NUR 120 FINAL PREP
BMI ranges 25.9 overweight 30 greater obesity
calculate BMI (weight/ heightxheigh)(703)
name the steps a nurse should take for an eviscerated wound.
call for help. provide a sterile moist dressing supine, HOB slightly with bent knees assess for shock
acute hemolytic reaction
chills, fever, LOW BACK PAIN, tachycardia, tachypnea, hypotension. blood in urine. serious, can lead to death.
when dealing with a NG tube, what technique would you use?
clean
Auscultation: absent
collapsed lung. atelectasis.
Auscultation: Crackles
cracking lungs. has fluid in the bubbles.
tactile
pertaining to the sense of touch
Maslow's Hierarchy of Needs
physiological, safety, social, esteem, self-actualization
olfactory
relating to the sense of smell
gustatory
relating to the sense of taste
expectorant
removal or decreasing viscosity
in the stages of GAS, the body is attempting to adapt to the stressor so vital signs and hormones return to normal.
resistance stage.
patient care goals
safety
resistance stage
second stage of the stress response; body attempts to return to normal
Auscultation: Vesicular
soft and low pitched; usually heard over most of both lungs. normal
when changing the dressing for a central line, what type of technique would you use?
sterile
blood transfusion reaction interventions
stop infusion, change tubing, switch to 0.9% NaCL, monitor VS stay with patient. notify provider.
this is the location the location that central lines terminates in the bodd.
superior vena cava
what type of solution should be used in a blood transfusion?
0.9 NS
nasal canula flow rate
1-6 L/min
the 5 steps of crisis intervention
1. Identify the problem 2. List alternatives 3. Choose from among alternatives 4. Implement the plan 5. Evaluate the outcome
nonrebreather mask flow rate
10-15 L/min
Simple face mask flow rate
5-8 L/min
partial rebreather mask flow rate
6-10 L/min
Hypermagnesemia
A serum magnesium level that exceeds 2.6 mg/dL. preeclamspia (pregnancy) antidote- calcium gluconate
What is the nursing process?
Assessment Diagnosis Planning Implementation Evaluation
fluid overload
Distended neck veins, increased BP, tachycardia, sob, crackles in lungs, edema. Treatment- stop infusion, raise hob, assess vs & O2 saturation, adjust the rate as prescribed, and administer diuretics as prescribed. Prevention- monitor I&O.
what is the difference between a PICC vs midline catheters?
PICC ends in SVC Midline ends in midline, subclavian
alarm stage
The first stage of the general adaption syndrome, includes the fight or flight response
Non-hemolytic febrile reaction
a reaction to the WBCs in the donor blood May be prevented by using a leukocyte reduction filter Symptoms: Fever, chills, flushing, back pain
a nurse is explaining the use of *written consent* forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? a. a client who has a prescription for a transfusion of packed red blood cells. b. a client who is being transported to radiography. c. a client who has a prescription for a TB test. d. a client who has a distended bladder and needs catheterization.
a. a client who has a prescription for a transfusion of packed red blood cells.
a nurse is caring for a client who is post operative following abdominal surgery. which of the following actions should the nurse take *FIRST* after discovering that the client's wound has eviscerated? a. cover the incision with a moist sterile dressing. b. have the client lie back with his knees flexed. c. call the surgeon. d. reassure the client.
a. cover the incision with a moist sterile dressing.
presbycusis
age related hearing loss
ABC
airway, breathing, circulation
a nurse in a provider's office is assessing a client who has heart failure. the client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of *fluid volume excess?* a. sunken eye balls b. hypotension c. poor skin turgor d. bounding pulse
d. bounding pulse
cough suppressants
depress the cough reflex
Broncodilators
dilates airways
fluid volume overload
distented neck veins crackles in lungs HTN SOB bounding pulse decrease serum labs
IV therapy
giving fluids through a needle or catheter inserted into a vein advantages-rapid action disadvantage-fluid over load. no room for errors
This electrolyte imbalance can manifest with absent deep-tendon reflexes, bradypnea, or even respiratory failure
hypermagnesaemia (pregnancy, preeclampsia) intervention- stop the infusion
this electrolyte imbalance can cause dysrhythmias, muscle weakness, and possible ileus.
hypokalemia (low K)
fluid volume deficit
hypotension tachycardia increase serum lab thirst dry mucous membranes tenting-skin turgor
what type of solution you should never give for a patient who has intracranial pressure?
hypotonic. always- hypertonic. to pull fluid out
pallor, local swelling at the site, decrease skin temp, around the site damp dressing, slowed rate of infusion.
infiltration
this disorder includes symptoms such as difficulty falling or staying asleep?
insomnia
Mucolytics
loosen thick secretions
oxygen safety
no smoking fire extinguisher avoid synthetic/wool clothing avoid petroleum jelly cords are grounded
This type of transfusion reaction usually presents with a sudden fever, chills, headaches, flushing, vomiting, and muscle pain
non-hemo febrile reaction
Stereognosis
the sense that perceives the solidity of objects, their size, shape, and texture
exhaustion stage
the third stage of the general adaption syndrome, it occurs when stress is prolonged and beyond a person's control
COPD monitoring with O2
too much O2 they will stop ventilating
position for an air embolus
trendelenburg, left side
auscultation: stridor
upper airway obstruction.