NUR112 HESI part 1

secondary prevention

Efforts to limit the effects of an injury or illness that you cannot completely prevent. SCREENING Ex: mammograms

primary prevention

Efforts to prevent an injury or illness from ever occurring. Ex: education, immunizations, check-ups

Who carries out the Nursing care plan?

RN,LPN,UAP

How to prioritize nursing diagnoses

- Airway, Breathing, Circulation -disabilities

A client in the postoperative setting asks the nurse if he or she will have compression stockings like after the last surgery. What is the next action by the nurse? A. Check the medical record for a provider's prescription for compression stockings. B. Retrieve compression stockings from the supply room. C. Measure the client for the appropriate sized compression stockings. D. Delegate the placement of compression stockings to the unlicensed assistive personnel (UAP).

A

Antibiotic teaching

-Don't take antibiotics for viral illnesses -Take entire prescription as ordered -Take with water -Take with or without food depending on type -Makes oral birth control ineffective -avoid sunlight -educate on side effects to watch out for -Don't take antibiotics if not needed.

neuro assessment

-General Appearance -Posture (flexion) -Alertness, eye contact, PEARRLA -Facial expression -Cranial Nerves - LOC

physiological responses to pain

-Increased blood pressure* -Increased pulse and respiratory rates* - Pupil dilation - Muscle tension and rigidity - Pallor (peripheral vasoconstriction) - Increased adrenalin output - Increased blood glucose

psychomotor learning

-Patient is learning how to complete a physical activity or motor skill themselves -example: client practices preparing insulin injections or taking their blood sugar

SQ injection volume

0.5mL-1mL

A nurse measures a client's apical pulse rate as 82 beats/min while another nurse simultaneously measures the client's radial pulse as 76 beats/min. What term will the nurse use to document this finding? A. pulse deficit B. pulse rhythm C. pulsus regularis D. pulse pressure

A

What should you do if your patient's O2 is 90%

1. Assess the patient for s/s of hypoxemia 2. Sit the patient up and ask them to take some deep breaths 3. change O2 monitor 4. Check Baseline data 5. Obtain an order to administer oxygen

A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variations in normal vital signs, which patients would the nurse document as having a normal vital sign? Select all that apply .A) A 4-month old infant whose temperature is 38.1°C (100.5°F) B) A 3-year old whose blood pressure is 118/80 C) A 9-year old whose temperature is 39°C (102.2°F) D) An adolescent whose pulse rate is 70 bpm E) An adult whose respiratory rate is 20 bpmF) A 72-year old whose pulse rate is 42 bpm

A, D, E, F

A patient complains of severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments? Select all that apply. A) An increase in the pulse rate B) A decrease in body temperature C) A decrease in blood pressure D) An increase in respiratory depth E) An increase in respiratory rate F) An increase in body temperature

A, E

ADLs

Activities of Daily Living such as eating, dressing, bathing.

High Fat foods

Advacodo(good fat) Ham/Bacon (bad fat) Starches

A nurse assesses an oral temperature for an adult patient. The patient's temperature is 37.5°C (99.5°F). What term would the nurse use to report this temperature?

Afebrile

nonmodifiable risk factors

Age Gender Family history Ethnic background

Loperamide

Antidiarrheal Decrease bowel motility and reduce pain Allow more time for water and electrolytes to be absorbed

A client reports throbbing pain caused by a laceration that occurred to the finger while cutting vegetables. Which terminology should the nurse use to document this pain? (Select all that apply.) A) somatic pain B) Visceral pain C) Acute pain D) Cutaneous Pain E) Chronic pain

C,D

A nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should A. palpate the radial artery during auscultation. B. use the bell of the stethoscope. C. have the client inhale and exhale though the mouth during auscultation. D. palpate both carotid arteries firmly first, then auscultate to compare.

B

A patient is having dyspnea. What would the nurse do first? A) Remove pillows from under the head B) Elevate the head of the bed C) Elevate the foot of the bed D) Take the blood pressure

B

The nurse instructor is teaching student nurses about the factors that may affect a patient's blood pressure. Which statements accurately describe these factors? Select all that apply. A) Blood pressure decreases with age .B) Blood pressure is usually lowest on arising in the morning. C) Women usually have lower blood pressure than men until menopause. D) Blood pressure decreases after eating food. E) Blood pressure tends to be lower in the prone or supine position. F) Increased blood pressure is more prevalent in African Americans.

