skills final
Function of the skin
-protection -secretion -excretion -temperature -regulation -sensation
what is the normal range of urine production?
1 to 2 liters a day
DIFFERENTIAL COUNT - EOSINOPHILS
1%-4% Increased in parasitic infection
The appropriate site for taking the pulse of a 2-year-old is: 1. Radial 2. Apical 3. Femoral 4. Pedal
2
The nurse has just taken vital signs for a 30-year-old client. Based on the results, the nurse will report the following finding that is out of the expected range for a client of this age: 1. T = 37.4° C 2. P = 110 beats/min 3. R = 20 breaths/min 4. BP = 120/76 mm Hg
2
The nurse recognizes that which of the following clients present at the annual July 4th marathon is at greatest risk for hyperthermia and the resulting heatstroke? 1. A 34-year-old running for the first time in the July 4th marathon who is sweating profusely 2. A 16-year-old volunteer, with type 1, insulin-dependent diabetes, who is checking runners in for the marathon at the starting gate 3. A 75-year-old who is prescribed medication for Crohn's disease and who is sitting outdoors watching her granddaughter run the marathon 4. A 55-year-old diagnosed with bipolar disease and prescribed a phenothiazine (Serentil), who will be walking the marathon course
2
Unstageable/Unclassified pressure ulcer
- Full-thickness Skin or Tissue Loss-Depth Unknown - ulcer in which the base of the wound cannot be visualized - depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan,brown, or black) - its either a Stage III or Stage IV
Stage IV pressure ulcer
- Full-thickness Tissue Loss (Muscle/Bone visible) - full-thickness tissue loss with exposed bone, tendon, or muscle - slough or eschar may be present - often includes undermining and tunneling (depth varies by anatomical location. the bridge of the nose, ear, occiput, and malleolus do not have adipose/subcutaneous tissue; these ulcers can be shallow. Can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle/etc. is visible or directly palpable)
Sanguineous drainage
- bright red; indicates active bleeding (bloody drainage)
Pruritus
- itching (side effect of med)
1. If obstructed, which component of the urination system would cause peristaltic waves? a. Kidney b. Ureters c. Bladder d. Urethra
ANS: B Ureters drain urine from the kidneys into the bladder; if they become obstructed, peristaltic waves attempt to push the obstruction into the bladder. The kidney, bladder, and urethra do not produce peristaltic waves. Obstruction of both bladder and urethra typically does not occur.
Sensory or Communication Impairment Risks
Associated with delirium, dementia, depression. Altered concentration/attention span, impaired memory, orientation changes. Likely to have falls or burns.
BMR
Basal metabolic rate affected by body surface area and by thyroid hormones
Critical Thinking Knowledge
Basic human needs, potential risks, influence of developmental stage on safety, influence of illness/medication on safety.
what does aldosterone do?
causes retention of water, which increases blood volume.
DISUSE ATROPHY
cells and tissue to reduce in size and function in response to prolonged inactivity results from bed rest, trauma, casting of a body part, or local nerve damage
BODY MECHANICS
coordinated efforts of musculoskelatal and nervous systems
COUGH ETIQUETTE and RESPIRATORY HYGIENE
cover your mouth or nose when coughing or sneezing wear a mask Teach patients, health care staff, patient's families, and visitors about respiratory hygiene or cough etiquette Proper use/disposal of tissues HAND HYGIENE!!
Motor Vehicle Accidents
Highest among 16-19 year old drivers. Teens often underestimate dangerous situations, and have the lowest seat belt use. Also high in people 75-80 years old because of decreased nervous system response and hearing acuity.
CONGENITAL HIP DYSPLASIA
Hip instability with limited abduction of hips occasionally adduction contractures - head of femur does not articulate with acetabulum because of abnormal shallowness of acetabulum
Dry powder inhalers (DPIs)
Hold dry, powdered medication and create an aerosol when the patient inhales through a reservoir that contains the medication
d) antagonist
Interacts with the receptor to block or produce the opposite effect. Acts opposite the substance that stimulates the receptor. a) drug toxicity b) drug tolerance c) agonist d) antagonist
COMPRESSION
Internal application of pressure by means of inflated balloon to prevent internal esophageal or GI hemorrhage
MODE OF TRANSMISSION - INDIRECT CONTACT
Personal contact with of a susceptible host WITH contaminated inanimate object sneezes, coughs object contamination food/water contamination animal-to-human exchange
CARRIERS
Persons who show no symptoms of illness but who have the pathogens that are transferred to others
What is the name of the procedure that examines the lower third of the colon?
Sigmoidoscopy
Poison
Substance that impairs health or destroys life when ingested, inhaled or absorbed. Young children at greater risk. Lead poisoning still very common.
[[Identify the guidelines to ensure safe administration of transdermal or topical medications.]]
a.) Document where the medication was placed in the MAR b.) Assess if patient has an existing patch before application c.) Medication history and reconciling medications d.) Apply a noticeable label to the patch e.) Document removal of medication on the MAR
Identify the advantages of the intravenous (IV) route of administration.
a.) Fast-acting medications must be delivered quickly b.) It provides constant therapeutic blood levels c.) It can be used when medications are highly alkaline and irritating to the muscle and subcutaneous tissue
Identify factors that can influence the patient's compliance with the medication regimen
a.) Health beliefs b.) Personal motivations c.) Socioeconomic factors d.) Habits
Identify the areas the nurse needs to assess to determine the need for and potential response to medication therapy.
a.) History b.) History of allergies c.) Medication data d.) Diet history e.) Patient's perceptual coordination problems f.) Patient's current condition g.) Patient's attitude about medication use h.) Patient's knowledge and understanding of medication therapy i.) Patient's learning needs
[[*Identify the major sites for topical administration*]]
a.) Skin b.) Mucous membranes
Identify the factors that must be considered when selecting a needle for an injection.
a.) The patient's size and weight b.) Type of tissue into which the medication is to be injected *Bevel side up*
excretion
The process by which metabolites and drugs are eliminated from the body.
f) duration
Time medication takes to produce greatest result. a) serum half-life b) trough c) onset d) peak e) plateau f) duration g) therapeutic range
The nurse recognizes that her older-adult patient needs additional teaching about skin care when the older adult says, "I should:
Use hot water for bathing.
Identify the outcomes for a patient with newly diagnosed Type 2 diabetes.
a.) Will verbalize understanding of desired effects and adverse effects of medications b.) Will state signs, symptoms, and treatment of hypoglycemia c.) Will monitor blood sugar to determine if medication is appropriate to take d.) Will establish a daily routine that will coordinate timing of medication with meal times.
Identify the factors that affect the rate and extent of medication distribution.
a.) circulation b.) membrane permeability c.) protein binding d.) metabolism e.) excretion
[[Intramuscular injections]]
a.) faster absorption that subcutaneous route b.) Angle: 90 degrees c.) Body surface area determines the size of needle to use
[[Identify the factors that influence drug absorption.]]
a.) route of administration b.) ability of the medication to dissolve c.) blood flow to the site of administration d.) body surface area e.) lipid solubility
TELEPHONE ORDER
abbreviated as "TO"
Tachycardia
an abnormally elevated heart rate; above 100 beats per minute in adults
Anorexia nervosa
an eating disorder characterized by a low weight, fear of gaining weight, a strong desire to be thin, and food restriction.
Bulimia nervosa
an eating disorder characterized by binge eating followed by purging
Hyperthermia
an elevated body temperature related to the body's inability to promote heat loss or reduce heat production
Hyperthermia
an elevated body temperature related to the inability of the body to promote heat loss.
urgency
an immediate and strong desire to void that is not easily deferred
HEALTH PROMOTION - INFECTION PREVENTION
better nutrition rest personal hygiene physiological protective mechanisms immunizations exercise
KAYEXALATE ENEMA
binds to and helps excrete potassium contraindicated in patients with hypokalemia (low potassium)
Eschar
black or brown necrotic tissue
eschar
black or brown necrotic tissue - has to be removed before healing can occur
MELENA
black, tarry stool due to occult blood in the stool upper GI tract blood has come in contact with HCl
hemorrhage
bleeding from a wound site
sanguineous
bright red which indicates active bleeding
inhalers updrafts anesthesia
What types of drugs would be excreted through the lungs?
Explain the reasons why polypharmacy happens to a patient.
When a patient needs to take several medications to treat their illnesses; take two or more medications from the same chemical class; use two or more medications with the same or similar actions or mix nutritional supplements or herbal products with medications
weekly
When applying topical medication, the site of application (unless for a wound) should be rotated how often?
pyelonephritis
a serious upper UTI
urinary incontinence
defined as the "complaint of any involuntary loss of urine"
NURSE PRACTICE ACTS (NPAs)
defines the scope of a nurses professional functions and responsibilities primary intent of NPAs is to protect the public from unskilled, undereducated, and unlicensed personnel
FOOD AND DRUG ADMINISTRATION (FDA)
ensures all medications undergo vigorous testing before they are sold to the public
HEALTH CARE INSTITUTIONS
establish individual polices to meet federal, state, and local regulations agency policies are often more restrictive than governmental controls
Febrile
feverish; pertaining to a fever
What are some principles to know when changing bed linens?
follow principles of medical asepsis. Keep articles away from body. Never throw linens on the floor. Never shake them.
SHEAR
force exerted against the skin skin remains stationary while the bony structures move
Shearing Force
force exerted against the skin while the skin remains stationary and the bony structures move
what does renin do?
functions as an enzyme to convert angiotensin into angiotensin I
DIGITAL REMOVAL OF STOOL
identify patient using two identifiers obtain baseline vital signs place on left side in Sims' position apply clean gloves and lubricate insert index finger into the rectum gently loosen the fecal mass by massaging around it work the feces downward toward the end of the rectum
HAND HYGIENE - CONTACT WITH SPORES
if exposed to Clostridium difficile, wash hands with nonantimicrobial soap and water
PATHOLOGICAL ABNORMALITIES AFFECT MOBILITY IN THE FOLLOWING WAYS:
impaired body alignment, balance, and mobility weakness muscle atrophy increased disability
LONG-TERM LAXATIVE USE
impairs bowel motility decreases response to sensory stimulus NOT RECOMMENDED FOR LONG-TERM USE
Nutritional assessment
important to ask about diet and health history and to do a physical exam.
INCONTINENCE
inability to control passage of feces and gas from the anus
nursing history
includes a review of the patient's elimination patterns, symptoms of urinary alterations, and assessment of factors that are affecting the ability to urinate normally.
CHEMICAL STERILANTS - HIGH LEVEL DISINFECTION (HLD)
includes the following: - alcohols - chlorines - formaldehyde - glutaraldehyde - hydrogen peroxide - iodophors - phenolics - quaternary ammonium compounds each product performs in a unique manner and is used for a specific purpose
DIARRHEA
increase in the number of stools passage of liquid, unformed feces
CONDITIONS WHERE ENEMA USE IS CONTRAINDICATED
increased intracranial pressure glaucoma recent abdominal, rectal, or prostate surgery
OSMOTIC
increases pressure in the bowel to act as a stimulant for peristalsis agents that pull fluid into the bowel to soften the stool distends the bowel to stimulate peristalsis Milk of Magnesia, Miralax
FACTORS THAT INFLUENCE - AGE
infants have immature defenses breastfed infants have greater immunity since they receive antibodies through breast milk viruses are most common in middle-aged adults
Where to inspect signs of discharge and abnormal odors?
inspect vaginal and perineal areas
reflex urinary incontinence
involuntary loss of urine occurring somewhat predictable intervals when patient reaches specific bladder volume related to spinal cord damage between C1 to S2
BOILING WATER
least expensive for use in the home Bacterial spores and some viruses resist boiling It is not used in health care facilities
trace elements
less than 100 mg is needed daily.
What are some body mechanics to remember when changing linens?
make sure to never work over side rails, bring bed to your waist level; put bed in low position when finished.
Anthropometry
measurement system of size and makeup of the body.
EXCRETION - MAMMARY GLANDS
medications that pass through breast milk medications that pass through breast milk are not always safe for infant. Check safety first!
RATE OF ABSORPTION - ORAL ADMINISTRATION
medications that pass through the GI tract will be absorbed slowly
MRSA
methicillin-resistant Staphylococcus aureus
MEASUREMENTS OF MEDICATION THERAPY
metric apothecary household
STATE GOVERNMENT
must conform to federal legislation states often have additional controls, including substances not regulated by the federal government
SHAPE OF STOOL - ABNORMAL
narrow pencil or ribbon shaped indicates possible obstruction increases in peristalsis
NEEDLE FOR IMMUNIZATIONS
needle width: 23 to 25 gauge needle length: 5/8 inch
Non-shivering thermogenesis
neonates (newborns) who cannot shiver. They will burn a minute amount of brown tissue (type of adipose tissue) in order to stay warm
MEDICATION RECONCILIATION
obtain/verify/document consider/compare reconcile communicate
Orthostatic hypotension
occurs when a normotensive person develops symptoms and low blood pressure when rising to an upright position; aka postural hypotension
Pyrexia
occurs when heat-loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature; aka fever
Fever
occurs when heat-loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature; aka pyrexia
Dehiscence
partial or total separation of wound layers
dehiscence
partial or total separation of wound layers - this happens when wounds fail to heal properly - occurs before collagen formation
Capnography
partial pressure of CO2, 35-45 mm Hg
Hematocrit
percentage of red blood cells in the blood; determines blood viscosity
ANUS
portal of exit for elimination of feces and flatus innervated by both parasympathetic and sympathetic nerves
BREAKING THE CHAIN OF INFECTION
rapid identification of organisms environmental sanitation disinfection/sterilization aseptic technique proper attire/PPE hand hygiene air flow control
PERISTALSIS - ABNORMALLY FAST
rapid movement means there is less time for water to be absorbed results in wet, watery stools
TYPES OF INSULIN
rapid-acting short-acting intermediate-acting long-acting
RANGE OF MOTION (ROM) EXERCISES
reduce the risk of contractures
Nutrient density
refers to the proportion of essential nutrients to the number of kilocalories.
PROTECTING SUSCEPTIBLE HOST INCLUDES - NATURAL DEFENSE MECHANISMS
regular bathing regular oral hygiene adequate fluid intake coughing/deep breathing immunizations
NERVOUS SYSTEM
regulates movement and posture
what is renin?
released from juxtaglomerular cells`
hygiene is never
routine, it is unique to each person
NORMAL SALINE ENEMA
safest solution exerts SAME osmotic pressure as fluids in the interstitial spaces volume of infused saline stimulates peristalsis
FECES - DESCENDING COLON
semi-formed to formed most water has been absorbed does not form a hardened mass
Hemostasis
series of events designed to control blood loss, establish, bacterial control, and seal the defect, occurs when there is an injury
epidermis
shields underlying tissue
PRE-FILLED CARTRIDGES
single-dose need holder or re-draw expel air
IMMOBILITY
the INABILITY to move about freely
MEMBRANE PERMEABILITY
the ability of a medication to pass through tissues and membranes to enter target cells
Basal metabolic rate (BMR)
the body's resting rate of energy expenditure
subcutaneous
tissue that lies beneath the skin
[[Routes of Medication Administration and absorption rates]]
topical: hrs to days Subligual: 3-5 mins PO:30-90 mins inhalation:3 mins SubQ: 3-20 mins IM: 3-20 mins IV: 30-60 secs Rectal: 5-30 mins/unpredictable ET: 3 mins
Evaporation
transfer of heat energy when a liquid is changed to a gas.
POSITIONING TECHNIQUES
trocanter roll hand roll trapeze bar supported Fowler's supine prone side-lying Sim's
idiosyncratic reactions
unpredictable overreaction or undereaction, or reaction different from normal reactions
ALLERGIC REACTIONS
unpredictable response to medication immunologically sensitized to initial dose medication/chemical acts as an antigen, triggering the release of antibodies in the body symptoms vary depending on patient and medication given
Linoleic acid
unsaturated fatty acid that is the only essential fatty acid for humans.
normal protein in urine
up to 8 mg/100 ml
URINARY ELIMINATION CHANGES
urinary stasis renal calculi
what is the most common healthcare-acquired infection?`
urinary tract infections (UTI)
overactive bladder
urinary urgency, often accompanied by increased urinary frequency and nocturne that may or may not be associated with urgency incontinence and is present without obvious bladder pathology or infection.
U-500 ML INSULIN
use a tuberculin syringe to draw up doses of this type of insulin
HAND HYGIENE - WHEN HANDS ARE NOT VISIBLY SOILED
use an alcohol-based, waterless antiseptic agent to perform hand hygiene
ADMINISTERING RX TO CHILDREN - INJECTIONS
use caution when selecting IM site since muscles may be underdeveloped Have another nurse or parent available to help comfort/restrain child if needed always awaken a child before giving an injection distraction can help reduce pain perception (i.e. bubbles, toy, conversation) lidocaine ointment can be applied to help reduce pain perception
blanching
when normal red tones of the light skinned patient are absent as when pressing a patient's fingertips to test capillary refill - blanching of the skin does not occur in darly pigmented skin
MEDICATION INTERACTION
when one medication modifies the action of another medication increase or diminish the action or alter the way another medication is absorbed, metabolized, or eliminated from the body
LOW RESIDUE FOODS
white rice potatoes bread bananas cooked cereals
LIGAMENTS
white, shiny, FLEXIBLE bands of fibrous tissue bind joints connect bones and cartilage ELASTIC aid joint flexibility/support
TRANSVERSE COLOSTOMY
will have thick liquid to soft form consistency
abdominal roetgenogram
x-ray film of the abdomen to determine the size, shape, symmetry, and location of the structures of the lower urinary tract
cystitis
irritation of the bladder
BRISTOL STOOL SCALE - TYPE 2
sausage shaped lumpy
Approximated
skin edges are closed
darkly pigmented skin
skin that remains unchanged (does not blanch) when pressure is applied on a bony prominence - this doesn't have anything to do with a patient's race or ethnicity
lactovegetarian
drink milk but avoids eggs
INTRINSIC FACTOR
essential for the absorption of vitamin B12
acute retention
suddenly unable to void when bladder is adequately full or overfull
STOMA
surgical opening in the ileum or colon - ileostomy - colonstomy
Why should you undress the unaffected side of the patient first?
allows easy manipulation of gown over body
HEMIPLEGIA
one-sided paralysis
DOSE CALCULATIONS
ratio and proportion method formula method dimensional analysis
granulation tissue
red moist tissue composed of new blood vessels which indicated progression toward healing
Vitamins
Organic substances present in small amounts in food and is essential for normal metabolism.
HEALTH CARE-ASSOCIATED INFECTION
"HAI" result from the delivery of health services in a health care facility occur as the result of invasive procedures, antibiotic administration, the presence of multidrug-resistant organisms (MDROs) breaks in infection prevention and control activities
A client has recently experienced difficulty hearing out of both ears. Which of the following is the best nursing response to the client?
"Try to avoid putting a Q-Tip (cotton-tipped applicator) into your ears. "
What would be the damage in a full-thickness wound?
- damage extends into the subcutaneous tissue
epithelialization
- the skin surface is repaired
Indicate the maximum volume of medication for an IM injection: *Older infants and small children* *Smaller infants*
1 mL 0.5 mL
Identify the advantages of the intravenous (IV) route of administration (3):
1. Fast acting 2. Constant therapeutic blood levels 3. Prevent irritation and used when medications are highly alkline
What is the recommended balloon size for adults
10 ml
Respirations
12-20 breaths
RX IN AQUEOUS SOLUTIONS
20 to 25 gauge needles
low sodium
4 gram, 2g, 1g, or 500 mg of salt
IRON LEVEL
80-180 mcg/mL for men 60-160 mcg/ml for women decreased in chronic infection
a) drug toxicity
A condition that may result from overdose, ingestion of a drug intended for external use, or the cumulative effect. a) drug toxicity b) drug tolerance c) agonist d) antagonist
c) agonist
A drug that interacts with a receptor to produce a response. Acts like the substance that stimulates the receptor. a) drug toxicity b) drug tolerance c) agonist d) antagonist
A solution is:
A given mass of a solid substance or given volume that dissolved in another known volume or fluid.
Intermittent catheter
A one time catheter
While planning morning care, which of the following patients would receive the highest priority to receive his or her bath first?
A patient who is experiencing frequent incontinent diarrheal stools
BACTERICIDAL
A temperature or chemical that destroys bacteria
INFECTIOUS DISEASE
Illnesses such as viral meningitis or pneumonia
8. Which patient is most at risk for increased peristalsis? a. A 5-year-old child who ignores the urge to defecate owing to embarrassment b. A 21-year-old patient with three final examinations on the same day c. A 40-year-old woman with major depressive disorder d. An 80-year-old man in an assisted-living environment
ANS: B Stress can stimulate digestion and increase peristalsis. Ignoring the urge to defecate, depression, and age-related changes of the elderly are causes of constipation.
10. Which physiological change can cause a paralytic ileus? a. Chronic cathartic abuse b. Surgery for Crohn's disease and anesthesia c. Suppression of hydrochloric acid from medication d. Fecal impaction
ANS: B Surgical manipulation of the bowel can cause a paralytic ileus. The other options are incorrect.
16. The nurse would anticipate which diagnostic examination for a patient with black tarry stools? a. Ultrasound b. Barium enema c. Upper endoscopy d. Flexible sigmoidoscopy
ANS: C Black tarry stools are an indication of ulceration or bleeding in the upper portion of the GI tract; upper endoscopy would allow visualization of the bleeding. No other option would allow upper GI visualization.
reported; documented
All medication errors must be _________________ and ______________.
*Explain the role of metabolism*
After a medication reaches its site of action, it becomes metabolized into a less active or inactive form that is easier to excrete.
EXCRETION
After medications are metabolized, they exit the body through the kidneys, liver, bowel, lungs, and exocrine glands chemical makeup of a medication determines the organ of excretion.
24-48 hours
After removing a catheter how long do you monitor voiding for?
FACTORS THAT INFLUENCE INFECTION PREVENTION/CONTROL
Age Nutritional status Stress Disease Treatments/Conditions that compromise the immune system
Assessment Risk for Falls
Age, fall history, elimination habits, medication, mobility and cognition. Assess fall risk on admission, change in condition, after a fall, when transferred. Make patients aware of risks.
Metabolism
All of the biochemical reactions within the cells of the body. Anabolic: building Catabolic: breaking down
PROTECTIVE ENVIRONMENT
Allogeneic hematopoietic stem cell transplants gene therapy
The nursing assessment of a 78-year-old woman reveals ortho- static hypotension, weakness on the left side, and fear of falling. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? 1. Activity Intolerance 2. Impaired Bed Mobility 3. Acute Pain 4. Risk for Falls
Answer: 4. For adults age 65 and older, orthostatic hypotension, fear of falling, and weakness on one side are risks for the nursing diagnosis of Risk for Falls.
NO
Are incident reports part of the patient chart?
adverse effects
Are severe responses to medications
Dysphagia is associated with an increase risk for what problem?
Aspiration
Ovolactovegetarian
Avoid meat, fish and poultry, but eat eggs and milk
A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe? a. Respiratory alkalosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory acidosis
B
In which patient will the nurse expect to see a positive Chvostek sign? a. A 7-year-old child admitted for severe burns b. A 24-year-old adult admitted for chronic alcohol abuse c. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism d. A 75-year-old patient admitted for a broken hip related to osteoporosis
B
The nurse observes that the patient's calcium is elevated. When checking the phosphate level, what does the nurse expect to see? a. Increased b. Decreased c. Equal to calcium d. No change in phosphate
B
The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? a. Sodium of 145 mEq/L b. Calcium of 15.5 mg/dL c. Potassium of 3.5 mEq/L d. Chloride of 100 mEq/L
B
What is a mini-infusion pump?
Battery operated machine that allows medications to be given in very small amounts (5 to 60 mL)
CONSTIPATION
Condition characterized by difficulty in passing stool or an infrequent passage of hard stool
Rectum
Bacteria forms stool
Bladder retraining
Behavioral therapy designed to help patients control bothersome urinary urgency and frequency.
A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let the blood infuse? a. 30 minutes b. 2 hours c. 4 hours d. 6 hours
C
water-soluble vitamins
C and B complex The body does not store water-soluble vitamins; thus we need them provided in our daily food intake. Water-soluble vitamins absorb easily from the GI tract
No: have to see all medications given
Can you leave medication for a patient to take after they get out of the shower?
REDUCE RESERVOIR - DRESSING CHANGES
Change dressings that become wet and/or soiled
Which of the following information provided by the client's bed partner is most associated with sleep apnea? A. Restlessness B. Talking during sleep C. Somnambulism D. Excessive snoring
D. Excessive snoring Partners of clients with sleep apnea often complain that the client's snoring disturbs their sleep.
COLONOSCOPY
DIRECT VISUALIZATION of the LOWER GI tract with a lighted fibrooptic tube
ENDOSCOPY
DIRECT VISUALIZATION of the UPPER GI tract with lighted fiberoptic tube
APPLICATION OF TOPICAL MEDICATIONS
DIRECT application of a liquid or ointment INSERTION of medication into a body cavity INSTILLATION of fluid into a body cavity IRRIGATION of a body cavity SPRAYING a medication into a body cavity
DOCUMENTATION - WHEN DOSE IS A WHOLE UNIT
DO NOT USE a trailing zero for doses expressed as whole numbers 5 mL
The most common form of nasal instillation is:
Decongestant spray or drops
Which response or action by Jamie is the appropriate initialresponse to the daughter's statement?
Explains why not to soak the feet.
Developmental Environment Psychological Timing
Factors affecting medication action:
unsaturated fatty acid
Fatty acid in which an unequal number of hydrogen atoms are attached and the carbon atoms attach to one another with a double bond.
saturated fatty acids
Fatty acid in which each carbon in the chain has an attached hydrogen atom.
MOST COMMONLY TRANSMITTED INFECTIONS VIA NEEDLESTICK
HBV HCV
Assessment Risk for Disasters
Hospitals must prepare to care for sudden influx of patients in disaster, like bioterrorism. Detect bioterrorism rapidly through syndrome surveillance and specific clinical reporting. Early signs of bioterrorism are often nonspecific.
Loose stools
How is stool in the ascending colon?
Digital removal
Impaction interventions
Valsalva maneuver
Increase pressure in abdomen
Carbohydrates
Main source of energy (glucose) in the diet.
ILLNESS STAGE
Manifests signs and symptoms to type of infection
Mouth
Mastication
Clean catch
Mid-stream, sterile cup
General Preventive Measures by Lighting
Night lights, exterior lights and locks on windows/doors reduce risk for crime.
pH-4.6-8.0 Specific gravity-1.005-1.030 RBC's-0-2 WBC's-0-4
Normal Urinalysis Values
Small intestine
Nutrients absorbed
BOWLEGS (GENU VARUM)
One or both legs bent outward at knee, which is normal until 2 to 3 years of age
Basic Needs
Physiological needs like oxygen, nutrition, and temperature influence patient safety.
Fiber
Polysaccharide. the structural part of plants that is not broken down by our digestive enzymes.
normal blood in the urine
SHOULDN'T BE PRESENT
RATE OF ABSORPTION - TOPICAL ADMINISTRATION
SLOWEST rate of absorption because of the physical makeup of the skin.
Laxatives
Short term action to empty the bowel
Explain the rationale for intradermal injections.
Skin testing; injected into the dermis where medication is absorbed slowly
What is a volume-control administration set?
Small container that attaches below infusion bag. (50 to 150 mL)
EFFICACY - PRESENCE OF SOAP
Soap causes certain disinfectants to be ineffective. Thorough rinsing of an object is necessary before disinfecting
Stomach
Stores and mixes
Intrapleural
Syringe, needle, or chest tube used to administer med directly into pleural space
Therapeutic effects
The expected or predictable physiological response to a medication.
*Absorption*
The passage of medication molecules into the blood from the site of administration.
SIGNS OF DEHYDRATION - ADULTS
Thirst Less frequent urination Dark-colored urine Dry skin Fatigue Dizziness Light-headedness
Physical Hazards
Threaten a persons safety and often result in physical or psychological injury or death.
Ureters
Transport urine from the kidneys to the bladders
ASEPSIS
absence of pathogenic microorganisms
INSTILLATION OF EAR DROPS - CHILDREN OVER 3 YRS TO ADULTS
auricle pulled upward and outward
INSTILLATION OF EAR DROPS - CHILDREN UP TO 3 YEARS
auricle should be pulled down and back
nocturia
awakened from sleep because of the urge to void
Pyrogens
bacteria or viruses that cause an elevation in body temperature because they are antigens that trigger the immune response
ENEMA ADMINISTRATION
can be delegated to NAP
PERISTALSIS
contractions that propel food/fluids through the GI tract
ORAL ROUTE
easiest and the most commonly used route of medication administration Medications are given by mouth and swallowed with fluid Oral medications have a slower onset of action
metabolites
end-product of biotransformation
STAT ORDER
given immediately in an emergency
What is the purpose of intact skin?
goal of optimal physiological functioning
STOMACH PRODUCES/SECRETES
hydrochloric acid (HCl) mucus pepsin intrinsic factor
RESPIRATORY CHANGES
increased risk for pulmonary/respiratory complications including: - atelectasis - hypostatic pneumonia
INTRADERMAL INJECTION
inserted at 5 to 15 degrees bevel of needle is pointed up as medication is injected, a small "bleb" should appear used for skin testing - tuberculin screen - allergy testing inner forearm upper back
Time of day affects temp
lowest at 6 AM, highest at 4 PM
METRIC SYSTEM
most logically organized based on units of 10
CHECKING THE MEDICATION ORDER
per agency policy was medication transcribed properly? double check the following: - dosage - appropriateness of Rx - allergies
PHYSICAL ACTIVITY
promotes peristalsis
DEVELOPMENTAL CHANGES - ADOLESCENTS
social isolation
Eupnea
the normal rate and depth of ventilation
VRE
vancomycin-resistant enterococcus
BRISTOL STOOL SCALE - TYPE 7
watery, liquid stool no solid pieces
hygiene asses:
-emotional status -health promotion practices -health care education needs
layers of the skin
-epidermis -dermis
The disadvantages of IV bolus medications are (2)
1. Most dangerous (not enough time to fix an error) 2. Can irritate lining of blood vessels
Identify the factors that must be considered when selecting a needle for an injection (2)
1. patient size & weight 2. type of tissue being injected
Indicate the maximum volume of medication for an IM injection: *Older children, older adults, and thin adults*
2 mL
how long is the female urethra?
3 to 4 centimeters
Pulse Average
60 to 100 BPM
What position should you keep someone in with aspiration precautions during eating and post eating?
90 degree high fowlers position
Fat-soluble vitamins
A, D, E, and K are stored in the fatty compartments of the body
Fat- soluble vitamins
A,D,E, and K
BODY DEFENSE - GASTROINTESTINAL TRACT
ACIDITY of GASTRIC secretions prevents retention of bacterial contents Rapid peristalsis in small intestine
URTICARIA
"hives" Raised, irregularly shaped skin eruptions with varying sizes and shapes eruptions have reddened margins and pale centers
PRECENTRAL GYRUS
"motor strip" the major voluntary motor area located in the cerebral cortex majority of motor fibers descend from the motor strip and cross at the level of the medulla.
A single medication may have three different names. Generic name:
"official name" - name give by who first developed it.
The nurse is preparing an insulin injection in which both regular and NPH will be mixed. Into which vial should the nurse inject air first? 1. The vial of regular insulin 2. The vial of NPH 3. Either vial, as long as modified insulin is drawn up first 4. Neither vial; it is not necessary to put air into vials before withdrawing medication
#2 rationale: When mixing rapid/short-acting insulin with intermediate (NPH) or long-acting, first aspirate volume of air equivalent to dose of insulin to be withdrawn into intermediate/long acting insulin first (to prepare, bc it will be aspirated LAST)
Using the body surface area formula, what dose of drug X should a child who weighs 12 kg (body surface area = 0.54 m2) receive if the normal adult dose of drug X is 300 mg? 1. 50 mg 2. 90 mg 3. 100 mg 4. 200 mg
#2: 90mg rationale** (looked this up): Child's dose= BSA of child/1.7m^2 x normal adult dose
tertiary intention
(delayed primary closure) is intentional closure after a delay of days to weeks. Similar to secondary intention, the wound is allowed to heal open for a period of time. However, the wound is then closed once the risk of infection has decreased
[[Positioning for Medication Administration]]
*Oral*-upright sitting position; completely alert *Ear*- tilt head to the side or to lie down on their side with the ear that you will be putting the ear drops into facing up. *Nose*-sit up with their head in an upright position *Rectal*- lie on side
Inflammatory phase (timing)
- 1 to 5 days
Proliferative Phase (timing)
- 5 to 21 days
Factor Affecting Skin Integrity
- Age: Elders- skin is less elastic, drier, longer regeneration (healing period) - Mobility status: Increased pressure leads to tissue breakdown - Nutrition/hydration: Poor nutrition --> less regeneration; Dehydration= poor turgor -Sensation level: diminished sensation leads to increased risk for pressure and breakdown - Impaired circulation: negatively affects tissue metabolism - Medications: side effects- (pruritus, dermatoses, photosensitivity, alopecia & pigment changes) - Moisture: leads to maceration - Fever: affects moisture; affects metabolic rate - Infection: impedes healing - Lifestyle: tanning, bathing, piercings; smoking, diet & exercise
MODE OF TRANSMISSION - VEHICLES
- Contaminated items - water - drugs - solutions - blood - food
Flat bed
- Entire bed frame horizontally parallel with floor - Used for patients with vertebral injuries and in cervical traction -Used for patients who are hypotensive -Patients usually prefer for sleeping
Reverse Trendelenburg's bed
- Entire bed frame tilted with foot of bed down - Used infrequently -Promotes gastric emptying -Prevents esophageal reflux
Trendelenburg's bed
- Entire bed frame tilted with head of bed down - Used for postural drainage -Facilitates venous return in patients with poor peripheral perfusion
Stage III pressure ulcer
- Full-thickness Skin Loss (Fat Visible) - subcutaneous fat may be visible; but bone, tendon, or muscle is not exposed. - Some slough may be present - may include undermining and tunneling (the depth of this pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have adipose/subcutaneous tissue so these ulcers can be shallow. Areas of significant adiposity can develop extremely deep stage __ pressure ulcers. Bone/tendon/muscle is not visible or directly palpable)
Semi-Fowler's bed
- Head of bed raised approximately 30 degrees; inclination less than Fowler's position; foot of bed may also be raised at knee - Promotes lung expansion, especially with ventilator-assistedpatients - Used when patients receive gastric feedings to reduceregurgitation and risk of aspiration
What are the risk factors for the development of a pressure ulcer
- Impaired sensory perception (altered sensory perception for pain and pressure) - Impaired Mobility (pt not able to change positions independently) - Alteration in Level of Consciousness (pt who are confused or disoriented; pt who have expressive aphasia or inability to verbalize; pt in coma; pt w/ changing levels of consciousness) - Shear - Friction - Moisture
What are the 3 stages of wound healing
- Inflammatory phase - Proliferative Phase - Maturation Phase (remodeling)
Stage I pressure ulcer
- Nonblanchable Redness of Intact Skin - discoloration of the skin, warmth, edema, hardness, or pain may also be present (the area may be painful, firm, soft, warmer, or cooler than adjacent tissue)
Stage II pressure ulcer
- Partial-thickness Skin Loss or Blister - a shallow open ulcer with a red-pink wound bed without slough - may also present as an intact or open/ruptured serum-filled or serosangineous filled blister (presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, incontinence-associated dermatitis,maceration, or excoriation)
What are the pressure factors that contribute to pressure ulcer development (3) and explain each one
- Pressure Intensity= how much pressure is being applied - Pressure Duration= how long the pressure applied lasts (low pressure over a prolonged period and high-intensity pressure over a short period) - Tissue Tolerance= the ability of tissue to endure pressure (depends on the integrity of the tissue and the supporting structures)
Braden Scale
- Range 6 to 23 - Cut off score for ulcer development is 18 - lower score= higher the risk for developing pressure ulcer
shaving
- Shave in the direction of hair growth. -Use longer strokeson the larger areas of the face. -Use short strokes around the chinand lips.
BODY SYSTEM DEFENSES
- Skin - Mouth - Eyes - Respiratory Tract - Urinary Tract - Genitourinary Tract - Vagina
What position would you put patient to decrease the risk of friction and shear
- at a 30-degree lateral turn and limit head elevation to 30 degrees
Maturation phase (timing)
- begins at the 2nd to 3rd week and continues until wound is fully healed
Hemorrhage
- bleeding from a wound site (can be internal or external)
PORTAL OF EXIT
- blood - skin - mucus membranes - respiratory tract - genitourinary tract (GU) - gastrointestinal tract (GI) - transplacental (mother to fetus)
Pigmentation changes
- change in skin tone (side effect of med)
Serous drainage
- clear, watery plasma (straw-colored; clear, watery plasma)
What would be the damage in a superficial wound?
- damage is only on the epidermis
What would be the damage in a partial-thickness wound?
- dame goes into the dermis
when do contaminated or traumatic wounds show signs of infection
- early, within 2 to 3 days
If a pressure ulcer has slough or eschar what stage pressure ulcer could this be? - why?
- either a Stage III or IV - bc. if either slough or eschar is present then its a Unstageable pressure ulcer(which unstageable pressure ulcers are either III or IV) - because these two stages involve tissue necrosis (eschar; the black/brown stuff)
what are signs/symptoms of infection
- fever, tenderness and pain at the wound site, and an elevated white blood cell count - edges of the wound appear inflamed - odorous and purulent drainage (yellow, green, or brown color)
when does a surgical wound infection usually develop
- fourth or fifth postoperative day
Alopecia
- hair loss (side effect of med)
What is the difference between Shear and Friction?
- in a Shear the tissue damage occurs deep in the tissues(dermis & subcutaneous layer) and in Friction the tissue damage occurs on the top layer of the skin (epidermis)
Hematoma
- is a localized collection of blood underneath the tissues - it appears as a swelling, change in color, sensation, or warmth or mass that often takes on a bluish discoloration (from internal bleeding)
Dehiscence: - what is it - give an example - is frequent in what location of the body
- is the partial or total separation of wound layers - e.g., have a surgical incision and it pops open - usually in patients that are obese - its frequent in abdominal wounds
Blanching
- occurs when the normal red tones of the light-skinned patient are absent (pressing on skin and it turns pale and the skin staying that color and not turning pink like it normally would) - the cause is occluded capillaries
Serosanguineous drainage
- pale, pink, watery; mixture of clear and red fluid (mix of blood and straw-colored; sometimes pink)
what kind of drainage would a infected would have?
- purulent drainage
A wound is infected if
- purulent material drains from wound, even if a culture is not taken or has negative results
Dermatoses
- rashes (side effect of med)
hemostasis
- series of events designed to control blood loss, establish bacterial control, and seal the defect occurs when there is an injury. (injured blood vessels constrict; platelets gather to stop bleeding; clots form a fibrin matrix that later provides a framework for cellular repair)
Photosensitivity
- skin becoming sensitive to sun and prone/easily to burn (side effect of med)
Maceration
- softening of the skin - moisture causes this
Purulent drainage
- thick, yellow, green, tan, or brown (yellow contains pus)
Wounds can have tissue loss or without tissue loss. Give an example of each
- tissue loss= pressure ulcer - without tissue loss= incision
Evisceration
- total separation of wound layers(protrusion of visceral organs through a wound opening) - is a surgical emergency - (pt is NPO)
Secondary Intention wound: - description - causes - implications for healing
- wound edges not approximated - pressure ulcers, surgical wounds that have tissue loss (usually from trauma, etc.) - wound heals by granulation tissue formation, wound contraction, and epithelialization (heals from inner layer to surface) (leaves scar) (usually wound has debris and/or exudate so it needs to be cleaned)
Chronic wound: description causes implications for heling
- wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity - vascular compromise, chronic inflammation, or repetitive insults to tissue - continued exposure to insult impedes wound healing
Primary Intention wound: - description - causes - implications for healing
- wound that is closed - surgical incision, wound that is sutured or stapled shut - healing occurs by epithelialization; heals quickly with minimal scar formation (skin edges are closed and the risk of infection is low)
Acute wound: description causes implications for healing
- wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity - trauma, a surgical incision - wounds are usually easily cleaned and repaired; wound edges are clean and intact
A patient who is cognitively impaired and has dementia requires hygiene care. The patient often displays aggressive behavior such as screaming and hitting during the bath. Which techniques make the bathing experience less stressful for both the nurse and the patient? (Select all that apply.)
