Review Fundamentals

Diagnosis Phase of the Nursing Process

-identify the patient's problem (NANDA) -problem, related to, as evidenced by, secondary to -actual, risk for, wellness

planning phase of nursing process

-set short-term and long-term goals and desired outcomes and identify appropriate nursing actions needed to reach these goals -focuses on patient and family needs

needle for IM

5/8-3 inch

drops to teaspoons

60 of this is equivalent to one of this in nursing measurements

hypertension (HTN)

Any blood pressure > 120/80

F= (degrees in Celsius x 1.8) + 32

Celsius to Fahrenheit conversion formula

steps of blood coagulation (clotting)

Clotting factors + platelets form a plug; platelets recruit help, coagulation cascade

CBR

Complete Bed rest abbreviation

Industry vs. Inferiority

Erikson's stage between 6 and 11 years, when the child learns to be productive

Bactria

Gas (flatulence) smells because of:

URINE DIP: positive gluc (glycosuria)

High blood sugar (DM)

Normal breath sounds: Bronchial

High pitch heard near the larger airways- 2nd and 3rd intercostal spaces. Expiration > Inspiration

Vegetarian diet,low carb diet , citrus fruits, metabolic or respiratory alkalosis, renal tubular acidosis, UTI

High urinary pH (>8.0) is seen in these circumstances

Vol of infusion (ml) x drop factor/ time of infusion (min)

Manual IV Flow rate (gtts/min) formula:

Trendelenburg position

The body is laid flat on the back (supine position) with the feet higher than the head by 15-30 degrees,

Dietary modifications or antibiotics

The major treatment options for excessive flatulence include

Organism's mode of transmission

To institute appropriate isolation precautions, the nurse must first know the:

Lower the enema fluid container.

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention?

straight catheter

a catheter that drains the bladder into sterile container and then is removed

S1 lub sound

closing of AV valves ( mitral + tricuspid) at the beginning of ventricular contraction (systole)

Hyperthermia

especially high fever; hyperpyrexia

lithotomy position

lying on back with legs raised and feet in stirrups

Sims position

lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back

Bradycardia

slow heart rate (less than 60 bpm)

oats, apples, citrus fruits, carrots, beans (legumes)

sources of soluble fiber

2 mL or less

the deltoid is used for ___ volume of IM medication

At risk diagnosis

type of nursing diagnosis; describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. - do NOT have related factors or defining characteristics because they have not occurred yet; instead they have risk factors.

Hydralazine (Apresoline)

vasodilator antihypertensive most commonly given IM

QRS complex

ventricular depolarization and atrial repolarization is represented by what complex in the electrical conductivity of the heart?

Graphic records

vital signs, I&O, and routine care, may be found on the graphic record. This where records of serial measurements and observations, nursing interventions, and nursing care plans are recorded.

Flaccid bladder

weak, soft, and lax bladder muscles

Reaching one foot over the sterile field

A newly hired at Nurseslabs Medical Center is assigned to the OR Department. Which action demonstrates a break in sterile technique?

10 seconds per mL

How quickly to inject IM medication

detrusor;spinal reflex

Micturition process entails contraction of the____ muscle and relaxation of the internal and external urethral sphincter. The process is slightly different based on age. Children younger than three years old have the micturition process coordinated by the___ ___.

Apical pulse location

Mid clavicular line, 5th intercostal space is the best location to assess ..

Holding the cane in her left hand, Mrs. Kennedy moves the cane forward first, then her right leg, and finally her left leg

Mrs. Kennedy had a CVA (cerebrovascular accident) and has a severe right-sided weakness. She has been taught to walk with a cane. The nurse is evaluating her use of the cane prior to discharge. Which of the following reflects the correct use of the cane?

Increases circulation

Nurse AJ is applying a warm compress. What should the nurse explain to the patient is the primary reason why heat is used instead of cold?

-apply suction pressure only while withdrawing the catheter, not while inserting it -suction as needed but @least q8° -perform w/ surgical aseptic technique - limit attempts to 2-3 to prevent hypoxemia

Nurse Aldrin is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow?

IgA

Nurse Berta is facilitating a monthly mothers' class at a small village. As a knowledgeable nurse, she must know that a mother who breastfeeds her child passes on which antibody through breast milk?

Potential for drug dependence

Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?

Location of an advance directive Biographic information may include name, address, gender, race, occupation, and location of a living will or durable power of attorney for health care. Biographic data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client's birth date, Social Security number, medical record number, or similar identifying data may be included in the biographic data section.

Nurse Patrick is acquiring information from a client in the emergency department. Which is an example of biographic information that may be obtained during a health history?

Anemia

Nurse Peter makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has:

Inspiratory volume will be increased.

Nurse Winona teaches a patient how to use an incentive spirometer. What patient outcome will support the conclusion that the use of the incentives spirometer was effective?

Rectum

The defecation reflex is activated when feces arrives in this structure.

Gordon's Functional Health Maslovs Hierarchy of Needs

The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to: Select all that apply.

Portal hypertension

The pathological process causing esophageal varices is/are:

¾ ml The nurse solves the problem as follows: 10,000 units/7,500 units = 1 ml/X 10,000 X = 7,500 X= 7,500/10,000 or ¾ ml

The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. The nurse should anticipate giving how much heparin for each dose?

1/2 ml

The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. How much of the drug should the nurse give?

25gtts/ min

The physician's order reads "Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal saline solution in 60 minutes." What is the flow rate if the drop factor is 10 gtt = 1 ml?

Neutral point

The treatment paradigm only leads a pt to a __ ___ or otherwise toward a non-illness state

Rectum

This is the last section of the large intestine that acts as a temporary storage space for feces before elimination.