B, C, E, F

What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery? A) Assess the patient's body language. B) Observe cardiac monitor for increased heart rate .C) Ask the patient to rate the level of pain. D) Ask the patient to describe the effect of pain on the ability to cope.

C

What can JVD indicate?

Congestive heart failure - fluid retention

What would you hear in a patient's lungs with pneumonia?

Crackles

A nurse is communicating with a client who is being prepared for a mastectomy to treat breast cancer. What is the primary issue for the nurse to discuss? A. history of breast cancer in the family B. impact of surgery on the family's coping abilities C. how body image changes will affect the client's sexual activity D. concerns regarding the cancer and how the surgery will affect the client

D

When measuring gastric residual volume in a client receiving continuous tube feeding through a gastrostomy tube, the nurse attaches a large syringe to the tube and withdraws all fluid remaining in the stomach. After noting the amount of fluid, what should the nurse do? A. Discard the aspirated fluid down the toilet B. Discard the aspirated fluid into a biohazard container C. Add the aspirated fluid to the bag of formula D. Readminister the aspirated fluid through the feeding tube

D

Which illustrates the nurse using the technique of inspection? a) The nurse detects tympany over the patient's lower abdomen. b) The nurse notes a rhythmic lub-dub over the patient's anterior thorax. c) The nurse notes increased warmth surrounding the patient's incision .d) The nurse detects a fruity odor of the patient's breath.

D

Vit D foods

Dairy products like milk

What's a nursing problem associated with Diarrhea?

Dehydration and Hypovolemia

What is a dash diet?

Dietary Approaches to Stop Hypertension (low sodium diet) Avoid: Ham, bacon, Salt Also known as a heart healthy diet

What should you do if a PMI cant be felt/heard?

Get the patient to lean forward

What would you hear in a patient's lungs with COPD ?

Wheezes

Nursing process: evaluation

Last step Refer to established outcomes Evaluate individual's condition and compare actual outcomes with expected outcomes Summarize results of evaluation Identify reasons for failure to achieve expected outcomes Take corrective action to modify plan of care Document evaluation in plan of care

somatic pain

Pain that originates from skeletal muscles: ligaments, tendons, bones, blood vessels, nerves

What should a nurse know about a Jehovah Witness patient?

They don't believe in Blood transfusions

visceral pain

a poorly localized, dull, or diffuse pain that arises from the abdominal organs, thorax, cranium

FLACC pain scale

can be used for children 0-5 years of age who cannot self-report pain F- face L- legs A- activity C- cry C- consolability

Vit C foods

citrus, tomatoes, strawberries, peppers

Venti mask

delivers specific amount of oxygen

Eupnea

normal breathing

radiating pain

perceived both at the source and extending to other tissues.

phantom pain

perceived in nerves left by a missing, amputated, or paralyzed body part

Apical Impulse (PMI)

pulsation created as the left ventricle rotates against the chest wall during systole Point of Maximal Impulse (Apex of the heart): between 4th to 5th intercostal space, midclavicular

Convalescent period

recovery period from the infection. The signs and symptoms disappear, and the person returns to a healthy state

orthostatic hypotension temporary fall in blood pressure associated with assuming an upright position; synonym for postural hypotension

temporary fall in blood pressure associated with assuming an upright position; synonym for postural hypotension

A client admitted to the mental health unit has exhibited physical behaviors that put him and others at risk. The nurse applies four-point restraints on the client without obtaining a physician's order or the client's consent. The nurse is at risk of being accused of what? A. negligence B. battery C. withdrawal D. malpractice

B

purse lip breathing

Technique helps keep airways open doing exhalation promotes carbon dioxide at excretion. use any time patient feel short of breath slows breathing- prolongs exhalation Teach the patient 1. Inhale slowly through the nose to the count of two using diaphragmatic breathing 2. Exhale slowly through pursed lips to the count of four

Who develops the Nursing Care Plan?

