Fundamentals

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds

Normal sodium levels

135-145 mEq/L

normal potassium levels

3.5-5.0 mEq/L

1 oz

30 mL

Normal calcium levels

8.5-10.5 mg/dL

normal chloride levels

95-105 mEq/L

According to evidence-based priority-setting framework, daily weight provides important information about the client's fluid status. A gain or loss of 1 kg indicates a gain or loss of 1 L of fluid; therefore, weighing the client daily will provide the most accurate fluid status measurements

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? Daily weight

The nurse should apply the safety and risk reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse should first escort the client back to his room to protect him from injury due to wandering.

A nurse is caring for a group of clients in a long-term care facility. One of the clients is walking along the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first? Accompany the client back to his room

Depression (stages of grief)

A nurse is talking with a client whose provider recently informed him of terminal pancreatic cancer. When the client reports that he understands the full impact of this diagnosis, the nurse should idenitfy that the client is in which of the following stages of dying? During the stage of _______ the client has realized the full impact of the loss and might express hopelessness and despair

balance

A romberg test evaluates standing ?, first with the client's eyes open and then with them closed. The nurse should remain nearby because the client could fall during the test

Fidelity Nursing Implications

Be faithful to the promise you make to the public to be competent and to be willing to use your competence to benefit the patient to your care.

peripheral pulses

when measuring peripheral pulses how would you document it?

Excessive wax in the ear canal

Factors that can make a hearing aide whistle include a poor seal with the ear mold, an ear infection, excessive wax in the ear canal, an improper fit, or malfunction

Hyponatremia S/S

Nausea Muscle cramps Confusion Muscular twitching, coma Seizures Headache

Death is viewed as an interruption of what might have been

Nurses should consider the following concept of death or young adults with terminal illnesses: ? YOung adults tend to see a whole life ahead of them, so death is often seen as interrupting that life. Young adults do not typically welcome death at this time.

Hypokalemia symptoms

muscle weakness, cramps, ileus, hyporeflexia, parasthesias, flaccid paralysis.

PASS (fire extinguisher)

Pull, Aim, Squeeze, Sweep

Hyperkalemia symptoms

Symptoms- diarrhea, apathy, confusion, cardiac dysrhythmias, muscle weakness, confusion, pulse irregular.

A nurse is preparing to change a dressing on a client who is recieving negative pressure would therapy. What sequence of actions should the nurse plan to take?

Turn off the vacuum on the NPWT device and administer the prescribed analgesic, remove the soiled dressing and preform hand hygiene, apply sterile or clean gloves and irrigate the wound, apply a skin protectant or a barrier film to the skin around the wound, place prepared foam into the wound bed and cover with a transparent dressing, connect the tubing to transparent film and turn on the NPWT unit

a vein soft on palpitation

What type of vein should be picked for a peripheral IV?

10

When preforming tracheostomy suctioning, the nurse should apply suctioning for no more than ? seconds

Incomplete proteins

are missing 1 or more of the essential amino acids necessary for the synthesis of protein in the body. Examples of incomplete proteins include lentils, vegetables, grains, nuts, and seeds

gelatin

counts as fluid intake

acceptance

during the stage of ____, the client will integrate the loss e.g. by making final arrangements

level of pain

establish ____ __ ___ before asking allergies because you need to establish that pain medication is needed before you worry about allergies

concrete operational stage

in Piaget's theory, the stage of cognitive development (from about 6 or 7 to 11 years of age) during which children gain the mental operations that enable them to think logically about concrete events

Hypernatremia

increased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution.

RACE (fire safety)

rescue, alarm, confine, extinguish

drainage

should be assisted by gravity

read

the damn questions

carminative

the nurse should administer a ? enema to assist a client to expel flatus

surgery prep

the nurse should administer a hypertonic fluid solution to cleanse the client's bowels

oil retention enema

the nurse should administer an oil retention enema prior to the removal of a fecal impaction to soften the stool. This make the procedure less painful for the client

sodium polystrene sulfate enema

the nurse should adminster this enema to a client who has a high potassium level

balance

the romberg test tests for?

normal saline

what do you soak the inner canula of a tracheostomy tube in?