NUR 304 Test 2 + EAQ 1: Safety and Infection Control Due sept 23rd + practice EAQ

HgB lower than _________ indicates blood transusion

7 or 8 with active bleed/symptomatic

What is the correct sequence for suctioning a patient? 1. Open kit and basin. 2. Apply gloves. 3. Lubricate catheter. 4. Verify functioning of suction device and pressure. 5. Connect suctioning tubing to suction catheter. 6. Increase supplemental oxygen. 7. Reapply oxygen. 8. Suction airway. 6, 4, 3, 1, 2, 5, 8, 7 4, 6, 1, 2, 3, 8, 5, 7 4, 6, 1, 3, 2, 5, 8, 7 6, 4, 1, 3, 2, 5, 7, 8

4, 6, 1, 3, 2, 5, 8, 7 these steps allow for smooth completion of procedure while helping to maintain patient's level of oxygenation.

Components of the Medication Order/Prescription:

Patient's full name Date and time Name of medication Dosage, size, frequency, (number of doses-may be omitted in hospital) Route of administration Signature of prescriber, including relevant credentials and legal registration number ALL COMPONENTS MUST BE PRESENT

Hemothorax v Pneumothorax

o Hemothorax-Accumulation of fluid and blood in pleural space o Pneumothorax-Accumulation of air in the pleural space

Core temperature : Axillary oral tympanic sublingual forehead pulmonary artery

Core temperature = tympanic, pulmonary artery, urinary bladder, esophageal (INSIDE) a. NOT CORE: axillary, sublingual, skin, temporal artery, oral, rectal --> not inserted in people's bodies

quadrants of the abdomen

Describing where an abdominal organ or pain is located is made easier by dividing the abdomen into four imaginary quadrants. *Right upper quadrant (RUQ) *Left upper quadrant (LUQ) *Right lower quadrant (RLQ) *Left lower quadrant (LLQ)

Mr. Jones was hospitalized with gastritis. He is being discharged home with a new medication, esomeprazole 40 mg PO Daily. He has told you he hates to take pills, since he never knows how or when to take them, and you identify a nursing diagnosis of Deficient Knowledge r/t medications underuse What are some goals for Mr. Jones?

Educate Mr. Jones on the importance of taking the medication to calm inflammation down from gastritis b/c is very painful—tell him to take before food so he will remember to do it and may help with pain Things that need to be on the prescription

After seeing a patient, the health care provider starts to give a nursing student a verbal order for a new medication. The nursing student first needs to: Follow ISMP guidelines for safe medication abbreviations. Explain to the health care provider that the order needs to be given to a registered nurse. Write down the order on the patient's order sheet and read it back to the health care provider. Ensure that the six rights of medication administration are followed when giving the medication.

Explain to the health care provider that the order needs to be given to a registered nurse. Nursing students cannot take medication orders.

You are providing care for a post operative patient and hear wheezing in the posterior lung fields. Which would be the appropriate response? Order a stat chest Xray Have the patient cough and listen again Order an ABG Instruct the patient not to breathe so deeply

Have the patient cough and listen again

Tips of Syringes

Luer-Lok syringe (note threaded tip) non-Luer-Lok syringe (note smooth graduated tip)

Blood flow through the heart

Name the flow Blood flow through the heart. The diagram shows the vena cava, right atrium (1), tricuspid valve (2), right ventricle (3), pulmonic valve, pulmonary arteries, pulmonary veins, left atrium (4), mitral valve (5), left ventricle (6), aortic valve, and the aorta. Contraction = systole Relaxation = diastole S1=av valve closure (TM) = start of systole S2 = semilunar valve closure (AP)= start of diastole

-CALCIUM AND PHOSPHATE HAVE A ________________ relationship*** ex: if patient has hyperphophatemia, calcium will __1__...if patient has___2___, phosphate will drop) Bones are always releasing or sucking calcium back; if we have low calcium in the blood, we will release more phosphate

RECIPROCAL RELATIONSHIP 1. drop 2. hypercalcemia ******** when calcium is low, PHOSPHATE goes up in blood and vice vera; so bones will basically respond in a way to protect the bones from bone loss

The nurse goes to assess a new patient and finds him short of breath with a rate of 32 and lying supine in bed. What is the priority nursing action? Raise the head of the bed to 60 degrees or higher. Get his oxygen saturation with a pulse oximeter. Take his blood pressure and respiratory rate. Notify the health care provider of his shortness of breath.

Raising the head of the bed will bring the diaphragm down and allow for better chest expansion thus improving oxygenation.

How would you assess a confused patient for sensory alterations? 2. Richard is a 90-year-old man who has been a resident at a skilled nursing facility for 10 years. He has no visitors, never leaves his room, has no television or radio in the room, and no longer speaks. He does not respond to verbal or tactile stimulation. He lies in bed in a fetal position. When staff try to move him, he moans and howls.

Sensory deprivation all around; wnt to perform AROM if can or PROM if cant; not talking so he responds to pain by howling or moaning/groaning

Match the concepts for a critical thinker on the right with the application of the term on the left. Truth seeking Open-mindedness Analyticity Systematicity 1. Anticipate how a patient might respond to a treatment. 2. Organize assessment on the basis of patient priorities. 3. Be objective in asking questions of a patient. 4. Be tolerant of the patient's views and beliefs

Truth seeking -->3. Be objective in asking questions of a patient. Open-mindedness-->4. Be tolerant of the patient's views and beliefs Analyticity-->1. Anticipate how a patient might respond to a treatment. Systematicity-->2. Organize assessment on the basis of patient priorities.

a patient suffers a broken leg and has a respiratory rate of 32 BPM. the nurse would suspect which of the following clinical manifestations? a. respiratory alkalosis from hyperventilation b. respiratory acidosis due to pain c. metabolic acidosis from blood loss d. metabolic alkalosis from hypoventilation

a. respiratory alkalosis from hyperventilation the only info you have is responsible rate is 32 BPM (DONT OVER-READ)

HYPOKALEMIA

deficient potassium in the blood CAUSES: -inadequate potassium intake -Excess loss --sweat --GI losses --diuretics --renal losses -transcellular losses --insulin -------------- *****CLINICAL MANIFESTATIONS -muscle weakness + leg cramps -fatigue -anorexia and N+V (nausea & vomiting) -decrease bowel sounds -cardiac arrhythmias (v-tach and v-fib arrest)

Only ____________ SALINE CAN BE RUN WITH BLOOD****

normal saline (0.9%) b/c isotonic and don't want to pull out products from blood—do not give blood w/ half saline

1. Water Loss-- Metabolic-fever, exercise, diarrhea, tube feedings 2. Sodium Gain (not as common)

two mechanisms of hypernatremia

The nurse writes an expected outcome statement in measurable terms. An example is: a. Patient will have normal stool evacuation b. Patient will have fewer bowel movements c. Patient will take stool softener every 4 hours d. Patient will report stool soft and formed with each defecation

d. Patient will report stool soft and formed with each defecation *Stool that is soft and formed at each defecation is measurable upon observation. "Patient will have normal stool evacuation" is a goal. Indicating that the patient will have fewer bowel movements is not specific enough for measuring improvement, and having a patient take a stool softener every 4 hours is an intervention

Hypomagnesemia

insufficient amount of magnesium in the extracellular fluid ETIOLOGY: -malabsorption: SB resection, enemas, diarrhea -alcoholism -diuretics **********WHAT TYPE OF PATIENTS HAVE LOW MAGNESIUM DIETS???????? SUBSTANCE ABUSERS -alchoholics, diuretic users, or if malabsorption nutrition issue) ----- **CLINICSL PRESENTATIONS -Decreased LOC -EKG changes: -Flat or inverted T waves, - prolonged QT interval -Hyperreflexia: overactive or overresponsive reflexes. -Dysrhythmias -Similar to hypocalcemia

A client is experiencing stomatitis as a result of chemotherapy. Which action should the nurse take when caring for this client? 1 Provide frequent saline mouthwashes 2 Use karaya powder to decrease irritation 3 Increase fluid intake to compensate for accompanying diarrhea 4 Offer meticulous skin care of the abdomen with a gentle antiseptic

1 Provide frequent saline mouthwashes Saline mouthwashes are soothing to the oral mucosa and help clean the mouth, minimizing infection. Stomatitis refers to the oral cavity; karaya is used to protect the skin around a stoma created on the abdomen. Stomatitis does not cause diarrhea or fluid loss. The abdomen is not involved; stomatitis is an inflammation of the oral mucosa. Stomatitis is inflammation of the mouth and lips. It refers to any inflammatory process affecting the mucous membranes of the mouth and lips, with or without oral ulceration.

The nurse is providing dietary teaching to a client who is receiving hemodialysis. What should the nurse encourage the client to include in the dietary plan? 1 Rice 2 Potatoes 3 Canned salmon 4 Barbecued beef

1 Rice Foods high or moderately high in carbohydrates and low in protein, sodium, and potassium are encouraged for clients on hemodialysis. Potatoes are high in potassium, which is restricted. Canned salmon is high in protein and sodium, which usually are restricted. Barbecued beef is high in protein, sodium, and potassium, which usually are restricted.

Which treatment is beneficial for a client with muscle spasm? 1 Thermotherapy 2 Muscle massage 3 Frequent position changes 4 Muscle-strengthening exercise regimen

1 Thermotherapy Thermotherapy, the use of heat therapy, eases pain and muscle contraction; therefore it is useful in treating muscle spasms. Muscle massage stimulates muscle tissue contraction and may worsen a muscle spasm. Frequent position changes are beneficial for a client with contracture. A muscle-strengthening exercise regimen is beneficial for a client with muscle atrophy.

1. Which of the following examples are steps of nursing assessment? (Select all that apply.) 1. Collection of information from patient's family members 2. Recognition that further observations are needed to clarify information 3. Comparison of data with another source to determine data accuracy 4. Complete documentation of observational information 5. Determining which medications to administer based on a patient's assessment data

1. . Collection of information from patient's family members 2. Recognition that further observations are needed to clarify information 3. Comparison of data with another source to determine data accuracy Assessment includes collection of data from secondary sources such as the patient's family. Recognizing that more observation is needed is an example of validation of data. Comparing data to determine accuracy is a feature of interpretation. Although complete documentation is an important step in communicating assessment data, it is not an assessment step.

14. The use of formal nursing diagnoses serves several purposes in nursing practice, including..? (Select all that apply.) 1. Defines a pt's problem, giving members of care team a common language for understanding the pt's needs 2. Allows physicians and allied health staff to communicate with nurses how they provide care among themselves 3. Helps nurses focus on the scope of nursing practice 4. Creates practice guidelines for collaborative health care activities 5. Builds and expands nursing knowledge

14. Answer 1, 3. The use of nursing diagnosis creates a common language for nurses to communicate patient care needs and allows nurses to focus on the realm and scope of nursing practice. It is not a language for physicians and allied health staff because they do not rely on providing nursing interventions. Terminology in nursing diagnosis may be familiar to other healthcare providers but not in a way for directing nursing interventions. Nursing diagnosis has the purpose of creating practice guidelines for nursing.

Which diagnostic test/exam would best measure a client's level of hypoxemia? a. chest x-ray b. pulse oximeter reading c. ABG d. peak expiratory flow rate A nurse is caring for an older bedridden male client who is incontinent of urine. Which action should the nurse take first? 1 Restrict fluid intake. 2 Offer the urinal regularly. 3 Apply incontinence pants. 4 Insert an indwelling urinary catheter. Which diagnostic test/exam would best measure a client's level of hypoxemia? a. chest x-ray b. pulse oximeter reading c. ABG d. peak expiratory flow rate

2 Offer the urinal regularly. Offering the urinal is the first step. Retraining the bladder includes a routine pattern of attempts to void, which may increase bladder muscle tone and produce a conditioned response. Restricting fluid intake can result in dehydration and a urinary tract infection in an older client. Applying incontinence pants does not address the cause of the incontinence; also it promotes skin breakdown and can lower self-esteem. Inserting an indwelling urinary catheter increases the risk of a urinary tract infection. Also, it requires a primary healthcare provider's prescription.

When a nurse requests that a client's pain intensity be rated on a scale of 0 to 10, the client states that the pain is "99." How does the nurse interpret the client's behavior? 1 Needs the instructions to be repeated 2 Requires an intervention immediately 3 Does not understand the numeric scale 4 Is using humor to get the nurse's attention

2 Requires an intervention immediately The client reported a number as instructed but chose a number beyond the stated intensity scale. When numbers above 10 are identified, clients are communicating that the pain is excessive; immediate nursing action is indicated. It is not likely that the client misunderstood the instructions or does not understand the numeric scale; the client reported a number as instructed but chose a number beyond the stated intensity scale. The client has the nurse's attention; the use of humor is not commonly associated with clients in pain.

While a nurse is teaching a client with diabetes about food choices, the client states, "I do not like broccoli." Which food should the nurse suggest to substitute for broccoli? 1 Peas 2 Corn 3 Green beans 4 Mashed potato

3 Green beans According to exchange lists for meal planning, green beans and broccoli are equivalent vegetable substitutes. Peas are a starch and are not an equivalent vegetable substitute for broccoli. Corn is a starch and is not an equivalent vegetable substitute for broccoli. Mashed potato is a starch and is not an equivalent vegetable substitute for broccoli.

