FINAL EXAM NURSING 131

types of antioxidants

*Beta-carotene *Lycopene *Vitamins C, E, and A *Other Substances

Causes of hypocalcemia include:

*Decreased Intake and Absorption* --Deficient diet --Vitamin D deficiency --Chronic diarrhea/laxative misuse --Steatorrhea (from pancreatitis) *Shift from ECF into bone or inactive form* --hypoparathyroidism --rapid administration of citrated blood --hypoalbuminemia --Alkalosis --Hyperphosphatemia *Increased output* --Steatorrhea --Chronic Diarrhea

Coarse rhonchi

*loud, low-pitched bubbling and gurgling sound* that start in early inspiration & may be present in expiration *(Pneumonia, pulmonary edema)*

developmental tasks of middle adulthood

- establish and guide the next generation - Accept middle-age changes - Adjust to the needs of aging parents - Re-evaluate one's goals and accomplishments

Zones of Personal Space

- intimate zone (0-18 inches) intrapersonal - personal zone (18 inches to 4 feet) interpersonal - social zone (4 to 12 feet) small-group - public zone (12 feet and greater) organiational

Factors impeding nutritional intake

-Anxiety -Pain -Fatigue -Anorexia nervosa (lack of appetite) -Nausea and vomiting

A patient has expressed the feeling that god has caused his illness, Which of the following would be most important for the nurse to consider when responding to the patient's feelings? 1. the nurse must not be judgmental or biased and should respond with compassion 2. the nurse should be comfortable with his or her own religious beliefs and background 3. the patient has the right to his or her feelings, so no response is necessary 4. the patient can rely on the family to give direction and support 5. the patient's religious clergy should be contacted and a visit arranged

1

a child has a minor cut on her scalp that continues to ooze blood after the wound is cleansed. which type of heat or cold application would be appropriate in this situation? 1. examination glove filled with ice 2. tepid sponge bath 3. warm k-pad 4. cooling blanket

1

a nurse is caring for a 65 year old female with type 1 diabetes. the patient is receiving an insulin bolus for a glucose reading of 310 mg/dL. how will the nurse give the insulin bolus? 1. give the medication all at once 2. give the med before meals 3. give the med after meals 4. give the med before and after meals and at bedtime

1

a patient has been restrained to prevent him from pulling out his ng tube. you assign the UAP to check on him. Which directions will you give? 1. check on him every 30 mins and release him every 2 hours dont forget to document all your checks on the flow sheet 2. look in on the patient from the doorway every two hours make sure the tube is still in place

1

a patient is placed on droplet precautions. You know his wife needs more teaching about what PPE to use when she says: 1. i dont need to wear a mask, if i stay a foot away from him 2. i will wash my hands and put on a face mask before i go into the room 3. i will remove the mask just inside the door of his room 4. this disease is spread through small droplets that spray out when he talks, coughs and sneezes

1

after administering medication in the enteral tube, how much water do you use to clear the tube? 1. 20-30 mL 2. 25-35 mL 3. 5-15 mL 4. 30-60 mL

1

an elderly client with dementia is brought to the primary physician's office . The client's daughter asks the nurse what is dementia? Which nursing response is appropriate? 1. it is the deterioration of all cognitive fxs 2. it is the inability to think usual clarity, speed and coherence 3. it is a feeling of intense sadness, helplessness and hopelessness 4. it is a perceptual disorder characterized by dreams and hallucinations

1

an elderly patient with diabetes is admitted with low bs and a syncopal episode. he is confused and unable to give clear answers to most questions. he is noted to have multiple decubiti, poor hygiene, and several old and new lacerations with varying areas of ecchymosis. which is the most concern to you the nurse? 1. the possibility that elder abuse is occurring 2. obtaining an accurate medical hx 3. the need for diabetic teaching 4. the need for a tetanus shot bc of his lacerations

1

if an IV order says to infuse 1,000 mL of fluid at the rate of 125 mL/hr how many hours will it take to complete the infusion 1. 8 2. 6 3. 12 4. 10 5. 125

1

the nurse is preparing a sitz bath for a postpartum mother. the nurse understands the water must be hung to what level? 1. 18-24 inches 2. 15-20 inches 3. 17-25 inches 4. 10-22 inches

1

the patient for whom you are caring for has been receiving furosemide, a diuretic in an effort to remove the excess water that has been retained as a result of heart failure. When you are preparing to assist the patient with a shower, she tells you that she is so tired today and that she just does not feel her legs will hold her up long enough to take a shower. you know that she took a shower each of the past 3 days and wonder to what you might attribute this change. Which of the following lab results could explain her fatigue and muscle weakness? 1. hypokalemia 2. hyperkalemia 3. hypocalcemia 4. hypercalcemia

1

to use proper body mechanics, you need to be most concerned about: 1. your center of gravity, your base of support, and using your leg muscles 2. obtaining lifting equipment, obtaining assistance, and keeping your feet apart 3. your center of support, base of gravity, and the position of your back 4. finding ways to avoid lifting and wearing a brace to protect your back

1

when reviewing the UA results of a patient with the diagnosis of dehydration which of the following would you expect to see: 1. specific gravity 1.032 2. pH of 7 3. +ketones 4. +nitrites

1

which of the following drug administration routes is the safest and most convenient 1. oral 2. topical 3. inhalation 4. intravenous

1

which of the following factors is most likely to result in diarrhea: 1. loss of intestinal normal flora 2. drinking excessive fluids 3. administration of opioid narcotics 4. manipulation of intestines during colon surgery 5. eating 10 to 15g of fiber per day

1

which of the following statements made by the patient with incontinence would indicate a need for further teaching? 1. i can stop doing kegel exercises when i no longer have a problem with leaking 2. i can take meds that may help with my incontinence 3. i may need surgery if other treatments do not work 4. i should start a moderate exercise program

1

you are about to administer a standard P.P.D to a 31 year old male. Which of the following needles and syringes would be appropriate to use? 1. tuberculin syringe with 27 G, 5/8 inch needle 2. 1 mL syringe with 20 G, 1 1/2 inch needle

1

you are using the PDR to look up a medication to determine its effects and side effects. The best way to obtain information is to look up the medication in the: 1. brand or generic name index and then read about it in the product info section 2. product identification section and then read about it in the product info section 3. manufacturers index and then locate it in the product id section 4. product category index and then the manufacturer's index

1

you know a patient with diabetes needs more teaching about nail care when he says: 1. my daughter can cut my toenails so they are rounded without and sharp edges 2. i wont clip my toenails anymore i will just file them 3. and reddened area on my feet can be a problem, so i will tell the doctor if i see any 4. i dont want to risk even a small cut on my toes

1

you know that your patient with chronic kidney disease will need more teaching when she says: 1. i will eat more oranges to prevent potassium build up 2. i will increase my milk intake to keep my calcium levels in the normal range 3. i will avoid bananas so my potassium level will not get too high 4. i can have scrambled eggs for breakfast as long as my calcium is not too high

1

indicate the path of the flow of urine through the following structures by numbering them in order: 1. ureter 2. bladder 3. kidneys 4. meatus 5. urethra

1 kidneys 2. ureter 3. bladder 4 urethra 5. meatus

a patient is taking a med to lower cholesterol. you know that the pt needs more teaching about the med when he says: 1. i will take the med each morning with grapefruit 2. this med is to lower my bp 3. if i experience any adverse effects or problems i will contact my doctor 4. i need to eat a low fat diet and exercise as well as take this med

1,2

Which are examples of independent nursing interventions? 1. Placing a patient on intake and output measurement 2. Assessing the abdomen when a patient is constipated 3. Encouraging high-fiber foods for a patient who is constipated 4. Administering an enema for a constipated patient 5. Administering a laxative and stool softener to a constipated patient

1,2,3

a nurse is caring for a 38 year old female who was admitted with Zika Virus. The nurse understands that which of the following will be given to the patient? 1. antipyretics 2. NSAIDS 3. fluids 4. morphine

1,2,3

a nurse is caring for a 78 year old male who was admitted with the Ebola virus. The nurse understands the Ebola virus spreads by: 1. blood 2. bodily fluids 3. large droplet secretions 4. small droplet secretions 5. IV fluids

1,2,3

if set up correctly, through which of the following could you directly administer an intermittent infusion of medications? 1. secondary IVPB administration set 2. PRN lock 3. Primary infusion administration set 4. Y-set blood tubing

1,2,3

which are examples of independent nursing interventions: 1. placing a patient on intake and output measurement 2. assessing the abdomen when a patient is constipated 3. encouraging high-fiber foods for a patient who is constipated 4. administering an enema to a constipated patient 5. administering a laxative and stool softener to a constipated patient

1,2,3

which steps should the nurse follow when administering a liquid cough syrup to a patient: 1. hold medicine at eye level and pour the prescribed dose 2. the measurement line should be even with the fluid level at the base of the meniscus 3. discard any access 4. dilute all liquids with water

1,2,3

When you use an EHR, you may enter information in which of the following ways? 1. hand-held computer 2. computer at a computer station in the hallway 3. computer at the nurses station 4. beside terminal in the patient's room 5. your personal laptop wherever t is convenient

