Nursing101

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Basal metabolic rate

(BMR) the rate of energy utilization in the body required to maintain essential activities such as breathing

Rebound Tenderness

(Blumberg's sign) looking for appendicitis

Hyperpyrexia

(Hyperthermia) very high very

Obtendation

(LOC), have to stimulate them to wake up, will arose but maybe very confused

Stupor

(LOC), painful stimuli to arose them, take knuckle and do a sternal tap (rub 2 knuckles into sternum)

Alert

(LOC), spontaneously opens eyes, answers questions, awake and responsive

Lethargic

(LOC), they can open their eyes but kind of drowsy

Point of maximal impulse

(PMI) the point where the apex of the heart touches the anterior chest wall

Exhalation

(expiration) the movement of gases from the lungs to the atmosphere

(extra sounds in heart) best heard with the bell, are kind of hard to hear, usually not harmful

(extra sounds in heart) best heard with the bell, very evident like a gallop

Crackles/Rales

(fine and coarse) made because air is moving over fluid in the lungs

Mouth Breathers

(gaping mouth breathing through it) typically means something is wrong with their nose

vial

(glass or plastic container of parenteral medication with a self-sealing rubber stopper) must be pierced with a needle or a needless adapter to remove medication.

Glasgow Coma Scale

(higher number the better), Eyes open, Best verbal response, Best motor response

Lordosis

(lumbar) sway back, hips come out

Purse Lip Breathing

(patients pucker their lips when breathe) patients with emphysema will do this

reconstitution

(process of adding liquid, known as diluent, to a powdered substance) is done before administering the drug parenterally.

referred pain

(referring to pain) pain that is felt at a location other than its origination; when one physician sends (refers) a client to another physician or specialist.

prefilled cartridges

(sealed glass cylinder of parenteral medication) the cartridge comes with an attached needle. the cylinder is made so that it fits in a specifically designed syringe.

ampules

(sealed glass drug container) must be broken to withdraw the medications.

Needle & gauge size for ID injections:

- 3/8 to 5/8 & 25 to 27

Parts of a 5mL syringe with Luer-Lok tip (5) :

- Luer-Lok tip - Rubber stopper - Barrel - Plunger -Flange

Parts of a 3 mL syringe (4) :

- Plain tip - Flange - Rubber stopper - Plunger

Max vol, needle size, gauge, & angle for a vastus lateralis injection:

-3mL -1 - 1.5 -18 to 25 -90 degrees

IM:

-absorbs rapidly into bloodstream from muscle mass -lower risk of tissue damage when given deep into muscle

When mixing 2 insulins, they must be ________.

-compatible

Adjuncts to Injection: "spreading vs. bunching"

-depends on thickness of subQ fat -use of nondominant hand to manipulate skin& subQ layer to accommodate needle length -if thin, 'bunch' -if thick or extremely large, may need to spread subQ tissue

3 traits of subQ tissue:

-less blood supply -slower absorption -fatty acids

Properties of 'VIal' injections:

-liquid or powder medication -single or multi dose -plastic or glass -aluminum/ plastic cover top -secured rubber topper

facts with 2 medications in 1 syringe:

-meds must be compatible in same syringe -total solution must not exceed MAX VOLUME for target sites -do NOT contaminate one med vial w/the other is using multidose vials; if so discard

Elevated risks for IM:

-nerve damage if given incorrectly -risk of giving meds directly into bloodstream -risk of infection b/c you have broken the skin

What are 4 things you must always do to avoid needle sticks?

-one handed recap -engage the safety cam away from pt -dispose in the 'sharps' correctly -use 'needle-less' devices

What tings should you consider what preparing a ampoule?

-place barrier -snap away from you -Always use filtered needle -carefully discard body & neck of ampoule in sharps box

what are the common subQ sites?

-posterior lateral aspect of upper arm (middle or lower 1/3) -abdomen- below costal margin to above iliac crest -anterior aspect of upper leg -back & 'love handles'

Technique for Z- track:

-pull skin & subQ sideways; hold in place -insert needle&aspirate; if their is no blood in aspirate, inject medication -withdraw needle at same angle, release at displaced skin

Multidose vials: Key points

-rubber top -swab w/alcohol, allow to dry -prime both containers -aspirate doses w/o contaimination -replace needle w/new needle for injection; write on new vial

Where is the deltoid muslce & where do you inject the med at?

-upper arm muscle; 2 to 3 fingers widths below edge of acromian process; inject in the denset of muscle

How do you do 'site selection' for subQ?

-use bunching technique if subQ tissue is scant -ALWAYS rotate sites -seperate by at least 1 in from previous site

ID injection techniques:

-use non-dominant hand to spread skin taunt; bevel MUST be up! -educate client, inject needle just beneath dermis 1/8" -inject med slowly so a 'wheal' or 'bleb' is formed

Board of Nursing

...

Nursing code of Ethics

...

Deltoid site : specs

.5-1mL max dosage 90-degree angle 23-25 gauge needle needle length of 5/8"-1.5" long SITTING, PRONE, SUPINE, or LATERAL position adult and pediatric (15mnths and older)

1 mcg=____g

0.000001

Micro

0.000001 - One millionth part of.

1 cc = _ L

0.001

1 mL=____L

0.001

1 mcg = _ mg

0.001

1 mcg=____mg

0.001

1 mg = _ grams

0.001

1 mg=____g

0.001

1 mm=____m

0.001

Milli

0.001 - One thousandth part of.

1 milliliter (mL)

0.001 liter (L)

1 millimeter (mm)

0.001 meter (m) = 0.1 cm

1/2 minim

0.003 ml

1 cm=____m

0.01

Centi

0.01 - One hundredth part of.

The doctor orders 0.125 mg of digoxin (Lanoxin) elixir for a patient developing heart failure and pulmonary edema. The bottle is labeled 0.05 mg/ml. How many milliliters should the nurse administer?

0.05 mgX xml = 0.125 mg X 1ml x = 2.5 ml

3/4 minim

0.05 ml

1 drop(gtt) = 1 minim (m)

0.06 mL

1 minim

0.06 ml

1 mm=____cm

0.1

Deci

0.1 - One tenth.

1 mm

0.1 cm

max volume for ID injections:

0.1 mL

1 1/2 minims

0.1 ml

Intradermal maximum does

0.1 ml

3 minims

0.2 ml

1/250 grains

0.25 mg

4 minims

0.25 ml

1/200 grains

0.3 mg

5 minims

0.3 ml

1/150 grains

0.4 mg

1/120 grains

0.5 mg

8 minims

0.5 ml

SubQ space can tolerate between ____ to ____ mL of fluid and the medication is aboserbed at a ______ rate than IM injections.

0.5 to 1 mL slower

In order for needle to penetrate the muscle the length of the needle must be ____ to ____ inches in length and ____ to ____ G in diameter.

0.5 to 3 inches 18 to 27 G

A patient has been taking 0.5g tablets of acetaminophen (Tylenol) P.O. for postoperative pain after an inguinal hernia repair. If the patient took a total of 1,500 mg in 72 hours, how many 0.5-g tablets were taken?

0.5g: 1 tab :: 1.5g : X tab= 3 tablets

1/100 grains

0.6 mg

10 minims

0.6 ml

12 minims

0.75 ml

1 L=____qt

1 mL : _____cc

1 mL = _ cc

1 qt : _____L

2.2 lb : ______kg

3 t=____T

30mL=_ounces

gr 15 : _____g

if the pulse is irregular then count for _ minute

iss

1 1/2 or one and a half

1 qt = ____ L

1 L

1000 mL

1 L

1000 mL = ____ L

1 L

39.4 in = ____ M

1 M

3 tsp = ____ T

1 T

15 mL

1 Tbsp

1 mL = ____ cc

1 cc

15 gtt or 15 m = ____ cc

1 cc

6 oz = ____ coffee cup

1 coffee cup

1 milliliter (ml) = ____ cc

1 cubic centimeter (cc)

8 oz

1 cup

240 milliliters (ml) = ___ c

1 cup (c)

8 ounces (oz) = ____ c

1 cup (c)

1 tsp

1 dram= 5mL

4 mL = ____ fl dr

1 fl dr

60 m = ____ fl dr

1 fl dr

2 T = ____ fl oz

1 fl oz

30 mL = ___ fl oz

1 fl oz

12 in = ____ ft

1 ft

1,000,000 mcg

1 g

1000 mg

1 g

15 gr

1 g

15 gr = ____ g

1 g

Conversions:

1 g = 1000 mg 1000 mcg = 1 mg 1 kg = 1000 g

Weight: Metric: 1 g or 1000 mg

1 g or 1000 mg = 15 (16) gr (apothecary)

4 qt

1 gal

4 qt = ____ gal

1 gal

4 quarts

1 gallon

8 oz = ____ glass or cup

1 glass or cup

60 mg = ____ gr

1 gr

Weight: Metric: 60 (65) mg

1 gr (apothecary)

1 m = ____ gtt

1 gtt

1 minim

1 gtt

2.5 cm

1 in

2.5 cm = ____ in

1 in

1000 g

1 kg

1000 g = ____ kg

1 kg

2.2 pound (lb)

1 kg (1000 g)

Other: Metric: 1 kg or 1000g

1 kg or 1000 g = 2.2 lbs (apothecary)

16 oz = ____ lb

1 lb

1 quart = ____ L

1 liter

1 gtt = ____ m

1 m

1 cc

1 mL

1 cc = ____ mL

1 mL

15 gtt or 15 m = ____ mL

1 mL

Max volume for subQ:

1 mL

Volume: Metric: 1 mL or 1 cc

1 mL or 1 cc = 15 (16) minims (apothecary) = 15 - 16 gtt (household)

How fast do you inject medication?

1 mL per 10 sec

Max Vol, needle size, gauge, & angle for deltoid muscle:

1 mL, 1 to 1.5 inch, 18 to 25, 90 degrees

1000 mcg

1 mg

1000 mcg = ____ mg

1 mg

Weight: Metric: 1 mg or 1000mcg

1 mg = .001 g

15 minims

1 ml

Insulin maximum dose

1 ml

Subcutaneous maximum dose

1 ml

30 mL

1 ounce

2 tablespoons (T or tbs)

1 ounce (oz)

30 gm

1 ounce (oz)

30 mL

1 oz

8 dr = ____ oz

1 oz

2 tbsp

1 oz= 30mL

16oz

1 pint

16 fl oz

1 pt

16 oz = ____ pt

1 pt

2 cups = ____ pt

1 pt

1 L = ____ qt

1 qt

1000 mL = ____ qt

1 qt

2 pt = ____ qt

1 qt

32 oz = ____ qt

1 qt

1 Litter

1 quart

240 mL

1 standard measuring cup

8 fl oz

1 standard measuring cup

The doctor orders 0.05 mg Synthroid P.O., but the only Synthroid on hand is in tablets that contain 0.025 mg each. How many tablets should you give?

1 tablet X 0.05mg = 0.05 mg X x x= 2 tablets

How long should a needle be for an IM injection?

1 to 1.5 inches to reach muscle

Needle size for IM:

1 to 1.5in; based on age/weight, sometimes it could be 1/2 to 2in.

5 mL

1 tsp

5 mL = ____ tsp

1 tsp

3 ft = ____ yd

1 yd

Intramuscular needle size

1"-3"

Which of the following are examples of well-stated nursing interventions? 1. Offer patient 60 mL water or juice (prefers orange or cranberry juice) every 2 hours while awake for a total minimum PO intake of 500 mL. 2. Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each shift to mark off fluid intake on record at bedside. 3. Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is awake. 4. Manage patient's pain.

1, 2, 3

1 L=____mL

1,000

1 g=____mg

1,000

1 kg=____g

1,000

1 m=____mm

1,000

1 mg=____mcg

1,000

1 g=____mcg

1,000,000

Dorsogluteal site : specs

1-2mL max dosage 90-degree angle 20-23 gauge needle needle length of 1"-1.5" long PRONE position adult and pediatric (2 years and older)

Vastus lateralis site (adult and pediatric) : specs

1-2mL max dosage 90-degree angle 20-23 gauge needle needle length of 1.25"-1.5" long SUPINE or SITTING posistion adult and pediatric (2 years and older)

Ventrogluteal site : specs

1-2mL max dosage given at a slight angle towards the iliac crest 20-23 gauge needle needle length of 1"-1.5" long SUPINE,LATERAL or STANDING position adult and pediatric (2 years and older)

What areas should a nurse be concerned with, within the nursing process, that are related to safety?

1. Assessing the individual 2. Assessing the environment 3. Risk factor assessment

Safety considerations for the toddler/preschooler?

1. Childproofing the home 2. Be alert to manifestations of child abuse 3. Use car seats appropriately

What is an incident report? What are important factors to remember when filing an incident report?

1. Documentation about an event that was out of the ordinary 2. Not intended for the pt chart 3. Be clear and concise and turn in to designated personnel.

Safety concerns for the older adult

1. Falls 2. Driving 3. Preventing burn injuries 4. Preventing skin tears

What are some of the safety goals of the Joint Commission?

1. Improve pt identification 2. Improve communication between caregivers 3. improve safety of using medications 4. Improve effectiveness of clinical alarm systems

what are the risk factors for skin breakdown?

1. Lifestyle variables 2. changes in health status 3. illness 4. therapeutic measures- IV can cause infection

Safety considerations for adolescents?

1. MVC- Importance of wearing a seatbelt 2. Alcohol and tobacco use 3. Body piercings

How is pt identification improved

1. Using two identifiers (DOB and Name) 2. Do not use room number or bed number!

What are the basics of the evaluation step?

1. Work with pt to measure the success of the outcomes 2. helps direct future nurse-pt interactions 3. id additional factors needed to achieve outcome (pictures) 4. plan modification 5. continue with care plan if more time is needed

Crepitations

1. a dry, crackling sound like that of crumpled cellophane, produced by air in the subcutaneous tissue or by air moving through fluid in the alveoli of the lungs ; 2. a crackling, grating sound produced by bone rubbing against bone.

Implementing

1. acquire first aid knowledge 2. preventing injury 3. teaching to promote safety

2 rules for maxing two insulin's:

1. always draw up fast acting insulin first, then long acting. 2. adminstering rule: manufacters recommend administering insul w/in minutes of preparation

Elements of evaluation

1. collecting evaluative data 2. interpreting and summarizing findings after identifying evaluative criteria 3. documenting judgment 4. modifying poc

3 purposes of Z- track:

1. creates a broken pathway to 'lock' med into targeted muscle 2. prevents seepage into subQ tissue 3. minimizes local skin irritation

What are the four steps of performance improvement

1. discover a problem 2. plan a strategy using indicators 3. implement the change 4. assess the change

Physical assessment

1. establishing nurse/patient relationship 2.assisting with hygiene practices-partial care, pt does most of the care with nurse assist 3. inspect and palpate skin

outcome identification and planning

1. identify unsafe situations 2.id potential hazards in the environment 3. demonstrates safety measures to prevent injury 4. establish safety measures with family 5. familiarity with environment 6. id resources for safety information 7. remain free of injury during hospitalization

Convert Celsius to Fahrenheit

1. multiply by 1.8 2. add 32

What is involved in a safety assessment?

1. nursing hx-hx of falls, assitive devices, drug/alcohol abuse 2. physical exam 3. assess the environment

methods of improving professional performance

1. peer review 2. quality assurance programs 3. structure evaluation 4. process evaluation 5. nursing audit

male peri care

1. perform hand hygiene and wear gloves 2. wash and rinse groin area with soap and water 3. clean tip of penis and then move downward 4. circular motion from meatus outward

vaginal care

1. perform hand hygiene and wear gloves 2. wash and rinse groin area with soap and water 3. spread labia wash from pubic area toward anal area 4. Inner to outer

5 Injection principles:

1. select site& cleanse outward motion 2. distract client 3.insert quickly using correct angle 4. aspirate if indicated (5 to 10 sec) 5. stop if blood in aspirate

tips on hair care

1. style how pt wants it 2. brush daily to distribute oils and stimulate circulation 3. comb tiny sections if tangled 4. braid if ok with pt 5. treat infestations as ordered

Convert Fahrenheit to Celcius

1. subtract 32 2. divide by 1.8

How should dentures be taken care of?

1. use gloves 2. cool or lukewarm water 3. over a towel lined basin 4. with a soft toothbrush and toothpaste or commercial cleaner 5. store in cool or lukewarm water

the right syringe choice will depend on 3 things:

1. volume of med 2. medication perscribed 3. method of measurement

tips in providing eye care

1. wear gloves 2. use water or ns with clean cotton ball or washcloth 3. wipe from inner to outer one cotton ball/cloth area per swipe

1/40 grains

1.5 mg

What can a nurse do to implement safety for patients?

1.Acquire first aid knowledge 2.Prevent injury 3. Teaching to promote safety

What are some safety concerns for the neonate infant?

1.Avoid behaviors that might harm the fetus. 2. Never leave the infant unattended 3. Use crib rails 4. Use car seats 5. Remember that the infant is helpless

tips in providing ear care

1.wash external ear with soap and water 2. do not use foreign bodies in the ear,like swabs 3. irrigate only with a dr.'s order 4. check batteries in hearing aids

1 T=____fl oz

1/2

1/2 or one half

Insulin needle size

1/2"-5/8"

Subcutaneous needle

1/2"-5/8"

grain 1/4 = 15 mg

1/4 grain __ = __ mg

1 cm : _____mm

1 cm=____mm

Deka

10 - Ten times.