-Allow the patient to perform as much of the care as possible. -Try an alternative to traditional bathing such as the "bag bath."
A patient who is receiving chemotherapy has inflamed gums and oral mucosa and painful sores in the mouth. Which of the following oral care actions are appropriate? (Select all that apply.)
-Applying water-soluble moisturizing gel on the oral mucosa -Encouraging intake of soft foods
pH
Acidity of the environment
CONVALESCENCE
Acute symptoms of infection disappear
A nurse caring for a male patient observes the nursing assistive personnel (NAP) performing perineal care. Which of the following observed actions indicates a need for further teaching for the NAP? The NAP:
-Did not retract the foreskin before cleansing.
Intraarterial
Administered directly into artery
Your patient wears full dentures. His usual denture care includes taking the teeth out once a day to brush. He wears the dentures overnight. You are concerned that he might be at risk for developing denture-induced stomatitis. Which points do you include in a teaching plan for denture care? (Select all that apply.)
-Do not wear damaged or poorly fitting dentures. -Observe mouth for reddened areas under the dentures and small red sores on the roof of the mouth. -See dentist regularly. -Rinse dentures after meals.
A male nurse is caring for a 32-year-old female Muslim patient who has an indwelling Foley catheter. After introducing himself to the patient, the nurse learns that the patient does not want him to help her with personal hygiene care. Which of the following is(are) appropriate actions? (Select all that apply.)
-Finding a female nurse to help the patient -Asking the patient if she prefers a family member assist with the care
During bathing your patient experiences shortness of breath and labored breathing with a respiratory rate of 30. The bed is in a flat position. You change the bed position to:
-Fowler's. -Fowler's upright sitting position facilitates breathing by allowing for full expansion of the chest and lungs. Although reverse Trendelenburg's position raises the head of the bed, it is a straight tilt position and is not likely as comfortable as the more supported Fowler's position.
Fowler's bed
-Head of bed raised to angle of 45 degrees or more; semi-sittingposition; foot of bed may also be raised at knee - While patient is eating -During nasogastric tube insertion and nasotracheal suction -Promotes lung expansion -Eases difficult breathing
one time only for a specific reason
An order written as a single-one time order may be administered:
The nurse is caring for a patient who has reduced sensation in both feet. Which of the following should the nurse do? (Select all that apply.)
-Wash the feet with lukewarm water and then dry well. -File the toenails straight across.
A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 50 mL/hr. At what time should the infusion be completed? a. 2300 Monday b. 2345 Monday c. 0015 Tuesday d. 0045 Tuesday
B
A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately? a. Blood pressure 110/60 b. Temperature 101.3° F c. Poor skin turgor and pallor d. Heart rate of 100 beats/min
B
types of baths
-complete -partial -sponge tub -shower -bag bath
tissue ischemia
-decreased blood flow to tissue, resulting in tissue death; occurs from obstructed capillary blood flow
bath guidelines
-provide privacy -maintain safety -maintain warmth -promote independence -anticipate needs
factors influencing hygiene
-social patterns -personal preferences -body image -socioeconomic status -health beliefs and motivation -cultural variables -developmental stage -physical condition
.
.
WBCs in the urine
0-4 per low-power field
what is the maximum amount of water-soluble medication given by the subcutaneous route?
0.5 to 1mL
DIFFERENTIAL COUNT - BASOPHILS
0.5% - 1.5% normal during infection
What is the maximum amount of water-soluble medication given by the subcutaneous route?
0.5-1 mL
Urinary retention
Bladder is distended Void small amounts with no relief Neurogenic in nature -restlessness, diaphoresis
After measuring the client's vital signs, the nurse obtains the following results: blood pressure = 180/100 mm Hg, pulse = 82 beats/min, R = 16 breaths/min, and rectal temp = 37.5° C. The nurse should: 1. Retake the blood pressure 2. Retake the client's temperature 3. Report all of the findings immediately 4. Record the findings as within normal limits
1
An 84-year-old client with diabetes is admitted for insulin regulation. Which of the following blood pressure, pulse, and respiration measurements, respectively, is considered to be within the expected limits for a client of this age? 1. BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/min 2. BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min 3. BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min 4. BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min
1
The client is seen in the emergency center for heat exhaustion as a result of exposure. The nurse anticipates that treatment will include: 1. Replacement of fluid and electrolytes 2. Initiation of oral antibiotic therapy 3. Application of hypothermia wraps 4. Alcohol sponge baths
1
The nurse appropriately instructs trained ancillary personnel to use an electronic blood pressure cuff to take the blood pressure of which of the following clients? 1. A 25-year-old who was admitted for alcohol detoxification 2. A 69-year-old diagnosed with Parkinson's disease 5 years ago 3. A 57-year-old placed on antihypertensive medication therapy 2 months ago 4. An 80-year-old client whose systolic BP is routinely assessed in the high 80s
1
The nurse enters the room to measure the client's pulse rate. The nurse recognizes that the client's rate may be increased as a result of: 1. A febrile condition 2. Administration of digoxin 3. The client's athletic conditioning 4. Unrelieved severe postoperative pain
1
The nurse has asked the assistive personnel to take the blood pressure of a client who experienced a left mastectomy 3 days ago. Which of the following statements by the assistive personnel shows the best understanding regarding the appropriate assessment technique for this particular client? 1. "Is there anything affecting her right arm?" 2. "Has she been experiencing any edema in that left arm?" 3. "How long has it been since she had her breast removed?" 4. "I'll wait until she's been medicated for pain before I take it."
1
The nurse has assessed a client's blood pressure (BP) using the left thigh because of bilateral upper arm casts. The client's precasting left arm BP was 108/70 mm Hg. The nurse expects the present BP reading to be: 1. 10-40 mm Hg higher systolic pressure than before the casting 2. 5-10 mm Hg higher reading in both systolic and diastolic pressures 3. Representative of the original baseline established before the casting 4. A slight decrease in the diastolic pressure when compared to precasting pressure
1
The nurse measures the blood pressure in the leg due to the fact that the client has bilateral casts on the upper extremities. The nurse palpates the pulse before the measurement at the: 1. Popliteal fossa behind the knee 2. Inner side of the ankle below the medial malleolus 3. Top of the foot between the extension tendons of the great toe 4. Inguinal ligament midway between the symphysis pubis and the anterior superior iliac spine
1
STEPS FOR CLEANING
1 - Rinse the contaminated object or article with cold running water to remove organic material 2 - After rinsing, wash the object with soap and warm water 3 - Use a brush to remove dirt or material in grooves or seams 4- rinse object with warm water 5 - Dry the object and prepare it for disinfection or sterilization if indicated by classification of the item 6 - brush, gloves, and sink used to clean the equipment are considered contaminated and are cleaned and dried according to policy
The nurse is assisting the wife of a client who has been diagnosed with hypertension to monitor his blood pressure. The nurse states that the blood pressure should be taken: (Select all that apply.) 1. At the same time each day 2. On the same arm each time 3. In the same position each time 4. After the client has had a brief rest 5. After his blood pressure medication 6. Right before getting up in the morning
1,2,3,4
The nurse is discussing risk factors for hypertension with family members attending a self-help group meeting for clients in cardiac rehabilitation. Which of the following statements made by the nurse are relevant to this discussion on prevention of this disorder? (Select all that apply.) 1. "Low fat foods are your blood pressure's best friend." 2. "Have your triglyceride's checked on a regular basis." 3. "Ideal weight is ideal for keeping blood pressure under control." 4. "Nicotine is a no-no when attempting to control blood pressure." 5. "If they are prescribed, take your blood pressure medicine as suggested." 6. "Keep alcohol consumption down and your blood pressure will be down."
1,2,3,4,6
Which of the following factors make using a pulse oximeter on an elderly client challenging? (Select all that apply.) 1. Possibility of decreased cardiac output 2. Potential for peripheral vascular disease 3. Existence of decreased red blood cell count 4. Uncooperative behavior related to senility 5. Inability to comprehend rationale for monitoring 6. Vasoconstriction related to impaired heat regulation
1,2,3,6
The nurse is discussing the correct technique for taking a blood pressure with clients and their caregivers. Which of the following nursing statements would appropriately identify the most likely causes for experiencing difficulty actually hearing the blood pressure? (Select all that apply.) 1. "The cuff cannot be too small or too big." 2. "Don't release the air out of the cuff to quickly." 3. "Keep the arm you are using at the level of the heart." 4. "If you are having difficulty, try taking it in the other arm." 5. "The stethoscope needs to be placed directly over a pulse point." 6. "Remember to pump up the cuff until you can no longer feel the pulse."
1,2,5,6
Circadian Rhythm and temperature
1-4 AM lowest 4 PM highest
Which of the following actions would best help prevent skin breakdown in a patient who is incontinent of stools and very weak and drowsy?
Checking frequently for soiling
Intraperitoneal medications
Chemotherapeutic agents, insulin, and antibiotics administered into the peritoneal cavity.
1. A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 lbs. Her vital signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8° C (98.2° F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy? 1. Temperature: 37° C (98.6° F) 2. Radial pulse: 112 3. Respiratory rate: 24 4. Oxygen saturation: 96% 5. Blood pressure: 134/78
1. Answer: 4. Oxygen saturation is an assessment of oxygen perfusion. Respiratory rate assesses ventilation, radial pulse and blood pressure assess the cardiovascular system, and temperature is an assessment of thermal regulation.
List four principles for administering eye instillations:
1. Avoid placing medication directly into the cornea 2. Avoid touching eye structures 3. Place on affected eye only 4. Never use another persons eye medications
Which of the following is not a parenteral route of administration? 1. Buccal 2. Intradermal 3. Intramuscular 4. Subcutaneous
1. Buccal rationale: Buccal is an oral route
Briefly describe the roles of the following in relation to the regulation of medications. *State Government*
Confirms to federal legislation but also have additional controls such as alcohol and tobacco.
Bad for cardiac patients,fecal impaction
Constipation complications
Perforation, vagal stimulation
Constipation interventions
Describe characteristics of following IM injection: Ventrogluteal (4)
1. Deep site away from nerves and vessels 2. Preferred for adults 3. Large medication volumes for children and infants 4 Irritating solutions
Explain the following types of inhalation inhalers: 1. Pressurized metered-dose inhalers (pMDIs): 2. Breath-actuated metered-dose inhalers (BAIs): 3. Dry powder inhalers (DPIs):
1. Delivers a measured dose with each push (often used with a spacer) 2. Releases medication when a patient raises a level and then inhales 3. The patient inhales through a reservoir to create an aerosol.
Identify the precautions to take when administering any oral preparation to prevent aspiration (10):
1. Determine the patient's ability to swallow and cough and check for gag reflex 2. Prepare oral medications in the form that is easiest to swallow 3. Allow the patient to self-administer medications if possible 4. If the patient has unilateral weakness, place the medication in the stronger side of the mouth 5. Administer pills one at a time, ensuring that each medication is properly swallowed before the next one is introduced 6. Thicken regular liquids or offer fruit nectars if the patient cannot tolerate thin liquids 7. Avoid straws because they decrease the control the patient has over volume intake, which increases the risk of aspiration 8. Have the patient hold the cup and drink it if possible 9. Time medications to coincide with meal times or when the patient is well rested and awake if possible 10. Administer medications using a different route if risk of aspiration is severe
Methods for applying medication to mucous membranes (5)
1. Directly applying liquid or ointment 2. Inserting med into body cavity 3. inserting fluid into body cavity 4. Irrigating a body cavity 5. Spraying med into cavity
Identify the guidelines to ensure safe administration of transdermal or topical medications (5):
1. Document placement of medication in MAR 2. Asses for existing patch 3. Review Medication history and reconciling medication 4. Apply a noticeable label on the patch 5. Document removal of medication in MAR
List the three principles to follow when mixing medications from two vials:
1. Don't contaminate medications with other medications 2. Ensure Accuracy 3. Maintain antiseptic technique
Identify the aseptic techniques to use to prevent an infection during an injection.
1. Draw medication quickly 2. Don't let needle touch contaminated surface 3. avoid touching the plunger and the inner barrel 4. Clean skin with antiseptic swab using friction in a circular motion. ( from center to outer region)
Describe characteristics of following IM injection: Deltoid (6)
1. Easy access (muscle isn't well developed) 2. Used for small amounts of meds. 3. Not used for children or infants 4. Risk of injury to radial and ulnar nerve 5. immunizations (toddlers, children, adults) 6. Recommended for Hep B and rabies injections
6 health promotion and restoration practices for a healthy bladder
1. Maintain adequate hydration 2. Keep good voiding habits 3. Keep the bowels regular 4. Prevent urinary tract infections 5. Stop smoking to reduce your risk for bladder cancer and reduce risk of developing a cough which can contribute to stress urinary incontinence 6. Report to your health care provider any changes in bladder habits, frequency, urgency, pain when voiding, or blood in the urine
List the methods a nurse can use to administer medications intravenously (3)
1. Mix with large volumes of IV fluids 2. Inject a bolus or small amount 3. Piggyback infusion
Which statement correctly characterizes drug absorption? 1. Most drugs must enter the systemic circulation to have a therapeutic effect. 2. Oral medications are absorbed more quickly when administered with meals. 3. Mucous membranes are relatively impermeable to chemicals, making absorption slow. 4. Drugs administered subcutaneously are absorbed more quickly than those injected intramuscularly.
1. Most drugs must enter the system circulation rationale: Absorption refers to the passage of medication molecules in the blood from the site of adminstration
Identify the best sites for subcutaneous injections (3):
1. Outer posterior of the upper arm 2. The abdomen 3. Anterior regions of the thigh
Rights of medication administration (7)
1. Patient 2. Medication 3. dose 4. route 5. time 6. documentation 7. to refuse
Identify two goals for safe and effective medication administration
1. Patients responds to therapy 2. Patient has the ability to assume responsibility for self-care
Explain the rationale for the Z-track method in IM injections.
1. Prevent skin irritation 2. Prevent skin decolonization ( Iron containing medications)
Rectal suppositories are used for:
1. Promoting defecation (local) 2. Reducing nausea (systemic)
List the advantages of using volume-controlled infusions (3):
1. Reduces risk of rapid infusion 2. Allows stability in administration 3. Control of IV fluid
Describe each of the following. 1. ampule 2. vial
1. Single liquid doses 2. Single or multiple dose container with a rubber seal (closed system)
Explain the rationale for intradermal injections.
1. Skin testing 2. Slow absorbtion
Vaginal medications are available as:
1. Suppositories 2. foam 3. Jellies 4. Creams
List the medication distribution systems
1. Unit dose cart: Carts with drawers that hold 24 hours of medication for each patient, includes PRNs. Narcotics are kept in larger locked drawer. 2. Automated medication dispensing system (AMDS): Controls distribution of all meds including narcotics.
List the techniques used to minimize patient discomfort that is associated with injections.
1. Use a small sharp needle in length and gauge 2. Reduce muscle tension (by use of positioning0
Process for medical reconciliation (4):
1. Verify: Verify all medications, OTC and prescribed 2. Clarify: Clarify that list is accurate with times and dosage amounts 3. Reconcile: Compare new orders with current list and investigate any discrepancies 4. Transmit: Communicate updated and verified med list to caregivers and patient
Identify the factors that affect the rate and extent of medication distribution (5):
1. circulation 2. membrane permeability 3. protein binding 4. metabolism 5. excretion.
Identify the common medication errors that can cause a patient harm (5)
1. inaccurate prescribing 2. Administering wrong med 3. giving med at wrong time interval or wrong route, 4. Administering extra doses 5. failure to give med
Describe characteristics of following IM injection: Vastus lateralis (4)
1. lacks major nerves and blood vessels 2. rapid drug absorption 3. site freq. used for infant immunizations (<12 mths) 4. Also immunizations for children & toddlers
Identify the principles to follow when mixing two types of insulin in the same syringe.
1. maintain routine preparing and administering medication 2. Never mix with any other medications or dilute medication 3. Never mix Glargine or Determir insulin with any other insulin 4. Inject rapid-actinh insulin 15mins before a meal. 5. Verify dose with another nurse before preparing it
Identify the factors that influence drug absorption (5):
1. route of administration 2. dissolving ability of med 3. blood flow to site of administration 4. BSA (body surface area) 5. lipid solubility
The recording of medication includes (5):
1. the name of the medication 2. dose 3. route 4. exact time of administration 5. site
Z-TRACK PROCEDURE - RATE OF INJECTION
10 seconds per milliliter if no blood return is noted on aspiration needle remains inserted for 10 seconds to allow the medication to disperse evenly release the skin AFTER withdrawing the needle this leaves a zig-zag path that seals the needle track and keeps medication from escaping muscle tissue
11. A pt has been admitted for a cerebrovascular accident (stroke). She cannot move her right arm, and she has a right-sided facial droop. She is able to eat with her dentures in place & swallow safely. The nursing assistive personnel (NAP) reports to you that the pt won't keep the oral thermometer probe in her mouth. What direction do you provide to the NAP? 1. Direct the NAP to hold the thermometer in place with her gloved hand 2. Direct the NAP to switch the thermometer probe to the left sublingual pocket 3. Direct the NAP to obtain a right tympanic temperature 4. Direct the NAP to use a temporal artery thermometer from right to left
11. Answer: 4. A temporal artery temperature verifies the forehead temperature in back of the left ear, which is the side not affected by the altered blood flow related to the stroke. Holding the thermometer or switching locations will not help the patient close her mouth during temperature assessment. The patient's right side has vascular changes related to the stroke.
12. The nursing assistive personnel (NAP) reports to you that the blood pressure (BP) of the pt in Question 11 is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? (Select all that apply.) 1. Notify the health care provider immediately 2. Repeat the measurements on both arms using a stethoscope 3. Ask the pt if she has taken her blood pressure medications recently 4. Obtain blood pressure measurements on lower extremities 5. Verify that the correct cuff size was used during the measurements 6. Review the pt's record for her baseline vital signs 7. Compare right and left radial pulses for strength
12. Answer: 2, 6. The systolic BP measurements are significantly different and may reflect the vascular and muscular changes caused by the stroke. However, unexpected findings require reassessment by the nurse with a comparison to previous values. It is premature to notify the provider; differences are not caused by medications; inappropriate cuff size would reflect similar systolic pressures; pulse strength would be similar for these BP measurements.
Blood pressure
120/80
13. The nursing assistive personnel (NAP) informs you that the electronic blood pressure machine on the pt who has recently returned from surgery following removal of her gallbladder is flashing a blood pressure of 65/46 and alarming. Place your care activities in priority order. ______, ______, ______, ______, ______, 1. Press the start button of the electronic blood pressure machine to obtain a new reading. 2. Obtain a manual blood pressure with a stethoscope. 3. Check the pt's pulse distal to the blood pressure cuff. 4. Assess the pt's mental status. 5. Remind the pt not to bend her arm with the blood pressure cuff.
13. Answer: 4, 1, 3, 2, 5. First priority is to verify that the patient's blood pressure is providing adequate blood flow to the brain and critical organs. Movement interferes with electronic blood pressure measurement; recycling the machine will obtain a blood pressure while you are assessing the patient. Check the distal pulse to verify circulation to the extremity and then obtain manual blood pressure if needed. Patient education can prevent false values and decrease patient anxiety with alarms.
14. A healthy adult pt tells the nurse that he obtained his blood pressure in "one of those quick machines in the mall" and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/92? (Select all that apply.) 1. Cuff too small 2. Arm positioned above heart level 3. Slow inflation of the cuff by the machine 4. Pt did not remove his long-sleeved shirt 5. Insufficient time between measurements
14. Answers: 1, 5. Using too small of a cuff and not allowing for insufficient time between measurements will result in false-high readings. Arm above heart level and slow inflation result in false low readings.
15. A pt is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant reports his admitting vital signs to the nurse. Which measurements should the nurse reassess? (Select all that apply.) 1. Right arm BP: 118/72 2. Radial pulse rate: 72 and irregular 3. Temporal temperature: 37.4° C (99.3° F) 4. Respiratory rate: 28 5. Oxygen saturation: 99%
15. Answer: 2, 4, 5. Irregular pulse and elevated respiratory rate are outside of expected values and require further assessment by the nurse. Pneumonia and shortness of breath can cause low oxygen saturation; an assessment of 99% may be a false-high value. Blood pressure and temperature are within expected values for the patient history.
how long is the male urethra?
18 to 20 centimeters
RX IN OIL BASED SOLUTIONS
18 to 21 gauge needles
A client is being monitored with pulse oximetry. On review of the following factors, the nurse suspects that the values will be influenced by: 1. The placement of the sensor on the extremity 2. A diagnosis of peripheral vascular disease 3. A reduced amount of artificial light in the room 4. The increased ambient temperature of the client's room
2
An individual contacts the emergency department of the local hospital to ask what to do for a skiing partner who appears to be suffering from hypothermia. The victim is alert and able to respond to questions. The nurse instructs the individual who has called to have the victim: 1. Take sips of brandy 2. Drink a bowl of warm soup 3. Drink a cup of very hot coffee 4. Run the affected extremities under hot water
2
The client comes to the emergency department after having been in the sun for an extended period of time. The nurse also determines that the client is taking a diuretic. Heatstroke is suspected and the nurse observes for: 1. Diaphoresis 2. Confusion 3. Temperature of 36 C 4. Decreased heart rate
2
The nurse appropriately instructs trained ancillary personnel to avoid using an electronic blood pressure cuff to take the blood pressure of which of the following clients? 1. A 25-year-old who was admitted for depression and anxiety 2. A 69-year-old diagnosed with Parkinson's disease 5 years ago 3. A 57-year-old prescribed antihypertensive medication 6 weeks ago 4. An 80-year-old client whose systolic BP is routinely assessed in the low 90s
2
The nurse has assigned nursing assistive personnel to obtain the blood pressures on the unit's clients. Which of the following statements made by the assistive personnel shows the best understanding regarding appropriate communication of the BP readings? 1. "I'll ask the clients what their blood pressure usually runs." 2. "I'll give you a list of all the readings I get before I chart them." 3. "I'll chart the results and let you know whose pressure is high." 4. "I'll recheck any pressure that seems higher than their normal."
2
The nurse has assigned the vital signs of the elderly clients residing in the facility's assisted living unit to the nursing assistant. Which of the following statements made by the ancillary personnel requires immediate correction by the RN? 1. "As you age your blood pressure may go up, but it doesn't have to if your vessels are healthy." 2. "If anyone's oral temperature is over 100° F, I'll let you know right away since that means they have a fever." 3. "I always wait a good 30 minutes after returning the older client back to bed before I count their pulse." 4. "I watch the elderly client's stomach and count the number of times it rises when I am counting respirations."
2
The nurse is assessing a client's blood pressure to establish a baseline. The pressure in the right arm is 12 mm Hg lower than that in the left arm. The nurse most appropriately realizes that these data: 1. Reflect a normal variation 2. Should be reported to the client's health care provider 3. Dictate that pressure should be monitored in the left arm 4. Indicate that the client may be experiencing vascular problems
2
The nurse is assessing an elderly client's blood pressure during a routine visit. When asked, the client volunteers that when he took his pressure at home yesterday it was 126/72 mm Hg. The nurse determines that the client's pressure today is 134/70 mm Hg. The nurse recognizes that the most likely cause of the elevation is: 1. The difference between the monitoring equipment being used 2. The client may be experiencing mild anxiety regarding the check-up 3. The effects of aging on the client's ability to hear the first Korotkoff sound 4. The client is not inflating the cuff sufficiently to detect the systolic pressure
2
The nurse recognizes that which of the following clients present at the annual July 4th marathon is showing the most compelling signs of hyperthermia and the resulting heatstroke? 1. The 75-year-old who has forgot where the car is parked 2. The 16-year-old volunteer whose skin appears sunburned but dry 3. The 34-year-old who finished the race and is reporting leg cramps 4. The 55-year-old observer who complains of nausea and being thirsty
2
Which of the following sites is best suited for measuring oxygen saturation (pulse oximetry)? 1. A polished ring finger of a client with pneumonia whose nail capillary refill time is 2.5 seconds 2. A pierced earlobe of a client with a closed head injury whose nail capillary refill time is 3.5 seconds 3. The ring finger of a client with Parkinson's disease that has a capillary refill time of less than 3 seconds 4. An earlobe of a client who is experiencing moderate diaphoresis with a nail capillary refill time of 3.5 seconds
2
While the nurse is taking the client's blood pressure, the client asks if the reading is high. In accordance with the newest guidelines, the nurse informs the client that a blood pressure measurement that is consistent with hypertension is: 1. 120/70 mm Hg 2. 130/84 mm Hg 3. 120/78 mm Hg 4. 118/80 mm Hg
2
DIFFERENTIAL COUNT - MONOCYTES
2%-8% Increased in protozoan, rickettsial, and tuberculosis infections
The nurse is discussing the proper technique for obtaining an accurate blood pressure reading with assistive nursing personnel. Which of the following statements reflect techniques that will minimize the risk of a false high systolic reading? (Select all that apply.) 1. "Slowly deflate the pressure from the cuff." 2. "Wrap the cuff snuggly around the client's arm." 3. "Always support the client's arm at the level of the heart." 4. "Be sure that the cuff is wide enough for the client's arm." 5. "Allow the arm to rest before repeating the blood pressure." 6. "Make sure your stethoscope is fitted in your ears appropriately."
2,3,4,5
The nurse is providing a health promotion session regarding the factors that contribute to heatstroke for members of a college cross-country running team. Which of the following statements should the nurse include in the discussion? (Select all that apply.) 1. "Take frequent breaks to rest out of the sun." 2. "The greater the humidity, the greater the hazard." 3. "Wear clothing that will absorb the perspiration." 4. "The higher the temperature, the higher the risk." 5. "The more fluids you drink, the fewer chances you take." 6. "Pay attention to pacing yourself when it's hot and muggy."
2,4,5,6
What is the name of a condition where there is difficulty or inability to swallow?
Dysphagia
2. The licensed practical nurse (LPN) provides you with the change-of-shift vital signs on four of your pts. Which pt do you need to assess first? 1. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% 2. 54-year-old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72 3. 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84 4. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62
2. Answer: 1. SpO2 89% is a critical value and requires immediate attention. Other values require attention but are not life threatening.
DIFFERENTIAL COUNT - LYMPHOCYTES
20%-40% Increased in chronic bacterial and viral infection decreased in sepsis
Erythropoietin
Essential in maintaining a normal RBC volume
LORDOSIS
Exaggeration of anterior convex curve of lumbar spine
Pelvic floor muscle training
Exercises work by increasing the pressure within the urethra by strengthening thee pelvic floor muscles and inhibits unwanted bladder contractions
Therapeutic Effect
Expected or predictable physiological response to a medication.
What angle should be used when administering a subcutaneous injection?
25-gauge 5/8 inch needle inserted at a 45-degree angle (cite for NCLEX) or a 1/2 inch needle inserted at a 90-degree angle.
COST OF HEALTHCARE ASSOCIATED INFECTION (HAI)
HAIs significantly increase health care costs - extended hospital stay - increased disability - increased antibiotic $$$$$ - prolonged recovery time
Dextro - 100 / 20 = # units
How do you determine the # of units to be given when determining dosage for insulin?
A client has developed pneumonia, and his temperature has increased to 37.7° C. The client is shivering and "feels uncomfortable." The nurse should: 1. Apply hot packs to the axilla and groin 2. Wrap the client's four extremities 3. Restrict oral fluid consumption 4. Apply a hypothermia mattress
3
A client has just gotten out of bed to go to the bathroom. As the nurse enters the room, the client says, "I feel dizzy." The nurse should: 1. Go for help 2. Take the client's blood pressure 3. Assist the client into a sitting position 4. Tell the client to take several deep breaths
3
The client appears to be breathing faster than before. The nurse should: 1. Ask the client if he has felt stressful 2. Have the client lay down on the bed 3. Count the client's rate of respirations 4. Palpate the client's own radial pulse
3
The client is identified by the nurse as having a remittent fever. The student asks what that means and the nurse explains that a remittent fever is: 1. A constant body temperature above 100.4° F with little fluctuation 2. Spikes that are interspersed with normal temperatures within 24 hours 3. Spikes and falls in temperature, but temperature does not return to the normal limits 4. Periods of febrile episodes interspersed with normal body temperatures
3
The client's apical pulse will be taken by a student. According to the nurse the stethoscope should be placed along the left clavicular line at the: 1. Second to third intercostal space 2. Third to fourth intercostal space 3. Fourth to fifth intercostal space 4. Fifth to sixth intercostal space
3
The nurse has assigned nursing assistive personnel to obtain the blood pressures on the unit's clients. Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate communication of the BP readings? 1. "I'll give you a list of all the readings after I chart them." 2. "May I ask the clients what their blood pressure usually runs?" 3. "I'll chart the results and let you know whose pressure is running high." 4. "Do you want me to take the readings before they get their medications?"
3
The nurse has assigned nursing assistive personnel to obtain the temperatures on the unit's clients. Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate temperature monitoring orally? 1. "Are all the clients cooperative enough to take the temperatures orally?" 2. "Do you want me to take the temperature tympanically on everyone?" 3. "I'll wait until breakfast is over so I won't distract them from eating." 4. "I'll chart the results and let you know whose temperature is running high."
3
The nurse is using a manual cuff to assess the blood pressure of a client experiencing hypertension. To best ensure accommodation for a possible auscultatory gap, the nurse should use which of the following as a guide for inflating the cuff appropriately? 1. Review the client's chart for his last blood pressure reading. 2. Ask the client what his typical blood pressure reading is when taken manually. 3. Inflate 30 mm Hg higher than where the radial pulse can no longer be palpated. 4. Take the client's blood pressure both sitting and standing and use the higher reading.
3
The nurse is working in the newborn nursery. In planning for temperature measurement, the nurse will obtain the reading on the infants by using the: 1. Oral site 2. Rectal site 3. Axillary site 4. Tympanic site
3
The student nurse is assessing the vital signs of a 10-year-old client. The expected values for a client of this age are: 1. P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg 2. P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm Hg 3. P = 80 beats/min, R = 22 breaths/min, BP = 110/70 mm Hg 4. P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hg
3
When using a glass thermometer at home to accurately assess axillary temperature, the nurse should tell the parent of a 1 1/2-year-old child to: 1. Hold the thermometer at the bulb end 2. Cleanse the thermometer in hot water 3. Assess the thermometer for 5 minutes 4. Allow the child to hold the thermometer
3
STOOL SAMPLE SIZE
3 cm mass (soft, formed stool) 15 to 30 mL (liquid stool)
Verbal medication order
If the order is given verbally to the nurse by the provider.
Land Pollution
Improper disposal of radioactive and bioactive waste products.
3. A 55-year-old female pt was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. Which sites do you instruct the nursing assistant to use for obtaining the pt's blood pressure and temperature? 1. Right antecubital and tympanic membrane 2. Right popliteal and rectal 3. Left antecubital and oral 4. Left popliteal and temporal artery
3. Answer: 1. IV in right arm can be turned off while blood pressure is obtained. Blood pressure should not be measured on fractured extremities that have compromised circulation. Sequential stocking should remain on all the time while the patient is in bed to promote blood flow in lower right extremity. Tympanic membrane temperature is not affected by oxygen; the oxygen would need to be removed to take an oral temperature. Forehead laceration excludes temporal measurement. Rectal temperature is more invasive.
KYPHOSIS
Increased convexity in curvature of thoracic spine
medication interaction
Increased or decreased action of a drug, altering the way it is absorbed, metabolized, or eliminated
SYSTEMIC INFECTION
Infection that affects entire body Can become fatal if undetected
ENDOGENOUS INFECTION
Infections produced INSIDE a cell or organism flora becomes altered due to broad spectrum antibiotics overgrowth results - staphylococci - enterococci - yeasts - streptococci
pulse pressure
30-50 (systolic-diastolic)
Intraarticular
Injection of a med into a joint
Intracardiac
Injection of med directly into cardiac muscle
ENTERAL FEEDING
Instillation of liquid nutritional supplements feedings into stomach or small intestine for patients with impaired swallowing
INCUBATION PERIOD
Interval between entrance of the pathogen into the body and appearance of the first symptoms
Sites for parenteral injections (4)
Intradermal (ID), Subcutaneous (Subcut), Intramuscular (IM), Intravenous (IV)
Stress incontinece
Involuntary leakage of small volumes of urine associated with increased abdominal pressure
A 6-year-old boy has just eaten a grape popsicle and the nurse is ready to take vital signs. An appropriate action would be to: 1. Take the rectal temperature 2. Take the oral temperature as planned 3. Have the child rinse out the mouth with warm water 4. Wait 20 minutes before assessing the oral temperature
4
A construction worker is seen in the emergency department with low blood pressure, normal pulse rate, diaphoresis, and weakness. These are clinical signs of: 1. Heatstroke 2. Heat cramp 3. Hypothermia 4. Heat exhaustion
4
Bowel retention
Leads to retention of stool in the rectum -stool dries and hardens, impact action, constipation,
A spouse assists the nurse evaluating the measurement of the client's blood pressure. The nurse feels additional teaching is required if the spouse is observed: 1. Deflating the cuff at 2 mm Hg/second 2. Having the client sit down for the measurement 3. Using the same time each day for the measurement 4. Taking the blood pressure after the client comes back from a walk
4
The client has bilateral casts on the upper extremities, so the nurse will be measuring the blood pressure in the leg. The nurse expects the diastolic pressure to be: 1. 10 to 40 mm Hg higher than in the brachial artery 2. 20 to 30 mm Hg lower than in the brachial artery 3. 40 to 50 mm Hg higher than in the brachial artery 4. Essentially the same as that in the brachial artery
4
The client is febrile, and the temperature needs to be reduced. The nurse anticipates that treatment will include: 1. An alcohol and water bath 2. Ice packs to the axillae and groin 3. Tepid, plain water sponge down 4. Application of a cooling blanket
4
LOCALIZED INFECTION
Localized symptoms such as: - pain - tenderness - warmth - redness
The nurse is alert to which of the following factors that lowers the blood pressure? 1. Stress-producing anxiety 2. Heavy alcohol consumption 3. Cigarette, cigar, or pipe smoking 4. Prescribed diuretic administration
4
The postoperative vital signs of an average size adult client are: BP = 110/68 mm Hg, P = 54 beats/min, R = 8 breaths/min. The client appears pale, is disoriented, and has minimal urinary output. The nurse should: 1. Retake the vital signs in 30 minutes 2. Continue with care as planned 3. Administer a stimulant 4. Notify the physician
4
Upon entering the room, the nurse notes that the client has an irregular respiratory rate, with periods of apnea and increases in respiration, followed by a reversal of the pattern. The nurse reports this respiratory assessment as: 1. Biot's respirations 2. Kussmaul's respirations 3. Hyperpneic respirations 4. Cheyne-Stokes respirations
4
4. The nurse observes a nursing student taking a blood pressure (BP) on a pt. The nurse notes that the student very slowly deflates the cuff in an attempt to hear the sounds. The pt's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. Which of the following BP readings made by the student is most likely caused by an incorrect technique? 1. 96/40 mm Hg 2. 110/66 mm Hg 3. 130/90 mm Hg 4. 156/82 mm Hg
4. Answer: 3. Deflating the cuff too slowly will result in a false-high diastolic blood pressure.
normal pH of urine
4.6-8.0
Older Adult
Medication effects, chronic disease and environmental factors increase falls, wandering.
Intraosseous infusion
Medication that is administered directly into the bone marrow; commonly used in infants and toddlers.
Chemical Restraints
Medications (anxiolytics and sedatives) used to manage patients behavior.
Explain role of Metabolism
Occurs under the influence of enzymes that detoxify, degrade and remove biologically active chemicals (mostly in the liver)
Verbal order ( VO )
Order made over the telephone
5. As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. What is the best response? 1. Nail polish attracts microorganisms and contaminates the finger sensor. 2. Nail polish increases oxygen saturation. 3. Nail polish interferes with sensor function. 4. Nail polish creates excessive heat in sensor probe.
5. Answer: 3. The pigment in black nail polish affects light absorption and reflection.
ADEQUATE FLUID INTAKE
50 mL/kg/hr promotes proper elimination of medications for the average adult
WHITE BLOOD CELL (WBC) COUNT
5000-10,000/mm3 increased in acute infection decreased in certain viral/overwhelming infections
DIFFERENTIAL COUNT - NEUTROPHILS
55%-70% Increased in acute suppurative (pus-forming) infection decreased in overwhelming bacterial infection (older adult)
6. A pt has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7° C (101.6° F) (0400), 36.6° C (97.9° F) (0800), 36.9° C (98.4° F) (1200), 37.6° C (99.6° F) (1600), and 38.3° C (100.9° F) (2000). How would you describe this pattern of temperature measurements? 1. Usual range of circadian rhythm measurements 2. Sustained fever pattern 3. Intermittent fever pattern 4. Resolving fever pattern
6. Answer: 3. Temperature was elevated above acceptable range, returned to normal, and then elevated.
The onset of drug action is the time it takes for a drug to:
Produce a response
Our body comprises how much water?
60-70 percent of total body weight
Restraint Objectives
Reduce fall risk, prevent interruption of therapy, prevent patients who are confused or combative from removing equipment, reduce risk of injury to others.
Kidney
Remove wastes from the blood to form urine
Type 1 diabetes
Requires both insulin and dietary restrictions for optimal controls
7. A pt presents in the clinic with dizziness and fatigue. The nursing assistant reports a slow but regular radial pulse of 44. What is your priority intervention? 1. Request that the nursing assistant repeat the pulse check 2. Call for a stat electrocardiogram (ECG) 3. Assess the pt's apical pulse and evidence of a pulse deficit 4. Prepare to administer cardiac-stimulating medications
7. Answer: 3. A radial pulse of 44 is a critical value and requires additional assessment by the nurse. Decreased peripheral pulse can indicate cardiac or vascular abnormality, which can be determined by apical pulse and pulse deficit assessment.
To administer oral care to a semi-comatose client, the nurse should place the client in which of the following positions?
Side-lying with the head turned toward the nurse
SBAR
Situation Background Assessment Recommendation
What size catheter should adults use?
Size 14 to 16 Fr
Absorption
Small intestine is the primary absorption site for nutrients. Body absorbs nutrients by means of passive diffusion, osmosis, active transport; and pinocytosis
RASH
Small, raised vesicles that are usually reddened; often distributed over entire body
*Identify the primary organ for drug excretion, and explain what happens if this organ's function declines.*
The [[*kidneys*]] are the primary organ for drug excretion. When renal function declines, a patient is at risk for medication toxicity.
ABILITY OF A MEDICATION TO DISSOLVE
The ability of an oral medication to dissolve depends largely on its form or preparation body absorbs solutions and suspensions already in a liquid state more readily than tablets or capsules Acidic medications pass through the gastric mucosa rapidly Medications that are basic are not absorbed before reaching the small intestine
[[Peak Concentration]]
The highest serum level concentration
Identify the primary organ for drug excretion, and explain what happens if this organ's function declines
The kidneys; when renal function declines, a client is at risk for for medication toxicity.
absorption
The passage of medication molecules into the bloodstream from the site of administration
Minimum effective concentration (MEC)
The plasma level of a medication below which the medication's effect will not occur.
8. Which pt is at highest risk for tachycardia? 1. A healthy basketball player during warmup exercises 2. A pt admitted with hypothermia 3. A pt with a fever of 39.4° C (103° F) 4. A 90-year-old male taking beta blockers
8. Answer: 3. Fever elevates metabolism by 10%, resulting in an increased heart rate to remove the heat produced. Hypothermia and beta blockers decrease heart rate. Healthy athletes have a lower heart rate as a result of conditioning.