A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. How should this be documented in the client's medical record? 1 Urge incontinence 2 Stress incontinence 3 Overflow incontinence 4 Functional incontinence

3 Overflow incontinence Overflow incontinence describes what is happening with this client; overflow incontinence occurs when the pressure in the bladder overcomes sphincter control. Urge incontinence describes a strong need to void that leads to involuntary urination regardless of the amount in the bladder. Stress incontinence occurs when a small amount of urine is expelled because of an increase in intraabdominal pressure that occurs with coughing, lifting, or sneezing. Functional incontinence occurs from other issues rather than the bladder, such as cognitive (dementia) or environmental (no toileting facilities).

A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea? 1 Increased fiber intake 2 Bacterial contamination 3 Inappropriate positioning 4 High osmolarity of the feedings

4 High osmolarity of the feedings The increased osmolarity (concentration) of many formulas draws fluid into the intestinal tract, which can cause diarrhea; such feedings may need to be diluted initially until the client develops tolerance or is changed to a more iso-osmolar strength formula. Formulas frequently have reduced fiber content. Bacterial contamination is not a factor if the manufacturer's recommendations are followed. Inappropriate positioning may increase the risk for aspiration, but it does not cause diarrhea.

To prevent skin breakdown on the scalp of an infant with hydrocephalus, how should the nurse position the infant? 1 On either side and flat 2 Supine and Trendelenburg 3 Prone, with the legs elevated about 30 degrees 4 Supine, with the head elevated about 45 degrees

4 Supine, with the head elevated about 45 degrees The head should be elevated, allowing gravity to minimize intracranial pressure. The Trendelenburg position is contraindicated because it can increase intracranial pressure. The infant may be positioned on the back or side to allow routine changes in head position.

Place the steps of the scientific method in their correct order with number 1 being the first step of the process. 1. Formulate a question or hypothesis. 2. Evaluate results of the study. 3. Collect data. 4. Identify the problem. 5. Test the question or hypothesis. 4, 3, 1, 5, 2 3, 4, 1, 2, 5 4, 3, 2, 1, 5 3, 4, 1, 5, 2

4, 3, 1, 5, 2 The correct order of the steps of the scientific method are: Identify the problem, collect data, formulate a question or hypothesis, test the question or hypothesis, and evaluate results of the test or study.

atelectasis v pneumothorax

A collapsed lung happens when air enters the pleural space, the area between the lung and the chest wall. If only part of the lung is affected, it is called atelectasis. If it is a total collapse, it is called pneumothorax

Your patient has hypokalemia with stable cardiac function. What are your priority nursing interventions? (Select all that apply.) Fall prevention interventions Teaching regarding sodium restriction Encouraging increased fluid intake Monitoring for constipation Explaining how to take daily weights

A. Fall prevention interventionsD. Monitoring for constipationHypokalemia causes bilateral skeletal muscle weakness, especially in the quadriceps, which creates a risk for falling. It also causes gastrointestinal smooth muscle weakness, which produces constipation.

Which assessment do you interpret as a transfusion reaction? Crackles in dependent parts of lungs High fever, severe hypotension Anxiety, itching, confusion Chills, tachycardia, and flushing

Anxiety, itching, confusion

A nurse has seen many cancer patients struggle with pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping patients focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of: Creativity. Fairness. Clinical reasoning. Applying ethical criteria.

Applying ethical criteria. The use of ethical criteria for nursing judgment allows a nurse to focus on a patient's values and beliefs. Clinical decisions are then just, faithful to the patient's choices, and beneficial to the patient's well-being.

After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection. What should the nurse do next? (Select all that apply.) Assess the injection site Administer an oral medication for pain Notify the patient's health care provider of assessment findings Document assessment findings and related interventions in the patient's medical record This is a normal finding so nothing needs to be done Apply ice to the site for relief of burning pain

Assess the injection site Notify the patient's health care provider of assessment findings Document assessment findings and related interventions in the patient's medical record If a patient describes localized pain, numbness, burning or tingling at an IM injection site, you need to suspect possible injury to nerve or tissues. Appropriate nursing actions include assessing the site, notifying the patient's health care provider, and documenting your findings.

A nurse accidently gives a patient the medications that were ordered for the patient's roommate. What is the nurse's first priority? Complete an occurrence report. Notify the health care provider. Inform the charge nurse of the error. Assess the patient for adverse effects.

Assess the patient for adverse effects. Correct Whenever a medication error occurs, the first action of the nurse is to assess the patient.

A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, "I think my hearing aid is broken. I can't hear anything." Which of the following teaching strategies should be implemented? (Select all that apply). Demonstrate hearing aid battery replacement. Review method to check volume on hearing aid. Demonstrate how to wash the ear mold and microphone with hot water. Discuss the importance of having wax buildup in the ear canal removed. Recommend a chemical cleaner to remove difficult buildup.

Demonstrate hearing aid battery replacement. Review method to check volume on hearing aid. Discuss the importance of having wax buildup in the ear canal removed. The earmold should be wiped with warm water and a mild soap. The microphone should not be allowed to get wet. Chemical cleaners should not be used. For difficult buildup the brush that was included with the aid should be used to sweep away debris.

By using known criteria in conducting an assessment such as reviewing with a patient the typical characteristics of pain, a nurse is demonstrating which critical thinking attitude? Curiosity Adequacy Discipline Thinking independently

Discipline Discipline is being thorough in whatever you do. Using known criteria for assessment and evaluation, as in the case of pain, is an example of discipline.

Your patient is hyperventilating from acute pain and hypoxia. Interventions to manage his pain and oxygenation will decrease his risk of which acid-base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Hyperventilation causes excessive excretion of carbonic acid, putting the patient at risk for developing respiratory alkalosis. Interventions to decrease the pain and hypoxia that are causing his hyperventilation will decrease his risk of respiratory alkalosis.

An intravenous (IV) fluid is infusing more slowly than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.) Infiltration at vascular access device (VAD) site Patient lying on tubing Roller clamp wide open Tubing kinked in bedrails Circulatory overload

Infiltration at vascular access device (VAD) site Patient lying on tubing Tubing kinked in bedrails Factors that could slow an IV infusion even if the infusion pump is set correctly include increased pressure at the outflow site (e.g., infiltration) and compression of the tubing lumen (e.g., patient lying on the tubing or tubing kinked in bedrails).

Hyponatermia

Low sodium, dehydration -can be hypertonic or hypotonic -Causes H20 to move out of the vascular space into the intersitital space and then into the intracellular space Labs: o Plasma sodium below 135 mEq/L o Osmolality below 285 mOsm/kg o Specific Gravity below 1.010 ------------------------- CAUSES: -Excessive sweating and loss of sodium -GI suction -Extreme Intake of salt free fluids -Adrenal Insufficiency -Head injury, stroke -Diuretic therapy --------------------- ********** KNOW SIGNS AND SYMPTOMS OF (CLINICAL MANIFESTATIONS) -malaise (feeling of debility), muscle cramps -apprehension -abdominal cramps -Nausea and vomiting, Diarrhea **NEUROSTATIC CHANGES, neurotransmission is off -headache -IRRITABILITY LEADING TO Confusion and Lethargy < 120 -Convulsions and Coma

normal values serum electrolytes ******MEMORIZE NORMAL GENERAL VALUES OF THE ELECTROLYTES AND THEIR RANGES OF THESE LABS*******

Na+ 135 to 145 mEq/L K+ 3.5 to 5.0 mEq/L Cl- 95 to 105 mEq/L Ca++ 8.5 to 10.5 mEq/L Mg++ 1.8 to 3.0 mEq/L Phos. 2.4 to 4.1 mEq/L Serum Osmolality: 280 to 300 mOsm/Kg H20

A nurse is preparing medications for a patient. The nurse checks the name of the medication on the label with the name of the medication on the doctor's order. At the bedside the nurse checks the patient's name against the medication order as well. The nurse is following which critical thinking attitude: Responsible Complete Accurate Broad

Responsible The nurse is demonstrating responsibility for correct medication and patient identification. The other three choices are critical thinking intellectual standards.

6 rights of drug administration

Right drug Right patient Right dose Right route Right time Right documentation Other Rights** Right reason Right to know Right to refuse

Your patient has severe hypercalcemia. What are your priority nursing interventions? (Select all that apply.) Fall prevention interventions Teaching regarding sodium restriction Encouraging increased fluid intake Monitoring for constipation Explaining how to take daily weights

Severe hypercalcemia causes lethargy, which creates a risk for falling and constipation. Increased fluid intake is important to prevent renal calculi during hypercalcemia.

when using a needle, should the bevel be up or down?

UP

Antidiuretic hormone is released when there is a(n): a. decreased blood osmolarity b. increased blood osmolality c. ion gap d. osmoreceptor decrease

b. increased blood osmolality-->ADH responds to increase in osmolality (the higher the serum osmolality, the more dehydrated b/c there are more solutes) ADH released when more solutes to water in plasma--> means there is less water Negative feedback system, so im going to hold onto ADH, tell kidneys to hold onto water to balance out solutes to water ======================================== if solute level normalizes, and hypothalamus is still secreting ADH

A patient is given a dose of narcotic pain medication and has the following ABG: 7.31 CO2 40 HC03 24 which is the correct interpretation of the ABG? a. metabolic acidosis, partial compensation b. metabolic alkalosis, no compensation c. respiratory acidosis, uncompensated d. respiratory alkalosis, partial compensation c. respiratory acidosis, uncompensated--> b/c bicarb is normal and holding on due to narcotic pain med CNS is decompensated; slowing down respiratory rate =========== a. metabolic acidosis, partial compensation--> bicarb would have to be above normal

c. respiratory acidosis, uncompensated--> b/c bicarb is normal and holding on due to narcotic pain med CNS is decompensated; slowing down respiratory rate =========== a. metabolic acidosis, partial compensation--> bicarb would have to be above normal

o INJECTION sites

INTRADERMAL • TB or Allergy tests • Uses 1 ml/25-28 gauge, ¼ to ⅝ inch needle • 5°-15° bevel up • Stretch skin taught • Do not aspirate • Inject slowly to create wheal • Do not wipe, massage, or bandage SUBQ • Insulin & Heparin, LMWH • Uses a ⅝ inch needle, 25-27 gauge, less than 1 inch • Little or NL SQ fat: 45°, pinch skin • Obese: 90°, skin taught • Do not aspirate heparin or insulin, optional for other meds INSULIN • ONLY SQ or IV • **Prescribed in Units, special syringes • Sliding Scale prescription • Automatic injectors • Insulin pumps • Insulin pens • Site rotation/documentation HEPARIN • ONLY SQ or IV • Preferred in abdomen, 5 cm (2 inch) from umbilicus • Do NOT massage or aspirate • Pinch skin, Inject whole needle into skin INTRAMUSCULAR INJECTIONS • Use a 1-5 ml syringe • 21-25 gauge • 1-3 inch needle • Identify landmarks o BUTTOCKS: the ventrogluteal site o VASTUS LATERALIS MUSCLE-- right thigh, used for an intramuscular injection. o Landmarks for the deltoid muscle of the upper arm • Aspirate-if blood appears, withdraw needle, discard • Z- Track Method o A) pull skin to side and hold o B) 90 degree angle into ventrogluteal, still keeping skin taugh, administer slowly o C) pull syringe slowly, release skin. Med help in tissues by zigzag pattern administration

The nurse is conducting discharge teaching for a patient with diminished tactile sensation. Which of the following statements by the patient would indicate that additional teaching is needed? "I am at risk for injury from temperature extremes." "I may be able to dress more easily with zippers or pullover sweaters." "A home care referral may help me achieve a maximum degree of independence." "I have right-sided partial paralysis and reduced sensation; so I should dress the left side of my body first."

"I have right-sided partial paralysis and reduced sensation; so I should dress the left side of my body first." If tactile sensation is diminished, the patient can dress more easily with zippers or Velcro strips, pullover sweaters or blouses, and elasticized waists. Patients with diminished tactile sensation are at risk for injury from temperature extremes and may benefit from a home care referral. If a patient has partial paralysis and reduced sensation, he or she dresses the affected side first.

What statement made by a 4-year-old patient's mother indicates that she understands how to administer her son's eardrops? "To straighten his ear canal, I need to pull the outside part of his ear down and back." "I need to straighten his ear canal before administering the medication by pulling his ear upward and outward." "I need to put my son in a chair and make sure that he's sitting up with his head tilted back before I give him the eardrops." "After I'm done giving him his eardrops, I need to make sure that my son remains sitting straight up for at least 10 minutes."

"I need to straighten his ear canal before administering the medication by pulling his ear upward and outward." When administering medications to people 3 years of age and older, you need to pull the auricle upward and outward to straighten the ear canal when giving eardrops.

A patient has been newly diagnosed with chronic lung disease. In discussing his condition with the nurse, which of his statements would indicate a need for further education? "I'll make sure that I rest between activities so I don't get so short of breath." "I'll practice the pursed-lip breathing technique to improve my exercise tolerance." "If I have trouble breathing at night, I'll use two to three pillows to prop up." "If I get short of breath, I'll turn up my oxygen level to 6 L/min.

"If I get short of breath, I'll turn up my oxygen level to 6 L/min. Hypoxia is the drive to breathe in a COPD patient who has become used to acidic pH and elevated CO2 levels. Turning up to 6 L/min will increase oxygen level which turns off the drive to breathe.