The RN

calcium affects what?

bones, teeth, musculoskeletal and neuro system

Diaphramatic breathing

breathing that promotes the use of the diaphragm rather than the upper chest muscles Deep Breathing- expands lungs Seen in COPD patients

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment? a) To collect subjective data related to the client's overall health b) To evaluate whether outcomes of treatment are met c) To determine any changes from the baseline data d) To perform a rapid assessment for prompt treatment

C

Hypocalcemia S/S

C.A.T.S. C - Convulsions A- Arrhythmias T - Tetany (involuntary contraction of muscles) S - Spasms and stridor

incentive spirometry purpose

* improve pulmonary ventilation *Increase Respiratory volume *Decrease Pneumonia chances * counteract the effects of anesthesia or hypoventilation * loosen respiratory secretions * facilitate respiratory gaseous exchange * expand collapsed alveoli

clean catch specimen

- Clean front to back with an antibacterial wipe - start voiding into toilet, then slide cup under stream, catching the urine midstream

Stages of infection

- Incubation period - Prodromal stage - Full stage of illness - Convalescent period

Initial Comprehensive Assessment

- Subjective Data - Objective Data - Past medical history - Family History - Lifestyle/Health practices

Standard precautions

- follow hand hygiene techniques - wear PPE - follow respiratory hygiene/ cough etiquette - avoid recapping used needles - use safe injection practices - facemask

Cardiac Assessment

- inspection, palpation, auscultation -listen for any bruits, murmurs, irregular heartbeats -feel for pulse sights (2+) -Auscultate carotids before palpating with the bell -Check for JVD -Check BP -Listen to heart valves (S1 and S2) with Diaphragm and Bell

NG tube insertion

1. check order, gather equipment, introduce yourself, identify Pt., provide privacy, explain procedure, hand hygiene, gloves. 2.. position in fowler's position 3. determine length of tube measure from the tip of the nose to the earlobe to the xiphoid process & mark appropriately 4. . apply lubricant to the tip of the tube(2-3in) 5. insert tube into nose with neck hyperextended & advance straight, when resistance is met, have patient swallow water or ice. increase pressure slightly or rotate tube, continue until mark is reached 6. use a syringe to aspirate a small amount of gastric content, test the PH of the contents using using the litmus paper. Also confirm placement with Xray 7. secure the tube with tape or other product to hold the tube in place

Skin breakdown prevention

-Use braden scale -Use lift sheets -Keep skin clean and dry -Provide nutritious foods -Increase mobility -Turning (repositioning) patients Q2H -barrier creams - frequent assessments (of sacrum, back of head, heels, elbows, any bony prominences)

HIPAA violations

-discussing patient's case with those other than clinical educators, patient and family or designated representative - talking about a patient's case in a nonprivate place -copying records and files -"loaning" patients file to someone else -Leaving your computer logged into -giving out your login information

Abdominal Assessment

-inspection, auscultation, percussion, palpation -auscultate second because we do not want to stir up things in abdomen too much which would result in false findings - listen for any aortic bruits, bowel sounds - palpating for any masses, tenderness, distention -

The nurse needs to administer enoxaparin 40 mg subcutaneously daily prophylactically for deep vein thrombosis in a client who had a left hip replacement. The drug is available as 60 mg/0.6mL. How many milliliters will the nurse give? Record your answer using one decimal place.

0.4

musculoskeletal system

Assess Gait, steadiness and balance Check ROM Muscle strength(5+) Squeeze hands Usage of assistive devices Observe endurance ( how quickly patient gets out of breath when walking)

What's the first thing you do as a nurse if a medication error has occurred?

Assess the patient

A normal BMI

18.5-24.9

SQ injection angle

45-90 degrees

Which nursing action best addresses the outcome: The client will be free from falls? A. Encourage use of grab bars and railings in the bathroom and halls. B. Use large muscle group when transferring client from bed to chair. C. Install a monitoring system to help the client in an emergency situation. D. Limit use of the stairs.

