NUR 336 Midterm Exam Fall 2022 ASU

Conversion of tbsp to mL

1 tbsp = 15 mL

Conversion of tsp to mL

1 tsp = 5 mL

Review of Initial Interaction

1. Gel in, wear gloves appropriately (provide privacy, assemble equipment, and verify policy) 2. Introduce self & reason for visit 3. Identify pt. using 2 identifiers 4. Check allergy band, have pt. state allergy & reaction to it 5. Check fall band & ascertain pt. understanding of fall risk 6. Use therapeutic comm., ask pt. about pain 7. Perform brief situational assess. (i.e. raise bed to working level) 8. At end of encounter, summarize visit & time you will return 9. Ensure call light within reach & bed in lowest position 10. Gel out, enurse gloves were removed

Donning PPE Sequence (CDC)

1. Gown 2. Mask/Respirator 3. Goggles/Face shield 4. Gloves

Review of Cranial Nerves

1. Olfactory nerve: Sense of smell. (s) 2. Optic nerve: Ability to see. (s) 3. Oculomotor nerve: Ability to move and blink your eyes. (m) 4. Trochlear nerve: Ability to move your eyes up and down or back and forth. (m) 5. Trigeminal nerve: Sensations in your face and cheeks, taste and jaw movements. (b) 6. Abducens nerve: Ability to move your eyes. (m) 7. Facial nerve: Facial expressions and sense of taste. (b) 8. Auditory/vestibular nerve: Sense of hearing and balance. (s) 9. Glossopharyngeal nerve: Ability to taste and swallow. (b) 10. Vagus nerve: Digestion and heart rate. (b) 11. Accessory nerve (or spinal accessory nerve): Shoulder and neck muscle movement. (m) 12. Hypoglossal nerve: Ability to move your tongue. (m) Mnemonic for sensory vs motor vs both of nerve: "Some say marry money, but my brother says big brains matter more" MY mnemonic for nerve names: "OMG, one of the talking alpacas forgot a good vegan appetizer huh?"

Review of Heart/Lung/Abdomen Assessment with normal findings

1. Posterior/Lateral Thorax and Lungs: skin condition pink/beige, no lesions, symmetrical, no bumps, lung sounds clear 2. Anterior Thorax and Lungs: skin condition pink/beige, no lesions, symmetrical, no bumps, lung sounds clear, rate and rhythm clear, unconscious effort no use of accessory muscles 3. Neck: skin condition pink/beige, no lesions, carotid pulse palpable 4. Upper Extremities: skin condition pink/beige, no lesions, temperature warm and dry, brachial/radial pulse +2, epitrochlear nodes non-palpable 5. Heart: Regular, rate, rhythm, S1 S2, no rubs, gallops, murmurs 6. Lower Extremities: skin condition pink/beige, no lesions, warm and dry skin, no pretibial edema, inguinal nodes non-palpable, Femoral, popliteal, dorsalis pedis, posterior tibial pulses +2, Homan's negative for pain bilaterally 7. Abdomen: skin pink/beige, no lesions, warm/dry, symmetrical, bowel sounds present in all 4 quadrants, no masses, no rebound tenderness, non-palpable urinary bladder

Review of HEENT/Neuro Assessment with normal findings

1. Pre-exam Behaviors (i.e. initial interaction 1-5) 2. Head and Face: symmetry, normocephalic head, temporal artery pulses equal, TMJ 5/5 strength equa, frontal and maxillary sinuses, no edema 3. Eyes: no ptosis bilaterally, clear conjunctiva, symmetrical corneal light reflex, pupils equal and reactive to light, pupils move parallel in 6 cardinal fields of gaze, red reflex, steady gaze 4. Ears: ear size, non-tender, tympanic membrane pearly gray, whisper test 5. Nose: symmetrical, mucosa and turbinates pink, moist, nares patent 6. Mouth and throat: buccal mucosa, gums pink, no lesions, tongue smooth and protrudes midline, gag reflex 7. Neck: symmetrical, no lumps, trachea midline, nodes non-palpable 8. Neuro: trigeminal light touch felt equally bilaterally, light touch present on upper arms, forearms, hands, thighs, legs, feet, pain present and equal on sharp/dull test, hand grips equal bilaterally, coordinated skilled smooth rhythmic turning, gait steady, Romberg negative 9. Post-exam Behaviors (i.e. initial interaction 8-10)