Feces

This is the term used for the remnants of undigested food that passes through the large intestine.

Nursing diagnosis

This is used to evaluate the response of the whole person to actual or potential health problems; a health problem that can be treated by nursing measures

normal saline enema

This isotonic enema is the safest solution to use because it exerts the same osmotic pressure as fluids in the interstitial spaces surrounding the bowel.

carminative enema

This type of enema provides relief from gaseous distention (flatus)

Cleansing enema

This type of enema stimulates peristalsis thorugh distention and irritation of colon and rectum, average adult is 500-1000ml

medicated enema

This type of enema uses a solution with drugs to reduce bacteria or remove potassium, medication absorption is through the rectal mucosa

Resident

This type of flora live deep in skin layers where they live and multiply harmlessly. They are permanent inhabitants of the skin and cannot usually be removed with routine hand washing.

Divides body into superior & inferior parts

Transverse plane

Biliary obstruction, hepatic/hemolytic

Urobilinogen on the urine dip stick is normally positive, however decreased in ___ ___ but increased in ___/___ disease.

Protective isolation precautions

Used by nurse when caring for a patient with a compromised immune system (ie. Leukemia) requires all PPE

lactose intolerance or ingestion of air

What is the root cause of most flatulence?

MMR to an infant

Which intervention is an example of primary prevention?

Z-track method

a technique used when injecting an IM drug that can irritate the subcutaneous tissue

Kock pouch

internal pouch created from the distal segment of the ileum to serve as a reservoir for stool or urine

Maslow's 2. safety needs

security of body, of employment, of resources, of morality, of the family, of health, of property demonstrates what stage of maslows hierarchy of needs?

stress incontinence

the inability to control the voiding of urine under physical stress such as running, sneezing, laughing, or coughing

ztrack method

*IM injection method* hold skin back and to the side when inserting needle, continue to hold skin back until injection is complete and needle is removed, then release skin; this is used to minimize skin irritation and seal med into muscle tissue

diminution in pleural effusion

*unilateral* lessening; reduction in size of chest with splinting or guarding

Nursing assessment order

-Inspection -Palpation -Percussion -Auscultation **Infant is different. do less invasive procedure -inspect -then auscultate and palpation.. -Do eyes,ears, nose, throat last (most invasive)

Focused charting

-Instead of problem lists, a modified list of nursing diagnoses is used as an index for nursing documentation -This format uses the nursing process and the more positive concept of the patient's needs rather than the medical diagnoses and problems. data,action,response

Percussion and postural drainage

-cupped hand application of strong rhythmic force to the chest wall -cupping corresponds to the involved segment -purpose -assist removal of secretions -4-5 reps until cough elicited -perform before meals or 1.5 hrs after

evaluation phase of the nursing process

-determine if goals and expected outcomes are achieved -were outcomes met in a way that satisfies the patient/family needs, values, and preferences?

Educator

A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role?

Restlessness: hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the patient restless, anxious, nervous, and irritable

A female patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse identifies which finding as an *early sign of shock*?

Demonstrating the procedure and having the patient return the demonstration

A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction?

Shock Dismay

A female patient with a terminal illness is in denial. Indicators of denial include:

Cool, pale fingers

A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal?

6mos?

A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written?

Review results of serum electrolytes

A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past two days. She appears lethargic and is complaining of leg cramps. What should the nurse do first?

Centers for Disease Control (CDC)

A nurse caring for a patient with an infectious disease who requires isolation should refer to guidelines published by the:

has a spinal cord injury; hip Fx. or hip replacement

A nurse determines that a fracture bedpan alleviates the need of turning patients. this should be used for the patient who:

Osteoporosis

A practitioner orders chest physiotherapy with percussion and vibration for a newly admitted patient. Which information obtained by the nurse during the health history should alert the nurse to question the practitioner's order?

Inhibition of the respiratory hypoxic stimulus

A prescribed amount of oxygen is needed for a patient with COPD to prevent:

Discard first voiding

A provider prescribes a 24-hour urine collection for a client. Which of the following actions should the nurse take?

runs longitudinally dividing the body into right and left regions. The sagittal plane or lateral plane (longitudinal, anteroposterior

A sagittal plane

Handling surgical instruments to the surgeon

A scrub nurse in the operating room has which responsibility?

Confirm if the pt can make any verbal sounds

Bradycardia and confusion are late manifestations of hypoxemia, along with stupor, cyanotic skin and mucous membranes, bradypnea, hypotension, and cardiac dysrhythmias

Constipation

Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following?

caput medusae

Dilated veins around the umbilicus, associated with cirrhosis of the liver.

antibody IgA

Dimer (2 "Y"s); Found in secretions, this antibody provides mucosal protection, and can help prevent infant respiratory infection (Milk).found in great amounts throughout the gut and respiratory system of adults. These secretory molecules passed to the suckling child are helpful in ways that go beyond their ability to bind to microorganisms and keep them away from the body's tissues.

Gluteus Maximus; PSIS

Dorso gluteal injection site is located in the ____ ___muscle between the __ __ __ __& the greater trochanter of the femur

urge incontinence

During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate?

-Fecal impaction -Perineal skin irritation -Fluid intake< 1500 ml/d -Hx UTI

During the assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following?

Promotive, preventive, and restorative health practices.

During the nursing assessment, which data represent information concerning health beliefs?

S/Sx of UTI

Dysuria, urgency, frequency, incontinence, nocturia, hematuria, back pain, cloudy, foul smell urine. Elderly may also have fatigue, change in cognitive function, fever .