Peak concentration
Time it takes med to reach its highest effective concentration
9. Which of the following pts are at most risk for tachypnea? (Select all that apply.) 1. Pt just admitted with four rib fractures 2. Woman who is 9 months' pregnant 3. Adult who has consumed alcoholic beverages 4. Adolescent waking from sleep 5. Three-pack-per-day smoker with pneumonia
9. Answer: 1, 2, 5. Patient with rib fractures is unlikely to breathe deeply and a large fetus restricts diaphragmatic movement, leading to decreased ventilatory volume. Pneumonia decreases gas exchange surface area. Tachypnea occurs to increase minute ventilation. Alcohol is a respiratory depressant.
What angle should be used for an intramuscular (IM) injection, and what needle?
90 degrees
CLUBFOOT
95%: Medial deviation and plantar flexion of foot (equinovarus) 5%: Lateral deviation and dorsiflexion (calcaneovalgus)
Temperature averages oral
98.6
how much glomerular filtrate is excreted as urine?
99% is resorbed into the plasma by the proximal convoluted tubule of the nephron, the loop of henle, and the distal tubule. 1% is excreted as urine
Pulse Ox
>95
2. A 74-year-old client currently has a temperature reading of 36° C. The client walks 1 mile every day and takes naps during the day. Which of the following is most likely the reason for the lowered body temperature? A. The lowered temperature is a natural result of the aging processes. B. Increased stress from exercise has probably reduced the temperature. C. The individual circadian rhythm requiring daytime naps lowers the temperature. D. Hormone levels are the most probable cause of the hypothermic condition
A
3. A construction worker comes to the emergency room with low blood pressure, normal pulse, cool skin temperature, diaphoresis, and weakness. These are clinical signs of: A. Heat exhaustion B. Heat stroke C. Heat cramp D. Hypothermia
A
A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions? a. Fluid volume overload b. Hemolytic reaction c. Anaphylactic shock d. Septicemia
A
A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output. The patient has voided 400 mL of urine. After reporting these values to the health care provider, which order does the nurse anticipate? a. Add a potassium supplement to replace loss from output. b. Decrease the rate of intravenous fluids to 100 mL/hr. c. Administer a diuretic to prevent fluid volume excess. d. Discontinue the nasogastric suctioning.
A
A nurse is caring for a patient with peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel? a. Recording intake and output b. Regulating intravenous flow rate c. Starting peripheral intravenous therapy d. Changing a peripheral intravenous dressing
A
A patient has dehydration. While planning care, the nurse considers that the majority of the patient's total water volume exists in with compartment? a. Intracellular b. Extracellular c. Intravascular d. Transcellular
A
A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient? a. Renal b. Endocrine c. Respiratory d. Gastrointestinal
A
An 84-year-old diabetic client is admitted for insulin regulation. Which of the following blood pressure, pulse, and respiration measurements, respectively, is considered within the expected limits for this client? A. 148/90, 68, 16 B. 94/52, 68, 30 C. 108/80, 112, 15 D. 132/74, 90, 24
A
Four patients arrive at the emergency department at the same time. Which patient will the nurse see first? a. An infant with temperature of 102.2° F and diarrhea for 3 days b. A teenager with a sprained ankle and excessive edema c. A middle-aged adult with abdominal pain who is moaning and holding her stomach d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60
A
The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare? a. 0.45% sodium chloride (1/2 NS) b. 0.9% sodium chloride (NS) c. Lactated Ringer's (LR) d. Dextrose 5% in Lactated Ringer's (D5LR)
A
The nurse administers an intravenous (IV) hypertonic solution to a patient. In which direction will the fluid shift? a. From intracellular to extracellular b. From extracellular to intracellular c. From intravascular to intracellular d. From intravascular to interstitial
A
The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient's medical record? a. Intake 255; output 375 b. Intake 285; output 375 c. Intake 505; output 125 d. Intake 535; output 125
A
The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis? a. pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L b. pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L c. pH 7.32, PaCO2 47 mm Hg, HCO3- 23 mEq/L d. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L
A
The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with D5W hanging with the blood b. A patient with type A blood receiving type O blood c. A patient with intravenous potassium chloride that is diluted d. A patient with a right mastectomy and an intravenous site in the left arm
A
The nurse is reviewing laboratory results. Which cation will the nurse observe is the most abundant in the blood? a. Sodium b. Chloride c. Potassium d. Magnesium
A
The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing? a. Osmosis b. Filtration c. Diffusion d. Active transport
A
The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order will the nurse perform the steps, starting with the first one? 1. Remove the sleeve of the gown from the arm without the IV. 2. Remove the sleeve of the gown from the arm with the IV. 3. Remove the IV solution container from its stand. 4. Pass the IV bag and tubing through the sleeve. a. 1, 2, 3, 4 b. 2, 3, 4, 1 c. 3, 4, 1, 2 d. 4, 1, 2, 3
A
6. Which nursing observation of the patient in intensive care indicates that the patient is sleeping comfortably? a. Eyes closed, lying quietly, respirations 12, heart rate 60 b. Eyes closed, tossing in bed, respirations 18, heart rate 80 c. Eyes closed, mumbling to self, respirations 16, heart rate 68 d. Eyes closed, lying straight in bed, respirations 22, heart rate 66
A (During NREM sleep, biological functions slow. During sleep, the heart rate decreases to 60 beats per minute or less. The patient experiences decreased respirations, blood pressure, and muscle tone.)
8. The nurse is discussing lack of sleep with a middle-aged adult. The nurse recognizes that insomnia in this age group is commonly due to a. Anxiety. b. Teenagers keeping them awake. c. Caring for pets. d. Late night television.
A (During middle adulthood, the total time spent sleeping at night begins to decline. Anxiety, depression, and illness can affect sleep, and women can experience menopausal symptoms. Insomnia is common because of the changes and stresses associated with middle age. Teenagers, caring for pets, and late night television can influence the amount of sleep; however, these are not the most common causes of insomnia in this age group.)
22. The nurse is caring for a patient on the medical-surgical unit who is experiencing an exacerbation of asthma. Which of the following interventions would be most appropriate to help the patient sleep? a. Bed placed in semi-Fowler's position b. Increased BNC oxygen to 5 L a minute c. A snack provided before bedtime d. Encouraging the patient to read
A (For patients with a physical illness, the nurse helps control symptoms that disrupt sleep. Placing the patient in an upright position eases the work of breathing. Increasing the oxygen provided would require a reason to do so, and a physician's order is required. Providing a snack and encouraging the patient to read may be good interventions for patients, but the most appropriate would be raising the head of the bed.)
11. The nurse is completing an assessment on an older patient who is having difficulty falling asleep. Which factor has the potential to contribute to this difficulty? a. Depression b. Smoking c. Alcohol d. Fatigue
A (Older adults and other individuals who experience depressive mood problems experience delays in falling asleep, earlier appearance of REM sleep, frequent awakening, increased total bed time, feelings of sleeping poorly, and early awakening. Smoking (nicotine) decreases the total sleep time and REM and causes awakening or difficulty staying asleep. Alcohol speeds the onset of sleep. A person who is moderately fatigued usually achieves restful sleep.)
The nurse is providing an educational session on sleep regulation for new nurses in the Sleep Disorder Treatment Center. Which of these statements by the nurses would best indicate that learning has occurred? a. "If the patient has a disease process in the central nervous system, it can influence the functions of sleep." b. "If the patient has a disease process in the cranial nerves, it can influence the functions of sleep." c. "If the patient has an interruption in the motor pathways, it can influence the functions of sleep." d. "If the patient has an interruption in the spinal reflexes, it can influence the functions of sleep."
A (Sleep involves a sequence of physiological states maintained by the central nervous system. Current theory indicates that it is an active multiphase process that involves many parts of the brain and hormone and chemical secretion. A disease process associated with the cranial nerves, motor pathway, or spinal reflexes may influence a person's ability to sleep, but the best answer is the central nervous system.)
16. The nurse is completing a sleep assessment on a patient. The nurse utilizes which of the following tools to complete the assessment? a. Visual Analogue Scale b. OUCHER scale c. FACES scale d. Glasgow Coma Scale
A (The Visual Analogue Scale is utilized for assessing sleep quality. The OUCHER and FACES scales are used to measure pain, and the Glasgow Coma Scale is used to measure level of consciousness.)
15. The nurse is caring for a patient who has been in holding in the emergency department for 24 hours. The nurse is concerned about the patient experiencing sleep deprivation. What would be the best action for the nurse to take? a. Expedite the process of obtaining a medical-surgical room for the patient. b. Pull the curtains shut, dim the lights, and decrease the number of visitors. c. Obtain an order for a medication to help the patient sleep. d. Ask everyone in the unit to try to be quiet so the patient can sleep.
A (The most effective treatment for sleep deprivation is elimination or correction of factors that disrupt the sleep pattern. Nurses play an important role in identifying treatable sleep deprivation problems. Obtaining a private room in the designated unit for the patient will help with decreasing stimuli and promoting more rest than an individual can obtain in an emergency department even with the interventions mentioned.)
24. The nurse is evaluating outcomes for the patient with the nursing diagnosis of Insomnia. During this process, the nurse recognizes that a. The patient is the best evaluator of sleep. b. Interventions will need to be adjusted. c. Medical conditions will not influence outcomes. d. Observations of the patient provide needed data.
A (The patient is the source for evaluating outcomes. The patient is the only one who knows whether sleep problems have improved and what has been successful. Interventions may or may not need to be adjusted. Observations do provide needed data, but in the case of insomnia, the patient is the source for evaluating the restfulness of sleep. Sometimes, the nurse has to work with the patient to redefine sleep expectations associated with medical conditions.)
What is a mini-infusion pump?
A battery-operated machine that allows medications to be given in very small amounts of fluid (5-60 mL)
VERBAL ORDER
abbreviated as "VO"
True fever
alteration in the hypothalamus "set point"
Resting energy expenditure (REE)
amount of energy you need to consume over a 24 hour period for your body to maintain all of its internal working activities while at rest.
Solution
A given mass of solid substance dissolved in a known volume of fluid or a given volume of liquid dissolved in a known volume of another fluid.
RESERVOIR
A place where a pathogen survives Factors that affect pathogen growth include: - food - oxygen - water - temperature - pH - light
INFECTIOUS PROCESS
A progressive course by four stages INCUBATION PERIOD PRODROMAL STAGE ILLNESS STAGE CONVALESCENCE
b) side effect
A secondary effect or one that is unintended. Usually predictable. a) therapeutic effect b) side effect c) adverse effect d) toxic effect e) idiosyncratic reaction f) drug interaction
Vial
A single dose or multi-dose container with a rubber seal at the top (closed system)
What is a piggyback set?
A small (25-250 mL) IV bag connected to short tubing lines that connects to the upper Y port of a primary infusion line
What is a volume-control administration set?
A small (50-150 mL) container that attaches below the primary infusion line.
What is a piggyback set?
A small IV bag connected to a short tubing line that connects to upper Y port of a primary infusion line.
b) drug tolerance
A state of requiring increased dosage of a drug to maintain a given therapeutic effect. a) drug toxicity b) drug tolerance c) agonist d) antagonist
a young girl with long hair is experiencing a problem with matting. the most appropriate action to take would be
braiding the hair to reduce tangles
LONG-ACTING INSULIN
brands: Lantus, Levemir onset: 0.8 - 4 hours peak: minimal duration: up to 24 hours often combined, when needed, with rapid- or short-acting insulin lowers blood glucose levels when rapid-acting insulins stop working taken once or twice a day
BRIGHT RED STOOL
bright red blood on stool surface indicates rectal bleeding ruptured hemorrhoid ingestion of beets
PRINCIPLES OF SURGICAL ASEPSIS
A sterile object remains sterile only when touched by another sterile object Only sterile objects may be placed on a sterile field A sterile object or field out of the range of vision or an object held below a person's waist is contaminated A sterile object or field becomes contaminated by prolonged exposure to air When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action Fluid flows in the direction of gravity the edges of a sterile field/container are considered to be contaminated
suprapubic catheter
A urinary drainage tube inserted surgically into the bladder through abdominal wall above the symphonies pubis
WARNING SIGNS FOR COLORECTAL CANCER
change in bowel habits rectal bleeding sensation of incomplete evacuation unexplained abdominal or back pain
approximated
closed
TED Hose
compression stockings Thrombo Embolytic Deterent
hesitancy
delay in start of urinary stream when voiding
PSYCHOSOCIAL EFFECTS
emotional & behavioral responses sensory alterations changes in coping
CHEMICAL NAME
exact description of composition and molecular structure i.e. N-acetyl-para-aminophenol
FUO
fever of unknown origin is a fever that has no determined cause
PRN
given when the client requires it as needed document assessment findings to confirm patient need document time of administration
CARTILAGINOUS JOINTS
have little movement but are elastic and use cartilage to unite separate bony surfaces ribs to the costal cartilage when bone growth is complete, the joints ossify
TAP WATER ENEMA
hypotonic exerts osmotic pressure LOWER than fluid in interstitial spaces net movement of water is low infused volume stimulates defecation before large amounts of water leave the bowel USE CAUTION - repeat enemas can cause water toxicity and/or circulatory overload
ultrasound-renal bladder
imaging go the kidneys, ureters, and bladder using sound waves identifies gross structural abnormalities and estimates the volume of urine in the bladder
pressure ulcer
impaired skin integrity related to unrelieved prolonged pressure
STOOL WITH JELLY-LIKE MUCUS
indicates inflammation
CHEMICAL AGENTS THAT TRIGGER INFLAMMATORY RESPONSE
internal/external irritants - harsh poisons - gastric acid
PARALYTIC ILEUS
intestinal obstruction caused by - reduced motility - surgery - electrolyte imbalance - infection - medications
what are the most common urinary elimination problems?
involve the inability to store urine or fully empty urine from the bladder.
BODY ALIGNMENT - LYING DOWN
lateral position head supported by pillow while body is supported by mattress vertebrae should be aligned without causing discomfort
FECES - TRANSVERSE COLON
liquid to semi-formed do not form a hardened mass
Fibrin
matrix that later provides a framework for cellular repair
Epithelialization
migration of epithelial cells the wound edges resurgacing
Frostbite
occurs when the body is exposed to subnormal temperatures
POSITIONING ON A BEDPAN
prevent muscle strain and discomfort elevate head of the bed 30-45 degrees wear gloves when handling bedpans
Enteral nutrition (EN)
provides nutrients to the GI tract
CARMINATIVE ENEMA
provides relief from gaseous distension MGW solution - 30 mL magnesium - 60 mL glycerine - 90 mL water
where is the bladder in females?
rests against the anterior wall of the uterus and vagina
STIMULATION OF THE VAGUS NERVE
results in a reflex that slows down the heart rate
BRISTOL STOOL SCALE - TYPE 1
separate hard lumps like nuts difficult to pass
SCD
sequential compression device applying SCDs can be delegated to nursing assistive personnel (NAP)
LEVIN TUBE
single lumen tube holes near the tip connects to drainage bag or intermittent suction device to drain stomach secretions
AIRBORNE PRECAUTIONS
smaller than 5 microns measles chickenpox (varicella) disseminated varicella zoster (shingles) pulmonary or laryngeal tuberculosis
Fever patterns
sustained, intermittent, remittent, relapsing
core temperature
temperature of deep tissue
Core temperature
temperature of the deep tissues
Chyme
the semi-fluid mass of partly digested food that is expelled by the stomach, through the pyloric valve, into the duodenum
dental caries
tooth decay
microscopic examination of RBC
up to 2
orthotropic neobladder
uses an ideal pouch to replace the bladder. the pouch is in the same position as the bladder was before removal, allowing the patient to void through the urethra using a valsalva technique
Diaphoresis
visible perspiration primarily occurring on the forehead and upper thorax
ABSORPTION
when medication molecules pass into the blood from the site of medication administration
mixed UI
when stress- and urgency-type symptoms are both present
SIGMOID COLOSTOMY
will have more formed stool
1. The nurse is caring for a patient who has not been able to sleep well while in the hospital. The nurse recognizes that lack of sleep can manifest in which of the following signs and symptoms? (Select all that apply.) a. Changes in physiological function such as temperature b. Decreased appetite and weight loss c. Anxiety, irritability, and restlessness d. Impaired judgment e. Nausea, vomiting, and diarrhea f. Shortness of breath and chest pain
A, B, C, D (The biological rhythm of sleep frequently becomes synchronized with other body functions. Changes in body temperature correlate with sleep pattern. When the sleep-wake cycle becomes disrupted, changes in physiological function such as temperature can occur. Patients can experience decreased appetite, loss of weight, anxiety, restlessness, irritability, and impaired judgment. Gastrointestinal and respiratory/cardiovascular symptoms such as shortness of breath and chest pain are not symptoms of a disrupted sleep cycle.)
3. The patient and the nurse discuss the need for sleep. After the discussion, the patient is able to state factors that hinder sleep. Which statements indicate that the patient has a good understanding of sleep? (Select all that apply.) a. "Drinking coffee at 7 PM could interrupt my sleep." b. "Worry about work can disrupt my sleep." c. "Exercising 2 hours before bedtime can decrease relaxation." d. "Changing the time of day that I eat dinner can disrupt sleep." e. "Taking an antacid can decrease sleep." f. "Staying up late for a party can interrupt sleep patterns."
A, B, D, F (Caffeine, alcohol, and nicotine consumed late in the evening produce insomnia. Worry over personal problems or situations frequently disrupts sleep. Alterations in routines, including changing mealtimes and staying up late at night for social activities, can disrupt sleep. Exercising 2 hours before bedtime actually increases a sense of fatigue and promotes relaxation. Taking an antacid does not decrease sleep)
2. The nurse is caring for a patient in the intensive care unit who is having trouble sleeping. The nurse explains the purpose of sleep and its benefits. What points should the nurse include in her teaching? (Select all that apply.) a. NREM sleep contributes to body tissue restoration. b. During NREM sleep, biological functions increase. c. Restful sleep preserves cardiac function. d. Sleep contributes to cognitive restoration. e. REM sleep decreases cortical activity. f. REM sleep assists with memory storage and learning
A, C, D, E (Sleep contributes to physiological and psychological restoration. NREM sleep contributes to body tissue restoration. It allows the body to rest and conserve energy. This is beneficial for the cardiac system by allowing the heart to beat fewer times each minute. During stage 4, the body releases growth hormone for renewal and repair of specialized cells such as the brain. REM sleep is necessary for brain tissue restoration and cognitive restoration and is associated with a change in cerebral blood flow and increased cortical activity. Sleep assists with memory storage and learning)
A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? (Select all that apply.) a. Check for contraindications to the extremity. b. Start proximally and move distally on the arm. c. Choose a vein with minimal curvature. d. Choose the patient's dominant arm. e. Select a vein that is rigid. f. Avoid areas of flexion.
A, C, F
Which assessments will alert the nurse that a patient's IV has infiltrated? (Select all that apply.) a. Edema of the extremity near the insertion site b. Reddish streak proximal to the insertion site c. Skin discolored or pale in appearance d. Pain and warmth at the insertion site e. Palpable venous cord f. Skin cool to the touch
A, C, F
Which of the following client statements made by young adults suggest a risk factor for sleep disturbance problems? (Select all that apply) A. "I have a job that requires my attention 110% of the time." B. "I really enjoy fishing; I wish we lived closer to a river or pond." C. "My wife just found out she is pregnant for the third time in 5 years." D. "My father recently suffered a heart attack, and Mom is so very worried about him." E. "The kids are so active in after-school things that we never have an evening at home." F. "Gardening always gave me such a sense of accomplishment, but I don't have much free time now."
A. "I have a job that requires my attention 110% of the time." C. "My wife just found out she is pregnancy for the third time in 5 years." D. "My father recently suffered a heart attack, and Mom is so very worried about him." E. "The kids are so active in after-school things that we never have an evening at home." It is common for the stresses of jobs, family relationships, and social activities to lead frequently to insomnia and the use of medication for sleep. The remaining options reflect a sense of loss but necessarily of stress.
A 22 year old male client shares with the nurse that he is always tired. In assessing the client's sleep pattern to determine the quantity of sleep the client is getting, the nurse should ask: A. "On a scale from 0 to 10, how much sleep do you think you get each night?" B. "What time do you usually go to bed?" C. "What time do you usually get up?" D. "Do you have a bedtime ritual?"
A. "On a scale from 0 to 10, how much sleep do you think you get each night?" This question helps quantify the length of sleep that the client receives. A brief subjective method to assess sleep is a numeric scale with a 0 to 10 sleep rating. Ask individuals to separately rate their quantity and quality of sleep on the scale.
An 11 year old boy in middle school is currently experiencing sleep-related fatigue during classes. Which of the following is the most appropriate response by the school nurse when counseling the child's parents regarding this assessment? A. "What are the child's usual sleep patterns?" B. "Establish bedtimes for the child, and withhold his allowance whenever those times are not adhered to." C. "We need to explore other health-related problems, because sleep problems are not likely the cause of his fatigue." D. "The bulbar synchronizing region of the child's central nervous system is causing these insomniac problems."
A. "What are the child's usual sleep patterns?" A school-age child will be tired the following day if allowed to stay up later than usual. The nurse should ask a question to assess the child's usual sleep patterns. The nurse should first assess the child's usual sleep patter to determine if the child is adhering to a bedtime. A sleep problem is often the cause of fatigue.
A 74 year old client has been having sleeping difficulties. To have a better idea of the client's problem, the nurse should respond: A. "What do you do just before going to bed?" B. "Let's make sure that your bedroom is completely darkened at night." C. "Why don't you try napping more during the daytime?" D. Do you eat a small snack before going to bed?"
A. "What do you do just before going to bed?" To assess the client's sleeping problem, the nurse should inquire about predisposing factors, such as by asking what they do just before going to bed. Assessment is aimed at understanding the characteristics of any sleep problem and the client's usual sleep habits so that ways for promoting sleep can be incorporated into nursing care.
Which of the following clients is most likely to experience difficulty returning to sleep? A. A 60 year old with benign hypertropic prostatic disease B. A 15 year old with type 1 diabetes C. A 35 year old diagnosed with hypothyroidism D. A 55 year old diagnosed with hypertension
A. A 60 year old with benign hypertropic prostatic disease Nocturia, or urination during the night, disrupts sleep and the sleep cycle. This condition is common in older people with reduced bladder tone or persons with cardiac disease, diabetes, urethritis, or prostatic disease. After a person awakens repeatedly to urinate, returning to sleep is difficult. The answer represents the client with the greatest tendency to be awakened during the night.
Although the most common effect of obstructive sleep apnea is disrupted sleep pattern, the condition can cause a serious decline in arterial oxygen levels that may result in: (Select all that apply) A. Hypertension B. Angina attacks C. Alzheimer's disease D. Cardiac dysrhythmias E. Cerebral vascular accidents F. Type 2 diabetes
A. Hypertension B. Angina attacks D. Cardiac dysrhythmias E. Cerebral vascular accident Obstructive apnea causes a serious decline in arterial oxygen saturation level. Clients are at risk for cardiac dysrhythmias, right-sided heart failure, pulmonary hypertension, angina attacks, strokes, and hypertension.
Teaching for a client who is currently taking a diuretic should include information that he or she may experience: A. Nocturia B. Nighmares C. Increased daytime sleepiness D. Reduced REM sleep
A. Nocturia For the client who is currently taking a diuretic, the nurse should inform the client that he or she might experience nighttime awakening caused by nocturia. Diuretic use does not cause nightmares or daytime sleepiness or reduce REM sleep.
The assistive nursing personnel reports that the heart rate of the sleeping 23 year old athlete, who is hospitalized following complications of a tonsillectomy, is 56. The assistive nursing personnel states that this is 10 beats per minute slower than when she took it earlier in the evening. The nurse knows that this is considered: A. Normal, and they will continue to monitor the vital signs as ordered B. Abnormally slow, and the health care provider should be notified immediately C. Abnormally slow, and the nurse will recheck the heart rate before taking any action D. Abnormally slow, signaling that the client may be hemorrhaging
A. Normal, and they will continue to monitor the vital signs as ordered A healthy adult's normal heart rate throughout the day averages 70 to 80 beats/min or less if the individual is in excellent physical condition. However, during sleep the heart rates falls to 60 beats/min or less. This means that the heart beats 10 to 20 fewer times in each minute during sleep or 60 to 120 fewer times in each hour. If the client were hemorrhaging, the heart rate would initially be tachycardic as the body attempts to compensate for the lost blood volume.
A 63 year old client is discussing the recent problem the client is experiencing with falling asleep. The nurse is discussing strategies to minimize this problem. Which of the following bedtime snacks would be the most likely to induce sleep? A. One slice of cheese on four wheat crackers and a glass of skim milk B. Two cups or air-popped popcorn and a glass of fruit juice C. Two fig cookies and a cup of decaffeinated tea D. One small pear and a glass of soy milk
A. One slice of cheese on four wheat crackers and a glass of skim milk One substance that promotes sleep in many people is L-tryptophan, a natural protein found in foods such as milk, cheese, and meats.
The night nurse goes quietly into the sleeping client's room to assess him. The client wakes up as soon as the nurse is in the room. The nurse knows that the client was most likely in which stage of sleep? A. Stage 1: NREM B. Stage 2: NREM C. Stage 3: NREM D. Stage 4: NREM
A. Stage 1: NREM Stage 1 NREM includes the lightest level of sleep. Sensory stimuli such as noise easily arouses the person. The stage lasts a few minutes. Decreased physiological activity begins with gradual fall in vital signs and metabolism. Awakened, person feels as though daydreaming has occurred. Stage 2 NREM is a period of sound sleep. Stage 3 NREM involves initial stages of deep sleep. Stage 4 NREM is the depends stage of sleep. It is very difficult to arouse the sleeper.
An older adult client diagnosed as being in the early stages of Alzheimer's disease shares with the nurse that her sleep is interrupted by "the nosies I hear all through the night." The nurse explains that the most likely reason for this problem is: A. The client's age B. A lack of presleep relaxation C. The amount of noise entering into the client's environment D. A manifestation of the disease process causing the brain disorder
A. The client's age With aging, sleep becomes more fragmented, and a person spends more time in lighter stages that are easily disturbed by noise. The remaining options may be a factor but not to the degree or normal aging.
A 44 year old female client shares with the nurse that she is having difficulty falling asleep at night, even though she is exhausted. The nurse knows that which of the following could be causing the sleeplessness? A. Two cups of hot cocoa every evening B. Vegetarian diet C. Afternoon exercise program D. Hot bath in the evening
A. Two cups of hot cocoa every evening Caffeine is a stimulant and can cause difficulty falling asleep. There is about 30 mg of caffeine in two cups of hot cocoa.
The nurse should instruct the client to do which of the following to promote good sleep hygiene at home? A. Use the bedroom only for sleep or sexual activity B. Eat a large meal 1 to 2 hours before bedtime C. Exercise vigorously before bedtime D. Stay in bed if sleep does not come after 1/2 after
A. Use the bedroom only for sleep or sexual activity The nurse should explain that, if possible, the bedroom should not be used for intensive studying, snacking, TV watching, or other nonsleep activity, besides sex. The nurse should instruct the client to avoid heavy meals for 3 hours before bedtime; a light snack may help. The nurse should also instruct the client to try to exercise daily, preferably in morning or afternoon, and to avoid vigorous exercise in the evening within 2 hours of bedtime.
5. A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? a. Grape and walnut chicken salad sandwich on whole wheat bread b. Broccoli and cheese soup with potato bread c. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing d. Turkey and mashed potatoes with brown gravy
ANS: A A healthy diet for the bowel should include foods high in bulk-forming fiber. Whole grains, fresh fruit, and fresh vegetables are excellent sources. Foods without much fiber and with high levels of fat can slow down peristalsis, causing constipation.
31. A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for further education? a. "If I get a positive result, I have gastrointestinal bleeding." b. "I should not eat red meat before my examination." c. "I should schedule to perform the examination when I am not menstruating." d. "I will need to perform this test three times if I have a positive result."
ANS: A A positive result does not mean GI bleeding; it could be a false positive from consuming red meat, some raw vegetables, or NSAIDs. Proper patient education is important for viable results. The patient needs to avoid certain foods to rule out a false positive. If the test is positive, the patient will need to repeat the test at least three times. Menses and hemorrhoids can also lead to false positives.
28. A nurse is caring for an 8-year-old patient who is embarrassed about urinating in his bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence? a. "Drink your nightly glass of milk earlier in the evening." b. "Set your alarm clock to wake you every 2 hours, so you can get up to void." c. "Line your bedding with plastic sheets to protect your mattress." d. "Empty your bladder completely before going to bed."
ANS: A ANS: A Nightly incontinence and nocturia are often resolved by limiting fluid intake 2 hours before bedtime. Setting the alarm clock to wake does not correct the physiological problem, nor does lining the bedding with plastic sheets. Emptying the bladder may help with early nighttime urination, but will not affect urine produced throughout the night from late-night fluid intake.
4. A patient requests the nurse's assistance to the bedside commode and becomes frustrated when unable to void in front of the nurse. The nurse understands the patient's inability to void because a. Anxiety can make it difficult for abdominal and perineal muscles to relax enough to void. b. The patient does not recognize the physiological signals that indicate a need to void. c. The patient is lonely, and calling the nurse in under false pretenses is a way to get attention. d. The patient is not drinking enough fluids to produce adequate urine output.
ANS: A Attempting to void in the presence of another can cause anxiety and tension in the muscles that make voiding difficult. The nurse should give the patient privacy and adequate time if appropriate. No evidence suggests that an underlying physiological or psychological condition exists.
19. When viewing a urine specimen under a microscope, what would the nurse expect to see in a patient with a urinary tract infection? a. Bacteria b. Casts c. Crystals d. Protein
ANS: A Bacteria indicate a urinary tract infection. Crystals would be seen with renal stone formation. Casts indicate renal alterations. Protein is not visible under a microscope and indicates renal disease.
21. After a patient returns from a barium swallow, the nurse's priority is to a. Encourage the patient to increase fluids to flush out the barium. b. Monitor stools closely for bright red blood or mucus, which indicates trauma from the procedure. c. Inform the patient that his bowel movements are radioactive, and that he should be sure to flush the toilet three times. d. Thicken all patient drinks to prevent aspiration.
ANS: A Encourage the patient to increase fluid intake to flush and remove excess barium from the body. Barium swallow is a noninvasive procedure for which no trauma would produce blood or mucus or increase aspiration risk. Barium is not a radioactive substance, so multiple flushes are not needed.
23. A nurse is educating a patient on how to irrigate an ostomy bag. Which statement by the patient indicates the need for further instruction? a. "I can use a fleet enema to save money because it contains the same irrigation solution." b. "Sitting on the toilet lets the irrigation sleeve eliminate into the bowl." c. "I should never attempt to reach into my stoma to remove fecal material." d. "Using warm tap water will reduce cramping and discomfort during the procedure."
ANS: A Enema applicators should never be used in the stoma because they can cause damage. A special coned irrigation device is used for ostomies. Irrigating a stoma into the toilet is an effective management technique. Fingers and other objects should not be placed into the stoma because they may cause trauma to the intestinal wall. Warm tap water will reduce cramping during irrigation.
6. A patient informs the nurse that she was using laxatives three times daily to lose weight. After stopping use of the laxative, the patient had difficulty with constipation and wonders if she needs to take laxatives again. The nurse educates the patient that a. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. b. Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis. c. Natural laxatives such as mineral oil are safer than chemical laxatives for relieving constipation. d. Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced.
ANS: A Long-term laxative use can lead to constipation. Increasing fluid and fiber intake can help with this problem. Laxatives do not cause scarring. Natural laxatives like mineral oil come with their own set of risks, such as inability to absorb fat-soluble vitamins. Even if malnourished, the body will produce waste if substance is consumed.
2. When reviewing laboratory results, the nurse should immediately notify the health care provider about which finding? a. Glomerular filtration rate of 20 mL/min b. Urine output of 80 mL/hr c. pH of 6.4 d. Protein level of 2 mg/100 mL
ANS: A Normal glomerular filtration rate should be around 125 mL/min
3. Which of the following is not a function of the large intestine? a. Absorbing nutrients b. Absorbing water c. Secreting bicarbonate d. Eliminating waste
ANS: A Nutrient absorption is done in the small intestine. The other options are all functions of the large intestine.
22. While a cleansing enema is administered to an 80-year-old patient, the patient expresses the urge to defecate. What is the next priority nursing action? a. Positioning the patient in the dorsal recumbent position with a bed pan b. Assisting the patient to the bedside commode c. Stopping the enema cleansing and rolling the patient into right-lying Sims' position d. Inserting a rectal plug to contain the enema solution
ANS: A Patients with poor sphincter control may not be able to hold in all of an enema solution. Positioning the patient on a bed pan in dorsal recumbent position will allow the nurse to continue to administer the enema. Having the patient get up to toilet is unsafe because the rectal tube can damage the mucosal lining. The purpose of the enema is to promote defecation; stopping it early may inhibit its effectiveness. Use of a rectal plug to contain the solution is inappropriate.
14. A patient asks about treatment for urge urinary incontinence. The nurse's best response is to advise the patient to a. Perform pelvic floor exercises. b. Drink cranberry juice. c. Avoid voiding frequently. d. Wear an adult diaper.
ANS: A Poor muscle tone leads to an inability to control urine flow. The nurse should recommend pelvic muscle strengthening exercises such as Kegel exercises; this solution best addresses the patient's problem. Drinking cranberry juice is a preventative measure for urinary tract infection. The nurse should not encourage the patient to reduce voiding; residual urine in the bladder increases the risk of infection. Wearing an adult diaper could be considered if attempts to correct the root of the problem fail.
38. Which observation by the nurse best indicates that bladder irrigation for urinary retention has been effective? a. Recording an output that is larger than the amount instilled b. Presence of blood clots or sediment in the drainage bag c. Reduction in discomfort from bladder distention d. Visualizing clear urinary catheter tubing
ANS: A Recording an output that is greater than what was irrigated into the bladder shows progress that the bladder is draining urine. The other observations do not objectively measure the increase in urine output.
39. The nurse should place the patient in which position when preparing to administer an enema? a. Left Sims' position b. Fowler's c. Supine d. Semi-Fowler's
ANS: A Side-lying Sims' position allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon. This helps to improve retention of the enema. Administering an enema in a sitting position may allow the curved rectal tube to scrape the rectal wall.
40. The nurse is assessing a patient 2 hours after a colonoscopy. Based on the procedure done, what focused assessment will the nurse include? a. Bowel sounds b. Presence of flatulence c. Bowel movements d. Nausea
ANS: A The nurse does want to hear the presence of bowel sounds; absent bowel sounds may indicate a complication from the surgery. Bowel movements and flatulence are not expected in the hours after surgery. The nurse does want to hear the presence of bowel movements. Nausea is not a problem following colonoscopy.
27. The nurse knows that the ideal time to change an ostomy pouch is a. Before eating a meal, when the patient is comfortable. b. When the patient feels that he needs to have a bowel movement. c. When ordered in the patient's chart. d. After the patient has ambulated the length of the hallway.
ANS: A The nurse wants to change the ostomy appliance when as little output as necessary ensures a smooth procedure. Patients with ostomies do not feel the urge to defecate because the sensory portion of the anus is not stimulated. Changing the ostomy pouch is a nursing judgment decision. After a patient ambulates, stool output is increased.
14. The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which of the following outcomes would the nurse evaluate as successful for the patient to establish normal defecation? a. The patient reports eliminating a soft, formed stool. b. The patient has quit taking opioid pain medication. c. The patient's lower left quadrant is tender to the touch. d. The nurse hears bowel sounds present in all four quadrants.
ANS: A The nurse's goal is for the patient to be on opioid medication and to have normal bowel elimination. Normal stools are soft and formed. Ceasing pain medication is not a desired outcome for the patient. Tenderness in the left lower quadrant indicates constipation and does not further address bowel elimination. Present bowel sounds indicate that the bowels are moving; however, they are not an indication of defecation.
2. The nurse would expect the least formed stool to be present in which portion of the digestive tract? a. Ascending b. Descending c. Transverse d. Sigmoid
ANS: A The path of digestion goes from the ascending, across the transverse, to the descending and finally passing into the sigmoid; therefore, the least formed stool would be in the ascending.
21. What signs and symptoms would the nurse expect to observe in a patient with excessive white blood cells present in the urine? a. Fever and chills b. Difficulty holding in urine c. Increased blood pressure d. Abnormal blood sugar
ANS: A The presence of white blood cells in urine indicates a urinary tract infection. Difficulty with urinary elimination indicates blockage or renal damage. Increased blood pressure is associated with renal disease or damage and some medications. Abnormal blood sugars would be seen in someone with ketones in the urine, as this finding indicates diabetes.
30. Which nursing action best reduces risk of excoriation to the mucosal lining of the nose from a nasogastric tube? a. Lubricating the nares with water-soluble lubricant b. Applying a small ice bag to the nose for 5 minutes every 4 hours c. Instilling Xylocaine into the nares once a shift d. Changing the tape holding the tube in place once a shift
ANS: A The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble lubricant decreases the likelihood of excoriation. Ice is not applied to the nose. Ice may be applied externally to the throat if the patient reports a sore throat. Xylocaine requires a physician order and is used to treat sore throat, not nasal mucosal excoriation. Changing the tape should be done daily, not every shift.
34. A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse would expect which other assessment finding? a. Hypoactive bowel sounds b. Jaundice in sclera c. Decreased skin turgor d. Soft tender abdomen
ANS: A Three or more days with no bowel movement indicates hypomotility of the GI tract. Assessment findings would include hypoactive bowel sounds, a firm distended abdomen, and pain or discomfort upon palpation.
10. Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. The nurse should follow up by asking a. "When was the last time you voided?" b. "Do you lose urine when you cough or sneeze?" c. "Have you noticed any change in your urination patterns?" d. "Do you have a fever or chills?"
ANS: A To obtain an accurate assessment, the nurse should first determine the source of the discomfort. Urinary retention causes the bladder to be firm and distended. Further assessment to determine the pathology of the condition can be performed later. Questions concerning fever and chills, changing urination patterns, and losing urine during coughing or sneezing focus on specific pathological conditions.
39. The nurse anticipates urinary diversion from the kidneys to a site other than the bladder for which patient? a. A 12-year-old female with severe abdominal trauma b. A 24-year-old male with severe genital warts around the urethra c. A 50-year-old male with recent prostatectomy d. A 75-year-old female with end-stage renal disease
ANS: A Urinary diversion would be needed in a patient with abdominal trauma who might have injury to the urinary system. Genital warts are not needed for urinary diversion. Patients with a prostatectomy may require intermittent catheterization after the procedure. End-stage renal disease would not be affected by rerouting the flow of urine.
26. A nurse anticipates urodynamic testing for a patient with which symptom? a. Involuntary urine leakage b. Severe flank pain c. Presence of blood in urine d. Dysuria
ANS: A Urodynamic testing evaluates the muscle function of the bladder and is used to look for the cause of urinary incontinence. Severe flank pain indicates renal calculi; CT scan or IVP would be a more efficient diagnostic test. Blood indicates trauma to the urethral or bladder mucosa. Pain on elimination may warrant cultures to check for infection.
37. To reduce patient discomfort during closed catheter irrigation, the nurse should a. Use room temperature irrigation solution. b. Administer the solution as quickly as possible. c. Allow the solution to sit in the bladder for at least 1 hour. d. Raise the bag of irrigation solution at least 12 inches above the bladder.
ANS: A Using cold solutions, instilling solutions too quickly, and prolonging filling of the bladder can cause discomfort and cramping. To reduce this, ensure that the solution is at room temperature, lower the solution bag so it instills slowly, and drain the bladder fully after an ordered amount of time.
2. The nurse properly obtains a 24-hour urine specimen collection by (Select all that apply.) a. Asking the patient to void and to discard the first sample. b. Keeping the urine collection container on ice. c. Withholding all patient medications for the day. d. Asking the patient to notify the staff before and after every void.