1,2,3,4

which of the following are examples of activities in which a nurse would need to use critical thinking? 1. prioritizing patient care 2. administering meds 3. writing nurses orders 4. questioning the appropriateness of the order 5. starting an IV infusion

1,2,3,4,5

a nurse is admitting a 74 year old chinese patient to the hospital who says that he practices traditional chinese medicine. the nurse understands that in order to be culturally competent when caring for this patient, she needs to understand anything that might influence his health, including: 1. perceptions 2. behavior 3. expectations 4. barriers to health care 5. the decision making process

1,2,3,5

a nurse needs to administer a med from an ampule. Which of the following steps should the nurse take when drawing up this medication? 1. snap off the ampule neck using a sterile gauze pad 2. hold the ampule away from the body when breaking 3. tilt the ampule and place the injection needle into the liquid 4. avoid tapping the top of the bottle 5. use a filter needle to draw up the med

1,2,3,5

a 68 year old african american female is admitted for HTN. She is at risk for HTN based on which of the following? 1. smoking 2. obesity 3. lower cholesterol level in the blood 4. moderate to heavy alcohol consumption 5. low stress level

1,2,4

the disadvantages of the oral and skin temperatures assessment routes for an adult patient include which of the following? 1. risk of body fluid exposure 2. affected by severe environmental temps 3. not affected by smoking 4. not for confused or unconscious patients

1,2,4

the patient is to receive a cleansing enema for relief of constipation. which of the following factors must be assessed prior to administration of the enema: 1. type of solution to administer 2. date of last bm 3. type of diet the patient has been receiving 4. assessment of bowel sounds 5. the patient's temperature

1,2,4

the nurse understands that local heat application can cause which of the following: 1. vasodilation 2. increased cellular metabolism 3. vasoconstriction 4. relaxed muscles 5. decreased pain 6.decreased blood flow to site

1,2,4,5

what are the four IV tubing drop factors (drop factors equal 1 mL): 1. 10 2. 15 3. 35 4. 20 5. 60 6. 5 7. 50

1,2,4,5

select the correct anatomical landmarks for the ventrogluteal: 1. iliac crest 2. greater trochanter 3. acromion process 4. coccyx 5. anterior superior iliac spine

1,2,5

an 80 year old patient is hospitalized with a UTI and peripheral vascular disease. in addition, he has glaucoma and diabetes. Which nursing actions would be appropriate for him? 1. assess finger stick blood sugar as ordered 2. assess peripheral pulses, capillary refill, warmth, and color of extremities 3. assess risk for suicide or self-harm 4. perform mouth care every 8 hours or more often as needed 5. protect from injury due to impaired vision 6. encourage weight-bearing exercise and increased calcium intake 7. scan the bladder to detect urinary retention 8. encourage fluid intake of liquids the patient likes to drink 9. administer antidiabetic meds as ordered 10. assess for improvement of signs and symptoms of UTI

1,2,5,7,8,9,10

eligibility for the HIS is: 1. based on having a CDIB 2. available to all people with at least 25% indian blood 3. set by each tribe 4. determined by a family genealogy 5. determined by blood type

1,3

the dying process: 1. is a flexible list of events 2. includes changes that are mostly physical and observable 3. includes a time of resting the physical while the mind and spirit are working 4. is amazingly similar for most patients 5. requires solitude

1,3

when cleaning a hearing aid, you should do which of the following? 1. turn off the hearing aid 2. turn the earlobe slightly away from the nose and lift up 3. store the aid in its case 4. store the aid in an open area within the patient's reach

1,3

an assertive behavior style includes: 1. standing up for ones own self 2. putting ones own needs, feelings, and rights before others 3. showing respect for others 4. acting in a conscious manner than enhances self-worth

1,3,4

which of the following txs would possibly help relieve a pt's discomfort from a muscle spasm in her lumbar area? 1. immersion in a whirlpool 2. administration of a tepid sponge bath 3. application of a warm pack 4. application of a cold pack

1,3,4

Which of the following are entry-level nursing programs? Select all that apply. 1. a minimum of two years at a private or community college 2. two or more years in graduate school at a university 3. nine months to 1 year at a technical college or career technology center 4. four-year college degree at a university 5. three years in a hospital-based program affiliated with a college or university

1,3,4,5

Which of the following times during 7 a.m. to 7 p.m. shift would be appropriate to document on a patient's chart? 1. as soon as possible after an occurrence or event 2. once at the beginning of the shift again about midway through the shift and the last time at the end of the shift 3. before the physician makes morning rounds at 10:15 a.m. 4. following the performance of physical assessments 5. not until all your patient care has been completed for the shift 6. at least every two hours

1,3,4,5

you are preparing to administer a schedule II drug. what special considerations are necessary? 1. it is kept under a double lok or with limited access in a computerized medication cabinet 2. it has a lower potential for abuse than a schedule III 3. the remaining meds must be counted 4. the count must match the total in the record book 5. if kept in a computerized medication cabinet the count is totaled by the nurse and the computer

1,3,4,5

which of the following are commonly used medical abbreviations 1. IM 2.SQ 3. kg 4. mL 5. TID 6. QID 7. mg

1,3,4,7

in which situations would it be inappropriate for the nurse to delegate the patient's personal care to a CNA or UAP? 1. a patient whose vital signs are unstable 2. a patient who requires total care 3. a patient whose capabilities to assist with personal care are unknown 4. a patient who is from a different culture 5. a patient who has a worsening skin condition

1,3,5

In a source-oriented medical record, which of these would be found in the nurse's notes section? 1. nurse's assessment data 2. HCP's assessment data 3. patient's response to initiation of IV therapy 4. Patient's living will 5. Report of chest X-ray results 6. Patient's complains of incisional pain

1,3,6

a bedridden patient has a different cultural background and speaks a different primary language than the nurse. In order to provide the culturally sensitive care to this patient, the nurse should od which of the following? 1. allow the patient time to get his or her thoughts together 2. allow the patient's family member to interpret during conversations 3. ask the patient to speak in his best english 4. be aware of the patient's nonverbal body language

1,4

uncontrolled hypertension can result in permanent damage of which organs? 1. heart and eyes 2. pancreas and spleen 3. large intestine and skeletal structures 4. brain and kidneys 5. urinary bladder

1,4

which steps of the nursing process does the LPN/LVN directly participate in? 1. assessment 2. diagnosis 3. planning 4. implementation 5. evaluation

1,4,5

which veins are used during PICC placement: 1. basilic 2. jugular 3. carotid 4. brachial 5. cephalic

1,4,5

which is true of performing hand hygiene 1. use before and after a snack in the break room 2. use hand gel if your hands are visibly dirty 3. do not perform hand hygiene if you will be donning gloves 4. use hand hygiene between providing care for two patients in the same room 5. there is no need to use hand hygiene if you leave a patient's room to obtain clean supplies and return immediately 6. use soap and water instead of hand gel if the hands could be contaminated with spore-forming microbes

1,4,5,6

several medications have GI side effects and may lead to diarrhea or constipation. indicate which of the following meds would be most likely to cause constipation in the pt. 1. amphojel 2. maalox 3. magnesium citrate 4. meperidine 5. amoxicillin 6. ferrous sulfate (iron) 7. imodium AD 8. milk of magnesia

1,4,5,7

you are giving evening care to your patient. What care will you provide? 1. assist with tolieting 2. give a warm, wet washcloth for washing hands and face 3. change the gown 4. offer a back massage 5. straighten the linens and get an extra blanket 6. brush or comb hair 7. remove glasses, dentures and hearing aids 8. ensure that needed items for night are within reach

1,4,5,7,8

a parenteral route of medication administration is one that bypasses which of the following: 1. stomach 2. kidneys 3. skin 4. heart 5. liver

1,5

1+ edema 2+edema 3+edema 4+edema mm

1-2mm 2-4mm 3-6mm 4-8mm

nasal cannula

1-6L 22-50% oxygen

pitting edema 1 2 3 4

1-barely detectable 2-slight indention 3-deeper indention 4-greater 30 seconds for skin to rebound

Number in order the steps of the nursing process:

1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation

medication administration steps

1. located med 2. compare med against mar 3. compare against mar and release med form container 4. save packet containers or keep pile of administered meds

digestion process

1. mechanical ex: mouth, teeth, chewing, stomach, churning, peristalsis 2. Chemical ex: mouth - ptyalin, starch to sugar, stomach - hydrochloric acid intestines, bile, lipid breakdown

blood pressure 4 circulatory qualities

1. strength of heart 2. blood viscosity 3. blood volume 4. peripheral vascular resistance

magnesium levels

1.3-2.3 mEq/L

sodium levels

135-145 mEq/L

A patient complains that he feels ill and the doctor told him it was a virus but that the doctor would not give him any antibiotics. He is upset with the doctor. What is the reason for health-care provider's action? 1. most viruses are immune to antibiotics 2. antibiotics only kill bacteria; they do not kill viruses 3. only the newest, most expensive antibiotics will kill viruses 4. antibiotics are not necessary unless the viral infections is severe

2

Which document would be found in the advanced directive section of source-oriented medical record? 1. signed surgical consent 2. living will 3. discharge plans 4. treatment plan for the diagnosis

