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Nur 114 > Test 4 > Flashcards

Test 4 Flashcards

1
Q

Difficulty swallowing or the inability to swallow

A

Dysphagia

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2
Q

The misdirection of oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract

A

Aspiration

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3
Q

For aspiration precautions which position should the patient sit in if receiving food orally?

A

Fowlers position

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4
Q

For aspiration precautions how should the patient be sitting for enteral feeding tube feeding

A

Semi fowler

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5
Q

for enteral food feeding what is the rationale for lowering the feeding

A

so that the patient does not aspirate

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6
Q

what do you for enteral or ng feeding first?

A

check residual because of vomiting

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7
Q

What are the assessments for dysphagia?

A

fever pnemonia coughing crackling in lung fields

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8
Q

gradual feeding on a timed pump

A

continuous

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9
Q

is a feeding that is giving all at once

A

bolus

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10
Q

How many mL of water are you supposed to flush after feeding?

A

30 mL

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11
Q

feeding that hangs like an IV can be made faster or slower depending of the position of the bag

A

gravity

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12
Q

feeding tube placed in opening of stomach

A

gastrostomy (peg) tube

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13
Q

Why is a PEG tube the best option and what clients is it ideal for ?

A

less risk for regurgitation and aspiration ; comatose

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14
Q

For gastrostomy (PEG) tube is it for short term or long term?

A

long term

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15
Q

What assessments would you do before a gastronomy (PEG) tube?

A

bowel sounds, vomiting, nausea, diarrhea

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16
Q

For a gastrostomy peg tube what should you do to ensure nothing is left behind and that it doesn’t get impacted

A

flush tube before and after feedings

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17
Q

Before inserting an NG tube what should you do?

A

assess for nasal obstructions and tissue irritation around nares

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18
Q

How do you check the placement of NG tube?

A

flush tube with air then withdrawal gastric fluid (check color consistency then put back in stomach then flush with 30 mL of water)

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19
Q

Steps for administering medication through enteral tube

A

Check medication order ( 3 checks)
gather materials
Aspirate residual then return it to stomach
flush 20 ml –> admin meds flush 5 mL between meds

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20
Q

Nursing process in promoting adequate nutrition

Assessment

A

assess for dietary data, bmi

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21
Q

Nursing process in promoting adequate nutrition

Analyze:

A

Analyze lab results and identify nutritional problem

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22
Q

Nursing process in promoting adequate nutrition

Planning/Outcome:

A

should be a SMART goal in filling nutritional void or keeping from an excess of nutritents through modified diets

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23
Q

Nursing process in promoting adequate nutrition

Implement:

A

teaching on nutritional information/rationale and modified diet

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24
Q

Nursing process in promoting adequate nutrition

Evaluation:

A

monitor nutritional status if goal is being reached

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25
Q

Requires minimal digestion and leaves minimal residue, includes coffee tea clear fruit juices clear broth gelatin popsicles

A

clear liquid diet

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26
Q

known as blenderized diet because the diet is made up of liquids and foods blenderized to liquid form all foods are allowed

A

pureed diet

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27
Q

regular diet with modifications for texture excludes most raw fruits and veggies foods are chopped ground mashed or soft

A

mechanically altered food

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28
Q

Protein lab range

A

240-480 mg/dl

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29
Q

Albumin lab range

A

3.5-5.5 g/dL

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30
Q

prealbumin range

A

23-43 mg/dL

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31
Q

iron normal range

A

12-18 g/dl

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32
Q

creatinine noraml range

A

0.4-1.5 mg/dl

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33
Q

decreased protein leads to?

A

anemia and protein deficency

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34
Q

decreased orealbumin leads to

A

malnutrition and protein depletion

35
Q

increased creatinine means

A

dehydration

36
Q

decreased creatinine means

A

severe malnutrition

37
Q

measure of density of chemicals and particles in urine

A

specific gravity

38
Q

Higher than normal specific gravity can indicate dehydration

A

concentrated urine

39
Q

lower than normal specific gravity can indicate overhydration

A

diluted urine

40
Q

discomfort when urinating

A

dysuria

41
Q

excessive urine output

A

polyuria

42
Q

strong desire to void

A

urgency

43
Q

involuntary loss of urine

A

urinary incontinence

44
Q

abnormally small amounts of urine

A

oligoria

45
Q

pus in urine

A

pyuria

46
Q

increase incidence of voiding

A

frequency

47
Q

for single use taken out immediately after use

A

straight catheter

48
Q

empties into bag that can attach to leg bed or wheel chair

A

indwelling (foley) catheter

49
Q

bladder does not completely empty with urination

A

urinary retention

50
Q

what are the assessments for urinary retention?

A

difficulty urinating, paid adominal distension, frequency

51
Q

from coughing sneezing laughing

A

stress incont

52
Q

strong need to urinate bu leaking occurs before client get to toilet

A

urge incont

53
Q

leakage as a result of nerve damage

A

reflex

54
Q

incomplete bladder emptying that results in the bladder overfilling when full leads to leakage

A

overflow

55
Q

physical inability to reach toilet in time (wheelchair bound, arthritis)

A

functional incont

56
Q

common in children but can occur in adults who have consumed too much alcohol

A

nocturnal enuresis

57
Q

ways to promote bowel elimination

A

high fiber diet
laxatives if needed
enemas if needed
mobility

58
Q

what are you looking for during an adominal assessment?

A

tenderness distension bowel sounds in all 4 quads

59
Q

what re the risk factors of constipation?

A

age immobility low fiber diet hydration status mediations

60
Q

what are different types of interventions for constipation

A

high fiber diet ecercise hydration bowel training stoool sofentig meds

61
Q

this enema soften stools and is used for constipation

A

retntion

62
Q

this enema has castile soap and is water based

A

cleansing enema

63
Q

is a type of laxative that encourages peristalsis

A

stimulant

64
Q

type of laxative that adds water to fecal matter in the gi tract to reduce compaction (colace)

A

stool softener

65
Q

type of laxative that is not fdigested absorbe liquid to form soft bulky stool used to treat diarrhea

A

bulk forming

66
Q

0.9% NaCl iv solution

A

isotonic

67
Q

lacatated ringer solutionq

A

isotonic

68
Q

5% dextrose in lactated ringer (d5lr)

A

hypertonic

69
Q

0.33% NaCl normal saline iv soulution

A

hypotonic

70
Q

0.45% NaCl

A

hypotonic

71
Q

FLuid volume excess

A

hypervolemia

72
Q

isotonic loss of water and solute lack of BV less blood prefusses to organs

A

hypovelemia

73
Q

s & s includes edema weight gain crackles in lungs tachypnea dysphagia

A

hypervolemia

74
Q

s & s includes dry mucous membranes excessive thirst dark urine tachycardia but low BP

A

hypovolemia

75
Q

isotnic overload of water and solute bv is excessive fluid overload

A

hypervolemia

76
Q

fluid excess in interstitial space

A

edmea

77
Q

what is an intervention for edema

A

eleavte swollen area of body if possible

78
Q

more water is taken into the body that Na+

A

overhydration

79
Q

normal level for Na

A

136-145 mEq/L

80
Q

normal level for K

A

3.5-5 mEq/L

81
Q

normal level for Ca

A

9.0-10.5 mEq?L

82
Q

normal level for Mg

A

1.3-2.1 mEq/L

83
Q

Muscle weakness leg cramps fatigue dysrhythmias

A

Hypokalemia

Nur 114 (9 decks)

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