A doctor orders 25 g of lactulose (Cephulac) for a patient entereing a prehapatic coma. The bottle is labeled 10 g/15ml. How many milliliters should the patient receive?

10 g X xml = 15 ml X 25g X= 37.5

1/6 grains

10 mg

1 centimeter = ____ mm

10 millimeters

2 1/2 drams

10 ml

1 cm

10 mm

D10

10% Dextrose

1 m : _____cm

100

1 m=____cm

100

Hecto

100 - One hundred times.

1 meter (m)

100 centimeters (cm) = 1000 mm

1 M = ____ cm

100 cm

1 m

100 cm

1000 mm = ____ cm

100 cm

1 1/2 grains

100 mg

The doctor orders 100 mg Dilantin oral suspension t.i.d. for your patient. The label reads Dilantin 125 mg/5ml. How many mililiters should you give?

100 mg X 5 ml = 125 mg X x x= 4ml

a fever is when the body temp rises above

100.4f(38.0c)

1 L : _____mL

1000

1 L = _ mL

1000

1 g: _____mg

1000

1 gram= _mg

1000

1 kg :______g

1000

1 kg = _ grams

1000

1 mg = _ mcg

1000

1 mg: _____mcg

1000

Kilo

1000 - One thousand times.

2.2 lb

1000 g

2.2 lb = ___ g

1000 g

1 Kilogram (kg)

1000 grams (g)

1 kilogram (kg) = ____ g

1000 grams (g)

1 L = ____ mL

1000 mL

1 qt = ____ mL

1000 mL

32 fl oz, 1 qt

1000 mL

1 quart (qt)

1000 mL (32 ounces)

1 mg = ____ mcg

1000 mcg

15 gr = ____ mg

1000 mg

15 grains

1000 mg

15 grains (gr)

1000 mg = 1 gram (g)

1 milligram (mg)

1000 micrograms (mcg)

1 milligram (mg) = ____ mcg

1000 micrograms (mcg)

1 gram (g)

1000 milligrams (mg)

1 gram (g) = ____ mg

1000 milligrams (mg)

1 liter (L)

1000 milliliters (mL)

1 liter (L) = ____ ml

1000 milliliters (ml)

1 M = ____ mm

1000 mm

1 m

1000 mm

100 cm = ____ mm

1000 mm

1 Kg

1000gm

1 Liter

1000mL

1 ft : _____in

1 ft

12 in

1 ft = ____ in

12 in

1 glass = ____ oz

12 ounces

Normal range respriatory rates adult Men

12-18

Newborn

120 - 60 beats/min

Normal blood pressure parameters for adults

120/80

average BP for healthy adult

120/80 mm Hg

1 gallon

128 oz

over _________ in an adult at least with 2 readings is considered hypertension

140/90

1 T : _____mL

1 T=____mL

1 g=____gr

1gram=_grains

3 t or tsp=_mL

Weight: Metric: 15 g

15 g = 4 drams (apothecary)

1000 mg = ____ gr

15 gr

1 cc = ____ gtt

15 gtt

1 mL = ____ gtt

15 gtt

1 cc = ____ m

15 m

1 mL = ____ m

15 m

1 tablespoon (T or tbs)

15 mL

Volume: Metric: 15 mL

15 mL = 0.5 oz or 4 dr (apothecary) = 1 T (household)

1/4 grains

15 mg

1 tablespoon (tbsp) = ____ ml

15 milliliters (ml)

1 tbsp.

15 ml

1/2 ounce

15 ml

2 1/2 grains

150 mg

1 tbsp

15mL

1 cc = _ minims

1 lb : _____oz

1 lb= _ oz

1 lb=____ oz

1 pt=____fl oz

1 lb = ____ oz

16 oz

1 pt = ____ oz

16 oz

1pint

16 oz

2 cups = ____ oz

16 oz

Normal range respriatory rates adult

16-20

Gauge size for IM:

18 to 25;

Trauma Care (TC) : specs

18-22 gauge needle needle length of 1" and longer

6 fl oz

180 mL

Volume: Metric: 180 mL

180 mL = 6 oz (apothecary) = 1 cup of coffee

Volume: Metric: 1 Liter

1L = 1 qt or 32 oz (apothecary) = 1 qt (household)

60mg

1grain (gr)

15 drops (gtt)

1mL

15 gtt= 15-16 minim (m)

1mL

Deltoid muscle allows only small amounts of medication (____mL or less) to be injected and a ____in or shorter needle must be used to avoid hitting the ______ bone.

1mL 1 inch humerous

8 drams

1oz

2 pints

1quart

palpate

1st two finger(no thumb)

weak pulse is documented as

1 L=____pt

1 fl oz=____T

1 oz : _____T

1 pt : _____C

1 pt=____cups

1 qt : _____pt

1 qt=____pt

hypertension is the #___ cause of dialosis

it takes ___people to get the pulse deficit

Which of he following outcomes are correctly written? 1. Offer Mr Myer 60 mL fluid every 2 hours while awake. 2. During the next 24-hr period, the patient's fluid intake will total at least 2,000 mL. 3. By discharge Mrs Gaston will know how to bathe her newborn. 4. At the next visit, 12/23/12, the patient will correctly demonstrate relaxation exercises.

2 & 4

1 fl oz = ____ T

2 T

30 mL = ____ T

2 T

1 pt = ____ cups

2 cups

16 oz = ____ cups

2 cups

1/30 grains

2 mg

30 minims

2 ml

1 quart = ____ pints

2 pints

1 qt = ____ pt

2 pt

32 oz = ____ pt

2 pt

32 fl oz

2 pt, 1 qt

1 ounce (oz) = ____ tbsp

2 tablespoons (tbsp)

During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to do which of the following? 1) Formulate and validate prioritized nursing diagnoses 2) Identify expected patient outcomes 3) Select evidence-based nursing interventions 4) Communicate the plan of nursing care

2, 3 & 4

Use Maslow's hierarchy of human needs to prioritize the following patient problems from highest priority (#1) to lowest priority (#4): 1) Disturbed Body Image 2) Ineffective Airway Clearance 3) Spiritual Distress 4) Impaired Social Interaction

2, 4, 1, 3

1 Kg = _ lb

2.2

1 kg=____lb

2.2

1 kg

2.2 lb

1 kg = ____ lb

2.2 lb

1000 g

2.2 lb

1000 g = ____lb

2.2 lb

1 kilogram (kg) = ____ lb

2.2 pounds (lb)

1Kg

2.2Ib

1 in : ______cm

2.5

1 in = _cm

2.5

1 in=____cm

2.5

1 inch (in) (") = ____ cm

2.5 centimeters (cm)

1 in = ____ cm

2.5 cm

1 inch (in)

2.5 cm

1 inch

2.54 cm

Other: Metric: 2.54 cm

2.54 cm = 1 in (household)

bladder should cover ____________ of the circumference of the upper arm

2/3

1/2 grains

20 mg

1/3 grains

20 mg

Intramuscular gauge size

20-23

3 grains

200 mg

Subcutaneous gauge needle

23-25

1 c : _____mL

240

1 cup=____mL

240

8 fl oz

240 mL

1 cup (standard measuring cup)

240 mL (8 ounces)

Volume: Metric: 240 mL

240 mL = 8 oz (apothecary) = 1 glass or 1 measuring cup (household)

8 ounces (oz) = ____ ml

240 milliliters (ml)

Gauge size for subQ:

25 to 27

4 grains

250 mg

2.5 L = _ mL

2500

Intradermal gauge needle

26-27

Insulin gauge size

27-29

1 oz : _____g

strong/normal pulse is documented as

1 T : _____t

1 T=____t

15 mL = _ t or tsp

1T or tbsp=_t or tsp

1 yd = ____ ft

3 ft

1/20 grains

3 mg

45 minims

3 ml

1 tablespoon (tbsp) = ____ tsp

3 teaspoons (tsp)

1 T = ____ tsp

3 tsp

intramuscular injection equipment

3-5 mL syringes are used. 22 gauge needle that is 1.5 to 2 inches long.

you have to hold the thermometer in place for ___________ in axillary temp.

3-9 minutes

Needle size for subQ:

3/8 to 5/8

How long should a needle be for a subQ injection?

3/8 to 5/8 inches to reach subcutaneous & intradermal tissue

Intradermal needle size

3/8"-5/8"

1 fl oz=____mL

1 ounce = _ mL

1 oz : _____mL

you have to wait _______minutes to take a oral temp. if the person have drunk anything

1 foot

30 cm

Weight: Metric: 30 g

30 g = 1 oz (apothecary)

1 fl oz

30 mL

1 fl oz = ____ mL

30 mL

1 ounce (oz)

30 mL

2 T = ____ mL

30 mL

Volume: Metric: 30 mL

30 mL = 1 oz or 8 dr (apothecary) = 2 T or 6 t (household)

1 ounce (oz) = ____ ml

30 milliliters (ml)

1 ounce

30 ml

5 grains

300 mg

1oz

30mL

1 L=____fl oz

1 qt=____fl oz

1 qt = ____ oz

32 oz

1 quart

32 oz

2 pt = ____ oz

32 oz

grains (gr) V = ____ mg

325 milligrams (mg)

Normal range oral temperature

35.5-37.5 C (95.5-99.5 F)

Axillary

36.5 C or 97.6 F

Tympanic

37.5 C or 99.5 F (core)

1 M = ____ in

39.4 in

there are ________ lobes in the right lung and ____________- in the left lung

3;2

bounding pulse is documented as

1 L=____cups

1 gal : _____ qt

1 qt=____cups

Volume: Metric: 4 - 5 mL

4 - 5 mL = 1 dr or 60 minims (apothecary) = 1 t (household)

1 fl dr = ____ mL

4 mL

1/15 grains

4 mg

1 dram = ____ ml

4 milliliters (ml)

1 dram

4 ml

1 gal = ____ qt

4 qt

SubQ: angle, volume, rate of absorption, level of discomfort, risk for tissue injury

40 or 90 degrees, up to 1 mL, slower, higher, elevated

Subcutaneous angle

3/4 grains

45 mg

Angle size for subQ: (what is the most common.?)

45 or 90 degrees; 45 is used most often!

1 t : _____mL

1 t=____mL

1t = _ mL

1 teaspoon (t or tsp)

5 mL

1 tsp

5 mL

1 tsp = ____ mL

5 mL

1 teaspoon (tsp) = ____ ml

5 milliliters (ml)

1 1/4 drams

5 ml

1 tsp.

5 ml

Angle needed for ID injections:

5 to 15 degrees

Dermis: angle, volume, rate of absorption

5 to 15 degrees, up to 0.1mL, Slow

5% Dextrose

The following are all classic elements of evaluation. What is the correct sequence? 1. Interpreting and summarizing findings 2. Collecting data to determine whether evaluative criteria and standards are met. 3. Documenting your judgment 4. Terminating, continuing, or modifying the plan 5. Identifying evaluative criteria and standards (what you are looking for when you evaluate, eg, expected pt outcomes)

5,2,1,3,4

Intradermal angle

5-10

1 pt : _____mL

500

1 pt=____mL

500

16 fl oz, 1 pt

500 mL

1 pint (pt)

500 mL (16 ounces)

Volume: Metric:

500 mL = 1 pt or 16 oz (apothecary) = 1 pt (household)

7 1/2 grains

500 mg

1 pint = ____ mg

500 milligrams (mg)

pain is the ____________ vital sign

5th

apical pulse is located at the ________________---

5th intercostal left, midclavicular line

1 fl oz=____t

1 ounce = _ t or tsp

1/10 grains

6 mg

1 coffee cup = ____ oz

6 ounces

1 coffee cup = ____ oz

6 oz

gr 1 : _____mg

gr i = _ mg

gr i=____mg

Adult

60 - 100 beats/min 12 - 18 breaths/min

1 fl dr = ____ m

60 m

1 gr = ____ mg

60 mg

1 grain

60 mg

1 grain (gr)

60 mg

Your patients's order reads aspirin gr 10 P.O. daily, but the unit-dose package says aspirin 325 mg. How many tablets should you administer daily?

60 mg X 10 grains = x X 1 grain x X 325 mg = 1 tablet X 600 mg X= 1.846 all probably round to 2

A prescriptoin reads phenobarbital gr 1/4 take gr 1/2 t.i.d. P.O. daily. How many milligrams of phenobarbital should this patient receive?

60 mg X grain 1/4 = X x 1 grain X x grain 1/4 = 15mg x 1/2 X= 30 mg

Normal Pulse Rate

60-100 bpm average pulse: 72 bpm

Normal pulse rate for adults

60-80 BPM ( beats per minute)

10 grains

600 mg

1 gr

65 mg

grains (gr) X = ____ mg

650 milligrams (mg)

viss

7 1/2 or seven and one-half or 7.5

1/8 grains

7.5 mg

average normal adult range in pulse______-`

72 bpm

6 - 12 years

75 - 110 beats/min

2 - 6 years

75 - 120 beats/min

1 C : _____oz

1 cup=____fl oz

1 oz = ____ dr

8 dr

2 drams

8 ml

1 cup = ____ oz

8 ounces

1 glass or cup = ____ oz

8 oz

1 cup

8 oz= 240 mL

1 - 12 months

80 - 100 beats/min 40 - 60 breaths/min (infants)

Insulin angle

90 degrees

Intramuscular angle

90 degrees

what are the requirements for lovenox injections?

90 degrees & skin bunched!

How do you give a Lovenox injection?

90 degrees, pinch skin up

Angle & volume for IM:

90 degrees, up to 3 mL

Normal temp. range

97.5 - 99.5

Axillary Temp. average

97.6 F or 36.7 C

Oral Temp. average

98.6 F or 37.0 C

Rectal Temp. average

99.6 F or 37.5 C

Vastus lateralis site (newborn) : specs

< 0.5mL (infants), 1.0mL (pediatric) max dosage 45-degree angle (directed towards the knee) 22-25 gauge needle needle length of 1/2"-1" long SUPINE or SITTING position pediatric (newborn to 2years)

Orthostatic hypotension

A fall in BP associated with dizziness, syncope (fainting), and blurred vision, which occurs upon standing; also called postural hypotension

Health Care Proxy

A person chosen by the patient to carry out the patients wishes as expressed in Advanced directive

Bradycardia

A slow pulse, less than 60 BPM

A/P: (apical/pulmonic) is the dub, aortic pulmonic valves closing in diastole, hear these with diaphragm of stethoscope

5 things to always remember when preparing injections?

ALWAYS: review, know, research, check, properly label

Emergent Assessment

AMPLE= Allergies, Medications, Past Medical History, Last Meal, Events Leading to Injury

ﬂatus

gas in the intestines or stomach; gas expelled through the anus.

Capillary Refill

gives idea of perfusion

verbal communication

giving information, news, or messages by speaking or writing.

communication

giving, receiving, and interpreting information (maybe verbal or nonverbal).

4 types of thermometers

glass bulb w/ mercury, electronic, tympanic and disposable

Properties of ampoule:

glass container, narrow, "scored neck"

onset stage of fever

gradual or sudden; happens when the body tries to conserve and manufacture heat to raise the core temperature

grain

gr.

grain

grain 1 = 60 mg

grain __ = __ mg

G or gm

gram

g, gm

gram

tachycardia

greater than 100 bpm

nursing care plan

guidelines used by healthcare facilities to plan the care for clients.

Malleus

hammer bone of the middle ear

Oral

hardest to take temperature many things affect the outcome 96.8 - 100.4 F or 36 - 38 C

Anemia

have lost or lack of oxygen carrying ability of the blood, tend to breath faster to carry more oxygen in

isometric

having the same length or dimensions, as isometric exercises(pushing against stable resistance);also called muscle setting.

headache

what is evaluative criteria

health problems, did interventions work, was the time frame met, is there a need for modification

Cranial Nerve VIII

hearing (ototoxity kills this)

______________ and __________ rate increase in order to meet _______________ in a fever

heart and respiration ; metabolic demands

3 steps in pulse

heart contracts to force out, walls expand to accept the pressure.. these waves are called pulse

support arm on surface @ ______________ when taking BP

heart level

Cardiac Output

heart output, how much blood is being pushed and how effeciciently is it being pushed

Evaporation

heat is lost through the process of changing from liquid to gas

height

____________ and ___________ are good predictors

height and weight

Nurse's responsibilities to patients in regards to safety and security

help provide a safe environment, gain knowledge about biological, chemical and radioactive agents, gain skills on how to deal with natural and manmade disasters. Safety drills.

bevel

helps skin to close quickly after the administration of a medication

Subcutaneous purpose

heparin, insulin, immunizations, allergy

occult

hidden

Wheeze

high pitched whistling sound of air forced past by a partial obstruction, as found in asthma or emphysema

trapeze

horizontal bar suspended above and attached to the bed, which is used to pull up to a sitting position or to lift the shoulders and hips off the bed.

h or hr

hour

h., hr.

hour

h.s.

hour of sleep

Strength/amplitude

how hard heart is beating

Respiratory effort

how hard they are trying to breathe (should have ease)

Respiratory Rate

how many times are they breathing in one hour

Blood Volume

how much blood the heart is trying to push through the body

Systemic Vascular Resistance

how much resistence the vessels are getting when heart is trying to pump

Abdominal Girth

how round it is (measure at umbillicus)

Blood Viscosity

how thick it is

parts of a needle

hub, shaft, bevel

Valsalva

huge drop in heart rate caused ny vagus nerve stimulation of trying to hard or bearing down

Kyphosis

hunch back

hypodermically

Would the client be hypertensive or hypotensive?

hypotensive

SOS

if necessary

Why might you need to 'spread' the subQ tissue?

if the individual is very very large

The ventrogluteal muscle is located just below the ______ ______?

iliac crest

STAT

immediately

stat

immediately

stat

immediately, at once

body language

impressions one conveys through body movements and posture, eye contact, and other non-verbal means.

intramuscular injections

in muscle tissue

planning

in nursing process, developing goals to prevent, reduce, or eliminate problems and identifying nursing interventions that will assist in meeting these goals.

planning

in nursing process, developing goals to prevent, reduce, or eliminate problems and identifying nursing interventions that will assist in meeting these goals..

evaluation

in nursing process, measuring the effectiveness of the other steps.

implementation

in nursing process, the carrying out of nursing care plans; also called interventions.