2

Which of these nursing diagnosis is correctly written? 1. Readiness for enhanced knowledge related to problems with diabetes 2. Risk for injury related to poor balance when walking 3. Risk for falls as manifested by frequent falls in the past 4. Anxiety and fear

2

a patient on birth control pills tells you that she is also taking St. John's wort as an herbal supplement for mild depression. which response will you make: 1. you need to be on a prescription drug for depression, not treat yourself 2. St. Johns wort increases estrogen by breakdown, so it can decrease the effectiveness of your birth control pills 3. st johns wont decrease the rate of excretion of estrogen so it cna increase the side effectiveness of your bc 4.have you looked up the meds you are taking to see if it interacts with any of them

2

a patient who is terminally ill with cancer is no longer being treated with radiation or chemotherapy(cancer attacking medications). The most appropriate level of care for this patient would be: 1. HHC 2. hospice 3. a skilled nursing facility 4. a long term care hospital

2

an elderly client states i can't afford to eat and buy all of these meds. what nursing intervention would be most appropriate? 1. refer the client to chaplain's services 2. refer the client to available social services 3. help the client choose between food and medicine 4. give the client 100 of your money

2

if a patient's blood pH is 7.33 the patient is in: 1. alkalosis 2. acidosis 3. hypovolemic shock 4. a state of dehydration

2

injection of a drug into the upper layers of the skin is known as which route of medication administration: 1.intra-articular 2. intradermal 3. subcutaneous 4. intramuscular

2

the circulatory effect of venous return is accomplished by bathing: 1. the back along the trapezius muscles 2. the extremities in a distal to proximal direction 3. the arm farthest away from your first, then the nearer arm 4. the extremities in a proximal to distal direction

2

what of the following would be the best enema to administer to a patient before digital removal of an impaction? 1. siphon enema 2. oil retention enema 3. soapsuds enema 4. harris flush enema

2

when you administer an antihypertensive med at a dose within normal ranges, the pt's bp drops to 84/60. this is an: 1. side effect 2. adverse effect 3. allergic reaction 4. anaphylatic reaction

2

which comment by the caregiver of an older adult patient with Alzheimer's disease would concern you the most? 1. i get tired but my daughter comes to relieve me each day 2. i can't sleep bc i am afraid he will get out of the house 3. the illness has affected the entire family not just him 4. the disease is progressing about the way we were told to expect it would

2

which of the following is not true about hospice care 1. it maintains patient autonomy and dignity 2. it incorporates therapies to extend the patient's life 3. the patient is thought to be in the final 6 months to live 4. family wishes are the primary direction for care 5. the primary goals are relief of pain, lessening of fear, and provision of caregiver respite

2

which of the following would be the most accurate statement about digestion and elimination 1. all individuals have at least one bowel movement daily 2. an infant may have up to 6 bowel movements daily 3. gi peristalsis increases with age, making incontinence a normal finding 4. a stool is only considered normal if the color is a shade of brown

2

which of these nursing diagnoses is correctly written? 1. readiness for enhanced knowledge related to problems with diabetes 2. risk for injury related to poor balance when walking 3. risks for falls as manifested by frequent falls in the past 4. anxiety and fear

2

which statement best describes the national patient safety goals? 1. they emphasize the importance of safe lifting and mandate hospitals to have equipment in place to phase out manual lifting 2. they address specific safety problems in the hospital setting and establish requirements for meeting each goal 3. they address needle stick injuries and requires hospitals to purchase needleless access devices 4. they identify specific communicable diseases and outline transmission based precautions for each

2

while rinsing a used surgical instrument in a disinfectant called Cidex, some of the Cidex splashes on your lips and nose. your first action is to: 1. rinse your nose and mouth immediately with running water 2. consult the SDS for Cidex to know what actions to take

2

your patient has been diagnosed with an enlarged prostate. he is at risk for which of the following: 1. urinary suppression 2. urinary retention 3. urinary incontinence 4. urinary diversion

2

your patient is admitted with alkalosis which lab finding would you expect: 1. pH of 7.30 2. pH of 7.48 3. decreased bicarbonate level 4. elevated carbon dioxide level

2

of the following symptoms, which is the most indicative of imminent death. select either one or two for each of the following choices. you should have six answers when you have completed the question: 1. tachycardia or 2. bradycardia 1. circumoral cyanosis or 2. peripheral mottling 1. tachypnea or 2. periods of apnea 1. reaching out to family or 2. withdrawal from family 1. pallor or 2. flushing 1. unresponsiveness or 2. agitation

2,2,2,2,1,1

during a cold application, which of the following assessment findings would indicate the cold pack should be removed immediately? 1. skin is pink 2. skin is white 3. skin is mottled 4. patient complains of a burning sensation 5. skin is very cool to touch 6. patient states the itching from the rash site is decreasing

2,3,4

which of the following may decrease the incidence of UTI: 1. using a diaphragm 2. increasing fluid intake 3. voiding after intercourse 4. frequent voiding

2,3,4

when referring to the hospice nurse, the phrase being there means: 1. being with the patient 24 hours of the day 7 days a week 2. being honest with the patient and family 3. being willing to listen 4. listening for what the patient/family does not say 5. experiencing the emotions elicited during the dying process 6. conquering your own fears

2,3,4,5,6

which of the following S&S may be an indication of vagal stimulation during the digital removal of an impaction? 1. complains of rectal pressure 2. pulse rate of 42 bpm 3. complaint of dyspnea 4. moist skin 5. c/o abdominal cramping 6. c/0 feeling faint

2,3,4,6

in which of the following injections should you avoid aspirating before injecting the medication: 1. IM injection of antibiotics 2. ID tb test 3. subcut injection 4. IM pain med 5. subcut anticoagulant

2,3,5

what are the S&S of phlebitis: 1. site cool to touch 2. edema at the site 3. erythema at the site 4. blanching or pallor of skin around the site 5. veins feel like a hard cord when palpated 6. solution leakage at site

2,3,5

Which of the following entries are good examples of succinct charting? 1. bed bath was given and teeth brushed. Hair was shampooed and tangles combed out. Soaked fingernails in warm soapy water for 20 minutes, then filed them and cleaned them using an orange stick. Legs were shaved and lotion applied to all pressure points and areas of dry skin. Gave her a back rub. 2. Sacral wound measures 2 X 4 cm with 1-cm depth. Wound bed pale and dry, with 1-cm black eschar center circumference by 0.5-cm dark erythema. No granulation noted. Moderate amount foul-smelling green purulent drainage. 3. Patient is having moderate amoutns of cramping in her abdomen. It seems to be from her uterus. When i inquired, the patient said it is time for her to start her menses. The patient also said she usually does not experience premenstrual cramping. 4. BP-124/72, T-98.8 degrees orally, P-64 strong and reg, R-17 reg and even

2,4

Which of these is considered subjective data? 1. the patient is resting on his side 2. the patient complains of a headache 3. the patient ambulated to the bathroom with assistance 4. the patient's mother states he does not eat well

2,4

active listening includes: 1. looking at the chart while the patient is speaking 2. pausing before speaking 3. checking your watch often during conversations 4. nodding your head in agreement

2,4

the nurse is assisting a patient of the jewish culture and faith in planning meals for the day. Which of the following might be a concern for the patient? 1. chopped steak 2. green beans with bacon 3. grilled chicken breast 4. pork chops 5. spinach

2,4

which is true of respiratory alkalosis: 1. the patient is hyperventilating 2. the patient is hypoventilating 3. this causes the pH to elevate above 7.45 4. this causes the pH to drop below 7.35

2,4

which of the following steps should the nurse perform when combining two types of insulin and administering them? 1. always withdraw intermediate-acting insulin first 2. when mixing insulins, remember clear before cloudy 3. insert needle at 45 to 90 degree angle 4. mix lantus with regular insulin

2,4

which of the following would not be considered medically necessary by an insurance company? 1. surgery to remove infected gallbladder 2. breast implants 3. breast implants after breast cancer surgery 4. botox injections to decrease facial wrinkles 5. skin grafts to repair a spider bite injury

2,4

which of these is considered subjective date? 1. patient is resting on his side 2. patient complains of a headache 3. the patient ambulated to the bathroom with assistance 4. the patient's mother states that he does not eat well

2,4

you promote trust with a patient by: 1. allowing family members to visit whenever they want 2. keeping medical info confidential 3. talking with her at length about her life 4. being sure to carry through when you say you will do something

2,4

in which of the following situations would it be inappropriate to delegate the vital sign assessment 1. routine vitals signs on a patient with pneumonia 2. a patient whose level of consciousness had gone from alert to responding only to pain stimuli 3. a teenager admitted with influenza A whose temperature 2 hours ago was 100.6 f Orally 4. a confused and lethargic patient brought to the ER after being involved in a car accident 5. an adult patient who become diaphoretic and pale and complains of sudden onset of severe left chest pain while ambulating in the hallway

2,4,5

during a heat application, which of the following assessment findings would indicate the heat pack should be removed immediately? 1. skin is pale pink 2. skin is dark red 3. temp of the site is slightly warmer than surrounding skin 4. patient denies discomfort 5. skin is starting to look bubbly 6. skin is hot to the touch

2,4,6

which of the following strengths of heparin would you use for flushing a PRN lock? 1. 1,000units/mL 2. 10 units/mL 3. 5,000 units/mL 4. 10,000 units/mL 5. 100 units/mL