Review of Vital Signs checklist

1. Pre-exam Behaviors (i.e. initial interaction 1-5) 2. Pain Assessment 3. Temperature Assessment 4. Radial Pulse 5. Respirations 6. Blood Pressure (two-step method) 7. Pulse Ox 8. Post-exam Behaviors (i.e initial interaction 8-10)

Review of NG Tube Insertion

1. Pre-exam Behaviors (i.e. initial interactions 1-5) + ensure wall suction is working 2. Assessment: auscultate bowel; inspect and palpate abdomen for distention; gag and cough reflexes 3. Inspect nares for patency & provide tissues and have pt. blow nose 4. Raise bed to working height, place pt. into high-Fowler's position w/pillows under head and shoulders 5. Place towel over pt. chest and have pt. blow nose 6. Measure tube from tip of pt. nose to earlobe and then to xiphoid process 7. Prepare tape or fixation device 8. Gloves 9. Lubricate tip ot tube and apply anesthetics if policy indicates 10. Give pt. cup of water w/straw and keep pt. neck in neutral position or have them flex head back on pillow 11. Insert tube following nasal passage and rotate to ease insertion 12. Provide reassurance to pt. if gagging occurs; make sure tube is not coiled 13. Have pt. flex chin to chest and encourage to sip via straw while tube advances 14. Stop procedure if pt. becomes cyanotic, unable to speak/hum, continuous coughing/gagging, or unable to advance after rotation 15. Stop advancement once measured mark is reached & secure w/tape 16. Verify facility policy for NG placement (definitive placement: chest x-ray to verify placement) 17. Apply skin barrier & secure tube to pt. gown 18. Apply clean gloves & provide oral hygiene 19. Document 20. Post-Exam Behaviors (i.e. initial interaction 8-10)

Review of PO Medication Administration Checklist

1. Verify facility policy 2. Verify MAR, 5 rights 3. Wash hands and assemble equipment 4. 1st safety check at PYXIS; verify MAR, 5 rights 5. 2nd safety check preparing medication; verify MAR, 5 rights 6. Pre-exam Behaviors (i.e. initial interactions) 7. 3rd safety check; verify MAR, 5 rights 8. Administer 9. Chart 10. Post-exam behaviors (i.e. initial interaction 8-10)

What 5 things should an incident report include?

1. client info 2. location and time of incident 3. description of what happened and what was done about it 4. condition of client 5. nurse's signature

Conversion of mL to L

1000mL = 1L

Conversion of mcg to mg

1000mcg = 1mg

Conversion of mg to g

1000mg = 1g

normal RR for a healthy adult

12-20/min

normal BP for a healthy adult

120/80

Ordered Cleocin 300mg IV Q6H; available 0.6g/4mL, how much mL to administer?

2 mL

MED MATH EXAMPLE Ordered Lamictal 2.5mg/kg p.o. daily; available in 25mg tablets, how many tablets? (pt. wt: 44lbs)

2 tablets

Conversion of lbs to kg

2.2 lbs = 1 kg

Ordered Prozac 10mg solution daily; available in 20mg/1tsp, how much mL to administer?

2.5 mL

Conversion of mL to oz

30mL = 1 oz

What is normal blood volume?

5000mL

normal HR for a healthy adult

60-100 bpm

Range for normal diastolic under normal blood volume?

60-79mmHg

Angle of injection for SC?

90 degree angle if fat>2inches, 45 degree angle if fat>1inch

Range for normal systolic under normal blood volume

90-119mmHg

normal pulse ox for a healthy adult

95%-100%

Normal oxygen saturation range

95-100%

Range for bradycardia

<60 bpm

Range for tachycardia

>100 bpm

Is BMI a good indicator of health? Why or why not?