Pleximeter

in percussion, the middle finger of the dominant hand placed firmly on the client's skin

Plexor

in percussion, the middle finger of the non-dominant hand or a percussion hammer used to strike the pleximeter

rectus femoris site

in the anterior aspect of the thigh. may be used for infants.

Semicircular canals

in the inner ear; contain the organs of equilibrium

potential needs

in the nursing process, needs which may occur; identiﬁed as at risk for...

incontinence

inability to control urination or defecation (adj: incontinent).

urinary retention

inability to empty the bladder of urine.

inch

disadvantages of rectal temp.

inconvenient, unpleasant, possible injury to rectum, must remain still

tahypnea

increase/rapid breathing

Glaucoma

increased introccullar pressure (increased pressure behind the eye)

shivering =

increased respiration's

Homan's sign

indicates pressence of a clot in their lower extremities

Furnucle

infected hair follicle, reddness around it

pediculosis

infested with lice

Conjunctivitis

inflammation of the bulbar and palpebral conjunctiva

Gingivitis

inflammation of the gums (red and swolle)

Dacryocystitis

inflammation of the lacrimal sac

Parotitis

inflammation of the parotid salivary gland

Glossitis

inflammation of the tongue

Paronychia

inflammation or the tissues surounding the nail

subjective data

information that consists of the client's opinions and feeling about what is happening, conveyed to the nurse either directly or through body language

inj

injection

common intradermal injection sites

inner aspect of the forearm, other areas that may be used are the back and upper chest.

Intradermal site

inner lower froearm, middle of the back

Bronchovesicular

inspiration and expiration, a medium pitched sound

Inhalation

inspiration; the act of breathing in; the intake of air or other substances into the lungs

intravenous injections

instilled into the vein

subcut injection sites

insulin and heparin is in the abdomen. also outer back, upper arm (where it's fleshier) the outer layer of the thigh and upper buttocks. absorption fastest to slowest is abdomen, arms, thights, and buttocks.

Units

insulin is measured in ___

pre-combined insulin

insulin pumps/ pens. Its commonly rapid acting form and an intermediate form (70/30).

Examples of meds for subcutaneous injections:

insulin, blood thinners, allergy

I & O

intake and output

hypoxemia

interference with blood oxygenation.

2 types of respiration's

internal and external

When a patient you are admitting to the unit asks you why you are doing a history and exam since the doctor just did one, your best reply is: a. "In addition to providing us with valuable information about your health status, the nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." b. "It's hospital policy. I know it must be tiresome, but I will try to make this quick." c. "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care. This information will help me develop a plan of care individualized to your unique needs." d. "We want to make sure that your responses are consistent and that all our data are accurate."

a. "In addition to providing us with valuable information about your health status, the nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths."

As a nurse, you follow the guidelines for a healthy lifestyle. How can this promote health in others? a. By being a role model for healthy behaviors. b. By not requiring sick days from work. c. By never exposing others to any type of illness d. By not being overweight

a. By being a role model for healthy behaviors. (Good personal health enables the nurse to serve as a role model for patients and families.)

To determine the significance of a blood-pressure reading of 148/100, it is first necessary to: a. Compare this reading to standards b. Check the taxonomy of nursing diagnoses for a pertinent label. c. Check a medical text for the signs and symptoms of high blood pressure d. Consult with collleagues.

a. Compare this reading to standards

regional anesthesia

interruption of sensory nerve conductivity to speciﬁc area of the body (includes conduction block, ﬁeld block, nerve block).

intradermal

four parenteral administration routes

intradermal injections, subcutaneous injections, intramuscular injections, intravenous injections.

Where do individuals learn their health beliefs and values? a. In the family b. In school c. From school nurses d. from peers

a. In the family (Healthcare activities, heal beliefs, and health values are learned within one's family)

A school nurse notices that Jill is losing weight and wants to perform a focused assessment on Jill's nutritional status, fearing that she might have an eating disorder. How should the nurse proceed? a. Perform the focused assessment. This is an independent nurse-initiated intervention. b. Request an order from Jill's physician since this is a physician-initiated intervention. c. Request an order from Jill's physician since this is a collaborative intervention d. Request an order from the nutritionist since this is a collaborative intervention

a. Perform the focused assessment. This is an independent nurse-initiated intervention

intramuscular

Which of the following levels of basic human needs is most basic? a. Physiologic b. Safety & Security c. Love & belonging d. Self-actualization

a. Physiologic

intravenous

IVPB

intravenous piggyback

breathing is ___________-

involuntary

A patient complains about feeling nauseated after lunch. This is an example of what type of data? a. Subjective b. Objective c. Signs and symptoms d. Overt

a. Subjective

Mr Price tells the nurse he fears becoming "hooked on drugs" and consequently waits until his pain becomes unbearable before requesting his prn analgesic. The nurse plans to be more attentive to Mr Price and to assess his needs for pain management more closely. Which of the following consequences of informal planning ought to be the major concern for this nurse? a. The lack of a coordinated plan known by everyone will result in uneven pain management. b. Faulty prioritization of patient needs c. Inability to evaluate the patient's responses to nursing care d. Lack of a record for reimbursement purposes

a. The lack of a coordinated plan known by everyone will result in uneven pain management.

From which of the following are outcomes derived? a. The problem statement of the nursing diagnosis b. The etiology of the problem of the nursing diagnosis c. The defining characteristics of the problem d. The evaluative statement

a. The problem statement of the nursing diagnosis (Outcomes are derived from the problem statement of the nursing diagnosis. For each nursing diagnosis in the plan of care, at least one outcome should be written that, if achieved, demonstrates a direct resolution of the problem statement)

An experienced nurse tells you not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underline your response? a. When intuition is used alone, there are increased risks and fewer benefits. Intuition often moves problem-solving forward quickly, but it might result in a lot of trial-and-error approaches. b. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. c. The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years. It's time to champion intuitive, creative thinking! d. It's simply a matter of preference. Some of us are logical, scientific thinkers, and some are intuitive, creative thinkers

a. When intuition is used alone, there are increased risks and fewer benefits. Intuition often moves problem-solving forward quickly, but it might result in a lot of trial-and-error approaches.

You tell your instructor that your patient is fine and has "no complaints." You are likely to hear: a. You made an inference that she is fine because she has no complaints.How did you validate this? b. She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship. c. Sometimes everyone gets lucky. Why don't you try to help another patient? d. Maybe you should reassess the patient. He has to have a problem. Why else would he be here?

a. You made an inference that she is fine because she has no complaints.How did you validate this?

The agent-host-environment model of health and illness is based on the concept of: a. risk factors b. infectious diseases c. behaviors to promote health d. stages of illness

a. risk factors (The interaction of the agent-host-environment creates risk factors that increase the probability of disease)

abbreviation for and

abbreviation for cubic centimeter

abbreviation for dram

gtt

abbreviation for drop

H.S./ hs

abbreviation for hour of sleep/ bedtime

m, M

abbreviation for mimim

abbreviation for ounce

cognitive function

ability to think and reason.

Astigmatism

abnormal curvature of the cornea so you can't see as well

diarrhea

abnormal frequency and ﬂuidity of discharge from the bowels

Adventitious breath sounds

abnormal or acquired breath sounds

herniation

abnormal protrusion of an organ or tissue through the structure usually containing it, as an inguinal hernia or hiatal hernia; rupture; condition is called herniation.

hypoxia

abnormal reduction of oxygen in the tissues.

Hyperopia

abnormal refraction in which light rays focus behind the retina, farsightedness

Myopia

abnormal refraction in which light rays focus in front of the retina (nearsightedness)

contracture

abnormal shortening of muscles with resultant deformity.

Wheeze

abnormal sound, constriction of the airway

Rhonchi

abnormal sound, occurs when there is very thick mucus in the lungs

fine crackles

abnormal, non musical sounds

Polypnea

abnormally fast respirations

Tachypnea

abnormally fast respirations, usually more than 24 respirations per minute

Tachypnea

abnormally fast respirations; usually more than 24 respirations per minute

hypertension

abnormally high BP

Hypertension

abnormally high blood pressure 140/90 or above

bradycardia

abnormally slow heart; slow pulse

Bradycardia

abnormally slow pulse rate, less than 60 per minute

Bradypnea

abnormally slow respiratory rate, usually less than 10 respirations per minute

Afebrile

absence of a fever

Afebrile

absence of a fever, can't have a fever 24 hrs before discharge

Apnea

absence of breathing

apnea

absence of breathing

pallor

absence of skin pigment; paleness.

Sordes

accumulation of foul matter (food, microorganisms and epithelial elements) on the teeth and gums

fecal impaction

accumulation of hardened stool in the rectum.

nociceptive pain

acute pain; a pain sensation that results abruptly

acute pain

acute pain; a pain sensation that results abruptly.

less __________________ affects the ability to hold temperature

adipose tissue

accommodation

adjustment, as the accommodation of the lens of the eye.

Insulin purpose

administer insulin

subcutaneous injections

administered more deeply than intradermal. medication is instilled between the skin and the muscle and absorbed fairly rapidly. volume is up to 1 mL. commonly used to administer insulin and heparin.

Parenteral Medication

administration of medication to specific types of tissue via an invasive surgery

after

p (has a line over it)

after

p.c.

after meals

postoperative

after surgery

average BO for children varies with ______- and ________

age and growth

factors that affect pulse rate??

age, body build, BO, drugs, emotions, blood loss, exercise, increase body temp, pain

objective data

all measurable and observable pieces of information about a client and his or her overall state of health

joint commission says that with pain____

all patients have the right to pain relief

antiembolism stockings

also called TED socks; elastic stockings that cover the foot (not the toes) and the leg, up to the knee or mid-thigh.

gas exchange with the blood occurs in the ______________

alveoli

Angle for IM: (can it be any different angle..?)

always 90 degrees.!

When giving Lovenox (anticoagulant), you must:

always give deep subQ 90 degrees, do it in the abdominal 'love handles' (anterior/posterior), prefilled airlock (don't repalce)

amt.

amount

residual urine

amount of urine that remains in the bladder after voiding at least once.

amp.

ampule

sharps container

ampules and vials are discarded in the______

filter needle or straw

ampules require a ______because there may be glass particles in the solution.

Lift

an abnormal anterior movement of the chest related to enlargement of the right ventricle

Hyperresonance

an abnormal booming sound produced during percussion of the lungs

calculi

an abnormal concretion usually composed of mineral salts, occurring in the hollow body organs; a "stone," as a calculus in the kidney (pl: calculi); deposit on the teeth (tartar).

Fasciculation

an abnormal contraction or shortening of a bundle of muscle fibers

kyphosis

an abnormal increase in the thoracic curvature of the spine, giving a hunchback appearance, commonly as a result of osteoporosis.

lordosis

an abnormal increase in the thoracic curvature of the spine, giving a hunchback appearance, commonly as a result of osteoporosis.

aphasia

an abnormal neurologic condition in which a person is unable to express oneself through speech or writing.

tumor

an abnormal new tissue growth that has no physiologic use and grows independent of its surrounding structures. May be benign or malignant.

ﬁstula

an abnormal tube-like passage or channel, as an anal ﬁstula or sinus tract.

Hypertension

an abnormally high blood pressure; over 140 mm Hg systolic and/or 90 mm Hg diastolic

Hypotension

an abnormally low blood pressure; less than 100 mm Hg systolic in an adult

Tachycardia

an abnormally rapid pulse rate, greater than 100 beats per minute

Tachycardia

an abnormally rapid pulse rate; greater than 100 beats per minute

analgesics

an agent that relieves pain without causing unconsciousness.

Precordium

an area of the chest overlying the heart

alias

an assigned name under which certain clients are admitted to (and records kept in) a healthcare facility in order to maintain anonymity.

Reflex

an automatic response of the body to a stimulus

short-term goal

an expected outcome or goal that a client can reasonably meet in a matter of hours or days.

short-term objective

an expected outcome or goal that a client can reasonably meet in a matter of hours or days.

Flatness

an extremely dull sound produced, during percussion, by very dense tissue, such as muscle or bone

Hyperthermia

an extremely high body temperature (e.g., 41 degrees C [105.8 degrees F])

sequela

an illness or injury that follows as a direct result of a previous condition or event.

enema

an injection of ﬂuid or medication into the rectum, usually to induce evacuation of the bowel

urinometer

an instrument that deter-mines urine's speciﬁc gravity; also called urometer, hydrometer.

Otoscope

an instrument used to examine the ears

Plaque

an invisible soft film consisting of bacteria, molecules of saliva, and remnants of epithelial cells and leukocytes that adheres to the enamel surface of teeth

personal space

an invisible, mutually understood area or zone around a per-son that is considered inappropriate for strangers to violate (varies between cultures). If a person invades another's personal space (comes too close), it may cause discomfort. Much nursing care must occur within the client's personal space.

Tremor

an involuntary trembling of a limb or body part

long-term goal

an outcome or goal that a client hopes to achieve but may require an extended amount of time to do so

long-term objective

an outcome or goal that a client hopes to achieve but may require an extended amount of time to do so.

Astigmatism

an uneven curvature of the cornea that prevents horizontal and vertical rays from focusing on the retina

complication

an unexpected event in a disease's course that delays a person's recovery.

Intramuscular purpose

analgesics, antiboitics, steroids, hormones, vaccines

data analysis

analyzing each piece of information to determine its relevance to a client's health problems and its relationship to other pieces of information.

spinal anesthesia

anesthetic injected into the subarachnoid space of the spinal cord providing an extensive conduction block. Many types of surgery can be performed in this manner.

90 degrees

angle of insertion in an IM injection

45-90 degrees

angle of insertion of a subcutaneous injection

5-15 degrees

angle of needle insertion in an intradermal injection-sites are forearm and back

Aphasia

any defects in or loss of the power to express oneself by speech, writing, or signs, or to comprehend spoken or written language due to disease or injury of the cerebral cortex

Family History

anyone sick, been sick

____________ is required before administering some meds

apical pulse

______________ is the most accurate pulse

apical pulse

____________ pulse will be higher than the ___________pulse

apical;radial

approx.

approximate

aqueous

aqueous: water

Patency

are they working as they should

ad lib

as desired

ad lib

as desired, freely

ad lib

as desired; freely

as much as is sufficient

p.r.n.

as needed

prn.

as needed

p r n

as needed or when necessary

as tol.

as tolerated

important elements of an IM injection

aspiration & z-track method

Rhinne

assessment of bone conduction using tunning fork

observation

assessment tool that relies on the use of the ﬁve senses to discover objective information about the client.

adjuvant

assisting or enhancing therapy given, especially in cancer, to prevent further growth or pain; therapy used which was originally intended for another purpose.

at bedtime

When giving Heparin (anticoagulant), you must:

avoid umbilicus (linea alba), don't aspirate or rub, & it can be only subQ abdomen!

______ temp is _ lower the oral temp.

axillary; 1

Fearful of attempting your first nursing history, you ask your instructor how anyone ever learns everything you have to ask to get good baseline data. You are most likely to hear: a. "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" b. " You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." c. "No one ever really learns how to do this well because each history is different." d. "Don't worry about learning all of the questions to ask. Every agency has its own assessment for you must use."

b. " You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care."