Deltoid IM injection

Easy to find muscle, but not well developed. Used for small medication volume or when other sites are inaccessible. Not used in infants or children. There is a risk for injury because of the nerves and arteries that lie in the upper arm and humerus.

Flow rate (ml/hr)= Total(ml)/total hrs

Electronic IV flow rate formula:

Dehydration (fever, vomiting,diarrhea), adrenal insufficiency, pre-renal failure, hyponatremia, glucosuria

Elevated urine specific gravity 1.035 or more general indications

integrity vs despair

Erikson's final stage in which those near the end of life look back and evaluate their lives

Trust vs. Mistrust

Erikson's first stage during the first year of life, infants learn to trust when they are cared for in a consistent warm manner

Autonomy vs. Shame and Doubt

Erikson's stage in which a toddler learns to exercise will and to do things independently; failure to do so causes shame and doubt

Generativity vs. Stagnation

Erikson's stage of social development in which middle-aged people begin to devote themselves more to fulfilling one's potential and doing public service

Initiative vs. Guilt

Erikson's third stage (preschool) in which the child finds independence in planning, playing and other activities

secretory diarrhea

Excessive mucosal secretion of chloride or bicarbonate rich fluid or inhibition of sodium absorption-E.coli/ V.Cholerae

hypertonic enema

Exert osmotic pressure that pulls fluid out of interstitil spaces. The colon fills with fluid, and the resultant distention promotes defecation. Used for patients who cannot tolerate large volumes of fluid

Traumatic injury or nervous system disease

Fecal incontinence occurs primarily due to :

s/sx of UTI in children

Fever, suprapubic tenderness, lack of circumcision Parental reported urine odor, diarrhea, vomiting, poor feeding does NOT correlate with UTI in children

IgM antibodies

First antibody produced in response to infection; pentamer;produced in the primary immune response to infectious agents or antigens

Intermittent fever

Fluctuating fever that returns to or below baseline then rises again.

Separate the skin folds with towels.

For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds?

5

For a well-developed adult, no more than ___ml of medication should be administered in a single IM injection because the muscle tissue does not absorb it well.

During abdominal assessment, auscultation should be performed before palpation and percussion to prevent altering bowel sounds.

For all body systems except the abdomen, what is the preferred order for the nurse to perform the following examination techniques?

Compensatory respiratory acidosis

Giving oxygen to COPD Pts helps prevent right sided heart failure. COPD pts are generally in a state of this respiratory condition due to the retention of carbon dioxide.

80%

Healed wounds/ repaired skin strength is only this percent of original strength

Provide oxygen supplementation

How can we improve a person's oxygen saturation levels if they have a pulmonary embolism?

Demonstrate use of equipment

How should the nurse modify the examination for a 7-year-old child?

Draw up the regular insulin, then the NPH insulin, in the same syringe.

How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?

Can convince pts they're not experiencing pain

Hypnotherapy can do what to pts w/ addiction who are complaining of pain?

tap water enema

Hypotonic Enema. After infusion into the colon, tap water escapes from the bowel lumen into interstitial spaces. (*Do not repeat because water toxicity or circulatory overload will develop)

Swelling & pallor, *not erythema*, near the insertion site. In *phlebitis, there is usually a slow onset of a tender red area along the superficial veins* on the skin. A long, thin red area may be seen as the inflammation follows a superficial vein. This area may feel hard, warm, and tender. The skin around the vein may be itchy and swollen. The area may begin to throb or burn.

IV Infiltration would result in:

+Nitrates

If a pt uses pyridium for Sx's of a UTI and a urine dipstick is ordered, if they're positive for a UTI, what else will be seen on the dipstick?

Self-actualization (Maslow)

In Maslow's hierarchy this one of the ultimate psychological needs that arises after basic physical and psychological needs are met and self-esteem is achieved; the motivation to fulfill one's potential

Bronchophony

In this spoken test, the patient repeats the words "99" as you auscultate down their back in a zig-zag motion over the lung fields. Normally, the sound is muffled and indistinct; you usually only hear what sounds like vibrations. Abnormal positive for pneumonia, you will actually hear the words clearly in the lung field.

Swelling , pain, heat, redness (4-6 days)

Inflammatory phase of wound healing / s/sx inflammation

Nursing Assessment technique of abdomen

Inspect first; auscultation; percuss then palpate

No. Optimal health is

Is the treatment paradigm the nurses goal

Community

It is described as a collection of people who share some attributes of their lives.

bed making

It refers to the preparation of the bed with a new set of linens

Surgical aseptic technique

Keep sterile objects in the line of vision, hands above waist, 1" border of sterile drape

Denial, anger, bargaining, depression acceptance

Kubler-Ross's five successive stages of death and dying are: DABDA

***Pink Puffer (emPhysema) ,

Lack of cyanosis Use of accessory muscles Pursed-lip breathing emphysema

Urine Dip: Positive Leuks

Likely UTI

focused physical assessment

Pertains to a particular topic, problem, body part, or functional ability rather than overall health status, and it adds to the database created by the comprehensive assessment

inspection, palpation, percussion, auscultation

Physical examination of everything (*not abdomen*) consist of what 4 steps?

Giardia

Protozoan/ parasitic cause of diarrhea

Erickson's theory

Psychosocial Development , 8 stages of psychosocial development unfold throughout the human lifespan. Each stage consists of a unique developmental task that confronts individuals with a crisis that must be faced. Stages 3, 4, and 5 relevant to education

1) blood; (2) all body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood; (3) non-intact skin, and (4) mucous membranes.