2,5

you will expect to find which of the following during the skin assessment of patient with dehydration: 1. redness 2. dryness 3. dependent edema 4. blisters 5. prolonged skin tenting

2,5

Venturi mask

24-60% oxygen 4-12 L

adults need how much fiber per day

25-35g per day

It is important to understand that as individual members of various ethnic, cultural, and religious groups we all are different and: 1. we should learn to agree with all the differences in these groups. 2. we must stick to our own beliefs and avoid accepting those differences from our own 3. we deserve to be treated with respect and dignity 4. yet we still need the exact same care

3

The most effective way to break the chain of infection is: 1. isolate all infected patients from remaining patients and assign only one staff member to each room 2. wear gowns, gloves, masks, and protective eyewear when entering every patient's room 3. perform effective hand hygiene according to CDC guidelines 4. use an N95 respirator when entering the room of any infected patient

3

Which of the following organizations has/have worked to provide the patient's right to culturally competent care in U.S. hospitals? 1. U.S. government 2. Bureau of immigration 3. the joint commission 4. American association of medical workers 5. patients rights committee

3

a female patient is recovering from abdominal surgery 2 days ago. Her abdomen is distended and firm and she complains of moderate to severe cramping and abdominal discomfort. as of yet, she had been unable to pass much flatus rectally. which type of enema would be most helpful to this patient? 1. fleet phspho-soda enema 2. oil retention enema 3. harris flush enema 4. small-volume enema

3

a newly admitted patient may be at risk for falls. While the patient is in the bathroom changing into a hospital gown, the admitting nurse would be most concerned about: 1. ordering soft device bolsters for the bed 2. arranging for a bed monitor to be placed on the bed 3. staying near the bathroom to help the patient back to bed 4. determining whether to ask the doctor for an order for restraints

3

a nurse is caring for an elderly patient. which physiological change is of the highest concerns? 1. urinary retention 2. slowing of metabolism 3. impaired visual acuity 4. development of age spots on the skin

3

a patient tells you that he is allergic to a muscle relaxed bc it makes him sleepy all day. you know that this is a common side effect of this med. what action will you take? 1. record it as an allergy in the chart only 2. explain to the patient he is not having an allergic response to the med 3. record it as an allergy in the chart with an explanation 4. notify the hcp immediately of the allergy and check for blood levels of the drug in the chart

3

an example of nonverbal communication that is congruent to the verbal statement by the patient, "im having a lot of back pain", would be: 1. smiling 2. reading a magazine 3. grimacing

3

hypovolemia refers to a condition resulting from: 1. dehydration caused by a loss of intracellular and extracellular fluids 2. water losses that are greater than electrolyte losses 3. excessive loss of equal proportions of extracellular fluid and electrolytes 4. excessive fluid loss of electrolytes in greater proportions than the loss of fluids

3

payment to hospitals for the care of medicare patients is based on: 1. a specified amount per member per month 2. the actual costs of all supplies, equipment, tests and nursing care 3. DRGs 4. a previously negotiated discount rate

3

the patient complains of SOB and is expectorating pink frothy sputum. the nurse would assess for further S&S of: 1. hyperkalemia 2. hypomagnesemia 3. fluid overload 4. fluid deficit 5. dehydration

3

what gauge and length of needle would you select to administer an IM injection of a nonviscous med in the ventrogluteal site of a 40 year old male construction worker who is in good health and weighs 185 lbs? 1. 25 G, 1 inch 2. 18 G, 1 1/2 inch 3. 22 G, 1 1/2 inch 4. 24 G, 2 inch 5. 20 G, 5/8 inch

3

when communicating with people who are HOH: 1. set the intercom on high 2. speak in an exaggerated way 3. find out how the person communicates best 4. if the person uses an interpreter, speak to the interpreter

3

which of the following drug administration routes is rapid and across a large surface area? 1. oral 2. topical 3. inhalation 4. rectal

3

which of the following preparations should be performed at the bedside? 1. mixing of IV med 2. verification of hcp's IV order with MAR 3. site selection 4. priming primary infusion administration set 5. calculation of infusion rate for gravity flow

3

which of the following objective vital signs all taken on adults have one or more components that fall outside of typical normal ranges? 1. bp 116/66, t 99.2, p 74 regular and strong, r 17, 02 99 2. bp-98/62, t 98.2, p 98 regular and strong, r 20, 02 97 3. bp 142/92, t 98.4, p 62 regular and bounding, r 14, o2 96 4. bp 120/74, t 100.6, p 86 regular and strong, r 24, o2 98

3,4

which of the following techniques are correct when inserting a rectal suppository: 1. position the patient on his or her right side with left leg flexed 2. during insertion tell the patient to hold his or her breath 3. lubricate the tip of the suppository 4. gently insert the suppository directing it with the index finger

3,4

What type of documentation would you as a nurse be responsible for performing in the section marked Physician's Orders? 1. The patient's plan of care to be followed 2. Vital signs taken during your shift along with the I&O totals 3. Transcription date, time, and your initials 4. When you noted the orders 5. Verbal order given to you by the physician 6. Nursing orders

3,4,5

which veins are used during central line placement: 1. brachial 2. cephalic 3. jugular 4. femoral 5. subclavian 6. basilic

3,4,5

the nurse is completing an I&O sheet for the patient. which will the nurse include in the output? 1. sweat 2. peritoneal fluid 3. liquid stool 4. emesis 5. interstitial fluid 6. urine

3,4,6

Which of the following phrases are written objectively? 1. Ate 45% full-liquid diet, Did not act very hungry and acted like she should not have drunk all that she did 2. Complaining of really severe pain and wants something for it 3. Ambulated unassisted the length of hallway without complaints of fatigue or shortness of breath 4. Does not feel good today. Angry and depressed 5. Makes good eye contact, smiling. States feels ,"much better today than yesterday".

3,5

Potassium normal range

3.5-5.0 mEq/L

simple mask

35-65 % oxygen 6-10 L

Given that all of the following are appropriate nursing diagnoses for your patient, which would be the priority? 1. ineffective coping 2. sedentary lifestyle 3. risk for loneliness 4. self-care deficit: bathing

4

Nursing care that involves or combines the elements of more than one culture is called which of the following names? 1. home care 2. acute care 3. hospice care 4. transcultural care 5. immigrant care

4

When you learn that your patient's infecting bacterium id identified as a gram-positive streptococcus, you know this means that: 1. it appears in rod-shaped pairs and cannot be treated by antibiotics 2. it appears in sphere-shaped clusters and stains red in the laboratory 3. it appear as a long, coiling cell and strains blue in the laboratory 4. it appears in sphere-shaped chains and stains purple in the laboratory

4

a patient with erythematous area at the site where you just discontinued an IV infusion. There is no edema but the patient complains of the site being very tender. Which of the following would be the treatment of choice: 1. telling the patient the tenderness will subside without tx 2. administering a sitz bath 3. applying an ice pack 4. applying a warm pack

4

during clinical you think you see a staff nurse swallow a narcotic medication she signed out for a patient. what will you do? 1. ask the staff if she just swallowed that pill 2. say nothing 3. tell a fellow student 4. confidentially tell your instructor what you thought you saw

4

given that all of the following are appropriate nursing diagnosis for your patient which would be a priority? 1. ineffective coping 2. sedentary lifestyle 3. risk for loneliness 4. risk for loneliness 5. self-care deficit: bathing

4

if an elderly person needed help with meals, medications, and personal care but did not need continuous nursing care, which inpatient setting would be the most appropriate level of care? 1. a skilled nursing facility 2. a long term care acute hospital 3. an assisted living facility 4a long term care facility

4

the drug name that is assigned and is not owned by the pharmaceutical company that develops the drug is the 1. chemical name 2. proprietary name 3. brand name 4. generic name

4

the minimum length of time that is safe for administration of IV push med is: 1. 1 hour 2. 30 seconds 3. 5 minutes 4. the amount of time designated by the medication manufacturer 5. 1 minute per 1 milligram

4

the nurse is assessing an old-old client. which assessment findings should the nurse consider as highest priority? 1. slowing of peristalsis 2. decreased sense of smell 3. loss of skin elasticity 4. temperature of 94

4

the staff nurses says that your patient refused her bath yesterday and really needs one today. the patient says she is too exhausted to have a bed bath and just wants to sleep. your best response would be: 1. that's fine. sleep is more important than a bath anyway. 2. i will do your bath first, then you will sleep better 3. i have other patients to care for so we need to do your bath now 4. you rest now and i will come back in about an hour to do you bath

4

upon assessing the vital signs of a 56 year old male, you find he has an apical pulse of 71 bpm and a radial pulse of 62 bpm. Which of the following numbers would be correct to document as the pulse deficit? 1. 0 2. 3 3. 7 4. 9 5. 133

4

what is the term that indicates that a message was communicated as intended? 1. sending 2. receiving 3. comprehending 4. shared meaning

4

which of the following assessment data might indicate the patient is having difficulty accepting his or her new colostomy: 1. asks questions about how to take care of the colostomy 2. observes as you irrigate the colostomy 3. looks at stoma and makes good eye contact with you during ostomy care 4. refuses to attempt care and tells you to just do it