ANS: A, B When obtaining a 24-hour urine specimen, it is important to keep the urine in cool condition. The patient should be asked to void and to discard the urine before the procedure begins. Medications do not need to be held unless indicated by the provider. If properly educated about the collection procedure, the patient can maintain autonomy and perform the procedure alone, taking care to maintain the integrity of the solution.
3. Which of the following are indications for irrigating a urinary catheter? (Select all that apply.) a. Sediment occluding within the tubing b. Blood clots in the bladder following surgery c. Rupture of the catheter balloon d. Bladder infection e. Presence of renal calculi
ANS: A, B, D Catheter irrigation is used to flush and remove blockage that may be impeding the catheter from properly draining the bladder. Irrigation is used to remove blood clots in the bladder following surgery. For patients with bladder infection, an antibiotic irrigation is often ordered. A ruptured catheter balloon will involve extensive follow-up and possible surgery to remove the particles. Renal calculi obstruct the ureters and therefore the flow of urine before it reaches the bladder
9. When caring for a patient with urinary retention, the nurse would anticipate an order for a. Limited fluid intake. b. A urinary catheter. c. Diuretic medication. d. A renal angiogram.
ANS: B A urinary catheter would relieve urinary retention. Reducing fluids would reduce the amount of urine produced but would not alleviate the urine retention. Diuretic medication would increase urine production and may worsen the discomfort caused by urine retention. A renal angiogram is an inappropriate diagnostic test for urinary retention.
29. Many individuals have difficulty voiding in a bedpan or urinal while lying in bed because they a. Are embarrassed that they will urinate on the bedding. b. Would feel more comfortable assuming a normal voiding position. c. Feel they are losing their independence by asking the nursing staff to help. d. Are worried about acquiring a urinary tract infection.
ANS: B Assuming a normal voiding position helps patients relax and be able to void; lying in bed is not the typical position in which people void. Men usually are most comfortable when standing; women are more comfortable when sitting and squatting. Embarrassment at using the bedpan and worrying about a urinary tract infection are not related to the lying-in-bed position. Fear of loss of independence is not related to use of the bedpan or urinal.
15. The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately? a. Liquid consistency of stool b. Presence of blood in the stool c. Noxious odor from the stool d. Continuous output from the stoma
ANS: B Blood in the stool may indicate a problem with the surgical procedure, and the physician should be notified. All other options are expected findings for an ileostomy.
9. A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate? a. "This is probably a false negative; we should rerun the test." b. "Do you take iron supplements?" c. "You should schedule a colonoscopy as soon as possible." d. "Sometimes severe stress can alter stool color."
ANS: B Certain medications and supplements, such as iron, can alter the color of stool. The fecal occult test takes three separate samples over a period of time and is a fairly reliable test. A colonoscopy is health prevention screening that should be done every 5 to 10 years; it is not the nurse's initial priority. Stress alters GI motility and stool consistency, not color.
6. The nurse knows that urinary tract infection (UTI) is the most common health care-associated infection because a. Catheterization procedures are performed more frequently than indicated. b. Escherichia coli pathogens are transmitted during surgical or catheterization procedures. c. Perineal care is often neglected by nursing staff. d. Bedpans and urinals are not stored properly and transmit infection.
ANS: B E. coli is the leading pathogen causing UTIs; this pathogen enters during procedures. Sterile technique is imperative to prevent the spread of infection. Frequent catheterizations can place a patient at high risk for UTI; however, infection is caused by bacteria, not by the procedure itself. Perineal care is important, and buildup of bacteria can lead to infection, but this is not the greatest cause. Bedpans and urinals may become bacteria ridden and should be cleaned frequently. Bedpans and urinals are not inserted into the urinary tract, so they are unlikely to be the primary cause of UTI.
34. When caring for a hospitalized patient with a urinary catheter, which nursing action best prevents the patient from acquiring an infection? a. Inserting the catheter using strict clean technique b. Performing hand hygiene before and after providing perineal care c. Fully inflating the catheter's balloon according to the manufacturer's recommendation d. Disconnecting and replacing the catheter drainage bag once per shift
ANS: B Hand hygiene helps prevent infection in patients with a urinary catheter. A catheter should be inserted in the hospital setting using sterile technique. Inflating the balloon fully prevents dislodgement and trauma, not infection. Disconnecting the drainage bag from the catheter creates a break in the system and an open portal of entry and increases risk of infection.
7. A patient with a hip fracture is having difficulty defecating into a bed pan while lying in bed. Which action by the nurse would assist the patient in having a successful bowel movement? a. Administering laxatives to the patient b. Raising the head of the bed c. Preparing to administer a barium enema d. Withholding narcotic pain medication
ANS: B Lying in bed is an unnatural position; raising the head of the bed assists the patient into a more normal position that allows proper contraction of muscles for elimination. Laxatives would not give the patient control over bowel movements. A barium enema is a diagnostic test, not an intervention to promote defecation. Pain relief measures should be given; however, preventative action should be taken to prevent constipation.
1. The nurse knows that most nutrients are absorbed in which portion of the digestive tract? a. Stomach b. Duodenum c. Ileum d. Cecum
ANS: B Most nutrients are absorbed in the duodenum with the exception of certain vitamins, iron, and salt (which are absorbed in the ileum). Food is broken down in the stomach. The cecum is the beginning of the large intestine.
20. A nurse is preparing a patient for a magnetic resonance imaging scan. Which nursing action is most important? a. Ensuring that the patient does not eat or drink 2 hours before the examination b. Removing all of the patient's metallic jewelry c. Administering a colon cleansing product 12 hours before the examination d. Obtaining an order for a pain medication before the test is performed
ANS: B No jewelry or metal products should be in the same room as an MRI machine because of the high-power magnet used in the machine. The patient needs to be NPO 4 to 6 hours before the examination. Colon cleansing products are not necessary for MRIs. Pain medication is not needed before the examination is performed.
13. Which nursing diagnosis related to alternations in urinary function in an older adult should be a nurse's first priority? a. Self-care deficit related to decreased mobility b. Risk of infection c. Anxiety related to urinary frequency d. Impaired self-esteem related to lack of independence
ANS: B Older adults often experience poor muscle tone, which leads to an inability of the bladder to fully empty. Residual urine greatly increases the risk of infection. Following Maslow's hierarchy of needs, physical health risks should be addressed before emotional/cognitive risks such as anxiety and self-esteem. Decreased mobility can lead to self-care deficit; the nurse's priority concern for this diagnosis would be infection, because the elderly person must rely on others for basic hygiene.
4. The nurse is caring for a patient who is confined to the bed. The nurse asks the patient if he needs to have a bowel movement 30 minutes after eating a meal because a. The digested food needs to make room for recently ingested food. b. Mastication triggers the digestive system to begin peristalsis. c. The smell of bowel elimination in the room would deter the patient from eating. d. More ancillary staff members are available after meal times.
ANS: B Peristalsis occurs only a few times a day; the strongest peristaltic waves are triggered by mastication of the meal. The intestine can hold a great deal of food. A patient's voiding schedule should not be based on the staff's convenience.
29. An older adult's perineal skin appears to be dry and thin with mild excoriation. When providing hygiene after a bowel movement, the nurse should a. Thoroughly scrub the skin with a wash cloth and hypoallergenic soap. b. Apply a skin protective lotion after perineal care. c. Tape an occlusive moisture barrier pad to the patient's skin. d. Massage the skin with deep kneading pressure.
ANS: B Proper skin care and perineal cleaning require that the nurse gently clean the skin and apply a moistening barrier cream. Tape and occlusive dressings can damage skin. Excessive pressure and force are inappropriate and may cause skin breakdown.
26. A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most appropriate? a. Changing the skin barrier portion of the ostomy pouch daily b. Selecting a pouch that is able to hold excess output to reduce the frequency of pouch emptying c. Thoroughly scrubbing the skin around the stoma to remove excess stool and adhesive d. Measuring the correct size for the barrier device while leaving a 1/8-inch space around the stoma
ANS: B Selecting a pouch that holds a large volume of output will decrease the frequency of emptying the pouch and may ease patient anxiety about pouch overflow. The barrier device should be changed every few days unless it is leaking or is no longer effective. Peristomal skin should be gently cleansed; vigorous rubbing can cause further irritation or skin breakdown. Approximately 1/16 of an inch is present between the barrier device and the stoma. Excess space allows fecal matter to have prolonged exposure to skin, resulting in skin breakdown.
13. Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs that prevents ambulation? a. Elevate the head of the bed 45 degrees 60 minutes after breakfast. b. Use a mobility device to place the patient on a bedside commode. c. Give the patient a pillow to brace against the abdomen while bearing down. d. Administer a soap suds enema every 2 hours.
ANS: B The best way to promote normal defecation is to assist the patient into a posture that is as normal as possible while defecating. Using a mobility device promotes nurse and patient safety. Elevating the head of the bed would be appropriate if the patient were to void with a bed pan. However, the patient's condition does not require use of a bed pan. Giving the patient a pillow may reduce discomfort, but this is not the best way to promote defecation. A soaps suds enema is indicated for a patient who needs assistance to stimulate peristalsis. It promotes non-natural defecation.
11. Which of the following is the primary function of the kidney? a. Metabolizing and excreting medications b. Maintaining fluid and electrolyte balance c. Storing and excreting urine d. Filtering blood cells and proteins
ANS: B The main purpose of the kidney is to maintain fluid and electrolyte balance by filtering waste products and regulating pressures. The kidneys filter the byproducts of medication metabolism. The bladder stores and excretes urine. The kidneys help to maintain red blood cell volume by producing erythropoietin.
27. A patient is having difficulty voiding in a bedpan but states that she feels her bladder is full. To stimulation micturition, which nursing intervention should the nurse try first? a. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient's progress b. Utilizing the power of suggestion by turning on the faucet and letting the water run c. Obtaining an order for a Foley catheter d. Administering diuretic medication
ANS: B To stimulate micturition, the nurse should attempt noninvasive procedures first. Running warm water or stroking the inner aspect of the upper thigh promotes sensory perception that leads to urination. A patient should not be left alone on a bedpan for 30 minutes because this could cause skin breakdown. Catheterization places the patient at increased risk of infection and should not be the first intervention attempted. Diuretics are useful if the patient is not producing urine, but they do not stimulate micturition.
33. The nurse would question an order to insert a urinary catheter on which patient? a. A 26-year-old patient with a recent spinal cord injury at T2 b. A 30-year-old patient requiring drug screening for employment c. A 40-year-old patient undergoing bladder repair surgery d. An 86-year-old patient requiring monitoring of urinary output for renal failure
ANS: B Urinary catheterization places the patient at increased risk for infection and should be performed only when necessary. Urine can be obtained via clean-catch technique for a drug screening or urinalysis. Spinal cord injury, surgery, and renal failure with critical intake and output monitoring are all appropriate reasons for catheterization.
12. While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, the nurse would expect to find a. An indwelling Foley catheter. b. Reddened irritated skin on the buttocks. c. Tiny blood clots in the patient's urine. d. Foul-smelling discharge indicative of a UTI.
ANS: B Urinary incontinence is uncontrolled urinary elimination; if the urine has prolonged contact with the skin, skin breakdown can occur. An indwelling Foley catheter is a solution for urine retention. Blood clots and foul-smelling discharge are often signs of infection.
17. The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. What is the next priority nursing action? a. Preparing the patient for a second tap water enema b. Donning gloves for digital removal of the stool c. Positioning the patient on the left side d. Inserting a rectal tube
ANS: B When enemas are not successful, digital removal of the stool may be necessary occasionally to break up pieces of the stool or to stimulate the anus to defecate. Tap water enemas should not be repeated because of risk of fluid imbalance. Positioning the patient on the left side does not promote defecation. A rectal tube is indicated for a patient with liquid stool incontinence but would not be applicable or effective for this patient.
5. The nurse understands that peritoneal dialysis and hemodialysis use which processes to clean the patient's blood? (Select all that apply.) a. Gravity b. Osmosis c. Diffusion d. Filtration
ANS: B, C Osmosis and diffusion are the two processes used to clean the patient's blood in both types of dialysis. In peritoneal dialysis, osmosis and dialysis occur across the semi-permeable peritoneal membrane. In hemodialysis, osmosis and dialysis occur through the filter membrane on the artificial kidney. In peritoneal dialysis, the dialysate flows by gravity out of the abdomen. Gravity has no effect on cleansing of the blood. Filtration is the process that occurs in the glomerulus as blood flows through the kidney.
4. Which of the following symptoms are most closely associated with uremic syndrome? (Select all that apply.) a. Fever b. Nausea and vomiting c. Headache d. Altered mental status e. Dysuria
ANS: B, C, D Uremic syndrome is associated with end-stage renal disease. Signs and symptoms include headache, altered mental status, coma, seizures, nausea, vomiting, and pericarditis.
1. Which nursing actions are acceptable when collecting a urine specimen? (Select all that apply.) a. Growing urine cultures for up to 12 hours b. Labeling all specimens with date, time, and initials c. Wearing gown, gloves, and mask for all specimen handling d. Allowing the patient adequate time and privacy to void e. Squeezing urine from diapers into a urine specimen cup f. Transporting specimens to the laboratory in a timely fashion g. Placing a plastic bag over the child's urethra to catch urine
ANS: B, D, F, G All specimens should be labeled appropriately and processed in a timely fashion. Allow patients time and privacy to void. Children may have difficulty voiding; attaching a plastic bag gives the child more time and freedom to void. Urine cultures can take up to 48 hours to develop. Gown, gloves, and mask are not necessary for specimen handling unless otherwise indicated. Urine should not be squeezed from diapers.
30. The nurse would anticipate inserting a Coudé catheter for which patient? a. An 8-year-old male undergoing anesthesia for a tonsillectomy b. A 24-year-old female who is going into labor c. A 56-year-old male admitted for bladder irrigation d. An 86-year-old female admitted for a urinary tract infection.
ANS: C A Coudé catheter has a curved tip that is used for patients with enlarged prostates. This would be indicated for a middle-aged male who needs bladder irrigation. Coudé catheters are not indicated for children or women.
28. The nurse administers a cathartic to a patient. The nurse determines that the cathartic has had a therapeutic effect when the patient a. Has a decreased level of anxiety. b. Experiences pain relief. c. Has a bowel movement. d. Passes flatulence.
ANS: C A cathartic is a laxative that stimulates a bowel movement. It would be effective if the patient experiences a bowel movement. The other options are not outcomes of administration of a cathartic
35. A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding would the nurse expect? a. Increased energy levels b. Distended abdomen c. Decreased serum bicarbonate d. Increased blood pressure
ANS: C ANS: C Chronic diarrhea can result in metabolic acidosis, which is diagnostic of low serum bicarbonate. Patients with chronic diarrhea are dehydrated with decreased blood pressure. Diarrhea also causes loss of electrolytes, nutrients, and fluid, which decreases energy levels. A distended abdomen would indicate constipation.
19. The nurse is preparing to perform a fecal occult blood test. The nurse plans to properly perform the examination by a. Applying liberal amounts of stool to the guaiac paper. b. Testing the quality control section before collecting the specimen section. c. Reporting any abnormal findings to the provider. d. Applying sterile disposable gloves.
ANS: C Abnormal findings such as a positive test should be reported to the provider. A fecal occult blood test is a clean procedure; sterile gloves are not needed. A thin specimen smear is all that is required. The quality control section should be developed after it is determined whether the sample is positive or negative.
15. The nurse suspects that a urinary tract infection has progressed to cystitis when the patient complains of which symptom? a. Dysuria b. Flank pain c. Frequency d. Fever and chills
ANS: C Cystitis is inflammation of the bladder; associated symptoms include hematuria and urgency/frequency. Dysuria is a common symptom of a lower urinary tract infection. Flank pain, fever, and chills are all signs of pyelonephritis.
25. A patient had an ileostomy surgically placed 2 days ago. Which diet would the nurse recommend to the patient to ease the transition of the new ostomy? a. Eggs over easy, whole wheat toast, and orange juice with pulp b. Chicken fried rice with stir fried vegetables and iced tea c. Turkey meatloaf with white rice and apple juice d. Fish sticks with macaroni and cheese and soda
ANS: C During the first week or so after ostomy placement, the patient should consume easy-to-digest low-fiber foods such as poultry, rice and noodles, and strained fruit juices. Fried foods can irritate digestion and can cause blockage. Foods high in fiber will be useful later in the recovery process but can cause blockage if the GI tract is not accustomed to digesting with an ileostomy.
32. A nurse notifies the provider immediately if a patient with an indwelling catheter a. Complains of discomfort upon insertion of the catheter. b. Places the drainage bag higher than the waist while ambulating. c. Has not collected any urine in the drainage bag for 2 hours. d. Is incontinent of stool and contaminates the external portion of the catheter.
ANS: C If the patient has not produced urine in 2 hours, the physician needs to be notified immediately because this could indicate renal failure. Discomfort upon catheter insertion is unpleasant but unavoidable. The nurse is responsible for maintaining the integrity of the catheter by ensuring that the drainage bag is below the patient's bladder. Stool left on the catheter can cause infection and should be removed as soon as it is noticed. The nurse should ensure that frequent perineal care is being provided.
20. The nurse would expect the urine of a patient with uncontrolled diabetes mellitus to be a. Cloudy. b. Discolored. c. Sweet smelling. d. Painful.
ANS: C Incomplete fat metabolism and buildup of ketones give urine a sweet or fruity odor. Cloudy urine may indicate infection or renal failure. Discolored urine may result from various medications. Painful urination indicates an alteration in urinary elimination.
18. The nurse should question which order? a. A normal saline enema to be repeated every 4 hours until stool is produced b. A hypertonic solution enema with a patient with fluid volume excess c. A Kayexalate enema for a patient with hypokalemia d. An oil retention enema for a patient using mineral oil laxatives
ANS: C Kayexalate binds to and helps excrete potassium, so it would be contraindicated in patients who are hypokalemic (have low potassium). Normal saline enemas can be repeated without risk of fluid or electrolyte imbalance. Hypertonic solutions are intended for patients who cannot handle large fluid volume and are contraindicated for dehydrated patients. Because mineral oil laxatives and an oil retention enema have the same intended effect of lubricating the colon and rectum, an oil retention enema is not needed.
24. Which statement by the patient about an upcoming computed tomography (CT) scan indicates a need for further teaching? a. "I'm allergic to shrimp, so I should monitor myself for an allergic reaction." b. "I will complete my bowel prep program the night before the scan." c. "I will be anesthetized so that I lie perfectly still during the procedure." d. "I will ask the technician to play music to ease my anxiety."
ANS: C Patients are not put under anesthesia for a CT scan; instead the nurse should educate patients about the need to lie perfectly still and about possible methods of overcoming feelings of claustrophobia. The other options are correct. Patients need to be assessed for an allergy to shellfish if receiving contrast for the CT. Bowel cleansing is often performed before CT. Listening to music will help the patient relax and remain still during the examination.
31. The nurse knows that which indwelling catheter procedure places the patient at greatest risk for acquiring a urinary tract infection? a. Emptying the drainage bag every 8 hours or when half full b. Kinking the catheter tubing to obtain a urine specimen c. Placing the drainage bag on the side rail of the patient's bed d. Failing to secure the catheter tubing to the patient's thigh
ANS: C Placing the drainage bag on the side rail of the bed could allow the bag to be raised above the level of the bladder and urine to flow back into the bladder. The urine in the drainage bag is a medium for bacteria; allowing it to reenter the bladder can cause infection. The drainage bag should be emptied and output recorded every 8 hours or when needed. Urine specimens are obtained by temporarily kinking the tubing; a prolonged kink could lead to bladder distention. Failure to secure the catheter to the patient's thigh places the patient at risk for tissue injury from catheter dislodgment.
8. A patient has fallen several times in the past week when attempting to get to the bathroom. The patient informs the nurse that he gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem? a. Clear the path to the bathroom of all obstacles before bed. b. Leave the bathroom light on to illuminate a pathway. c. Limit fluid and caffeine intake before bed. d. Practice Kegel exercises to strengthen bladder muscles.
ANS: C Reducing fluids, especially caffeine and alcohol, before bedtime can reduce nocturia. Clearing a path to the restroom or illuminating the path, or shortening the distance to the restroom, may reduce falls but will not correct the urination problem. Kegel exercises are useful if a patient is experiencing incontinence.
36. A nurse is providing education to a patient being treated for a urinary tract infection. Which of the following statements by the patient indicates an understanding? a. "Since I'm taking medication, I do not need to worry about proper hygiene." b. "I should drink 15 to 20 glasses of fluid a day to help flush the bacteria out." c. "My medication may discolor my urine; this should resolve once the medication is stopped." d. "I should not have sexual intercourse until the infection has resolved."
ANS: C Some anti-infective medications turn urine colors; this is normal and will dissipate as the medication leaves the system. Even if the patient is on medication, hygiene is important to prevent spread or reinfection. Fluid intake should be increased to help flush out bacteria; however, 15 to 20 glasses is too much. Sexual intercourse is allowed with a urinary tract infection, as long as good hygiene and safe practices are used.
5. The nurse knows that indwelling catheters are placed before a cesarean because a. The patient may void uncontrollably during the procedure. b. A full bladder can cause the mother's heart rate to drop. c. Spinal anesthetics can temporarily disable urethral sphincters. d. The patient will not interrupt the procedure by asking to go to the bathroom.
ANS: C Spinal anesthetics may cause urinary retention due to the inability to sense or carry out the need to void. The patient is more likely to retain urine, rather than experience uncontrollable voiding. With spinal anesthesia, the patient will not be able to ambulate during the procedure. A full bladder has no impact on the pulse rate of the mother.
16. Which assessment question should the nurse ask if stress incontinence is suspected? a. "Does your bladder feel distended?" b. "Do you empty your bladder completely when you void?" c. "Do you experience urine leakage when you cough or sneeze?" d. "Do your symptoms increase with consumption of alcohol or caffeine?"
ANS: C Stress incontinence can be related to intra-abdominal pressure causing urine leakage, as would happen during coughing or sneezing. Asking the patient about the fullness of his bladder would rule out retention and overflow. An inability to void completely can refer to urge incontinence. Physiological causes and medications can effect elimination, but this is not related to stress incontinence.
3. A patient is experiencing oliguria. Which action should the nurse perform first? a. Increase the patient's intravenous fluid rate. b. Encourage the patient to drink caffeinated beverages. c. Assess for bladder distention. d. Request an order for diuretics.
ANS: C The nurse first should gather all assessment data to determine the potential cause of oliguria. It could be that the patient does not have adequate intake, or it could be that the bladder sphincter is not functioning and the patient is retaining water. Increasing fluids is effective if the patient does not have adequate intake, or if dehydration occurs. Caffeine can work as a diuretic but is not helpful if an underlying pathology is present. An order for diuretics can be obtained if the patient was retaining water, but this should not be the first action.
32. A nurse is caring for an older adult patient with fecal incontinence due to cathartic use. The nurse is most concerned about which complication that has the greatest risk for severe injury? a. Rectal skin breakdown b. Contamination of existing wounds c. Falls from attempts to reach the bathroom d. Cross-contamination into the upper GI tract
ANS: C The nurse is most concerned about the worst injury the patient could receive, which involves falling while attempting to get to the bathroom. To reduce injury, the nurse should clear the path and reinforce use of the call light. The question is asking for the greatest risk of injury, not the most frequent occurrence or the event most likely to occur.
18. To obtain a clean-voided urine specimen for a female patient, the nurse should teach the patient to a. Cleanse the urethral meatus from the area of most contamination to least. b. Initiate the first part of the urine stream directly into the collection cup. c. Hold the labia apart while voiding into the specimen cup. d. Drink fluids 5 minutes before collecting the urine specimen.
ANS: C The patient should hold the labia apart to reduce bacterial levels in the specimen. The urethral meatus should be cleansed from the area of least contamination to greatest contamination (or front-to-back). The initial steam flushes out microorganisms in the urethra and prevents bacterial transmission in the specimen. Drink fluids 30 to 60 minutes before giving a specimen.
11. Fecal impactions occur in which portion of the colon? a. Ascending b. Descending c. Transverse d. Rectum
ANS: D A fecal impaction is a collection of hardened feces wedged in the rectum that cannot be expelled. It results from unrelieved constipation. Feces at this point in the colon contain the least amount of moisture. Feces found in the ascending, transverse, and descending colon still consist mostly of liquid and do not form a hardened mass.
36. The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately? a. Stoma is protruding from the abdomen. b. Stoma is moist. c. Stool is discharging from the stoma. d. Stoma is purple.
ANS: D A purple stoma may indicate strangulation or poor circulation to the stoma and may require surgical intervention. A stoma should be reddish-pink and moist in appearance. It can be flush with the skin, or it can protrude. Stool is an expected outcome of stoma placement.
12. The nurse provides knows that a bowel elimination schedule would be most beneficial in the plan of care for which patient? a. A 40-year-old patient with an ileostomy b. A 25-year-old patient with Crohn's disease c. A 30-year-old patient with C. difficile d. A 70-year-old patient with stool incontinence
ANS: D ANS: D A bowel elimination program is helpful for a patient with incontinence. It helps the person who still has neuromuscular control defecate normally. An ileostomy, Crohn's disease, and C. difficile all relate to uncontrollable bowel movements, for which no method can be used to set up a schedule of elimination.
7. An 86-year-old patient tells the nurse that she is experiencing uncontrollable leakage of urine. Which nursing diagnosis should the nurse include in the patient's plan of care? a. Urinary retention b. Hesitancy c. Urgency d. Urinary incontinence
ANS: D Age-related changes such as loss of pelvic muscle tone can cause involuntary loss of urine known as Urinary incontinence. Urinary retention is the inability to empty the bladder. Hesitancy occurs as difficulty initiating urination. Urgency is the feeling of the need to void immediately.
25. The nurse anticipates preparing a patient who is allergic to shellfish for an arteriogram by a. Obtaining baseline vital signs after the start of the procedure. b. Monitoring the extremity for neurocirculatory function. c. Keeping the patient on bed rest for the prescribed time. d. Administering an antihistamine medication to the patient.
ANS: D Before the procedure is begun, the nurse should assess the patient for food and other allergies and should administer an antihistamine, because a contrast iodine-based dye is used for the procedure. Baseline vitals should be obtained before the start of the procedure and frequently thereafter. The procedure site is monitored and the patient kept on bed rest after the procedure is complete
35. An 86-year-old patient asks the nurse what lifestyle changes will reduce the chance of a urinary tract infection. Which response is accurate? a. Urinary tract infections are unavoidable in the elderly because of a weakened immune system. b. Decreasing fluid intake will decrease the amount of urine with bacteria produced. c. Making sure to cleanse the perineal area from back to front after voiding will reduce the chance of infection. d. Increasing consumption of acidic foods such as cranberry juice will reduce the chance of infection.
ANS: D Cranberry juice and other acidic foods decrease adherence of bacteria to the bladder wall. Urinary tract infections are avoidable in the elderly population with proper knowledge and hygiene. Perineal skin should be cleansed from front to back to avoid spreading fecal matter to the urethra. Increasing fluids will help to flush bacteria, thus preventing them from residing in the bladder for prolonged periods of time.
38. A guaiac test has been ordered. The nurse knows that this is a test for a. Bright red blood. b. Dark black blood. c. Blood that contains mucus. d. Blood that cannot be seen.
ANS: D Fecal occult blood tests are used to test for blood that may be present in stool that cannot be seen by the naked eye. This is usually indicative of a GI bleed. All other options are incorrect.
22. The nurse would anticipate an order for which diagnostic test for a patient who has severe flank pain and calcium phosphate crystals revealed on urinalysis? a. Renal ultrasound b. Bladder scan c. KUB x-ray d. Intravenous pyelogram
ANS: D Flank pain and calcium phosphate crystals are associated with renal calculi. An intravenous pyelogram allows the provider to observe pathological problems such as obstruction of the ureter. A renal ultrasound is performed to identify gross structures. A bladder scan measures the amount of urine in the bladder. A KUB x-ray shows size, shape, symmetry, and location of the kidneys.
23. A nurse is caring for a patient who just underwent intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse's first priority in caring for this patient? a. Turn the patient on the right side to alleviate pressure on the left kidney. b. Encourage the patient to increase fluid intake to flush the obstruction. c. Administer narcotic medications to alleviate pain. d. Monitor the patient for fever, rash, and difficulty breathing.
ANS: D Intravenous pyelography is performed by administering iodine-based dye to view functionality of the urinary system. Many individuals are allergic to shellfish; therefore, the first nursing priority is to assess the patient for an allergic reaction that could be life threatening. The nurse should then encourage the patient to drink fluids to flush dye resulting from the procedure. Narcotics can be administered but are not the first priority. Turning the patient on the side will not affect patient safety.
33. The nurse is caring for a patient with Clostridium difficile. Which of the following nursing actions will have the greatest impact in preventing the spread of bacteria? a. Monthly in-services about contact precautions b. Placing all contaminated items in biohazard bags c. Mandatory cultures on all patients d. Proper hand hygiene techniques
ANS: D Proper hand hygiene is the best way to prevent the spread of bacteria. Monthly in-services place emphasis on education, not on action. Biohazard bags are appropriate but cannot be used on every item that C. difficile comes in contact with, such as a human. Mandatory cultures are expensive and unnecessary and would not prevent the spread of bacteria.
37. A patient has constipation and hypernatremia. The nurse prepares to administer which type of enema? a. Oil retention b. Carminative c. Saline d. Tap water
ANS: D Tap water enema would draw fluid into the system and would help flush out excess sodium. Oil retention would not address sodium problems. Carminative enemas are used to provide relief from distention caused by gas. A saline enema would worsen hypernatremia.
17. When establishing a diagnosis of altered urinary elimination, the nurse should first a. Establish normal voiding patterns for the patient. b. Encourage the patient to flush kidneys by drinking excessive fluids. c. Monitor patients' voiding attempts by assisting them with every attempt. d. Discuss causes and solutions to problems related to micturition.
ANS: D The nurse should assess first to determine cause, then should discuss and create goals with the patient, so nurse and patient can work in tandem to normalize voiding. The nurse should incorporate the patient's input into creating a plan of care for the patient. Drinking excessive fluid will not help and may worsen alterations in urinary elimination. The nurse does not need to monitor every void attempt by the patient; instead the nurse should provide patient education. The nurse asks the patient about normal voiding patterns, but establishing voiding patterns is a later intervention.
EXCRETION - LUNGS
gaseous and volatile compounds such as nitrous oxide and alcohol Deep breathing and coughing help patients eliminate anesthetic gases more rapidly after surgery
SHAPE OF STOOL - NORMAL
generally round resembles the diameter of the rectum
SINGLE (ONE-TIME) ORDER
given one time only for a specific reason
PPE - ORDER FOR TAKING OFF
gloves goggles/face shield gown mask/respirator (MEMORY TIP: these are in alphabetical order)
PPE - ORDER FOR PUTTING ON
gown mask/respirator goggles/face shield gloves (MEMORY TIP: from the bottom up, with hands above the head)
dehydration specific gravity of urine
greater than 1.035
Induration
hardening of a tissue, particularly the skin, because of edema or inflammation
Afebrile
having no fever
BODY ALIGNMENT - SITTING
head is erect neck & vertebral column are straight body weight distributed evenly on the buttocks & thighs thighs are parallel and in horizontal plane both feet supported on the floor
BODY ALIGNMENT - STANDING
head is erect and midline shoulders & hips are straight and parallel vertebral column is straight arms at sides abdomen tucked in
SUPPORTED FOWLER'S POSITION
head of the bed is elevated 45 to 60 degrees, and the patient's knees are slightly elevated without pressure to restrict circulation in the lower legs.
Primary Intention
healing occurs by epithelialization; heals quickly with minimal scar formation
Behavioral temperature control
healthy individuals should be able to maintain and healthy and comfortable body temp through 1) recognition 2) degree of temp extremes 3) ability to add remove clothes 4) emotions and thought control
Body Temperature
heat produced-heat lost
Metabolism regulates
heat production
Malignant hyperthermia
hereditary condition of uncontrolled heat production, occurring when susceptible persons receive certain anesthetic drugs
Hypertension
high blood pressure; diastolic reading greater than 90 mm Hg and systolic reading greater than 140 mm Hg
what is the result of dark amber urine?
high concentrations of bilirubin in patients with liver disease
BULK FORMING
high fiber content absorbs water increases solid intestinal bulk stretching of the intestinal wall stimulates peristalsis passage of stool within 12-24 hours must be taken with water Metamucil, Citrucel, Fibercon
NURSING INTERVENTIONS - METABOLIC SYSTEM
high protein/high calorie diet vitamin B supplement - energy metabolism vitamin C supplement - skin integrity/healing
ILEOSTOMY - CONSIDERATIONS
high risk for fluid and salt loss through the stoma need to replace fluids to prevent dehydration encourage patients to drink 8 oz of water when they empty their pouch
AUTOMATED MEDICATION DISPENSING SYSTEM (AMDS)
high tech computerized medication system security codes and bio-identification required You select the patient's name and his or her drug profile before the AMDS dispenses a medication in these systems you are allowed to select the desired medication, dosage, and route from a list displayed on the computer screen The system causes the drawer containing medication to open, records it, and charges it to the patient
PEAK CONCENTRATION
highest serum level of medication in the blood stream
LIPID SOLUBILITY
highly lipid-soluble medications cross cell membranes easily and are absorbed quickly
General anesthesia can cause temporary cessation of peristalsis. This can lead to a condition called?
ileus
intravenous pyelogram IVP
imaging of the urinary tract that views the collecting ducts and renal pelvis and outlines the ureters, bladder, and urethera
Pressure ulcer
impaired skin integrity related to unrelieved, prolonged pressure
PRESSURE ULCER
impairment of the skin as a result of prolonged ischemia (decreased blood supply) in tissues characterized initially by inflammation and usually forms over a bony prominence Ischemia develops when the pressure on the skin is greater than the pressure inside the small peripheral blood vessels supplying blood to the skin.
CENTER OF GRAVITY
in the midline the line of gravity is from the middle of the forehead to a midpoint between the feet Laterally the line of gravity runs vertically from the middle of the skull to the posterior third of the foot
FACTORS THAT DECREASE PERISTALSIS
inactivity and poor diet prolong the effects of medication
Sphygmomanometer
includes a pressure manometer, an occlusive cloth or vinyl cuff that encloses an inflatable rubber bladder, and a pressure bulb with a release valve that inflates the bladder
Hygiene
includes cleaning and grooming activities that maintain personal body cleanliness and apprearance
transient incontinence
incontinence caused by medical conditions that in many cases are treatable and reversible
multifactorial incontinence
incontinence that has multiple interacting risk factors, some within the urinary tract and others nor, such as multiple chronic illnesses, medications, age-related factors, and environmental factors.
diuretics
increase urinary output by preventing resorption of water and certain electrolytes
BLOOD RETURN ON NEEDLE ASPIRATION
indicates improper placement withdraw needle and prepare the injection again
Age and Temperature
infants have more regulation systems and are subject to wide fluctuation in temperature, young adult is very flexible, older adults become more and more sensitive to extremes again as their control mechanisms deteriorate
urinary problems can result from what?
infection irritable or overactive bladder obstruction of urine flow impaired bladder contractility issues that impair innervation to the bladder
gingivitis
inflammation of the gums
HYPOSTATIC PNEUMONIA
inflammation of the lung from stasis or pooling of secretions
ALLERGY CONSIDERATIONS
inform members of health care team if patient has history of allergies to medications and foods medications may have ingredients also found in food sources i.e. Diprivan (propofol) has egg lecithin and soybean oil as inactive ingredients patients with egg/soy allergy should not receive propofol
INTRAOSSEOUS
infusion of medication directly into the bone marrow used most commonly in infants and toddlers who have poor access to their intravascular space when an emergency arises and IV access is impossible
PARENTERAL ROUTES
injecting medication into the body tissues. Four major sites: - intradermal (ID) - subcutaneous (SubQ) - intramuscular (IM) - intravenous (IV)
INTRAMUSCULAR (IM)
injection into a muscle
INTRAVENOUS (IV)
injection into a vein
SUBCUTANEOUS
injection into tissues just below the dermis of the skin
INTRAARTICULAR
injection of medication into a joint performed by physician
hemostasis
injured blood vessels constrict and platelets gather to stop bleeding
minerals
inorganic elements essential to the body as catalysts in biochemical reactions
SUBCUTANEOUS INJECTION
inserted at 45 degrees and at 90 degrees slower absorption rate than IM injections upper arms abdomen anterior aspects of the thighs Heparin (abdomen)
INTRAMUSCULAR (IM) INJECTION
inserted at 90 degrees faster route than SubQ route due to vascularity of muscles ventrogluteal vastus lateralis deltoid immunizations including: - hepatitis B - tetanus - diphtheria - pertussis
Scientific Knowledge Base 1. Briefly summarize the roles of the following in relation to the regulation of medications. a. Federal government: b. State government: c. Health care institutions: d. Nurse Practice Act:
a. FDA ensures all medications undergo vigorous testing before sold. b. conform to federal legislations but also has additional controls such as alcohol & tobacco c. individual policies must meet federal and state regulations. d. denies the cope of a nurse's professional functions and responsibilities.
endoscopy-cystoscopy
introduction of a cystoscope through the urethra into the bladder to provide direct visualization, specimen collection, and/or treatment of the bladder and urethra.
stress urinary incontinence
involuntary leakage of small volumes of urine associated with increased intrabdominal pressure related to either urethral hypermobility or an incompetent urinary sphincter
What angles should be used when administering a subcutaneous injection, and with which needle should they be used?
a.) 25-gauge, 5/8-inch needle inserted at a 45-degree angle b.) 1/2 inch needle inserted at a 90-degree angle
Identify seven of the potential nursing diagnoses used during medication administration.
a.) Anxiety b.) Ineffective Health Maintenance c.) Readiness for Enhanced Immunization Status d.) Deficient knowledge e.) Noncompliance f.) Effective Therapeutic Regimen Management g.) Impaired Swallowing
List the methods a nurse can use to administer medications intravenously.
a.) As mixtures within large volumes of IV fluids b.) Injection of a bolus or small volume of mediation c.) Piggyback infusion
List four principles for administering eye instillation.
a.) Avoid instilling any eye medication directly onto the cornea b.) Avoid touching the eyelids or other eye structures with eye droppers or ointment tubes c.) Use medication only for the patient's affected eye d.) Never allow a patient to use another patient's eye medications
Briefly summarize "The Patient Care Partnership" related to medication administration
a.) Be informed of the medication's name, purpose, action, and potential undesired effects b.) Refuse a medication regardless of the consequences c.) Have qualified nurses or physicians assess a medication history d.) Be properly advised of the experimental nature of medication therapy and give written consent e.) Receive labeled medications safely without discomfort f.) Receive appropriate supportive therapy g.) Not receive unnecessary medications h.) Be informed if medications are a part of a research study
List the five advantages of using intermittent venous access devices.
a.) Cost saving b.) Convenience c.) Increased mobility d.) Safety e.) Patient comfort
[[Identify the precautions to take when administrating any oral preparation to prevent aspiration.]]
a.) Determine the patient's ability to swallow and cough and check for gag reflex b.) Prepare oral medications in the form that is easiest to swallow c.) Allow the patient to self-administer medications if possible d.) If the patient has unilateral weakness, place the medication in the stronger side of the mouth e.) Administer pills one at a time, ensuring that each medication is properly swallowed before the next one is given f.) Thicken regular liquids or offer fruit nectars if the patient can't tolerate thin liquids g.) Avoid straws because the decrease the control the patient has over volume intake, which increases the risk of aspiration h.) Have the patient hold the cup and drink it if possible i.) Time medications to coincide with meal times or when the patient is well rested and awake if possible j.) Administer medications using another route if risk of aspiration is severe
Identify five methods for applying medications to mucous membranes.
a.) Directly applying a liquid or ointment b.) Inserting a medication into a body cavity c.) Instilling fluid into a body cavity d.) Irrigating a body cavity e.) Spraying
List the three principles to follow when mixing medications from two vials
a.) Do not contaminate one medication with another b.) Ensure that the final dose is accurate c.) Maintain aseptic technique
[[Identify the aseptic techniques to use to prevent an infection during an injection]]
a.) Draw medication from ampule quickly; do not allow for it to stand open b.) Avoid letting the needle touch contaminated surface c.) Avoid touching the length of the plunger or inner part of the barrel d.) Prepare the skin, use friction and a circular motion while cleaning with an antiseptic swab, and start from the center and move outward
[[Identify the common medication errors that can cause patient harm]]
a.) Inaccurate prescribing b.) Administration of the wrong medicine c.) Giving the medication using the wrong route or time interval d.) Administering extra doses e.) Failing to administer a medication *Patient safety is top priority when an error occurs* *RN is responsible for medication errors*
[[*Identify other routes of medication administration*]]
a.) Inhalation route b.) Intraocular c.) The ear
[[*Identify the four major sites for parenteral injections*]]
a.) Intradermal b.) Subcutaneous c.) Intramuscular d.) Intravenous
The disadvantages of IV bolus medications are:
a.) It is the most dangerous method because there is no time to correct errors b.) A bolus may cause direct irritation to the lining of blood vessels
Identify the principles to follow when mixing two types of insulin in the same syringe
a.) Need to maintain their individual routine when preparing and administering their insulin b.) Do not mix insulin with other medications or diluents c.) Never mix insulin glargine or insulin detemir with other types of insulin d.) Inject rapid-acting insulin mixed with NPH within 15 minutes before a meal e.) Verify insulin dosages with another nurse while preparing them
[[*Identify the three types of oral routes.*]]
a.) Oral b.) Buccal c.) Sublingual
Identify two goals for safe and effective medication administration.
a.) Patient responds to therapy b.) Patient has the ability to assume responsibility for self-care
Identify the components of medication orders
a.) Patient's full name b.) Date and time that the order was written c.) Medication name d.) Dose e.) Route of administration f.) Time and frequency of administration g.) Signature of provider
[[*List the six rights of medication administration*]]
a.) Right medication b.) Right dose c.) Right patient d.) Right route e.) Right time f.) Right documentation
Vaginal medications are available as:
a.) Suppositories b.) Foam c.) Jellies d.) Creams
The recording of medications includes:
a.) The name of the medication b.) Dose c.) Route d.) Exact time of administration e.) Site
Identify the best sites for subcutaneous injections
a.) The outer posterior aspect of the upper arm b.) The abdomen (below the costal margins to the iliac crests) c.) The anterior aspects of the thighs
List the advantages of using volume-controlled infusions.
a.) They reduce risk of rapid infusion by IV push b.) They allow for administration of medications that are stable for a limited time in solution c.) They allow for control of IV fluid intake
List the medication distribution systems
a.) Unit dose b.) Automated medication dispensing systems (AMDS)
List the techniques used to minimize patient discomfort that is associated with injections.
a.) Use a sharp beveled needle in the smallest suitable length and gauge b.) Position the patient as comfortably as possible to reduce muscle tension c.) Select the proper injection site d.) Apply a vapocoolant spray or topical anesthetic to the site if possible e.) Divert the patient's attention from the injection f.) Insert the needle quickly and smoothly g.) Hold the syringe while the needle remains in tissues h.) Inject the medication slowly and steadily
Identify the process for medication reconciliation
a.) Verify b.) Clarify c.) Reconcile d.) Transmit
Failure to instill ear drops at room temperature causes:
a.) Vertigo b.) Dizziness c.) Nausea
Dysrhythmia
abnormal heart rhythm
fistula
abnormal passage between two organs or between an organ and the outside of the body - caused by diseases, cancer, radiation, and trauma that prevent tissue layers from closing properly allowing a fistula tract to form. Fistulas increase risk of infection and fluid and electrolyte imbalances from fluid loss. Chronic drainage of fluids through a fistula all predispose a person to skin breakdown.
