida
primigravida
multigravida / secundigravida
mature female reproductive cell,
Can divide to give rise to an embryo usually only after fertilization by a male cell.
How long do they live
Ovum
24 hrs
When does ovulation occur in a 28 day cycle
Day 14, plus or minus 2 days
Why is
Providing wound care for a client’s venous ulcer at an ambulatory clinic near the client’s home
More Community Based Nursing
Than
Organization of blood pressure screening clinic at a shopping mall
Community based care is
Providing care for acute and chronic illnesses In the Geographic Region near client’s home
BP screening and health maintenance education are
Population-based and Community Health Initiatives
Distinct from COMMUNITY BASED CARE
What is the difference between
Developmental Stage & Functional Age
Developmental Stage: Understanding cognitive, emotional, social Development
Functional Age: Refers to ability to preform daily tasks
A potentially dangerous pregnancy complication characterized by high blood pressure.
usually begins after 20 weeks of pregnancy in a woman whose blood pressure had been normal. It can lead to serious, even fatal, complications for both mother and baby.
Name 4 Symptoms
Pre-eclampsia
High BP
EpiGastric Pain
Swelling of Hands & Feet
Protein in Urine
_____ A portable device that continuously monitors patient ECG, respiratory rate and/or oxygen saturations while automatically transmitting information to a central monitor.
Telemetry
The ______ method is a combination of methods. The two most commonly used are the Basal body temperature method and the cervical mucus method. The Marquette method combines BBT and cervical mucus tracking with use of an electronic hormonal fertility monitor. The monitor detects hormones in urine to confirm fertile days.
symptothermal
Laminectomy is….
surgery Removing bone spurs and tissues associated with arthritis of the spine.
Removing a small piece of the back part (lamina) of the small bones of the spine (vertebrae).
Laminectomy enlarges the spinal canal to relieve pressure on the spinal cord or nerves.
Laminectomy is often done as part of a decompression surgery
Hot-cold concept of humoral medicine (Hispanic Folklore)
Health is believed to be a balance between hot and cold elements in the body.
When the body’s equilibrium is upset by being too “hot” or too “cold,” illness can occur.
Balance can be restored by treatment with foods, remedies, or medicines of the opposite valence.
True or False
True
Access skin tugor in an elderly
What should nurse keep in mind
Over hydration causes skin tenting
Dehydration causes skin to appear edematous and spongy
Inelastic skin turgor is normal aging
Normal is moist and boggy
Inelastic skin tugor is normal part of aging
Dehydration- not over hydration- causes Inelastic skin with tenting.
Normal skin turgor is dry and firm
Match the following
Rapid, deep breathing without pauses.
Shallow breathing with an increased resipatory rate
Breaths gradually become faster and deeper than normal and then slower with periods of apnea
Deep breathing at normal rate.
A. Hyperpnea
B. Cheyne-Strokes
C. Kussmaul
D. Tachypnea
C. Kussmaul
D. Tachypnea
B. Cheyne- Strokes
A. Hyperpnea
Weighing the diaper of an infant after micturition revelas an increase in weight of 40 g
How much urine is this
40 mL
Best way for nurse to assess for bladder distention in Male & Female clients
Palpate for rounded swelling above the pubis
Client with possible concussion should be positioned with HOB @ ….
30 degrees
Promoting Venus return from the head
In hemorrhagic stroke
Monitor ______ to avoid aspiration
Gag reflex
Correct placement to palpate the Maxillary and frontal sinuses
Maxillary: either side of nose; below the cheekbone (zygomatic bone)
Frontal: just above eye; under the bony ridge of the orbit
______ increased pressure in an enclosed space that can compromise muscle,vascular, and nerve function, can be caused by a Cast that is too tight.
Name 5 symptoms
Compartment Syndrome
Inability to feel light touch
Pain
Paresthesia
Coolness
Pallor distal to cast
In compartment syndrome associated with a Tight Cast
To reduce swelling and pressure under the cast and promote venous return the nurse should
Elevate leg
Bivalve a cast ….
Define
To cut a cast to relieve pressure
A fat embolism can occur how?
Name 5 manifestaciones
Long bone fracture
Hypotension, tachycardia, hypoxemia, dyspnea, petechiae, change in LOC level of consciousness
Fasciotomy is…
Surgery to improve Compartment Syndrome
Assess Dark Skinned client for cyanosis.
Which is the best spots
Conjunctiva
Lips
Oral mucos membranes
Nail beds are NOT APPROPRIATE ASSESSMENT FOR CYANOSIS IN ANYONE
Is a medical scale used to measure the agitation or sedation level of a person
Richmond Agitation-Sedation Scale (RASS)
_______ scale is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to communicate their pain.
The scale is scored in a range of 0–10 with 0 representing no pain
The FLACC scale or Face, Legs, Activity, Cry, Consolability
Rates critically ill patients’ pain based on clinical observation.