Your neighbor, Alan, asks you to come over because he has a high temperature, feels "awful," and did not go to work. What stage of illness behavior is Alan exhibiting? a. Experiencing symptoms b. Assuming the sick role c. Assuming the dependent role d. Achieving recovery and rehabilitation

b. Assuming the sick role (When people assume the sick role, they define themselves as ill, seek validation of this experience from others, and give up normal activities)

Although the nursing process is presented as an orderly progression of steps, in reality there is great interaction and overlapping among the five steps. This characteristic of the nursing process is described as: a. Systematic b. Dynamic c. Interpersonal d. Outcome oriented

b. Dynamic

Maslow's Hierarchy of basic human needs is useful when planning and implementing nursing care as it provides a structure for : a. Making accurate nursing diagnoses b. Establishing priorities of care c. Communicating concerns more concisely d. Integrating science into nursing care

b. Establishing priorities of care

Of the following statements, which is most true of health and illness? a. Health and illness are the same for all people b. Health and illness are individually defined by each person c. People with acute illness are actually healthy d. People with chronic illnesses have poor health beliefs

b. Health and illness are individually defined by each person

The nursing process ensures that nurses are patient centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristics of the nursing process? a. Systematic b. Interpersonal c. Dynamic d. Universally applicable in nursing situatins

b. Interpersonal (Each of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process)

Which was the first state to identify diagnosing as part of the legal domain of professional nursing? a. New Jersey b. New York c. North Carolina d. North Dakota

b. New York

Which of the following would you expect to find in the Nursing Interventions Classification Taxonomy? a. Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions. b. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings. c. A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention. d. A complete list of reimbursable charges for each nursing intervention.

b. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings

This text is based upon a notion of blended skills. .Simply described, this means: a. Nursing works best when nurses competently use the intellectual and technical skills that achieve patient outcomes. Nursing has been held back by outdated notions of care and compassion (interpersonal skills), which can be done by anyone. b. Nursing works best when each nurse competently uses the intellectual, interpersonal, technical, and ethical/legal skills demanded by each situation. c. All of the blended skills are important, but not every nurse has to be skilled in each area. d. Every nursing situation demands the same blend of basic nursing skills, intellectual, technical, interpersonal, and ethical/legal skills.

b. Nursing works best when each nurse competently uses the intellectual, interpersonal, technical, and ethical/legal skills demanded by each situation.

One element of a healthy community is that it: a. Meets all the needs of its inhabitants b. Offers access to healthcare services c. Has mixed residential and industrial areas d. Is little concerned with air and water quality

b. Offers access to healthcare services

A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is what type of nursing diagnosis? a. Actual b. Risk c. Possible d. Wellness e. Syndrome

b. Risk

Careful hand-washing and using sterile techniques are ways in which nurses meet which basic human need? a. Physiologic b. Safety & Security c. Self-esteem d. Love & belonging

b. Safety & Security (By carrying out careful hand-washing and using sterile technique, nurses provide safety from infection)

Of the following characteristics, which one is not a part of chronic illness? a. Permanent change in body structure or function b. Self-treatment that relieves symptoms c. Long period of treatment and care d. Often has remission and exacerbation

b. Self-treatment that relieves symptoms

Subcutaneous site

back of arm, abdomen, thigh

halitosis

bad breath

base of support

balance or stability provided by the feet and their positioning

base of support

balance or stability provided by the feet and their positioning.

parts of a syringe

barrel, tip, plunger. There are 3 types: single use, disposable, and luer-lok

BMR stands for??

basal metabolic rate

tepid sponge bath

bath with water below body temperature, 70 to 85º F, used to reduce fever

perineal care

bathing genitals and surrounding area

Rate

beats/min

why is the use of douches discouraged?

because it kills normal flora and makes women more susceptible to infections

occupied bed

bed holding a client that is unable to get up as a result of his or her condition or generalized weakness.

postoperative bed

bed prepared for a client who is returning from surgery or another procedure that requires transfer into the bed from a stretcher or wheelchair.

open bed

bed that allows linens to be turned down, making it easier for a person to get into or out of.

unoccupied bed

bed that is empty at the time it is made up.

closed bed

bed used when preparing a unit for a new client—an unoccupied bed

before

a (has a line over it)

before

a.c.

before meals

preoperative

before surgery

subcutaneous injections

beneath the skin but above the muscle

intradermal injections

between the layers of the skin, commonly used for diagnostic purposes. examples include tuberculin test and allergy testing. small volumes, usually 0.01-0.05 mL are injected because of the small tissue space.

ecchymosis

bleeding into the tissue sunder the skin, leaving small bruise.

cyanosis

bluish discoloration around mouth and in nail beds

Cyanosis

bluish discoloration of the skin and mucous membranes caused by reduced oxygen in the blood

Two Point Discrimination

blunt end of paper, have patients close eyes, see if they can discriminate 2 seperate points on the body, laterally and on same side

a fever increases the ____, __________ and _____

bmr, heart rate, temperature

transfer board

board made of hard plastic used to move patients who are unable to stand from the side of the bed to a chair.

febrile stage of fever

body temperature rises due to hypothalamus and remains there until there is resolution of the cause of fever

both ears

both eyes

if hypertension is not controlled it can cause permanent _________, ____ and ___________- damage

brain , kidney and retina

lipotrophy

breakdown of subcut fat at the site of repeated injections

Gynecomastia

breast tissue in males, not normal assessment

BMR maintains ___________

breathing

Eccymosis

bruising, change in color

lipohypertrophy

buildup of subcut fat at the site of repeated injections

per

p.o.

by mouth

Crackles

Abnoraml non musical sound heard on auscultation of the lungs during inspiration; also called rales

Hypotension

Abnormally low blood pressure 90/60 or below

AROM/PROM

Active Range of Motion: actively more all joints through different positions; Passive Range of Motion: need help to move a joint

Battery

Actual physical contact that has been carried out against a persons will

________________ have the highest prevalence of hypertension

African american men

AMA

Against Medical Advice, if patient wishes to leave listen to patient, offer for physician to speak with them, insurance may not cover, have them sign an AMA form, if they refuse note it in their chart

Developmental considerations

Age specific (children ,hazards multiply as motor skills develop), adolescents(drugs,alcohol,high risk behaviors), elderly (abuse)

Cloudy, Clear; Clear, Cloudy

Air goes into __ 1st, then air goes into __ 2nd, and then __ is drawn up 1st, & then __ is drawn up 2nd.

Who provides the safe environment?

All healthcare workers, but it is the primary concern of nursing care.

Which of the following guidelines for outcome writing are correct? 1. At least one of the outcomes shows a direct resolution of the problem statement in the nursing diagnosis. 2. The patient (and family) values the outcomes. 3. The outcomes are supportive of the total treatment plan. 4. Each outcome is brief and specific (clearly describes one observable, measurable patient behavior/manifestation), is phrased positively, and specifies a time line.

All of the above

Student Nurse

Although not licensed yet, are held to the same standards as a licensed nurse, Need to know the nurse practice act.

What do you need for an insulin injection? what form does it come in?

An insulin syringe; Units!

Axillary

Armpit

Discharge Begins

At admission ____________ begins

Pulse normally assessed:

At radial artery of the wristor at the apex of the heart

Pinna

Auricle; flap of the ear

What do you want to avoid with an IM sit selection?

Avoid scarred, damaged skin, bony prominences, inflammed areas, flaccid, atrophied muscles (if possible)

Heat and Body

Blood flow from internal organs carries heat to skin and heat is radiated to body and absorbed

Cyanosis

Bluish discoloration or skin color changes particularly around the mouth and in the nail beds, due to lack of oxygen

Hypothalamus

Body's thermostat

Temperature Conversion: Fahrenheit to Celsius

C = 5/9 (F-32) or (F -32) / 1.8 = C

Fahrenheit to Celsius

C = F - 32/1.8

Oral Medications: When preparing ORAL LIQUIDS:

Calculate to the hundredth and round to the tenth: 2.32 mL = give 2.3 mL 2.36 mL = give 2.4 mL

Body Weight:

Calculate to the hundredth and round to the tenth: 7.35 kg = 7.4 kg

Oral Medications: Scored Tablets

Calculate to the tenth and round to the nearest half tablet: 1.5 tablets = give 1 1/2 tablets 1.7 tablets = give 2 tablets

Oral Medications: ALL other oral pills

Calculate to the tenth and round to the whole number: 1.4 tablets = give 1 tablet 1.9 tablets = give 2 tablets

Patient Belongings

Care for patients belongings, if the patient does not wish to send valuables home get a valuable envelope and make a list of everything in the envelope and put in safe. Be sure not to misplace any patient belongings!

Celsius, centigrade

Advance Directive

Consent constructed before the need for it arises; it spells out a patients wishes regarding surgery and diagnostic and therapueutic treatments

Nursing

Considered an art and science

Rhonchi

Continuous dry, rattling sounds heard on ausscultation of the lungs; caused by partial obstruction

Managed Care

Controversial, patients can not establish long term relationship with doctor. Documentation, important to help with costs!

While administering a medication to relieve a patient's pain, you wonder if there are some nonpharmacologic interventions that would enhance relief by complementing the pain medication. When you discuss this with your instructor you are most likely to hear: a. "You should wait until after you evaluate the effect of the medication you just administered before planning a different intervention" b. "One step at a time, dear. Don't start planning a new intervention until you evaluate the old." c. "Lets talk about this... we often get new information that we can incorporate successfully into the plan of care. Sometimes the steps of the process interact or overlap." d. "Think about this patient. Nonpharmacologic interventions wouldn't be effective with her."

c. "Lets talk about this... we often get new information that we can incorporate successfully into the plan of care. Sometimes the steps of the process interact or overlap."

Identify all of the following that are purposes of diagnosing. The purpose of diagnosing is to identify: 1. How an individual, group, or community responds to actual or potential health and life processes. 2. Factors that contribute to or cause health problems (etiologies) 3. Strengths the patient can draw on to prevent or resolve problems. 4. Nursing interventions to resolve health problems a. 1 & 2 b. 3 & 4 c. 1, 2, & 3 d. All of the above

c. 1, 2, & 3

The patient is Vietnamese and does not speak English. Her son is with her and does speak English. How should you respond? a. Ask the son if he is willing to translate and be sure to thank him if he says yes. b. Determine if the son can translate medical information, and if so, begin. c. After determining that the son can translate, evaluate if he can do so objectively and if the patient wants him to serve in this capacity. d. Explain to the son that hospital policy forbids using family members as translators and find a hospital approved translator.

c. After determining that the son can translate, evaluate if he can do so objectively and if the patient wants him to serve in this capacity.

John and Mary, each parents of one child, are both divorced. When they marry, the family structure that is formed will be: a. Nuclear family b. Extended family c. Blended family d. Cohabiting family

c. Blended family

The best description of critical thinking indicators (CTIs) is which of the following: a. Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice. b. Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice. c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics and skills that promote critical thinking in clinical practice. d. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice.

c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics and skills that promote critical thinking in clinical practice.

Which group is responsible for the promotion and organization of activities to continue the development, classification, and scientific testing of nursing diagnoses? a. American Nurses Association b. National Nursing Diagnosis Association c. North American Nursing Diagnosis Association d. Clearinghouse for Nursing Diagnoses

c. North American Nursing Diagnosis Association

When helping Mr Price turn in bed, the nurse notices that his heels are reddened and plans to place him on precautions for skin breakdown. This is an example of: a. Initial Planning b. Standardized planning c. Ongoing planning d. Discharge planning

c. Ongoing planning

You are asked to teach a group of preschool parents about poison control in the home. This activity is an example of what level of preventive care? a. Lowest b. Tertiary c. Primary d. Secondary

c. Primary (teaching poison control in the home is an example of primary preventive care)

Of the following terms, which would be defined as a disease? a. Excess fluid volume b. Risk for infection c. Rheumatoid arthritis d. Altered body image

c. Rheumatoid arthritis

You are a brand new RN. When you orient to a new nursing unit that is currently understaffed, you are told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response? a. Allow the UAPs to do the admission assessment and report the findings to you. b. Do your own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. c. Tell the charge nurse that you are choosing not to delegate the admission assessment at this time until you can get further clarification from administration. d. Contact your labor representative and complain.

c. Tell the charge nurse that you are choosing not to delegate the admission assessment at this time until you can get further clarification from administration.

Of the following statements, which one is true of self-actualization? a. Humans are born with fully developed self-actualization b. Self-actualization needs are met by having confidence and independence c. The self-actualization process continues throughout life d. Loneliness and isolation occur when self-actualization needs are unmet

c. The self-actualization process continues throughout life. (Self-actualization, or reaching one's full potential, is a process that continues through life.)

Of the following clinic patients, which one is most likely to have annual breast examinations and mammograms based on the physical human dimension? a. Jane, because her best friend had a benign breast lump removed. b. Sarah, who lives in a low-income neighborhood. c. Tricia, who has a family history of breast cancer. d. Nancy, because her family encourages regular physical examinations

c. Tricia, who has a family history of breast cancer.

You are surprised to detect and elevated temperature (102 F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. The first thing you do is to: a. Inform the charge nurse b. Inform the surgeon c. Validate your finding d. Document your finding.

c. Validate your finding

IV Problems: When calculating mg/min, mcg/hr, units/mL, mL/hr:

calculate to the hundredth and round to the tenth

Tube Feeding: When calculating mL/hr:

calculate to the hundredth and round to the tenth

Injections: When giving more than 1 mL:

calculate to the hundredth and round to the tenth: 1.26 mL = give 1.3 mL 1.38 mL = give 1.4 mL

IV Problems: When calculating drop factor:

calculate to the tenth and round to the whole number

Tube Feeding: When calculating calories:

calculate to the tenth and round to the whole number

Injections: When giving less than 1 mL:

calculate to the thousandth and round to the hundredth: 0.823 mL = give 0.82 mL 0.666 mL = give 0.67 mL

insulin syringe

calibrated in units

Diminished

can't really hear anything

wound sinus

canal or passage leading to an abscess.

disadvantages of tympanic thermometer

cant use if the patient has an inflammatory condition of the ear or discharge

Cap.

capsule

cap

capsule

inspection

careful, close, and detailed visual examination of a body part.

IV Problems: When calculating titration factor:

carry out to the thousandth and round off to the nearest hundredth.

elective

case in which the client's condition is not life-threatening and may choose whether or not to have surgery; also called optional surgery

venous access lock

catheter used to maintain an open route to a client's venous system to give ﬂuids and/or medications.

Why don't you massage after injecting a medication?

cause meds need to absorb & can go where they aren't supposed to; can lead to bruising

internal respiration is at the _______________level

cellular

metabolism is the ___________--

cellular chemical reactions in the body

centimeter

hypothalamus is located b/n ______________

cerebral hemispheres

apnea

cessation of breathing

Analog (ends in "-log")

chem. altered DNA. (they offer a extremely rapid action of a longer & more balance ctrl. of bld. glucose levels.)

neuropathic pain

chronic pain or discomfort that continues for six months or longer and interferes with normal functioning.

circumduction

circular movement of a limb or the eye.

catheter care

clean length of catheter from meatus toward cath bag

acuity

clearness; or a disorder's level of severity; minimum level or need for healthcare services that must be met for a client to be admitted to an acute care facility.

the _______--to the heart the ______________________

closer; stronger the pulse and rate

Cataract

cloudy film on eye

Types of outcomes

cognitive, psychomotor, affective, physiologic

Would the client have feelings of being hot or cold? Chills or no chills?

cold; chills

atelectasis

collapse of all or part of a lung.

Hematoma

collection of bloood under the skin

abscess

collection of pus in a localized area

orange

color of insulin syringes?

conjunctivitis

commonly called pinkeye; inﬂammation of the conjunctiva.

therapeutic communication

communication (usually verbal) with a client that is helpful and beneficial; creating a healing, curative, and safe milieu by using communication.

c/o

complain(t)s of

anesthesia

complete or partial loss of sensation.

anuria

complete suppression of urine secretion in the kidney.

cpd or comp

compound

cone

concentrate

bradypnea

condition in which breaths are abnormally slow and fall below ten per minute.

conscious sedation

condition in which internal sedative medications are used alone or in conjunction with local anesthetics and the client has a depressed level of consciousness but is still able to breathe and respond to verbal stimuli.

Diabetes Mellitus

condition where the Pancreas isn't working properly and insulin injections are given 3-4 times a day.

purulent

consisting of or secreting pus.

Deciliter.

Hypoxemia

Decreased ammount of oxygen in the blood stream

What is bioterrorism?

Deliberately spreading pathogens into a community to make people sick

Miosis

constricted pupils

what are some abnormal conditions that may be noted during an oral exam?

