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Nursing Fundamentals > Skills- Exam 2 > Flashcards

Skills- Exam 2 Flashcards

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1
Q

The abdomin can be divides ino

A

4 Quadrant
9 Regions

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2
Q

bruits

A

unusual bowel sound

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3
Q

While in supine position, you should inspect the abdomen for?

A

-Size, shape, and symmetry
-Color lesion and scars
-Movement, respiratory, and peristalsis
-Umbilicus position, contour, or bulging

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4
Q

Abdominal Distension

A

swelling

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5
Q

How should ear plugs of a stethoscope be positioned?

A

toward your nose

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6
Q

Diaphragm

A

high-pitched sounds
(breath & bowel sounds)

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7
Q

Bell

A

low-pitched sounds
(Blood pressure & apical pulse & bruits)

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8
Q

Using a stethoscope

A

-lightly wet chest hair
-Quiet environment
-Warm stethoscope
-Skin to scope
-Close eyes

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9
Q

When listening for bowels sounds, where should you start? And why

A

RLQ
thats where digestion starts

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10
Q

What should you do before saying bowels sounds are absent?

A

Listen for at least 5 mins. each quadrant

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11
Q

Absent-Bowel sounds

A

no bowel sounds

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12
Q

Hypoactive-Bowel sounds

A

soft
infrequent
>20 seconds

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13
Q

Normal-Bowel sounds

A

high-pitched, gurgling
irregular
1-4 sounds heard in 20 seconds

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14
Q

Hyperactive-Bowel sounds

A

high-pitched, rushing, tinking sounds

diarrhea/early intestinal obstruction

> 4 sounds in 20 seconds

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15
Q

Where to auscultate for the bruits?

A

Aorta
Renal
Iliac
Femoral

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16
Q

How to palpate for tenderness?

A

light palpation

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17
Q

Enema

A

solution introduced into the rectum and large intestine

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18
Q

The point of an Enema

A

to distend intestine and increase peristalsis and excretion

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19
Q

Types of enemas

A

FLEETS-hypertonic solution (90-120ml) for 5-10 mins
TAP WATER-hypotonic (500-1000ml) for 15-20 mins
RETENTION-oil solution (90-120ml) for 30mins-3hrs
SOAP SUDS-3-5ml soap (500-1000ml) for 10-15 mins
ISOTONIC-0.9 Normal Saline (500-1000ml) for 15-20 mins.

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20
Q

Can a client administer their own enema if they want to?

A

Yes

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21
Q

Bowel Diversions

A

Watery –> firm

Ileostomy
Ascending Colostomy
Transverse Colostomy
Descending Colostomy
Sigmoidostomy

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22
Q

How often should the ostomy faceplate be changed?

A

Once a week

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23
Q

What can help control odor from ostomy?

A

Charcoal filters
Diet change
Sprays for room

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24
Q

Enteral

A

of or relating to the intestines

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25
Q

Enteral Tubes

A

Nasogastric
Nasoduodenal
Nasojejunal
Gastrostomy
Jejunostomy

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26
Q

Gastrointestinal Suction

A

-relieves abdominal distention
-maintains gastric decompression after surgery
-removes blood and secretions from the gastrointestinal tract
-maintains the patency of the NG tube

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27
Q

If any pain of abdomen when should you palpate that area?

A

Last

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28
Q

Gastric Secretions

A

grassy green/off white/tan
pH 1-4

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29
Q

Intestinal Secretions

A

golden yellow/brownish-green
pH = to or > 6

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30
Q

Respiratory Secretions

A

more alkaline
7 or greater

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31
Q

Gastrointestinal Suction

A

Confirm placement
Assess function
Maintain patency with irrigation
Maintain mouth care

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32
Q

Removing a Nasogastric Tube

A

Assess abdomen
-check for bowel sounds
-check for flatus
-check for nausea & vomiting

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33
Q

Enteral Feeding

A

the introduction of nutrients directly into the GI tract by a feeding tube

34
Q

Percutaneous Endoscopic Gastrostomy (PEG) Tube

A

surgically installed

35
Q

Types of Enteral Feedings

A

OPEN only 4-8hrs
(Powders/Cans)
CLOSED 24-48 hrs
(ready to hang)

36
Q

Tube Feeding bag and tubes should be changed?

A

every 24 hrs/change daily

37
Q

Continuous Feeding

A

-Specific amount & rate of formula over 18-24hrs
-recommended by dietician
-well tolerated by patient
-Inhibits mobility and ADLs

38
Q

Intermittent Feeding

A

-300-500ml of formula several times per day over atleast 30 minutes
-administered by syringe/gravity
-check for residual before every feeding
-not always tolerated by patient
-promotes mobility & ADLs

39
Q

CAUTI

A

Catheter Associated UTI

40
Q

Why do people need urinary catheterization?

A

-Incontinence
-Urinary retention
-Difficulty voiding after surgery
-During long surgical procedures
-Measuring accurate I&O

41
Q

What are catheters measured in?