4

which setting(s) may use kardexes and paper charts? 1. inpatient hospitals 2. outpatient surgery centers 3. home health care 4. long-term care

4

which site for subcutaneous administration has the most rapid absorption of insulin? 1. Vastus lateralis 2. dorsogluteal 3. back of upper arm 4. abdomen 5. deltoid

4

you walk into a patient's room and fins a fire involving the trash can and curtains. What will you do first? 1. use the call light to tell the unit clerk to activate the code red 2. step into the hall and call for help announcing fire in the room 3. use the phone in the room to notify the fire department 4. remove patient from the room to a safer area

4

your patient has a low pattasium level uncorrected by oral medications. The physical orders 30 mEq of KCI added to the IV of 1,000 mL of normal saline to infuse at 80 mL per hour. Which nursing intervention is the most importance to perform today? 1. serve a diet with potassium rich foods 2. restrict sodium in the diet 3. monitor blood levels of all electrolytes 4. make certain urine output is at least 30 mL per hour 5. monitor for fever and tachypnea

4

your patient has been prescribed timolol maleate eyedrops. where should you instill the eyedrops: 1. cornea 2. pupil 3. eyelid 4. lower conjunctival sac

4

the difference between a primary IV administration set and a secondary IVPB administration set includes which of the following: 1. the secondary IVPB administration set is used for administering IV push medication 2. the primary IV administration set always has a drop factor of 60 3. the primary IV administration set is longer than the secondary IVPB administration set 4. the secondary IVPB administration set has a drip chamber for visualizing the drip rate while the primary administration set does not 5. there is no difference

5

normal wbc count

5,000-10,000/mm3

you have removed an indwelling cath how long until the patient voids for ob and regular patient

6 hours ob 8 hours patient

ICF ECF

70 within cells 30 outside cells intravascular within the vascular system interstitial-surrounds cells/tissues

calcium levels

8.6-10.2 mg/dL

hypoglycemia range

90 mg/dL or below

nonrebreather mask

95-100% 10-15 L/min

calcium is found in

99 % teeth and bones 1% blood

ethnicity

A group of people associated by a common heritage.

aseptic technique

A procedure performed under sterile conditions.

Hemoglobin A1c

A test that measures the level of hemoglobin A1c in the blood as a means of determining the average blood sugar concentrations for the preceding two to three months.

vasodilation

A widening of the diameter of a blood vessel.

antioxidants

A,C,E deactivate free radicals

total body weight adult older adult newborn early human embryo

A- 50-60% OA- 45-55% N- 70-80% E- 97%

Fat souble vitamins include.

ADEK stored in fat

medicating enemas

Administer medication

Hypomagnesium Causes

Alcoholism GI suction Diarrhea Intestinal fistulas Poorly controlled DM (diabetes) Malabsorption syndrome

Protein

An organic compound that is made of one or more chains of amino acids and that is a principal component of all cells

pathogen

An organism that causes disease

Phases of FDA clinical approval

Animal vs. Human 1. healthy volunteers 2. given to people with disease for comparison against those without disease 3. double-blind placebo controlled study 4. fda evaluates the data and allows ,marketing-monitoring continues

Which steps of the nursing process does the LVN/LPN directly participate in

Assessment, Implementation, Evaluation

water soluble vitamins

B and C absorbed directly into blood stream cannot be stored

body's defense against infection

Body's normal flora Inflammatory response Immune response

Calcium abbreviation

Ca

rate and depth of breathing

Changes in response to tissue demands Controlled by respiratory centers in the medulla and pons Activated by impulses from chemoreceptors Increase in carbon dioxide is the most powerful respiratory stimulant

Causes of Accidental Injuries in Older Adults

Changes in vision and hearing Loss of mass and strength of muscles Slower reflexes and reaction time Decreased sensory ability Combined effects of chronic illness and medications Economic factors

factors affecting body temperature

Circadian rhythms Age and gender Environmental temperatures

chloride abbreviation

Cl

three learning domains

Cognitive: storing and recalling of new knowledge in the brain Psychomotor: learning a physical skill Affective: changing attitudes, values, and feelings

Vitamins

Compounds found in food that help regulate many body processes

pressure ulcers

Compromised circulation secondary to pressure or pressure combined with friction

Functions of fat

Concentrated amount of energy, protects organs and provides insulation.

Types of topical medications

Creams, gels, lotions, ointments, transdermal patches

enteral nutrition

Delivers nutrition via the GI tract

Mental Impairment in Older Adults

Dementia Alzheimer disease Sundowning syndrome Cascade iatrogenesis

medical diagnosis

Describes problems for which the physician directs the primary treatment

factors influencing communication

Developmental level Gender Sociocultural differences Roles and responsibilities Space and territoriality Physical, mental, and emotional state Values Environment

osmosis

Diffusion of water through a selectively permeable membrane

causes of hypokalemia

Diuretics (Lasix), Diarrhea, GI loss, polyuria, sweating

Minerals

Elements found in food that are used by the body

Life Changes of the Middle Years

Employment Relationship with a spouse Relationships with adult children Relationships with aging parents Midlife transition

active transport

Energy-requiring process that moves material across a cell membrane against a concentration difference

factors affecting body temperature

Environment, time of day, gender, Physical Activity and Exercise, Medications, food intake, Stress, Illness

convection heat loss

Flow of heat from body to cooler air

Partial Parenteral Nutrition (PPN)

For patients who are able to meet some of their nutritional needs orally, but require additional calories or nutrients for a limited time due to illness

bicarbonate abbreviation

HCO3-

a cost-efficient way to provide care to people who are confined to their homes because of illness or disability

HHC

pulse variations

Increased or decreased pulse rate Pulse amplitude and quality Regular or irregular pulse rhythm

four types of nursing assessments

Initial comprehensive Focused Emergency Time-lapsed

assessing respirations

Inspection Listening with stethoscope Monitoring arterial blood gas results Using a pulse oximeter

An RN student asks a friend who is an LPN/LVN student, "will you be able to start IVs when you get out of school" Which is the best response.

It depends on the NPA in which state i work

Potassium abbreviation

K

Moral and Spiritual Development of Older Adults

Kohlberg: Older adults have completed their moral development and most are at a conventional level. Spiritually, an adult may be at an earlier level, often at the individuative-reflective level. Many adults demonstrate conjunctive faith and trust in a greater power. Self-transcendence is characteristic of later life.

water leaves the body: lungs skin sweat kidney intestines total all together what does that mean

L-350mL S-350mL diffusion Sweat- 100mL Kidney- 1,400 mL In-200mL totals 2,400 mL in equals out

infiltration

Leakage of intravenous fluids into surrounding tissues

hyperkalemia causes

M.A.C.H.I.N.E. M - Medications - ACE inhibitors, NSAIDS A - Acidosis - Metabolic and respiratory C - Cellular destruction - Burns, traumatic injury H - Hypoaldosteronism, hemolysis I - Intake - Excesssive N - Nephrons, renal failure E - Excretion - Impaired

leading causes of death in middle adulthood

Malignant neoplasms Cardiovascular disease Unintentional injury including poisoning, motor vehicle accidents, and falls Diabetes mellitus Chronic lower respiratory disease Cerebrovascular causes

collaborative problems

Managed by using physician-prescribed and nursing-prescribed interventions

catabolism

Metabolic pathways that break down molecules, releasing energy.

magnesium abbreviation

Mg

The first role for a woman in health care was that of a

Midwife

diffusion

Movement of molecules from an area of higher concentration to an area of lower concentration.

Sodium abbreviation

Na

NANDA-I

North American Nursing Diagnosis Association International

fluid volume excess

OVERHYDRATION: fluid intake or fluid retention exceeds fluid needs of the body

phosphate abbreviation

PO4

ensuring bedside safety

Patient call light is functioning and within reach Bed is positioned properly, at appropriate height, wheels locked Side rails are safely used when indicated Principles of medical asepsis are followed Electrical equipment is safely grounded Walk space is uncluttered

QSEN

Patient-Centered Care Teamwork and Collaboration Evidence-Based Practice Quality Improvement Safety Informatics

Changes of Older Adulthood

Physical strength and health Retirement and reduced income Health of spouse Relating to one's age group Social roles Living arrangements Family and role reversal

Development of the Older Adult

Physiologic: all organ systems undergo some degree of decline, body less efficient Cognitive: does not change appreciably, may take longer to respond and react Psychosocial: Self-concept is relatively stable throughout adult life. Disengagement theory: An older adult may substitute activities but does disengage from society. Erikson: ego integrity versus despair and disgust; life review Havighurst: major tasks are maintenance of social contacts and relationships

Electrolyte composition of ICF

Prevalent cation is K+ Prevalent anion is PO43-

electrolyte composition of ECF

Prevalent cation is Na+ Prevalent anion is Cl-

functions of minerals

Provide structure to bones teeth and nails Assist in fluid balance (acid base balance) Regulate nerve cell transmission and muscle contraction Assist in activation of vitamins enzymes and hormones

transfer of body heat to external environment

Radiation Convection Evaporation Conduction

Hypermagnesemia causes

Renal failure, Adrenal insufficiency, Excess replacement

engel's six stages of grief

Shock and disbelief Developing awareness Restitution Resolving the loss Idealization Outcome