Dental carries, periodontal disease, pyorrhea, Pt who is NPO or has a NG tube

Factors affecting safety of patients

Developmental considerations, Lifestyle, mobility, sensory perception, knowledge, ability to communicate, physical health, psychosocial health state

DW, D/W

Dextrose in water

Patient Rights

Dignity, privacy, freedom of movement, and information needs of the patient

serous

containing clear ﬂuid; drainage made up of serum

Vestibule

contains the organs of equilibrium; found in the inner ear

Insensible water loss

continuous and unnoticed water loss

Vaporization

continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin

Diaphragmatic (abdominal) breathing

contraction and relaxation of the diaphragm, observed by the movement of the abdomen, which occurs as a result of the diaphragm's contraction and downward movement

footdrop

contracture deformity that prevents the client from putting the heel on the ﬂoor; results from improper positioning or anterior leg muscle paralysis; abnormal plantar ﬂexion of the foot.

footdrop

contracture deformity that prevents the client from putting the heel on the floor; results from improper positioning or anterior leg muscle paralysis; abnormal plantar flexion of foot.

hypothalamus

controls the body's temperature by a feedback mechanism

nonverbal communication

conveying information or messages without speaking or writing. Components include items such as therapeutic touch, gestures, body language, facial expression, and eye contact.

assertiveness

conﬁdence without aggression or passivity, an important skill for a nurse to possess in interpersonal communication.

hypothermia blanket

cooling blanket; also called hypothermia blanket

Extraoccullar Movement

coordination of the eye muscles

pyorrhea

copious discharge of pus

Rate

count rate of breaths per minute (or 30 seconds times 2) to get RR, rise and fall is one

Strabismus

cover/uncover test: cross-eyed, when you uncover the eye gets tired and the cornea will go towards your nose

cubic centimeter

sphygmomanometer

cuff for measuring BP

___________ is important to get accurate reading

cuff size

what are some factors affecting personal hygeine

culture, socioeconomic class, development level, spiritual practices, health state-disease or illness, personal preference

cup

Scoliosis

curvature in spine (s shaped curve)

what are agents used in bioterrorism?

cyanide, anthrax, nerve agents, plague, viruses, botulism

Fever

Elevated Temp.

Celsius to Fahrenheit

F = (1.8)C + 32

Temperature Conversion: Celsius to Fahrenheit

F = 9/5 C + 32 or (C x 1.8) +32 = F

Fahrenheit

Remittent Fever

Falling of a high temp, usually in the morning, and then raises later in the day, fever never falls to normal

Intermittent Fever

Falling of high temp, in the evening and raises in the morning, fever never falls to normal

Tachycardia

Fast heart rate, faster than 100, causes: fever, exercise, pain, stress, anxiety, drugs, bleeding (internal or external), this is one of the initial signs of bleeding

Febrile

Fever

Pyrexia

Fever, 100.2 or above

Oral Temp. is never used:

For unconscious or uncooperative paitent or one who may have a siezure

Where do you administer an intradermal injection? How?

Forearm; 5 to 15 degrees

C degrees = (F-32)/(1.8)

Formula for determining degrees C.

F degrees = (1.8C) + 32

Formula for determining degrees F.

65 milligrams (mg) = ___ gr

Grains (gr) 1

Gram.

Alopecia

Hair loss

Broad Assessment

Health History

HMO

Health Maintenance Organizations, a type of group practice, enroll patients for a set fee per month, Provide limited network of physicians, hospitals, and other health care providers. (GOAL- Keep patients healthy and out of the hospital)

How can sensory perception affect safety?

Heating pads and hot water can burn.

Hypothalamus

Helps regulate body temp (main way)

what type of site are you going to choose for an ID? Why?

Highly pigmented, hairless skin -allows observation of reaction

Chronic Illness

Hypertension, develops slowly over a long period of time and lasts without (Diabettes)

Hyperpyrexia

Hyperthermiaan extremely high body temperature (e.g., 41 degrees C [105.8 degrees F])

Rectus Femoris can be used for ____ injections.

Z-track all __ injections.

Routes of parenteral medication:

IM, ID, IV, SubQ

IVP

IV Push

IVPB

IV piggyback

Error on Document

If there is an error on a document to be signed, any changes must be clear and initialed, any deletions must be crossed with a single line with the word error, and the nurses initials above. If concent form as been transcribed inacurately or physican orders change in the wording destroy document and make a new one

OSHA

Improve work environment for safety and regulations

Physician

In most cases it is the responsibility of the _________ office to obtain authoriziation for services.

increased metabolism =

Increased body temp

Body heat production (Metabolism)

Increased metabolism, more heat produced, causes a fever. When pathogens invade the body and phagocytosis tries to destroy them, the increased activity results in fever.

Tachypnea

Increased rapid breathing

Vastus Lateralis is the optimal site for?

Infants, children and thin, debilitated adults.

Inspiration

Inhalation; the act of breathing in; the intake of air or other substances into the lungs

Normal

Inspection, Palpatation, Percussion, Ausculation

Abdominal

Insppection, Ausculation, Percussion, and Palpatation

100 Units per 1 ml (also labelled U-100)

Insulin is provided in a proportion of ___ Units per __ ml

(cloudy) NPH & Lente

Insulin: Intermediate-acting (slow):

Onset = 1-4hrs; duration 14-26 hrs

Insulin: Intermediate-acting: Onset & Duration

(cloudy) Ultralente; Levemir; & Lantus

Insulin: Long-Acting (slowest):

Onset = 1-2hrs; Duration up to 24 hours

Insulin: Long-Acting: Onset & Duration

(clear) Regular & Semilente

Insulin: Rapid or Short-Acting

Onset = 30min. ; Duration = 8hrs

Insulin: Rapid or Short-Acting: Onset = _min.; Duration = _hrs.

Novolog, Humalog, & Apidra

Insulin: Very Short-Acting (fastest)

Onset = 10-30min; Duration 3-5hr.

Insulin: Very short acting: Onset = _-_min; Duration = _-_hrs.

Terminal Illness

Is one for which there is no cure available, ends in death, death usally occurs within a short period

Defamation

Is when one person makes remarks about another person that are untrue, and the remarks damage that other persons reputation

Kilogram.

How can mobility affect safety?

Limitations create risk, an unsteady gait presents risks for falls.

Whats the fibrous band that runs vertically along the center of the anterior abdominal wall? Whats its significance?

Linea Alba; interferes with absorption

Auscultation

Listening for sounds produced within the body, usually with a stethoscope

Liter.

METHOD

M-Medication E-Environment T-Treatments H-Health Teaching O-Outpatient referral D-Diet

M/T: (mitral/tricuspid: closing) is the lub sound (wooosh), 2 valves are closing left ventricla pushing heart is in systole

Medication Administration Record

MAR

Heat Production

Metabolism (primary way), Muscle Activity, Thyroid Hormones

mcg

Microgram.

different sites for ID:

Middle third of inner forearm, upper back over scapula, dorsal aspect of upper arm

Milligram.

Milliliter.

Apical/Mitral

Mitral valve apical site (5th intercostals mid-clavicular)

Insulin aspiration

Insulin massage

Intradermal aspiration

Intradermal massage

Afebrile

No fever

Can you use a 1 mL syringe to draw up and adminster insulin?

No, because its not measured in mL

NS, N/S

Normal Saline (0.9% NaCl)

Eupnea

Normal, relaxed breathing pattern

NPO

Nothing by mouth, let patient know as soon as they come into the unit, if they have no fluid restricition, fill the water carafe and place it withing the patients reach

Heat loss

Occurs to skins exposure to environment

Nursing care plan

One of the main purposes of the nursing care plan is to allow other people to care for your patient

Acute Illness

One that develops suddenly and resolves in a short period of time. (Intestinal Flu)

Primary Illness

One that develops without being caused by another health problem

Two-point discrimination

One-point discrimination; the ability to sense whether one or two areas of the skin are being stimulated by pressure

Slander

Oral (Spoken) defamation

pancreas --> islets of Langerhan's --> Beta cells --> insulin

Pancreas --> __ --> __ --> insulin

7 Components of a med order:

Patient, document, medication, amount, route, time, dose, reason

Transfer of patient

Patients physician must be notified if the patient must be moved, in emergency situations patient can be moved without concent. If patient must be transfered attempt to go with for the transfer.

Informed Concent

Permission for treatment, if patient is medicated must wait at least 4 hours for medication to be out of patients system

PPO

Preferred provider organizations, discount in fees in return for large pool of patients. PPO's allows insurance companies keep premium rates lower, usually large # of physicians to choose from.

Oral Temp. placed?

Probe is placed under tongue at the base of the sublingual pocket.

Sites for core temp in ICU

Pulmonary artery, esophagus, urinary bladder

Tachycardia

Pulse greater than 100 BPM

Tachycardia

Pulse greater than 100 bpm

Bradycardia

Pulse lower than 60 bpm

PERRLA

Pupils, Equal, Round, Reactive, Light, Accommodation (use a pen light, should get smaller, take away should, should go back to normal)

Discharge Planner

RN implements and organizes plan for patient discharge. Actual discharge orders written by the physician.

Patient Chart

Record, the chart (record) is the property of the hospital or agency or physician, NOT the patient (patient may have access to chart)

Most accurate core temp.

Rectal Temp.

______ ______ is located on the anterior aspect of the thigh, and can also be used for IM injections.

Rectus Femoris

Surface Temp.

Reflects temp. of the skin, not core temp.

What is your responsiblities with nursing peers and diversion issues?

Report it!!!

PRN

Requested as needed medication, bring as soon as possible, do not allow pain to go untreated

Code of Nurses

Respect for human dignity, continuing education, confidential nurse-patient

Kussmauls Respirations

Respirations having an increased rate and depth with panting and long grunting exhalations

Biot's Respirations

Respirations that are shallow for 2 or 3 breaths with a period of variable apnea

Cheyne- Stokes Respirations

Respirations that gradually become more shallow and are followed by periods of apnea, with repetition of the pattern

Respiratory character

Respiratory quality;

Secondary Illness

Results from or is caused by a primary illness

normal assessment finding =

S1S2

What is the difference between side effects and adverse effects?

SE- predictable & often unavoidable secondary effects produced at a usual therapeutic dose; AE- unintended, undesirable, &often unpredictable severe responses to medication

Expiration

See Exhalation

Inspiration

See Inhalation

Maslows Hierarchy

Self Actualization, Self-esteem, Love and Belonging, Safety and Security, Physiologic

what are 3 additional required equipment for filter needles?

Sharps container, alcohol pads, disposable gloves

Skin is chilled

Shivering, Vasoconstriction, Decreased sweating

Sources of Heat Loss

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

Bradypnea

Slow and shallow breathing

Stridor

Small, harsh sound on inspiration; caused by the obstruction of the upper air passage, as occurs in croup or lyringytis

NaCl

Sodium Chloride

Korotkoff Sounds

Sounds that relate to the effect of arterial wall vibrations during auscultation of BP

Blood Pressure Cuff

Sphygmomanometer

Febrile

Stage in fever in which body temp. rises to the new set point established by the hypothalamus & remains there until there is a resolution to the cause of the fever.

Nurse Practice Act

State licensure is required for all nurses where they abide by laws upon license

Hypoxia

State of sufficient oxygen in the blood

Check labels carefully w/ MAR; Rotate to mix the cloudy insulin; Clean both vials w/ Alcohols; Figure the combined dosage; Choose proper size of insulin syringe; Draw up air and inject into vials; Pull insulin from clear insulin; & Pull insulin from cloudy insulin

Steps for combining insulin: (8)

How can the psychosocial health state affect safety?

Stress can narrow a person's attention span and make them more prone to accidents. Depression and confusion can lead to accidents.

The most frequently used parenteral routes are (4) :

Subcutaneous - Intramuscular - Intradermal - Intravenous

False, they're measured in Units

T/F insulin is measured in mL

Intradermal purpose

TB test, allergy test

Accountability

Taking responsibility for ones actions

Core Temperature

Temp. deep within the body

Vital Signs

Temp., blood pressure, pulse, respiration, pain level

Vital Signs

Temperature, Pulse, Respiration, BP, Pain

During a Z track injection, how many seconds do you wait to remove the needle?

Ten seconds & then release skin after removing needle

Meter

The basic unit for length.

Liter

The basic unit for volume (liquid).

Gram

The basic unit for weight (solid).

steatorrhea

The excretion of abnormal quantities of fat with the feces owing to reduced absorption of fat by the intestine.

dental caries

The formation of cavities in the teeth by the action of bacteria; tooth decay.

BMR (Basal Metabolic Rate)

The rate at which heat is produced when the body is at rest

Assault

The threat to harm another, or even to threaten to touch another without that persons permission

Temp. affected by:

Time of day, environment, age, exercise, hormones, emotional stress, disease conditions, and certain drugs

What is an incident report used for?

To detect and hopefully solve problems

U, u

Unit

One of the developmental tasks of the older adult family is to: a. Maintain a supportive home base b. Prepare for retirement c. Cope with loss of energy and privacy d. Adjust to loss of spouse

d. Adjust to loss of spouse (A developmental task of the older adult family is adjusting to the loss of a spouse)

Which one of the following is an example of an affective outcome? a. within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. b. By 6/12/12, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. c. By 6/19/12, the patient's ulcer will begin to show signs of healing (eg, size shrinks form 3" to 2.5"). d. By 6/12/12, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

d. By 6/12/12, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer. (Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes describe increases in patient knowledge of intellectual behaviors; psychomotor outcomes describe the patient's achievement of new skills. )

Which of the following is an optional element in a measurable outcome? a. Subject b. Verb c. Performance criteria d. Conditions e. target time

d. Conditions (Conditions specify the particular circumstances in or by which the outcome is to be achieved. Not every outcome specifies conditions.)

What do both the health-illness continuum and the high-level wellness models demonstrate? a. Illness as a fixed point in time b. The importance of family c. Wellness as a passive state d. Health as a constantly changing state

d. Health as a constantly changing state (both these models view health as a dynamic, constantly changing state)

Jeanne is a college student who wants to lost 20 pounds. She meets with the student health nurse and develops a plan to increase her activity level and decrease the consumption of the wrong types of foods and excess calories. The nurse plans to evaluate her weight loss monthly. When Jeanne arrives for her first "weigh-in", the nurse discovers that instead of the projected weight loss of 5 pounds, Jeanne has only lost 1 pound. Which is the best nursing response? a. Congratulate Jeanne and continue the plan of care. b. Terminate the plan of care since it is not working. c. Try giving Jeanne more time to reach the targeted outcome. d. Modify the plan of care after discussing possible reasons for Jeanne's partial success

d. Modify the plan of care after discussing possible reasons for Jeanne's partial success.

Altered Health Maintenance is an example of: a. Collaborative problem b. Interdisciplinary problem c. Medical problem d. Nursing problem

d. Nursing problem (because it describes a problem that can be treated by nurses within their scope of independent nursing practice)

Of all the physiologic needs, which one is the most essential? a. Food b. Water c. Elimination d. Oxygen

d. Oxygen (Oxygen is the most essential of all needs because all body cells require oxygen for survival)

When you receive shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over body prominences. You should: a. Correct the initial assessment form. b. Redo the initial assessment and document current findings. c. Conduct and document an emergency assessment. d. Perform and document a focused assessment on skin integrity

d. Perform and document a focused assessment on skin integrity

Following the birth of his first child and after reading about the long-term effects of nicotine, John decides to stop smoking. This behavior change is most likely based on John's perceptions of all but one of the following. Which one is not true? a. His susceptibility to lung cancer b. How serious lung cancer would be c. What benefits his stopping smoking will have d. Personal choice and economic factors

d. Personal choice and economic factors (the others are components of the health-belief model)

Which of the following statements about the nursing process is most accurate? a. The nursing process is a four-step procedure for identifying and resolving patient problems. b. Beginning in Florence Nightingale's days, nursing students learned and practiced the nursing process c. Use of the nursing process is optional for nurses, since there are many ways to accomplish the work of nursing. d. The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept

d. The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept (a.The nursing process is a five-step process, b. The term nursing process was first used by Hall in 1955, c. Standards demand the use of the nursing process, so it is not optional.)

The terms diagnose and diagnosis have legal implications. they imply that there is a specific problem that requires management by a qualified expert. Which of the following statements is false? a. If you make a diagnosis, it means that you accept accountability for accurately naming and managing the problem b. If you treat a problem or allow a problem to persist without ensuring that the correct diagnosis has been made, you may cause harm and be accused of negligence. c. You are accountable for detecting, identifying, or recognizing signs and symptoms that may indicate problems beyond your expertise. d. When nurses diagnose a medical problem, they are just as accountable as physicians for detecting, identifying, and managing the signs and symptoms of disease.

d. When nurses diagnose a medical problem, they are just as accountable as physicians for detecting, identifying, and managing the signs and symptoms of disease.

What is the best broad definition of a family? a. A father, a mother, and children b. Members are biologically related c. Includes aunts, uncles, and cousins d. A group of people who live together

d. a group of people who live together (Although all the responses may be true, the best definition is a group of people who live together.)

What is a special subQ consideration?

Use a 2 needle system: -draw up med & repalce needle -insulin & pre-packed are exceptions! (ex.lovenox)

How do you avoid needle sticks?

Use one hand (not 2)

General Principles for IM site selection:

Use well-developed, relaxed muscle, away from major blood vessels, free of nerves

What is the purpose for ID injections?

Used for skin testing such as PPD (TB), and allergy

Describe a 'low guage'

Used for thick solutions; 18 ga

______ _______ is the muscle located on the anterior LATERAL aspect of the thigh.

Vastus Lateralis

What is the perferred site for IM injection?

Ventrogluteal

_______ ______ is located on the side of the hip, just below the iliac crest.

Ventrogluteal Muscle

What are the different IM injection locations?

Ventrogluteal, Vastus Lateralis, deltoid

What is the most perferred site for an IM injection? Why?

Ventrogluteal; less blood vessels, and nerves

What is the difference between V.O and T.O?