BMI is not a good indicator of health because it does not differentiate between muscle/fat, sex, genetics, race, bone density, etc.

Review types of pain assessment tools

CRIES pain assess for postoperative pain in preterm and term neonates; behavioral and psychological indicators on 3pt scale FACES/OUCHER scale: commonly use with peds patients 0-10 scale Descriptor scale for older adults to describe different levels of pain intensity Nonverbal cues: facial expressions, behavior, vocal sounds, unusual movements

What are side effects of chlorhexidine when ingested?

Chlorhexidine can cause changes in taste and nausea if ingested; usually need an order

Types of bathing processes

Complete: pt. unable to bathe themselves Partial: pt. can do partial bathe but need assistance in areas like perineal, axillary, back Therapeutic: part of treatment plan for skin disorders, burns, etc.

Standard precautions are:

Hand hygiene before & after, gloves, masks/eyewear/gowns when needed, cough etiquette, sharps safety, safe injection practices, sterility, etc.

Examples of parenteral routes?

IM, IV, SC, ID, epidural, intrathecal, inhalations

How do you assess for pain?

P- provoking factors Q- quality R- radiation/region S- severity T- time

Examples of non parenteral routes?

PO, SL, top, transdermal, ophthalmic, otic, nasal, rectal, vaginal

Review of Korotkoff sounds

Phase 1: tapping (systolic) Phase 2: soft swish, woosh Phase 3: knocking Phase 4: soft blowing (diastolic) Phase 5: silence

Review of Hair/Skin/Nails & Musculoskeletal Assessment with normal findings

Pre-exam behaviors (i.e. initial interaction 1-5) Hair Assessment*** Even distribution, no dandruff, lesions, hair texture smooth Skin/Nails Assessment*** Includes inspection, clubbing, capillary refill < 3 seconds hands then toes, turgor (instant recoil), temperature, skin moisture (should be dry/smooth), pretibial edema Musculoskeletal Assessment*** 1. TMJ: inspect for symmetry, palpate, smooth motion/audible clicks/snaps/crepitus, ROM, strength 2. Cervical Spine: inspect for symmetry, palpate spinous processes/ sternomastoid/trapezius for tenderness/spasms, ROM, strength 3. Shoulder: inspect for symmetry, palpate, ROM note any crepitus, strength 4. Elbow: inspect for symmetry, palpate olecranon bursa/elbow, ROM, strength 5. Wrist/Hand/Fingers: inspect for symmetry, palpate joint in wrist/hands/fingers, ROM, strength 6. Hip: pt. lay supine; inspect skin, palpate joints for symmetry, ROM 7. Knee: inspect for symmetry, palpate knee/quads, have pt. sit up and palpate knee for crepitus, strength 8. Ankle/Foot/Toes: inspect for symmetry, palpate joint/feet/interphalangeal joints, ROM, strength 9. Spine: ask pt. to stand, inspect for symmetry, palpate spinous processes/paravertebral muscles, inspect convex thoracic curve/concave lumbar curve, instruct pt. to bend forward, inspect back flexion for symmetry, instruct and observe pt. to walk, ROM of knee, stabilize pelvis, ROM, inspect for pain Post-exam Behaviors (i.e. initial interaction 8-10) Normal findings for Musculoskeletal***: all joints bilaterally symmetrical, no gross deformities, skin intact, no visible lesions or redness bilaterally, no tenderness, masses, crepitus bilaterally with palpation, FROM bilaterally, muscle strength 5/5 bilaterally

Why is oral care important?