SBAR

Situation Background Assessment Recommendation

sources of heat loss

Skin (primary source) Evaporation of sweat Warming and humidifying inspired air Eliminating urine and feces

excoration

Skin sore or abrasion produced by scratching or scraping

oil retention enemas

Soften the hard stool of impaction

total parenteral nutrition

TPN; a hypertonic solution of nutrients designed to meet almost all caloric and nutritional needs

eviseration

The displacement of organs outside of the body.

contamination

The introduction of dangerous chemicals, disease, or infectious materials.

disinfection

The process of destroying pathogens

Fat soluble vitamins

Vitamins A, D, E, K absorbed from sml intestines into body fat can be stored when intake exceeds need

Hyponatremia causes

Vomiting Diuretics Excessive administration of dextrose and water IVs Burns, wound drainage Excessive water intake SIADH less than 135

you are working on a large medical unit with 30 patients who require medications, therapies, dressing changes, and pain management. Nursing staff for the day shift consists of two RNs, three LPNs, and three CNAs. Which type of nursing care delivery would you expect to work best on this unit? 1. team nursing 2. client-centered care 3. primary care nursing 4. case management

`1

lipohypertrophy

a build-up of subcutaneous fat tissue at a site where insulin has been injected continuously.

electrolytes

a chemical compound that conducts electricity by changing into ions when melted or dissolved into a solution

disinfectant

a chemical substance that kills harmful bacteria or viruses

What is a care plan

a documented plan for giving patient care and includes p.o nur diagnosis and nursing orders

antipyretic

a drug that relieves fever

universally applicable

a framework for all nursing activities

decision

a framework used by all nurses to determine the needs of their patients and to decide how to care for them

Body Mass Index (BMI)

a measure of body weight relative to height

evidence-based practice

a problem-solving approach to clinical practice that integrates the conscientious use of best evidence in combination with a clinician's expertise and patient preferences and values in making decisions about patient care

adventious sounds

abnormal breath sounds

Cheyne-Stokes

abnormal breathing pattern; periods of dyspnea and apnea

mucosal route

absorbed through the mucosa, such as medications applied through the rectum, vagina, eye, or ear, and inhaled into the lungs and bronchi

GI tract

absorbs water and nutrients that enter the body through this route

the large intestine functions

absorption of water manufacture of some vitamins formation of feces expulsion of feces from the body

pharmacokinetics

absorption, distribution, metabolism, excretion

instrumental activities of daily living (IADLs)

actions that require some intellectual competence and planning ex: driving, talking on the phone

types of loss

actual, perceived, physical loss vs psychological loss, maturational , situational, anticipatory

oral route

administration of drugs by way of the mouth

document observed iv site for adult for children

adult every 4 hours child every 2 hours

patient's ethical rights 5 components

advocacy respect dignity honesty compassion

what causes variations in fluids

age- younger or older body fat gender

regulation synopsis adrenal glands

aldosterone controls potassium and sodium cortisol affects water retention

Which of the following are examples of activities in which a nurse would need to use critical thinking? 1. prioritizing patient care 2. administering medication 3. writing nursing orders 4. questioning the appropriateness of an order 5. starting an IV infusion

all of the above

a patient has been prescribed an MDI for the management of her asthma. which of the following instructions should be given to the patient? 1. shake the inhaler before use 2. breathe slowly and fully before administration 3. administer by pressuring the canister down 4. hold your breath as long as possible

all of the above

factors that affect communication include: 1. personal space 2. culture 3. attitude 4. emotions

all of the above

open-ended questions are good types of questions to use in what situation: 1. introducing broad topics during an interview 2. beginning an interview 3. changing topics in an interview 4. asking a patient about his or her feelings

all of the above

the nurse knows the seven rights of medication administration are which of the following: 1. right patient 2. right route 3. right indication 4. right dosage 5. right documentation 6. right medication 7. right date and time

all of the above

the nurse understands that which of the following methods are moist heat? 1. hot compress 2. soaks 3. sitz bath 4. whirlpool bath

all of the above

the nurse would refrain from taking a BP on which of the following areas? 1. amputation of the arm 2. mastectomy on the affected side 3. IV infusion on the selected side s 4. Presence of a shunt

all of the above

your patient can approach loss and death with a sense of peace when which of the following needs are met: 1. fear of the unknown is relieved by adequate knowledge 2. pain and other signs and symptoms are effectively managed 3. reconciliation with significant others is accomplished 4. spiritual reconciliation is completed 5. estate and financial matters have been settled

all of the above

open-ended questions

allow client to verbalize freely

colloids

always hypertonic

digestion begins in the mouth with..

amylase working on fats and carbs

The NCLEX is

an examination taken to become licensed as a nurse

diagnosing

analyzing data to identify strengths and problems

when your patient states: its not fair that my cancer wasnt found sooner he is expressing emotions described as:

anger

pirtuitary gland

anti-diuretic hormone ADH

topical route

application of drugs directly to the skin

specified dx

applies to one defined pt

Enteric-coated tablets

are made to dissolve in the small intestine

number in order the steps of the nursing process

assessment diagnosis planning implementation evaluation

bacterial flora transient resident

attached loosely to the skin removed with ease found in creases in the skin requires friction with brush to remove

clarifying questions

avoid misperceptions

functions of vitamins b and c

b- serves as coenzyme for metabolism stimulate appetite maintain nervous and integumentary system c- immune system functioning absorbed iron wound healing

vitamin b3 vitamin b6

b3-niacin txs hyperlipidemia pyridoxine-prevent peripheral neuropathy

subcutaneous injection sites

back upper arms abdomen anterior thighs area of back below scapulae upper buttocks

What causes illness?

bacteria, viruses, fungi, parasites, drug resistant microbial strains

if i make it through this chemotherapy and radiation then god will let me live is an example of

bargaining

Buccal

between the gum and cheek

buccal tablets are administered:

between the upper lip and gum

additional roles of vitamins

blood clotting synthesis of hemoglobin bone and collagen formation new tissue growth and repair nerve impulse conduction

bicarbonate

body's primary buffer system

Vital signs

bp pulse temperature oxygen saturation respirations pain

lipoatrophy

breakdown of subcutaneous fat at the site of repeated insulin injections

tablets

broken down by digestive system and absorbed into the bloodstream

advantages of med by injections

bypass gi tract rapid onset ease of administration better absorption

parathyroid gland

calcium and HPO4^2 which influence calcium in bones, intestines and kidneys if we do not have calcium we have the antagonist phosphate

Macrominerals

calcium, phosphorus, magnesium

macronutrients

carbohydrates, proteins, and fats water and minerals required in large amounts

major health problems in geriatrics

cardiovascular and pulmonary disease cancer rheumatoid arthritis diabetes obesity alcoholism depression

sites for assessing pulse

carotid, brachial, radial, popliteal, femoral, dorsalis pedis, posterior tibialisis

implementing

carrying out the plan of care

prolonged grief

characterized by intense preoccupation with memories

Charting by exception

charting only abnormal findings

cross-linkage

chemical reaction produces damage to the DNA and cell death

specific drug interactions with nutrition chemotherapy steroids lasix lithium

chemo- causes anorexia and give antiemetic ster-cause weight gain lasix- depletes potassium lithium- closely related to sodium levels monitor labs

potassium

chief regulator of cellular enzyme activity and water content

Assessment of heat therapy

circulation of the area skin sensation and integrity for open wounds= provide an ideal climate for growth of microorganisms so check do not apply to a wound w/o an order

assessment for cold therapy

client's sensation of hold and cold at the site decreased circulation systemic temp if large areas exposed to cold therapy age- tolerance

Sources of data

client, family, S/O, client record, hcp, nursing and other hc literature

Assessment

collecting ,validating ,and communication of data

4 purposes of documentation

communicate with h/c team permanent record record of accountability for quality insurance legal record for pt and hcp

the nurse is taking care of a 78 year old male patient who is bedridden. which type of bath would be appropriate for this patient

complete bed bath

middle age life cycle of death

concerns with consequences of own death

types of cleaning

concurrent cleaning- daily terminal cleaning- discharge/room change cleaning

sepsis

condition resulting from presence of pathogens

Film-coated tablets

contact prevented with active ingredient during normal handling

complete proteins

contain all essential amino acids

message

content of the conversation, includes verbal and non-verbal

wheezes

continuous high-pitched whistling sounds produced during breathing

sodium

controls and regulates volume of body fluids sidekick to oxygen

Pharmoeconomics

cost of drug therapy

meniscus

curves up on sides lower in the middle of medicine cup

fluid balance desirable usual

d-1500-3500 mL/day u-2400-26--mL/day

stage 4 pressure ulcer

damage to muscle, bone and supporting structures tunneling

inflammatory process

damaged blood vessels constrict and retract signs of inflammation

focus

data action response

ages 5-10 life cycle of death

death becomes real what happens after death believe death occurs by accident

adolescence life cycle of death

death is inevitable permanent

young adulthood life cycle of death

death is unwelcome and intrusion

applying cold therapy purposes

decrease blood flow to area decreases tissue metabolism, o2 consumption, inflammation, and edema formation local anesthetic effect decreases muscle tension reduces fever