Verbal order- more emergency; repeat it back, signed before MD leaves Telephone order- read back & clarify; MD has to sign within 24 hrs

When you enter the patient's room to begin your nursing history, the patient's wife is there. You should: a. Introduce yourself to both and thank the wife for being present. b. Introduce yourself to both and ask the wife if she wants to remain. c. Introduce yourself and ask the wife to leave. d. Introduce yourself and ask the patient if the would like the wife to stay.

d. introduce yourself and ask the patient if he would like the wife to stay.

What do you do with new vials?

date & initial

Would the client have an increase or decrease of urinary output?

decrease

Orthostatic hypotension

decrease in blood pressure related to positional or postural changes from lying to sitting or standing positions

Atrophy

decrease in muscle size

___________can cause problems because they

decrease the healing by increasing vessels pressure

How would the client's muscular coordination be?

decreased (lack of muscle coordination)

hypoxemia

decreased 02 in the blood

Does the body temp, pulse and resps increase or decrease if the client has hypothermia?

decreases

Intramuscular maximun dose

deltoid 1 ml, vastus lateralus 3 ml

Intramuscular site

deltoid, vastus lateralus

Common meds for 2 meds in 1 syringe:

demerol, vistcoul, morphine sulfate, phenergan

subcut injection equipment

depends on the medication. Insulin is prepared in an insulin syringe, heparin is prepared in a tuberculin or it may be in a prefilled cartridge. needle lengths may very from 1/2 - 5/8 inch.

urgency

desire or sensation of needing to void immediately.

D5W

dextrose 5% in water

oliguria

deﬁcient urinary secretion or infrequent urination

diagnosis

gauge

diameter of the needle

cheyne -stokes is aka

dieing breathing

pulse deficit

difference between apical and radial pulse

Pulse Deficit

difference bewteen apical site and somewhere else

pulse pressure

different b/n systolic and diastolic pressure

korotkoff sounds

different sounds heard when taking manual BP

Dyspnea

difficult and labored breathing

dyspnea

difficult and labored breathing( very visual)

orthopneic position

difficult breathing, relieved by sitting or standing erect; orthopneic position: sitting and leaning forward, to facilitate breathing.

constipation

difﬁcult or infrequent and hardened bowel movements.

dysuria

difﬁcult or painful urination or voiding.

dysphasia

difﬁculty in understanding or expressing language.

dil

diluted

gravital plane

direction of gravitation pull; an imaginary vertical line through the top of the head, center of gravity, and base of support.

line of gravity

direction of gravitation pull; an imaginary vertical line through the top of the head, center of gravity, and base of support.

Pulmonic

directly across from teh aortic valve on left side

defecation

discharge of solid waste matter (feces) from the intestines.

DC or d/c

discontinue

acute disease

disease or illness that develops suddenly and runs its course in days or weeks; illnesses that interfere with the continuum for a short period of time.

rate and depth controlled by respiratory center in the brain can be influenced by (7)

disease, emotions, pain, activity,age, fever, drugs

Periodontal disease

disorder of the supporting structures of the teeth

Would the client be oriented or disoriented?

disoriented

disp

dispense

Convection

dispersion of heat through air currents

local anesthesia

disruption of sensation to a speciﬁc body area without causing unconsciousness; caused by inﬁltration or topical application of anesthetic, usually to a small area; not general.

What are 3 things you must NEVER do after giving an injection?

do NOT aspirate, rub, or massage

nursing progress notes(nurses' notes):

documentation by nurses of care given and observations made; charting data input

The ______ muscle is located in the upper, outer quadrant of the gluteal muscle.

dorsogluteal

What is the best site for IM injections?

dorsogluteal muscle

superior gluteal artery and sciatic nerve

dorsogluteal site for IM injections pose unacceptable risks to____________and the___________, therefore it is no longer used.

intramuscular injection sites

dorsogluteal, ventrogluteal, vastus lateralis, rectus femoris, and deltoid.

diplopia

double vision

cursive "z"

dram

Crust

dried blood or scab

gt, gtt

drop(s)

gtt

drop/drops

Lifestyle/Social History

drugs, alcohol, smokings, caffiene/feel safe at home

rhonchi

dry, rattled ( partial obstruction)

Lobule

earlobe

Montgomery straps

easily removable straps that stay in place to facilitate dressing removal

Fever

elevated body temperature

Clubbing

elevation of the proximal aspect of the nail and softening of the nail bed

elix

elixir

elix.

elixir

projectile vomiting

emesis expelled with great force.

Mydriasis

enlarged pupils

Hypertrophy

enlargement of muscles due to strenghtening

what is structure evaluation

environment in which care is provided, physical facilities and equipment, organizational characteristics, policies and procedures

goal-oriented

establishment of objectives or speciﬁc desired outcomes early in the nursing process.

evening/afternoon

every

q (with a line over it)

every

every day

q.d.

every day, daily

q8h

every eight hours

q4h

every four hours

every hour

q.o.d.

every other day

qod

every other day

qod/ QOD

every other day

q2h

every two hours

urinalysis

examination of urine

lithotomy

examination position in which the client is lying on his or her back with the feet in stirrups.

Fowler's position

examination position in which the client is lying on his or her back with the head elevated.

Sims' position

examination position in which the client is lying on his or her left side with right knee ﬂexed.

hemorrhage

excessive bleeding(internal or external); escape of blood from non-intact blood vessels.

diaphoresis

excessive sweat production

Libel

Written Defamation

patient is to receive 0.25 mg of Synthroid. The medication is only available in tablets that contain 125mcg each. How many tablet should the nurse administer?

X = 2 tablets

The doctor's order reads glyburide 1.5 mg 3 tablets P.O. daily. What's the total dose in milligrams?

X = 4.5 mg

Diaphoresis

excessive sweat production, which attempts to cool body by evaporation

Your patient receives a prescription for 62.5 mcg of digoxin elixir P.O. daily. The elixir reads 0.05 mg/ml. How many milliliters of digoxin should you give?

X x 0.05 mg = 1 ml x 0.0625 X= 1.25

nocturia

excessive voiding (urination) during the night.

external respiration

exchange of respiratory gases in the lung(pulmonary)

Intramuscular aspiration

YES

Subcutaneous aspiration

YES

Subcutaneous massage

YES

Intramuscular massage

YES, except for Z-track

example of voluntary muscle movement

exercise

Kegel exercises

exercises designed to increase sphincter tone by tightening, holding, and releasing the muscles of the pelvic ﬂoor and sphincter, used to improve incontinence.

traction

exertion of a pulling force; an apparatus attached to the client to maintain stability of a joint or aligned fracture or to exert a pulling force elsewhere, as in the lower back, to relieve pressure.

trial and error problem-solving

experimental problem solving that tests ideas to decide which methods work and which do not.

What do you always check with a vial?

expiration date

1 L = 1000 ml

__ L = __ ml

1 cup = 8 oz

__ cup = __ oz

1 dram = 4 mL

__ dram = __ mL

1 dram = 60 minims

__ dram = __ minims

1 gal. = 4 qt

__ gal. = __ qt

1 in. = 2.5 cm

__ in = __ cm

1 kL = 1000 L

__ kL = __ L

1 kg = 1000 g

__ kg = __ g

1 kg = 2.2 lb

__ kg = __ lb

1 lbs = 16 oz = 1 pt

__ lbs = __ oz = __ pt

1 mL = 1 cc

__ mL = __ cc

1 mg = 1000 mcg

__ mg = __ mcg

1 oz = 8 drams

__ oz = __ drams

1 oz = 30 mL

__ oz = __ mL

1 oz = 2 tbs

__ oz = __ tbs

1 pt = 1 lb

__ pt = __ lb

1 pt = 16 oz

__ pt = __ oz

1 qt = 1 L = 32 oz

__ qt = __ L = __ oz

1 qt = 2 pt

__ qt = __ pt

insulin

__ takes sugar out of the bld and puts into the cells for storage.

1 tbs = 15 mL

__ tbs = __ mL

1 tbs = 3 tsp

__ tbs = __ tsp

1 tsp = 60 drops

__ tsp = __ drops

1 tsp = 5 mL

__ tsp = __ mL

0.5-3

_____ = normal dose for tablets. Make sure to question anything outside of this range.

smaller, larger

________diameter=__________gauge

Cyst

a >1 cm elevated fluid filled lesion (BIG blister)

sitz bath

a bath used to apply heat to the pelvic area.

Bruit

a blowing or swishing sound created by turbulence of blood flow

Pyrexia

a body temperature above the normal range, fever

Intermittent fever

a body temperature that alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures

Mastoid

a bony prominence behind the ear

how does your body produce temperature??

a by product of metabolism

Apical pulse

a central pulse located at the apex of the heart

Mixed hearing loss

a combination of conduction and sensorineural loss

Apnea

a complete absence of respirations

Arteriosclerosis

a condition in which the elastic and muscular tissues of the arteries are replaced with fibrous tissue

inﬂammation

a condition resulting from irritation in any body part, marked by pain, heat, redness, and swelling.

Fissure

a crack, usually in an irregular pattern

Triangular fossa

a depression of the antihelix

strabismus

a deviation of the eye; squint. (Convergent strabismus is called cross-eye; divergent strabismus is called exotropia or walleye. Other types include cyclotropia ,esotropia, hypertropia, and hypotropia.)

incentive spirometer

a device used to force the client to concentrate on inspiration and promote full inﬂation of the lungs, while providing immediate feedback; used particularly after surgery and in lung disorders.

Goniometer

a device used to measure the angle of a joint in degrees

chronic disease

a disease of long duration that generally manifests itself in an individual as recurring problems that tend to worsen in severity over time.

secondary disease

a disease that directly results from or depends on another disease.

primary disease

a disease that occurs independently, not related to another disease.

Glaucoma

a disturbance in the circulation of aqueous fluid; causes an increase in intraocular pressure

risk factor

a factor that increases a person's likelihood of developing a certain disease.

egg crate mattress

a foam pad, shaped like an egg carton, which is used on top of a regular bed mattress to provide comfort and to pre-vent pressure areas.

embolus

a foreign substance, blood clot, fat globule, piece of tissue, or air bubble carried in a blood vessel, which partially or completely obstructs blood ﬂow (embolism; pl. emboli)

conduction block

a form of regional anesthesia, also known as conduction block.

bed cradle

a frame used to prevent bedclothes from touching all or part of a person's body.

interview

a goal-directed conversation in which one person seeks information from the other.

induration

a hardened place, a lump, as in the skin in a positive reaction to a tuberculin test.

Nstagmus

a jerky eye, eyes will jerk at both sides

Resonance

a low-pitched, hollow sound produced over normal lung tissue when the chest is percussed

auscultation

externally listening to sounds from within the body to determine abnormal conditions, as auscultation of blood pressure with a stethoscope

auscultation

externally listening to sounds from within the body to determine abnormal conditions, as auscultation of blood pressure with a stethoscope.

EXT

extract

Tympany

a musical or drumlike sound produced during percussion over an air filled stomach and abdomen

endorphins

a naturally occurring analgesic that the body produces in response to exercise and other stimuli

Pulse oximeter

a noninvasive device that measures the arterial blood oxygen saturation by means of a sensor attached to the finger

guided imagery

a process through which the client receives a suggestion that helps control his or her pain or disease. The person learns to visualize himself or herself as powerful and able to conquer pain or disease.

Hernia

a protrusion (such as of the intestine through the inguinal wall or canal)

Exophthalmus

a protrusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or staring expression

Peripheral pulse

a pulse located in the periphery of the body (eg, foot, wrist)

Arrhythmia

a pulse with an abnormal rhythm

Dysrhythmia

a pulse with an irregular rhythm

Wheal

a reddened collection of fluid that's elevated from the skin (hive or bug nite if filled with fluid)

Erythema

a redness associated with a variety of skin rashes

Hordeolum (sty)

a redness, swelling, and tenderness of the hair follicle and glands that empty at the edge of the eyelids

Pyrexia

a rise in the temperature of the body

Cochlea

a seashell-shaped structure found in the inner ear; essential for sound transmission and hearing

Korotkoff's sounds

a series of five sounds produced by blood within the artery with each ventricular contraction

stridor

a shrill and harsh sound (usually refers to the inspiratory sound that occurs when the larynx is obstructed).

pustule

a small elevation of the skin ﬁlled with pus or lymph.

wheal

a smooth, slightly elevated skin area, usually pale in the center with are ddened periphery, often accompanied by severe itching when caused by an allergic reaction; small elevation caused by injection of an intra-dermal medication, such as the PPD test for tuberculosis or other skin test

Constant fever

a state in which the body temperature fluctuates minimally but always remains above normal

nursing diagnosis

a statement about the client's actual or potential health concerns that can be managed through independent nursing intervention.

Quality

a subjective description of a sound (e.g., whistling, gurgling)

speciﬁc gravity

a substance's weight, as compared with another. Fluids, such as urine, are compared to (pure water, which has a speciﬁc gravity of 1.000) and (Urine 1.010-1.025)

Fever spike

a temperature that rises to fever level rapidly following a normal temperature and then returns to normal within a few hours

Blanch test

a test during which the client's fingernail is temporarily pinched to assess capillary refill and peripheral circulation

Hemoccult

a test for occult (hidden) blood in stool or body secretions

Hematest

a test for occult (hidden) blood in stool or body secretions.

Hemoccult

a test for occult (hidden)blood in stool or body secretions.

Homans' sign

a test for thrombophlebitis in which pain occurs behind the knee when the foot is hyper ﬂexed upward (dorsiﬂexion).

Dullness

a thudlike sound produced during percussion by dense tissue of body organs such as the liver, spleen, or heart

Resting tremor

a tremor that is apparent when the client is at rest and diminishes with activity

endoscope

a tube-shaped, lighted device used to visualize or operate on hollow organs or within body cavities. Specialized endoscopes include the gastroscope, broncho-scope, and proctoscope. (Process of visualization using this tool is called endoscopy.)

Thrill

a vibrating sensation over a blood vessel which indicates turbulent blood flow

Tartar

a visible, hard deposit of plaque and dead bacteria that forms at the gum lines

emaciation

a wasting away of the ﬂesh, causing extreme leanness, starvation. (adj: emaciated).

wheeze

a whistling respiratory sound, typical of asthma.

Jaundice

a yellowish color of the sclera, mucous membranes, and/or skin

macule

a ﬂat discolored spot on the skin (also, macule); a dense scar of the cornea that can be seen without optical aids.

Kardex

a ﬂip ﬁle with card slots or a notebook for each client on a unit or nursing care team; a system for recording background information and care related to a client's treatment.

friable

fagile; easily broken

risk factor assessment

falls, fires, poisoning, suffocating and choking, and firearm injuries

Presbyopia

far sided impaired near vision

kussmaul's

fast and deep breathing (not normal)

Tachpnea

fast breathing, greater than 18

Insulin site

fatty tissue, upper arm, lower abdomen, middle and lower back, thigh region

Self-care deficits

feeding, bathing and hygiene, dressing and grooming, toileting

Palpatation

feel puel pulse

malaise

feeling of illness; general bodily discomfort.

pain

feeling of suffering, distress or agony, caused by stimulation of specialized nerve endings, a protective device of the body; a subjective sensation (reported by the client).

body cue

feelings experienced in response to body rhythms, self-monitoring

Romberg's test

feet apart, hands down at sides, eyes closed, may start to sway (checking coordination, gait, balance, strength)

feet, foot

Fibrocystic Breast Disease

fibro cysts can develop, much more prominent during menstruation breasts get ver sore and tender

Plaque

film over teeth

4 types of adventitious breathing sounds

fine crackles, coarse crackles, rhonchi,wheezes

Auricle

flap of the ear

client-oriented

focused on meeting individualized needs.

Focused Assessment

focussing on the problem

foot

subcut injection technique

for obese person who has a 2 inch fold when hunched, 90 degree angle. for a thin person with a 1 inch fold, 45 degree angle.

thrombophlebitis

formation of a blood clot in a vein, with inﬂammation

thrombophlebitis

formation of a blood clot in a vein, with inﬂammation.

suppuration

formation or discharge of pus (adj: suppurative).

sordes

foul, dark matter that collects around the teeth and lips in low grade fever

qid

four times a day

qid/ QID

four times a day

q.i.d.

four times per day

friable

fragile; easily broken

symptom

functional evidence of a disease or condition that a client perceives subjectively (as opposed to signs, which the examiner or others perceive).