Prevent halitosis (bad smelling breath), tooth decay, gingivitis, periodontitis, infection prevention, swallow/eating impairment

List the rights of medication administration

Right patient Medication Dose Route Time ALSO Documentation Education Assessment Evaluation Refusal Then- right expiration date, reason, response

normal temperature for a healthy adult (all types)

Tympanic: 36.8-37.8C Oral: 36-38C Temporal: 37.1-38.1C Rectal: 0.5C greater than oral Axillary: 0.5C less than oral

Doffing PPE Sequence (CDC)

Type 1: gloves, goggles, gown, mask, hand hygiene Type 2: gown/gloves, goggles, mask, hand hygiene

what is apnea?

absence of breathing

What does p stand for

after

What does PC stand for?

after meals

Why is hair and scalp hygiene important?

appearance of patient

Besides counting respirations, what is another assessment technique of respirations?

assessing depth (tidal volume)

What is pulse deficit?

associated with irregular cardiac rhythm and a sign of change in CO; need two people to assess at same time

How often does independent oral care occur?

at least 2x daily with flossing

How often does dependent oral care occur?

at least once per shift but consider before or after meals; clear debris & make it easier to eat

What is fat bias?

attitude toward people being overweight like "it's the person's fault," viewed as a trait rather than a medical condition

What does AC stand for?

before meals

Review of Perineal Care

can be very embarrassing, so maintaining privacy and dignity is important Male: retract foreskin and clean urethral meatus in circular motion from center out, make sure to return foreskin to original position to prevent swelling and discomfort Female: front to back, clean between skin folds Incontinent Care: same as perineal but since skin breakdown is common, applying ointment or skin barrier afterwards is important

How do you do oral care for an NPO patient?

can brush teeth just be careful w/NG tube; ask if they can have swabs soaked in water; dry mouth gels may help especially w/oxygen

What is anatomically occurring during S2?

closing of pulmonary and aortic valves

What is anatomically occurring during S1?

closing of tricuspid and mitral valves

What is NG tube compression?

compression of bleeding sites until endoscopy

What is pulse pressure?

difference between systolic and diastolic (30-50mmHg)

Review of denture care

do not use hot water, avoid soaking overnight, store in container with a small amount of water; be sure to return dentures as soon as possible since it contributes to speech, appearance, and self image

What breathing issue is commonly seen with tachycardia?

dyspnea

how often does unconscious oral care occur?

every 2 hrs & PRN; use suction, swabs, chlorhexidine rinses if prescribed

What are contraindications of NG tube insertions?

facial trauma, recent brain surgery, recent nasal surgery, polyps, deviated septum, esophageal varices

NG tube administers what?

feedings, medications, and contrast

When should you use an electric shaver when shaving patients?

for pt. who takes anticoagulants or high-dose aspirin

Range for tachypnea

greater than 20/min

Airborne Precautions are:

hand hygiene before & after, N-95, negative pressure rooms

Contact Precautions are:

hand hygiene before & after, gloves, gown, disposable equipment

Droplet Precautions are:

hand hygiene before & after, mask

When do you administer pain analgesic during the bed making process?

if pt. is experiencing pain prior, administer PRN prescribed analgesic before making bed

Why is nail, hand, and foot care important?

important if they have DM, peripheral neuropathy, or peripheral vascular disease; when cutting nails cut straight across

What are barriers inhibiting a patient's ability to eat a healthy diet?

lack of knowledge, cost, busy schedule, location, culture/religion limitations, swallowing, large families, healthy food more perishable

Range for bradypnea

less than 12/min

Barriers to nutrition for those with dysphagia and in general?

modified consistency is unappealing, easily tired and takes a lot of energy to swallow/chew, frustration from above or decreased independence, alter in taste, accommodation for cultural or dietary preferences/requirements

What is PMI of apical pulse?

point of maximal impulse at midclavicular line and 5th intercostal space

Define decompression in relation to NG tube insertion

remove fluid and air via gravity

What are some reasons a client may need help with feeding?

risk for aspiration, decreased cough/gag reflexes, altered LOC, motor deficits, visual impairments

Insulin is what type of injection?

subcutaneous

Orthostatic hypotension effects on systole and pulse

systolic drop >20mmHg or pulse increase of 20/min

Transfer types

transfer boards transfer sheets mechanical lift 200+ lbs

Review of using gait belts

use proper body mechanics like keeping center of gravity over a wide base; when turning, avoid twisting and instead move entire body to direction you wish to face

What does c stand for?

with

What does s stand for?

without

How do you confirm placement of NG tube?

x-ray or fluid aspiration of stomach pH