Maslow's Hierarchy of Needs

(level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization ****MASLOW'S HIERARCHY MUST KNOW THIS CHART AND HOW IT WORKS When looking at levels(moving upwards) First is physiologic: water, food, rest ---must meet basic needs Ex: many homeless patients—once physiologic needs met, then look to safety and security Safety and security Love & belonging Self-esteem Cognitive: knowledge, understanding exploration—what is going on around me Aesthetic (symmetry): look at myself and looking normal Self-actualization: your personal growth to reaching your potential Transcendence: self helping beyond yourself

CENTRAL VENOUS CATHETERS

***ONLY NURSE not on PICC team can put in PERIPHERAL IV and NOT CVCs** - when catheter goes to heart RN cant put in unless on PICC TEAM PICC = peripheral Intravenous Central catheter in brachial vein (going directly to heart, stting below the shoulder) Put in by PICC team unless nurse is part of this team Nontunneled CVC: central venous catheter put in jugular or subclavian put in surgically under sterile procedures under clavical in superior vena cava Put in by nurse if ONLY on PICC team Port to draw blood on, port to draw meds (3 ports total) Nontunneled can see the CVC Tunneled CVC: tunneled underneath the skin Cannot see the catheter port Implantable Ports Intraosseous Thick catheter to inject into long bone in emergency situations to be given Ivs Usually in pediatrics whenc ant get other ones

Gordon's functional health patterns

-organizes info and makes assessments identifying functional and dysfunctional patterns -ie sleep and rest dysfunction Health perception-health management pattern Nutritional-metabolic pattern Elimination pattern Activity-exercise pattern Sleep-rest pattern Cognitive-perceptual pattern Self-perception-self-concept pattern Roles-relationships pattern Sexuality-reproductive pattern Coping-stress tolerance pattern Values-beliefs pattern

A nurse is providing postoperative teaching to a client who is scheduled to have an above-the-knee amputation. The client will use crutches during the postoperative period. Which activity will prepare the client for crutch walking? 1 Lifting weights 2 Changing bed positions 3 Caring for the residual limb 4 Performing phantom limb exercises

1 Lifting weights Preparation for crutch walking includes exercises to strengthen arm and shoulder muscles. Position changes help prevent hip flexion contractures but do not prepare the client for crutch walking. Caring for the residual limb promotes healing and helps prepare the limb for the prosthesis; it does not prepare the client for crutch walking. The phantom limb sensation includes a feeling that the absent limb is present; there are no specific exercises for this phenomenon.

A nurse is caring for several school-aged children on the pediatric unit who are on prolonged bed rest and eating regular diets. Which breakfast should the nurse recommend to the children? 1 Oatmeal with raisins and milk 2 Pancakes with sausage and syrup 3 Scrambled eggs with home fries and toast 4 French toast with bacon and cinnamon sugar

1 Oatmeal with raisins and milk Prolonged immobility can result in constipation and demineralization of bone. Oatmeal and raisins contain roughage, which helps prevent constipation, and milk contains calcium, which is needed for bone strength and growth. Pancakes and French toast each lacks roughage and contains inadequate calcium. Eggs, fries, and toast do not provide needed roughage while on bed rest.

3. When a nurse conducts an assessment, data about a patient often comes from which of the following sources? (Select all that apply.) 1. An observation of how a patient turns and moves in bed 2. The unit policy and procedure manual 3. The care recommendations of a physical therapist 4. The results of a diagnostic x-ray film 5. Your experiences in caring for other patients with similar problems

1. An observation of how a patient turns and moves in bed 3. The care recommendations of a physical therapist 4. The results of a diagnostic x-ray film There are many sources of data for an assessment, including the patient through interview, observations, and physical examination; family members or significant others, health care team members such as a physical therapist, the medical record (which includes x-ray film results, and the scientific and medical literature.

2. Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) 1. Impaired Skin Integrity related to physical immobility 2. Fatigue related to heart disease 3. Nausea related to gastric distention 4. Need for improved Oral Mucosa Integrity related to inflamed mucosa 5. Risk for Infection related to surgery

1. Impaired Skin Integrity related to physical immobility 3. Nausea related to gastric distention Answer 1, 3. The related factors in diagnoses "Fatigue related to heart disease" and "Need for improved oral mucosa integrity related to inflamed mucosa" are incorrect. The related factor of a medical diagnosis (in Fatigue related to heart disease) cannot be corrected through nursing intervention. In "Need for improved oral mucosa integrity related to inflamed mucosa" there is no diagnosis, but instead a goal of care. "Risk for infection related to open wound" is incorrect because At Risk diagnoses do not have related factors match between clinical cues and the nursing diagnosis.

A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment findings when she conducts rounds on the patient? (Select all that apply.) 1. The nurse asks the patient to rate his pain on a scale of 0 to 10. 2. The nurse asks the patient what caused his fall. 3. The nurse asks the patient if he has had pain in his back in the past. 4. The nurse assesses the patient's lower-limb strength. 5. The nurse asks the patient what pain medication is most effective in managing his pain

1. The nurse asks the patient to rate his pain on a scale of 0 to 10. 4. The nurse assesses the patient's lower-limb strength. Listen attentively to the patient's story. Use gestures that reinforce your questions or comments. maintain direct eye contact. Ask questions quickly to reduce the patient's fatigue. Approaches for collecting an older-adult assessment include listening patiently, using nonverbal communication when a patient has a hearing deficit, and maintaining patient directed eye gaze. Leaning forward, not backward, shows interest in what the patient has to say.

10. A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse's assessment reveals that the infant cries when breastfeeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the pt's nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best "related to" factor? 1. Infant crying at breast 2. Infant unable to latch on to breast correctly 3. Mother's deficient knowledge 4. Lack of infant weight gain

10. Answer 3. In this scenario the related factor is the mother's deficient knowledge. A related factor is a condition, historical factor, or etiology that gives a context for the defining characteristics, in this case the infant crying, inability to latch on to breast and absent weight gain.

11. A nurse is getting ready to assess a pt in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse's cultural competence in making an accurate diagnosis? (Select all that apply.) 1. How is your diabetic diet affecting you and your family? 2. You seem to not want to follow health guidelines. Can you explain why? 3. What worries you the most about having diabetes? 4. What do you expect from us when you do not take your insulin as instructed? 5. What do you believe will help you control your blood sugar?

11. Answer: 1, 3. Asking "How is your diabetic diet affecting you and your family" and "What worries you the most about having diabetes" are open ended and allow the patient to share his values and health practices. The statements "You seem to not want to follow health guidelines. Can you explain why?" and "What do you expect from us, when you do not take your insulin as instructed" both show the nurse's bias.

12. A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse reviews clusters of data that include the pt's report of frequent awakenings at night, reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the correct PES format? 1. Disturbed Sleep Pattern evidenced by frequent awakening 2. Disturbed Sleep Pattern related to family caregiving responsibilities 3. Disturbed Sleep Pattern related to need to improve sleep habits 4. Disturbed Sleep Pattern related to caregiving responsibilities aeb frequent awakening and not feeling rested

12. Answer: 4. A nursing diagnosis in a PES format includes the diagnostic label, related factor and the defining characteristics the diagnosis is evidenced by. The second nursing diagnosis is the correct format in the 2-part format for writing a diagnosis. The first diagnosis has no related factor. The third diagnosis is an error, using a goal as a related factor. PES = Problem, Etiology (related factors) and Signs/Symptoms

15. Which of the following nursing diagnoses is stated correctly? (Select all that apply.) 1. Fluid Volume Excess related to heart failure 2. Sleep Deprivation related to sustained noisy environment 3. Impaired Bed Mobility related to postcardiac catheterization 4. Ineffective Protection related to inadequate nutrition 5. Diarrhea related to frequent, small, watery stools

15. Answer 2, 4. The correct diagnoses of sleep deprivation and ineffective protection are worded with related factors that will respond to nursing interventions. Nursing interventions do not change a medical diagnosis or diagnostic test. . Instead, you direct nursing interventions at behaviors or conditions that you are able to treat or manage. The two incorrect diagnoses use a medical diagnosis and diagnostic procedure respectively as related or etiological factors. These are not conditions that nursing interventions can treat.

Which statement made by a diabetic client shows that dietary teaching by the nurse was effective? 1 "My diet should be rigidly controlled to avoid emergencies." 2 "My diet can be planned around a wide variety of commonly used foods." 3 "My diet is based on nutritional requirements that are the same for all people." 4 "My diet must not include eating any combination dishes and processed foods."

2 "My diet can be planned around a wide variety of commonly used foods." Each client should be given an individually devised diet consisting of commonly used foods from the American Diabetic Association (Canadian Diabetes Association) diet; family members should be included in the diet teaching. Rigid diets are difficult to follow; appropriate substitutions are permitted. Nutritional requirements are different for each individual and depend on many factors, such as activity level, degree of compliance, and physical status. Combination dishes and processed foods can be eaten when accounted for in the dietary regimen.

A healthcare provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is most appropriate for the nurse to teach the client about meal management? 1 Snack daily in the evenings 2 Divide food into four to six meals a day 3 Eat the last of three daily meals by 8:00 PM 4 Suck a peppermint candy after each meal

2 Divide food into four to six meals a day The volume of food in the stomach should be kept small to limit pressure on the lower esophageal sphincter. Snacking in the evening can cause reflux. The last meal should be eaten at least three hours before bedtime; individual bedtimes vary. Peppermint promotes reflux because it relaxes the lower esophageal sphincter, allowing food to be regurgitated into the esophagus.

A nurse is caring for a client who will have a below-the-knee amputation with an immediate postoperative prosthesis. The client asks the nurse the advantage of having an immediate prosthesis. What should the nurse explain is the advantage? 1 Decreases phantom limb sensations 2 Encourages a normal walking pattern 3 Reduces the incidence of wound infection 4 Allows for fitting of the prosthesis before discharge

2 Encourages a normal walking pattern Without a prosthesis, a walker or crutches are necessary, and these require readjustment of weight bearing on one leg. Early use of a prosthesis does not affect the incidence of phantom limb pain, which occurs in about 10% of clients with amputations. Early use of a prosthesis has no effect on wound infection. Although true, fitting of the prosthesis before discharge is not the major purpose; a prosthesis can be fitted easily after discharge when the residual limb has healed completely and is no longer edematous. prosthesis: an artificial body part, such as a leg, a heart, or a breast implant. edematous - swollen with an excessive accumulation of fluid.

How can a nurse best soothe a hospitalized infant who appears to be in pain? 1 Feeding the infant 2 Holding the infant 3 Playing soft music in the room 4 Providing a quiet environment

2 Holding the infant Physical contact provides security for a distressed infant. Feeding to provide comfort is not always an option because the infant may have been fed recently, may be anorexic, or may be on nothing-by-mouth status. Music or a quiet environment may not always have a calming influence; often infants are not aware of the environment.

How should a nurse prepare a client for cranial surgery? 1 Assist the client with securing a wig onto the head. 2 Obtain the client's consent to have the head shaved. 3 Shampoo the client's hair with a medicated shampoo. 4 Tell the client that head shaving is needed before anesthesia.

2 Obtain the client's consent to have the head shaved. Because of legal and cosmetic concerns, consent for head shaving must be obtained before a client receives anesthesia. Because head shaving is a nursing intervention, the nurse should obtain this consent. The surgeon will obtain the consent for surgery. The client will not be able to wear a wig to surgery as wigs could become a source of infection and should not be worn until healing occurs. Washing the client's hair with a medicated shampoo is unnecessary because the hair will be shaved to help prevent contamination of the surgical site. Shaving of some areas of the head or the entire head is typically performed after the client is anesthetized.

The nurse is administering an intravenous (IV) push medication to a patient who has a compatible IV fluid running through intravenous tubing. Place the following steps in the appropriate order. 1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration. 2. Select injection port of intravenous (IV) tubing closest to patient. Whenever possible, injection port should accept a needleless syringe. Use IV filter if required by medication reference or agency policy. 3. After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate. 4. Connect syringe to port of intravenous (IV) line. Insert needleless tip or small-gauge needle of syringe containing prepared drug through center of injection port. 5. Clean injection port with antiseptic swab. Allow to dry. 6. Occlude intravenous (IV) line by pinching tubing just above injection port. Pull back gently on syringe plunger to aspirate blood return. 2, 5, 4, 1, 3, 6 2, 5, 6, 4, 1, 3 5, 4, 2, 6, 1, 3 2, 5, 4, 6, 1, 3

2, 5, 4, 6, 1, 3 Correct This is the appropriate order for a nurse to administer an intravenous (IV) push medication to a patient who has a compatible IV fluid running through intravenous tubing.