Standard precautions apply to the care of all patients, irrespective of their disease state. These precautions apply when there is a risk of potential exposure to

ketonuria

Term used for ketones in the urine associated with incomplete fat metabolism, low carb high protein diets, starvation, diabetes, alcoholism, eclampsia, and hyperthyroidism

the science and study of death and dying from multiple perspectives—medical, physical, psychological, spiritual, ethical, and more.

Thanatology is

Not likely harm or help the pt

The administration of nitroglycerin to a person with chest pain who, in reality, has pulmonary embolism will _____.

low-pitched sounds, such as murmurs, bruits, and jugular hums. The diaphragm should be used to hear high-pitched sounds that normally occur in the heart, lungs, and abdomen.

The bell of the stethoscope should be used to hear

Gently pull just below the cuff and invert the gloves when removing them

The best way to decrease the risk of transferring pathogens to a patient when removing contaminated gloves is to:

Leaves the catheter in place & gets a new sterile catheter

The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action?

Bathe the patient's entire body using 8 to 10 washcloths (bag bath)

The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed?

Functional nursing

The charge nurse on the medical-surgical floor assigns vital signs to the nursing assistive personnel (NAP) and medication administration to the licensed vocational nurse (LVN). Which nursing *model* of care is this floor following?

PR interval

The delay of AV node to allow filling of ventricles 5at lasts 0.12-0.20 seconds is what interval?

The amount of urine retained after voiding increases

The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following?

The diaphragm detects high-pitched sounds best.

The nurse uses a stethoscope to auscultate a male patient's chest. Which statement about a stethoscope with a bell and diaphragm is true?

Kick pouch

The nurse will need to assess the client's performance of clean intermittent self catheterization (CISC) for a client with which urinary diversion?

Transient Flora/Microbiota

The type of flora that occurs d/t contact with other objects or other people that can be removed by hand washing

Maslow's 3.Love and Belonging Needs

The understanding and acceptance of others in both giving and receiving love, and the feeling of belonging to groups such as families, peers, friends, a neighborhood, and a community.

teach the reasoning, techniques & theory of knowledge understand the fundamental concepts & have know-how about how something works & its mechanism

Theoretical knowledge helps the practitioner to:

right upper quadrant

This abdominal quadrant contains the Liver, Right Kidney, Colon, Pancreas, Gallbladder

left upper abdominal quadrant

This abdominal quadrant contains the liver, spleen, left kidney, stomach, colon, pancreas

Hand washing

This act can prevent about 30% of diarrhea-related illnesses and about 20% of respiratory infections (e.g., colds).

Teach client to be effective health consumer

This can be considered the nurse's role in health promotion?

Vitamin B6 deficiency

This deficiency is usually caused by pyridoxine-inactivating drugs (eg, isoniazid), protein-energy undernutrition, malabsorption, alcoholism, or excessive loss. Deficiency can cause *peripheral neuropathy, seborrheic dermatitis, glossitis, and cheilosis, and, in adults, depression, confusion, and seizures.*

Pantothenic acid deficiency

This deficiency is very rare in the United States. Severe deficiency can cause *numbness and burning of the hands and feet, headache, extreme tiredness, irritability, restlessness, sleeping problems, stomach pain, heartburn, diarrhea, nausea, vomiting, and loss of appetite.*

external anal sphincter

This final muscular ring is under your voluntary control giving you control over when to eliminate wastes.

Deep breathing & huff coughing

This style of breathing technique helps the pt to prevent air from being trapped into the lungs & stimulates coughing to clear central airways of sputum

Supplemental oxygen

This type of therapeutic intervention is a well-established therapy with clear evidence for benefit in patients with COPD and severe resting hypoxemia, which is defined as a room air Pao2 55 mm Hg or 59 mm Hg with signs of right-sided heart strain or polycythemia.

<30ml/hr

To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. She should notify the physician if the urine output is:

Roll the vial gently between the palms.

To ensure homogenization when diluting powdered medication in a vial, the nurse should:

Arterial blood gas (ABG) analysis

To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?

Swallowing problems & limb weakness

Tumors of the medulla cause:

Excessive hydration, diabetes insipidus, pyelonephritis,

Urine specific gravity (concentration) less than 1.005 general indications

Transcultural nursing

Using a comparative study of cultures to understand similarities and differences across human groups to provide specific individualized care that is culturally appropriate

infants, toddlers, & children

Vastus lateralis & ventrogluteal the site of most vaccinations for

Rotavirus

Viral cause of diarrhea

REM

Vivid dreaming occurs in which stage of sleep?

Initiate abdominal thrust maneuver

What does the nurse do when a pt has shown s/sx of choking and the pt demonstrates an inability to cough or verbalize a sound?

Leaves the bed in the high position when finished.

What does the nurse in charge do when making a surgical bed?

'Lean forward' technique

What does the nurse recommend when pts have a hard time swallowing pills before checking if there's a liquid form of the medication?

Gives the client control over pain syndrome

What is the main advantage of cutaneous stimulation in managing pain?

1.002-1.035

What is the normal range for urine specific gravity in normal kidney function?

Lying flat on the back with knees flexed or supine horizontal recumbent

What position should a pt be placed in for a breast exam?

Epigastric region

What region contains Parts of the right and left lobes of the liver, a large portion of the stomach

Avoid fanning soiled linens MRSA + VRE can survive for days on linens

What should be done in order to prevent contaminating the environment in bed making?

Subjective & objective data

What type of information is collected in step 1. Of the nursing process (assessment)?

inductive reasoning in nursing

When a nurse notices cues, makes generalizations & creates hypotheses, they're using what type of reasoning?