Fiber functions

decrease ldl promote norm bowel fxs increase absorption of minerals lowers colon pH supports GI tract promotes weight loss

hypoxemia

decreased level of oxygen in the blood

energy production heat production

decreases increases

parasympathetic stimulation of pulse sympathetic stimulation of pulse

decreases heart rate increases heart rate

Hypocalcemia

deficient calcium in the blood

Hypokalemia

deficient potassium in the blood less than 3.5

stages of grief

denial, anger, bargaining, depression, acceptance

Distribution

depends on the adequacy of circulation protein bound vs. free protein- allows drugs to be stored and released for later may extend duration of action free/unbound acts directly on cells

nursing diagnosis

describes clients problems nurses can treat independently

Effects of interactions of medications

desired effect side effect adverse effect allergic reactions anaphalaxis toxicity drug interactions

narrative

detailed account of care pt receives occur in chronological order

pulse pressure

difference between systolic and diastolic pressure

pulse deficit

difference between the apical and radial pulse rates radial pulse slower than apical pulse

dysphagia

difficulty swallowing

types of interventions

direct patient care indirect pt care independent dependent

nonvesicant

does not cause blistering and death of tissue

indications for use are

dosages contradictions cautions interactions

hypertonic solution

draws fluid and electrolytes into intravascular compartment dehydrating intracellular and interstitial compartments

Pharmacotherapy

drug therapy; the use of drugs to prevent, diagnose, or treat signs, symptoms, and disease processes

cardiac glycosides

drugs used to improve heart output by increasing the muscular contraction

antianginals

drugs used to treat chest pain

excretion

elimination of drug from body requires adequate circulation and organs of excretion kidneys, liver, bowels, and skin most by the kidneys

reflective questions

encourage patient to elaborate on thoughts and feelings

applying dry heat

enhances circulation promotes healing reduces swelling and inflammation reduces pain and muscle spasms increases systemic temp

water enters the body

enters from digestive tract liquids and in foods

what releases and alters metabolism

epinephrine and norepinephrine

Extravasation

escape of blood from the blood vessel into the tissue

ethical/legal skills

establishing a personal moral code and professional role responsibilities

when working in long-term care, the nurse is required to document assessment data on a resident how often?

every week

Hypernatremia causes

excess water loss, excess sodium administration, diabetes insipidus, heat stroke, hypertonic IV solutions greater than 145

Hyperkalemia

excessive potassium in the blood greater than 5 in ecf

isotonic solution

expands intravascular compartment only similar consistency to our own blood, fluid stays put

amount of water in: foods ingested fluids catabolism total all together per 24 hour

f-700mL il-1,500 mL c-200mL totals 2,400 mL per 24 hours

conditions that affect water balance

fever vomiting/diarrhea burns mechanical ventilation meds

soluble fiber

fiber that dissolves in water or is broken down by bacteria in the large intestine

insoluble fiber

fiber that does not dissolve in water and is not broken down by bacteria in the large intestine

distorted grief

fixed in the anger stage where exaggerated normal behaviors of hopelessness

delayed or inhibited grief

fixed in the denial stage where emotional pain not experienced

the most famous kaiserworth deaconess is

florence nightingale

movement and distribution are influenced by

fluid intake fluid pressures osmolality of body fluid

cholesterol function

form each of the body cell membranes in every system produce adrenal and sex hormones as well as bile protect our nerves convert sunshine to vitamin d help metabolize fat-soluble vitamins

sterile

free of all organisms, including spores and viruses

Hyperglycemia S/S

frequent urination, deep rapid labored respirations, thirst, hunger, dry mucous membranes, weakness, malaise, rapid, weak pulse, hypotension, soft eyeballs, hot dry skin

stage 3 pressure ulcer

full thickness skin loss necrosis of subcutaneous tissue may undermine through adjacent skin deep crater

capsule

gelatin shell containing powder or pellets of medication

anasarca

generalized edema accumulation of fluid in interstitial space

you are initiating a 24 hour urine specimen collection for a patient as ordered by her hcp which of the following will you do first

get rid of the first void

parenteral route

given beneath the skin, includes all injections

components in IV fluid

glucose electrolytes vitamins amino acids

physiologic geriatrics

gradual internal and external physiological changes occur

dynamic

great interaction and overlapping among the 5 steps

Hypercalcemia levels

greater than 11 mg

cardiac output

heart rate x stroke volume

stridor

high-pitched crowing sounds

administer liquid medicine by

holding label in the palm of your hand

what increases metabolism

hormones, muscle movements, and exercise

nosocomial infection

hospital acquired infection

3 parts of a needle

hub- fits onto the tip of the syringe shaft- connects to the hub bevel- slanted tip

interpersonal

human being is always at the heart of nursing

body temperature is regulated through

hypothalamus

nutritional assessments

identify specific allergies identify special diets and dietary preferences note cultural or ethnic requirements or restrictions assess physical capabilities and the need for assistance assess meds

vitamin c

immune system fx, helps body aborb iron vital wound healing

regulation synopsis of thyroid gland

increases blood flow in the body and increases renal circulation

chain of infection

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

Airbourne

infectious small and lightweight particles can float in the air and spread through air currents

thrombophlebitis

inflammation of a vein associated with a clot formation

objective data

information that is seen, heard, felt, or smelled by an observer; signs

bacteriostatic

inhibits bacterial growth

Fats

insoluble in water and blood composed of hydrogen oxygen and carbon

phosphate

involved in important chemical reactions in the body, cell division, and hereditary traits

Metabolism

involves inactivation of drugs most drugs are lipid soluble which aids their movement across cell membranes kidney can only secrete water soluble substances most be conversion of fat soluble to water soluble metabolites

Microminerals

iron, zinc, manganese, and iodine

conduction heat loss

is the loss of heat from the BODY SURFACE to COOLER SURFACES in direct contact

Radiation heat loss

is the loss of heat from the body surface to COOLER SOLID SURFACES NOT in direct contact but in relative proximity

Droplet

larger droplets cough sneezes talks

ages 3-5 life cycle of death

least anxious about death death is sleep

water leaves the body

leaves body by kidneys, lungs water in expired are and skin and intestines

apothecary

less convenient and concise basic unit or wt is grain

severe adverse reactions

life threatening, require intervention to prevent permanent impairment or death, lead to congenital anomaly, disability, hospitalization, or death

scope of practice

limitations and allowances of what a nurse can do

cognitive geriatrics

little change from adulthood

main regulation of homeostasis

liver, kidneys

the document that explains the patient's wishes regarding, withholding or withdrawing life-sustaining treatments such as artificial nutrition and hydration is the:

living will

documentation of wounds

location depth shape drainage color size odor

rectus femoris

longitude midline of anterior thigh

causes of fluid volume deficit

loss of body fluids occurs more rapidly when coupled with decreased intake can be caused by prolonged decreased intake

general function of electrolytes

maintain body fluid volume and osmolarity distribute body water between compartments regulate acid/base balance promotes neuromuscular irritability (contraction)

functions of calcium

maintains normal cell permeability normal muscle and never activity formation bones and teeth clotting mechanisms

chloride

maintains osmotic pressure in blood, produces hydrochloric acid

technical skills

manipulating equipment skillfully to produce desired outcome

crystalloids

may be isotonic, hypertonic and hypotonic

monosaturated fats

may lower ldl

intake/outputs are items that are

measurable

evaluating

measuring extent to which a client achieved outcomes

primary source of heat production is

metabolism

magnesium

metabolism of carbohydrates and proteins, vital actions involving enzymes

Risk Factors in the Elderly

mobility sensory perception knowledge ability to communicate physical state of health psychosocial health state

free radical

molecules with separated high-energy electrons have adverse effects on adjacent molecules

filtration

movement of fluids and particles occurs through a semi-permeable membrane

Nine essential amino acids

must be obtained from food sources body is unable to produce them

realistic/specific action

must state precisely what is to be accomplished

mental registration

name 3 unrelated objects ask for all three repeat until patient learns all 3

chemical name of meds

name of the exact ingredients of the med chemical formula

Hypoglycemia S/S

nausea, nervousness, & irritability, sweatinesss w/ pale skin.diaphoresis, pale cool skin, irritability, normal/shallow respirations, tachycardia and palpitations, strange or unusual respirations. slurred speeech, headache and blurred vision, decreasing loc, seizures leading to coma, change in emotional behavior,difficulty thinking.

