SI exam review Flashcards
what is the nurses role in informed consent
witnessing
list the principles of basic aseptic technique
inch border
chest to table level, up 2 inches above elbow
all materials entering sterile field must be sterile
can’t cross over field with a contaminated object
what is malignant hyperthermia
rare metabolic disease that causes rigidity of muscles
what medication would the nurse give if the patient is experiencing malignant hyperthermia during surgery
dantrolene
you are caring for a patient who is coming out of anesthesia what are your priority assessments
airway
breathing
circulation
what is steroteyping
viewing member of a culture, race or ethnic group as being alike and sharing all the same beliefs
what is the most reliable indicator of pain
patients self report
post surgery drainage is expected to change from
sanguinous to serosanginus to serous
red to pink to clear
what if your patient is a chinese women and you re unsure of their cultural preference what do you do
ask
what four things does cultural competence consist of
skill
knowledge
awareness
encounter
in community based nursing care is directed to
individuals, families, and communities
in prochaska change theory, if a person is planning for a change they are in stage
preparation
if a person is deomstrating a newly learned task what learning domain in blooms taxonomy is this
psychomotor
what is a communicating fracture
open fracture with external envionrment
what is a comminuted fracture
2 or more fragment from a crushing injury
what is the cardinal sign of a fracture
deformity
what is traction
pulling force on a distal fragment to maintain it with a proximal fragment
what are the 6 ps of compartment syndrom
pain pressure pallor pulselessness peristhesia paralysis
what are some s/s of a hip fracture
external rotation tenderness/severe pian limited mobility leg could be shorter muscle spasms
what are two medication that my be used for anticoagulant therapy
warfarin
enoxapairin
if the use is suspecting a fat embolism in her patent what is one s/s that sets it apart from a pulmonary embolisms
petechiae
neck and chest
if your patient is expierincg compartment syndrome would you elevate the extremity
no
what role does enoxaparin (lovenox) play in clotting cascade
prevent the conversion of fibrinogen to fibrin
prothrombin to thrombin
warfarin (coumadin) mediation is to be taken at what part of the day
afternoon around 4 p.m same time every day
what vitamin would a patient on warfarin not want to consume too much of
vitamin K leafy greens green tear prunes blueberries
if your patient is on both enoxaparin and warfarin and their INR is 2.o what will you do
stop the enoxaparin
what is an INR
person ability to clot
what is the normal range of an INR
less than 1.1
what are the 3 phases of wound care
inflammatory
proliferative
remodeling
which phase of wound care is the retraction and scarring phase
remodeling
_____ and the _____ are both part of the inflammation phase
vascular response and cellular response
the vascular response begins ____ minutes after an acute injury occurs
10
T/F the growth facts are the most important cell of the vascular response
false, platelets are the most important because they stimulate growth factor
does histamine vasodilate or vasocontrict
vasodilate
what creates pus, this usually occurs 6-8 hours post injury
neutrophils
what is a shift to the left
a lot of immature neutrophils
what are the two kinds of healing processes and which is easier of the body to do
regenreation and repair
regeneration is easiest t
what is an example of a body part that goes under regenration
tongue
a partient has just come out of knee replacement surgery and has staples holding the incision closed, what type of intention is the patients would healing by
primary
what kind of intention is used when a wound that is brought together once and infection has cleared
tertiary
a patient presents to the emergency room with a gunshot wound in his arm, how ill the nurse anticipate this would will heal in terms of intention
secondary
T/F when a wound is healing in the proliferative stage, new capillary networks are being formed this a a very fragile stage
true
you should asses your patients ____ 30 mins prior to doing wound care
pain
you notice in your patients labs that he has a WBC count of 15,000 what is this called
leukocytosis
what is the norma range for white blood cells
5,000 to 11,000
what is is called if your patient WBC count is below 5,000
leukopenia
when is a wound consider chronic
no specfic time frame of healing
a ______ is when a disruption occurs in previously joined wound edges
dishescense
what are things that can cause a dehiscence
infection obesity coughing albumin levels under 3. 5 jerky movments poor nutritional status
what is an evisceration
medical emergecny
bowel protrude through incision
what are the steps to take with evisceration
ask for sterile dressing and normal saline
put heat of bed up to relieve pressure
call surgeon
pour saline on top, put dressing on abdomen
put ABD on top keep it moist
patient have IV and NPO