GRAY STOOL
absent bile pigment associated with liver - cirrhosis - hepatitis - gall stones
Liver
absorb nutrients carried here, where major metabolic processes occurs. regulates energy through controlling glucose metabolism
JEJUNEM
absorbs carbohydrates and proteins absorbs the most nutrients and electrolytes in tandem with the duodenum
ILEUM
absorbs water, fats, and bile salts
LARGE INTESTINE - THREE FUNCTIONS
absorption secretion elimination
FLATULENCE
accumulation of gas in the intestines causing walls to stretch can be expelled through the mouth (belching) or through the anus (flatulence)
THROMBUS
accumulation of platelets, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery sometimes occludes the lumen of the vessel
ISOMETRIC EXERCISES
activities that involve muscle tension without muscle shortening can help improve activity tolerance
INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)
activities to be independent in society - shopping - preparing meals - house cleaning - banking - taking medicine
HIGH FIBER DIET
adds bulk to the stool eliminates excess fluids promotes more frequent/regular bowel movements
NON-TIME-CRITICAL MEDICATIONS
administer within 1-2 hours before or after scheduled time
TIME-CRITICAL MEDICATIONS
administer within 30 minutes before or after the scheduled time
STANDING OR ROUTINE ORDER
administered until the dosage is changed or another medication is prescribed
DISTRIBUTION
after a medication is absorbed, it is distributed within the body to tissues and organs and ultimately to its specific site of action rate and extent of distribution depend on the physical and chemical properties of the medication and the physiology of the person taking it
FACTORS THAT INFLUENCE BOWEL ELIMINATION
age diet fluid intake physical activity psychological factors personal habits position during defecation pain pregnancy surgery/anesthesia medications diagnostic tests
IMMUNE SENESCENCE
age-related functional deterioration in immune system function increases suseptibility of the body to infection slows overall immune response
STIMULANT CATHARTICS
agents that cause local irritation to the intestinal mucosa increase intestinal motility inhibit resorption of water in the large intestine cause formation of soft-to-liquid stool in 6-8 hours Dulcolax, Senokot
CATHARTICS/LAXATIVES
agents that promote short-term action of emptying the bowel carthartics have stronger, more rapid effect on the intestines therapeutic effect to the patient is a bowel movement
PROTECT PATIENT FROM ASPIRATION
allow self-administration if possible know signs of dysphagia assess patient's ability to swallow/cough prepare medications in the form that is easiest to swallow position patient upright, seated position administer pills ONE at a time avoid straws
pain
also a vital sign
BOWEL TRAINING
also called "habit training" set up a daily routine attempt to defecate at the same time every day use measures to promote that promote defecation
CORRECTION INSULIN
also known as "sliding scale" insulin provides dose of insulin based on patient's blood glucose level indicates that small doses of rapid or short-acting insulin are needed to correct patient's elevated blood sugar
exudate
amount, color, consistency, and odor of wound drainage
PEPSIN
an enzyme that digests protein
Shivering
an involuntary body response to temperature differences in the body
CAUTI catheter-associated UTI
an ongoing problem for hospital because they are associated with increased hospitalizations, increased morbidity and mortality, longer hospital stays, and increased hospital costs
patients with kidney impairment can have what kind of problems?
anemia hypertension electrolyte imbalances
Neural and Vascular control of body temperature
anterior hypothalamus=heat loss posterior hypothalamus=heat gain The hypothalamus works just like a thermostat adjusting accordingly by using either vasoconstriction/dilation, muscle contraction, sweating, etc.
NEOMYCIN ENEMA
antibiotic enema solution that is used to reduce bacteria in the colon before bowel surgery
NURSING INTERVENTIONS - PSYCHOSOCIAL SYSTEM
anticipate change in patient status provide routine/informal socialization stimuli to maintain patient's orientation
CHLORHEXIDINE (CHG)
antiseptic/antibacterial agent Brands include Betasept, Dyna-Hex, Hibiclens required if there is a risk for methicillin-resistant Staphylococus aureus (MRSA) or other resistant bacteria
NURSING DIAGNOSIS FOR MEDICATION ADMINISTRATION
anxiety ineffective health maintenance readiness for enhanced immunization status deficient knowledge noncompliance impaired swallowing effective therapeutic regimen management
What should the nurse wear before performing a Complete Bed Bath?
apply clean gloves, especially use for areas of non intact skin and discharges. Check patient for latex allergy.
ketones
are substances that are made when the body breaks down fat for energy.
how long do you have to get urine to the lab after the sample is taken
around 2 hours
ESOPHAGUS
as food enters upper esophagus, it passes through the upper esophageal sphincter
STERILE PROCEDURE - STEPS
assemble all equipment don cap, mask, eyewear open sterile packages open sterile items on flat surface open a sterile item while holding it prepare a sterile field pour sterile solutions surgical scrub apply sterile gloves don sterile gown
bacteriuria
bacteria in the urine, does not always mean that there is a UTI
BARIUM ENEMA
barium is instilled through the anal opening via enema x-ray film, with the barium contrast medium, allows for examination of structures and motility of the LOWER GI tract
BARIUM SWALLOW
barium is swallowed by the patient x-ray film, with the barium contrast medium, allows for examination of structures and motility of the UPPER GI tract
FACTORS THAT INFLUENCE - STRESS
basal metabolic rate increases Adrenocorticotropic hormone (ACTH) increases serum glucose levels decrease in anti-inflammatory responses increased cortisol
Daily values
based on percentages of a diet consisting of 2000 kcal/day for adults and children 4 years or older.
PEDIATRIC DOSES
based on weight ordered in milligrams per kilogram (mg/kg)
What does the nurse place over the patient before starting a bed bath?
bath blanket
HAND HYGIENE
before, during, after and between contact with patients after contact with blood, body fluids, mucous membranes, nonintact skin, secretions, excretions, or wound dressings after contact with inanimate surfaces or articles in a patient room immediately after gloves are removed
GAIT BELT
belt device used to support patients during ambulation when used properly, it supports patient's center of gravity
chronic retention
bladder does not empty completely during voiding, and urine is retained in the bladder
Puncture
bleed in relation to the depth and size of the wound
Hemorrhage
bleeding from the wound site
Laceration
bleeds more profusely, depending on the depth and location of the wound
gross hematuria
blood is easily seen in the urine
microscopic hematuria
blood not visualized but measured on urinalysis
BLOOD FLOW TO THE SITE OF ADMINISTRATION
blood supply to the site of administration will determine how quickly the body can absorb a drug Medications are absorbed as blood comes in contact with the site of administration The richer the blood supply to the site of administration, the faster a medication is absorbed
TRADE NAME
brand name, or proprietary name is the name under which a manufacturer markets a medication. i.e. Tylenol™
RAPID-ACTING INSULIN
brands: Humalog, Novolog, Apidra onset: 10-30 minutes peak: 30 minutes - 3 hours duration: 3-5 hours usually taken before a meal to cover blood glucose elevation from eating used with longer acting insulin
INTERMEDIATE-ACTING INSULIN
brands: NPH (N) onset: 1.5 - 4 hours peak: 4 - 12 hours duration: up to 24 hours Covers the blood glucose elevations when rapid-acting insulins stop working often combined with rapid- or short-acting insulin usually taken twice a day
SHORT-ACTING INSULIN
brands: Regular (R) onset: 30 minutes - 1 hour peak: 2 - 5 hours duration: up to 12 hours only insulin that can be given intravenously usually taken about 30 minutes before a meal to cover the blood glucose elevation from eating used with longer-acting insulin.
Sanguineous
bright red, indicates active bleeding
After making occupied bed what should the nurse do?
bring down bed into lowest position and put call bell in reach of patient.
how do you asses for tenderness in the kidneys?
by gently percussing the costovertebral angle
VIRULENCE
Ability to survive in the host or outside the body
INFLAMMATORY EXUDATE
Accumulation of fluid, dead tissue cells, and WBCs forms an exudate at the site of inflammation. Usually carried away through lymphatic drainage Platelets and plasma proteins (fibrinogen) form mesh-like matrix at the site of inflammation to prevent spread
Critical Thinking Standards
Accuracy, significance, completeness when assessing patient safety, apply ANA standards, apply agency practice standards, review and apply current TJC goals.
High Fiber
Addition of fresh uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruits
Soft/low residue
Addition of low fiber, easily digested foods such as pastas, casseroles, moist tender meats
EPIDURAL
Administered in epidural space via a catheter placed by a nurse anesthetist or an anesthesiologist Nurses who have advanced education in the epidural route can administer medications by continuous infusion or a bolus dose
Epidural Injections
Administered in the epidural space via a catheter, usually used for postoperative analgesia.
Adolescent Developmental Interventions
Adults must serve as roll models, enroll in driver education class, inform about alcohol and drugs, school and community activities, safe use of internet.
Adult Risks
Alcohol, vehicle accidents, smoking, stress.
[[Anaphylactic Reactions]]
Allergic reactions that are life threatening and characterized by sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and shortness of breath.
How should you cleanse the penis?
Always cleanse from the tip of the penis down the shaft in a circular motion
CHAIN OF INFECTION
An infectious agent/pathogen Reservoir or source Portal of exit Mode of transmission Portal of entry Susceptible host
COMMUNICABLE DISEASE
An infectious disease that is transmitted directly from one person to another
when the patient requires it
An order given PRN will be administered when?
immediately in an emergency
An order given STAT will be administered when?
until the dosage is changed or another medication is prescribed
An order given standing or routine will be administered when?
When a medication is needed right now, but not STAT
An order given to be prescribed "Now" will be used when?
Glycogenesis
Anabolism of glucose into glycogen for storage
glycogenesis
Anabolism of glucose into glycogen for storage
A nurse is educating parents to look for clues in teenagers for possiblesubstanceabuse.Whichenvironmentalandpsychosocial clues should the nurse include? (Select all that apply.) 1. Blood spots on clothing 2. Long-sleeved shirts in warm weather 3. Changes in relationships 4. Wearing dark glasses indoors 5. Increased computer use
Answer 1, 2, 3, 4. Environmental clues include the presence of drug-oriented magazines, beer and liquor bottles, drug paraphernalia and blood spots on clothing, and the continual wearing of long-sleeved shirts in hot weather and dark glasses indoors. Psychosocial clues include failing grades, change in dress, increased absenteeism from school, isolation, increased aggressiveness, and changes in interpersonal relationships.
You are conducting an education class at a local senior center on safe-driving tips for seniors. Which of the following should you include? (Select all that apply.) 1. Drive shorter distances 2. Drive only during daylight hours 3. Use the side and rearview mirrors carefully 4. Keep a window rolled down while driving if has trouble hearing 5. Look behind toward the blind spot 6. Stop driving at age 75
Answer: 1, 2, 3, 4, 5. Educate patients regarding safe driving tips (e.g., driving shorter distances or only in daylight, using side and rearview mirrors carefully, and looking behind them toward their "blind spot" before changing lanes). If hearing is a problem, encourage the patient to keep a window rolled down while driving or reduce the volume of the radio or CD player. Counseling is often necessary to help older patients make the decision of when to stop driving.
A couple who is caring for their aging parents are concerned about factors that put them at risk for falls. Which factors are most likely to contribute to an increase in falls in the elderly? (Select all that apply.) 1. Inadequate lighting 2. Throw rugs 3. Multiple medications 4. Doorway thresholds 5. Cords covered by carpets 6. Staircases with handrails
Answer: 1, 2, 3, 4, 5. Falls most often occur while transferring from beds, chairs, and toilets; getting into or out of bathtubs; tripping over items such as cords covered by rugs or carpets, carpet edges, or doorway thresholds; slipping on wet surfaces; and descending stairs. Multiple medications also contribute to fall risk.
A nurse is evaluating a patient who is in soft wrist restraints. Which of the following activities does the nurse perform? (Select all that apply.) 1. Check the patient's peripheral pulse in the restrained extremity 2. Evaluate the patient's need for toileting 3. Offer the patient fluids if appropriate 4. Release both limbs at the same time to perform range of motion (ROM) 5. Inspect the skin under each restraint
Answer: 1, 2, 3, 5. The nurse should evaluate patient for signs of injury every 15 minutes (e.g., circulation, vital signs, ROM, physical and psychological status, and readiness for discontinuation. The nurse should evaluate patient's need for toileting, nutrition and fluids, hygiene, and elimination and release restraint at least every 2 hours but should do it one limb at a time
What is your role as a nurse during a fire? (Select all that apply.) 1. Help to evacuate patients 2. Shut off medical gases 3. Useafireextinguisher 4. Single carry patients out 5. Direct ambulatory patients
Answer: 1, 2, 3, 5. Direct all ambulatory patients to walk by themselves to a safe area. If you have to carry a patient, do so correctly (e.g., two-man carry). After a fire is reported and patients are out of danger, nurses and other personnel take measures to contain or extinguish it such as closing doors and windows, placing wet towels along the base of doors, turning off sources of oxygen and electrical equipment, and using a fire extinguisher.
A nurse knows that the people most at risk for accidental hypo- thermia are: (Select all that apply.) 1. People who are homeless. 2. People with respiratory conditions. 3. People with cardiovascular conditions. 4. The very old. 5. People with kidney disorders.
Answer: 1, 3, 4. Exposure to severe cold for prolonged periods causes frostbite and accidental hypothermia. Older adults, the young, patients with cardiovascular conditions, patients who have ingested drugs or alcohol in excess, and people who are homeless are at high risk for hypothermia.
The nursing assessment of an 80-year-old patient who demon- strates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: 1. Place a bed alarm device on the bed. 2. Place the patient in a belt restraint. 3. Provide one-on-one observation of the patient. 4. Apply wrist restraints.
Answer: 1. Consider and implement alternatives as appropriate before the use of a restraint. A bed alarm is an alternative that the nurse implements independently
At 12 noon the emergency department nurse hears that an explo- sion has occurred in a local manufacturing plant. Which action does the nurse take first? 1. Prepare for an influx of patients 2. Contact the American Red Cross 3. Determine how to resume normal operations 4. Evacuate patients per the disaster plan
Answer: 1. The emergency department nurse needs to prepare for the potential influx of patients first. Staff need to be aware of the disaster plan. Patients may need to be evaluated but not initially. The American Red Cross is not contacted initially. Determination of how to resume normal operations is part of the disaster plan and is determined before an actual event
The nurse is caring for a patient who is having a seizure. Which of the following measures will protect the patient and the nurse from injury? (Select all that apply.) 1. If patient is standing, attempt to get him or her back in bed. 2. With patient on floor, clear surrounding area of furniture or equipment. 3. If possible, keep patient lying supine. 4. Do not restrain patient; hold limbs loosely if they are flailing. 5. Never force apart a patient's clenched teeth.
Answer: 2, 4, 5. During a seizure, if a patient is standing, guide to floor. Do not try to place in bed. Do not position the patient supine; instead turn patient onto one side with head tilted slightly. When patient is on the floor, remove any furniture or objects that he or she could strike during tonic and clonic activity. Never force apart a patient's clenched teeth; you might be bitten. Do not restrain patient; hold limbs loosely if they are flailing. A postictal phase follows the seizure, during which the patient has amnesia or confusion and falls into a deep sleep.
A patient has been newly admitted to a medicine unit with a history of diabetes and advanced heart failure. The nurse is assess- ing the patient's fall risks. Place the following steps for measuring the "Timed Get-up and Go Test" (TUG) in the correct order: 1. Have patient rise from straight-back chair without using arms for support. 2. Begin timing. 3. Tell patient to walk 10 feet as quickly and safely as possible to a line you marked on the floor, turn around, walk back, and sit down. 4. Check time elapsed. 5. Look for unsteadiness in patient's gait. 6. Have patient return to chair and sit down without using arms for support.
Answer: 3, 1, 2, 5, 6, 4. These are the correct steps for performing the TUG.
You are caring for a patient who frequently tries to remove his intravenous catheter and feeding tube. You have an order from the health care provider to apply a wrist restraint. Place the steps for applying a wrist restraint in the correct order. 1. Be sure that patient is comfortable with arm in anatomic alignment. 2. Wrap wrist with soft part of restraint toward skin and secure snugly. 3. Identify patient using two identifiers. 5. Assess condition of skin where restraint will be placed.
Answer: 3, 4, 1, 5, 2. These are the correct steps for applying a wrist restraint.
You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. His wife stated that he has a history of high blood pressure, which is controlled by an antihy- pertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impul- sive. He has moderate left-sided weakness that requires the assis- tance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. Which factors increase his fall risk at this time? (Select all that apply.) 1. Smokes a pack a day 2. Used a cane to walk at home 3. Takes antihypertensive and diuretics 4. History of recent fall 5. Neglect, spatial and perceptual abilities, impulsive 6. Requires assistance with activity, unsteady gait 7. IV line, urinary catheter
Answer: 3, 4, 5, 6, 7. Smoking is not a risk factor for falls. Use of the cane at home is not a current risk factor for falls. Risk is determined by his current status
The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.) 1. Contact the nursing supervisor. 2. Restrict the family's visiting privileges. 3. Ask the family to stay with the patient if possible. 4. Inform the family of the risks associated with side-rail use. 5. Thank the family for being conscientious and put the four rails up. 6. Discuss alternatives that are appropriate for this patient with the family.
Answer: 3, 4, 6. The family is concerned about ensuring a safe environment for their loved one. The nurse should discuss their concerns, the risk of using restraints related to using four side rails, and safer alternatives such as the presence of a family member. If the family still insists on use of four side rails, you could contact the nursing supervisor to further discuss the situation with them. This is not a reason to restrict visitation; but, although you should appreciate their concern, the use of four side rails should be avoided
A parent calls the pediatrician's office to ask about directions for using a car seat. Which of the following is the most correct set of instructions the nurse gives to this parent? 1. Only infants and toddlers need to ride in the back seat. 2. All toddlers can move to a forward facing car seat when they reach age 2. 3. Toddlers must reach age 2 and the height/weight requirement before they ride forward facing. 4. Toddlers must reach age 2 or the height or weight requirement before they ride forward facing.
Answer: 4. The American Academy of Pediatrics (2011a) recommends that all infants and toddlers ride in the back seat with a rear-facing-only seat and rear-facing convertible seat until they are 2 years of age or they reach the highest weight or height allowed by the manufacturer of the car safety seat.
VALSALVA MANEUVER
Any forced expiratory effort against a closed airway an individual holds their breath and tightens their muscles increases pressure to help expel feces
Saccharides
Any substance that is either a simple sugar (aldose or ketose) or a compound of such substances in glycosidic linkage to each other. classified as mono-, di-, tri-, and polysaccharides according to the number of monosaccharide groups composing them
ENEMA - RECTAL TUBE
Appropriate-size rectal tube: Adult: 22 to 30 Fr Child: 12 to 18 Fr
side effects
Are the unintended, secondary effects a medication will predictable cause.
The client has a red, raised skin rash. Which of the following is most important when cleansing the skin?
Assess for further inflammatory reactions
. Which of the following is an appropriate site for taking the pulse of a 2-year-old? A. Radial B. Apical C. Femoral D. Pedal
B
A nurse is administering a diuretic to a patient and teaching the patient about foods to increase. Which food choices by the patient will best indicate successful teaching? a. Milk and cheese b. Potatoes and fresh fruit c. Canned soups and vegetables d. Whole grains and dark green leafy vegetables
B
A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit? a. Moist mucous membranes b. Postural hypotension c. Supple skin turgor d. Pitting edema
B
A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding will the nurse expect? a. Dry mucous membranes b. Abdominal distention c. Distended neck veins d. Flushed skin
B
The client begins to breathe rapidly. The nurse should: A. Ask the client if there have been any stressful visitors B. Measure the oxygen saturation level C. Count the rate of respirations D. Take the radial pulse
B
Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis? a. pH 7.60, PaCO2 40 mm Hg, HCO3- 30 mEq/L b. pH 7.53, PaCO2 30 mm Hg, HCO3- 24 mEq/L c. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L d. pH 7.25, PaCO2 48 mm Hg, HCO3- 23 mEq/L
B
17. The nurse is beginning a sleep assessment on a patient. Which of the following would be the most appropriate question to ask? a. "What is going on?" b. "How are you sleeping?" c. "Are you taking any medications?" d. "What did you have for dinner last night?"
B (Asking patients how they are sleeping is an introductory question. After this beginning question is asked, problems with sleep such as the nature of the problem, signs and symptoms, onset and duration of the issue, severity, predisposing factors, and the effect on the patient can be assessed. What is going on is too broad and open ended for information about sleep to be obtained specifically. Medications and food intake can be part of the detailed assessment of sleep issues.)
25. A patient has received a nursing diagnosis of sleep deprivation. Which of the following statements by the patient would indicate that outcomes are being met? a. "I wake up only once a night to go the bathroom." b. "I feel rested when I wake up in the morning." c. "I go to sleep within 30 minutes of lying down." d. "I only take a 20-minute nap during the day."
B (Being able to sleep and feeling rested would indicate that outcomes are being met for sleep deprivation. Limiting a nap to 20 minutes is an intervention to promote sleep. Going to sleep within 30 minutes indicates that the patient may not be experiencing insomnia. Waking up during the night may indicate insomnia, and decreasing fluids in the evening is an intervention to help prevent this situation.)
10. The nurse is having a conversation with an adolescent regarding the need for sleep. The adolescent states that it is common to stay up with friends several nights a week. Which nursing action should the nurse take? a. Discuss with the adolescent's parent staying up with friends and the need for sleep. b. Discuss with the adolescent sleep needs and the effects of excessive daytime sleepiness. c. This is a normal occurrence for adolescents and action is not required. d. Explore the reason for staying up late with friends several nights a week.
B (On average, a teenager needs about 71/2 hours of sleep per night. Many activities at school, social activities, and jobs can reduce the number of sleep hours, resulting in excessive daytime sleepiness. This can lead to decreased performance at school, vulnerability to accidents, behavior and mood problems, and increased use of alcohol. Discussion regarding adolescent sleep needs should first occur with the adolescent. Although it may be common for this adolescent to want to visit with friends and experience activities that go late into the night, these activities can and do impact the hours of sleep and the physical needs of the adolescent, no matter the reason for the late nights, and they do need to be addressed.)
The nurse is caring for a patient who is having trouble sleeping. To encourage decreased stimulus to the reticular activating system and activation of the bulbar synchronizing region, which actions would the nurse implement? a. Encourage television for distraction. b. Encourage relaxed positions. c. Walk with the patient. d. Provide a favorite beverage.
B (Researchers believe that the ascending reticular activating system -RAS- located in the upper brainstem contains special cells that maintain alertness and wakefulness. Researchers also hypothesize that the release of serotonin from specialized cells in the bulbar synchronizing region -BSR- produces sleep. As the patient closes his eyes and assumes relaxed positions, stimuli to the RAS decrease, and at some point the BSR takes over. Television, walking, and drinking a favorite beverage would not necessarily encourage sleep.)
7. The nurse is discussing with a new mother the sleep requirements of a neonate. Which of these comments would indicate that the patient has an understanding of the neonate's sleeping pattern? a. "I can't wait to get the baby home to play with the brothers and sisters." b. "I will ask my mom to come after the first week, when the baby is more alert." c. "I will get the baby on a sleeping schedule the first week while my mom is here." d. "I won't be able to nap during the day because the baby will be awake."
B (The neonate averages about 16 hours of sleep. During the first week of life, the child sleeps almost constantly.)
4. A community health nurse is providing an educational session at the senior center on how to promote sleep. Which practices should the nurse recommend? (Select all that apply.) a. Take a nap in the afternoon. b. Sleep where you sleep best. c. Use sedatives as a last resort. d. Decrease fluids 2 to 4 hours before sleep. e. Watch television right before sleep. f. Get up if unable to fall asleep in 15 to 30 minutes.
B, C, D, F (The nurse should instruct the patient to sleep where she sleeps best, to use sedatives as a last resort, to decrease fluid intake to cut down on bathroom trips, and, if unable to sleep in 15 to 30 minutes, to get up out of bed. Naps should be eliminated if not part of the individual's routine schedule, and if naps are taken, they should be limited to 20 minutes or less a day. Television can stimulate and disrupt sleep patterns)
A nurse is discontinuing a patient's peripheral IV access. Which actions should the nurse take? (Select all that apply.) a. Wear sterile gloves and a mask. b. Stop the infusion before removing the IV catheter. c. Use scissors to remove the IV site dressing and tape. d. Apply firm pressure with sterile gauze during removal. e. Keep the catheter parallel to the skin while removing it. f. Apply pressure to the site for 2 to 3 minutes after removal.
B, E, F
A client is discussing his recent restlessness and increased irritability. Which of the following assessment questions is likely to be most helping in determining the cause of these complaints? A. "When did you start noticing these changes?" B. "Has anything caused you to change your usual routine lately?" C. "Do you have any idea what might be causing these problems?" D. "What makes you think that you are more irritable that is normal for you?"
B. "Has anything caused you to change your usual routine lately?" When the sleep-wake cycle becomes disrupted, other physiological functions usually change as well. For example, the person experiences a decreased appetite and loses weight. Anxiety, restlessness, irritability, and impaired judgment are other common symptoms of sleep cycle disturbances.
The nurse and a client are discussing possible behaviors that might be interfering with the client's ability to fall asleep. Which of the following assessment questions is most likely to identify possible problems with the client's sleep routine that possibly are contributing to the difficulty? A. "When do you usually retire for the night?" B. "What do you do to help yourself fall asleep?" C. "How much time does it usually take for you to fall sleep?" D. "Have you changed anything about your presleep ritual lately?"
B. "What do you do to help yourself fall asleep?" As people try to fall asleep, they close their eyes and assume relaxed positions. Stimuli to the RAS decline. If the room is dark and quiet, activation of the RAS further declines. At some point, the BSR takes over, causing sleep.
Which of the following symptoms should the nurse assess with a client who is deprived of sleep? A. Elevated blood pressure and confusion B. Confusion and irritability C. Inappropriateness and rapid respirations D. Decreased temperature and talkativeness
B. Confusion and irritability Psychological symptoms of sleep deprivation include confusion and irritability. Elevated blood pressure is not a symptom of sleep deprivation. Rapid respirations are not a symptom of sleep deprivation. There may be a decreased ability of reasoning and judgment that could lead to inappropriateness. Decreased temperature is not a symptoms of sleep deprivation. The client with sleep deprivation is often withdrawn, not talkative.
The nurse knows that which of the following habits may interfere with a client's sleep? A. Listening to classical music B. Finishing office work C. Reading novels D. Drinking warm milk
B. Finishing office work At home, a client should try not to finish office work or resolve family problems before bedtime. Noise should be kept to a minimum.
The nurse is caring for a 35 year old father of three young children who has experienced a compound fracture femur as a result of a work-related incident. He has expressed great concern over both his physical recovery and his long-term ability to work again. This has affected both his emotional status and his sleeping patterns. The nurse's most immediate concern is that: A. The client needs medication to prevent depression B. The lack of appropriate rest will affect his healing process C. An occupational therapy consult should be ordered to help him regain his ability to return to this job D. A psychiatric consult should be ordered to help the client deal with his various emotional concerns
B. The lack of appropriate rest will affect his healing process You must always be aware of the client's need for rest. A lack of rest for long periods causes illness or worsening of existing illness.
The nurse and a client are discussing the importance of an effective 24 hour sleep cycle. Which of the following responses by the client may be a direct result of an inadequate sleep pattern? (Select all that apply) A. Gaining weight B. Usually feeling cold C. Always feeling "tired" D. A heart that beats "really fast" E. Often feeling "blue" or depressed F. Feeling dizzy when getting up from a chair
B. Usually feeling cold C. Always feeling "tired" D. A heart that beats "really fast" E. Often feeling "blue" or depressed F. Feeling dizzy when getting up from a chair The predictable changing of body temperature, heart rate, blood pressure, hormone secretion, sensory acuity, and mood depend on the maintenance of the 24 hour circadian cycle. Weight gain is not typically a result of poor sleep patterns.
AEROBIC BACTERIA
Bacteria that require oxygen for survival
ANAEROBIC BACTERIA
Bacteria that thrive with little or no free oxygen
Upper GI series
Barium swallow, X-ray pictures(series)
Overflow incontinence
Bladder is full, but small amounts are leaking out. No urge to urinate -head or spinal injury
e) plateau
Blood serum concentration is reached and maintained. a) serum half-life b) trough c) onset d) peak e) plateau f) duration g) therapeutic range
MEDICATION ACTION - PLATEAU
Blood serum concentration of medication reached and maintained after repeated fixed doses
High Fiber diet includes?
Bran, oatmeal, fresh uncooked fruit, dried fruits, steamed veggies
metabolism
Breakdown of a drug to an inactive or active state
Some foods that provide fiber (bulk) in the diet also produce gas. What are these foods?
Broccoli, cabbage, beans
National Quality Forum Mission
Builds consensus on national priorities and goals for performance, endorses national consensus standards for measuring/public reporting on performance, promoting attainment of national goals through education.
. A client complains of pain and asks the nurse for pain medication. The nurse first assesses vital signs: blood pressure, 134/92; pulse, 100; and respiration 32. The nurse's most appropriate action is to: A. Ask if the client is anxious B. Check the client's dressing for bleeding C. Give the medication D. Recheck the client's vital signs in 30 minutes
C
A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan? a. Stimulate the patient's appetite to eat. b. Deliver antibiotics to fight off infection. c. Replace fluid, electrolytes, and nutrients. d. Provide medication to raise blood pressure.
C
A nurse is preparing to start a blood transfusion. Which type of tubing will the nurse obtain? a. Two-way valves to allow the patient's blood to mix and warm the blood transfusing b. An injection port to mix additional electrolytes into the blood c. A filter to ensure that clots do not enter the patient d. An air vent to let bubbles into the blood
C
A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute flow rate (drops/min)? a. 12 drops/min b. 24 drops/min c. 125 drops/min d. 150 drops/min
C
A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare? a. 0.225% sodium chloride (1/4 NS) b. 0.45% sodium chloride (1/2 NS) c. 0.9% sodium chloride (NS) d. 3% sodium chloride (3% NaCl)
C
The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients? a. Assess the patients for edema in extremities. b. Ask the patients to record their intake and output. c. Weigh the patients every morning before breakfast. d. Measure the patients' blood pressures every 4 hours.
C
The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action will the nurse take first? a. Offer calcium-rich foods. b. Administer diuretic. c. Raise head of bed. d. Increase fluids.
C
The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement? a. Urine output increases to 150 mL/hr. b. Systolic and diastolic blood pressure decreases. c. Serum sodium concentration returns to normal. d. Large amounts of emesis and diarrhea decrease.
C
The nurse observes edema in a patient who has venous congestion from right heart failure. Which type of pressure facilitated the formation of the patient's edema? a. Osmotic b. Oncotic c. Hydrostatic d. Concentration
C
While the nurse is taking a patient history, the nurse discovers the patient has a type of diabetes that results from a head injury and does not require insulin. Which dietary change should the nurse share with the patient? a. Reduce the quantity of carbohydrates ingested to lower blood sugar. b. Include a serving of dairy in each meal to elevate calcium levels. c. Drink plenty of fluids throughout the day to stay hydrated. d. Avoid food high in acid to avoid metabolic acidosis.
C
12. The nurse is caring for an adolescent who is complaining of difficulty falling asleep. Which intervention would be most appropriate? a. Adjust the temperature in the patient's room to 21° C (70° F). b. Ensure that the night light in the patient's room is working. c. Encourage the discontinuation of soda and chocolate nightly snack. d. Close the door to decrease noise from unit activities.
C (Cola and chocolate contain caffeine, which interferes with the ability to fall asleep. Personal preference influences the temperature of the room, as well as the lighting of the room. Noise can be a factor in the unit and can awaken the patient, but caffeine can make it difficult to fall asleep.)
13. Which of the following would be most important for the nurse to monitor in a patient who has obstructive sleep apnea? a. Gastrointestinal function b. Circulatory status c. Respiratory status d. Neurological function
C (In obstructive sleep apnea, the upper airway becomes partially or completely blocked, diminishing airflow and stopping it. The person still attempts to breathe because the chest and abdominal movement continue, which results in loud snoring and snorting sounds. According to the ABCs of prioritizing care, airway and respiratory status take priority.)
18. The nurse assigns a nursing diagnosis of ineffective breathing pattern. Which of the following sleep conditions would support this diagnosis? a. Insomnia b. Narcolepsy c. Obstructive sleep apnea d. Sleep deprivation
C (Obstructive sleep apnea -OSA- occurs when the muscles or structures of the oral cavity or throat relax during sleep. The upper airway becomes partially or completely blocked, diminishing airflow or stopping it for as long as 30 seconds. The person still attempts to breathe because chest and abdominal movements continue, resulting in snoring or snorting sounds. With narcolepsy, the person feels an overwhelming wave of sleepiness and falls asleep. Insomnia is characterized by chronic difficulty falling asleep. Sleep deprivation is a condition caused by dyssomnia. OSA is the only one of these conditions that results in blockage of the airway and impacts the ability to breathe.)
14. The patient has just been diagnosed with narcolepsy. The nurse provides an educational session and teaches the patient to avoid a. Antidepressant medications. b. Naps shorter than 20 minutes. c. Sitting in hot, stuffy rooms. d. Chewing gum.
C (Patients with narcolepsy need to avoid factors that increase drowsiness such as alcohol, heavy meals, exhausting activities, long-distance driving, and long periods of sitting in hot, stuffy rooms. Patients are treated with antidepressants, and management techniques involve scheduling naps no longer than 20 minutes and chewing gum. Additional management techniques include exercise, light high-protein meals, deep breathing, and taking vitamins.)
4. The nurse is caring for a patient in the sleep lab. The nurse recognizes that the patient is in stage 4 NREM from which of the following assessments? a. The patient awakens easily. b. Body functions slow. c. The patient is difficult to awaken. d. Eyes rapidly move.
C (Stage 4 NREM is the deepest stage of sleep. The patient is difficult to arouse, vital signs are significantly lower, and this stage lasts about 15 to 30 minutes. Sleep walking and enuresis sometimes occur. Lighter sleep is seen in stages 1 and 2, where the patient awakens easily. In stage 2, body functions slow and REM sleep is characterized by rapid eye movement.)
26. The older patient is visiting the clinic after a fall during the night. Which of the following data points obtained most likely would contribute to this fall? a. The patient has been taking glucosamine. b. The patient has been taking a fish oil. c. The patient has been taking Benadryl (diphenhydramine). d. The patient has been taking vitamin C.
C (When older adults are using Benadryl -diphenhydramine-, an over-the-counter medication for sleep, caution them that they may experience dizziness, drowsiness, confusion, constipation, and urinary retention because of the long duration of action of the medication. This can contribute to a fall in an older adult. Fish oil given for the treatment of cholesterol, although an issue after a fall with potential bleeding, is not a cause for the fall, nor is glucosamine, which is used in the treatment of joint issues. Neither of these substances are utilized for sleep. Vitamin C is used to support the immune system; it is not used for sleep and does not cause falls.)
The nurse is caring for a young adult patient on the medical-surgical unit. When doing midnight checks, she sees that the patient is awake and is doing a puzzle. What is the best explanation for the patient being awake? A. The patient was waiting to talk with the nurse B. The patient misses his family and is lonely C. The patients sleep-wake cycle preference is late evening D. The patient has been kept up by the noise on the unit
C (All persons have biological clocks that synchronize their sleep-wake cycle. This explains why some individuals fall asleep in the early evening and some late evening or early morning. This patient is awake and alert enough to do a puzzle. The individual's sleep-wake preference is probably late evening. Waiting to talk with the nurse, being lonely, and noise on the unit may contribute to lack of sleep, but the best explanation for the patient being awake is the biological clock.)
The nurse is discussing child care strategies with a mother of a newborn. The mother asks the nurse, "What causes SIDS?" Which of the following responses is most likely to answer the mother's question therapeutically? A. "SIDS is a common fear for new mothers. The best advice is to put your baby to sleep on her back." B. "We aren't sure exactly, but it may have something to do with undetected cardiac or oxygen problems." C. "Research is inconclusive, but it's thought to be a result of a nervous system problem that occurs when the baby is asleep." D. "Your pediatrician wants you to put your baby to sleep on her back because research has shown that more stomach sleepers are victims."
C. "Research is inconclusive, but it's though to be a result of a nervous system problem that occurs when the baby is asleep." Some have hypothesized that SIDS is caused by abnormalities in the ANS that are manifested during sleep, resulting in apnea, hypoxia, and/or cardiac dysrhythmias.
