PN 2006 FINAL (some questions)
Irregular heart of an older adult
Notify the physician
Use of mobility device appropriate for?
Patient with muscle weakness
Treatments for COPD
Pursed lip breathing Diaphramatic breathing Lung Excercises
How to collect wound culture?
Rotate sterile swab at deep point in the would
Appropriate position for a rectal examination?
Sims Position
Sputum specimen collection
You will ask your person to cough deeply in order to cough up mucous from their bronchi & trachea
assess patients daily weights
graphic sheet and flow sheet
what would right sided CVA affect
left hemiplegia, spatial and perceptual abilities impaired - judging distance/size/speed and position. left sided neglect and problems with short term memory
5th intercostal space
maximum point of impulse
signs of imminent death
mottled skin and pale pallor/cheyne- stokes/decline in BP/no light reaction in pupils/profuse sweating/dyspnea and periods of apnea/cold extremities/loss of hearing and vision/rapid or weak pulse/bladder or bowel incontinence
Cardiopulmonary function
older adults are easily bothered by dyspnea
peripheral perfusion indicator
pain with excercise
signs of hyperglycemia
polydipsia, polyuria, polyphagia, blurred vision, H/A, fatigue, weight loss, blood sugar less than 7, confusion, warm and flushed, increased thirst
10 rights of medication admin
right patient/drug/dosage/time and frequency/route/to be informed/to refuse/reason/drug-drug interaction/documentation
what would left sided CVA affect
right sided hemiplegia, verbal and written language, reasoning, numerical and scientific functions
subcutaneous regular humulin insulin
select at 25 gauge 5/8
S1
the first heart sound, heard when the atrioventricular (mitral and tricuspid) valves close
sliding scale insulin
the nurse will obtain a blood glucose reading immediately prior to administering
S2
the second heart sound, heard when the semilunar (aortic and pulmonic) valves close
What is purulent drainage?
thicker than serous, contains pus with leukocytes and bacteria
When checking glucose it is not appropriate?
to squeeze or milk the finger
Intramuscular injection on 7 month old
vastus lateralis
sites for IM injection
vastus lateralis, deltoid, dorsal gluteal, ventrogluteal
24hr urine collection
Discard all urine and begin another collection if collection process is disrupted
Diarrhea after tube feed is related to?
Formula intolerance
Dyspnea, hyperproduction of mucous and cyanosis is a sign of?
Chronic Bronchitis
Cleared through coughing?
Crackles
double void specimen
discard first specimen and then collect the 2nd
2mm edema is equal to?
4 + pitting edema
Maximum point of impulse
5th intercostal space
Location of APICAL PULSE
5th intercostal space, midclavicular line
When administering a fleet enema?
A patient should be lying on left side
Breathe during auscultation
Breathes with mouth open
S3
CHF, kentucky, with bell
to pronounce death
Check apical pulse/ no pain/no respirations/no pulse/no pearla
What is an example of a report?
audio taped exchange
signs of hypoglycemia
cold and clammy, nervousness and anxiety, irritability, light headed and dizzy, hunger, nausea, shakiness/tremors, coma and death, tachycardia
Wound Care
control bleeding; clean by irrigating with clean, sterile water (never use hydrogen peroxide, never scrub); apply dressing and bandage (dressing is applied directly to the wound, the bandage holds the dressing in place
Artherosclerosis
creates blood flow, affects elimination
Hypoxia
decreased H.R, angina, diaphoresis