A

prodromal stage

A person is most infectious during the prodromal stage.- Early signs and symptoms of disease are present, but these are often vague and nonspecific, ranging from fatigue and malaise to a low-grade fever. This period lasts from several hours to several days. During this phase, the patient often is unaware of being contagious. As a result, the infection spreads.

A client admitted for investigation of a tumor asks the nurse, "Do you think I have cancer?" Which response by the nurse is most therapeutic? A. "Your healthcare provider can tell you more about that." B. "You sound concerned about what the tests results might be." C. "Tumors are very common and not always cancerous." D. "We won't know for sure until you undergo some tests."

B

Heparin

Anticoagulant given SC or IV - don't massage Check PPT and platelet count Have patient notify dentist Patient needs to avoid taking any other NSAIDS Put of bleeding precautions(electric razor, soft toothbrush) Watch for hematuria

A client is being discharged after abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care? A. advocating for the client by ordering Meals on Wheels 5 days a week B. asking the physician to write an order for home skilled nursing assessments and interventions C. asking an occupational therapist to evaluate the client at home D. notifying the American Cancer Society (Canadian Cancer Society) of the client's diagnosis

B

A nurse is performing a sterile dressing change. Which action contaminates the sterile field? A. leaving a 1″ (2.5-cm) edge around the sterile field B. pouring solution onto a sterile field cloth C. holding sterile objects above the waist D. opening the outermost flap of a sterile package away from the body

B

A school nurse is performing an assessment of a student who states: "I'm too tired to keep my head up in class." The student has a low-grade fever. The nurse would interpret these findings as indicating which stage of infection? A) Incubation period B) Prodromal stage C) Full stage of illness D) Convalescent period

B

A staff nurse on a busy pediatric unit would like to function effectively in the role of a leader. Which action would the nurse employ to be a leader? Tell the staff on the unit how to do their job effectively based on current research and relevant experience. A. Ask the nursing administration for the authority to make decisions that will affect the staff. B. Encourage the staff to participate in the unit's decision-making process, and C. help the staff to improve their clinical skills. D. Follow unit and hospital policy in daily situations.

B

Several large boxes of supplies need to be relocated to another room on a client care area. Which action should be taken to prevent the staff from experiencing back injuries when moving these supplies? A. Push the boxes across the floor with the legs to the new location. B. Break the boxes into smaller and lighter loads. C. Pull the boxes across the floor to the new location. D. Stack the boxes so more can be moved at one time.

B

A young adult client is involved in a motorcycle collision and has just learned the medical staff must perform an emergency below-the-knee amputation. What action(s) will the nurse include in the immediate plan of care to support the client's grief and loss processes? Select all that apply. A. Show the client various prosthetic devices that can be used postoperatively. B. Explore client's support system including family, friends, and spiritual supports. C. Assess and treat the client's pain and physical discomfort promptly. D. Validate the client's right to be angry and to express negative emotions. E. Reassure that the procedure will not occur until the client is emotionally ready. F. Offer detailed responses to all the client's questions about the procedure.

B,C,D, F

Lorazepam

Benzodiazepine -used for Anxiety, Seizures - Watch for respiratory depression - Avoid driving and alcohol - Don't give to patients with Alzheimer's

How is blood pressure affected if the patient is wearing a cuff too large?

Blood pressure will be low

fluid overload s/s

Bounding, high pulse, pulmonary edema with dyspnea and tachypnea, hypertension Crackle in lungs, congestion

A client with two young children is diagnosed with breast cancer. The client says, "This is the worst time in my life. How can I adjust to all of this without losing it?" What is the nurse's best response? A. "Before making life changes, you should wait to learn more about your prognosis after the surgery." B. "The important thing is to stay strong for yourself and for your children. We have support groups to help." C. "What ways have you used to help reduce stress and cope with significant events in your life?" D. "Would you like me to call one of your relatives or friends so you can talk to them about how you feel?

C

A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? A) The nurse carries the patients' soiled bed linens close to the body to prevent spreading microorganisms into the air .B) The nurse places soiled bed linens and hospital gowns on the floor when making the bed .C) The nurse moves the patient table away from the nurse's body when wiping it off after a meal. D) The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items.