The symptomatic quadrant last

When examining a patient with abdominal pain the nurse in charge should assess:

The penis and condom should be checked 1/2 hour after application to ensure that it's not too tight. and the tubing is taped to the leg or attached to a leg bag a one inch space should be left between the condom and penis

Which action represents the appropriate nursing management of a client wearing a condom catheter?

Biocultural needs

Which factor is least significant during assessment when gathering information about cultural practices?

The client will return to his or her previous fecal elimination pattern.

Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection?

The patient's cognitive abilities

Which human element considered by the nurse in charge during assessment can affect drug administration?

Have the patient expectorate the sputum into a sterile container

Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing?

Elevating the head of the bed.

Which nursing action is essential when providing continuous enteral feeding?

Disturbed body image; social isolation; at risk impaired skin integrity

Which nursing diagnosis is/are most applicable to a client with fecal incontinence? Select all that apply.

Practice supported by scientific research

Which of the following aspects of nursing is essential to defining it as both a profession and a discipline?

Soaking in a warm tub bath may ease the irritation associated with the catheter"

Which statement indicates a *need for further teaching* of a home care client with a long term indwelling catheter?

"I need to take a laxative such as milk of magnesium or if I don't have a BM every day"

Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching?

Provide care while aware of one's own bias, focusing on the client's individual needs rather than the staff's practices

Which statement would best explain the role of the nurse when planning care for a culturally diverse population? The nurse will plan care to:

Orthopnea

Which term does the nurse document to best describe a client experiencing shortness of breath while lying down who must assume an upright or sitting position to breathe more comfortably and effectively?

Reconnect the tube to the water seal

While a client with chest tubes is ambulating, the connection between the tube and the water seal dislodges. Which action by Nurse Flora is most appropriate?

800ml x 20ggts per ml/ 20h = 16000gtt/ 20h x60 min= 16000gtt/1200min= 13gtt per min

You are to infuse 800ml lactated ringers over 20 hrs using IV administration set that delivers 20gtts/ ml. What is the drip rate?

Infant Vaccinations

Z track method should be avoided in this individual and purpose

Admission form

contains baseline information. In health care organizations, the EHR, oral reports, handoffs, conferences, and health information technologies (HIT) are intended to facilitate information flow. In particular, the JCAHO specifically conceptualizes the care planning process as the structuring framework for coordinating communication that will result in safe and effective care.

overflow incontinence

continuous leaking from the bladder either because it is full or because it does not empty completely

glucosuria, glycosuria

glucose (sugar) in the urine is due to elevated serum glucose, as well as the use of cephalosporins, penicillin, tetracyclines, lithium,

Normal Breath Sounds: Vesicular

heard over most of the lung fields; low pitch, soft and long inspiration; short expirations.

Occupational therapy

help patients regain function and independence. treat injured, ill, or disabled patients through the therapeutic use of everyday activities. They help these patients develop, recover, improve, as well as maintain the skills needed for daily living and working.

4 stages of wound healing

hemostasis, inflammation, proliferation, remodeling

tympany

high-pitched, loud, drum-like sound produced over the stomach which may indicate pneumothorax is termed what?

Percussion: Tympany

hollow, high, drumlike sounds. Tympany is normally heard over the stomach, but is not a normal chest sound. Tympanic sounds heard over the chest indicate excessive air in the chest (pneumothorax)

osmotic diarrhea

hypotonic loss fluid; laxatives, lactase deficiency causes this type of diarrhea

Incident/ occurance report

if you suspect your patient's personal items to be lost or stolen.This also provides vital information the facility needs to decide whether restitution should be made—if personal belongings were lost or damaged, for example. Without proper documentation of the incident, there's no way to make these important decisions effectively.invariably makes its way to risk managers and other administrators, who review it rapidly and act quickly to change any policy or procedure that appears to be a key contributing factor to the incident.

Bladder training

important form of behavior therapy that can be effective in treating urinary incontinence. The goals are to increase the amount of time between emptying your bladder and the amount of fluids your bladder can hold. It also can diminish leakage and the sense of urgency associated with the problem.

suprapubic catheter

indwelling catheter inserted directly in the bladder through an abdominal incision above the pubic bone that includes a collection system that allows urine to be drained into a bag; used in patients requiring long-term catheterization

Foley catheter

indwelling catheter inserted through the urethra and into the bladder that includes a collection system allowing urine to be drained into a bag; the catheter can remain in place for an extended period

theoretical knowledge

information, facts, principles, & evidence-based theories in nursing & related disciplines. Knowledge gained by reading/learning (knowing the steps involved, factual information, who what when where & why)

S2 (dub)

second sound; produced by turbulent blood flow through the semilunar valves (aortic + pulmonic)

Vesicostomy

stoma (opening) created between the bladder and the abdomen. This allows urine to drain freely, with low pressure, to help protect and prevent harm to the kidneys. It is a surgical procedure that typically involves an overnight stay in the hospital.

esophageal varices

swollen, varicose veins at the lower end of the esophagus

Towel bath

technique for bathing in which a single large towel is used to cover and wash a client

pain tolerance

the amount of pain a patient can endure without its interfering with normal function

body temperature

the balance between the heat produced by the body and the heat lost from the body

deductive reasoning

the conclusion is true if the premises are true; top down approach; moves from generalizations to specifics; This type of reasoning proves generalizations / theories.

Semi-Fowler's Position

the head of the bed is raised 30 degrees; or the head of the bed is raised 30 degrees and the knee portion is raised 15 degrees

IM injection angle

90 degrees

soap suds enema

Added to tap water or saline to create the effect of intestinal irritation to stimulate peristalsis. Used with caution on pregnant women and older adults because they cause electrolyte imbalance or can damage the intestinal mucosa.