A

French (fr) scales

42
Q

Catheter sizing:

A

8-10 French = children (3ml ballon)

#14-16 French = women (10 ml ballon)
#18 French = men (10 ml ballon except prostate procedures, 30 ml)

43
Q

Supra-Pubic Catheter

A

surgically inserted by doctor

44
Q

Venous vs. capillary Blood glucose

A

Venous- blood draw (should not be done for morning)
Capillary- Finger stick

45
Q

Normal Blood Sugar Ranges

A

Adults & Children >2 = 70-99mg/dl
Infants= 40-90mg/dl
Neonates= 30-60 mg/dl

46
Q

Blood glucose in adults

A

Normal = 70-99mg/dl
Impaired = 100-125mg/dl
At risk for diabetes = >126 mg/dl

47
Q

Type I vs Type II Diabetes Mellitus

A

Type I = Insulin dependent (born with it/genetics)
Type II = Non insulin dependent (adult onset)

48
Q

Hyperglycemia

A

High blood sugar
>140mg/dl

Symptoms:
-Extreme thirsts
-Frequent urination
-Dry skin
-Hunger
-Blurry vision
-Drowsiness
-Nausea

49
Q

Hypoglycemia

A

Low Blood Sugar
<70 mg/dl

Symptoms:
-Shaking
-Fast Heartbeat
-Sweating
-Anxious
-Impaired vision
-weakness/fatigue
-Hunger
–Drowsiness
-Headache
-irritable

50
Q

Glycosylated Hemoglobin
(Hmg A1c or A1C or Hgb A1C)

A

Normal = 4%-5.6%
Increased risk = 5.7%-6.4 %
Diabetes = 6.5% or higher (Goal is <7%)

Testing occurs 3-4x /year

51
Q

Clean Void Urine Specimen

A

Used for routine examination
First am void (10ml)

52
Q

Clean catch/Midstream Specimen

A

Used for possible UTI/ culture
void-stop-void into sterile container (30ml, need 3 ml for culture)

53
Q

Timed Urine Specimen

A

24 hour urine collection

Same container for all urine
Kept on ice
send to lab at 24 hrs

54
Q

Indwelling Urine Catheter Specimen

A

-Clamp Foley Catheter 30 mins before collecting sample
-Don’t for

55
Q

Orthopnea

A

Need to sit/stand to breath comfortable

56
Q

Tachypnea

A

abnormal breathing
rate >20

57
Q

Dyspnea

A

difficulty breathing

58
Q

Apnea

A

no breathing

59
Q

Hyperventilation

A

increased rate/depth

rate >20

60
Q

Eupnea

A

normal breathing

61
Q

Lobes of the lungs

A

2 Lobes on the Left
3 Lobes on the right

(BC of position of heart)

62
Q

Normal Breath Sounds

A

Vesicular
Bronchovesicular

63
Q

Adventitious Breath Sounds

A

Wheezes (whistling)
Crackles/Rales (fire)
Gurgles/Rhonchi -may clear w/ coughing
Friction rub (leather)

64
Q

Wheeze

A

(whistling)
expiratory

65
Q

Friction rub

A

(leather)
inspriation & expiration

66
Q

Crackles/Rales

A

(fire)
soft/high pitched

67
Q

Gurgles/Rhonchi -may clear w/ coughing

A

Low
Expiratory

68
Q

Vesicular

A

Soft/low pitched

69
Q

Bronchovesicular

A

Medium pitch

70
Q

Stridor

A

Medical Emergency

suggests obstructed trachea/ larynx

71
Q

Early Signs of Hypoxia/Hypoxemia

A

-Rising vital signs
-Irritability
-Headache
-Agitation
-Confusion

72
Q

Late Signs of Hypoxia/Hypoxemia

A

-Falling Vital Signs
-Seizures
-Coma
-Brain Tissue Swelling

73
Q

Pulse Oximetry

A

noninvasive device that measures the arterial blood oxygen by saturation

74
Q

Why use a Peak Flow Meter?

A

-Assesses if medication is working
-Evaluate when to add or stop medicine
-Decide when to seek emergency care

75
Q

Peak Flow Zones

A

Green = 80-100% Good control
Yellow = 50-79% Asthma is getting worse
Red = Below 50% Seek help STAT

76
Q

Nasal Cannula

A

1-6 liters/min
Oxygen concentration of 24-40%

77
Q

Simple Face Mask

A

6-10 liters/min
Oxygen concentration of 40-60%

78
Q

Non-Rebreather Mask

A

10-15liters/min
Oxygen concentration of 95-100%

79
Q

Advair

A

DPI= dry powder inhaler

should not be taken more than twice a day

breath quickly and deeply

80
Q

Nebulizer

A

-used to deliver humidity & medication
-for patients who can not use MDI/DPI
-children under 5
-patients with severe asthma

81
Q
A

Nursing Fundamentals (12 decks)

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