The client asks the nurse, "How will I know if I'm really rested?" The nurse's most therapeutic response is: A. "Everyone's definition of rested is different. How would you define rested?" B. "When you aren't tired when you get up in the morning or after an afternoon nap." C. "When you are mentally, physically, and emotionally ready to go about your daily activities." D. "You are rested if you fall asleep easily and sleep uninterruptedly for at least 6 to 8 hours."
C. "When you are mentally, physically, and emotionally ready to go about your daily activities." When people are at rest they are in a state of mental, physical, and spiritual activity that leaves them feeling refreshed, rejuvenated, and ready to resume the activities of the day.
A new mother is concerned that her 2 week old daughter is not sleeping through the night. The nurse should respond that infants usually develop a nighttime pattern of sleep by: A. 1 month B. 2 months C. 3 months D. 6 months
C. 3 months
It is determined that the client will need pharmacological treatment to assist with the client's sleep pattens. The nurse anticipates that treatment with an anxiety-reducing, relaxation-promoting medication will include the use of: A. Barbiturates B. Amphetamines C. Benzodiazepines D. Tricyclic antidepressants
C. Benzodiazepines The benzodiazepines cause relaxation, antianxiety, and hypnotic effects by facilitating the action of neurons in the CNS that suppress responsiveness to stimulation, therefore decreasing levels of arousal. Withdrawal from CNS depressants, such as barbiturates, can cause insomnia and must be managed carefully.
A female client describes the most elaborate dreams to the nurse. She states that she could see colors, hear music, and even had the sensation of flying. The nurse replies to the client that her dreams indicate that she must be: A. Depressed B. Pragmatic C. Creative D. Mentally Ill
C. Creative Personality influences the quality of dreams; for example, a creative person has elaborate and complex dreams, whereas a depressed person dreams of helplessness. Most people dream about immediate concerns such as an argument with a spouse or worries over work. Sometimes a person is unaware of fears represented in bizarre dreams.
Which of the following may improve the sleep of an older adult client? A. Drinking an alcoholic beverage before bedtime B. Using an OTC sleeping agent C. Eliminating naps during the day D. Going to bed at a consistent time even if not feeling sleepy
C. Eliminating naps during the day To promote sleep, daytime naps should be eliminated. If naps are used, they should be limited to 20 minutes or less twice a day. The client should engage in quiet activities that promote relaxation and then may go to bed.
The nurse is preparing to discuss the management of the sleeping disorder narcolepsy. In addition to the prescription of stimulants and antidepressants, which of the following non-pharmaceutical strategies should be included and shared with the client? (Select all that apply) A. Wine with meals B. Regular use of a sauna C. Light but high-protein meals D. Regular use of chewing gum E. Adoption of a regular exercise routine F. Brief daytime naps of 20 minutes or less
C. Light but high-protein meals D. Regular use of chewing gum E. Adoption of a regular exercise routine F. Brief daytime naps of 20 minutes or less Narcoleptics may be helped by brief daytime naps no longer than 20 minutes, a regular exercise program, avoiding shifts in sleep, eating light meals high in protein, practicing deep breathing, chewing gum, and taking vitamins. Clients with narcolepsy need to avoid factors that increase drowsiness.
The nurse understands that the client with which of the following conditions is at risk for obstructive sleep apnea? A. Heart disease B. Respiratory tract infections C. Nasal polyps D. Obesity
C. Nasal polyps Structural abnormalities, such as a deviated septum, nasal polyps, certain jaw configurations, or enlarged tonsils predispose a client to obstructive apnea. Individuals with mixed apnea often have signs and symptoms of right-sided heart failure. Respiratory tract infections do not predispose a client to obstructive sleep apnea. Clients with obstructive apnea are often middle-age, obese men. Obesity itself does not predispose a client to obstructive sleep apnea.
New research indicates that to increase safety the nurse should instruct parents to do which of the following? A. Provide a stuffed toy for comfort B. Cover the infant loosely with a blanket C. Place the infant on his or her back D. Use small pillows in the crib
C. Place the infant on his or her back Infants are usually placed on their backs to prevent suffocation or on their sides to prevent aspiration of stomach contents.
A 25 year old client's wife complains to the nurse that he sleepwalks during the night. The nurse knows that his behavior normally occurs in which stage of sleep? A. Stage 2: NREM B. Stage 3: NREM C. Stage 4: NREM D. REM
C. Stage 4: NREM Stage 4 NREM sleep is the deepest stage of sleep. It is very difficult to arouse the sleeper. If sleep loss has occurred, the sleeper will spend a considerable portion of the night in this stage. Vital signs are significantly lower than during waking hours. The stages lasts approximately 15 to 30 minutes. Sleepwalking and enuresis sometimes occur. REM sleep involves vivid, full-color dreaming. Loss of skeletal muscle tone occurs. Typified by autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, and increased or fluctuating blood pressure.
On a 2 week follow-up visit to the health care provider, a 64 year old female postoperative client shares with the nurse that she is having difficulty sleeping and has never had a history of sleeping problems. The nurse shares with the client that: A. Because of her age, the client should expect to begin having some problems sleeping B. It may take a while to get used to sleeping in her bed at home after getting used to sleeping on a hospital bed C. The medications used for anesthesia can disturb sleep cycles for several weeks following surgery D. She may not be sleeping as well as her partner after being in a bed by herself while being hospitalized
C. The medications used for anesthesia can disturb sleep cycles for several weeks following surgery If the client has recently had surgery, expect the client to experience some disturbance in sleep. Clients usually awaken frequently during the first night after surgery and receive little deep or REM sleep. Depending on the type of surgery, it takes several days to months for a normal sleep cycle to return.
The physiology of sleep is complex. Which of the following is the most appropriate statement in regard to this process? A. Ultradian rhythms occur in a cycle longer than 24 hours B. Nonrapid eye movement (NREM) refers to the cycle that most clients experience when in a high-stimulus environment C. The reticular activating system is partly responsible for the level of consciousness of a person D. The bulbar synchronizing regions (BSR) causes the rapid eye movement (REM) sleep in most normal adults
C. The reticular activating system is partly responsible for the level of consciousness of a person The reticular activating system locating in the upper brain stem is believed to contain special cells that maintain alertness and wakefulness. Infradian rhythms occur in a cycle longer than 24 hours. NREM refers to the sleep cycle that most clients experience in a low stimulus environment. The bulbar synchronizing region is the area of the brain where serotonin is released to produce sleep.
A client hospitalized for a myocardial infarction in a cardiac critical care unit is most likely to experience sleep deprivation as a result of: A. A drug-disrupted circadian sleep pattern B. Generally diminished cardiac output C. Unfamiliar environmental stimuli D. Increased emotional stressors
C. Unfamiliar environmental stimuli Hospitalization, especially in intensive care units, makes clients particularly vulnerable to the extrinsic and circadian sleep disorders that cause "ICU syndorme of sleep deprivation." Constant environmental stimuli within the ICU, such as strange noises from equipment, the frequent monitoring and care given by nurses, and ever-present lights, confuse clients and lead to sleep deprivation.
BODY DEFENSE - RESPIRATORY TRACT
CILIA (coated by mucus) traps inhaled microbes and sweeps them outward in mucus to be expectorated or swallowed MACROPHAGES engulf and destroy microorganisms that reach alveoli of the lung
Critical Thinking Experience
Caring for those whose mobility, cognitive or sensory impairment threatens safety, personal experience caring for children.
Gluconeogenesis
Catabolism of amino acids and glycerol into glucose for energy
Glycogenolysis
Catabolism of glycogen into glucose, carbon dioxide, and water
glycogenolysis
Catabolism of glycogen into glucose, carbon dioxide, and water
Catheter
Catherterize 24-48 hours, before antibiotics
Intrathecal
Catheter placed in subarachnoid space of one of the ventricles of the brain
Water
Cell function depends on a fluid environment. 60-70% of total body weight. Lean people are higher than obese.
A single medication may have three different names. Chemical name:
Chem name: exact description of med's compositional and molecular structure.
Elimination
Chyme moves by peristaltic action through the ileocecal valve into the large intestine where it becomes feces
Adult Developmental Interventions
Classes to quit smoking, stress management, exercise regularly, healthy diet, relaxation techniques, adequate sleep.
Insulin
Classified by Rate of action (rapid, short, intermediate, and long acting); each has a different onset, peak and duration of action
Bouillon, clear fat-free broth, clear fruit juices, gelatin, popsicles
Clear liquid diet
Full liquid diet contains?
Clear liquids with smooth-textured products ( ie. ice cream), custards pureed vegetables, puddings, frozen yogurts, strained or blended cream soups
Clear liquids
Clear, fat free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit, ices, popsicles
Jamie helps wash Mrs. Winkler's feet and applies a lanolin cream. Which approach should Jamie take regarding trimming Mrs. Winkler's toenails?
Collaborate with Mrs. Winkler's nurse to obtain a podiatrist consult order
Teamwork and Collaboration
Collaboration with patient, family, other health professionals. Communication by dry-erase boards in patients room with information. Patient and family understand need for resources.
End colostomy
Colon cancer- permanent
What is the name of the procedure which examines the entire length of the colon?
Colonoscopy
Flatulence
Common cause of abdominal fullness, pain, and cramping Causes-reduced intestinal motility, intestinal irritation, anxiety, swallowed air, anesthesia, cabbage Interventions-walk, look for and treat cause, burping
MEDICATION RECONCILIATION - RECONCILE
Compare new medication orders with the current list investigate any discrepancies with the patient's health care provider document changes
g) therapeutic range
Concentration of the med in the blood to produce desired effect. a) serum half-life b) trough c) onset d) peak e) plateau f) duration g) therapeutic range
NEGATIVE NITROGEN BALANCE
Condition occurring when the body excretes more nitrogen than it takes in.
ignoring urge, low fluid and fiber intake, diet high in animal fats/refined sugars, prolonged bed rest,laxative, post-op patients
Constipation causes
Ampule
Contains single doses of medications in a liquid
HAI - RESPIRATORY TRACT
Contaminated respiratory therapy equipment Failure to use aseptic technique while suctioning airway Improper disposal of secretions
Air Pollution
Contamination of atmosphere with harmful chemical. Industrial waste and vehicle exhaust causes pulmonary disease. Cigarette smoke primary cause.
HAI - BLOODSTREAM
Contamination of intravenous (IV) fluids by tubing Insertion of drug additives to IV fluid Addition of connecting tube or stopcocks to IV system Improper care of needle insertion site Contaminated needles or catheters Failure to change IV access at first sign of infection or at recommended intervals Improper technique during administration of multiple blood products Improper care of peritoneal or hemodialysis shunts Improperly accessing an IV port
Water Pollution
Contamination of lakes, rivers and streams by industrial pollutants. Public must drink bottled or boil water for drinking and cooking in case of contamination or flood.
Type 2 diabetes
Control initial with exercise and diet therapy. Common to add oral meds. Insulin injections if it worsens
ENEMA - VOLUME OF SOLUTION
Correct volume of warmed solution: Infant: 150 to 250 mL Toddler: 250 to 350 mL School-age: 300 to 500 mL Adolescent: 500 to 700 mL Adult: 750 to 1000 mL
Generic Name
Created by the manufacturer who first develops the medication; official name
4. The nurse is ready to take vital signs on a 6-year-old child. The child has just enjoyed a grape popsicle. An appropriate action would be to: A. Take the rectal temperature B. Take the oral temperature as planned C. Have the child rinse out the mouth with warm water D. Wait 30 minutes and take the oral temperature
D
A client has developed pneumonia and his temperature has increased to 37.7C. The client is shiver and feels uncomfortable. Which of the following is true concerning the physiology of heat production in this client? A. Increased BMR is probably causeing the febrile condition B. Encouraging the client to ambulate would help decrease heat production C. The shivering is likely the cause of the increased temperature D. The client may need to consume more nutrients during the febrile condition
D
A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)? a. Preps skin with povidone-iodine solution. b. Suggests the femoral vein for insertion site. c. Applies double gloving without hand hygiene. d. Uses chlorhexidine skin antisepsis prior to insertion.
D
A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient's peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action? a. Record a phlebitis grade of 4. b. Assign an infiltration grade. c. Apply moist compress. d. Discontinue the IV.
D
A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one? 1. Clean site. 2. Select vein. 3. Apply tourniquet. 4. Release tourniquet. 5. Reapply tourniquet. 6. Advance and secure. 7. Insert vascular access device. a. 1, 3, 2, 7, 5, 4, 6 b. 1, 3, 2, 5, 7, 6, 4 c. 3, 2, 1, 5, 7, 6, 4 d. 3, 2, 4, 1, 5, 7, 6
D
A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, which is the nurse's next action? a. Discontinue the IV catheter. b. Return the blood to the blood bank. c. Run normal saline through the existing tubing. d. Start normal saline at TKO rate using new tubing.
D
If measuring blood pressure is necessary in the leg, the nurse expects the diastolic pressure to be: A. 10 to 40 mm Hg higher than in the brachial artery B. 20 to 30 mm Hg lower than in the brachial artery C. 50 mm Hg higher than in the brachial artery D. Essentially the same as that in the brachial artery
D
The client's pulse is 72/minute, easily palpated. In addition, the pedal pulses are equal in strength in both feet. To best assess for an irregularity in the pulses, the nurse should: A. Determine the rate of the pedal pulses B. Auscultate for the strength of the apical pulse C. Examine the electrocardiogram's reading D. Ask the client if there is a pulsation that is abnormal
D
The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? a. Gastrointestinal b. Neurological c. Respiratory d. Cardiac
D
Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? a. Weak quadriceps muscles b. Decreased deep tendon reflexes c. Light-headedness when standing up d. Tingling of extremities with possible tetany
D
23. A young mother has been hospitalized for an irregular heartbeat (arrhythmia). The night nurse comes in to see the patient awake. What would be the most appropriate nursing intervention? a. Inform the patient that it is late and time to go to sleep. b. Ask the patient if she would like medication to help her sleep. c. Recommend the great movie that is on television tonight. d. Take time to sit and talk with the patient about her inability to sleep.
D (Assessment is the first step of the nursing process; therefore assessment needs to be done first and involves ascertaining the cause of the patient's inability to sleep. Patients who are admitted to the hospital for uncertain diagnoses can be stressed and worried about the testing and outcomes. In addition, a young mother can be worried about the care of the children and those caring for the children. This uncertainty and change in routine can cause difficulty in resting or falling asleep. Take the time to talk with the patient to determine the cause of the inability to sleep. A distraction such as a television may or may not work for the patient. After assessment is completed, a sedative may or may not be in order. Telling the patient that it is late and time to go to sleep is not a therapeutic response for an adult who is under stress.)
20. The patient presents to the clinic with reports of irritability, being sleepy during the day, not being able to fall asleep, and being tired. Select the most appropriate nursing diagnosis. a. Anxiety b. Fatigue c. Sleep deprivation d. Insomnia
D (Insomnia is experienced when the patient has difficulty falling asleep, frequent awakenings from sleep, and/or short sleep or nonrestorative sleep. It is the most common sleep-related complaint and includes symptoms such as irritability, excessive daytime sleepiness, not being able to fall asleep, and fatigue. Anxiety is a vague, uneasy feeling of discomfort or dread accompanied by an autonomic response. Fatigue is an overwhelming sustained sense of exhaustion with decreased capacity for physical and mental work at a usual level. Sleep deprivation is a condition caused by dyssomnia and includes symptoms caused by illness, emotional distress, or medications.)
21. The nurse is preparing an older patient's evening medications. Which of the following does the nurse recognize as relatively safe for difficulty sleeping? a. Benadryl (diphenhydramine) b. Melatonin c. Valerian d. Lorazepam
D (One group of medications that are relatively safe are the benzodiazepines such as lorazepam. These medications cause relaxation and antianxiety and hypnotic effects. Caution older adults about using over-the-counter antihistamines because their long duration of action can cause confusion, constipation, and urinary retention. Use of nonprescription sleeping aids is not advisable. Patients need to learn the risks associated with these drugs and should be aware that the U.S. Food and Drug Administration does not regulate herbal products.)
9. A single dad is discussing with the nurse the sleep needs of a preschooler. Which of the following directions would be most helpful to the parent? a. "It is important that the 5-year-old get a nap every day." b. "Preschoolers sleep soundly all night long." c. "On average, the preschooler needs to sleep 10 hours a night." d. "The preschooler may have trouble settling down after a busy day."
D (The preschooler usually has difficulty relaxing or settling down after long, active days. By the age of 5, naps are rare for children, except those for whom a siesta is a custom. Preschoolers frequently partially awaken during the night. On average, a preschooler needs 12 hours of sleep.)
what regulation do the kidneys affect?
calcium and phosphate regulation by producing a substance that converts vitamin D into its active form
RENAL CALCULI
calcium stones that lodge in the renal pelvis or pass through the ureters immobilized patients are at risk for calculi because they frequently have hypercalcemia.
END OSTOMIES
can be permanent or reversible rectum may be left intact or removed
STRESS
can stimulate digestion and increase peristalsis diarrhea may result
Z-TRACK TECHNIQUE
can use for all IM injections reduces skin irritation by keeping medication within the muscle tissue prevents medication from leaking back into SQ tissues reduces pain/discomfort (although it is not meant to) prevents skin stains good for elderly who have decreased muscle mass
19. The nurse is caring for a postpartum patient. The patient's labor has lasted over 28 hours within the hospital; the patient has not slept and is disoriented to date and time. What is the most appropriate nursing diagnosis? a. Impaired parenting b. Insomnia c. Ineffective coping d. Sleep deprivation
D (This patient has been deprived of sleep by staying awake during a 28-hour labor. Disorientation is one potential sign of sleep deprivation. In this scenario, we have a clear cause for the patient's lack of sleep, and it is a one-time episode. Insomnia, on the other hand, is a chronic disorder whereby patients have difficulty falling asleep, awaken frequently, or sleep only for a short time. This scenario does not indicate that this has been a chronic problem for this patient. Although ineffective coping can manifest as a sleep disturbance, we have clear evidence that it was labor that deprived this patient of sleep, not an inability to cope. It could be difficult to care for an infant when sleep deprived; however, this scenario gives no evidence that this mother displays impaired parenting and is not caring adequately for her child or lacks the skills to do so.)
5. The patient shares with the nurse the vivid, full color dreams experienced by the patient last night. These data would indicate that the patient has reached what stage of sleep? a. Stage 1 NREM b. Stage 2 NREM c. Stage 3 NREM d. REM
D (Vivid, full color dreaming occurs during REM sleep. This stage usually begins about 90 minutes after sleep has begun. The eyes move rapidly, and heart rate, respiratory rate, and blood pressure fluctuate; loss of skeletal muscle tone occurs. The patient has an increase in gastric secretions and is difficult to arouse.)
gluconeogenesis
catabolism of amino acids and glycerol into glucose for energy.
INTRATHECAL
catheter surgically placed in the subarachnoid space or one of the ventricles of the brain intrathecal medication administration often is a long-term treatment medications administered by physicians and specially trained nurses
what can blackflow do?
cause infection
DIARRHEA CONSIDERATIONS
cause of diarrhea must be determined first before effective treatment can be ordered if cause is due to infection, antibiotic is given if cause is due to inflammation, a steroid may be given
puncture
caused by an object piercing the skin and creating a hole. bleeding determined by depth and size. primary dangers are internal bleeding and infection.
functional UI
caused by factors that prohibit or interfere with a patient's access to the toilet or other acceptable receptacle for urine
Hypothermia
caused by heat loss during prolonged exposure to cold overwhelming the body's ability to produce heat
RECTAL DISTENSION
causes relaxation of internal anal sphinter triggers sensory awareness of the need to defecate
what does angiotensin II do?
causes vasoconstriction and stimulates aldosterone release from the adrenal cortex.
INFLAMMATION
cellular response of the body to injury, infection and/or irritation protective vascular reaction that delivers fluid, blood products and nutrients to an area of injury process neutralizes and eliminates pathogens or necrotic tissues establishes a means of repairing body cells and tissues
amitriptyline
changes the color of urine to blue/green
levodopa
changes the color of urine to brown/black
methylene blue
changes the color of urine to green
rifampin
changes the color of urine to orange/brown
How do you assess patient tolerance for bathing?
check activity tolerance, comfort level, cognitive ability, musculoskeletal movement, shortness of breath, visual status, hand grasp, ROM.
WHEN A MEDICATION ERROR OCCURS
check patient's condition immediately observe for adverse effects notify nurse manager and physician write description of error and remedial steps taken on medical record complete incident report
nocturnal enuresis
children who wet the bed at night without waking up.
What pre-moistened towels can be used to cleanse the patient?
chlorhexidine towels
A 70 year old client is reporting to the nurse a concern over "taking longer to fall asleep and waking up three to four times during the night." The most therapeutic nursing response to the client's concern is: A. "I think you need to mention your concerns to your health care provider." B. "Older adults seem to need less sleep. Do you still feel rested in the morning?" C. "I suggest that you plan for a nap in the afternoon to make up for that missed sleep." D. "As we age, those kinds of problems seem more common. Does this disruption in your sleep cause you to be tired or irritable?"
D. "As we age, those kinds of problems seem more common. Does this disruption in your sleep cause you to be tired or irritable?" An older adult awakens more during the night, and it takes more time for an older adult to fall asleep. The answer provides an opportunity for a discussion about the effect this problem may be creating.
A client has reported to the nurse that his sprained ankle resulted from "a careless accident. I seem so clumsy and unfocused lately." Which of the following assessment questions is most likely to reveal information regarding the cause of these symptoms? A. "How many accidents have you had lately?" B. "Have the accidents resulted in serious injuries?" C. "Have there been any changes in your daily routine lately?" D. "Do you have any idea what is responsible for this lack of focus?"
D. "Do you have any idea what is responsible for this lack of focus?" A loss of REM sleep leads to feelings of confusion and suspicion. Various body functions are altered when prolonged sleep loss occurs. Research estimates that traffic, home, and work-related accidents caused by falling asleep are often a result of sleep loss. This answer is the best question because it directly opens up the opportunity for the client to discuss possible sleep problems if they exist.
The nurse is completing an assessment of the client's sleep patterns. A specific question that the nurse should ask to determine the potential presence of sleep apnea is: A. "How easily do you fall asleep?" B. "Do you have vivid, lifelike dreams?" C. "Do you every experience loss of muscle control or falling?" D. "Do you snore loudly or experience headaches?"
D. "Do you snore loudly or experience headaches?" To assess for sleep apnea, the nurse may ask if the client snores loudly or experiences headaches after awakening. A positive response may indicate the client experiences sleep apnea.
A client is concerned that their habit of sleeping during the day and being awake at night is not "healthy or normal." The nurse's most therapeutic response to the client's concern is: A. "What makes you think that sleeping during the day and being up at night is unhealthy or abnormal?" B. Many people share your sleeping habits. As long as you feel all right, I don't think there is anything to worry about." C. Are you interested in changing your sleep habits for any particular reason? Is sleeping during the day a problem for you?" D. Everyone has a different biological clock that controls his or her sleep cycle. As long as you are sleeping and functioning well, your habit isn't abnormal or unhealthy."
D. "Everyone has a different biological clock that controls his or her sleep cycle. As long as you are sleeping and functioning well, your habit isn't abnormal or unhealthy." All persons have biological clocks that synchronize their sleep cycles. If the sleep pattern does not adversely affect the client's health or ability to function, it is not problematic.
The nurse and the parents of a 3 year old are discussing their child's sleep habits. They share a concern over the child's tendency to wake up several times during the night crying out loudly but not really being awake. The nurse addresses the parents' concern more therapeutically by responding: A. "Have you every tried reading a bedtime before putting her to bed?" B. "If she does that only a few times a week, I wouldn't be too overly concerned." C. "Children her age often become poor sleepers. Have you discussed this with her pediatrician?" D. "It is common for children to have trouble relaxing, and this behavior is the result. It's usually temporary."
D. "It is common for children to have trouble relaxing, and this behavior is the result. It's usually temporary." The preschooler usually has difficulty relaxing or quieting down after long, active days and has problems with bedtime ears, waking during the night, or nightmares. Partial wakening followed by normal return to sleep is frequent. In the waking period, the child exhibits brief crying, walking around, unintelligible speech, sleepwalking, or bedwetting.
A 9 year old client asks the nurse, "Why do I need sleep?" The nurse's most age-appropriate, informative response is: A. "Everyone needs to sleep to feel rested." B. "It gives your body a chance to really rest." C. "You'll be able to do so much better in school if you're rested." D. "Your body needs to rest in order to grow and be really healthy."
D. "Your body needs to rest in order to grow and be really healthy." Sleep contributes to physiological and psychological restoration, maintenance, and growth of the body at any age. The body needs sleep to routinely restore biological processes.
triglycerides
circulate in the blood and are composed of three fatty acids attached to a glycerol
How should you cleanse the buttocks?
cleanse from front to back
perineal care
cleansing patients' genital and anal areas
EXUDATE - SEROUS
clear like plasma
Serous
clear, watery plasma
serous
clear, watery plasma
A client shares with the nurse that "My wife complains about my snoring, and I never feel rested." Which of the following responses best attempts to explain the cause of the problem to the client? A. "Sleep disturbances can really affect all aspects of your life. How long have you been experiencing this problem?" B. "You need to get help to breathe more effortlessly at night so both you and your wife can get sufficient deep stage sleep." C. "Something is interfering with your ability to breathe while you are asleep. Have you talked to your health care provider about the problem?" D. "Your upper airway is blocked, and that is making it difficult for you to breathe effectively, so you are spending most of the night in the light sleep stage."
D. "Your upper airway is blocked, and this is making it difficult for you to breathe effectively, so you are spending most of the night in the light sleep stage." The upper airway becomes partially or completely blocked, and diminished nasal airflow can result for as long as 30 seconds. The person attempts to breathe, which often results in loud snoring and snorting sounds. The effort to breathe during sleep results in arousals from deep sleep, often to the stage 2 cycle, causing interference with deep sleep and thus the client's not feeling rested.
Which of the following clients experiencing disrupted sleep patterns is most at risk for obstructive sleep apnea? A. A 15 year old boy with type 1 diabetes B. A 22 year old diagnosed with Crohn's disease C. A 49 year old man who is an avid cross-country runner D. A 58 year old diagnosed with chronic depression
D. A 58 year old diagnosed with chronic depression Many think obstructive sleep apnea affects middle-age men more frequently, particularly when they are obese. However, obstructive sleep apnea is also common in postmenopausal women, younger women, and children. Although the clients in all of the options may experience obstructive sleep apnea, the postmenopausal woman has the greatest risk.
PARTS OF MEDICATION ORDER
client's full name date/time order is written medication name dosage of drug route of administration time/frequency of administration signature of person writing the Rx
Vital signs are the basis for ______
clinical decision making and medication management
ASYMPTOMATIC
clinical signs and symptoms are NOT present
SYMPTOMATIC
clinical signs and symptoms are present
The nurse recognizes that the sleep patterns of older adults differ and older adults generally: A. Are more difficult to arouse B. Require more sleep than middle age adults C. Take less time to fall asleep D. Have a decline in stage 4 sleep
D. Have a decline in stage 4 sleep As people age, there is a progressive decrease in stages 3 and 4 NREM sleep; some older adults have almost no stage 4, or deep, sleep. Older people do not become more difficult to arouse, and do not require more sleep than the middle-age adult.
ATELECTASIS
collapse of alveoli
The mother of a 2 year old child is frustrated because the child does not want to go to bed at a scheduled bedtime. The nurse should suggest that the parent: A. Offer the child a bedtime snack B. Eliminate one of the naps during the day C. Allow the child to sleep longer in the mornings D. Maintain consistency in the same bedtime ritual
D. Maintain consistency in the same bedtime ritual The nurse should advise the parent to maintain a regular bedtime and wake-up schedule and to reinforce patterns of preparing for bedtime. A bedtime routine used consistently helps young children avoid delaying sleep. If a bedtime snack is already apart of that routine, then this is allowable.
A 74 year old male client who normally sleeps on his right side recently underwent a right-side hip replacement surgery and now has trouble sleeping. One of the interventions that the nurse might try with this client is to: A. Request medication to help the client sleep while in the hospital B. Carefully prop the client on his operative side using pillows to support the hip C. Schedule therapy for the evening to help the client become tired so he can sleep D. Question the client to learn more about his normal sleep pattern
D. Question the client to learn more about his normal sleep pattern Knowing a client's usual, preferred sleep pattern allows a nurse to try to match sleeping conditions in a health care setting with those in the home.
FECAL IMPACTION
collection of hardened feces wedged in the rectum cannot be expelled a result of unrelieved constipation contain LEAST amount of moisture
what do you inspect the patient's urine for?
color clarity odor
Lomotil
combination of two drugs, diphenoxylate and atropine. It is used to treat acute diarrhea (diarrhea of limited duration)
SYNERGISTIC EFFECT
combined effect is greater than the effect of the medications when given separately i.e. alcohol is a central nervous system depressant that has a synergistic effect on antihistamines, antidepressants, barbiturates, and narcotic analgesics
Fatty acids
composed of chains of carbon and hydrogen atoms with an acid group on one end of the chain and a methyl group at the other.
LARGE INTESTINE
comprised of six sections - cecum - ascending colon - transverse colon - descending colon - sigmoid colon - rectum
FACTORS THAT INFLUENCE EFFICACY OF DISINTECTION/STERILIZATION
concentration of solution duration of contact type/number of pathogens surface area to treat temperature the environment presence of soap presence of organic materials
JOINTS
connections between bones classified according to its structure and degree of mobility CARTILAGINOUS FIBROUS SYNOVIAL
Benefit of administering med via inhalation
Deep passage of respiratory tract provides a large surface area for med absorption
Describe the characteristics of the following intramuscular injection sites: *Ventrogluteal*
Deep site away from nerves and blood vessels; preferred site for medications for adults; children and infants for larger volumes and viscous and irritating solutions *Gluteus medius*
Pressurized metered-dose inhalers (pMDIs)
Delivers a measured dose of medication with each push of a canister often used with a spacer
As we age peristalsis declines or slows. With limited mobility and a decrease in water and fiber intake can lead to what condition?
constipation
A factor that can hinder chewing and avoidance of meat, fruit, and vegetables
Dental problems ( missing teeth or dentures)
STAT medication order
Describes a single dose of a medication to be given immediately and only once
Double lumen catheter
Designed for indwelling catheters, provides one lumen for drainage and second to inflate the balloon
Assessment in Health Care Environment
Determine existing hazards, contact clinical engineers for questions about equipment.
Toxic Effects
Develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion
toxic effects
Develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion.
Renal failure that cannot be controlled by conservative management -diet and meds don't correct electrolyte imbalance Worsening of uremic syndrome r/t end-stage renal disease -nausea, vomiting, neurological changes Severe electrolyte and/or fluid imbalances that cant be controlled by simpler measure -hyperkalemia, pulmonary edema
Dialysis causes
Laxatives Lack of enzymes Drugs Stress Anxiety
Diarrhea causes
Dehydration Shock Electrolyte imbalance
Diarrhea complications
Remove causative factors Prevent dehydration and spread Provide soft diet Protect skin Promote rest
Diarrhea interventions
REDUCE RESERVOIR - BOTTLED SOLUTIONS
Do not leave bottled solutions open Keep solutions tightly capped Date bottles when opened and discard in 24 hours
Nope
Does the physician's nurse have the prescriptive ability to read you an order that the doctor has written over the phone?
Write out the formula used to determine the correct dose when preparing solid or liquid forms of medications.
Dose Ordered/Dose on hand x Amount on hand = Amount to administer
Lifestyle Risks
Driving under the influence, working at dangerous jobs, stress, anxiety, fatigue alcohol/drug withdrawals, prescription medication.
Hypothalamus
controls body temperature similar to a thermostat; located between the cerebral hemispheres
Drainage Evacuators
convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage
drainage evacuators
convenient, portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage.
MODE OF TRANSMISSION - AIRBORNE
Droplet nuclei or residue that suspend in the air smaller than 5 microns
SIGNS OF DEHYDRATION - INFANTS AND YOUNG CHILDREN
Dry mouth and tongue No tears when crying No wet diapers for 3 hours or more Sunken eyes or cheeks or soft spot in the skull High fever Listlessness or irritability
continent urinary reservoir
created from a distal part of the ileum and proximal part of the colon. the ureters are embedded into the reservoir. the reservoir is situated under the abdominal wall and has a narrow ideal segment brought out through the abdominal wall to form a stoma.
Patient's response
During step 11 of the medication process, (Evaluation), what should be evaluated?
Describe the characteristics of the following intramuscular injection sites: *Deltoid*
Easily accessible but muscle not welled developed; use small amounts; not used for infants and children; potential for injury to radial and ulnar nerves; immunizations for children; recommended site for Hepatitis B and rabies injections.
Infant, Toddler and Preschooler Developmental Interventions
Educate parents on reducing risks, immunizations, baby-proofing, covers for electrical outlet, keyless locks, window guards, CPR, car seats.
Implementation Skills
Effective use of technology and standardized practices, effective use of strategies to reduce risks to self or others, appropriate strategies to reduce reliance on memory.
Acute Care Safety for Electrical Hazards
Electronics must be well maintained. See safety inspection sticker wit expiration date.
TJC and CMS "Speak Up" Campaign
Encourages patients to take role in preventing health care errors by being active, involved and informed participants on health care team.
Basal Metabolic Rate (BMR)
Energy needed at rest to maintain life-sustaining activities for a certain amount of time.
MEDICATION RECONCILIATION - COMMUNICATE
Ensure that all the patient's health care providers have the most updated list of medications Communicate and verify changes in medications as with the patient
Factors influencing nutrition
Environmental, developmental needs, illness, age, adverse effects, cognitive impairment.
The nurse should avoid using lemon-glycerin swabs on a client's tongue and mucous membranes because regular use of this product:
Erodes tooth enamel
Incontinence-associated dermatitis (IAD)
Erythema and edema of the surface of the skin, sometimes accompanied by Bullard with serous exudates, erosion or secondary cutaneous infection
Proteins
Essential for growth, maintenance, and repair of body tissue. Blood clotting, fluid regulation, and acid-base balance all require protein.
What are rectal suppositories used for?
Exerting local effects (promoting defecation) or systemic effects (reducing nausea)
You are helping a female patient bathe. As you are about to perform perineal care, the patient says, "I can finish my bath." The patient has discomfort and burning in the perineal area. What action do you need to take initially?
Explain to the patient that, because of her symptoms, you need to observe the perineal area.
RATE OF ABSORPTION - INTRAVENOUS INJECTION
FASTEST rate of absorption medications are available immediately when they enter the systemic circulation.
Route of administration Ability to dissolve Blood flow to site of administration Body surface area Lipid solubility
Factors that influence absorption
Fall Prevention
Fall risk assessment on admission and routinely until patient discharge. Yellow colored wristbands mean fall risk. Establish elimination schedules, fall pad on floor of bed, gait belt, check rubber tips of assistive aids, non slip shoes, safety bars near toilets, call lights.
Monounsaturated fatty acids
Fatty acid in which some of the carbon atoms in the hydrocarbon chain are joined by double or triple bonds. have only one double or triple bond per molecule and are found as components of fats in such foods as fowls, almonds, pecans, cashew nuts, peanuts, and olive oil
Polyunsaturated fatty acids
Fatty acid that has two or more carbon double bonds.
Disasters
Floods, tsunamis, hurricanes, tornadoes, wildfires. Result in death and leave many homeless. Includes bioterrorism.
Diabetic
Focus on total energy, nutrient and food distribution include a balanced intake of carbs, fats and proteins
what is the fuel of metabolism?
Food
Describe the characteristics of the following intramuscular injection sites: *Vastus lateralis*
For adults and children, muscle is thick and well developed; anterior lateral aspect of the thigh
PATHOLOGICAL FRACTURES
Fractures resulting from weakened bone tissue frequently caused by osteoporosis or neoplasms
Overactive bladder
Frequency and urgency of urination increase -UTI
Random urine specimen
Hat, cup, urinal
IMMUNOCOMPROMISED
Having an impaired immune system
School-Age Child Risks
Head injury (sports), bicycle accidents, decreased use of seat belts.
Factors that can influence a patients compliance with medication regimen
Health beliefs, personal motivation, socioeconomic factors, habits
Condom type external catheters
Held in place by an adhesive coating of the internal lining of the sheath, a double-sided self-adhesive strip, brush-on adhesive applied to the penile shaft, or in rare cases an external strap or tape
The nurse is assisting a patient with rheumatoid arthritis to bathe at the sink. During the bath the patient states that she is tired. The nurse notices the patient is breathing rapidly and the pulse is rapid. What is the nurse's best response?
Help the patient return to bed
Identify the areas a nurse needs to assess to determine the need for and potential response to medication therapy (9)
History History of allergies Medication data Diet history Patient's perceptual coordination problems Patient's current condition Patient's attitude about medication use Patient's knowledge and understanding of medication therapy Patient's learning needs
distribution
How drugs move through the body to tissues, organs, and to specific sites of action
30 min - an hour
How long does it take for po medication to take effect?
Promote urinary elimination -toileting schedule -hygiene -muscle training -maintain adequate fluid intake -positioning -running of water(sensory) -warm water on the perineum
How to manage urinary retention?
RBVO
How would you abbreviate in documentation that you read back an order to a physician that was given to you as a verbal order?
Falls
Huge problem in adults >65, reduced vision, orthostatic hypotension, history of falls, lower extremity weakness, gait and balance problems, urinary incontinence, improper walking aids, medication effects.
Acute Care Safety for Disasters
Identify emergency and impact, adequate supplies, formal plan
Critical Thinking Assessment
Identify patient's perception of safety needs/risks, identify threats, determine impact of illness on safety, identify developmental stage and environment risks, effect of environmental influence on safety.
RESPONSIBILITIES OF INFECTION CONTROL
Identifying/recommending adoption of evidence-based practices for prevention of HAIs Providing staff/patient education on infection prevention & control Developing/reviewing infection prevention & control policies/procedures Recommending appropriate isolation procedures for specific patients Screening patient records for community-acquired infections that are reportable to the public health department Consulting with employee health departments Gathering statistics regarding the epidemiology (cause and effect) of HAIs Notifying the public health department of incidences of communicable diseases Consulting with all hospital departments to investigate unusual events or clusters of infection Monitoring antibiotic-resistant organisms in the institution.
syringe
If liquid medication is less than 5ml, would you use a syringe or a cup?
NO
If patient's BP is 90/50, would you give blood pressure medication?
check with MD
If there is no order for a medication that the patient normally takes at home, what should the nurse do?
SUBCUTANEOUS INJECTION RULE
If you can grasp 2 inches (5 cm) of tissue, insert the needle at a 90-degree angle if you can grasp 2.5 cm (1 inch) of tissue, insert the needle at a 45-degree angle
buildup - could cause overdose
If you had renal failure, what would happen with drugs that are excreted via the kidney?
The nurse is caring for a client who is paralyzed on the right side. Which of the following factors is most likely to result in decubitus ulcer formation?
Immobility
HAI - SURGICAL/TRAUMATIC WOUNDS
Improper skin preparation before surgery (e.g., shaving versus clipping hair; not performing a preoperative bath or shower) Failure to clean skin surface properly Failure to use aseptic technique during operative procedures and dressing changes Use of contaminated antiseptic solutions
FOOTDROP
Inability to dorsiflex and invert foot because of peroneal nerve damage permanent fixation of the foot in plantar flexion
TORTICOLLIS
Inclining head to affected side sternocleidomastoid muscle is contracted
Assessment in Nursing History
Includes data about patients level of wellness and threats to safety. Review as analyze assessment info and if patient taking medications/undergoing procedures.
Environmental Safety
Includes patients physical and psychosocial factors that influence life of the patient and allows staff to function optimally.
Skin breakdown Change in daily activities Change in social relationships
Incontinence leads to what?
Biofeedback,timed and prompter voiding, use of protective pads, skin care
Incontinence managment
Side Rails
Increase patient mobility and/or stability, most commonly used as restraint, can cause falls or death if climbed over.