Micronutrients (trace elements)

needed in small amounts vitamins trace minerals

Anions

negatively charged ions

calcium

nerve impulse, blood clotting, muscle contraction, B12 absorption

ages 1-3 life cycle of death

no concept of death

Third spacing and FVD causes

non thermal trauma and surgery burns intestinal obstruction sepsis acities

Stage 1 pressure ulcer

non-blanchable erythema redness remains 30 minutes after pressure removed epidermis intact

viruses

not made up of cells tiny parasites that live within cells of the host and reproduce there

outcome oriented

nurses and clients work together to identify outcomes

parenteral nutrition

nutrition administered directly into the bloodstream IV bypassing the GI tract

secondary data

obtain info from family members, friends and pt's chart

directing questions

obtain more patient information

reconstruction phase

occurs about 21 days after injury proliferation phase

bacteria

one-celled microorganisms found everywhere even in the body invade outside normal location problem results

absorption

onset of drug reaction route of admission blood flow to site of absorption GI fx presence of other food or drugs

patent

open allowing fluids to pass through

benefits of nursing process for nurse

opportunity to work collaboratively with other hcw satisfaction or making a difference opportunity to grow professionally

route of medication administration

oral sublingual mucosal topical parenteral

normal range for vital signs with adults

oral temp 98.6 pulse- 60-100 respirations- 12-20 blood pressure- 120/80

sites for assessing temperature

oral, anal, axillary, tympanic

incubation period

organisms growing and multiplying

problem-oriented records

organized around the patients problems

membrane transport processes

osmosis diffusion filtration active transport

regulation synopsis of lungs

pH control fastest H+ respiratory fluids

systematic

part of an ordered sequence of activities

stage 2 pressure ulcer

partial thickness skin loss involving epidermis, dermis, or both superficial lesion blister, abrasion, shallow crater

Anticholingerics

peristalsis, reduce stomach acid production

prodromal stage

person is most infectious, vague and nonspecific signs of disease

old age life cycle of death

philosophic, inevitable, final

Maslow's Hierarchy of Needs

physiological safety and security love and belonging self esteem cognitive aesthetic self actualization transcendence

sequencing questions

place events in chronological order

crackles (rales)

popping sounds heard on auscultation of the lung when air enters diseased airways and alveoli; occurs in disorders such as bronchiectasis or atelectasis

ions

positively and negatively charged atoms

Cations

positively charged ions

full stage of illness

presence of specific signs and symptoms

community infection

present within 48 hours of admission

antiplatelet agents

prevent blood clotting

parts of nursing diagnosis statements

problem Etiology- root of the problem S- Signs and Symptoms

P.I.E

problem intervention evaluation

body function of protein

produce heat and energy build new tissue manufacture hormones enzymes and anitbodies maintain acid-base balance assist in fluid balance

nonessential amino acids

produced by the liver not essential in diet

Functions of the liver

production of bile, metabolizes and detoxifying potentially harmful agents in the blood

thermogenesis

production of heat

applying moist heat purposes

promotes vasodilation increase capillary permeability decreases blood viscosity increase tissue metabolism reduces muscle tension

interpersonal skills

promoting the dignity and respect of patients and establishing caring relationships

incomplete proteins

proteins that lack one or more of the essential amino acids

primary data

pt is primary data, info pt gives

coring

puncturing out a circular piece of skin

deep tissue injury

purple, blood filled blister, mushy, bruise

Characteristics of data

purposeful, complete, factual and accurate, relevant

closed questions

questions that ask for specific information and elicit a short, one- or two- word answer, a "yes" or "no," or a forced choice

trans fats

raise LDL and lower HDL

saturated fats

raise ldl

dietary cholesterol

raises ldl

wellness diagnosis

readiness for enhancement pt willingness to improve

convalescent stage

recovery from the infection

functions of body water

regulates temp medium for food digestion lubricates joints and membranes transportation of nutrients electrolytes and 02 to cells excretion of waste

nervous system

regulates thirst mechanism, inhibits/stimulates fluid balance via sodium and water I&O

cleansing enemas

relieve constipation or empty bowel

principles of body mechanics

remain close to the object use short lever arms for better control and efficiency maintain your center of gravity close to the objects

maturation phase

remodeling phase

Return flow enema (Harris flush)

removing gas

secondary HTN

renal/endocrine disease process elevates bp

What is a description of professional behavior by a nurse?

requesting assistance if you realize you will not be able to finish your assigned duties on time

four characteristics of being a nurse

responsible, honest, caring, competent

fluid volume deficit

results when water and electrolytes are lost in an isotonic fashion isotonic dehydration

regulation synopsis kidney

retention/excretion maintain ecf electrolytes pH control H+ metabolic waste/toxic substances body fluids

dihiscence

rupture separion of one or more layers of a wound.

benefits of nursing process for client

scientifically based, holistic individualized continuity of care clear, efficient, cost-effective

localized edema

secondary to traumatic injury ex: accidents or surgery, burns

a patient is receiving a ng tube feeding will have which common bed position

semi-fowlers

Basic elements of communication

sender message receiver channel environment feedback

Sensible and insensible fluid

sensible-can be measured insensible-cannot be measured

cell membranes

separate intracellular and extracellular fluids

capillary membranes

separate plasma from interstitail fluid (squamous epithelial cells). Allow solute molecules (glucose, sodium), dissolved gases, water to cross.

epithelial membranes

separate transcellular fluid from interstitial fluid and plasma

vitamin b

serves as coenzymes for metabolism stimulates appetite health nervous and skin assist with growth

hypotonic solution

shift fluids and electrolytes out of intravascular compartment hydrating intracellular interstitial compartments

protozoa, fungi, helminths

single celled animals that live in water made up of one or more cells parasitic worms

assessment for dry heat

skin integrity client's tolerance of heat client's vascular status preexisting illness presence of lotion or ointment

stertorous

snoring

when teaching a patient about ways to avoid fluid overload the nurse explains it is best to eat a diet that is low in

sodium

Maceration

softening of tissue by soaking

phagocytes

specialized blood cells

planning

specifying outcomes and related nursing interventions

which member of the therapy staff would be consulted if a patient had difficulty swallowing

speech therapist

homeostasis

state of equilibrium of internal environment

esophagus transports food to

stomach (peristalsis)

pharmacology

study of drugs

Methods of charting: SOAP

subjective data objective data assessment data plan intervention evaluation revision

sustained-release tablets

swallow hole, do not chew or crush

acities

the accumultion of fluid within the peritoneal cavity

mourning or grieving

the active process of learning to adapt to the loved one's death

Stroke Volume (SV)

the amount of blood d/c from the L ventricle with each contraction

basal metabolic rate

the amount of energy expended while at rest

vasoconstriction

the constriction of blood vessels, which increases blood pressure.

desired effect

the effect that was intended

bereavement

the feelings, thoughts, and responses that loved ones experience following a death

which is true of a one-plus-one program?

the first year of a two-year program prepares the student to take the NCLEX-PN. The student can work as an LPN/LVN while completing the second year of nursing school to become an ADN

Evaporation heat loss

the loss of heat that occurs when a liquid is converted to a vapor

pulse rate

the number of heartbeats or pulses felt in 1 minute of a peripheral artery

a nurse working in the hospital complains about his assignment saying i dont have a single patient younger than 70 years old. I'll be babbling and confused by the end of my shift. these comments reflect

the practice of ageism

gastric decompression

the process of reducing the pressure within the stomach by emptying it of its contents, including ingested food and liquids, gastric juices, and gas

simple carbohydrates (sugars)

the single sugars (monosaccharides) and the pairs of sugars (disaccharides) linked together.

Carbohydrates

the starches and sugars present in foods

culture

the way of life of a group of people

medical uses for drugs

therapeutic-desired effect preventative diagnosis curative health maintenance contraception

subjective data

things a person tells you about that you cannot observe through your senses; symptoms

unwanted fluids

third spacing- accumulation of trapped extracellular fluid in an actual or potential body space where it is not easily exchanged with ECF

psychosocial geriatrics

time of increased personal freedom; economic stability and social relationships

which of the following drug administration routes is through the epidermal layer of the skin into the dermis:

topical

homeostasis with ions

total cations equal total anions

osmolarity

total concentration of all solute particles in a solution

brand name of meds

trade name owned by pharmaceutical

Categories of fats

trans saturated dietary cholesterol monosaturated unsaturated polyunsaturated

antihyperlipidemics

tx high cholesterol and triglycerids in blood

complex carbohydrates (polysaccharides)

types of carbohydrates that are made up of starches and fibers cellulose

sublinqual

under toungue

adverse effects

unintended but more severe or harmful than side effects

When to assess vital signs

upon admission policy and procedures anytime change in condition before and after surgery before and after activity that increases risk before administering meds

cognitive skills

using critical thinking a systematic way to form and shape ones thinking

critical thinking

using skillful reasoning and logical thought to determine the merits of a belief or action

Conditional amino acids

usually not essential, except in times of illness and stress

validating questions

validate what is heard

safest IM injection site

ventrogluteal

regulation synopsis heart/blood

vessels- keep kidneys under pressure to produce urine, react to low blood volume

nutrition, hydration of wound healing

vitamins a c niacin sulfer zinc 8 glasses of water per day

the bed-bath supplies the nurse would plan for when caring for a patient are

washcloth, towels, bath blanket, bath basin

mental orientation

what is the year date day month where are we

antabolism

when body uses components to build/reconstruct new components/tissues

allergic reactions

when the pt's body reacts to the med as a foreign invader to be destroyed 1st time=no response next time will react with allergic response

Basis for Teaching Plan for Older Adults

•Chronic illness limits activities in almost half of older adults. •Meeting expenses of health care is often difficult. -Medication costs, hospitalization costs, and costs of special equipment and supplies •Family members must learn to cope with needs of the ill person. •Family members must adapt to psychological stressors.

forms of communication

•Verbal (language) •Nonverbal (body language) -Facial expressions, touch, eye contact -Posture, gait, gestures -General physical appearance -Mode of dress and grooming -Sounds, silence -Electronic communication