8. A nurse is assigned to a new pt admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the pt. Place the following steps for making a nursing diagnosis in the correct order, beginning with the first step. ______, ______, ______, ______ 1. Considers context of pt's health problem and selects a related factor 2. Reviews assessment data, noting objective and subjective clinical information 3. Clusters clinical cues that form a pattern 4. Chooses diagnostic label

2,3,4,1

A 10-year-old child with acute glomerulonephritis (AGN) is selecting foods for dinner from a menu. Which foods should the nurse encourage? 1 Baked potato, meatloaf, banana, and pretzels 2 Baked ham, bread and butter, peaches, and milk 3 Corn on the cob, baked chicken, rice, apple, and milk 4 Hot dog on a bun, potato chips, dill pickle slices, and brownie

3 Corn on the cob, baked chicken, rice, apple, and milk Corn, chicken, rice, apples, and milk are permitted on the low-sodium, low-potassium diet that the child should be following. Bananas and potatoes are high in potassium, and pretzels are high in sodium. Only the peaches are low in sodium, and all but the butter are fairly high in potassium. Processed foods are high in sodium and fairly high in potassium. Acute glomerulonephritis (AGN) is active inflammation in the glomeruli. There are many diseases that cause an active inflammation within the glomeruli. Some of these diseases are systemic (i.e., other parts of the body are involved at the same time) and some occur solely in the glomeruli

Which nursing interventions indicate client care that supports physical functioning? Select all that apply. 1 Interventions to facilitate client's learning 2 Interventions to alter client's undesirable behavior 3 Interventions to maintain client's nutritional status 4 Interventions to maintain client's regular bowel patterns 5 Interventions to prevent complications in the client related to electrolyte imbalance

3 Interventions to maintain client's nutritional status 4 Interventions to maintain client's regular bowel patterns Providing interventions to maintain the client's nutritional status and providing interventions to maintain the client's regular bowel patterns indicates interventions that support physical functioning[1] [2]. Providing interventions to facilitate a client's learning and providing interventions to alter the client's undesirable behavior indicates interventions to support psychosocial functioning and facilitates lifestyle changes. Providing interventions to prevent complications related to electrolyte imbalance indicates the nursing care that supports homeostatic regulation.

A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1 station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse's priority intervention be? 1 Teach the client how to push with each contraction. 2 Encourage the client to perform patterned, paced breathing. 3 Provide the client with comfort measures used for women in labor. 4 Prepare to have the client's blood typed and crossmatched in the event of the need for a transfusion.

3 Provide the client with comfort measures used for women in labor. The client is experiencing the expected discomforts of labor; the nurse should initiate measures that will promote relaxation. The client is in early first-stage labor; pushing commences during the second stage. Patterned, paced breathing should be used in the transition phase, not the early phase of the first stage of labor. There is no evidence that the client's bleeding is excessive or unexpected and that a transfusion will be needed. primigravida: a woman who is pregnant for the first time

A nurse instructs a client with viral hepatitis about the type of diet that should be ingested. Which lunch selected by the client indicates understanding about dietary principles associated with this diagnosis? 1 Turkey salad, french fries, sherbet 2 Cottage cheese, mixed fruit salad, milkshake 3 Salad, sliced chicken sandwich, gelatin dessert 4 Cheeseburger, tortilla chips, chocolate pudding

3 Salad, sliced chicken sandwich, gelatin dessert The diet should be high in carbohydrates, with moderate protein and fat content. A salad, chicken and gelatin meal is the best choice. Turkey salad, french fries, and sherbet are too high in fat. Cottage cheese, mixed fruit salad, and a milkshake are dairy products and may cause lactose intolerance; the hepatitis virus injures the intestinal mucosa and reduces the client's ability to metabolize lactose. Cheeseburger, tortilla chips, and chocolate pudding are too high in fat.

What steps should the nurse take for managing an adolescent that sustained drug poisoning? Select all that apply. 1 Induce gastric lavage. 2 Give ipecac syrup to the client. 3 Turn the head of the client to the side. 4 Empty the mouth to clean the residue of the drug. 5 Call local poison control center before any intervention.

3 Turn the head of the client to the side. 4 Empty the mouth to clean the residue of the drug. 5 Call local poison control center before any intervention. The nurse should turn the head of the client to the side to avoid aspiration. The nurse should empty the mouth if there is any remaining drug. If the victim is conscious and alert, the nurse should call the local poison control center or the national toll-free poison control center number before attempting any intervention. The nurse should refrain from inducing vomiting in the client as there is a risk of aspiration. Ipecac syrup causes vomiting so it is no longer recommended for routine treatment of poisoning.

4. The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n): 1. Risk nursing diagnosis. 2. Problem-focused nursing diagnosis. 3. Health promotion nursing diagnosis. 4. Wellness nursing diagnosis.

4. Answer 2. This is an example of a problem focused nursing diagnosis with a related factor, based on NANDA - I diagnostic terminology. Most health promotion diagnoses do not have established related factors based on NANDA - I, their use is optional. Wellness diagnoses are not one of the types of NANDA-I diagnoses.

A new nurse is going to help a patient walk down the corridor and sit in a chair. The patient has an eye patch over the left eye and poor vision in the right eye. What is the correct order of steps to help the patient safely walk down the hall and sit in the chair? 1. Tell patient when you are approaching the chair. 2. Walk at a relaxed pace. 3. Guide patient's hand to nurse's arm, resting just above the elbow. 4. Position yourself one-half step in front of patient. 5. Position patient's hand on back of chair. 3, 1, 4, 5, 2 3, 4, 1, 2, 5 3, 4, 2, 1, 5 4, 3, 2, 5, 1

3, 4, 2, 1, 5 These steps ensure safety when guiding a patient with impaired vision to walk and sit in a chair. In addition, they help to provide patient education and independence in carrying out activities of daily living.

3. A nurse reviews data gathered regarding a pt's ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (Select all that apply.) 1. Data collection. 2. Data clustering. 3. Data interpretation. 4. Making a diagnostic statement. 5. Goal setting.

3. Answer 3. This is an example of an error in interpretation and data collection. When making a diagnosis you must interpret data you have collected by identifying and organizing relevant assessment patterns to support the presence of patient problems. In the case of the two diagnoses in this question, there can be conflicting cues. The nurse must obtain more information and recognize the cues that point to the correct diagnosis. A data cluster is a grouping of patient data or cues that points to the existence of a problem (e.g., a series of readings). The nurse must then identify strengths and problems and determine if the patient is motivated to address them. Subscribe to view the full document.

4. The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of: 1. Cue. 2. Reflection. 3. Clinical inference. 4. Probing.

3. Clinical inference An inference is your judgment or interpretation of cues such as the shuffling gait and reduced leg strength. Any information gathered through your senses is a cue. Probing is a technique used in interviewing. Reflection is an internal process of thinking back about a situation. PROBING = conducting a thorough search; investigating

14. During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing? 1. So you've had headaches periodically in the last week and sometimes they cause you to feel nauseated—correct? 2. Have you taken anything for your headaches? 3. Tell me what makes your headaches begin. 4. Uh huh, tell me more.

3. Tell me what makes your headaches begin. An open-ended question that probes such as "Tell me what makes your headaches begin" encourages a fuller description of a situation. The statement "So you've had headaches periodically in the last week, and sometimes they cause you to feel nauseated—correct?" is a summative statement. Asking whether the patient has taken anything for the headaches is a closed-ended question. Saying "Uh huh, tell me more" is an example of back channeling.

Which assessment finding supports the nurse's conclusion that a prosthesis for a client with an above-the-knee amputation fits correctly? 1 Skin that is cool to the touch 2 Shrinking of the residual limb 3 Absence of phantom limb pain 4 Evenly darkened skin of the residual limb

4 Evenly darkened skin of the residual limb Even distribution of hemosiderin (iron-rich pigment) in the tissue in response to pressure of the prosthesis indicates a proper fit. Cool skin may indicate inadequate tissue perfusion, which may be caused by progression of the disease, inadequate wound healing, or excessive pressure from the prosthesis. Shrinking of the residual limb results in an improper fit. Absence of phantom limb pain is unrelated to a proper fit.

The nurse is caring for a client two days after the client had a brain attack (cerebrovascular accident, CVA). To prevent the development of plantar flexion, which action should the nurse take? 1 Place a pillow under the thighs. 2 Elevate the knee gatch of the bed. 3 Encourage active range of motion. 4 Maintain the feet at right angles to the legs.

4 Maintain the feet at right angles to the legs. Maintaining the feet at right angles to the legs produces dorsiflexion of the feet and prevents the tendons from shortening, preventing footdrop. Placing a pillow under the thighs and elevating the knee gatch of the bed will not prevent plantar flexion; it can promote hip and knee flexion contractures. The client will not have the ability or strength to perform range-of-motion exercises unassisted at this time.

What does a nurse consider the most significant influence on many clients' perception of pain when interpreting findings from a pain assessment? 1 Age and sex 2 Physical and physiological status 3 Intelligence and economic status 4 Previous experience and cultural values

4 Previous experience and cultural values Interpretation of pain sensations is highly individual and is based on past experiences, which include cultural values. Age and sex affect pain perception only indirectly because they generally account for past experience to some degree. Overall physical condition may affect the ability to cope with stress; however, unless the nervous system is involved, it will not greatly affect perception. Intelligence is a factor in understanding pain so it can be tolerated better, but it does not affect the perception of intensity; economic status has no effect on pain perception.

5. A nurse interviewed and conducted a physical examination of a pt. Among the assessment data the nurse gathered were an increased respiratory rate, the pt reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of: 1. Collaborative data set. 2. Diagnostic label. 3. Related factors. 4. Data cluster.

4. Data cluster.

What is the correct order for discontinuing intravenous (IV) access? 1. Perform hand hygiene and apply gloves. 2. Explain procedure to patient. 3. Remove IV site dressing and tape. 4. Use two identifiers to ensure correct patient. 5. Stop the infusion and clamp the tubing. 6. Carefully check the health care provider's order. 7. Clean the site, withdraw the catheter, and apply pressure. 6, 4, 2, 1, 5, 3, 7 4, 6, 2, 1, 5, 3, 7 6, 4, 2, 5, 3, 1, 7 6, 2, 4, 1, 3, 7, 5

6, 4, 2, 1, 5, 3, 7 A health care provider's order is necessary before discontinuing IV access, unless there is a complication such as infiltration or phlebitis. Identifying the patient and explaining the procedure are performed before hand hygiene and glove application to maintain clean gloves. Removing the site dressing before stopping the infusion and then withdrawing the catheter keeps the vascular access device patent without forming a clot that could embolize during catheter withdrawal.

6. In which of the following examples are nurses making diagnostic errors? (Select all that apply.) 1. The nurse who observes a pt wincing and holding his left side and gathers no additional assessment data 2. The nurse who measures joint range of motion after the pt reports pain in the left elbow 3. The nurse who considers conflicting cues in deciding which diagnostic label to choose 4. The nurse who identifies a diagnosis on the basis of a pt reporting difficulty sleeping 5. The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia.

6. Answer 1, 4. When the nurse observes the patient wincing and holding his left side, but does not gather additional assessment data, the nurse makes a data collection error by omitting important data, pain severity. A nursing diagnosis cannot be made on basis of a single defining characteristic, as seen when the nurse identifies a diagnosis on the basis of a patient reporting difficulty sleeping. The nurse that measures joint range of motion after the patient reports pain is correctly validating findings. Considering conflicting clues ensures the nurse does not make an interpretation error.

a. Respiratory Acidosis (COPD) -->j. Renal Bicarbonate Reabsorption b. Metabolic Acidosis --> k. Respiratory compensation via increased Ve c. Metabolic Alkalosis (vomiting)-->l. Respiratory compensation via lower Ve (hypoventilation) d. Respiratory Alkalosis--> i. Renal Bicarbonate Excretion

6. Match the following: a. Respiratory Acidosis (COPD) b. Metabolic Acidosis (Exercise/diabetic coma) c. Metabolic Alkalosis (vomiting) d. Respiratory Alkalosis i. Renal Bicarbonate Excretion j. Renal Bicarbonate Reabsorption k. Respiratory compensation via increased Ve l. Respiratory compensation via lower Ve (hypoventilation)

Atelectasis

: when the lungs collapse

medical v nursing diagnosis

A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human response to actual or potential health problems and life processes. For example, a medical diagnosis of Cerebrovascular Attack (CVA or Stroke) provides information about the patient's pathology. The complimentary nursing diagnoses of Impaired verbal communication, risk for falls, interrupted family processes and powerlessness provide a more holistic understanding of the impact of that stroke on this particular patient and his family - they also direct nursing interventions to obtain patient-specific outcomes.

The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following? a. Physical care technique b. Activity of daily living c. Indirect care measure d. Lifesaving measure

a. Physical care technique *Administering a tube feeding is an example of a physical care, a direct care technique

solutions that have a greater osmolality than the intracellular fluid are a. hypertonic b. hypotonic c. hyperactive d. isotonic

a. hypertonic ----------------------------------- Hypotonic = less osmolality; more water on board

1. A nurse identified that a pt has difficulty turning in bed, moves slowly when assisted into a chair, and expresses having breathlessness after walking to the bathroom and back. The pt has been in the hospital for over 4 days. Write a three-part nursing diagnostic statement using the PES format.

An appropriate PES diagnostic statement would be: Impaired physical mobility related to deconditioning evidenced by difficulty turning in bed and breathlessness after walking.

Which of the following describes a nurse's application of a specific knowledge base during critical thinking? (Select all that apply.) Initiative in reading current evidence from the literature Application of nursing theory Reviewing policy and procedure manual Considering holistic view of patient needs Previous time caring for a specific group of patients

Application of nursing theory Reviewing policy and procedure manual Considering holistic view of patient needs A nurse's specific knowledge base will vary but includes basic nursing education, continuing education courses, and additional college degrees. In addition, it includes the knowledge gained from a nurse reading the nursing literature and acquiring information and theory from the basic sciences, humanities, behavioral sciences, and nursing. Nurse's knowledge base also involves a different way of thinking holistically about patient problems.

A nurse prepares to insert a Foley catheter. The procedure manual calls for the patient to lie in the dorsal recumbent position. The patient complains of having back pain when lying on her back. Despite this, the nurse positions the patient supine with knees flexed as the manual recommends and begins to insert the catheter. This is an example of: Accuracy. Reflection. Risk taking. Basic critical thinking.