Amino acid (simplest from of protein)
Indispensable: provided in our diet Dispensable: body synthesizes high quality protein: complete protein. Contains all essential amino acids (fish, chicken)
SUSCEPTIBILITY
Individual's degree of resistance to pathogens
NURSING DX - IMMOBILITY
Ineffective Airway Clearance Ineffective Coping Impaired Physical Mobility Impaired Urinary Elimination Risk for Impaired Skin Integrity Risk for Disuse Syndrome Social Isolation
PATHOGEN
Infectious agent
RHINITIS
Inflammation of mucous membranes lining nose causes swelling and clear, watery discharge
Intraosseous
Infusion of med directly into bone marrow
Identify the benefit of the inhalation route.
Inhaled medications are readily absorbed and work rapidly because of the rich vascular alveolar capillary network present in the pulmonary tissue.
INTRADERMAL (ID)
Injection into the dermis just under the epidermis
Infant, Toddler and Preschooler Risks
Injuries, poisoning, fire (playing with matches), choking, unrestrained in vehicle, drowning, head trauma.
Minerals
Inorganic elements essential to the body as catalysts in biochemical reactions. Macro= more than 100 mg and trace=less than 100 mg.
BODY DEFENSE - MOUTH
Intact multilayered MUCOSA provides mechanical barrier to microorganisms SALIVA washes away particles containing microorganisms saliva contains microbial inhibitor enzymes (lysozyme)
Nitrogen balance
Intake and output of nitrogen is equal. Positive: intake of nitrogen is higher than output. Required for growth, pregnancy, maintenance of body, and wound healing. Negative: higher output. Burns, fever, starvation.
Urethra
Internal and external sphincters control urine flow through the urethral meatus
PIGEON TOES (METATARSIS VARUS)
Internal rotation of forefoot or entire foot; common in infants
MODE OF TRANSMISSION - VECTOR
Internal transmission - mosquito - louse - flea - tick External transmission - flies
INTRAOCULAR ROUTE
Intraocular medication delivery involves inserting a medication similar to a contact lens into a patient's eye eye medication disk has two soft outer layers that have medication enclosed in them nurse inserts the disk into the patient's eye, much like a contact lens medication remains in the eye for up to 1 week
Urge incontinence
Involuntary passage of ursine associated with strong sense of urgency
CAUSES OF CONSTIPATION
Irregular bowel habits Chronic illnesses Low fiber/high fat diet Low fluid intake Stress Physical inactivity Medications (opiates) Life changes (pregnancy, aging, travel) Neurological conditions Chronic bowel dysfunction
LAVAGE
Irrigation of stomach used in cases of active bleeding, poisoning, or gastric dilation Ewald tube is often used
Pepto-Bismal (Bismuth subsalicylate)
It can treat diarrhea, heartburn, nausea, and upset stomach.
Imodium
It can treat diarrhea. It can also decrease the amount of drainage in patients with ostomies.
Briefly describe the roles of the following in relation to the regulation of medications. *Nurse Practice Act*
It defines the scope of a nurse's professional functions and responsibilities.
Medication Classification
It indicates the effect of the medication on a body system, the symptoms the medication relieves, or the medication's desired effect.
PRURITIS
Itching of skin accompanies most rashes
NON-CRITICAL ITEMS
Items that come in contact with intact skin, but NOT mucous membranes MUST BE DISINFECTED!! Bedpans Blood pressure cuffs Bedrails Linens Stethoscopes Bedside trays/patient furniture Food utensils
SEMI-CRITICAL ITEMS
Items that come into contact with mucous membranes or nonintact skin MUST BE HIGH-LEVEL DISINFECTED (HLD)!! Respiratory and anesthesia equipment Endoscopes Endotracheal tubes GI endoscopes Diaphragm fitting rings
REDUCE RESERVOIR - SURGICAL WOUNDS
Keep drainage tubes and collection bags patent prevents accumulation of serous fluid under the skin surface
Calcium and phosphate regulation Bicarbonate and hydrogen ion regulation
Kidneys affect what regulation?
ANAPHYLACTIC REACTIONS
LIFE THREATENING!! characterized by: sudden constriction of bronchiolar muscles edema of the pharynx and larynx severe wheezing shortness of breath
MODE OF TRANSMISSION - DROPLET
Large particles (> 5 microns) Can travel up to 3 feet Contact with a host
SCOLIOSIS
Lateral S- or C-shaped spinal column with vertebral rotation, unequal heights of hips and shoulders
Fire
Leading cause is careless smoking, improper use of cooking equipment/appliances. Only buy new space heaters.
KNOCK-KNEE (GENU VALGUM)
Legs curved inward so knees come together as person walks
anaphylactic reactions
Life threatening constriction of bronchiolar muscles, swelling of throat, and shortness of breath
Acute Care Safety for Radiation
Limit time spent near source, make distance from source as great as possible, use shielding devises.
The client is unable to rest even after medication. The nurse decides to give the client a backrub. Which of the following strokes should the nurse use when finishing the backrub?
Long firm strokes down the back
Acute Care Safety for Seizures
Look out for aura before seizure, protect patient from injury, position for ventilation and drainage of oral secretions, provide privacy and support.
Older Adult Developmental Interventions
Lowe fall risk, safe driving tips, color code hot water faucets to avoid burns, wear reflectors when walking at night, stay on sidewalk, cross at corners, assess waling rout for unequal or damaged walkways.
Oil retention enema
Lubricate the feces to become softer and easier to pass
CONTACT PRECAUTIONS - "MRS. WEE"
M = MDRO R = respiratory infection S = skin infections W = wound infections E = enteric (C. diff) E = eye infection
Body Mass Index (BMI)
Measures weight corrected for height and serves as an alternative to traditional height- weight relationships
d) toxic effect
Medication accumulates in the blood stream a) therapeutic effect b) side effect c) adverse effect d) toxic effect e) idiosyncratic reaction f) drug interaction
INTRAPERITONEAL
Medications administered into the peritoneal cavity are absorbed into the circulation Chemotherapeutic agents, insulin, and antibiotics are administered in this fashion
Kidney Liver Bowel Lungs Exocrine glands
Medications are excreted through:
RATE OF ABSORPTION - MUCOUS MEMBRANES/RESPIRATORY TRACT
Medications placed on the mucous membranes and respiratory airways are absorbed quickly because these tissues contain many blood vessels
Intraarterial medications
Medications that are administered directly into the arteries.
Intrapleural medications
Medications that are administered directly into the pleural space; commonly chemotherapeutic agents
Intracardiac medications
Medications that are injected directly into the cardiac tissue.
Intraarticular medications
Medications that are injected into a joint.
EXCRETION - GI TRACT
Medications that enter the hepatic circulation are broken down by the liver and excreted into the bile After chemicals enter the intestines through the biliary tract, the intestines resorb them
prescriptions
Medications to be taken outside of the hospital are what?
How much water do adults need per day?
Men 3 liters daily, Women 2.2 Liters daily ( perry and Potter)
FLUID INTAKE
Men = 3 L/day Women = 2.2 L/day liquids can be ingested through drinking and through foods (i.e. fruits)
What should the nurse assess prior to feeding a client with aspiration precautions?
Mental status, alertness, orientation, ability to follow simple commands
NORMAL FLORA
Microorganisms that reside in: - surface & deep layers of skin - saliva - oral mucosa - intestinal walls - genitourinary tract
b) trough
Minimum blood serum concentration before next scheduled dose. Drawn in the 30 mins before the next dose. a) serum half-life b) trough c) onset d) peak e) plateau f) duration g) therapeutic range
Trough concentration
Minimum blood serum concentration reached just before next scheduled dose of med
Now order
More specific than one time, used when patient needs med quickly but not right away like STAT orders
Fats (lipids)
Most calorie dense. Composed of triglycerides (circulate in the blood) and fatty acids.
[[What correctly characterizes drug absorption?]]
Most drugs must enter the systemic circulation to have a therapeutic effect. The passage of medication molecules into the blood from the site of administration.
Impaired Mobility Risks
Muscle weakness, paralysis, poor coordination causes falls. Other risks like physiological and environmental from dependence, vehicle not handicap accessible.
VALSALVA MANEUVER - RISK
NOT RECOMMENDED for patients with: cardiovascular disease glaucoma ICP new surgical wounds
Basic Needs Environmental Interventions for Oxygen
No smoking/O2 in use signs in room. Keep O2 away from electrical equipment, store tanks upright to present tipping, check tubing for kinks, keep at prescribed flow,
14-16 Fr, 10-mL balloon
Normal catheter size and balloon size
Peritoneal dialysis
Normal life, just do it at night
CIRCULATION
Once a medication enters the bloodstream, it is carried throughout the tissues and organs How fast it reaches a site depends on the vascularity of the various tissues and organs Conditions that limit blood flow or blood perfusion inhibit the distribution of a medication.
Fecal test
One smear, 3 different bowel movements
PRODROMAL STAGE
Onset of nonspecific signs and symptoms to more specific symptoms
Antidiarrheal meds
Opiates, used with caution, used in patients with diarrhea
Oral medication routes (3)
Oral (swallowed), buccal, and sublingual
Standing or routine order
Order carried out until cancelled by Doctor
Single (one-time) medication order
Order for medication that is given only once at a specified time.
PRN medication order
Order for medication that is given only when a patient requires it.
PRN order
Order to be given only when patient requires it. As needed
vitamins
Organic compounds essential in small quantities for normal physiological and metabolic functioning of the body. With few exceptions, vitamins cannot be synthesized by the body and must be obtained from the diet or dietary supplements.
O&P Culture
Ova and parasites -needs to be kept warm to read
e) idiosyncratic reaction
Over or under reaction to the medication a) therapeutic effect b) side effect c) adverse effect d) toxic effect e) idiosyncratic reaction f) drug interaction
Assessment Risk for Medical Errors
Overwork, fatigue when working 12 hour shifts lead to errors. Use 2 identifiers before administrating medicine/performing procedure.
Transmission of Pathogens
Pathogens and parasites are a threat to safety. Educate about hand hygiene and immunization.
Patient-Inherent Accidents
Patient is primary reason for accident, self-harm, injuries, burns, ingestion/injection of substances, self-mutilation or fire setting, pinching fingers in drawers. Common predisposition is seizure.
Assessment Through the Patient's Eyes
Patient's view of safe different than nurses. Patients often uninformed/inexperienced to threats.
FACTORS THAT INFLUENCE - DISEASE PROCESS
Patients with diseases of the immune system are at particular risk for infection. Diseases that compromise immune defenses include: - leukemia - AIDS) - lymphoma - aplastic anemia
Adolescent Risks
Peer pressure, drinking, smoking, drug use, vehicle accidents, STI's.
Patients Home Environment
Perform hazard assessment, walk home with patient. Adequate lighting, safety devices, furniture placement, flooring condition, safety of kitchen/bathroom, food preparation, medication/cleaning supplies location, heating/cooling, smoke detectors, lead in paint in old homes.
Esophagus
Peristalsis
Critical Thinking Attitudes
Perseverance when identifying safety threats, collect unbiased, accurate data about patients threats to safety, discipline in conducting review of patient home environment.
MODE OF TRANSMISSION - DIRECT CONTACT
Person-to-person contact touching, kissing, sexual contact, contact with oral secretions, contact with body lesions Physical source AND susceptible host
Physical Restraints
Physical or mechanical device, material or equipment that immobilizes or reduces ability of patient to move.
Functional incontinence
Physically or external object that prevents someone from getting to the toilet
REDUCE RESERVOIR - CONTAMINATED SHARPS
Place all needles, safety needles, and needleless systems into puncture-proof containers Federal law requires the use of needle-safe technology Blood tube holders are single use only
REDUCE RESERVOIR - CONTAMINATED ARTICLES
Place tissues, soiled dressings, or soiled linen in fluid-resistant bags for proper disposal
BED REST
Placement of the patient in bed for therapeutic reasons for a prescribed period.
Minimum effective concentration (MEC)
Plasma level of med too low, the effect does not occur
Continuous bladder irrigation
Post-prostate surgery Calculate intake and output
Side Effects
Predictable and often avoidable secondary effects a medication predictably will cause.
Goals and Outcomes
Prevent and minimize safety threats, are measurable and realistic, may include active patient participation.
Hydration, fiber intake, exercise, toileting schedule
Prevent bowel elimination problems
What is the priority concern when providing oral hygiene for a patient who is unconscious?
Preventing aspiration
PATIENT GOALS - INFECTION
Preventing further exposure to infectious organisms Controlling or reducing the extent of infection Maintaining resistance to infection Verbalizing understanding of infection prevention and control techniques
BACTERIOSTASIS
Prevention of growth and reproduction of bacteria by cold temperatures
Setting Priorities
Prioritize nursing diagnoses and interventions to provide safe and efficient care. Maintain independence and involvement. Educate patient and family.
AIRBORNE - BARRIER PROTECTION
Private room NEGATIVE pressure airflow of at least 6 to 12 exchanges per hour via high-efficiency particulate air (HEPA) filtration mask or respiratory protection device, N95 respirator (for TB)
PROTECTIVE ENVIRONMENT - BARRIER PROTECTION
Private room POSITIVE airflow with 12 or more air exchanges per hour HEPA filtration for incoming air mask to be worn by patient when out of room during times of construction in area
CONTACT - BARRIER PROTECTION
Private room or cohort patients gloves, gowns Patients may leave their room for procedures or therapy if infectious material is contained or covered, placed in a clean gown, and if hands are cleaned
DROPLET - BARRIER PROTECTION
Private room or cohort patients mask or respirator required (depending on condition) (refer to agency policy)
IRRIGATION
Process of washing out a body cavity or wounded area with a stream of fluid
Impaction
Prolonged constipation At risk-weak, confused, unconscious, dehydrated
Enema
Promote defication by stimulating peristalsis Tap water Normal saline Hypertonic Soap suds-irritant to stimulate the bowel Medicated-used with patients with high potassium levels
Acute Care Safety for Fires
Protect patients from immediate injury, report location of fire, contain and extinguish if possible, evacuate when appropriate.
Chemical Name
Provides an exact description of the medication's composition and molecular structure.
Enteral Nutrition
Provides nutrients into the GI tract. Preferred method with dysphagia.
Pyuria
Pus in the urine
VASCULAR/CELLULAR RESPONSE
Rapid vasodilation that causes redness @ site localized warmth chemical mediators increase permeability of small blood vessels fluid/protein/cells enter interstitial spaces pain/swelling
DISUSE OSTEOPOROSIS
Reductions in skeletal mass routinely accompanying immobility or paralysis.
Absorption is:
Refers to the passage of medication molecules into the blood from site of adminstration
DIET
Regular daily food intake Fiber in the diet Bulk-forming foods such as whole grains, fresh fruits, and vegetables help remove the fats and waste gas producing foods promote colonic motility bowel walls stretch, creating peristalsis and initiating the defecation reflex
Breath-actuated metered-dose inhalers (BAIs)
Releases medication when a patient raises a level and then inhales
Indwelling catheter
Remains in place over a period of time. Can be short term or long term
DECOMPRESSION
Removal of secretions and gaseous substances from gastrointestinal (GI) tract prevention or relief of abdominal distention
General Preventive Measures by Changing the Environment
Remove obstacles from heavily traveled areas, objects on bedside table within reach of patient but not of children, end tables are secure and have straight legs, eliminate clutter, no small rugs or secure with nonslip pad, electronic alert device.
Equipment-Related Accident
Result from malfunction, disrepair, misuse, or electrical hazard.
You ask the nursing assistive personnel (NAP) to clean a patient who has been incontinent of urine. Several minutes later you pass the open door of the room and see the NAP changing the patient's gown and linen. Which of the following requires your immediate attention?
Room door is open to the hallway.
DROPLET PRECAUTIONS - "SPIDERMAN"
S = Sepsis/Scarlet fever/Streptococcus pharyngitis P = Parvovirus B19/Pneumonia/Pertussis I = Influenza D = Diptheria (pharyngeal) E = Epiglottitis R = Rubella M = Mumps/Meningitis/Mycoplasma/Meningeal pneumonia An = Adenovirus
Mechanical Soft
Same as for clear and full liquid and pureed with addition of all cream soups, ground or finely diced meats, flaked fish, and cottage cheese
Full liquids
Same as for clear liquid with addition of smooth textured dairy products
Pureed
Same as for clear, full liquid with addition of scrambled eggs, pureed meats,vegetables, and fruits
Colonoscopy Occult blood screening-colon cancer Flexible sigmoidoscopy
Screening for elimination
Digestion and absorption of food occurs mainly where?
Small intestine
GRANULATION TISSUE
Soft, pink, fleshy projections of tissue that form during the healing process in a wound not healing by primary intention.
Forms of Medications
Solid, liquid, topical, parenteral forms Table 31-1 page 567
ABSORPTION - WHEN FOOD IS IN THE STOMACH
Some oral medications are absorbed more easily when administered between meals because food changes the structure of a medication and sometimes impairs its absorption
Lack of Safety Awareness Risks
Some people unaware of safety precautions like keeping medication/poison away from children and expiration date on food.
IV fat emulsions
Sometimes added to PN to provide supplemental kilo-calories, prevent essential fatty acid deficiencies and help control hyperglycemia during periods of stress
Anus
Sphincter to deficate
STERILIZATION - MOIST HEAT
Steam is moist heat under pressure. When exposed to high pressure, water vapor reaches a temperature above boiling point to kill pathogens and spores
Shake if needed Place cap upside down Hold label next to palm Hold med cup at eye level Wipe lid and recap
Steps to giving liquid medication
Critical Thinking
Successful critical thinking requires a synthesis of knowledge, experience, critical thinking attitudes, and intellectual and professional standards. Ongoing process.
BODY DEFENSE - EYES
TEARING & BLINKING are mechanisms that reduce entry Tears help wash away pathogens
Basic Needs Environmental Interventions for Food
Teach basic techniques for food preparation.
School-Age Child Developmental Interventions
Teach child about safety in school and at play, proper bicycle safety, sports safety, not to operate electronics unsupervised, firearms in locked cabinets.
PROTEIN BINDING
The degree to which medications bind to serum proteins such as albumin affects their distribution Most medications partially bind to albumin, reducing the ability of a drug to exert pharmacological activity unbound or "free" medication is its active form Older adults and patients with liver disease or malnutrition have decreased albumin in the bloodstream Because more medication is unbound in these patients, they are at risk for an increase in medication activity, toxicity, or both
A medication classification indicates:
The effect of the medication on the body system, symptoms its relieves/ medication's desired effect.
[[Trough concentration]]
The lowest serum level concentration
Celsius
The metric unit of temperature measurement
Trade Name
The name that the manufacturer has trademarked to identify the particular version they manufacture.
The Patient Care Partnership (8)
The patient is informed of meds and what they do, they can refuse meds, they need quality nursing care, need to be properly advised, receive labeled meds, not receive unnecessary meds, be informed of meds involved in research study
Catheterization
The placement of a tube through the urethra into the bladder to drain urine
What does the form of medication determine?
The route of administration
Pharmacokinetics is:
The study of how medications enter the body, reach their site of action, metabolize and exit the body.
[[Pharmacokinetics]]
The study of how medications enter the body, reach their site of action, metabolize, and exit the body.
a) serum half-life
The time required to reduce the concentration of drug in the body by one-half a) serum half-life b) trough c) onset d) peak e) plateau f) duration g) therapeutic range
Convection
The transfer of heat away by air movement
A 61-year-old client with diabetes mellitus has physician's orders for meticulous foot care. Which of the following is the best rationale for this order?
There is increased neuropathy with diabetes mellitus that places the client at risk.
Briefly describe the roles of the following in relation to the regulation of medications. *Health Care Institutions*
They have individual policies to meet federal and state regulations.
d) peak
Time at which a medication reaches its highest effective concentration. 30 mins after last dose has been given. - The point at which elimination rate equals the rate of absorption a) serum half-life b) trough c) onset d) peak e) plateau f) duration g) therapeutic range
c) onset
Time it takes for a medication to produce a response. a) serum half-life b) trough c) onset d) peak e) plateau f) duration g) therapeutic range
MEDICATION ACTION - PEAK
Time it takes for a medication to reach its highest effective concentration
Biological half-life
Time it takes for excretion process to lower amount of unchanged med by half
Explain the rationale for the Z-track method in IM injections.
To minimize local skin irritation by sealing the medication in muscle tissue
*Explain the role of Distribution*
Transportation of drug form absorption to its site of action
Bethanechol
Treat urinary retention
IATROGENIC INFECTION
Type of HAI caused by an invasive diagnostic or therapeutic procedure Examples include: - bronchoscopy - treatment with broad spectrum antibiotics
BODY DEFENSE - URINARY TRACT
URINE FLOW washes away microorganisms on lining of bladder and urethra INTACT MULTILAYERED EPITHELIUM provides barrier to microorganisms
DOCUMENTATION - WHEN DOSE IS LESS THAN A WHOLE UNIT
USE a leading zero BEFORE the decimal point 0.5 mL
80% related to indwelling catheters Failure to wipe front to back Not hand washing Frequent sexual intercourse
UTI causes
Catheter care, perineal care, patient teaching
UTI interventions
Local-dysuria(pain), hematuria(blood), cloudy Local kidney-tenderness, low flank pain' Systemic-fever, chills, malaise, increase WBC's, nausea
UTI symptoms
ADVERSE EFFECTS
Undesired, unintended, and often unpredictable responses to medication
c) adverse effect
Unintended, undesirable, and often *unpredictable* severe response. a) therapeutic effect b) side effect c) adverse effect d) toxic effect e) idiosyncratic reaction f) drug interaction
Adverse Reactions
Unintended, undesirable, and often unpredictable severe responses to medication.
[[Idiosyncratic Reactions]]
Unpredictable effects in which a patient overreacts or under reacts to a medication or has a reaction that is different than normal.
Allergic reaction
Unpredictable response to a medication caused by an immunologic reaction to the drug
allergic reactions
Unpredictable response to medication becoming immunologically sensitized to initial dose
Allergic Reactions
Unpredictable responses to a medication
HAI - URINARY TRACT
Unsterile insertion of urinary catheter Improper positioning of the drainage tubing Open drainage system Catheter and tube becoming disconnected Drainage bag port touching contaminated surface Improper specimen collection technique Obstructing or interfering with urinary drainage Urine in catheter or drainage tube being allowed to reenter bladder (reflux) Repeated catheter irrigations Improper perineal hygiene
MAJOR ROUTE OF TRANSMISSION
Unwashed hands of a health care worker
ERYTHROCYTE SEDIMENTATION RATE (ESR)
Up to 15 mm/hr for men Up to 20 mm/hr for women elevated in presence of inflammatory process
Mixed incontinence
Urgency and frequency mixed together -pregnancy
Phenazopyridine
Urinary analgesics that turns urine bright yellow
Suprapubic catheter
Urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis -paraplegic patients
Double lumen catheter
Urine and balloon to fill with fluid
REDUCE RESERVOIR - BATHING
Use soap and water to remove drainage, dried secretions, or excess perspiration
STANDARD PRECAUTIONS
Use with all patients regardless of Dx apply to blood, blood products, all body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes
Triple lumen catheter
Used for continuous bladder irrigation or when it becomes necessary to instill medications into the bladder
Single lumen catheter
Used for intermittent/straight catheterization
Antimuscarinics
Used to treat urgency, frequency, and nocturia -adverse effects:dry mouth, constipation, and blurred vision -monitor bp because of increases
Intrathecal administration
Via a catheter that is in the subarachnoid space or one of the ventricles of the brain.
Foods to avoid before testing for occult blood int he stool
Vitamin C, raw fruits, aspirin, vegetables
When giving a bath to a newborn, the nurse should:
Wash with water only
The nurse delegates morning care to a new certified nursing assistant. Which of the following actions by the assistant would appropriate?
Washing the client's legs with long strokes from the ankle to the knee
Large intestine
Water absorbed
Peristalsis
Wavelike muscular contractions move the food from the base of the esophagus above the cardiac sphincter.
REDUCE RESERVOIR - DRAINAGE BOTTLES AND BAGS
Wear gloves and protective eyewear if splashing or spraying with contaminated blood or body fluids is anticipated Empty and dispose of drainage suction bottles according to agency policy Empty all drainage systems on each shift unless otherwise ordered by a health care provider Never raise a drainage system (e.g., urinary drainage bag) above the level of the site being drained unless it is clamped off
Blood flow to the tissues Drug's ability to leave the blood stream Drug's ability to enter the cells
What affects distribution of medication?
diabetes high BP infections medications
What are some disease processes/situations that can cause renal failure?
Patient Medication Dose Route Time (frequency) Document
What are the 6 rights of medication administration?
taste irritation absorption
What are the concerns with medication administered orally.
patient's name date & time name of drug dosage route frequency signature
What are the parts of a medication order?
written verbal by telephone
What are the three ways that a physician can give a nurse an order?
contact the physician
What do you do with an inappropriate order?
not to alter dose without checking with their provider
What do you want to be sure to instruct the patient during the evaluation step of the medication process?
slow IV push
What does SIVP stand for?
look-a-like and sound-a-like medications
What else do you need to be cautious about during the medication process?
eye meds (drops)
What is OPHTHALMIC medication?
cholesterol
What is lipitor given for?
tylenol (acetaminophen) & oxycodon
What is percocet a combination of?
pain
What is percocet used for?
clean the eye and eyelashes
What is the first step to administering ophthalmic medication (after completing your MAR checks and medication process)?
1. Check order on MAR with original doctor's order 2. Assess contraindications for receiving oral meds 3. Select correct medication 4. Calculate correct dose 5. Prepare the medication 6. Identify patient 7. Ask patient if they have any questions 8. Check medication to MAR 9. Administer medication 10. Record on MAR & Nurses notes. 11. Evaluation
What is the medication process (8 steps)?
oral
What is the most common and least expensive route of medication administration?
liver
What is the primary site for metabolism?
synergistic
What kind of effect occurs when the combined effect of two medications is greater than the effect of the medications given separately.
refuse medication
What other right does a patient have that isn't technically part of the 6 rights of medication administration?
document
What should you ALWAYS make sure to do when you contact a physician about an inappropriate order.
Absence of bowel movement, nausea, cramping, vomiting
What symptoms follow an intestinal obstruction?
1. Compare med label to MAR as you remove from storage area 2. Compare med label to MAR as you prepare the drug 3. Compare med label to MAR at patient's bedside before you administer each drug
What three checks are performed against the MAR to determine that you have the correct medication?
physician nurse practitioner licensed physician's assistant
What three individuals can prescribe medication?
medication expiration date current dose
What three things do you check with medication against the MAR?
Creatinine
What value do you check for kidney function?
150
When a dextro stick is greater than _____, you need to determine the dosage for insulin units?
BODY SURFACE AREA
When a medication comes in contact with a large surface area, it is absorbed at a faster rate majority of medications are absorbed in the small intestine rather than the stomach
Medical Errors
When medical care plans don't work out or the wrong plan is used.
f) drug interaction
When one drug alters the effect of another drug or both. a) therapeutic effect b) side effect c) adverse effect d) toxic effect e) idiosyncratic reaction f) drug interaction
Synergistic Effect
When the combined effect of the two medications is greater than the effects of the medications when given seperately.
if you have to touch the eye (otherwise clean gloves are fine)
When would you need to wear sterile gloves when applying ophthalmic medication?
cheek
Where should a buccal medication be placed?
sharps container (have another nurse witness)
Where should a narcotic transdermal patch be disposed of?
d) Use a heating pad to help medication absorb
Which of the following is NOT an appropriate action with applying topical medication? a) Wear gloves b) Confirm the area to apply is free of hair c) Hold the patch in place for 10 sec d) Use a heating pad to help medication absorb
a) A patient with renal failure seeing a specialist and a general practice physician. (This patient has 2 risk factors: another condition and seeing multiple doctors)
Which of the following patients is MOST at risk for a medication error? a) A patient with renal failure seeing a specialist and a general practice physician. b) A pregnant patient c) A 34 year old patient on multiple medications who asks lots of questions d) A 2 year old child
- on multiple meds - another condition (renal impairment, pregnancy, etc.) - cannot communicate well - more than one doctor - don't take an active role in med use - children & babies
Which patients are most at risk for medication errors?
Barium enema
White and chalky, have to drink plenty of fluids
FACTORS THAT CONTRIBUTE TO THROMBUS FORMATION - VIRCHOW'S TRIAD
damage to vessel wall alterations in blood flow alterations in blood constituents
PURPOSES OF NASOGASTRIC INTUBATION
decompression enteral feeding compression lavage
ANTIDIARRHEAL AGENTS
decrease intestinal muscle tone to slow the passage of feces as a result, the body absorbs more water through the intestinal walls loperamide diphenoxylate with atropine
Why should you cleanse the buttocks from front to back?
decrease risk of contamination from anal area to urinary tract. Decreases risk of infection.
AGE FACTOR - OLDER ADULTS
decreased chewing ability peristalsis declines esophageal emptying slows muscle tone in perineal floor and anal sphincter weakens
METABOLIC CHANGES DUE TO IMMOBILITY
decreases metabolic rate alters metabolism of CHO, fats & proteins causes fluid, electrolyte & calcium imbalance causes GI disturbance - decreased appetite - slowing of peristalsis
NURSING INTERVENTIONS - RESPIRATORY SYSTEM
deep breath/coughing every 1-2 hours controlled coughing chest physiotherapy (CPT) incentive spirometry
INHALATION ROUTE
deeper passages of the respiratory tract provide a large surface area for medication absorption inhaled medications enter through the nasal and oral passages or endotracheal or tracheostomy tubes endotracheal tubes enter the patient's mouth and end in the trachea tracheostomy tubes enter the trachea directly through an incision made in the neck
DEVELOPMENTAL CHANGES - INFANTS, TODDLERS, & PRESCHOOLERS
delays in the following: gross motor skills intellectual development musculoskeletal development
PARENTERAL NUTRITION
delivery of nutritional supplements through a central/peripheral intravenous catheter
IMMOBILIZATION
depresses peristalsis
Exudate
described as the amount, color, consistency and odor of wound drainage and is part of the wound assessment
GAIT
describes a particular manner/style of walking coordinated action that requires integration of: - sensory function - muscle strength - proprioception - balance - properly functioning CNS
ETHYLENE OXIDE (ETO) GAS
destroys spores and microorganisms by altering the metabolic processes of cells Fumes are released within an autoclave-like chamber ETO gas is toxic to humans, and aeration time varies with products
computerized axial tomography CT
detailed imagery of the abdominal structures provided by computerized reconstruction of cross-sectional images.
NURSE'S ROLE - MEDICATION ADMINISTRATION
determines that medication ordered is the correct medication assesses patient's ability to self-administer administers medication correctly monitors patient for effects educate patients and caregivers
TOXIC EFFECTS
develop after prolonged intake of a medication when a medication accumulates in the blood because of impaired metabolism or excretion
Vaccum Assisted Closure (VAC)
device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together
sweet, fruit-like odor of urine
diabetes
RISK FACTORS FOR COLORECTAL CANCER
diet high in animal fats/red meat low intake of fruit/vegetables smoking/tobacco products excessive alcohol
SIMS' POSITION
differs from the side-lying position in the distribution of the patient's weight. In Sims' position the patient places the weight on the anterior ileum, humerus, and clavicle.
DYSPHAGIA
difficulty swallowing
Dysphagia
difficulty swallowing
HYDROCHLORIC ACID
digests protein
HEMORRHOIDS
dilated, engorged veins in the lining of the rectum can be internal or external
oliguria
diminished urinary output in relation to fluid intake
CONTACT PRECAUTIONS
direct patient contact or environmental contact requires gown & gloves Colonization or infection with multidrug-resistant organisms such as VRE and MRSA, Clostridium difficile, shigella, and other enteric pathogens major wound infections herpes simplex scabies varicella zoster (disseminated) respiratory syncytial virus in infants, young children, or immunocompromised adults
CARPUJETS
disposable injection units single-dose pre-filled syringes sterile cartridge-needle units
wound
disruption of the integrity and function of tissues in the body
SMALL INTESTINE
divided into three sections - duodenum - jejunem - ileum
ANTEGRADE CONTINENCE ENEMA
done in children with fecal soiling associated with neuropathic or structural abnormalities of the anal sphincter continence valve with an opening to the abdomen is surgically created in the intestine patient/caregiver inserts enema via a tube contents flow out through the anus
Write out the formula used to determine the correct dose when preparing solid or liquid forms of medications
dose ordered / dose on hand x amount on hand = amount to administer
MIXING TWO TYPES OF INSULIN
draw up clear insulin BEFORE the cloudy insulin prevents contamination of short-acting insulin with a long-acting insulin
Z-TRACK PROCEDURE
draw up medication change needle pull skin taut laterally 1-1.5 inch insert needle aspirate and inject withdraw needle allow skin to return to normal position
TROUGH LEVEL
drawn 30 minutes before a drug in administered. medication scheduled at 0900 would have a trough drawn at 0830
Antipyretics
drugs that reduce fever
xerostomia
dry mouth
MEDICATION CLASSIFICATION
effect of a medication on a body system symptoms a medication relieves medication's desired effect
Nutrients
elements necessary for normal function of the body. Carbohydrates, protein, Fats, water, vitamins, and minerals.
STERILIZATION
eliminates or destroys all forms of microbial life, including spores
Gluten free
eliminates wheat, oats, rye, barley, and their derivatives.
CARE OF OSTOMY
empty pouch when it is 1/3 to 1/2 full change pouch every 3-7 days assess the stoma color - it should be red assess the skin for irritation or breakdown
MEDICATED ENEMAS
enema solutions that contain drugs. Kayexalate = used to treat patients with high serum potassium levels Neomycin = antibiotic solution that reduces bacteria in the colon before bowel surgery
identify the outcomes for a patient with newly diagnosed type 2 diabetes
Will verbalize understanding of desired effects and adverse effects of medications Will state signs, symptoms, and treatment of hypoglycemia Will monitor blood sugar to determine if medication is appropriate to take Will establish a daily routine that will coordinate timing of medications with meal times
low doses
With the elderly, normally we start with _____ _________ and then watch to see how it affects them.
infants elderly
With which two groups do you need to be very careful when giving medication?
THERAPEUTIC EFFECT
expected or predictable physiological response to a medication
DEFECATION
external anal sphincter relaxes abdominal muscles contract intrarectal pressure increases stool is forced out through the anus
laceration
a break or opening in the skin that may be smooth or jagged. bleed more depending on location and depth
Auscultatory gap
a brief time period when Korotkoff sounds disappear during auscultation of blood pressure; common with hypertension
Heatstroke
a dangerous heat emergency with a high mortality rate
Vacuum-assisted Closure (V.A.C)
a device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together
Wound
a disruption of the integrity and function of tissues in the body
ORTHOSTATIC HYPOTENSION
a drop of blood pressure greater than 20 mmHg in systolic pressure or 10 mmHg in diastolic pressure symptoms include: - dizziness - light-headedness - nausea - tachycardia - pallor - fainting (syncope) occurs when patient changes from the supine to standing position
Fever of unknown origin (FUO)
a fever whose etiology cannot be determined
on gentle palpation how will the bladder feel?
a full bladder may be felt as a smooth and rounded mass
SOLUTIONS
a given mass of solid substance dissolved in a known volume of fluid a given volume of liquid dissolved in a known volume of another fluid used for injections, irrigations, and infusions
UGI endoscopy
a long, flexible tube with a camera—to see the lining of your upper GI tract.
ureostomy or ill conduit
a permanent incontinent urinary diversion created by transplanting the ureters into a closed-off part of the intestinal ileum and bringing the other end out onto the abdominal wall forming a stoma
MOBILITY
a person's ABILITY to move about freely
SIDE EFFECT
a predictable and often unavoidable adverse effect produced at a usual therapeutic dose.
Intravenous fat emulsions
a preparation of 10% fat administered into a vein to help maintain the weight of an adult patient or the weight and growth of a younger patient.
thick and cloudy urine
a result of bacteria and white blood cells
Anaphylactic reaction
a severe allergic reaction that usually occurs immediately after the administration of the drug. Is life threatening.
Dietary reference intakes (DRIs)
a system of nutrition recommendations from the Institute of Medicine (IOM) of the National Academies (United States)
collagen
a tough fibrous protein
Collagen
a tough, fibrous protein
TRAPEZE BAR
a triangular device that hangs down from a securely fastened overhead bar that is attached to the bedframe It allows a patient to pull with the upper extremities to raise the trunk off the bed, assist in transfer from bed to wheelchair, or perform upper-arm exercises
kilocalories
a unit of heat equal to 1000 calories; symbol kcal.
Hypervitaminosis
fat soluble vitamins overdose
PALE YELLOW & OILY STOOL
fatty stool (steatorrhea) occurs with malabsorption syndrome
GUAIAC TEST
fecal occult blood test tests for blood that may be present in stool, but not visible by the naked eye blue color indicates a positive result (meaning there is blood in the stool)
Hormones and temperature
females generally experience more temperature fluctuation than men do especially as progesterone levels rise and fall with the eb and flow of the menstrual cycle
afebrile
fever breaks
what does the glomerulus do?
filters water, glucose, amino acids, urea, uric acid, creatinine, and major electrolytes.
NASOGASTRIC TUBE CATEGORIES
fine/small-bore tube large-bore tube
FIBROUS JOINTS
fit closely together and are fixed, permitting little, if any, movement syndesmosis between the tibia and fibula
SCREENING FOR COLORECTAL CANCER
flexible sigmoidoscopy every 5 years starting at age 50 colonoscopy every 10 years starting at age 50
BRISTOL STOOL SCALE - TYPE 6
fluffy pieces with ragged edges mushy stool
shearing force
force exerted parallel to skin resulting from both gravity pushing down on the body and resistance (friction) between the client and a surface. when the head of the bed is elevated and the sliding of the skeleton starts but the skin is fixed because of friction with the bed
FRICTION
force that occurs in a direction to oppose movement the greater the surface area of the object that is moved, the greater the friction
CONSIDERATIONS - WHEN CHOOSING A DIET THAT PROMOTES NORMAL ELIMINATION
frequency of defecation characteristics of feces foods that impair/promote defecation
in patients with renal disease what does the urine look like?
freshly voided urine appears cloudy because of protein concentration
urinary incontinence associated with chronic retention of urine (overflow urinary incontinence)
involuntary loss of urine caused by an overdistended bladder often related to bladder outlet obstruction of poor bladder emptying because of weak or absent bladder contractions
urge or urgency urinary incontinence
involuntary passage of urine often associated with strong sense of urgency related to an overactive bladder caused by neurological problems, bladder inflammation, or bladder outlet obstruction in many cases bladder overactivity is idiopathic
CONTINENT ILEOSTOMY
involves creating a new pouch from the small intestine continent stoma on the abdomen has a valve that can be drained when a large catheter is placed into the stoma procedure is rarely done
malabsorption
involves problems with the body's ability to take in nutrients from food.
