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.