NUR 160 FINAL
Assertive communication techniques
"I" statements Fogging Confidence Manage nonverbal communication Thinking before speaking Avoid unnecessary apologizing
evisceration interventions
- Semi-Fowler's - Notify MD - Cover intestine with sterile gauze and NS - Monitor VS - Prepare for OR
How do we prevent pneumonia
-Cough and deep breathing -Incentive spirometer
dehiscence interventions
-Cover with sterile dressing/towel moistened with saline -Notify the surgeon -Bend legs/avoid abdominal pressure
The nurse has orders to collect a sputum spec imen from a patient who has a frequent cough and greenish sputum. The patient repeats back the instructions the nurse gave them. Which patient statement indicates further teaching?
-I should rinse my mouth out with mouthwash prior to giving the specimen
What is traction used for?
-reduce muscle spasms -realign bones -relieve pain -prevent deformities
Infertility is defined as not being pregnant despite having unprotected sex for how long?
1 Year
Therapeutic Communication Techniques
1) ACTIVE LISTENING - Shows clients that they have your undivided attention 2) OPEN-ENDED QUESTIONS - Used initially to encourage clients to tell their story in their own way. Ask questions in a language that a client can understand 3) CLARIFYING - Questioning clients about specific details in greater depth or directing them toward relevant parts of the history. 4) SUMMARIZING - Validates the accuracy of the story.
pneumonia interventions
1. Assess lung sounds for signs of crackles, Check RR, TEMP, AND O2 SAT, pulse, BP. 2. Call MD stat 3. Place patient in high fowlers 4. TCDB/Incentive spirometry 5.Collect sputum sample if ordered 6. Anticipate an order for respiratory to obtain breathing treatments 7.Give oxygen if needed 8.Anticipate an order for a chest X-ray, ABG, CBC 9.Give fluids
What is the normal level for PSA?
4
The nurse are responsible for which action when the patient signs an informed consent?
A witness
A patient with emphysema is having difficulty breathing after ambulating to the bathroom which medication will the patient take for immediate re lief of the breathing difficulty / asthma attack
Albuterol
Adverse event is?
An event in which care resulted in an undesirable clinical outcome.
Which member of the hospice team is going to follow up 1 year after death?
Bereavement coordinator
Missty vision
Cataracts
Osteoarthritis
Caused by gradual degenerative changes of the joint. Causing pain, swelling and reduced mobility of the joint
Fluid Volume Excess (FVE
Cerebral edema - can lead to hyponatremia
Patient with post-op with getting turp what do you expect to see in their bag in the first 24 hours?
Cherry red pink urine in the catheter bag
What is compartment syndrome?
Compartment syndrome is a serious condition that involves increased pressure in a muscle compartment. It can lead to muscle and nerve damage and problems with blood flow.
What catheter do you use for a male with an enlarged prostate with urinary retention?
Coude
Ambulation with a crutches
Crutch measurement: crutch pad 2 inches (2-3 finger widths) below axilla, crutch tips 6 inches to side and 6 inches in front of pa taint's feet. Elbows should be flexed 15-30 de grees.
Fluid volume deficit (FVD)
Dehydration is - hypernatremia- (too much sodium) can lead to con fusion, drowsiness and coma
Five stages of Kubler-Ross grief?
Denial, Bargaining, Acceptance, Anger, Depression
Older adults most experience what type of accident?
Falls
The LPN is caring for a patient who has crackles bilaterally on inspiration that does not clear with coughing. Which would the LPN anticipate as the cause of crackles?
Fluid in the lungs
A patient is exhibiting the following signs and symptoms: dry mucus membranes, poor skin tur gor and tenting of skin. The nurse knows there are signs and symptoms of which of the following?
Fluid volume deficit (FVD
The post operative patient tells the nurse "I felt some thing pop near my incision" Upon assessing the sur gical safe, the nurse noticed the wound is it in the process of dehiscence. The nurse understands this may have occurred due to which process?
Forceful coughing
You assess a patient with the following changes BP 90/80 Potassium 6.2 Hypokalemia
Give patient loop diuretic
halo vision
Glaucoma
Sentinel event
Harm to death or permanent injury
Which of these signs indicates infection of cast extremity?
Hot Spot on Cast
The nurse assessing a patient that has exhibited positive Chovestick and Trousseau signs. The nurse knows these are signs of which imbalance?
Hypocalcemia
. The nurse has orders to collect a sputum spec imen from a patient who has a frequent cough and greenish sputum. The patient repeats back the instructions the nurse gave them. Which patient statement indicates further teaching?
I should rinse my mouth out with mouthwash prior to giving the specimen
Which medication can be brought over the counter is for Inflammation
Ibuprofen
When should a self breast exam be done?
Immediately after menstruation or on day 5-7 of cycle
What is pelvic inflammatory disease?
Infection of the reproductive tract in the female, usually but not always an advanced stage of gonorrheal infection.
Fluid balance is maintained in which body system?
Kidneys
2 point Gait Crutch Walking Directions
Left crutch/Right foot move in unison, followed by opposite crutch/foot
se balance when caring for a patient with long term diarrhea
Metabolic Acidosis
The LPN is caring for a patient admitted to the hospital with hyperemesis, nausea, weakness, low potassium of 2.9 , and placed on continuous nasogastric suctioning. Which primary acid base imbalance is the patient at risk for if the patient remains on continuous nasogastric suctioning?