Food security
is critical for all members of a household. This means that all household members have access to sufficient, safe, and nutritious food to maintain a healthy lifestyle
what will bleeding from the bladder or urethra cause the urine to look like?
it usually causes the urine to be bright red
what will bleeding from the kidneys make the urine look like?
it usually causes the urine to become dark red
REDUCE RESERVOIR - BEDSIDE UNIT
keep table surfaces clean and dry
what does adequate elimination depends on the coordinated function of what?
kidneys ureters bladder urethra
Guidelines for measuring vital signs
know your ranges, vitals are your responsibility so even if you delegate you need to make sure the vitals obtained are obtained accurately with equipment that is working properly and in an environment that predicts what the patients actual conditions are
DROPLET PRECAUTIONS
larger than 5 microns, within 3 feet of patient requires surgical mask, proper hand hygiene and dedicated care equipment
dribbling
leakage of small mounts of urine despite voluntary control of micturition
low cholesterol
less than 300 mg a day
TOXIC CONCENTRATION
level at which toxic effects occur
MINIMUM EFFECTIVE CONCENTRATION (MEC)
level of a medication below which the effect of the medication does not occur the concentration is too low to be effective
bacteremia
life-threatening bloodstream infection
BRISTOL STOOL SCALE - TYPE 3
like a sausage cracks on the surface
BRISTOL STOOL SCALE - TYPE 4
like a sausage or snake smooth and soft
oral cavity
lines with mucous membrane
EXCRETION - EXOCRINE GLANDS
lipid soluble medications exit through sweat glands skin often becomes irritated, requiring you to teach patients good hygiene practices
FECES - ASCENDING COLON
liquid to semi-liquid least formed rich in digestive enzymes do not form a hardened mass
ADMINISTERING RX TO CHILDREN - ORAL MEDICATIONS
liquids are safer to swallow use droppers for infants offer juice/beverage afterwards if mixing with food/liquid, mix into a small amount avoid mixing in child's favorite foods plastic/disposable oral syringe is most accurate
hematoma
localized collection of blood underneath the tissues
Hematoma
localized collection of blood underneath tissues
Radial pulse
located at the radial or thumb side of forearm at wrist; common site used to assess character of pulse peripherally and assess status of circulation to hand
functional incontinence
loss of continence because of causes outside the urinary tract. direct result of caregivers not responding in a timely manner to requests for help with toileting
MUSCULOSKELETAL CHANGES
loss of endurance, strength, and muscle mass decreased stability/balance impaired calcium metabolism impaired joint mobility osteoporosis joint contractures footdrop
Hypotension
low blood pressure; systolic reading falls to 90 mm Hg or below
Hypoxemia
low levels of arterial O2
HYPERTONIC SOLUTION ENEMA
low volume solution exerts an osmotic pressure that PULLS fluid out of interstitial spaces colon fills with fluid resultant distension promotes defecation patients unable to tolerate large amounts of fluid benefit from this type of enema
TROUGH CONCENTRATION
lowest serum level of medication in the blood stream
OIL RETENTION ENEMA
lubricate the feces in the rectum and colon feces absorb the oil feces are softer and easier to pass
PRONE POSITION
lying face down/chest down head is often turned to the side (no pillow)
the does the external urethral sphincter do?
made up of striated muscles, contributes to voluntary control over the flow of urine
EXCRETION - KIDNEYS
main organs for medication excretion Some medications escape extensive metabolism and exit unchanged in the urine Others undergo biotransformation in the liver before the kidneys excrete them
HAND ROLL
maintain the thumb in slight adduction and in opposition to the fingers maintains a functional position.
GENERIC NAME
manufacturer who first develops the medication gives the GENERIC or non-proprietary name generic name becomes the official name listed in official publications such as the United States Pharmacopeia (USP) i.e. acetaminophen
RANGE OF MOTION
maximum amount of movement available at a joint in one of the three planes of the body: sagittal, transverse, or frontal
anticholinergics
may increase the risk for urinary retention by inhibiting bladder contractility
hypnotics and sedatives
may reduce the ability to recognize and act on the urge to void
PHYSICAL AGENTS THAT TRIGGER INFLAMMATORY RESPONSE
mechanical trauma temperature extremes radiation
MOUTH
mechanical/chemical breakdown of nutrients (food/liquids) into USABLE size and form
thermoregulation
mechanisms in the body regulate what is lost heat wise and what is gained
MEDICAL ASEPSIS
medical aseptic techniques break the chain of infection. Use these techniques for all patients, even when no infection is diagnosed. Aggressive preventive measures are highly effective in reducing HAIs. Hand hygiene, barrier techniques, and routine environmental cleaning can be performed at home
PRESCRIPTIONS
medication (s) taken outside of the hospital
UNIT DOSE SYSTEM
medication storage system varies by health care agency single-unit packages that contain the ordered dose of medication that a patient receives at one time each table/capsule is wrapped separately carts containing a drawer with a 24-hour supply of medications for each patient
MEDICATION FORMS
medications are available in a variety of forms/preparations - solid - liquid - other oral forms - topical - parenteral - instillation - inhalation the form of medication determines its route of administration
MDROs
multi-drug resistant organisms Include: - MRSA - VRE - Clostridium difficile
Exercise and temperature
muscle activity increase blood supply and fat break down and therefore increases body temperature
Shivering
muscle contraction that requires energy but produces as much to 4 to 5 times greater heat than normal
nephrostomy
nephrostomy tube are small tubes that are tunneled through the skin into the renal pelvis. these tubes are placed to drain the renal pelvis when the ureter is obstructed. patients do go home with these tubes and need careful teaching about site care and signs of infection.
CULTURES/GRAM STAIN OF WOUND, SPUTUM, AND THROAT
no WBC's on gram stain possible normal flora WBCs on gram stain and presence of microorganisms indicates infection
CARTILAGE
non-vascular supporting connective tissue located in the: - joints - thorax - trachea - larynx - nose - ear
BODY DEFENSE - VAGINA
normal FLORA causing vaginal secretions to achieve low pH inhibit growth of microorganisms
CULTURES OF URINE AND BLOOD
normally sterile, without microorganism growth presence of microorganism growth indicates infection
VIALS
note date/time once opened wipe with alcohol before each use inject with the same amount of air as quantity of solution you will be removing
What should you notice about the skin when bathing a patient?
note redness, scaling, flaking, and cracking of skin. Also note areas of tenderness and pain.
Parenteral Nutrition (PN)
nutritional support provided intravenously
Nonshivering thermogenesis
occurs primarily in neonates; because neonates cannot shiver, a limited amount of vascular brown tissue, present at birth, is metabolized for heat production
Postural hypotension
occurs when a normotensive person develops symptoms and low blood pressure when rising to an upright position; aka orthostatic hypotension
Heat exhaustion
occurs when profuse diaphoresis results results in excess water and electrolyte loss
friction
occurs when skin is dragged across a coarse surface (bed linens) usually affecting the top layer or epidermis of skin
micturition
occurs when the brain gives the bladder permission to empty, the bladder contracts, the urinary sphincter relaxes, and urine leaves the body through the urethra.
Blanching
occurs when the normal red tones of the light skinned patient are absent
BLACK STOOL
occurs with ingestion of iron supplements or bismuth preparations (pepto bismol)
common times for urination
on awakening after meals before bedtime most people void on average of 5 or more times a day.
HEMIPARESIS
one-sided weakness
VANCOMYCIN - SIDE EFFECT
ototoxicity assess hearing in patients taking this medication
dysuria
pain or discomfort associated with voiding
what color does normal urine range?
pale straw to amber, depending on the concentration
Serosanguineous
pale, pink, watery, mixture of clear and red fluid
serosanguineous
pale, red, watery; mixture of clear and red fluid
SIDE-LYING POSITION
patient rests on the side with the major portion of body weight on the dependent hip and shoulder.
SUPINE POSITION
patient's in supine position rest on their backs the relationship of body parts is essentially the same as in good standing alignment, except that the body is in the horizontal plane.
NURSING INTERVENTIONS - MUSCULOSKELETAL SYSTEM
perform active/passive ROM exercises use continuous passive motion (CPM) machines
valsalva technique
performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one's mouth, pinching one's nose but while pressing out as if blowing up a balloon
ACTIVE RANGE OF MOTION
performed by the patient unassisted performed to the point of patient's ability
PASSIVE RANGE OF MOTION
performed by the practitioner (nurse, therapist, etc) performed to the point of resistance should not cause pain
EXERCISE
physical activity for conditioning the body, improving health, and maintaining fitness
TRIGGERS FOR INFLAMMATORY RESPONSE
physical agents chemical agents microorganisms
Thermoregulation
physiological and behavioral mechanisms regulating the balance between heat lost and heat produced
DEVELOPMENTAL CHANGES - ADULTS
physiological systems at risk potential job loss
PRIMARY PURPOSES - MASKS
placed on health care personnel to protect them from contact with infectious material from patients (e.g., respiratory secretions) placed on health care personnel when engaged in procedures requiring sterile technique to protect patients from exposure to infectious agents carried in a health care worker's mouth or nose placed on coughing patients to limit potential dissemination of infectious respiratory secretions from the patient to others.
BUCCAL ADMINISTRATION
placing the solid medication in the mouth against the mucous membranes of the cheek until it dissolves teach patients to alternate cheeks with each subsequent dose to avoid mucosal irritation warn patients not to chew or swallow the medication or to take any liquids with it buccal medication acts locally on the mucosa or systemically as it is swallowed in a person's saliva
HAI RISKS - OLDER ADULTS
poor nutrition compromised immunity underlying medical conditions use of invasive treatment devices including IV catheters and indwelling urinary catheters
POSTURE
position of the body in relation to the surrounding space
NURSING INTERVENTIONS - INTEGUMENTARY SYSTEM
position/reposition patient every 1-2 hours provide skin care
ASEPTIC TECHNIQUE
practices/procedures that help reduce the risk for infection. two types of aseptic technique: - medical asepsis - surgical asepsis.
SALEM SUMP TUBE
preferable for stomach decompression one lumen to remove gastric contents a second lumen to provide an air vent a blue "pigtail" is the air vent that connects with the second lumen
STEPS TO PREVENT MEDICATION ERRORS
prepare Rx for one patient at a time follow 6 rights of medication administration read labels at least 3 times use 2 patient identifiers focus on task/patient double check dose calculations verify with a second nurse, when required clarify directly with provider if anything is unclear question unusually large/small doses document all medications as soon as they are given
PHARMACIST
prepares and distributes prescribed medications and ensures: - correct medication - correct dose - correct amount - correct patient provides client education about drug: - side effects - toxicity - interactions - incompatibilities
PRESCRIPTION VS. MEDICATION ORDER
prescription includes more detailed information than a medication order patient needs to understand how to take the medication and when to refill the prescription if necessary
INTEGUMENTARY CHANGES
pressure ulcers break in skin integrity
UPPER ESOPHAGEAL SPHINCTER
prevents air from entering the esophagus prevents food from refluxing into the throat
SURGICAL ASEPSIS
prevents contamination of an open wound serves to isolate the operative area from unsterile environment maintains sterile field for surgery requires MORE stringent techniques
TROCANTER ROLL
prevents external rotation of the hips when a patient is in a supine position.
ENEMA
procedure involving introduction of a solution into the rectum for cleaning/therapeutic purposes cleaning of the bowels
PLEURODESIS
procedure that causes the membranes around the lungs to stick together prevents the buildup of fluid in the space between the membranes (pleural space). Pleurodesis is done in cases of severe recurrent pleural effusions to prevent the reaccumulation of the fluid
Biotransformation
process by which a drug is converted to a less active form
DISINFECTION
process that eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objects
DUODENUM
processes fluid from the stomach Absorbs the most nutrients and electrolytes in tandem with the jejunem
CLEANSING ENEMA
promote complete evacuation of feces from the colon they act by stimulating peristalsis through the infusion of a large volume of solution
MUCUS
protects stomach mucosa from acidity and enzyme activity
FEDERAL GOVERNMENT
protects the health of the people by ensuring medications are safe and effective
FUNCTION OF SKELETAL SYSTEM
protects vital organs - skull (the brain) - ribs (heart & lungs) aids in calcium regulation.
proteinuria
protein found in the urine
Evisceration
protrusion of visceral organs through a wound opening
evisceration
protrusion of visceral organs through a wound opening
NURSING INTERVENTIONS - ELIMINATION SYSTEM
provide adequate hydration serve diet rich in fluids, fruits, vegetables, and fiber
BODY DEFENSE - SKIN
provides a BARRIER to microorganisms and antibacterial activity SHEDDING of skin (outer layer) SEBUM contains fatty acids that kill some bacteria
fibrin
provides a framework for cellular repair. protein involved in the clotting of blood. form a "mesh" that forms a hemostatic plug or clot (in conjunction with platelets) over a wound site
Ideal body weight (IBW)
provides an estimate of what a person should weigh.
SKELETAL SYSTEM
provides attachements for muscles & ligaments provides leverage necessary for mobility
HIGH FIBER FOODS THAT PROMOTE REGULARITY
prunes orange apple w/skin banana raspberries lentils almonds cooked artichoke hearts 100% bran cereal
Wound Contraction
pulling of wound together with black, polyurethane (PU) foam has larger pores and is most effective in stimulation granulation of tissue
HAND HYGIENE - TECHNIQUE
push wristwatch above wrists & avoid wearing rings rinse both hands & wrists 3-5ml soap rub hands vigorously to lather/promote friction wash hands for 20 seconds rinse with warm water for 15 seconds dry hands - fingers to wrists
FOUR AREAS OF ASSESSMENT OF PATIENT MOBILITY
range of motion gait exercise and activity tolerance body alignment
AGE FACTOR - ADOLESCENCE
rapid growth increased metabolic rate increased gastric secretions
3 CHECK RULE
read the label THREE times when you reach for the med before opening/pouring when you replace the med to the drawer and before giving to the patient
SAFE MEDICATION PRACTICES - TELEPHONE PRESCRIPTIONS
read the order back to the provider and get verbal confirmation that the order is correct question any part of the order that is unclear or inappropriate transcribe the order into patient's medical record as it is obtained and verified obtain provider's signature within 24 hours
SUBLINGUAL ADMINISTRATION
readily absorbed after being placed under the tongue to dissolve instruct patients not to swallow a medication given by the sublingual route or drink anything until the medication is completely dissolved
Granulation Tissue
red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing
Normal Reactive Hyperemia
redness-localized vasodilation; blanching w/ fingertip pressure; lasts less than 1 hour
normal reactive hyperemia
redness-localized vasodilation; blanching w/ fingertip pressure; lasts less than 1 hour
NURSING INTERVENTIONS - CARDIOVASCULAR SYSTEM
reduce orthostatic hypotension reduce cardiac workload prevent thrombus formation use of SCDs and TED hose
FACTORS THAT INFLUENCE - NUTRITIONAL STATUS
reduced intake of protein, carbohydrates, and fats reduces body defenses against infection impairs wound healing
metabolism
refers to all of the biochemical reactions within the cells of the body
LOCAL GOVERNMENT
regulate the use of alcohol and tobacco
BODY ALIGNMENT
relationship of one body part to another while in different positions positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying center of gravity is stable
you are caring for a non-English speaking male patient. when preparing to assist him with personal hygiene, you should
remember that culture and ethnicity influence hygiene practices
Debridement
removal of nonviable, necrotic tissue
debridement
removal of nonviable, necrotic tissue
CLEANING
removal of organic material and/or inorganic material from objects and surfaces use water, detergent, and mechanical scrubbing occurs BEFORE disinfection and sterilization procedures
what do the nephrons do?
remove waste products from the blood and play a major role in the regulation of fluid and electrolyte balance
OSTOMY
requires a pouch to collect fecal material location of an ostomy determines stool consistency effective pouching system: - protects skin - contains fecal material - remains odor free - comfortable - inconspicuous
where is the bladder in males?
rests against the rectum
paraphimosis
retracted foreskins can cause dangerous swelling of the penis
LOOP COLOSTOMY
reversible stomas constructed in the ileum or colon two openings through a single stoma distal end = drains mucus proximal end - drains stool
MEDICATION RECONCILIATION - CONSIDER/COMPARE
review what the patient was taking at home or preadmission make sure that the list of medications, dosages, and frequencies is accurate compare this list to the current ordered medications and treatment plan to ensure accuracy include family caregiver in this discussion when appropriate
6 RIGHTS
right medication right patient right dosage right route right time right documentation
NURSING DX - INFECTION
risk for infection imbalanced nutrition impaired oral mucous membrane impaired skin integrity social isolation impaired tissue integrity
DAILY INSULIN INJECTION
rotate injection site within anatomical area provides greater consistency in absorption of medication
FACTORS THAT INFLUENCE ABSORPTION
route of administration ability of the medication to dissolve blood flow to site of administration body surface area (BSA) lipid solubility of medication
vital signs
routine health measurements taken as a indication of health status Evaluation and alteration allows for assessment and signal in change of physiological function -remember that off vital signs are a measure of how much the body is counteracting for improper physiological function
bacteria in the urine
should not be present
crystals in the urine
should not be present
normal glucose in the urine
should not be present
normal ketones in the urine
should not be present
SCD/TED HOSE - CONSIDERATIONS
skill can be delegated to NAP assess for risk factors in VIRCHOW's TRIAD DO NOT MASSAGE patient's legs avoid wrinkles in elastic stockings
Bradycardia
slow heart rate; below 60 beats per minute in adults
PERISTALSIS - ABNORMALLY SLOW
slow movement allows more time for water to be absorbed results in hard stools
URINARY STASIS
slowing or stopping of urine flow In the upright position urine flows out of the renal pelvis and into the ureters and bladder because of gravitational forces. When a patient is recumbent or flat, the kidneys and ureters move toward a more level plane. Urine formed by the kidney needs to enter the bladder unaided by gravity. Because the peristaltic contractions of the ureters are insufficient to overcome gravity, the renal pelvis fills before urine enters the ureters
AGE FACTOR - INFANTS
smaller stomach fewer digestive enzyme secretions rapid intestinal peristalsis ability to control defecation does not occur until 2-3 yrs of age
What are factors that influence hygiene?
social practices, personal preferences, body image, socioeconomic status, health beliefs and motivations and cultural variables.
BRISTOL STOOL SCALE - TYPE 5
soft blobs with clear cut edges passes easily
Slough
soft yellow or white tissue (stingy substance attached to wound bed)
AIRBORNE INFECTION ISOLATION ROOM
specially equipped room with negative pressure air flow N95 respirator must be worn when entering the room
GAIT BELT - CONTROLLED FALL TECHNIQUE
stand with feet apart to provide a base of support extend one leg and let patient slide against it to the floor bend knees to lower body as patient slides to the floor
what does erythropoietin do?
stimulates re blood cell production and maturation in the bone marrow.
END COLOSTOMY
stoma formed by bringing a piece of intestine out through a surgically created opening in the abdominal wall turned down like a "turtleneck" sutured to the abdominal wall
EMOLLIENT OR WETTING
stool softeners are detergents that lower surface tension of feces allows water and fat to penetrate increases secretion of water by the intestine Colace, Surfak, Dialose
STOMACH
storage of swallowed foods/liquids mixing of food/liquids with digestive juices to produce CHYME regulated emptying of contents into the small intestine
Stress
stress both physical and emotional are going to increase body temperature
slough
string substance attached to wound bed - has to be removed before wound can heal properly
PHARMACOKINETICS
study of how medications enter the body, reach their site of action, metabolize and exit the body
Abrasian
superficial with little bleeding and is considered a partial-thickness wound
abrasion
superficial wound with little bleeding, considered a partial-thickness wound. Often appears "weepy" because of plasma leakage from damaged capilliaries
ILEOANAL POUCH ANASTOMOSIS
surgical procedure for patients who need to have a colectomy for treatment of ulcerative colitis or familial adenopolyposis (FAP)
MEDICATIONS VIA ENTERAL TUBE - METHODS
syringe method gravity method
INTRAPLEURAL
syringe, needle, or chest tube used to administer med directly into pleural space chemotherapeutic agents are the most common medications administered via this method
NEEDLE FOR INTRAMUSCULAR (IM) INJECTION - CHILD/INFANTS
syringe: 0.5 to 1 mL needle length corresponds to site of injection, age, and size of patient ventrogluteal: 1/2 to 1 inch vastus lateralis: 5/8 to 1 inch deltoid: 1/2 to 1 inch
NEEDLE FOR INTRADERMAL (ID) INJECTION
syringe: 1 mL tuberculin syringe needle width: 25 to 27 gauge needle length: 1/2 to 5/8 inch
NEEDLE FOR SUBCUTANEOUS U-500 INSULIN
syringe: 1 mL tuberculin syringe needle width: 25 to 27 gauge needle length: 1/2 to 5/8 inch
NEEDLE FOR SUBCUTANEOUS U-100 INSULIN
syringe: 1 mL with preattached needle needle width: 28 to 31 gauge needle length: 5/16 to 1/2 inch
NEEDLE FOR SUBCUTANEOUS INJECTION
syringe: 1 to 3 mL needle width: 25 to 27 gauge needle length: 3/8 to 5/8 inch
NEEDLE FOR INTRAMUSCULAR (IM) INJECTION - ADULT
syringe: 2 to 3 mL needle length corresponds to site of injection, age, and size of patient ventrogluteal: 1.5 inch vastus lateralis: 5/8 to 1 inch deltoid: 1 to 1.5 inch
Vital signs
temperature, pulse, blood pressure, respiratory rate, oxygen saturation, and pain; they indicate the effectiveness of circulatory, respiratory, neural, and endocrine body functions
BOWEL DIVERSIONS
temporary or permanent artificial openings in the abdominal wall
SOAPSUDS ENEMA
the addition of soapsuds to tap water or saline solutions creates the effect of intestinal irrigation to stimulate peristalsis
poistvoid residual
the amount of urine left in the bladder after voiding and is measured either by ultrasound or straight catheterization
Catabolism
the breakdown of biochemical substances into simpler substances and occurs during physiological states of negative nitrogen balance.
Anabolism
the building of more complex biochemical substances by synthesis of nutrients
simple carbohydrates
the classification for both monosaccharides and disaccharides; they are found primarily in sugars.
malnutrition
the condition that develops when the body does not get the right amount of the vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ function.
Vegetarianism
the consumption of a diet consisting predominantly of plant foods.
macrominerals
the daily requirement is 100 mg or more. help to balance the pH of the body, and specific amounts are necessary in the blood and cells to promote acid-base balance.
Pulse pressure
the difference between systolic and diastolic pressure
Pulse deficit
the difference between the apical and radial pulse rates; created by an inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site
Perfusion
the distribution of red blood cells to and from the pulmonary capillaries
Blood pressure
the force exerted on the walls of an artery by the pulsing blood under pressure from the heart
Friction
the force of two surfaces moving across one another such as the force exerted when skin is dragged across course surface such as bed linens
phimosis
the foreskin will become tight and cannot be retracted, increasing risk for inflammation and infection
EFFICACY - TYPE & NUMBER OF PATHOGENS
the greater the number of pathogens on an object, the longer the required disinfecting time.
NEEDLE GAUGE
the higher the number, the smaller the needle hub colors vary by manufacturer
urinary retention
the inability to partially or completely empty the bladder
primary areas to be assessed
the kidneys bladder external genitalia urethral meatus perineal skin
A single medication may have three different names. Trade name:
the medication's name as trademarked by whoever is manufacturing it (the name the product is being sold by).
Diastolic pressure
the minimal pressure exerted against the arterial walls at all times
Ventilation
the movement of gases in and out of the lungs
Diffusion
the movement of oxygen and carbon dioxide between the alveoli and the red blood cells
epithelialization
the natural act of healing by secondary intention; the proliferation (rapid reproduction) of new epithelium into an area devoid of it but that naturally is covered by it
what do you do if the urine output falls below 30 ml/hr?
the nurse should immediately assess for signs of blood loss and notify the health care provider
Systolic pressure
the peak of maximum pressure when ejection occurs
Tissue Ischemia
the pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time
Enzymes
the protein-like substances that act as catalysts to speed up chemical reactions.
cystectomy
the removal of the bladder
wound contraction
the shrinkage and spontaneous closure of open skin wounds. begins almost concurrently with collagen synthesis. centripetal movement of wound edges that facilitates closure of a wound. maximal 5-15 days after injury
Skin temperature regulation
the skin has many blood vessels (very vascular) and the constriction or dilation of these vessels controls temperature regulation
Fahrenheit
the temperature scale used in the United States
BIOLOGICAL HALF-LIFE
the time it takes for excretion processes to lower the amount of unchanged medication by half
Convection
the transfer of heat away by air movement
Evaporation
the transfer of heat energy when a liquid is changed to gas
Conduction
the transfer of heat from one object to another with direct contact
Radiation
the transfer of heat from the surface of one object to the surface of another without direct contact between the two
Medical nutrition therapy (MNT)
the use of specific nutritional therapies to treat an illness, injury, or condition. It is necessary to help the body metabolize certain nutrients, correct nutritional deficiencies related to the disease, and eliminate foods that may exacerbate disease symptoms.
Cardiac output
the volume of blood pumped by the heart during 1 minute; the product of heart rate (HR) and the ventricle's stroke volume (SV)
what do pelvic floor muscles do?
these muscles stabilize the urethra and contribute to urinary continence
what do kidneys do?
they play a major role in blood pressure control via the renin-angiotensin system.
Purulent
thick, yellow, green, tan or brown
purulent
thick, yellow, green, tan, or brown pus or drainage
ACHILLES TENDON
thickest and strongest tendon in the body
Sutures
threads or metal used to sew body tissues together
sutures
threads or metal used to sew body tissues together
PATIENT RIGHTS
to be informed about a medication to refuse a medication to have a medication history to be properly advised about experimental nature of medication to receive labeled medications safely to receive appropriate supportive therapy to NOT receive unnecessary medications to be informed if medications are part of research study
NEEDLE ASPIRATION FOR IM INJECTIONS
to ensure that the needle is in the muscle and not in the vascular system blood return upon aspiration indicates improper placement
Radiation
transfer of heat from the surface of one object to the surface of another without any direct contact. (as much as 85% of the body radiates heat out) -something to consider in the OR because if the room is cold heat will radiate out
CLOSTRIDIUM DIFFICILE
transmitted via oral-fecal route harder to eliminate from the environment alcohol based hand sanitizers are INEFFECTIVE with C. diff spore-forming microorganism can remain on surfaces (e.g., bedside table, stethoscope) in a dormant state for long periods of time. MUST wear gloves/gowns
SYNOVIAL JOINTS
true joints, hinge type at the elbow are freely movable and the most mobile, numerous, and anatomically complex body joints
ACTIVITY TOLERANCE
type and amount of exercise or work that a person is able to perform without undue exertion or possible injury Assessment of activity tolerance is necessary when planning activity such as walking, ROM exercises, or ADLs. Activity tolerance assessment includes data from physiological, emotional, and developmental domains
Who are at most risk for infection?
uncircumsized males, patients with indwelling catheters, those recovering from rectal or genital surgery or childbirth
IDIOSYNCRATIC REACTION
unpredictable overreaction or undereaction reaction different from normal reactions i.e. benedryl causes agitation or excitement instead of drowsiness in young children
UI associated with chronic retention of urine
urine leakage caused by an overfull bladder
MEDICATIONS VIA ENTERAL TUBE
use a 60 mL syringe with appropriate tip - catheter tip for large bore tube - luer-lok for small bore tube - enteral-only connector (ENFit)
AMPULES
use a gauze pad and break away from you a colored ring around the neck indicates where the ampule is prescored so you can break it easily use filter needle to withdraw medication change needle
DIGITAL REMOVAL OF STOOL - CONSIDERATIONS
use only as a last resort procedure is uncomfortable for patient excess rectal manipulation causes irritation to the mucosa, bleeding, and stimulation of the vagus nerve
TRANSCRIBING A PRESCRIPTION
use whole numbers - no decimal points - no terminal zero i. e. 5 mg tablet Only quantities SMALLER than one must be shown with zero preceding decimal point i.e. 0.5 mg tablet
LARGE-BORE TUBES
used for gastric decompression or removal of gastric secretions Levin and Salem sump tubes are the most common for stomach decompression
EWALD TUBE
used for gastric lavage
FINE/SMALL-BORE TUBES
used for medication administration and enteral feedings
PATIENTS AT MOST RISK
very young older adults women patients taking multiple medications patients extremely underweight or overweight patients with renal or liver disease
Diaphoresis
visible perspiration primarily occurring on the thorax and head -per hour of exercise 1/2-2 L of body fluid can be lost
arteriogram
visualization of renal arteries and branches to detect narrowing, occlusion or deformity
polyuria
voiding excessive amounts of urine
frequency
voiding more than 8 times during waking hours and/or at decreased intervals such as less than ever 2 hours
HAND HYGIENE - WHEN HANDS ARE VISIBLY SOILED
wash them with either a nonantimicrobial (C. diff) or an antimicrobial soap and water
EFFICACY - CONCENTRATION OF SOLUTION
weakened concentration or shortened exposure time lessens its effectiveness
DEVELOPMENTAL CHANGES - OLDER ADULTS
weaker bones increased fall risk increased physical dependence on others accelerated functional losses
NOW ORDER
when a medication is needed right away, but not STAT
POLYPHARMACY
when a patient takes multiple medications or potentially inappropriate or unnecessary medications when a medication does not match a diagnosis
Fever or Pyrexia
when excessive heat production gets out of control and the heat loss systems can no longer keep up resulting in an abnormal rise in body temperature
When should you change bed linens?
when linen becomes soiled or wet. Make sure there are no wrinkles.
tissue ischemia
when living tissue is deprived of oxygen - depriving tissue of adequate blood flow is the same as depriving tissue of oxygen
When are privacy, comfort and safety important?
when making an occupied bed
Explain the reason why polypharmacy happens to a patient.
when patients need to take several medications to treat their illnesses, take two or more medications with the same or similar actions or mix nutritional supplements or herbal products with medications,
RENAL FUNCTION
when renal function declines, the kidneys cannot excrete medications adequately increased risk for medication toxicity
denuded skin
when the top layer is off, sore is very superficial and usual caused from a shearing force or friction "sheet burn"
Environment
whether in a warm room or in a cold room your body will regulate accordingly
TENDONS
white, glistening, fibrous bands of tissue occur in various lengths/thickness strong, flexible, INELASTIC connect muscle to bone
primary intention
wound healing with skin edges that are approximated, risk of infection is low, healing occurs quickly with minimal scar formation as long as infection and secondary breakdown is prevented (similar to a surgical wound)
Secondary Intention
wound heals by granulaion tissue formation, wound contraction, and epithelialization
secondary intention
wound is left open until it fills with scar tissue, wound healing takes longer and chance of infection is greater. If scarring is severe often a permanent loss of tissue function occurs - (usually burns, pressure ulcers, or severe laceration)
INTRACARDIAC
Injection of med directly into cardiac muscle performed by physician
Conduction
The transfer of heat from one object to the other with direct contact
[[Biological half-life]]
The time it takes for excretion processes to lower the serum medication concentration by half.
MEDICATION ACTION - DURATION
Time during which medication is present in concentration great enough to produce a response
MEDICATION ACTION - ONSET
Time it takes after a medication is administered for it to produce a response
vegan
consume only plant food
EXUDATE - PURULENT
contains WBC's and bacteria
dermis
contains bundles of collagen, nerve fibers, blood vessels, sweat glands, sebaceous glands, and hair follicles
EXUDATE - SANGUINEOUS
contains red blood cells
SKELETAL MUSCLES
contract and relax working elements of movment
BOWEL SOUNDS
hypoactive normoactive hyperactive borborygmi
A false high blood pressure reading may be assessed, as the nurse explains to the nurse assistant, if the assistant: 1. Wraps the cuff too loosely around the arm 2. Deflates the blood pressure cuff too quickly 3. Repeats the blood pressure assessment too soon 4. Presses the stethoscope too firmly in the antecubital fossa
1
A nurse administers pain medication for a client complaining of pain. The nurse first assesses vital signs and finds them to be as follows: blood pressure, 134/92 mm Hg; pulse, 90 beats per minute; respirations, 26 breaths per minute. The nurse's most appropriate action is to: 1. Give the medication 2. Ask if the client is anxious 3. Check the client's dressing for bleeding 4. Recheck the client's vital signs in 30 minutes
1
Failure to instill ear drops at room temperature causes:
1. Vertigo 2. Dizziness 3. Nausea
What is the maximum IM injection volume of medication for a: 1. well developed adult 2. older children, older adults, THIN adults 3. older infants and small children
1. 2-5 mL in a large muscle 2. 2mL 3. 1ml
List the five advantages of using intermittent venous access devices.
1. Cheaper 2. Convenient 3. Increases mobility 4. Safety 5. Patient comfort
The onset of drug action is the time it takes for a drug to: 1. Produce a response 2. Accelerate the cellular process 3. Reach its highest effective concentration 4. Produce blood serum concentration and maintenance
1. produce a response rationale: Definition of onset
specific gravity of urine
1.003-1.030
Indicate the maximum volume of medication for an IM injection: *Well developed adults*
2 to 5 mL into a large muscle
Procedure-Related Accidents
Caused by healthcare providers. Medication/fluid administration errors, improper application of external devices, accidents related to improper performance.
CRITICAL ITEMS
Items that enter sterile tissue or the vascular system MUST BE STERILE!! Surgical instruments Cardiac or intravascular catheters Urinary catheters Implants
The study of how drugs enter the body, reach their sites of action, are metabolized, and exit from the body is called: 1. Pharmacology 2. Pharmacopoeia 3. Pharmacokinetics 4. Biopharmaceutical
3. Pharmacokinetics
The form of the medication determines its:
Its route of administration
24. A patient is diagnosed with a bowel obstruction. The nurse chooses which type of tube for gastric decompression? a. Salem sump b. Dobhoff c. Sengstaken-Blakemore d. Small bore
ANS: A A bowel obstruction causes a backup into the gastric area; a nasogastric tube may be inserted to decompress secretions and gases from the gastrointestinal tract. The Salem sump has the width and functionality needed to both feed and suction, and it is ideal for a bowel obstruction. A Dobhoff tube is used for instillation of feedings. A Sengstaken-Blakemore tube is used to compress stomach contents to prevent hemorrhage. A small bore is intended for nutritional feedings only and does not have suction capacity.
synergistic effect
Combined effects of two medications are greater than if meds were given separately
INTRA-ARTERIAL
Administered directly into artery common in patients who have arterial clots and receive clot-dissolving agents
Epidural
Administered in epidural space via a catheter
Intraperitoneal
Administered into peritoneal cavity
EFFICACY - SURFACE AREA
All dirty surfaces and areas need to be fully exposed to disinfecting and sterilizing agents. The type of surface is an important factor. Is the surface porous or nonporous?
weight
All medications with infants are calculated by what?
Identify seven of the potential nursing diagnoses used during the administration of medications (7)
Anxiety Ineffective Health Maintenance Readiness for Enhanced Immunization Status Deficient Knowledge Noncompliance Effective Therapeutic Regimen Management Impaired Swollowing
A 2-year-old child is brought into the emergency department after ingesting a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis
B
The client is unable to perform self-care for the hair. Which of the following is accurate when performing hair care?
Brushing the hair distributes the natural oils evenly.
Overuse of antibiotics and contact with C. Diff
Causes of C.Diff
A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate? a. "Are you following any weight loss program?" b. "How many calories a day do you consume?" c. "Do you have dry mouth or feel thirsty?" d. "How many times a day do you urinate?"
D
EFFICACY - PRESENCE OF ORGANIC MATERIALS
Disinfectants become inactivated unless blood, saliva, pus, or body excretions are washed off
EFFICACY - TEMPERATURE OF THE ENVIRONMENT
Disinfectants tend to work best at room temperature
OSTEOPOROSIS
Disorder characterized by abnormal rarefaction of bone, occurring most frequently in postmenopausal women, sedentary or immobilized individuals, and patients on long-term steroid therapy.
a) therapeutic effect
Expected or predictable The desired effect of the drug or the reason the drug is prescribed. a) therapeutic effect b) side effect c) adverse effect d) toxic effect e) idiosyncratic reaction f) drug interaction
Abnormal reactive hyperemia
Excessive vasodilation and induration; skin is bright pink to red; NO blanching with fingertip pressure; can last 1 hour to 2 weeks; Stage I pressure ulcer
abnormal reactive hyperemia
Excessive vasodilation and induration; skin is bright pink to red; NO blanching with fingertip pressure; can last 1 hour to 2 weeks; Stage I pressure ulcer
EXOGENOUS INFECTION
Infection originating OUTSIDE an organ or part Do not exist in normal flora Examples include: - Salmonella - Clostridium tetani - Aspergillus
HOUSEHOLD MEASUREMENTS
Household units of measure are familiar to most people include drops, teaspoons, tablespoons, and cups for volume and pints and quarts for weight.
15 min
How long does it take for IV medication to take effect?
decreased metabolism = decreased drug affects
Liver damage will result in what?
Measurements used in medication therapy (3)
Metric, Apothecary, and household
MEDICATION ACTION - TROUGH
Minimum blood serum concentration of medication reached just before the next scheduled dose
hepatitis alcoholism diabetic malnutrition cirrhosis of the liver
Name 2 diseases/conditions that would affect the liver (and its ability to metabolize drugs).
can't swallow unconscious intubated NPO order vomiting
Name some contraindications for receiving oral meds
Components of medication orders (7)
Name, date, time, med name, dose, route, time and frequency to give med(eg. bid), signature of healthcare provider
What are the 3 different liquid viscosities?
Nectar, Honey and Pudding liquids
COLONIZATION
Organism that multiplies within a host but does not cause an infection
Which assessment does Jamie need to complete before helping Mrs. Winkler and Carol continue with foot care?
Observing condition of the feet and nails
MEDICATION RECONCILIATION - OBTAIN/VERIFY/DOCUMENT
Obtain a comprehensive and current list of a patient's medications whenever he or she experiences a change in health care setting Include all current prescriptions and over-the-counter (OTC) medications
Now medication order
Order for medication when a patient needs a medication quickly but not right away; the nurse has up to 90 minutes to administer.
STAT order
Order for single dose to be given immediately and only once
Standing or routine medication order
Order that is carried out until the prescriber cancels it by another order or until a prescribed number of days elapse.
Single (One time) order
Order to be given only once at a specified time
[[Biotransformation]]
Occurs under the influence of enzymes that detoxify, break down, and remove active chemicals Occurs in the [[ liver*]]
BIOTRANSFORMATION
Occurs under the influence of enzymes that detoxify, degrade and remove biologically active chemicals (mostly in the liver)
Medication Interaction
Occurs when one medication modifies the action of another medication; it may alter the way another medication is absorbed, metabolized, or eliminated from the body.
Restraint Ongoing Assessment
Proper documentation of behaviors that necessitated application of restraints, procedure used in restraining, condition of restrained body part, evaluation of patient response.
Briefly describe the roles of the following in relation to the regulation of medications. *Federal Government*
Protects the health of the people by ensuring that medications are safe and effective. FDA ensures that all medications undergo vigorous testing before being sold.
FECAL SPECIMENS - NON STERILE COLLECTION
RN can delegate to UAP fecal specimens must be free of urine, water from toilet, and toilet tissue
FECAL SPECIMENS - STERILE COLLECTION
RN must collect sample using aseptic technique sterile swab used to collect specimen specimen placed into sterile collection cup
Insulin is classified by...
Rate of action ( Each has a different onset, peak, and duration of action)
Bladders
Reservoir for urine until the urge to urinate occurs
A nurse teaching a family member caregiver how to bathe the patient explains the importance of using long strokes on the patient's extremities, moving from distal to proximal. Which explanation does the nurse include? Long strokes moving from distal to proximal are used to:
Stimulate venous return.
Some causes of dysphagia can occur after what conditions?
Stroke, Multiple Sclerosis ( MS), Parkinson's disease, Cerebral Palsy (CP).
True
T/F: Home medications are generally continued in hospital settings.
Transient incontienence
Temporary because of what is going on -infection -coughing
topical medications
Tube or prepackaged dermal applications
Read back, telephone order
What does RBTO stand for?
Identify the three types of measurements used in medication therapy.
a.) *Metric* b.) Apothecary c.) Household
PARALYTIC ILEUS - SIGNS/SYMPTOMS
abdominal pain absent bowel sounds nausea and vomiting
JOINT CONTRACTURE
abnormal and possibly permanent fixation of a joint caused by disuse, atrophy, and shortening of muscle fibers
induration
abnormal firmness or hardness of tissue with margins as a result of edema or inflammation
Pyrogens
bacteria and viruses that act as antigens, triggering immune system responses and elevating the body temperature
pyridium
changes the color of urine to orange
what is chronic urinary retention?
has a slow, gradual onset during which patients may experience a decrease in voiding volumes, straining to void, frequency, urgency, incontinence, and sensations of incomplete emptying.
SENGSTAKEN-BLAKEMORE TUBE
use for compression internal application of pressure by means of inflated balloon prevents internal esophageal or GI hemorrhage
FACTORS THAT INCREASE PERISTALSIS
use of laxatives and enemas accelerate medication excretion through the feces
DOBHOFF TUBE
used for enteral feeding
MILLER-ABBOTT TUBE
used for gastric decompression