Basic critical thinking. Correct Basic critical thinking is concrete and based on a set of rules or principles such as the guidelines in a hospital procedure manual. The nurse's approach is not accurate because accuracy requires use of all of the facts (e.g., the patient's discomfort). A critical thinker is willing to take risks to try different ways to solve problems; following one basic approach is not risk taking. This is also not an example of reflection.

Your patient has severe hypercalcemia. What are your priority nursing interventions? (Select all that apply.) Fall prevention interventions Teaching regarding sodium restriction Encouraging increased fluid intake Monitoring for constipation Explaining how to take daily weights

C. Encouraging increased fluid intake D. Monitoring for constipation Severe hypercalcemia causes lethargy, which creates a risk for falling and constipation. Increased fluid intake is important to prevent renal calculi (kidney stones) during hypercalcemia

Pick all that apply: Identify the patient outcome/goal that is written correctly. a. The patient's urine output will be adequate by the end of the shift b. The patient's pneumonia will be resolved as evidenced by clear breath sounds bilaterally by discharge c. The patient will ambulate 20 feet in the hallway using his walker by evening shift tomorrow d. The patient will drink more fluids than he did yesterday by 7:00 pm today

C. The client will ambulate 20 feet in the hallway using his walker by evening shift tomorrow.This statement meets all of the criteria for a correctly written client outcome. "Adequate" is not measurable; clear breath sounds only would not be evidence of the resolution of pneumonia and this is the medical diagnosis; "more fluids than yesterday" is vague and unclear.

When you assess pain and redness at a vascular access device (VAD) site, which action do you take first? Apply a warm, moist compress Monitor the patient's blood pressure Aspirate the infusing fluid from the VAD Stop the infusion and discontinue the intravenous infusion

Stop the infusion and discontinue the intravenous infusion Pain and redness at a VAD site are indicators of phlebitis. When phlebitis occurs, the infusion must be stopped, and the VAD removed as the highest priority.

A nurse checks an intravenous (IV) solution container for clarity of the solution, noting that it is infusing into the patient's left arm. The IV solution of 9% NS is infusing freely at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site was changed as scheduled per standard of care. While in the room the nurse inspects the condition of the dressing and notes the date on the dressing label. In which ways did the nurse evaluate the condition of the IV site? (Select all that apply.) a--Checked the IV infusion rate b--Checked the type of IV solution c--Confirmed from nurses' notes the time of dressing change d--Inspected the condition of the IV dressing at the site e--Checked clarity of IV solution

Checked the IV infusion rate Inspected the condition of the IV dressing at the site The condition or status of the IV site is determined by checking the IV infusion rate and the condition of the IV site dressing. Checking the type of solution is important to ensure that correct therapy is being administered but is not a measure of the IV site condition. Confirming a dressing change or the appearance of the IV solution is not an indicator of the IV site status.

Which assessment do you interpret as a transfusion reaction? Crackles in dependent parts of lungs High fever, severe hypotension Anxiety, itching, confusion Chills, tachycardia, and flushing

Chills, tachycardia, and flushing A transfusion reaction occurs when the immune system reacts against the blood that is being transfused. Chills, tachycardia, and flushing are common manifestations.

Critical Question Identify the long-term goal Client's pulse oxygenation level will be greater than 92% on room air by tomorrow Client will administer his own insulin using correct technique by discharge Client's pressure ulcer will show presence of granulation tissue in 30 days Client's urine output will be 400 mL per 8 hour shift within 72 hours

Client's pressure ulcer will show presence of granulation tissue in 30 days Long-term goals: To be achieved over a longer period of time (week, month, or more) Short-term goals: To be achieved within a few hours or days (less than a week)

A nurse changed a patient's surgical wound dressing the day before and now prepares for another dressing change. The nurse had difficulty removing the gauze from the wound bed yesterday, causing the patient discomfort. Today he gives the patient an analgesic 30 minutes before the dressing change. Then he adds some sterile saline to loosen the gauze for a few minutes before removing it. The patient reports that the procedure was much more comfortable. Which of the following describes the nurse's approach to the dressing change? (Select all that apply.) Clinical inference Basic critical thinking Complex critical thinking Experience Reflection

Complex critical thinking Experience The nurse relies on experience and the ability to adapt a procedure such as a dressing change (complex critical thinking) to make it successful.

A nurse on a busy medicine unit is assigned to four patients. It is 10 am. Two patients have medications due and one of those has a specimen of urine to be collected. One patient is having complications from surgery and is being prepared to return to the operating room. The fourth patient requires instructions about activity restrictions before going home this afternoon. Which of the following should the nurse use in making clinical decisions appropriate for the patient group? (Select all that apply.) Consider availability of assistive personnel to obtain the specimen Combine activities to resolve more than one patient problem Analyze the diagnoses/problems and decide which are most urgent based on patients' needs Plan a family conference for tomorrow to make decisions about resources the patient will need to go home Identify the nursing diagnoses for the patient going home

Consider availability of assistive personnel to obtain the specimen Combine activities to resolve more than one patient problem Analyze the diagnoses/problems and decide which are most urgent based on patients' needs Analyzing urgency of problems helps to prioritize as does considering the resources that are available (such as assistive personnel) to complete patient care activities. Deciding how to combine activities is good time management. Holding a family conference is a good idea but in this case would be too late to be beneficial to the patient. To determine priorities the nurse must identify nursing diagnoses for all patients.

For any patient with an altered level of consciousness, the Glasgow Coma Scale score will help the nurse in planning care. a. true b. false

Correct answer: A, true The coma scale score correlates to the client's ability to function. As the score decreases, he is less able to meet his own basic needs, requiring greater nursing intervention. ----need to know if changes if patient had stroke or brain damage; even if score changes by 1 point, that is huge

Critical Check The nurse has identified the nursing diagnosis Risk for Aspiration for her patient with a swallowing disorder. In deciding which feeding technique will prevent aspiration, the nurse should: a. Ask the UAP who has 20 years of experience b. Perform a "Google" search on the topic c. Ask the physician to write an order with specific instructions d. Search for evidence-based, clinical practice guidelines

Correct answer: D Nursing interventions should be based on the most current clinical evidence that is based on science and research.

Your older-adult patient is receiving intravenous (IV) 0.9% NaCl. You detect new onset of crackles in the lung bases. What is your priority action? Notify a health care provider Record in medical record Decrease the IV flow rate Discontinue the IV site

Decrease the IV flow rate Correct When an IV fluid is infusing, monitor for excess infusion. Crackles in the lung bases are an indication of extracellular fluid volume excess. For patient safety the IV flow rate must be decreased immediately.

NANDA Nursing Diagnosis: Components

Diagnostic label Decreased Cardiac output Definition Inadequate blood pumped by the heart to meet the metabolic demands of the body Defining characteristics S: "Fatigue, short of breath, palpitations" O: Tachycardia, weight gain, clammy skin, dyspnea Related factors/Risk factors Decreased venous return, altered contractility

Hypernatremia

EXTRA SODIUM ON BOARD -Excess Na+ in the blood plasma -Increased extracellular osmotic pressure causes fluid to move out of the cells into the ECF -Cell become dehydrated Water loss Plasma Sodium exceed 145 mEq/L -Greatest in elderly and infants who can't express thirst Two Mechanisms: 1. Water Loss-- Metabolic-fever, exercise, diarrhea, tube feedings 2. Sodium Gain ---------------------- **********KNOW -hypernatremia signs look a lot like symptoms of fluid volume deficit or dehydration -Thirst -Dry mucus membranes -Rapid, thready pulse -Hypotension -OLIGURIA: drop in urine output (b/c not enough water on board) -Muscle weakness Twitching -Convulsions -Coma *Plasma Sodium exceed 145 mEq/L *Specific gravity of urine about 1.030

Hypocalcemia***** DEF KNOW

Etiology: Poor Absorption: • GI • Pancreatitis • Vitamin D Renal Failure Hypoparathyroidism Hyperphosphatemia ----------------------- *****Clinical Presentation: - Tetany: spasm or rigidity of muscles - + Trousseau Sign: put BP cuff over arm and then it spasms - + Chvostek Sign: pain going down face when tap facial nerve - Prolonged ST & QT - Laryngeal Stridor: if we don't have enough calcium on board, the laryngeal muscles will contract and have trouble breathing (stridor= high pitched sound coming from the neck meaning airway is going to shut down) >muscle weakness - Impaired clotting - Hypotension-arrest

Which of the following statements correctly describes the evaluation process? (Select all that apply.) a--Evaluation is an ongoing process. b--Evaluation usually reveals obvious changes in patients. c--Evaluation involves making clinical decisions. d--Evaluation requires the use of assessment skills. e--Evaluation is only done when a patient's condition changes.

Evaluation is an ongoing process. Evaluation involves making clinical decisions. Evaluation requires the use of assessment skills Evaluation is ongoing throughout the nursing process once nursing diagnoses or patient health problems have been identified. It is a process that involves clinical decision making and use of assessment skills as evaluative measures. Evaluation may reveal changes in patients that often are not obvious. It occurs after any intervention and not only when a patient's condition changes.

Carla is a third year nursing student assigned to a surgical nursing unit. Mr. Javier Ramirez is a 55-year-old construction worker, admitted after falling off scaffolding on a construction site. His x-ray films reveal a right femur fracture and right wrist fracture. An abdominal computed tomography (CT) scan shows bruising of the liver. Mr. Ramirez has not been hospitalized in the past. When he first meets Carla, he is very quiet and asks few questions. ========================== Mr. Ramirez's leg is in skeletal traction and his right arm is in a soft cast. Carla decides that she needs to begin her care by assessing Mr. Ramirez and determining his health status. She begins by reviewing his medical history. She learns that he has a history of smoking and was diagnosed with type 2 diabetes just 5 years ago. ======================== CRITICAL THINKING

FIRST Introduce yourself and orient him to room and the hospital in order to establish trust with patient ================== with this information that you have with him: He is here in hospital b/c fell and broke his femur and wrist ==================== You will always have this nursing process and will do for every patient Mr. Ramirez Assessment: pain, vitals, head-to-toe initial assessment then move to focus exam for his leg and arm (not head if oriented and didn't hit) leads to why is he here Diagnosis: impaired mobility, anxiety worry about having the inability to work, cost of bill with no health insurance Planning: keep him stable, manage his pain, explain everything you do as you do it, speak to social social about discharge (discharge starts at admission) complication of fractures: Pulmonary embolism (fat cells on inside of bone and if brake bone, it goes in blood system and creates clot); cast-->can impair circrulation so always check circulation to make sure those pulses are there b/c can develop compartmental system and lose the limb Implementation: Active range of motion (AROM) exercises--worry about his comfort level and pain while in traction, hygiene (ADLs)---ex: brushing his teeth Evaluation: pain level (has it improved from admission with pain meds)—must assess pain everday; if pain is much worse, there is something wrong such as clot b/c circulation has stopped or infection *must do nursing process every day for every patient b/c things will change and another nurse may not care for him as well; must remove covers to see problems yourself ============== Carla knows that Mr. Ramirez is likely to be in pain because he is reluctant to move and take part in any activity. Her options include conducting a thorough pain assessment and learning how Mr. Ramirez feels about his pain. She must also be culturally sensitive and consider how Mr. Ramirez's Hispanic heritage may influence his response to pain. Carla will then take what she learns and use pain control therapies Mr. Ramirez will be likely to accept. ================= When Carla notices that Mr. Ramirez is slow to respond to her questions, grimaces when shifting weight on his back, and is reluctant to have a bed bath, her critical thinking leads to the inference that Mr. Ramirez is in pain. Carla decides to assess the situation more thoroughly by asking Mr. Ramirez specific questions about his comfort, such as, "Tell me if you are hurting," "Show me where the pain is located," and "Is this pain you have felt before?" Carla does what she can to position Mr. Ramirez more comfortably and makes sure his leg discomfort is under control. She knows that the increased pain and tightness he is experiencing suggest that something is causing pressure in the abdomen. ------->New finding: right side pain and must let physician know what is going on with his liver It could mean the patient is having bleeding from his bruised liver. Carla decides to call Mr. Ramirez's physician immediately.

Your patient has hypokalemia with stable cardiac function. What are your priority nursing interventions? (Select all that apply.) Fall prevention interventions Teaching regarding sodium restriction Encouraging increased fluid intake Monitoring for constipation Explaining how to take daily weights

Fall prevention interventions Monitoring for constipation Hypokalemia causes bilateral skeletal muscle weakness, especially in the quadriceps, which creates a risk for falling. It also causes gastrointestinal smooth muscle weakness, which produces constipation.

