Reduction of Risk Potential Flashcards

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1
Q

What is the most appropriate comparison for vital signs: the standard acceptable ranges or the client’s baseline?

A

the client’s baseline

If the client has a baseline that is higher than the standard acceptable range, a vital sign reading considered high may actually be acceptable for the client.

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2
Q

Kidney function is best assessed using which laboratory value?

A

creatinine

While both BUN & creatinine are collected when testing kidney function, creatinine is more indicateive of kidney failure. BUN alone is not significant but should be used in conjunction with creatinine results.

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3
Q

When is a glucose reading most accurate & indicative of glucose homeostasis?

A

when fasting

A fasting glucose reading is most indicative of glucose homeostasis as glucose levels naturally rise after meals & fall as the pancreas secretes insulin.

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4
Q

Which group typically has a higher concentration of red blood cells in the blood, males or females?

A

males

The normal range for hematocrit is higher for males compared to females. This also leads to higher normal ranges for hemoglobin

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5
Q

For a client who is having a heparin drip started, what is the most critical lab value to monitor?

A

aPTT

When starting a heparin drip, aPTT tests are performed typically Q6H so that the client’s response to the dose can be measured & the dose can be adjusted if needed.

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6
Q

___ is the most appropriate laboratory test to assess for diabetes mellitus.

A

HgbA1C

When diabetes is suspected, a test of the client’s hemoglobin A1C (HgbA1C) will determine long-term control of the client’s glucose levels. A normal HgbA1C ranges between 4 & 5.6%. Levels greater than 6-4% can be indicative of poor glucose control due to diabetes.

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7
Q

What segment of the EKG waveform indicates ventricular repolarization or relaxation?

A

ST segment

The ST segment is the segment between the QRS-complex & the T-wave, & it represents the time where the ventricles are relaxing or repolarizing to prepare for the next contraction.

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8
Q

What is the expected time for capillary refill in a healthy client?

A

less than 3 seconds

If the client’s capillary refill is greater than 3 seconds, they may have impaired circulation to that limb.

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9
Q

Which cranial nerve is responsible for visual acuity?

A

Cranial Nerve II

Cranial Nerve II is the optic nerve, & it is responsible for vision & visual acuity.

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10
Q

The client has been diagnosed with a UTI, & the primary care provider has ordered Bactrim & a urine culture. Which should be completed first, the medication administration or the urine culture?

A

the urine culture

The urine culture should be collected prior to administering Bactrim, since Bactrim may alter the test results.

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11
Q

When administering medication through a nasogastric tube, when should the tube be irrigated?

A

prior to & following medication administration

To check for tube placement & maintain patency of the nasogastric tube, the tube should be irrigated both prior to & following medication administration.

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12
Q

Is suctioning of a tracheostomy tube a sterile procedure, clean procedure, or a dirty procedure?

A

sterile procedure

Due to the infection risk that could lead to pneumonia, suctioning of a tracheostomy tube is a sterile procedure. Sterile technique must be maintained to keep this risk as low as possible.

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13
Q

Are all clients required to be NPO prior to a surgical procedure?

A

no

The necessity for the client to be NPO is dependent upon the planned anesthesia type for the procedure. For a client undergoing general anesthesia, NPO is required to prevent aspiration. However, if the procedure will be done under local anesthesia, the client may not be required to be NPO.

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14
Q

Nurses should encourage post-operative clients to reach a target volume of ___ when using an incentive spirometer.

A

600-900

Following surgery, the client will use the incentive spirometer to encourage a return to baseline of the respiratory system. When using the incentive spirometer, the client should be instructed to inhale slowly & consistently, aiming for a value between 600-900.

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15
Q

How often should the injection caps on the lumen of a central venous access device be changed?

A

7 days or anytime there is leakage

For a client with a central venous access device, the injection caps should be changed every 7 days or when there is a leak.

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