Saunders- NCLEX Flashcards
Triage Levels
Emergent (red):
Immediate threat to life, requires immediate tx and continuous evaluation
ex) trauma, chest pain, severe respiratory distress or cardiac arrest, pt w/ limb amputation, pt w/ acute neurological deficits, chemical splashes to eyes
Urgent (yellow):
not life-threatening if treated w/in 1-2 hours, require continous evaluation every 30-60 min thereafter
ex) simple fracture, asthma w/o respiratory distress, fever, HTN, abdominal pain or renal stone
Nonurgent (green):
local injuries w/o complications and can wait several hours for medical tx, require evaluation every 1-2 hrs after.
ex) minor laceration, sprain, or cold symptoms
Dead or dying (black):
injuries to severe to benefit from care
Type of Leader
Autocratic:
- focused, maintains strong control, makes decisions, and addresses all problems.
- dominates the group and commands, rather than seeks suggestions or input
Situational:
- use a combo of styles based on needs of group and the tasks to be achieved
- work w/ the group to validate that the info gained is accurate and problem exists
- Take time to get to know the group
Democratic:
- participative, and would likely meet w/ each staff person individually to determine the staff member’s perception of the problem
- speak w/ staff about any issues and ask for input with developing a plan
Laissez-faire:
- passive and nondirective
- state what problem is and inform the staff that they needed to come up with a plan to “fix it”
Guidelines that the nurse should use when delegating and planning assignments
- ensure client safety
- be aware of individual variations in work abilities
- determine which tasks can be delegated and to whom
- match the task to the delegatee on teh basis of nurse practice act and appropriate position descriptions
- provide directions that are clear, concise, accurate, and complete
- validate the delegatee’s understanding of the directions
- communicate a feeling of confidence to the delegatee
- provide feedback promptly after the task is performed
- maintain continuity of care as much as possible when assigning pt care
Normal osmolality of plasma
270 - 300 mOsm/gk water
Osmolality refers to the number of osmotically active particles per kg of water; concentration of a solution
Hypotonic solution
when a solution contains a lower concentration of salt or solute than another, more concentrated solution
1/2 NS, 1/3 NS, 1/4 NS
- has less salt, and more water than isotonic sol’n
- lower osmolality than blody fluids
- WATER LEAVES SOL’N (vascular space) and ENTERS CELLS VIA OSMOSIS
Hypertonic solution
has higher concentration of solutes than another, less concentrated solution
3% NS, 5% NS, D10W, D5W with NS
- fluid pulled out of the cells
Electrolyte imbalance affect on ECG: wave changes
Hypocalcemia:
- prolonged ST segment
- prolonged QT interval
Hypercalcemia:
- shortened ST segment
- widened T wave
Hypokalemia:
- ST depression
- Shallow, flat, or inverted T wave
- Prominent U wave
Hyperkalemia:
- tall peaked T waves
- Flat P waves
- widened QRS complex
- prolonged PR interval
Hypomagnesemia:
- tall T waves
- depressed ST segment
Hypermagnesemia:
- prolonged PR interval
- widened QRS complexes
Absent P waves
atrial fibrillation
junctional rhythms
ventricular rhythms
Foods high in sodium
bacon
butter
canned food
cheese
frankfurters
ketchup
lunch meat
milk
mustard
processed food
snack food
soy sauce
table salt
white and whole-wheat bread
Foods high in Potassium
avocado
bananas
cantaloupe
carrots
fish
mushrooms
oranges
potatoes
pork, beef, veal
raisins
spinach
strawberries
tomatoes
Foods high in Calcium
cheese
collard greens
milk and soy milk
rhubarb
sardines
spinach
tofu
yogurt
(fruit doesn’t seem helpful)
Foods high in magnesium
avocado
canned white tuna
cauliflower
green leafy vegetables (spinach and broccoli)
milk
oatmeal, wheat bran
peanut butter, almonds
peas
port, beef, chicken, soy beans
potatoes
raisins
yogurt
(fruit doesn’t seem helpful)
Foods high in phosporus
fish
pumpkin, squash
nuts
pork, beef, chicken, organ meats
whole-grain breads and cereals
dairy products
(fruit doesn’t seem helpful)
Normal Electrolyte levels
Sodium 135- 145
Potassium 3.5- 5.0
Calcium 8.6- 10
Magnesium 1.6- 2.6
Phosphorus 2.7- 4.5
signs of fluid volume deficit
increased respirations and HR
decreased CVP
weight loss
poor skin turgor
dry mucous membranes