Thrush

fungus grows on tongue (metallic taste)

Cranial Nerve IX

gag reflex

gal

gallon

Intention tremor

involuntary trembling when an individual attempts a voluntary movement

enuresis

involuntary urine discharge, usually occurring during sleep; bedwetting.

cystitis

inﬂammation of any bladder(most often refers to urinary bladder)

arrhythmia

irregular pulse rate rhyme

Nodule

is a bigger papule, nodulated and hard

Macule

is a flat and unelevated skin lesion (like a freckle)

Vesicle

is a fluid filled rounder oval lesion (like blister)

Pulse Ox

is a measurement, amount of blood saturated with oxygen (norm respiratory disease free is 95 - 100%)

Pustule

is a vessicle filled with pussy (purulent instead of pussy) (infected acne)

Thrills

is a vibration, put hand on heart and buzzes or vibrates

Bronchial Sounds

is heard on expiration, listen over trachea that's what it would sound like

Sclera

is white

why do we check vital signs??

it indicates the state of health of an individual

When working with fractions that have repeating decimal:

it is recommended that you leave the fraction intact while working through the problem: 1/6 = 0.16666 -- leave as 1/6 to calculate the problem

JVD

jugular vein distention, jugular veins bulge, raise bed up 30 - 45 degree angle

Subcutaneous (SubQ) : specs

just below the surface of the skin 45-degree angle 25-26 gauge needle needle length of 1/2" - 5/8" administered with a 3mL Hypodermic Syringe

KVO

keep vein open

Gag reflex

keeps things out of the lungs

kilogram

Dyspnea

labored breathing

lactated ringers

The dorsogluteal muscle has been the traditional site for IM b/c it can receive a ______ ______ of fluid with minimal pain.

large volume

deltoid

lateral aspect of the upper arm. it is the least used intramuscular injection site because it is a smaller muscle than the others. it's used ONLY for adults because the muscle is not sufficiently developed in infants and children. limited to 1 mL of solution.

scoliosis

lateral curvature of the normally straight, vertical line of the spine, sometimes is S-shaped ("curvature of the spine").

Tricuspid

left 4th intercostals space

left eye

Erbs point

left of the sternum, 3rd intercostal

SubQ: if you can pinch 2+ inches of tissues AND.....

length of needle is 1/2 the width(or less) of pinched tissue, THEN injection is to be given at 90 degree angle

SubQ: if you can pinch 2 inches or less AND/OR...

length of needle is longer than 1/2 the width of the pinched tissue, then the injection is given at 45 degrees

shaft

length of the needle, depends on the depth which the medication will be instilled.

bradycardia

less than 60 bpm

evaluative standards

levels of performance accepted and expected by nursing staff or other health team members-established by authority, custom or consent- nurses must meet at least a 90% scan rate when giving medications

nits

lice eggs

liq

liquid

liq.

liquid

auscultation

listening with a stethoscope

liter

Petechia

little unelevated red bumps, can't feel them, very bad

in a child (tympanic temp) pull the ________________

lobe down and back

What is the use & location of filter needles?

location- HUB; used w/ ampules and vials

Lesions

look at color shape, elevation, tender or sore, any drainage, is it bleeding

Braden Scale

look at risk for skin break down

eye contact

looking another person in the eye, as in "making eye contact."

Perfusion

looks at the exchange of O2 and CO2 in the body in the alveoli, as the flow of blood in and out of the capillaries

Spider vein

looks blue

Presbyopia

loss of elasticity of the lens and thus loss of ability to see close objects as a result of the aging process

Ulcer

loss of skin

Where is lovenox given?

lovehandles

hypotension

low BP less than 90/60

Hypovolemia

low blood volume

hypothermia

low body temperature; also a syndrome (accidental hypothermia), caused by exposure to cold, which may be fatal. Hypothermia may also be induced for therapeutic purposes such as surgery, or pathologic as a result of faulty thermoregulation (temperature control)

Hypoxia

low oxygen

Vesicular Sounds

low pitched soft sound, that's heard on inspiration

pain threshold

lowest intensity of a stimulus that causes a subject to recognize pain.

Rhythm

lub dub (one beat)

pneumonia

lung inﬂammation, with consolidation and drainage

supine

lying on back

gait

manner or style of walking

never take BP on arm if patient has had a _________ or serious injury

mastectomy

exudate

material that escapes from blood vessels and is deposited in tissues or on tissue surfaces; usually contains protein substances.

Pulse Pressure

mathematical difference between systolic and diastolic

ﬂotation mattress

mattress or pad ﬁlled with a gel-type material which supports the body in a way to pro-vide comfort and avoid creating pressure points, thereby helping to prevent skin breakdown.

disadvantage of oral temperature

may be bitten or broken.... inaccurate if just eaten, drunk or smoked

Stridor

means patient in big trouble, airway obstruction and struggling to breathe, anaphylaxis sounds like this

expected outcome

measurable behavior that indicates whether a person has achieved the expected beneﬁt of nursing care

evaluative criteria

measurable qualities, attributes or characteristics that specify skill, knowledge or health states-describe acceptable levels of performance by stating expected behaviors-Pt needs to have O2 sats above 92% on room air to be d/c

tips for applying ted hose

measure legs to determine correct size, assess skin for abnormalities, place while in supine position

Apical-radial pulse

measurement of the apical beat and the radial pulse at the same time

Vital signs

measurements of physiological functioning, specifically body temperature, pulse, respirations, and blood pressure; may include pain and pulse oximetry

vital signs

measurements of temperature, pulse, respiration, and blood pressure.

Pulse oximetry

measures O2 saturation by determining the percentage of hemoglobin that is bound with O2

Diastolic

measures when left ventricle is in relaxation

parenteral medications

medication delivered through a hollow needle, propelled though skin. Used for rapid results or if PT can't swallow or tolerate meds

_______________ expands with heat

mercury

the ______________ increases while the body fights pathogens

metabolism

meter

peripheral neurovascular assessment

method for evaluating the status of an extremity in a bandage or case

logroll turn

method of turning a client that keeps the body in straight alignment, used for clients with injuries to the back and/or spinal cord.

mcg

microgram

mEq

milliequivalent

milligram

milliliter

millilter

millimeter

mm HG stands for

millimeters of mercury

minim

The dorsogluteal muscle has been the traditional site for IM b/c it can receive a large volume of fluid with ______ pain.

minimal

min.

minute

Do not _____ insulin without reading.

mix

critical thinking

mix of inquiry, knowledge, intuition, logic, experience, and common sense.

What are things you want to avoid when choosing an ID site?

moles, scars, tattoos, and vessels

morning

advantage of oral temperature

most accessible and convenient

administering insulin

most common route for administration is subcut or IV injection. special syringes hold volumes of 0.3, 0.5 and 1.0 mL. 100 units per mL.

Arterial Insufficiency

most time down on their lower extremities, shiny in appearance and hair won't grow

paralysis

motion loss or impairment of sensation in a body part.

5 sites to measure temperature

mouth, rectum, axilla, ear, skin

______________ controls inhalation and exhalation

movement of the diaphragm

Diffusion

movment of air in and out of lungs

vastus lateralis site

muscle of the outer thigh. it is desirable for infants and small children and clients who are thin with poorly developed gluteal muscles.

Rectal

must be in Sims position 37.5 C or 99.5 F (core)

multiuse vials

must be labeled with the date it was opened, and RN initials

Demographic Data

name, age, occupation, gender, race

if the bladder is to _______ the BP is too high

narrow

nasogastric

N & V

nausea and vomiting

Myopia

near sided, can't see far

granulation tissue

new tissue that forms when old destroyed tissue is sloughed off.

noc

night

NKA

no known allergies

Would the client be awake and alert?

no, the client would be drowsi and this could progress to coma

Normocephalic

normal head size

nociception

normal pain transmission

you must know the ______________ to recognize the abnormal

normal range

Eupnea

normal respirations

normal saline

Eupnea

normal, quiet breathing

eupnea

normal, relaxed, regular and automatic breathing

Dysrythmia

not in a lub dub rhythm

are side rails a restraint

not is a patient requests them

_____any abnormalities in the nurses notes and _____________

note; tell what action was taken

NPO

nothing by mouth

intradermal injection techniques

nurse instills the medication shallowly at a 10-15 degree angle of entry

intramuscular injection technique

nurses use a 90 degree angle. may use Z-track technique

sign

objective evidence of disease that another person can note (as opposed to symptom, which only the client can describe).

Erosion

occures when you take off the first layer of skin, doesn't bleed but lots of fluid comes out, very moist

intraoperative

occurring during a surgical operation.

Friction rub

occurs when plura (linning of the thorax) comes together and rubs against the plura (linning of the lungs)

of each

ung

ointment

crackle

on auscultation, an abnormal discontinuous non-musical respiratory sound heard on inspiration; formerly called rale.

one half

1/4 NS

one-fourth normal saline (0.22% NaCl)

1/2 NS

one-half normal saline (0.45% NaCl)

ampules

only come in single use form

Aortic

only valve on the right hand side (located 2 intercostal)

3 stages of fever

onset, febrile and defervescence

Cataracts

opacity of the lens or capsule of the eye

dehiscence

opening or separation of the surgical incision.

Corneal Light Reflex

opthalmascope and shine patients eye, see if each cornea reflex the light equally (turn red)

ounce

gurney

our-wheeled cart; also called gurney, wheeled stretcher. A litter scale is used to weigh clients who cannot stand.

OTC

over the counter

aquathermia pad

pad which produces a dry heat by the use of temperature-controlled water ﬂowing through a waterproof shell.

trochanter roll

padding placed onsides of legs and feet of a client in bed, to prevent abnormal outward rotation and related sequela.

chronic pain

pain that lasts more than six months; neuropathic pain.

Discrimination

pain, light touch vibration

What would the client's skin be like?

pale, cool, waxy

paraplegia

paralysis of the legs and sometimes the lower part of the body; a person with this condition is called a paraplegic.

hemiplegia

paralysis on one side of the body.

Perfusion

passage of blood constituents through the vessels of the circulatory system

melena

passage of dark-colored stools containing partially or fully digested blood; also used to mean abnormal blood in the stool or vomitus.

micturition

passage of urine from the urinary bladder; also called voiding, urinating.

Vitiligo

patches of hypopigmented skin, caused by the destruction of melanocytes in the area

3 Steps in a Fever

pathogens enter, body fights pathogens, fever occurs

PCA

patient controlled analgesia

Pyrexia

patient has a fever, any temp above 100.4 F

get up and go test

patient sits in a chair, stands, closes eyes, opens eyes and walks across room in 9-10 seconds

Cheyne-Stokes respirations

pattern of breathing typically seen right before a patient dies, very abnormal pattern

hyperventilation

pattern that increases in rate and depth of breath (CO2 in expelled so low levels)

cheyne -stokes

pattern's of dyspnea and apnea

ulcer

pen sore on an external or internal body surface that causes gradual disintegration of tissues, often an ulcer of the stomach (pepticulcer) or a pressure sore (decubitus ulcer).

per rectum

Febrile

pertaining to a fever; feverish

organs is respiration

pharynx, larynx, trachea, bronchi and lungs

Skin Turgor

picking up skin letting it go

client reminder device

piece of equipment, most often a vest or a belt, used to ensure the safety of the client (ie, helping client to remain in a chair without falling); also called a client reminder device.

piggy back or IVPB

in an adult (tympanic temp) pull the ______________

pinna up and back

pint

Elasticity of the arterial wall

pliability or expansibility of the vessels

pain tolerance

point at which a per-son can no longer tolerate pain.

PMI

point of maximum impulse, mid-clavicular 5th intercostals

complications of parenteral administration

poor technique making drug response too fast/slow, bleeding, tissue necrosis, sterile abscess due to irritation from decreased blood flow to an area, nerve injury causing pain

prone

positioning a client so that he or she is lying on the stomach

prone

positioning a client so that he or she is lying on the stomach.

dangling

positioning of a client so that he or she is sitting on the edge of the bed with legs down and feet supported by a footstool or the floor. This is an exercise in preparation for sitting in a chair and/or walking.

post or after

people susceptible to hypothermia

post-op clients, newborns, elderly and debilitated clients

pound

pwd

powder

scientiﬁc problem-solving

precise method of investigating problems and arriving at solutions

what time frame do you observe when preparing & administering insulins?

prepare last, but give first!

systolic

pressure of blood as a result of the contraction of the ventricles

diastolic

pressure when the ventricles are at rest ( b/n contractions)

prioritization

prioritizing: in the nursing process, following speciﬁc steps to determine the client's most important needs.

collaborative problem

problem in which nurses work with physicians or other healthcare providers.

rotation

process of turning about an axis, as rotation of the hand

rotation

process of turning about an axis, as rotation of the hand.

prognosis

projected client outcome.

Cranial Nerve VII

puff out cheeks, facial movements (smile)

__________ is used when the radial is difficult or irregular

pulse deficit

carotid pulse

pulse felt on either side of the neck, over the carotid artery.

apical pulse

pulse normally heard at the heart's apex, which usually gives the most accurate assessment of pulse rate.

4 signs of life

pulse, respiration, blood pressure, temperature

venipuncture

puncture of a vein, usually with a needle. May be used to obtain a blood specimen or to start an intravenous infusion (IV).

Pyorrhea

purulent (pus) periodontal disease

Distention

pushes out

history of Present Illness

put in chronological order, what helps it, makes it worse, does it start and stop

fever is aka

pyrexia

quart

closed-ended question

questions that can usually be answered by one word, such as "yes" or "no;" also called close-ended questions.

open-ended question

questions used in therapeutic communication and interviews that promote in-depth answers and encourage clients to talk about themselves and their concerns.

advantages of tympanic thermometer

quick and useful in children

8 pulse points

radial, temporal, carotid, apical, brachial, femoral popliteal, pedal

factors that decrease the BMR that are also the body's way of ___________

radiation, conduction/convection, evaporation, vaporization;...heat balance

70/30

rapid acting form and an intermediate form of insulin (combined already) ratio

Hyperventilation

rapid deep respirations

Nystagmus

rapid involuntary rhymthmic eye movement

rhonchi

rattling sounds in the throat that resemble snoring (singular, rhonchus).

apical-radial pulse

reading done by measuring both the apical and radial pulses simultaneously, used when it is suspected that the heart is not effectively pumping blood.

Stereognosis

recognition of an object when you put something in their hand

Graphethesia

recognization of something written on your palm

_____________ is the most accurate temp.

rectal

___________ temp is ________ higher then oral temp.

rectal; 1

rectal mercury thermometer is _____________ at the tip

red

Conjuctiva

red or or goop

Gingivitis

red, swollen gingia (gums)

during hypothermia cellular activity is ______

reduced

benefit for 2 meds in 1 syringe:

reduces need to give two seperate injections

Respiratory rhythm

refers to the regularity of the expirations and the inspirations

Respiratory quality

refers to those aspects of breathing that are different from normal, effortless breathing, includes the amount of effort exerted to breathe and the sounds produced by breathing

pulse can also be _____, ________, ________ and ______-

regular,irregular, thready, absent

Pulse

regulated by Sinoatrial (SA) Node

HIPPA

regulation regarding patient privacy and electronic medical records. Failure to comply may lead to civil penalties.

biopsy

removal of a sample of body tissue or ﬂuid for diagnostic examination, usually microscopic; most often used to detect the presence of cancer.

in case of accidental injury

report injury to supervisor, document the injury in writing, identify the client if possible, obtain HIV and hep B virus client status results if it is legal to do so, obtain counseling on the potential for infection, receive the most appropriate post-exposure drug treatment prophylaxis, be tested for presence of antibodies at appropriate intervals, monitor for potential symptoms and obtain medical follow up.

right eye

six rights

right medication, dose, client, route, time, documentation

Instead of shaking insulin vials, you....

rotate the vials in palm

Type of Medication: Scored Tablets:

round to 1/2 tablet

Type of Medication: Injection less than 1 mL:

round to the hundredth

Tube Feeding mL/hr

round to the nearest tenth

Calories:

round to the nearest whole number

Body Weight:

round to the tenth

Type of Medication: Injections over 1 mL:

round to the tenth

Type of Medication: Oral Liquids:

round to the tenth

mg/min, mcg/hr, units/mL, mL/hr

round to the tenth

Drop factors

round to the whole number

Type of Medication: Oral Pills:

round to whole tablet

parenteral route

route of administration other than oral or through the gastrointestinal tract

axillary temp. advantages is that its

safe and non invasive

Ptosis

sagging eyelid, sliding down

protective device

same as client reminder device

litter

same as gurney

infants lose heat through their ____________-

scalp

keloid

scar or scar tissue

The biggist risk with the dorsogluteal muscle is the possibility of damage to the ______ ______.

sciatic nerve

smegma

sebaceous gland secretion that may collect under foreskin of penis in an uncircumcised male.

Hyperpyrexia

see Hyperthermia

Respiratory character

see Respiratory quality

Cardinal signs

see Vital signs

Heaves

see chest rise with the beats of their heart

steps the hypothalamus takes in regulating the body

sends signal through the NS that causes vasodilation, sweating , inhibition of heat production and shivering

chills

sensations of cold and shaking of the body

sensitive issue

Chemo receptors

sensitive to the presence of carbon dioxide, receptors respond to high levels of CO2 stimulate the body to breathe

Proprioceptors

sensory receptors that are sensitive to movement and the position of the body

renal colic

severe, penetrating lower back pain, caused by a stone becoming lodged in the ureter

Hypoventilation

shallow respirations

Biot's

shallow with periods of apnea

_____________ can increase heat production up to 5x's normal

shivering

example of involuntary muscle movement

shivering

possible factors of hypotension

shock, hemorrhage, orthostatic hypotension

corneas

should be nice and round

lateral

side-lying

erythema

skin redness produced by capillary congestion, as may follow a tuberculin test; bright red color associated with capillary dilation, can indicate fever or infection.

turgor

skin resiliency and plumpness; also called skin turgor.