Types of syringes

Figure 35-16. Three kinds of syringes: A, hypodermic syringe marked in tenths (0.1) of milliliters and in minims; (low skin—used form IM medication and what needle to put on end) B, insulin syringe marked in 100 units; C, tuberculin syringe marked in tenths and hundredths (0.01) of cubic millimeters and in minims. THESE ARE NOT IDENTICAL AND CANNOT BE FLIPPED

How would you assess a confused patient for sensory alterations? 1. Joshua is a 28-year-old patient in the intensive care unit (ICU). He had a car accident 3 weeks ago and has had several surgeries to repair a fractured femur, ruptured spleen, and intracranial bleeding. He was on a ventilator for 10 days and has had numerous invasive procedures. The nurses report that he is very confused and has been hallucinating

First reorient Joshua and assess him; tell him what has happened to him, where he is and what will happen to him in hospital—may have to say that everyday or multiple times a day Senses that are off: LOC is altered -medications are so strong as well as intracranial bleed will make him hallucinate

Identify the priority nursing diagnosis Impaired verbal communication related to altered central nervous system Fluid volume excess related to compromised regulatory mechanism Impaired physical mobility related to discomfort Activity intolerance related to generalized weakness

Fluid volume excess related to compromised regulatory mechanism • PRIOTITIZING NURSING DIAGNOSIS: • High-ABC, Safety, & Pain (Remember Maslow!) • Intermediate-Non emergent, non-life threatening needs • Low priority-Affects a patient's future well being

Which assessment do you use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? Dryness of mucous membranes Presence or absence of edema Fullness of neck veins when supine Fullness of neck veins when upright

Fullness of neck veins when supine ECV deficit involves decreased vascular and interstitial volume. One way to assess vascular volume is to examine the fullness of neck veins when an individual is supine. With normal ECV neck veins are full when the individual is supine. With ECV deficit they are flat.

A patient is returning to an assisted-living apartment following a diagnosis of declining, progressive visual loss. Although she is familiar with her apartment and residence, she reports feeling a little uncertain about walking alone. There is one step into her apartment. Her children are scheduling themselves to be available to their mom for the next 2 weeks. Which of the following approaches will you teach the children to assist ambulation? (Select all that apply) Walk one-half step behind and slightly to her side. Have her grasp your arm just above the elbow and walk at a comfortable pace. Stand next to your mom at the top and bottom of stairs. Stand one step ahead of mom at the top of the stairs. Place yourself alongside your mom and hold onto her waist.

Have her grasp your arm just above the elbow and walk at a comfortable pace. Stand next to your mom at the top and bottom of stairs. To help a visually impaired person ambulate, offer an elbow or arm. Instruct the patient to grasp your arm just above the elbow. If necessary, physically assist the person by guiding his or her hand to your arm or elbow. When assisting a person to ascend or descend stairs, stand next to the person.

Measuring Arterial Blood O2***KNOW TERMS

Hemoglobin PO2 (partial pressure of O2)---reflects the amount of oxygen gas dissolved in the blood. SaO2 (saturation of O2)--should be between 95-100% for non-copd patient FIO2 (Fraction of inspired O2)---is thus 21% (or .21) throughout the breathable atmosphere.

Administering medication

Identify the client - 2 identifiers Inform the client - intended action, side effects, adverse effects Administer the drug - 3 checks required Evaluate the client's response to the drug -pain reassess in 30 min for effectiveness ----------------- Identify the client - 2 identifiers (scan bracelet, name & DOB) Inform the client - intended action, side effects, adverse effects Administer the drug - 3 checks required Evaluate the client's response to the drug -pain reassess in 30 min for effectiveness High Alert medications- require two RN (ex: heparin, insulin) Overrides of automatic dispensing unit Like sounding medications

Consider Mr. Lawson's case. His pain was partially relieved after receiving an analgesic (rating of 4 on scale of 0 to 10), and Tonya has helped him out of bed and into a chair. However, the patient becomes restless, cannot get comfortable, and begins to feel short of breath. Tonya wonders if something other than the incision is causing Mr. Lawson's discomfort. She sits down next to him and asks, "Is the pain you're feeling now different from before I gave you your medication?" The patient tells her that the pain feels sharper, in his chest. Tonya quickly takes a set of vital signs. His heart rate, which was 88 and regular 1 hour ago, is now 102 and irregular. Tonya calls the physician and notifies her of the changes in Mr. Lawson's condition. Tonya thought outside of the box. Rather than assume that Mr. Lawson's continued pain was from his incision, she gathered more data and recognized that the patient possibly was experiencing a life-threatening condition, a pulmonary embolu

In complex critical thinking each solution has benefits and risks that you weigh before making a final decision. There are options. Thinking becomes more creative and innovative. The complex critical thinker is willing to consider different options from routine procedures when complex situations develop. You learn to gather additional information and take a variety of different approaches for the same therapy.

A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation? Sonorous wheezes in the left lower lung Rhonchi mid sternum Crackles only in apex of lungs Inspiratory crackles in lung bases

Inspiratory crackles in lung bases Correct Decreased effective contraction of left side of heart leads to back up of fluid in the lungs increasing hydrostatic pressure and causing pulmonary edema.

72 y/o female who fell at home PMH: osteoarthritis (hands only) HPI: diarrhea, N/V >24H, NPO No fractures Labs: Na 148 mEq/L, K 3.0 mEq/L What other information do we want to obtain?

Na = HIGH (HYPERNATREMIA)---norm =Na+ 135 to 145 mEq/L S&S: Hypernatremia Thirst CNS Deterioration** Increased intestinal fluid Excess sodium on board Hypernatremia NURSING IMPLEMENTATION Treat underlying cause If oral fluids cannot be ingested, IV solution of 5% dextrose in water or hypotonic saline Diuretics Serum sodium levels must be reduced gradually to avoid cerebral edema ---------------------------------- K = LOW (HYPOKALEMIA---norm =K+ 3.5 to 5.0 mEq/L S&S: Bradycardia ECG changes CNS changes HYPOKALEMIA---IMPLEMENTATION KCl supplements orally or I----Should not exceed 10 to 20 mEq/hr To prevent hyperkalemia and cardiac arrest IF potassium is high will cause ventricular fibrillation and then cause cardiac arrest*** Must know safe range of meds

When delegating input and output (I&O) measurement to nursing assistive personnel, you instruct them to record what information for ice chips? The total volume Two-thirds of the volume One-half of the volume One-quarter of the volume

One-half of the volume

When delegating input and output (I&O) measurement to nursing assistive personnel, you instruct them to record what information for ice chips? The total volume Two-thirds of the volume One-half of the volume One-quarter of the volume

One-half of the volume When ice chips melt, their water volume is one-half the volume of the ice chips. The water volume should be recorded as intake.

Which of the following skills can be delegated to nursing assistive personnel (NAP)? (Select all that apply.) Nasotracheal suctioning Oropharyngeal suctioning of a stable patient Suctioning a new artificial airway Permanent tracheostomy tube suctioning Care of an endotracheal tube (ETT)

Oropharyngeal suctioning of a stable patient Permanent tracheostomy tube suctioning Oropharyngeal suctioning of a stable patient and permanent tracheostomy tube suctioning may be safely delegated to a NAP. The other skills require nursing assessment and clinical decision making as the skill progresses.

For the nursing diagnosis of Deficient Knowledge a nurse selects an outcome from the Nursing Outcome Classification (NOC) of patient knowledge of arthritis treatment. Which of the following are examples of an outcome indicator for this outcome? (Select all that apply.) a--Nurse provides four teaching sessions before discharge. b--Patient denies joint pain following heat application. c--Patient describes correct schedule for taking antiarthritic medications. d--Patient explains situations for using heat application on inflamed joints. e--Patient explains role family caregiver plays in applying heat to inflamed joint.

Patient describes correct schedule for taking antiarthritic medications Patient explains situations for using heat application on inflamed joints. The patient must exhibit behaviors that measure knowledge of arthritis treatment. This would include describing his medication schedule and explaining when to apply heat to inflamed joints. The nurse providing teaching sessions is not a patient outcome. The patient denying joint pain is not an evaluative indicator of knowledge. Explanation of the family caregiver's role is not a measure of the patient's knowledge of treatment.

A nurse is performing an assessment on a patient admitted to the unit following treatment in the emergency department for severe bilateral eye trauma. During patient admission the nurse's priority interventions include which of the following? (Select all that apply.) Conducting a home-safety assessment and identifying hazards in the patient's living environment Reinforcing eye safety at work and in activities that place the patient at risk for eye injury Placing necessary objects such as the call light and water in front of the patient to prevent falls caused by reaching Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye Placing signage on the patient's room door and over the bed to alert health care providers about patient's visual status

Placing necessary objects such as the call light and water in front of the patient to prevent falls caused by reaching Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye Placing signage on the patient's room door and over the bed to alert health care providers about patient's visual status Safety is a top concern when setting priorities for patients who experience eye trauma. Patients with eye trauma may experience serious visual impairments. The patient needs to be oriented to the environment, and necessary objects placed in front of him or her to reduce anxiety and prevent further injury. Signage alerts the staff to patient's visual impairment.

The nurse is caring for a patient who exhibits labored breathing, using accessory muscles, and is coughing up pink frothy sputum. The patient has bilateral lung bases and diminished breath sounds. What are the priority nursing assessments for the nurse to perform prior to notifying the patient's health care provider? (Select all that apply.) SpO2 levels Amount, color and consistency of sputum production Fluid status Change in respiratory rate and pattern Pain in lower leg

SpO2 levels Amount, color and consistency of sputum production Change in respiratory rate and pattern These are key respiratory assessments that provide data on patient's worsening respiratory status. While fluid status does impact respiratory status, it is not a priority assessment at this time. Pain in lower leg is assessed later.

nurse in a community health clinic has been caring for a young teenager with asthma for several months. The nurse's goal of care for this patient is to achieve self-management of asthma medications. Identify appropriate evaluative indicators for self-management for this patient. (Select all that apply.) a--Quality of life b--Patient satisfaction c--Use of clinic services d--Adherence to use of inhaler e--Description of side effects of medications

Quality of life Use of clinic services Adherence to use of inhaler Relevant and appropriate evaluative indicators of self-management include self-efficacy, health behavior or attitude, health status, health service use, quality of life, and psychological indicators. In this case the patient's quality of life, use of clinic services, and adherence (behavior) to use of an inhaler are all appropriate. Patient satisfaction is a perception and not an indicator of self-management. Ability to describe medication side effects is a measure of knowledge but does not necessarily equate with successful self-management.

Two hours after surgery, the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 ml of dark red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? Record the amount and continue to monitor drainage Notify the physician. Strip the chest tube starting at the chest Increase the suction by 10 mm Hg

Record the amount and continue to monitor drainage Dark red drainage after surgery (50-200 ml per hour in first 3 hours) is expected but be aware of sudden increases greater than 100 ml per hour after the first three hours especially if becomes bright red in color.

A patient with progressive vision impairments had to surrender his driver's license 6 months ago. He comes to the medical clinic for a routine checkup. He is accompanied by his son. His wife died 2 years ago, and he admits to feeling lonely much of the time. Which of the following interventions reduce loneliness? (Select all that apply.) Sharing information about senior transportation services Reassuring the patient that loneliness is a normal part of aging Maintaining distance while talking to avoid overstimulating the patient Providing information about local social groups in the patient's neighborhood Recommending that the patient consider making living arrangements that will put him closer to family or friends

Sharing information about senior transportation services Providing information about local social groups in the patient's neighborhood Recommending that the patient consider making living arrangements that will put him closer to family or friends Loneliness is not a normal part of aging. Principles for reducing loneliness include providing information about local social groups and recommending alterations in living arrangements if physical isolation occurs. Access to senior transportation services is important, since transportation challenges can lead to social isolation.

A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (Select all that apply). Sharp pleuritic pain that worsens on inspiration Crackles over lung bases of affected lung Tracheal deviation toward the affected lung Worsening dyspnea Absent lung sounds to auscultation on affected side

Sharp pleuritic pain that worsens on inspiration Worsening dyspnea Absent lung sounds to auscultation on affected side When the lung collapses, as with a pneumothorax, the thoracic space fills with air, which irritates the parietal pleura causing inspiratory pain. Because of the collapsed lung there is reduced gas exchange in the affected area, reduced oxygenation and dyspnea result. When an area of the lung collapses, breath sounds over affected area are absent.

A patient has been on contact isolation for 4 days because of a nosocomial infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Which are the correct nursing interventions to reduce sensory deprivation? (Select all that apply.) Teaching how activities such as reading and using crossword puzzles provide stimulation Moving him to a room away from the nurse's station Turning on the lights and opening the room blinds Sitting down, speaking, touching, and listening to his feelings and perceptions Providing auditory stimulation for the patient by keeping the television on continuously

Teaching how activities such as reading and using crossword puzzles provide stimulation Moving him to a room away from the nurse's station Turning on the lights and opening the room blinds Patients who are isolated in a health care setting are at risk for sensory deprivation because they are unable to enjoy normal interactions with others. To help them adjust to their environment, promote meaningful stimulation. You can do this best by sitting down, speaking, touching, and listening to his or her feelings and perceptions and teaching self-stimulation.

In which of the following examples is a nurse applying critical thinking skills in practice? (Select all that apply.) The nurse thinks back about a personal experience before administering a medication subcutaneously. The nurse uses a pain-rating scale to measure a patient's pain. The nurse explains a procedure step by step for giving an enema to a patient care technician. The nurse gathers data on a patient with a mobility limitation to identify a nursing diagnosis. A nurse offers support to a colleague who has witnessed a stressful event.

The nurse thinks back about a personal experience before administering a medication subcutaneously. The nurse uses a pain-rating scale to measure a patient's pain. The nurse gathers data on a patient with a mobility limitation to identify a nursing diagnosis. Reflection, using a pain-rating scale to be precise and specific, and nursing assessment (the first step of the nursing process) are examples of critical thinking skills. Explaining a procedure based on policy is not critical thinking. However, performing a procedure following policy is basic critical thinking. Offering support to a colleague is an important way to help another manage stress but is not a critical thinking skill.

before giving med, what are the 3 checks?