C

A client is prescribed to ambulate with a cane. Which action should the nurse take when helping the client use this assistive device? Select all that apply. A. Advance the cane 4 to 12 in (10 to 30 cm) first before advancing the strong leg. B. Advance the cane and strong leg together before advancing the weaker leg. C. Ensure the cane height causes the elbow joint to flex at 30 degrees. D. Advance the weaker leg after advancing the cane. E. Instruct the client to hold the cane on the stronger side of the body.

C,D,E

How do you deal with a patient that can not speak English?

Get a translator approved by the hospital- speak directly to patient No family members

What organ does magnesium affect?

Heart

High Sodium levels can lead to

Hypertension, delirium, excess thirst

Subjective Data

Information given to you by the patient - Sensations/symptoms - Feelings - Perceptions - Desires - Preferences - Beliefs - Ideas - Values - Personal information

Correct way to use a walker

Level at the wrist Walk into it

How to improve sleep hygiene?

Limiting screen time exercise Limit caffeine intake Routine

Respiratory Assessment

Listen to lung sounds Check capillary Refill and O2 stats Count Respiratory rate and check rhythm Inspect nares and airway and usage or assessory muscles

purpose of log rolling

Maintain alignment of the spine while turning & moving the patient who has had a spinal injury, pelvic fracture or documented spinal surgery

What color is stool during GI bleed?

Melena (black and tarry) - away from rectum Bright red- close to rectum (most likely hemorrhoids)

Fluid overload intervention

Monitor vital signs Monitor I/Os Elevate legs Fluid and salt restrictions

Hypercalcemia S/S

Muscle weakness, Constipation, Anorexia, N/V, Polyuria, Polydipsia, Neurosis, Dysrhythmias, lethargy

Vit E foods

Nuts (sunflower seeds)

If your patient's BMI is 26 what are they considered?

Overweight

Why get an axillary temp instead of an oral temp?

Patient just drank something cold or hot has a wound in the mouth is intubated experiencing seizures

bowel training

Program of exercises through which the client gains control of bowel reflexes by setting up a daily routine, attempting to defecate at the same time each day, and using measures that promote defecation.

How to take a tympanic temperature on an adult?

Pull ear down and out

What kind of diet is prescribed for patients experiencing Dysphagia?

Puree and thick liquids

What position does the patient need to be in during an abdominal assessment?

Supine

Best way to evaluate patient teaching?

Teach back, return demonstration

Airborne precautions

Use these for patients who have infections that spread through the air such as tuberculosis, varicella (chicken pox), rubeola (measles), and possibly SARS (severe acute respiratory syndrome). - Place patient in a private room that has monitored negative air pressure in relation to surrounding areas. - Wear a mask or respirator when entering room of patient with known or suspected tuberculosis. - Transport patient out of room only when necessary and place a surgical mask on the patient if possible.

True or False: People are more like to have a bowel movement after meals

True

tertiary prevention

actions taken to contain damage once a disease or disability has progressed beyond its early stages Treatment

nonrebreather mask

an oxygen-delivery apparatus used to deliver high flow rates and high concentrations of oxygen via a mask that fits snugly over the patient's mouth and nose

IM injection sites

deltoid, ventrogluteal, vastus lateralis

Modifiable risk factors

diet, exercise, smoking,weight

24 hour urine specimen patient teaching

discard first sample collect every specimen after keep it cold (refrigerator/ice) Void at the 24 hour mark Label sample in patient room by bedside- (comparing with armband)

potassium affects what?

heart

hospice care

holistic, compassionate care given to dying people and their families -form of palliative care -Patient that have less then 6 months to live - Enhance quality of life: comfort and pain management (opioids, morphine, fentanyl)

Vit K foods

leafy greens

A BMI of 36 is considered

morbidly obese

SQ injection sites

posterior arms anterior thighs 4 quadrants of abdomen, 2 inches below umbilicus

Medical Asepsis

practices designed to reduce the number and transfer of pathogens; synonym for clean technique

surgical Asepsis

practices that render and keep objects and areas free from microorganisms; synonym for sterile technique

How to take a Tympanic Temperature on a child

pull ear up and back

Your patient's BMI is below 18.5, what are they are considered?

underweight