Critical Care Pain Observation Tool
(CPOT)
________ is an easy-to-use and easy-to-evaluate tool designed to help cancer patients and professionals communicate accurately about the prevention and control of nausea and vomiting that may occur with chemotherapy.
The MASCC Antiemesis Tool (MAT)
Serotonin receptor antagonists: The cornerstone for preventing nausea and vomiting caused by radiotherapy
EXP.
5-HT3 Ondansetron (Zofran)
Four-drug regimen: For preventing acute nausea and vomiting after non-AC ChT with a high emetic risk, the guidelines recommend a regimen of:
A single dose of a 5-HT-RA
Dexamethasone
An NK-RA (aprepitant, fosaprepitant, netupitant, fosnetupitant, or rolapitant)
Olanzapine
Which task is most appropriate for an LPN
Assessing Clients oxygen status
Assisting client ambulate
Administración of tube feeding
Reminding client to use the bathroom
Tube food
A child with the following symptoms maybe suffering from which disease
High fever
Muffled speech
Inspiratory stridor
Drooling
Epiglottitis
Client admitted to hospital for Aspiration Pneumonia secondary to progression of Parkinson’s disease
Which findings should the nurse expect
Cough while drinking fluid
Muscle flaccid of lower extremities
Bilateral upper muscle weakness
Tremors in fingers, increased with movement
Cough while drinking fluids
Oliguria is a medical term for low urine output (how much you pee).
In the case of an adult, this means less than ________ of urine per 24 hour
400 milliliters (mL) to 500 mL (around two cups
Which nursing assessment finding in an elderly client with sepsis requires immediate intervention
Temp. 97.9
Confusion when listening to instructions
Polydipsia
<90 mL urine output over past 6 hrs
<90 mL urine in 6 hrs.
Decreased urine output
Tachypnea
Tachycardia
Hypotension
Associated with deterioration due to sepsis
Which is the priority for a client showing symptoms of MI
Assess pain level, administration of prescribed Analgesics
Assess level of anxiety, provide emotional support
Prepare client for pulmonary artery catheterization
Ensure family is kept informed
Pain & analgesics
Prepare to admin Nitroglycerin or Morphine
Priority to stabilize medically
Pulmonary Artery Catheterization is used to diagnose: Pulmonary hypertension, Shock, Heart Function
Doctors use _______ to diagnose and evaluate common heart and blood vessel problems
Chest pain or an abnormal stress test due to coronary artery disease
Heart valve conditions like a leaky or narrowed valve, a high blood pressure condition in the lungs
Blood clots in the lungs from an embolism
Enlarged heart
cardiac catheterization
Soft to firm, circular, moveable, unlikely to cause nipple retractions
Fibrocystic disease or Cancer
Fibrocyctic Disease
Irregular in shape, firm, non moveable, nipple retractions.
Fibrocystic Disease or Cancer
Cancer
The ear canal slants ____ in children and ____ in adults.
To best visualize tympanic membrane in an infant (describe maneuver)
To best visualize tympanic membrane in an adult (describe maneuver)
Children Down & Adult Up
Grasp auricle with nondominant hand pull Down and Back from 6 - 9 posistion (Child)
Grasp auricle with nondominant hand pull Up and Back toward 10 posistion (Adult)
Normal intraocular pressure is _____ mm Hg
Greater than this range is associated with
Type of eye drops and side effect associated with them
10 - 21
Glaucoma
Prostaglandin (Change color of iris)
In ______ glaucoma, the increase in pressure is often small and slow.In _______ glaucoma, the increase is often high and sudden. Either type can damage the optic nerve
open-angle / closed-angle
After suctioning client with trach tube
Which finding indicates no further interventions are needed
Pulse ox changes 85 to 89
Resp rate drops from 24 to 16
Coughing out yellow sputum
Coarse breath sounds in anterior chest diminish
Resp rate drops.
Proper suctioning should produce a patent airway as Demonstrated by Resp Rate within norms
New onset confusion, headache, Bounding pulse been drinking copious amounts of water and voiding frequently
Which abnormal lab value is associated with these findings
Serum Sodium: 122 mmol/L
Norm (135 - 145 mmol /L)
Urine Specific Gravity: 1.041
Norm (1.003 - 1.035)
Serum Osmolality 325 mmol/kgH²O
Norm (275 -295 mmol/kgH²O)
Hyponatremia
Nurse would expect the Serum Osmolality & Specific Gravity to be LOW not HIGH
functional nursing, team nursing, primary nursing and total patient care
Are all types of…
Nursing care delivery systems
A task oriented approach to delivering care
Tasks are delegated to team members
Team members focus on their specific task - Instead of treating the whole patient
Functional Nursing
Led by RN team leader
Leader assigns patients to members of the team.
Each member is responsible for the individual patient care and outcomes
Team
Focus on keeping nurse at bedside
Actively involved in patient care
One nurse is responsible in managing care from admission to discharge.