decreased urine volume
increased urine specific gravity
increased hematocrit
altered LOC
causes of FVD
vomiting
diarrhea
conditions that cause increased respirations
conditions that cause increased urine output
insufficient IV replacement
draining fistula
presence of ileostomy or colostomy
causes of fluid volume excess
decreased kidney function
heart failure
use of hypotonic fluids to replace isotonic fluid losses
excessive irrigation of wounds and body cavities
excessive ingestion of sodium
pt taking diuretics
pt with an ileostomy
pt who requires GI suuction
Causes of respiratory acidosis
PRIMARY DEFECTS IN THE FUNCTION OF THE LUNGS OR CHANGES IN NORMAL RESPIRATION PATTERNS
Any condition that causes an obstruction of the airway or depresses the respiratory system
asthma
atelectasis
brain trauma
bronchiectasis
bronchitis
central nervous system depressants
emphysema
hypoventilation
pneumonia
pulmonary edema
pulmonary emboli
Causes of respiratory alkalosis
CONDITIONS THAT CAUSE OVERSTIMULATION OF RESPIRATORY SYSTEM:
fever
hyperventilation
hypoxia
hysteria
overventilation of mechanical ventilators
pain
PT and INR
for warfarin therapy
PT: 9.6 to 11.8 seconds (male adult); 9.5 to 11.3 seconds (female adult)
**PT should be 1.5 to 2x the labortory control value
INR: 2 to 3 for standard warfarin therapy
INR: 3 to 4.5 for high-dose warfarin therapy
BLEEDING PRECAUTIONS IF PT > 30 sec
aPTT
for heparin therapy
aPTT: 20 to 36 seconds, depending on the type of activator used
- **should be between 1.5 and 2.5 times normal when the client is receiving heparin therapy (so not less than 30 or greater than 90sec)*
- **BLEEDING PRECAUTIONS IF > 90sec*
serum GI lab studies
Albumin: 3.4 - 5
Ammonia: 10-80
ALT: 10-40
AST: 10-30
Amylase: 25-151 (chronic pancreatisis, level not to exceed 3x normal/ acute can be 5x normal)
Lipase: 10-140
Cholesterol: 140-199
LDLs: lower than 130
HDLs: 30-70
Triglycerides: lower than 200
Protein: 6-8
Total bilirubin: lower than 1.5 (pt with liver dz have prolonged clotting times and need prolonged pressure on punctures site)
Renal Function lab studies
serum Creat: 0.6-1.3 (increased levels indicate slowing glomerular filtration rate)
BUN: 8 -25 (increased level can indicate dehydration, below normal may be caused by FV overload)
WBC
WBC: 4500 - 11000
Differential: info on specific white blood cell types
“shift to the left” means that an increased number of immature neutrophils is present in the blood
normal Digoxin level
0.5 - 2.0
Troponin level that indicates a MI occured
troponin T value that is higher than 0.1 to 0.2 ng/mL
HgbA1c
Good control: 7% or less
Fair control: 7% - 8%
Poor control: 8% or higher
Signs of hyperglycemia
excessive thirst
fatigue
restlessnes
confusion
weakness
Kussmaul’s respirations
diuresis
coma (when severe)
6 rights of medication administration
Intervention for air embolism
- clamp tubing
- turn pt on left side w/ HOB lower than feet to trap air in rt atrium (trendelenburg)
- notify HCP
autonomic dysreflexia
overstimulation of nervous system
signs of infection
Local:
redness, swelling, and drainage at site
Systemic:
chills, fever, malaise, h/a, N/V, backache, tachycardia
signs of infiltration
edema, pain, coolness at site
may or may not have blood return
(from seepage of IV fluid out of vein)
signs of phlebitis
heat, redness, tenderness at the site
not swollen or hard
intravenous infusion sluggish
(from mechanical or chemical/medication trauma or from a local infection that causes inflammation)
sign of thromobplebitis
hard and cordlike vein
heat, redness, tenderness at site
IV infusion sluggish
sign of circulatory overload
increased BP
distended jugular veins
rapid breathing
dyspnea
moist cough and crackles
signs of catheter embolism
decrease in BP
pain along the vein
weak, rapid pulse
cyanosis of the nail beds
loss of consciousness
proper documentation
Document the occurence, actions taken, and pt’s response
signs of hypoxemia
signs of pulmonary embolism
sudden dypsnea
sudden sharp chest or upper abdominal pain
cyanosis
tachycardia
a drop in BP
LIFE THREATENING AND REQUIRES EMERGENCY ACTION
signs of hemorrhage
restlessness
weak and rapid pulse
hypotension
tachypnea
cool, clammy skin
reduced urine output
CAN LEAD TO SHOCK!!!
signs of wound infection
REEDA
redness
erythema
ecchymosis
drainage
approximation of wound edges
autonomic dysreflexia
sudden onset of excessively high BP