Muscle weakness

After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most significant symptom of his disorder?

Stages of sleep

Alpha: awake but relaxing with eyes closed -Waves slower than beta waves Beta: high frequency and occur when person is alert or attending mental task that requires concentration Stage 1 Theta: Dozing off; slower frequencies and higher voltages Stage 2 shows theta waves along with sleep spindles and K complexes Stage 3 and 4 Delta: low frequency, high voltage sleep wave; becomes difficult to rouse someone from sleep

Stiffness of the joints

An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?

Pressurized steam penetrates the supplies better.

An autoclave is used to sterilize hospital supplies because:

Primary prevention

An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?

Midline (mid-sagittal)

An imaginary line drawn down the center of the body, dividing it into right and left halves.

Riboflavin (B2) deficiency

Ariboflavinosis: cracks on lips and corners of mouth, swelling of mouth/throat is s/sx of this vitamin deficiency

over weight

BMI 25 to 29.9 is

Obese

BMI greater than 30 is considered

Salmonella

Bacterial cause of diarrhea

Discard the syringe to avoid a medication error.

Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient's medication drawer. What should the nurse in charge do?

Liver disease or biliary obstruction

Bilirubin is red blood cell degradation in the liver..Presence of bilirubin in the urine can indicate early.

assisting the patient to stand to void

Bladder training in a male patient who has urinary incontinence after a stroke includes

systolic pressure

Blood pressure in the arteries during contraction of the ventricles.(left ventricle during systole)

COPD, Right sided Heart failure, bronchitis

Blue bloater refers to the characteristic physical exam findings of what disease?

hypertension crisis (emergency care needed)

Bp Systolic: Higher than 180 & Diastolic: Higher than 110 can lead to heart attack or stroke

Late indications of hypoxemia

Bradycardia & confusion along with stupor, cyanotic skin & mucous membranes, bradypnea, hypotension, & cardiac dysrhythmias are s/sx of what stage of hypoxemia?

No.

Can Bence Jones globulin associated with multiple myeloma, lymphoma, and macro globulin anemia be detected in urine dip stick urinalysis?

neobladder

Clients can control their voiding. During this surgery, the surgeon takes out the existing bladder and forms an internal pouch from part of the intestine. The pouch stores the urine.

C= (degrees in Fahrenheit- 32) x .5556

Fahrenheit to Celsius conversion

Clots

Hemostatsis primarily uses these to close wounds

Thiamine (Vitamin B1)

Most common deficiency in alcoholics

adrenaline (epinephrine)

Most common medication administered for low bp or anaphylaxis

Buccal cyanosis and capillary refill greater than 3 seconds.

Mr. Teban is a 73-year old patient diagnosed with pneumonia. Which data would be of greatest concern to the nurse when completing the nursing assessment of the patient?

Deltoid

Muscles that absorb medication faster when giving IM injection

BMI 20 to 25

Normal BMI range for adults

Huff coughing technique

Sit up straight with chin tilted slightly up and mouth open. Take a slow deep breath to fill lungs about three quarters full. Hold breath for two or three seconds. Exhale forcefully, but slowly, in a continuous exhalation to move mucus from the smaller to the larger airways. Repeat this maneuver two more times and then follow with one strong cough to clear mucus from the larger airways. Do a cycle of four to five as part of your airway clearance.

True (for boards)

Subcutaneous injection must be given at 45 degrees. (T/F)

Transient flora from the skin

The clinical instructor asks her students the rationale for handwashing. The students are correct if they answered that handwashing is expected to remove:

Practical knowledge

Type of knowledge gained by doing things; practicing & efficiently taking blood pressure & withdrawing medications are examples of

Aging-related physiological changes

When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients have adverse drug effects?

Increases venous blood return. Washing from distal to proximal areas stimulates venous blood flow, thereby preventing venous stasis.

When bathing a patient's extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique:

RN (regular comes before NPH) but you have to add air to nph vial 1st, then add air to reg vial & immediately draw up the reg insulin then draw up nph

When drawing up regular insulin & NPH together, remember:

Floor of the mouth

When teaching a female patient how to take a sublingual tablet, the nurse should instruct the patient to place the table on the:

NKA

When the nurse completes the patient's admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding?

Severe cramps Vomiting and nausea Diarrhea or constipation Fever (which may be a sign of infection) Blood in the stool (which is always a medical emergency)

When to go to the hospital due to flatulence:

Point of maximal impulse (PMI)

Where heartbeat is best palpable on chest wall; 5th intercostal space, midclavicular line

Cleaning from the center outward in a circular motion.

Which action by the nurse in charge is essential when cleaning the area around a Jackson-Pratt wound drain?

. "I should inhale slowly and steadily to keep the balls up."

Which client statement informs the nurse that his teaching about the proper use of an incentive spirometer was effective?

Chocolate Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to reflux and clinical symptoms of GERD. Ingesting cocoa can cause a surge of serotonin. This surge can cause the esophageal sphincter to relax and gastric contents to rise. Caffeine and theobromine in chocolate may also trigger acid reflux.

Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophageal reflux disease (GERD)?

Sitting, facing the client in a chair at the client's bedside, using active listening. Active listening should be used during an interview. The nurse should face the patient, have relaxed posture, and keep eye contact. Nonjudgmental interest in the patient's problems (active listening), empathy (communicating to the patient an accurate assessment of emotional state), and concern for the patient as a unique person are among the most important tools in the physician's interpersonal repertoire.

Which of the following is an example of appropriate behavior when conducting a client interview?