Primary/ Relationship Based Practice
Nurse take total responsibility of planning and delivering care to patient for an Assigned Time Period
Total patient care approach/ Patient Focused Care
Urine output should be ____ in 24 hrs
20ml /h
When accessing a client’s incision one day after surgery a nurse sees redness and warmth around incision site.
Select best action
A. Culture the wound
B. Apply a cool compression
C. Assess for blanching
D. Note the wound edges in the client’s chart
D.
Warmth and redness are normal sign of inflammation and don’t require interventions.
Blanching would not demonstrate that there is a wound infection
Correct technique when applying an elastic bandage to a leg
A. Increase tension with each turn of the bandage
B. Start at distal end of extremity and move towards the trunk.
C. Secure bandage with clips over the area of the inner thigh
D. Overlap each layer 2 times when wrapping.
B.
Tension should be kept even to prevent circulation impairment
Overlapping can impairment circulation
Clips placed on the outer aspect of the leg to Avoid Pressure Point on Other Leg
Swelling around the eyes and in the feet and ankles
Foamy urine
Weight gain due to excess fluid retention.
Proteinuria and hypoalbuminemia Results in edema and hyperlipidemia
History of diabetes places client at risk
A kidney disorder that causes the body to excrete too much protein in the urine.
Nephrotic Syndrome
Urine culture and sensitivity test identifies….
Organisms in urine
Why apply a warm compress
Vasodilation/ Vasoconstriction
Vasodilation
Promotes circulation
Increase tissue metabolism
Leukocyte mobility
Why apply cold compress to an area
Vasodilation/ Vasoconstriction
Vasoconstriction
Prevent swelling
Why is a cather bag placed in a location below the bladder
To prevent back flow of urine into the bladder
To avoid injury, remember
The center of gravity is located…
At the Pelvis
Which is the correct way for a client to clean a tracheostomy dressing
A. Clean around the incision site, using gauze squares and full-strength hydrogen peroxide
B. Rinse around the clean incision site, using gauze squares moistened with normal saline.
C. Cleaning around the incision site, the client applies cotton-filled gauze squares as a sterile dressing.
B.
Use 50/50 hydro peroxide/ saline if crust are difficult to remove.
Don’t use cotton-filled gauze squares.
Use non-raveling material
When changing a sterile surgical dressing, a nurse first must
A. Wash hands
B. Put on sterile gloves
C. Remove old dressing while wearing clean gloves
D.Open sterile packages and moisten the dressing with sterile saline solution
A. Always wash hands first
Remove old dressing while wearing clean gloves
Put on sterile gloves
Open packages and moisten dressing with saline
Are all correct but come after
Before bronchoscopy (visualization of the trachea and bronchial tree) the Client is instructed what? Why?
After procedure The client is put in semi-Fowlers position
Not to eat 6 hours prior
Prevent aspiration
What is insensible fluid loss
Give examples
Fluid loss that is not easily measured
Respitory system, skin, stool
Use of Montgomery straps when changing a dressing is…
Prevent skin breakdown
The Montgomery straps work to hold dressing in place instead of Tape (which when removed will break skin down)
Proper position for AED pads
Right upper sternum
Left 5 / 6 intercoastal space left of anterior axillary line
Best way to communicate with client with a trachea tube
Does a trachea plug help?
Magic slate to write
No, a plug is used when being weaned off a trachea
First action to take when giving the client the wrong meds
Assess for potential allergies and vitals
Then, notify practitioner and charge nurse
What action can a nurse take to help minimize loss of calcium from clients bones.
A. Provide dairy products at frequent intervals
B. Supplemental feedings between meals
C. Encourage client to walk down hallway
C.
Calcium absorption diminishes with reduced physical activity
Due to decreased bone stimulation
Dairy products won’t help because
Additional calcium doesn’t increase bone stimulation or osteoblast activity
What should a nurse do to a client who presents to the hospital with anaphylaxis shock?
A. Admin Diphenhydramine
B. Insert IV
C. Admin metoprol
D. Have resp therapy provide Albuterol treatment
E. Monitor International Normalized Ratio IRN Level
A, B, D
While cleaning around a G-tube placed 1 week ago and changing the gauze dressing
Which type of Precautions are needed.
Sterile procedure, droplets Precautions
Clean procedure, universal Precautions
Clean procedure, contact Precautions
Sterile procedure, airborne Precautions
Clean procedure, universal Precautions
3 factors for radiation safety
Time, Distance, shielding
A blister is found on the heel of a patient with compression stockings.
What would be the correct next steps regarding this issue
How often does a nurse check skin in compression stockings
Discontinue for Discoloration, markings, or blisters in heel.
Notify provider
Sequential compression devices will be used instead to prevent DVT
Does massage increase or decrease blood flow to the area
Decrease
What is the purpose of a Time Out Procedure in the OR.
Review of client safety
Review surgical site markings
ID correct surgical procedure
Confirm clients name band