Metabolic Alkalosis
Signs and symptoms of Parkinson's disease
Mild tremors Shuffling gait Change in speech Muscle Rigidity
Bucks Traction
Minimize muscle spasms. Keep fracture in alignment. provide immobilization.
. What intervention do you take when a patients potassium level is too low?
Monitor heart rate and rhythm
Nurses' priority action an hour before surgery when a patient does not sign an informed consent.
Notify the doctor.
The LPN notices on assessment the patient has tachycardia and hypotension. Which of the following is the nurse's next action?
Notify the physician to request an in crease in the IV fluid rate.
The nurse has attempted to insert a foley into a patient with a history of Benign Prostate Hyperplasia (BPH) without success. Which action is the nurse's priority?
Obtain an order for a coude catheter
COPD patient experiencing an episode of dyspnea leaning on the bed side table what position is this called?
Orthopneic
The most common arthritis is?
Osteoarthritis
Your patient is taking (Coumadin) for anticoagulation. Which lab will you need to draw
PT/INR
The nurse is administering heparin to a post-op patient following a recent surgical procedure. Which lab value should be checked?
PTT
What is palliative care?
Palliative care promotes quality of life through pain and symptom management.
The LPN is completing a head-to- toe assessment on a patient. Which pulse assessment is not appropriate for the nurse to take?
Palpate the carotid arteries bilaterally at the same time
Intervention strategy for respiratory alkalosis
Paper bag breathing
What is the myths about hospice?
Patients are forced. Only provided for cancer patients. Giving up hope. Just for patients that are actually dying. Sign a DNR
The nurse is providing care to a patient had a bowel resection, with a midline incision that has ten sutures. In order to predict and manage potential complications, which action should the nurse take?
Place the patient in semi fowlers knees slightly flexed
Respiratory focused assessment
Post ox Count respirations.
Proscar teaching for medication. what should you educate them on?
Pregnant family members shouldn't have it crushed.
Signs and Symptoms of Osteoporosis
Prevent with Vitamin D Bone fractures occurs more frequent Receding gums Weakened grip strength Stooped posture. This is caused by the compression of the vertebrae which may also cause a slight curving of the upper back. Loss of height over time Lower back Pain worsens with Cough and deep breath or sharp movements- Fosamax meds- Know how to take meds Take once a week early in the morning on empty stomach, sit up right for 30mins
HP high, CO2 high, CO3 normal
Respiratory Acidosis
The most severe arthritis?
Rheumatoid arthritis
Autonomic dysreflexia is a sign and symptoms?
Sever throbbing headache.
What causes cataracts?
Smoking diabetes long term cortical steroid use Exposure to maternal ruella
A person that gives the patient spiritual advice?
Spiritual coordinator
Treatment for osteoporosis
Surgery for joint replacement Swimming bike riding ibuprofen Tylenol 4000mg daily dose
The patient asks the LPN what could have con tinued to their diagnosis of metabolic acidosis. Which of the following statements would be an appropriate response by the nurse?
The diarrhea you experienced during the last week caused your imbalance"
The patient asks the LPN what could have contin ued to their diagnosis of metabolic acidosis. Which of the following statements would be an appropriate response by the nurse?
The diarrhea you experienced during the last week caused your imbalance"
What factors affect therapeutic communication negativity?
Trust the way we talk
Adverse effects
Undesirable effect that are a direct response to drugs
Position a COPD patient sits in
Up learning over the bed side table
How do we lose fluid from the body?
Urine Stool Sweat
What absorbs calcium?
Vitamin D
An older adult patient who has rheumatoid arthritis wants recommendations on how to get daily exercise. Which response by the nurse would be the most appro priate?
You should try swimming. It eases movement"
. Rheumatoid arthritis
a chronic autoimmune disorder in which the joints and some organs of other body systems are attacked
how does eyes get tested in Snellen chart
assessing visual acuity while looking through a pinhole
Risk factors for osteoporosis
cigarette smoking European ancestry slender build
Hypocalcemia
deficient calcium in the blood
What hormones do the ovaries produce?
estrogen and progesterone
Hypercalcemia
excessive calcium in the blood
Good therapeutic communication
explaining everything you doing to the patient
Patient hearing aids teaching
keep them charged when isn't in use
Distended bladder Least appropriate measure
limiting bladder cauterization
What are the clinical signs of death?
no blood pressure no apical pose no respirations NO VITALS
which of the following are interrelated concepts to reproduction. select all that apply.
nutrition, gas exchange, perfusion, anxiety, hormonal
When should a self breast exam be done on menopausal women
on the same day each month
The LPN is caring for a patient with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Which arterial blood gas values indicate that the patient is in respiratory acidosis?
pH 721 PaCO2 49. HCO3 25
what action would the nurse take when caring for Jackson Pratt drainage
secure the drain to the client gown below the wound
TNM classification
staging
Evisceration
the protrusion of organs outside the body
Dehiscence
the separation of a surgical incision or rupture of a wound