Three Checks--if perform, will never make med error 1. Before you pour Check the medication label against the MAR (medication administration record) 2. After you pour—check right amount Verify the label against the MAR 3. At the bedside Check the medication again

2. Place the order of blood flow from right side of heart to pulse oximetry measurement. ORDER: a. Deoxygenated blood flows to pulmonary capillaries b. O2 diffuses from alveoli to blood c. Hemoglobin saturated w/ O2 flows to pulmonary veins d. O2 blood flow pumps from left side of heart to peripheral arteries

a. Deoxygenated blood flows to pulmonary capillaries b. O2 diffuses from alveoli to blood c. Hemoglobin saturated w/ O2 flows to pulmonary veins d. O2 blood flow pumps from left side of heart to peripheral arteries

Purposes of the Nursing Outcomes Classification (NOC) include which of the following? (Select all that apply.) a--To identify and label nurse-sensitive patient outcomes b--To test the classification in clinical settings c--To establish health care reimbursement guidelines d--To identify nursing interventions for linked nursing diagnoses e--To define measurement procedures for outcomes

To identify and label nurse-sensitive patient outcomes To test the classification in clinical settings The NOC classification offers a language for the evaluation step of the nursing process. The purposes of NOC are to (1) identify, label, validate, and classify nurse-sensitive patient outcomes; (2) field test and validate the classification; and (3) define and test measurement procedures for the outcomes and indicators using clinical data.

What assessment do you make before hanging an intravenous (IV) fluid that contains potassium? Urine output Arterial blood gases Fullness of neck veins Level of consciousness

Urine output Increased potassium intake when potassium output is decreased is a major risk for hyperkalemia. Before increasing IV potassium intake, check to see that urine output is normal.

The home care nurse is instructing a nursing assistant about interventions to facilitate location of items for patients with vision impairment. Which are effective strategies for enhancing a patient's impaired vision? (Select all that apply.) Use of fluorescent lighting Use of warm, incandescent lighting Use of yellow or amber lenses to decrease glare Use of adjustable blinds, sheer curtains, or draperies Indirect lighting to reduce glare

Use of warm, incandescent lighting Use of yellow or amber lenses to decrease glare Use of adjustable blinds, sheer curtains, or draperies Interventions to enhance vision include the use of warm, incandescent lighting; yellow or amber lenses to decrease glare; and adjustable blinds, sheer curtains, or draperies to allow for the adjustment of natural light. Fluorescent lighting can contribute to indirect and direct glare.

which of the following is pictured? pick all that apply: a) poor turgor b) increased turgor c) dehydration d) fluid overload

a) poor turgor c) dehydration ==================== b) increased turgor---increased turgor would snap right back

Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply) a. Checks scientific literature or policy and procedure b. Reassesses the patient's condition c. Collects all necessary equipment d. Delegates the procedure to a more experienced nurse e. Considers all possible consequences of the procedure

a. Checks scientific literature or policy and procedure b. Reassesses the patient's condition c. Collects all necessary equipment e. Considers all possible consequences of the procedure *The nurse does not delegate a procedure to a more experienced nurse. Instead the nurse has another nurse (e.g., staff nurse, faculty, nurse specialist) who has completed the procedure correctly and safely provide assistance and guidance

***In caring for a client with a tracheostomy, the nurse would give priority to the nursing diagnosis of a. Risk for ineffective airway clearance b. Anxiety related to suctioning c. Social isolation related to altered body image d. Impaired tissue integrity

a. Risk for ineffective airway clearance A tracheostomy is a medical procedure — either temporary or permanent — that involves creating an opening in the neck in order to place a tube into a person's windpipe. The tube is inserted through a cut in the neck below the vocal cords. This allows air to enter the lungs tracheostomy: Ineffective Airway Clearance. Impaired Verbal Communication. Deficient Knowledge. Risk for Impaired Gas Exchange. Risk for Infection. Anxiety. Deficient Knowledge. Risk for Aspiration.

A nurse working on a surgery floor is assigned five patients and has a patient care technician assisting her. Which of the following shows the nurse's understanding and ability to safely delegate to the patient care tech? (Select all that apply) a. The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test b. Determining what is the patient care technician's current workload c. The nurse chooses to delegate the measurement of a stable patient's vital signs and not the assessment of the patient arriving from a diagnostic test d. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure e. The nurse confers with another registered nurse about organizing priorities

a. The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test c. The nurse chooses to delegate the measurement of a stable patient's vital signs and not the assessment of the patient arriving from a diagnostic test d. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure *A nurse must consider priorities of all assigned patients in deciding which activities should be delegated to NAP. When the decision is between vital signs versus a patient arriving from a diagnostic test, delegation of routine vital signs is appropriate. Ensuring that a NAP is competent to perform an activity is also important. Conferring with another RN about organizing and checking the tech's personal workload are not factors that will assist the RN's own priority setting

Critical question Care plans that focus on DRGs and are organized on a timeline to meet recommended lengths of stay are called standardized nursing care plans. a. True b. False

a. True A diagnosis-related group (DRG) is a patient classification system that standardizes prospective payment to hospitals and encourages cost containment initiatives. In general, a DRG payment covers all charges associated with an inpatient stay from the time of admission to discharge.

Mr. Arbor complains to the nurse that he is feeling anxious. He states, "I'm just so tired of all these tests they are doing, and it's so noisy here at night." Mr. Arbor's pulse is 110 bpm, and his blood pressure is 140/70 mm Hg. Nursing actions should include which of the following? a. Turn on the television to provide distraction. b. Ask the client if he would like to discuss his anxiety further. c. Close the blinds, dim the lights, and ask the patient what other measures would help him rest. d. Call the physician and obtain an order for an anti-anxiety medication for PRN use.

a. Turn on the television to provide distraction. b. Ask the client if he would like to discuss his anxiety further. c. Close the blinds, dim the lights, and ask the patient what other measures would help him rest. ---if these dont work then resort to meds

Mr. Arbor complains to the nurse that he is feeling anxious. He states, "I'm just so tired of all these tests they are doing, and it's so noisy here at night." Mr. Arbor's pulse is 110 bpm, and his blood pressure is 140/70 mm Hg. Nursing actions should include which of the following? a. Turn on the television to provide distraction.b. Ask the client if he would like to discuss his anxiety further.c. Close the blinds, dim the lights, and ask the patient what other measures would help him rest.d. Call the physician and obtain an order for an anti-anxiety medication for PRN use.

a. Turn on the television to provide distraction. b. Ask the client if he would like to discuss his anxiety further. c. Close the blinds, dim the lights, and ask the patient what other measures would help him rest. ---if these dont work then resort to meds The coma scale score correlates to the client's ability to function. As the score decreases, he is less able to meet his own basic needs, requiring greater nursing intervention. ----need to know if changes if patient had stroke or brain damage; even if score changes by 1 point, that is huge

What assessment do you make before hanging an intravenous (IV) fluid that contains potassium? Urine output Arterial blood gases Fullness of neck veins Level of consciousness

a. Urine Output Increased potassium intake when potassium output is decreased is a major risk for hyperkalemia. Before increasing IV potassium intake, check to see that urine output is normal ECV deficit involves decreased vascular and interstitial volume. One way to assess vascular volume is to examine the fullness of neck veins when an individual is supine. With normal ECV neck veins are full when the individual is supine. With ECV deficit they are flat

An aldosterone blocking agent would result in which of the following manifestations? a. hyperklemia b. hypernatremia c. water retention d. vasoconstriction

a. hyperklemia when ALDOSTERONE released by RAAS cascade, it holds onto sodium and gets rid of potassium; if you BLOCK aldosterone, sodium will go away and potassium will stay

The client who has had a stroke states to the nurse, "You know I can't even tell where my left leg IS." This reflects lack of response to stimuli by the a. mechanoreceptors b. proprioceptors c. thermoreceptors d. chemoreceptors

a. mechanoreceptors thermoreceptors—respond to temperature, proprioceptors —respond to pain and pressure, photoreceptors —respond to light

The client who has had a stroke states to the nurse, "You know I can't even tell where my left leg IS." This reflects lack of response to stimuli by the a. mechanoreceptors b. proprioceptors c. thermoreceptors d. chemoreceptors

a. mechanoreceptors b/c cant feel leg thermoreceptors—respond to temperature, proprioceptors —respond to movement and position, photoreceptors —respond to light

The term "Kussmaul" refers to a high-pitched, harsh, crowing inspiratory sound that occurs due to partial obstruction of the larynx. a. true b. false

a. true

signs of fluid volume overload include which of the following? pick all that apply. a. weigh gain b. increased sodium level c. distended neck veins d. crackles e. positive skin turgor

a. weigh gain--hold on to fluid c. distended neck veins w/ fluid volume overload (JVD of 30 degrees) d. crackles--fluid in lungs ----------------- b. increased sodium level---DECREASE sodium b/c diluted e. positive skin turgor---only due to DEHYDRATION which causes poor turgor (only a sign when negative or poor); positive skin turgor not a thing

Critical Check The nurse teaches the patient how to change his wound dressing. This is an example of: a. An indirect-care intervention b. An independent intervention c. A dependent intervention d. A collaborative intervention

b. An independent intervention Teaching a client about care does not require a physician's order and is in response to the nursing diagnosis of Deficient Knowledge. Teaching falls under the category of direct-care interventions and there is no evidence that the nurse needed to collaborate with the wound-nurse to complete this teaching

A client with a history of heart failure presents with crackles and dyspnea. which of of the following labs will be elevated a. sodium levels b. B-Natriuretic peptide level c. potassium level d. aldosterone level

b. B-Natriuretic peptide level-excreted by heart when heart is overloaded w/ fluid which tries to oppose renin Crackles= fluid overload edema in longs dyspnea is shortness of breath ================================= a. sodium levels--if Na elevated, not enough water on board c. potassium level d. aldosterone level

A nurse is visiting a patient in the home and is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (Select all that apply) a. Reviewing the family caregiver's availability during medication administration times b. Making a judgment of the value of improved adherence for the patient c. Reviewing the number of medications and time each is to be taken d. Determining all consequences associated with the patient missing specific medicines e. Reviewing the therapeutic actions of the medications

b. Making a judgment of the value of improved adherence for the patient d. Determining all consequences associated with the patient missing specific medicines *Tips for making good clinical decisions during implementation include making a judgment of the value of the consequence to the patient, reviewing all possible consequences associated with each nursing action, determining the probability of all possible consequences, and reviewing the set of all possible nursing interventions for a patient's problems

Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnoses? (Select all that apply) a. Numbered order of diagnosis on the basis of severity b. Notion of urgency for nursing action c. Symptom pattern recognition suggesting a problem d. Mutually agreed on priorities set with patient e. Time when a specific diagnosis was identified

b. Notion of urgency for nursing action c. Symptom pattern recognition suggesting a problem d. Mutually agreed on priorities set with patient *These three factors are considered in setting priorities for a patient's nursing diagnoses or collaborative problems. The other options are inappropriate because a numbering system and time of identification hold little meaning when a patient's condition changes

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions? (Select all that apply) a. The application of the skin barrier is a dependent care measure b. The call to the ostomy and wound care specialist is an indirect care measure c. The cleansing of the skin is a direct care measure d. The application of the skin barrier is an instrumental activity of daily living. e. Inspecting the skin in a direct care activity.

b. The call to the ostomy and wound care specialist is an indirect care measure c. The cleansing of the skin is a direct care measure *The call to the specialist is a referral and an indirect care measure on the patient's behalf. Cleansing of the skin is an example of direct care. Application of a skin barrier is an independent measure and it is not an instrumental activity of daily living. Inspecting the skin is assessment, not direct care

a client has a phosphate level of 8.5. which assessment finding would concern the nurse? a. bone loss b. pain along cheek c. decreased energy level d. confusion

b. pain along cheek--> called Chvosteck's sign (pain along facial nerve when touch cheek) AT BED SIDE: 8.5 = high phosphate level that would cause low calcium (HYPOCALECEMIA) ===================== a. bone loss--> cant assess bone loss c. decreased energy level d. confusion

the greatest concern for a nurse is which of the following a. sodium level of 132 b. potassium levels of 6.5 c. calcium level of 8.5 d. magnesium level of 3.0

b. potassium levels of 6.5--anything above 5 can kill patient ***KNOW VALUES OF MAJOR ELECTOLYTES

for parental meds, *****The lower the gauge, the ________ the needle

bigger -----the higher the gauge, the smaller the needle (30 for NICCU) ***bevel should ALWAYS be facing up and never down Minimum gauge is 20 in hospital

this type of needle is ONLY TO DRAW BLOOD OUT AND NOT FOR IV

butterfly needle Used to draw blood; NEVER USE TO START IV b/c CANT BE LEFT INSIDE--***ONLY TO DRAW BLOOD OUT AND NOT FOR IV

The nurse displays a NEED FOR FURTHER UNDERSTANDING when erroneously stating which of the following? a. "I will use a BP cuff that is 40% off patient's upper arm circumference" b. "I will use a BP cudd that is 80% of patient's upper arm length" c. "A blood pressure cuff that is too wide for the patient will give falsely high BP" d. Too narrow of BP gives high BP

c. "A blood pressure cuff that is too wide for the patient will give falsely high BP"

Which diagnostic test/exam would best measure a client's level of hypoxemia? a. chest x-ray b. pulse oximeter reading c. ABG d. peak expiratory flow rate

c. ABG

What is the importance of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey? a. Measures a nurse's competency in interdisciplinary care b. Measures the number of adverse events in a hospital c. Measures quality of care within hospitals d. Measures referrals to a health care agency

c. Measures quality of care within hospitals *HCAHPS is a survey that has become a standard for measuring and comparing quality of hospitals. It is a survey of patient perceptions