Cricadian Rhythm

sleep cycle, vital signs lower at night and higher during the day

Bradypnea

slow breathing, less than 12

bradypnea

slow shallow breathing

Bradycardia

slow, heart rate less than 60, someone who is very physically fit will have a lower resting heart rate

1-2 Units

small lines on the insuline syringes are either _-_ Units

vesicle

small sac containing liquid; small blister.

papule

small, solid, circumscribed skin elevation, less than 0.5-1.0 cm in diameter.

Cranial Nerve I

smell

maceration

softening of a solid due to soaking, until connective tissue ﬁbers are dissolved, such as maceration of the skin under a cast or bandage

Papule

solid elevation of skin lesion (like a wart)

SOL

solution

What is a 'needle stick?'

source of infecting self or others with blood borne pathogens

cancer pain

speciﬁc type of pain identiﬁed by IASP, caused by a malignancy; often intractable and severe; usually chronic

expectorate

spitting out and coughing up mucus or other ﬂuid from the lungs and the throat.

pulse points

spots where pulse can be felt wherever a superficial artery can be held against firm tissue(bone)

medical diagnosis

statement formulated by a primary healthcare provider that identiﬁes the disease a person is believed to have, which provides a basis for prognosis and treatment decisions.

Stapes

stirrups bone of the middle ear

vomitus

stomach contents expelled by vomiting or emisis

urinary suppression

stopping or inhibition of urination. Suppression of secretion urine is not formed. Suppression of excretion urine is not expelled

striae

stretch marks

hypertension can cause a ___________

stroke

the third leading cause of death

stroke

gait belt

sturdy webbed belt used by the nurse to help provide support to the weak or unsteady person.

transfer belt

sturdy webbed belt used by the nurse to help provide support to the weak or unsteady person.

SC/subq

subcutaneous

sub-Q or sc

subcutaneous

routes of parenteral medications

subcutaneous, intramuscular, intradermal, intravenous

pain is __________-

subjective

sublingual

Hypothermia

subnormal body temp.

hypothermia

subnormal body temperature( below 94)

Hypothermia

subnormal temperatures

pyrogens

substances that cause fever

supp

suppository

Past Medical History

surgery, diseases, immunizations, allergies to meds, food, and environmental

susp

suspension

Diaphoresis

sweating

distention

swelling or fullness, as in urinary distention.

Edema

swelling, fluid under skin

syr

syrup

nursing assessment

systematic and continuous collection and analysis of information about the client

nursing process

systematic method in which the nurse and client work together to plan and carry out effective nursing care. (The steps include assessment, nursing diagnosis, planning, implementation, and evaluation.)

because blood moves in waves, there are 2 measures, ______________ and ________

systolic and diastolic

___________ is the 1st beat heard and __________ is the last

systolic; diastolic

T or tbs

tablespoon

T, tbs

tablespoon

Tbsp, T

tablespoon

tab

tablet

take: by prescription

disadvantages axillary temp.

takes longer

percussion

tapping a body part with short sharp blows to elicit sounds or vibrations that aid in diagnosis; often refers to the use of a percussion hammer to elicit a reﬂex.

t or tsp

teaspoon

t, tsp

teaspoon

tsp,t

teaspoon

z-track technique

technique for manipulating the tissue to seal medications, especially an irritant in the muscle.

Celsius

temperature scale in which water boils at 100 degrees and freezes at zero (formerly centigrade). "Normal" oral body temperature is 37 degrees Celsius. Celsius scale most often used in health care facilities.

Sites for taking pulses

temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibial, pedal

intractable pain

that which cannot be relieved; continuous, relentless, as in intractable pain.

Stereognosis

the ability to recognize objects by touching and manipulating them

One-point discrimination

the ability to sense whether one or two areas of the skin are being stimulated by pressure

Pallor

the absence of underlying red tones in the skin and may be most readily seen in the buccal mucosa

Inhalation

the act of breathing in; the intake of air or other substances into the lungs

Respiration

the act of breathing; transport of oxygen from the atmosphere to the body cells and transport of carbon dioxide from the cells to the atmosphere

palpation

the act of feeling with the hand, placing the ﬁngers on the skin to determine the condition of under-lying parts.

intramuscular injections

the administration of up to 3 mL of medication into one muscle or group of muscles. irritating medications are given this way. absorption from this type of injection occurs more rapidly than from any other parenteral site.

cardiac output

the amount of blood pumped by the left ventricle in 1 minute

Antihelix

the anterior curve of the auricle's upper aspect

Incus

the anvil bone of the middle ear

Visual fields

the area an individual can see when looking straight ahead

Body temperature

the balance between the heat produced by the body and the heat lost from the body

general anesthesia

the blockage of all body sensations, causing un-consciousness and loss of reﬂexes.

Sternum

the breastbone

Tragus

the cartilaginous protrusion at the entrance to the ear canal

Hypothalamic integrator

the center in the brain that controls the core temperature; located in the preoptic area of the hypothalamus

center of gravity

the center of one's weight; half of one's body weight is below and half above, and half to the left and half to the right of the center of gravity. This concept is important in body mechanics.

Ishiharaa Test

the circles with the numbers in it to see if you can see all of them or which you can't to see if color blind

Meniscus

the crescent-shaped upper surface of a column of fluid

Visual acuity

the degree of detail the eye can discern in an image

Pulse deficit

the difference between the apical pulse and the radial pulse

Pulse pressure

the difference between the systolic and the diastolic blood pressure

Convection

the dispersion of heat by air currents

Tympanic membrane

the eardrum

External auditory meatus

the entrance to the ear canal

Palpation

the examination of the body using the sense of touch

internal respiration

the exchange of gases b/n blood and tissue

respiration

the exchange of oxygen and carbon dioxide in the lungs and tissues

Extinction

the failure to perceive touch on one side of the body when two symmetric areas of the body are touched simultaneously

the first heart sound which occurs when the atrioventricular valves (mitral and tricuspid) close

Percussion

the forceful striking of the chest with cupped hands to loosen secretions in the lungs; a method in which the body surface is struck to elicit sounds that can be heard or vibrations that can be felt

Pitch

the frequency or number of the vibrations heard during auscultation

Manubrium

the handlelike superior part of the sternum that joins with the clavicles

fever stimulates ??

the immune system to produce substances to fight pathogens

External respiration

the interchange of oxygen and carbon dioxide between the alveoli of the lungs and the pulmonary blood

External respiration

the interchange of oxygen and carbon dioxide between the alveoli of the lungs and the pulmonary blood (this is not a bold term but I think it was part of the test on my nursing lab)

Internal respiration

the interchange of oxygen and carbon dioxide between the circulating blood and the cells of the body tissues

Internal respiration

the interchange of oxygen and carbon dioxide between the circulating blood and the cells of the body tissues (this is not a bold term but I think it was part of the test on my nursing lab)

infection

the invasion and multiplication of infective agents in body tissues with a resultant reaction(illness or injury) to their presence and/or their toxins.

Angle of Louis

the junction between the body of the sternum and the manubrium; the starting point for locating the ribs anteriorly

Duration

the length of time that a sound is heard

Alopecia

the loss of scalp hair (baldness) or body hair

Intensity

the loudness or softness of a sound, amplitude

blood pressure is ??

the measure of pressure exerted by blood as it pulsates through the arteries

Arterial blood pressure

the measure of the pressure exerted by the blood as it pulsates through the arteries

Ventilation

the movement of air in and out of the lungs; the process of inhalation and exhalation

Remittent fever

the occurrence of a wide range of temperature fluctuations (more than 2 degrees C [3.6 degrees F]) over the 24-hour period, all of which are above normal

Relapsing fever

the occurrence short febrile periods of a few days interspersed with periods of 1 or 2 days of normal temperature

contralateral

the opposite side

contralateral

the opposite side.

Eustachian tube

the part of the middle ear that connects the middle ear to the nasopharynx; stabilizes air pressure between the external atmosphere and the middle ear

What is the last thing a nurse should always check?

the patients allergies!!

Pulse rhythm

the pattern of the beats and intervals between the beats

Systole

the period during which the ventricles contract

Diastole

the period during which the ventricles relax

perioperative

the period surrounding surgery; includes the preoperative, intraoperative, and postoperative periods

Point of maximal impulse (PMI)

the point where the apex of the heart touches the anterior chest wall

Helix

the posterior curve of the auricle's upper aspect

Edema

the presence of excess interstitial fluid in the body

Diastolic pressure

the pressure of the blood against the arterial walls when the ventricles of the heart are at rest

Systolic pressure

the pressure of the blood against the arterial walls when the ventricles of the heart contract

Auscultation

the process of listening to sounds produced within the body

Hematocrit

the proportion of red blood cells (erythrocytes) to the total blood volume

evisceration

the protrusion of the intestines through an abdominal wound; removal of the internal body contents.

BMR is???

the rate at which heat is produced when body is at rest

Basal metabolic rate (BMR)

the rate of energy utilization in the body required to maintain essential activities such as breathing

Sensorineural hearing loss

the result of damage to the inner ear, the auditory nerve, or the hearing center in the brain

Conduction hearing loss

the result of interrupted transmission of sound waves through the outer and middle ear structures

the second heart sound which occurs when the semilunar valves (aortic and pulmonic) close

Heat balance

the state a person is in when the amount of heat produced by the body exactly equals the amount of heat lost

Chemical thermogenesis

the stimulation of heat production in the body through increased cellular metabolism caused by increases in thyroxine output

Pulse volume

the strength or amplitude of the pulse, the force of blood exerted with each heart beat

core temperature

the temperature of the deep tissues of the body

Core temperature

the temperature of the deep tissues of the body (e.g., thorax, abdominal cavity); relatively constant at 37°C (98.6°F)

Surface temperature

the temperature of the skin, the subcutaneous

Auscultatory gap

the temporary disappearance of sounds normally heard over the brachial artery when the sphygmomanometer cuff pressure is high and the sounds reappear at a lower level

Ossicles

the three middle ear bones of sound transmission

Conduction

the transfer of heat from one molecule to another in direct contact

Radiation

the transfer of heat from the surface of one object to the surface of another without contact between the two objects

mitered (corners)

the type of beveled corners used when making a hospital bed.

axillary

the underarms

dorsogluteal site

the upper outer quadrant of the buttocks is a common location for intramuscular injections. this site is avoided in clients under the age of 3 because their muscle is not sufficiently developed. if not identified correctly, can cause damage to the sciatic nerve.

proxemics

the use of space in relationship to communication.

Inspection

the visual examination i.e. assessing by using the sense of sight

Tidal volume

the volume of air that is normally inhaled and exhaled

stroke volume

the volume of blood pushed into the aorta per heartbeat

Pulse

the wave of blood within an artery that is created by contraction of the left ventricle of the heart

Cerumen

the wax-like substance secreted by glands in the external ear canal

Febrile

they have a fever

Viscous

thick, sticky

three safety injection devices

those with plastic shields that cover the needle after use, those with needles that retract into the syringe, gas pressured devices that inject medications without needles.

suture

thread used to hold an incision together while it heals; also called stitches.

tid

three times a day

t.i.d.

three times per day

factors the increase the BMR

thyroid hormone, epinephrine, nor epinephrine, testosterone, voluntary and involuntary muscle movement

times,for

tr or tinct

tincture

alveoli

tiny thin walled sacs

parts of a syringe that must be kept sterile

tip and plunger

parts of the syringe

tip, barrel, plunger

necrosis

tissue death

internal respiration is aka ??

tissue respiration

voiding

to cast out wastes, as to urinate, micturate.

TKO/KVO

to keep open

dehumanization

to make a person/client feel like an object, to remove one's dignity.

slough

to shed; to cast off (noun: slough—a mass of dead tissue).

Cranial Nerve XII

tongue movement

guaiac

tool examination for blood; also known as Hemoccult.

Caries

tooth cavities

Systolic

top number, measure of left ventricle pushing

The dorsogluteal muscle has been the ______ site for IM b/c it can receive a large volume of fluid with minimal pain.

traditional

Conduction

transfer of heat from one body to another with contact

Radiation

transfer of heat from one object to another without contact

Orthopnea

trouble breathing laying down, breaths easier in upright position

urinary catheter

tube inserted into the bladder through the urethra to remove urine.

intradermal injection equipment

tuberculin syringes hold 1mL of fluid and calibrated in 0.01 mL increments. 25-27 gauge needle measuring half inch in length.

Weber

tuning fork, strike then put on top of head

inversion

turning inside out; reversing.

eversion

turning inside out; turning outward

pronation

turning the hand so that the palm faces downward or backward.

bid

twice a day

b.i.d.

two times per day

ear temperature is aka

tympanic

measurements by a __________ thermometer comes closet to the core body temperature

tympanic

decisions when administering parenterally

type of med, volume of solution, needle length and gauge, size/weight of pt, type of tissue, site of injection

thrombolytic

type of medication designed to dissolve a clot and clear a blocked blood vessel.

selecting a syringe and a needle

type of medication, depth of tissue, volume of prescribed drug, viscosity of the drug, size of the client.

nodule

type of skin lesion appearing as a small knot or protuberance

Kerlix

type of stretchy gauze used to hold dressings in place.

oral temp. is not taken on a ________________ person

unconscious

leading cause of mortality/.morbidity in children

unintentional gun shot wound

unit

units

max volume for IM:

up to 3 mL

risk factors for hypertension

urban living, stress, men, race, obesity

hydrometer

urinometer (used to measure speciﬁc gravity of a liquid, such as urine).

IM injections on women greater than 200 lbs and men greater than 260 lbs

use 1 1/2" to 2" needle

IM injections on women 130-200 lbs and men 130-260 lbs

use 1"-1 1/2" needle

IM injections on pt less than 130 lbs

use 5/8" to 1" needle

splinting

use of a pillow or large towel to provide support along a suture line.

body mechanics

use of safe and efficient methods of moving and lifting

body mechanics

use of safe and efficient methods of moving and lifting.

Costal (thoracic) breathing

use of the external intercostal muscles and other accessory muscles, such as the sternocleidomastoid muscles

prevention of needle sticks

use safety devices, needless devices, sharps disposal, one-handed re-capping, never recap contaminated needles

What do you use if a filter needle is unavailbale?

use the smallest guage needle (29)

What is subcutaneous injections used for?

used for small doses of water soluble meds;

Describe a 'high guage'

used for thin solutions; 29 ga (ex.insulin)

ventogluteal site

uses the gluteaus medius and gluteaus minimus in the hip for injection. safe to use for children. no large nerves or blood vessels, less fatty and cleaner.

Fever

usually not harmful to patient unless it exceeds 102.2 F

ID injections have limited __________ & a low chance for ______.

vascularity & anaphylaxis

sites of an IM injection

ventrogluteal, vastus lateralis, deltoid

footboard

vertical support at the foot of a bed, helps to prevent footdrop.

Hyperventilation

very deep, rapid respirations

Hypoventilation

very shallow respirations

Angioma

vessel bursting under the skin, are arterial (very red)

28 day

vials have a _________expiration.

IM injections are used for ______ or _______ meds

viscous or irritating

vital signs means???

vital for life

polyuria

voiding an excessive amount of urine.

urinary frequency

voiding more often than usual without an increase in total urine volume

nursing history

way of soliciting information from the client; may also be called a health interview.

health interview

way of soliciting information from the client; may also be called a nursing history.

Health Promotion Behaviors

wear sunscreen, wear seatbelt, diet and exercise

weight

Chief complaint

what are you here

Objective

what the nurses asses (BP)

Subjective

what the patient tells us

Force

what we measure in BP

Murmur

when blood rushes through a valve that hasn't properly closed or valve is still opened

inhibition of heat production is when??

when body heat increases above normal

Clubbing

when end of their fingers get fatter and flatter on the end, comes from living in a state of low oxygen

clear before cloudy

when mixing insulin, draw up ______________.

compatibility of medications, contaminate, accurate, aseptic

when mixing medications, determine_______of meds, do not __________, ensure the final dose is ________ and maintain__________technique.

wheezes

whistling sound of air being forced past

with

c (has a line over it)

with

Intravenous (IV) : specs

within or into a vein 25-degree angle 18-22 gauge needle needle length of 1" - 1.5" administered with a 5mL Hypodermic Syringe

Intradermal (ID) : specs

within the dermal layer of the skin 10-15 degree angle 25-28 gauge needle needle length of 3/8" - 5/8" administered with a 1mL Tuberculin Syringe

Intramuscular (IM) : specs

within the muscle 90-degree angle 18-23 gauge needle needle length of 1" - 3" administered with a 3mL or 5mL Hypodermic Syringe

without

s (with a line over it)

without

Coma

won't respond to any kind of stimulus

Patent

works or functionc as it should

Your patient needs 400 mg of erythromycin oral suspension. the label reads erythromycin 200 mg/ 5 ml. How many milliliters should you give?

x X 200mg = 5 ml X 400 mg x= 10ml

Your patient is receiving 500 mg of cefaclor oral suspension. The lable reads cefaclor 250mg/5ml, and the bottle contains 100ml. How many milliliters of cefaclor should you give? ,

x X 250 mg = 5 ml X 500 mg X= 10 ml

yard

Tarter

yellow stains on gum line

Would the client be shivering if experiencing hypothermia?

yes, initially

Is frost bite associated with hypothermia? If yes, what body parts would be first?

Nursing101

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