*Semi soft tar colored stools* *Blood in the upper GI tract is black and tarry*. Gastrointestinal (GI) bleeding is a symptom of a disorder in the digestive tract. The blood often appears in stool or vomit but isn't always visible, though it may cause the stool to look black or tarry. The level of bleeding can range from mild to severe and can be life-threatening.

Which of the following is most likely to validate that a client is experiencing intestinal bleeding?

Prevent spread ov microorganisms

Which of the following is the most important purpose of handwashing?

Make sure you have a written order from MD; Document restraint used & pts behavior

Which of the following is the nurse's legal responsibility when applying restraints?

Administration of an antibiotic Attending rehab Assessing a surgical incision

Which of the following is/are an example(s) of a health restoration activity?

Frontal/coronal

Which of the following planes divides the body longitudinally into anterior and posterior regions?

Change solution every 24°

Which of the following should be included in a plan of care for a client receiving total parenteral nutrition (TPN)?

Frozen yogurt can be included in the diet

Which of the following should be included in a plan of care for a client who is lactose intolerant?

Fixed, dilated pupils

Which of the following symptoms is the best indicator of imminent death?

Carotid

Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?

Similar to the effects found in adults

Which statement best describes the effects of immobility in children?

. "I'm going to have to irrigate my stoma so I have a bowel movement every morning"

Which statement by a patient with an ileostomy alerts the nurse to the need for further education?

Mass movements

While peristalsis helps move feces through the colon, much of the movement is the result of these strong contractions that occur one to four times a day.

whispered pectoriloquy

a whispered "1.2.3 or 99" phrase heard through the stethoscope that sounds faint and inaudible over normal lung tissue; abnormal pnuemonia if heard clearly

bradypnea

an abnormally slow rate of respiration usually of less than 10 breaths per minute

Egophony

ask patient to say "eeee" while listening to all lung fields: positive for pneumonia if it sounds like "aaaa"

P wave

atrial depolarization (contraction of atria) represented by what wave in the electrical conductivity of the heart?

Nitrates/Nitrites

bacteriuria is most indicative when there's a presence of this in the urine dip due to gram neg bacteria like klebsiella or E.coli

Legal exercises

can help make the muscles under the uterus, bladder, and bowel (large intestine) stronger. They can help both men and women who have problems with urine leakage or bowel control.

Blood clotting disorders, trauma, infection, calculi, neoplasia

detects intact or hemolyzed RBCs and free hemoglobin in the urine dipstick which shows +blood, which means the pt could have:

Last step of abdominal exam

diaphragm of the stethoscope should be placed on the right side of the umbilicus to listen to the bowel sounds, and their rate should be calculated after listening for at least two minutes. Normal bowel sounds are low-pitched and gurgling, and the rate is normally 2-5/min. Absent bowel sounds may indicate paralytic ileus and hyperactive rushes (borborygmi) are usually present in small bowel obstruction and sometimes may be auscultated in lactose intolerance

Horizontal Plane (transverse)

divides the body into upper and lower portions. Rotation occurs within the horizontal plane

problem-oriented medical record (POMR)

documentation system organized according to the person's specific health problems; includes database, problem list, plan of care, and progress notes

Phases of infection

incubation, prodromal period, illness, decline, convalescence

Dorsal recumbent

lying on the back with knees up and feet flat on the table

diminution in COPD

symmetrical reduction in size of chest

Pulse pressure

systolic pressure minus diastolic pressure =

coronal (frontal) plane

vertical division of the body into front (anterior) and back (posterior) portions

ADPIE (adopie)

• Assessment: 1st step, subjective and objective data • Diagnosis: analysis, formulation of nursing diagnosis * some include *outcomes* • Planning: prioritizing problems, determining goals, plan of care • Implementation: nursing action (rather than medical action) • Evaluating: comparing outcomes, communicate and document findings

Viborg's triangle

formed by jugular vein, carotid, and trachea

protein

glomerulus problem demonstrates what in the urine dip

"Let's talk about what's bothering you."

A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient's anxiety?

Circulatory Overload S/S

- Dyspnea, Crackles, JVD - Tachycardia, orthopnea, peripheral edema, HTN

implementation phase of nursing process

- Implement in a safe and timely manner - Use evidence-based interventions - Collaborate with colleagues - Use community resources - Coordinate care delivery - Provide health teaching and health promotion - Document implementation and any modification

ileal conduit

- It is used to divert urine outside of the body when the urinary bladder has been removed. The conduit cannot store urine the way the bladder did; therefore, urine will be flowing continuously and an appliance must be worn as a collection device. The bag should be emptied approx. every 2 hours to prevent leakage, skin irritation and infection.

Check ID band

The nurse must verify the client's identity before administration of medication. Which of the following is the safest way to identify the client?

Make a late entry note

At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take?

incentive spirometry steps

1) Sit upright 2) Exhale 3) Insert mouthpiece 4) Inhale for 3 seconds, and then HOLD for 3- 10 seconds; repeat 10 breaths every hour

8 stages of psychosocial development

1) Trust vs. mistrust (infancy). Nurturing stage. 2) Autonomy vs. shame and doubt (early childhood), due to being unable to handle situations one encounters in life. 3) Initiative vs. guilt (preschool years), child developes either a sense of Initiative and self confidence or feelings of guilt depending on how successful they are in exploring their environment and dealing with peers. 4) Industry vs. inferiority (grammar school years), focus shifts away from family to school where the child develops conceptions of being industrious or inferior. 5) Identity vs. role confusion (adolescence), failure to establish a clear and firm sense of one's self results in identity confusion 6) Intimacy vs isolation (young adulthood), one meets or fails to meet the challenge presented by young adulthood of forming stable relationships, outcome: Intimacy or Isolation. 7) Generativity vs stagnation (middle adulthood), A persons' contribution to the well being of others through citizenship, work, and family becomes self generated, and fulfilling primary tasks of adulthood is complete. 8) Integrity vs despair (late adulthood), developmental challenge posed by the knowledge one is dying. Challenge is to find a sense of continuity and meaning, not to despair.