how many stages of pressure ulcers are there
6
what is normal albumin levels
3.5-5
what is one of the most important roles of the nurse
prevent tissue injury
the c reactive protein is indicative of infection what is a normal range
0-10
wounds can be classified by 3 colors
red yellow black
does your patient understand his discharge teaching when he states “ my wound is classified as red meaning at home i should use hydrogen peroxide to keep it free of infection
no too harsh, red wound very delicate use saline or tape water
you are getting ready to care for a patient with a yellow wound and 75% slough on it, what can the nurse anticipate she will use
vinegar or acidic acid if 60% or greater slough
T/F your patient has a black found on his right elbow with eschar on it. you should lan to clean the wound first then remove the eschar
true
what body part would you not want to remove eschar from
the heel because is already has less circulation
your patient is using leech therapy on a wound, this is a form of ______debridement
biological
if you are planning to use shape debridement on a wound, what will you expect to see. when would a nurse anticipate using this method
blood, only use if wound is chronic
T/F a culture is required prior to using antimicrobial
false
a _______dressing forms a soft, gel that absorbs when it comes into contact with would exudate
calcium aginate
your patient ate breakfast 5 hours ago and has a blood glucose reading of 135mg/dL
normal
fed state with a blood glucose reading of 210mg/dL
diabetes
fasting state with a blood glucose of 92 mg/dL
normal
fed state with a blood glcouse of 110mg/dL
normal
fasting state with BG of 135 mg/dL
diabetes
fasting state with BG 119mg/dL
pre diabetes
your patient ate dinner at 7pm the next morning at 7 am she checks her blood sugar prior to eating breakfast and has a reading of 105 mg/dl
pre diabetes
what is normal fasting state BG
less than 100
what is pre diabetes fasting state BG
greater than or equal to 100
less than 126
what is diabetes fasting state BG
greater than or equal to 126
what is normal fed state BG
less than 140
what is pre diabetes fed state BG
less than 200
greater than or equal to 140
what is diabetes fed state BG
greater than or equal to 200
during morning rounds you notice your patient is showing sign of reduced condition and very grumpy, he is sweating, without taking his blood sugar what do you anticipate your patient is expiericngin
hyporglycemia
what are the s/s of hyperglycemia
the polys dehydration weightloss fatigue fruity odor to breath poor wound healing
insulin resistance starts at a BMI of ___ what race is an exception to this and why
25
asian is 23 bc due to where they carry adipose tissue
what 3 anabolic things happen in the body after a meal
stimulates storage of flcuose as glycogen in liver/muscle
enhances fat deposit in adipose tissue
promotes protein syntheis
what is the purpose of the counter regularly hormones
oppostie action of insulin
what are the count regulatory hormones
glucagon
epinephrine
growth hormone
cortisol
T/F counterregulatory hormones decrease glucose levels
false
what are incretins and why are they important
hormones that secrete insulin secretion in repose to meal
type 2 have a deficiency
taking what we know about incretins, why would carbohydrates taken orally work quicker to secrete insulin than when given IV
because IV drugs bypass the GI tract
type1/type2 will experience the honeymoon period
type 1
type 1/type2 require exogenous insulin to live
type 1
what are some characteristics of type 2
delayed onset, geneticc, obesity
what are some symptoms of type 2
poly plus fatigue, visual changes because dehydrated
T/F the higher someone blood sugar the more dehydrated they are
true
is type 1/type2 ketosis resistance
type 2
recommendaton to prevent or delay the onset of type 2
150 min/week physical activity
weight loss of 7% body weight
healhty diet
health belief model predicts behavior based on what 4 factors
precieved illnes from a threat
belief threat has serious or nonserious consequences
belief is that required recommendation will be effective
belief that there are a few barriers
what are the 5 goals of nutritional therapy
near normal blood sugars optinmum serum lipid levels reasonable weight revention/treatment of acute/chronic complications improvemnnts of overall health
which type of diabetes should not drink alochol
they both care but people with type 1 should eat while drinking
exercise can lead to hypoglycemia if your patient has type 1 what should you recommend they do prior to working out
check BG levels and if low eat 15 g of carbs before
the goal of diabetes is
euglycemia
what are some SMBG goal for control
80-130 before meals
100-140 bedtime
goal of A1C is 7%
you go into your patients room and notice that she is displaying shakiness, is confused and irritable with slurred speech what you doh suspect is happening g
hypoglycemia
risk factor for diabetes
overwight
physical inactive
high risk race
first degree relative
s/s of hypoglycemia
tremors, reducted cognition diaphysis- sweating hunger weakness heacache seizure iritabiltly coma/death