Critical Check The nurse has determined that the goal for a particular nursing diagnosis on the patient's plan of care has not been met. It will be most important for the nurse to a. Report this finding to the physician b. Note this finding in the patient's record c. Revise the plan of care d. Remove the nursing diagnosis from the plan

c. Revise the plan of care

a patient has an intestinal infection and has multiple bouts of diarrhea. the nurse suspects the patient to have which of the following blood gases? a. respiratory alkalosis from hyperventilation b. respiratory acidosis due to pain c. metabolic acidosis from gastric loss d. metabolic alkalosis from diarrhea

c. metabolic acidosis from gastric loss when you lose from belly button up--you lose acid rich fluid making you alkalodic; losing from belly button down you are losing alkalodic rich fluid and thus becoming more acidic ---YOU WOULD EXPECT TO SEE pH to be low (because more acidic)

A nurse has been caring for a patient over the last 10 hours. The patient's plan of care includes the nursing diagnosis of Nausea related to effects of postoperative anesthesia. The nurse has been asking the patient to rate his nausea over the last several hours after administering antiemetics and using comfort measures such as oral hygiene. The nurse reviews the patient's responses over the past 10 hours and notes how the patient's self-report of nausea has changed. This review an example of: a--Comparing outcome criteria with actual response. b--Gathering outcome criteria. c--Evaluating the patient's actual response. d--Reprioritizing interventions

comparing outcome criteria with actual response The key to this question is observation for change. The nurse compares the patient's actual self-report rating of nausea with the expected outcome of a reduction in nausea. Gathering outcome criteria simply involves having the patient rate nausea. Evaluating the behavior or self-report is the determination of the patient's actual response.

probing

conducting a thorough search; investigating

Which of the following does a nurse perform when discontinuing a plan of care for a patient? a--Confirms with the patient that expected outcomes and goals have been met b--Talks with the patient about reprioritizing interventions in the plan of care c--Changes the frequency of interventions provided d--Reassesses how goals were met

confirms with the patient that expected outcomes and goals have been met When you discontinue a plan of care, you determine that expected outcomes and goals have been met, and you confirm this evaluation with the patient when possible. If you and the patient agree, you discontinue that part of the care plan. Reassessing how goals were met is not necessary if you confirm that discontinuation of a plan is appropriate. Talking with the patient about reprioritizing interventions in the plan of care and changing the frequency of the interventions provided are not appropriate when a plan is discontinued.

Which of the following activates the RAAS Cascade? a) sodium level of 132 b) decreased albumin c) potassium level of 5.6 d) blood pressure of 85/43

d) blood pressure of 85/43 low perfusion, low BP

A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? a. Patient will be turned every 2 hours within 24 hours b. Patient will have normal bowel function within 72 hours c. Patient's skin integrity will remain intact through discharge d. Erythema of skin will be mild to none within 48 hours

d. Erythema of skin will be mild to none within 48 hours *Turning the patient every 2 hours in a 24-hour period is an intervention. Both "Patient will have normal bowel function within 72 hours" and "Patient's skin integrity will remain intact through discharge" are goals

A patient has been febrile and coughing thick secretions; adventitious lung sounds indicate rales in the left lower lobe of the lungs. The nurse decides to perform nasotracheal suction because the patient is not coughing. The nurse inspects the mucus that is suctioned, which is minimal. The nurse again auscultates for lung sounds. Auscultation and mucus inspection are examples of: a- Evaluative measures. b- Expected outcomes. c- Reassessments. d- Reflection

evaluative measures Auscultation of lung sounds and inspection of mucus after the intervention of suctioning are examples of evaluative measures. An outcome would be clear secretions or clear lung sounds. It is not a reassessment because the nurse has not yet compared findings with expected outcomes. Suctioning is a standard of care.

Hypermagnesemia

excess of magnesium in the extracellular fluid mostly see with patients who are in renal failure or people that use magnesium laxatives, causing everything to slow down (#1 cause of renal failure) ETIOLOGY: -renal failure -excessive intake (Po, IV, laxatives) ------- ***CLINICAL PRESENTATIONS -EKG changes: Peaked T waves Bradycardia -Decreased LOC -Decreased respirations -Hyporreflexia: depresses CNS • High magnesium inhibits acetylcholine release and can cause diminished neuromuscular function; magnesium slows everything down o Also block calcium channels

Hyperkalemia

excessive potassium in the blood -renal insufficiency; All about the kidneys with hyperkalemia; if they are not working properly, cant clear potassium and it will build up in the blood -CKD (chronic kidney disease) -Autoimmune nephropathy -Acidosis -Adrenal insufficiency -ACEI/ARB's: (angiotensin converting enzyme inhibitors) and ARBs (angiotensin-receptor blockers) are used to treat high blood pressure (hypertension) and congestive heart failure, to prevent kidney failure in patients with high blood pressure or diabetes, and to reduce the risk of stroke. -potassium sparing diuretics ICF to ECF movement; potassium/hydrogen ion Excessive administration RBC destruction due to trauma, those cells when they burst, spill potassium b/c it lives inside the cell--> HYPERKALEMIA --------------------  ****Clinical Manifestations -Generalized muscle weakness -Respiratory muscle weakness -Paresthesias: an abnormal sensation, typically tingling or pricking ("pins and needles"), caused chiefly by pressure on or damage to peripheral nerves. -Cardiac arrythmias and can lead to cardiac arrest just like hypokalemia

A patient is being discharged after treatment for colitis (inflammation of the colon). The patient has had no episodes of diarrhea or abdominal pain for 24 hours. Following instruction, the patient identified correctly the need to follow a low-residue diet and the types of food to include if a bout of diarrhea develops at home. These behaviors are examples of: a- Evaluative measures. b- Expected outcomes. c- Reassessments. d- Standards of care.

expected outcomes The absence of diarrhea and abdominal pain and the ability to identify the correct diet are expected outcomes. If outcomes had not been met, the nurse would reassess. The low-residue diet is a standard of care, but the patient's ability to describe it is an outcome. An evaluative measure is the nurse questioning the patient about symptoms.

• *******MUST KNOW 5 STEPS OF NURSING PROCESS************

o Assess a patient o Diagnosis o Planning o Implementation o Evaluation Critical thinking skills are interwoven-cognitive processes used in complex thinking operations such as problem solving and decision making •

• ***Problems with Gas Exchange

o Hypoxia: deficient amount of O2 reaching body tissue; O2 sat less than 90% o Hypoxemia: low level of O2 in blood, less than 85% o Hypercarbia: CO2 above normal levels (above 45) o Hypocarbia: CO2 below normal levels (below 35) o Bradypnea: slowing breathing less than 12 breaths per min o Apnea: not breathing

• TYPES of assessments:

o Initial- Why is patient seeking care? Collect data o Ongoing- performed as needed, dynamic o Comprehensive= EVERYTHING o Observation o Physical Assessment o Nursing Interview o Focused -Obtain data about an actual, potential, or possible problem that has been identified or suspected, not on overall health status (focusing on one thing ex: asthma patient—just focus on their breathing) o Special needs- in depth focused assessment, stemming from specific patient needs (depends on patient)

O2 delivery devices

o LOW-FLOW devices (from least to most % O2) Nasal cannula (prongs) • 24-45% FIO2 @ 2-6 L per min (USUALLY 2L at 25-28% FIO2) Simple face mask • Minimum rate of 5-8 L/min (40-60% FIO2) o Mask must be correct size for client. May cause sense of claustrophobia in some. May be uncomfortable. Check skin behind ears and also bridge of nose for sores. also assess cheeks and chin for chaffing and keep skin dry. Rebreather masks • Non-Rebreathing Mask. 10-15 LPM. 60-90% set to keep bag inflated o Used in severe HYPOXEMIA for highest concentration of oxygen delivery o Dependent on patient rate and depth of breathing o Need snug fit o Frequently not well tolerated • PARTIAL REBREATHER MASK 6-11 L/min (60-90% FIO2) o HIGH-FLOW devices Venture mask (venti mask) • Delivers the most accurate O2 content. 24-55% O2 at 4-10 L/min • Mask must fit snugly and tubing must be free from kinks Aerosol face masks Face tents • Variable oxygen delivery at low flow 21-50% amount dependent on rate and depth patient breathing o Less claustrophobic than NRB Tracheostomy collars

• COUGH

o Sputum amount, color, odor o White or clear-viral (don't need antibiotic) o Yellow or green-bacterial infection (need antibiotic) o Black-coal, smoke or soot o Rust colored-pneumococcal pneumonia, TB o Hemoptysis-bloody sputum o Pink and frothy-associated with pulmonary edema

Normal values: pH of ECF normal is __________ CO2: Basic ---_____________---Acid Bicarb: Acid---___________---alk

pH of ECF normal is 7.35-7.45 CO2: Basic ---35-45---Acid Bicarb: Acid---22-26---alk

After caring for a young man newly diagnosed with diabetes, a nurse is reviewing what was completed in his plan of care following discharge. She considers how she related to the patient and whether she selected interventions best suited to his educational level. It was the nurse's first time caring for a new patient with diabetes. The nurse's behavior is an example of which of the following? a-- Reflection-in-action b-- Reassessment c-- Reprioritizing d-- Reflection-on-action

reflection on action The nurse is performing reflection-on-action. This means that when you gather evaluative measures about a patient, reflection on the findings and the exploration about what the findings might mean improve your ability to problem solve. The other three measures occur during evaluation because the nurse is still actively intervening in the patient's care. Reflection-on-action refers to the retrospective (in the past) contemplation of practice undertaken in order to uncover the knowledge used in practical situations, by analysing and interpreting the information recalled Reflection-in-action on the other hand refers to thinking about what one is doing whilst one is doing it

the most serious effect of hyperkalemia is on ________________ function. Serum __________ levels are directly or indirectly regulated by parathyroid hormone (PTH) and vitamin D.

the most serious effect of hyperkalemia (AND HYPOKALEMIA) is on ____CARDIAC________ function. ================================================ Serum __CALCIUM________ levels are directly or indirectly regulated by parathyroid hormone (PTH) and vitamin D.

Hypercalcemia

too much calcium in blood stream; • Calcium level greater than 10mg/dL (too much in blood and not in bone) Etiology: -Increased bone release • Immobility • Fractures -Hypophosphatemia -Malignancies tumors release chemicals that cause Ca release from bones -Hyperparathyroidism -Increased GI absorption ----------------- CLINICAL presentation*** • Immobility- calcium seeps out into blood • Bone becomes brittle • Hypophosphatemia: Low phosphate and high calcium • Kidney stones form with high calcium levels • Calcium deposits in eyes- band keratopathy phos, < calcium (reciprocal relationship)

primary effects of meds---***KNOW THESE TERMS

• PALLIATIVE EFFECTS: S&S that does NOT decrease the disease; not going to cure patient but will help deal with the pain (usually given end of life) • SUPPORTIVE EFFECTS: support the integrity of body functions until other medications can become effective o Substitutive replaced chemical lacking Ex: insulin---not cure but helps body • CHEMOTHERAPEUTICS: destroys disease producing microorganisms • RESTORATIVE: Returns the body to health

Types of Nursing Diagnoses

• PROBLEM-FOCUSED: A clinical judgment concerning an undesirable human response to health conditions/life processes that exists in an individual, family, group, or community. o In order to make a problem-focused diagnosis, the following must be present: defining characteristics (manifestations, signs, and symptoms) that cluster in patterns of related cues or inferences. Related factors (etiological factors) that are related to, contribute to, or antecedent to the diagnostic focus are also required. o Directly to the point • HEALTH PROMOTION: A clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential. These responses are expressed by a readiness to enhance specific health behaviors, and can be used in any health state. Health promotion responses may exist in an individual, family, group, or community o In order to make a health-promotion diagnosis, the following must be present: defining characteristics which begin with the phrase, "Expresses desire to enhance...". o Just a PREVENTION ex: if person has STD, a nursing diagnosis would be to TEACH/EDUCATE atient how to prevent getting another STD such as wearing a condom during sec • RISK: A clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes. In order to make a risk-focused diagnosis, the following must be present: supported by risk factors that contribute to increased vulnerability. o No defining characteristics or related factors, only risk factors!

scope of practice v standard of care

• Scope of practice: where you can get fired if practicing outside of scope b/c under LAW (varies from state to state) • Standard of care: the same across the board; set MINIMUM criteria for job proficiency • The "medical standard of care" is typically defined as the level and type of care that a reasonably competent and skilled health care professional, with a similar background and in the same medical community, would have provided under the circumstances that led to the alleged malpractice.

******DRUG ABUSE/ MISUSE

• Tolerance: decreased response—drug not working way it use to so may need stronger dose or change the drug altogether • Drug dependence: reliance; patient now depends on med (ex: pain killers) • Drug misuse: indiscriminant, improper use - alcohol • Drug abuse: inappropriate intake (not talking about street drugs but med drugs) • Illicit Drugs

Types of Medication Orders***

• WRITTEN ORDER: most given and in computer • AUTOMATIC "stop" date: pre-order • STAT order: immediately given • STANDING ORDER: Written and approved documents containing rules, policies, procedures, • regulations, and orders for the conduct of patient care in various stipulated clinical settings. o Ex: if blood risk for med, you can give aspirin because know there is high risk • PRN ORDER: As needed; most pain meds • SINGLE ORDER: Order for one time use