Status of Nursing Diagnosis

1. Actual Diagnosis 2. Health Promotion Diagnosis 3. Risk Nursing Diagnosis 4. Syndrome Diagnosis

proliferation/ fibroblastic repair phase of wound healing

1. Epithelialization (granulation tissue) 2. Neovascularization 3. Collagen synthesis ( wound margins) 4. Contraction

Maslov's Hierarchy of Needs

1. Physiological 2. Safety 3. Love & Belonging 4. Self Esteem 5. Self Actualization

Bed making guidelines

1. bed linens must be changed when they are wet, soiled, or when they are too wrinkled for comfort 2 wash hands before getting clean linen 3.gather linen in order of placements on the bed 4.carry linens away from your uniform 5.bring linen into one residents room at a time 6.never pick up linen from one room & transfer it to another room 7.place clean linen on a clean surface within reach 8.use proper body mechanics when making beds 9.look at linens closely for any personal items 10.roll dirty linen away from you as you remove it from the bed 11.do not shake linen because it may spread contaminants 12.place used linens in proper container 13.make one side of the bed first to save energy 14.keep beds wrinkle free & free of all crumbs 15.wash hands after handling linens

Different types of enemas

1. cleansing 2. tap water 3. normal saline 4. hypertonic solutions 5. soap suds 6. oil retention 7. carminative 8. medicated

needle for subq

1/2 to 1 inch

Fever ranges

100° - 102° F (37.8° - 39° C) Slight fever: helpful, good range 102° - 104° F (39 - 40° C) Average fever: still ok, helpful Over 104° F (40° C) High fever: prolonged can be dangerous Over 106° F (41.1° C) Very high fever: important to bring it down Over 108° F (42.3° C) Harmful fever: fever itself can cause brain damage

Prehypertension

120-139/80-89

HTN, Stage 1 Range

140-159 / 90-99

Stage 2 hypertension

160 or > / 100 or >

Chlamydia trachomatis; Neisseria Gonorrhea

1g ceftriaxone (rocephin) dissolved into 3.6ml 1% lidocaine(250mg/ml) or 500mg/1.8 ml 1% lidocaine(250mg/ml) or 250mg /0.9 ml of 1% lidocaine (250mg/ml) is generally given IM for the treatment of this infection in most sexually active people

Axillary temp

A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client's body temperature?

Hypotension

abnormally low blood pressure 90 mmhg or </ 60 or <

Hypothermia

abnormally low body temperature

Accept the clients report of pain

A client in a long-term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to

Decrease inflammation in the airways

A client with emphysema is prescribed corticosteroid therapy on a short-term basis for acute bronchitis. The client asks the nurse how the steroids will help him. The nurse responded by saying that the corticosteroids will do which of the following?

psychosocial assessment

A comprehensive document which looks at the client as a whole person (not as a set of symptoms) and holistically combines the spiritual, emotional, physical, mental, behavioral, and social dimensions is what type of assessment?

Tachycardia

abnormally rapid heartbeat (over 100 beats per minute)

Low, small volume Small volume enemas along with other preparations are used to prepare the client for this procedure. The *small volume enema is used to clean the lower portion of the colon or the sigmoid. This type of cleansing enema* is often used for the patient who is constipated but does not need cleansing of the higher colon. The *amount used is less than 500 ml and the bag is raised no higher than 12 inches*.

A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema?

A client with uncontrolled diabetes (infection free)

A client requires protective isolation. Which client can be safely paired with this client in a client-care assignment? One:

Check to be sure the catheter is patent

A client who has an indwelling catheter reports the need to urinate. Which of the following interventions should the nurse perform?

Side lying

A client who is unconscious needs frequent mouth care. When performing mouth care, the best position of a client is:

After assessing the stoma and surrounding skin, notify the surgeon.

A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action?

A clean gown and gloves must be worn when in contact with the client.

A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions?

Cyanosis:

A client with chronic pulmonary disease has a bluish tinge around the lips. The nurse charts which term to most accurately describe the client's condition?

identity v. role confusion

5th stage in Erikson's model; adolescents (young adult) must develop a sense of identity or suffer lack of direction

Supine (horizontal recumbent)

A back-lying position with legs extended; with or without pillow under the head.

Intact skin

A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection?

Dysrythmias: hold the breath while bearing down. This maneuver increases the intrathoracic and intracranial pressures, which can precipitate dysrhythmias, brain attack, and respiratory difficulties; all of these can be life threatening. Strain at stool causes blood pressure rise, which can trigger cardiovascular events such as congestive heart failure, arrhythmia, acute coronary disease, and aortic dissection.

A nurse discourages a patient from straining excessively when attempting to have a bowel movement. What physiological response primarily may be prevented by avoiding straining on defecation?

Prostate enlargement

A nurse has identified that the patient has overflow incontinence. What is a major factor that contributes to this clinical manifestation?

Eliminate consumption of caffeine & alcohol

A nurse in a provider's office is assessing a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions are appropriate for helping to control or eliminate the clients incontinence?

-provide supplemental oxygen in response to any decline in oxygenation saturation while performing -Use surgical asepsis to remove & clean inner cannula -Clean outer surface in circular motion from stoma site outward

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? Select all that apply.

Poor skin turgor; fever; hypotension (longer effects not homeostatic response)

A nurse is caring for a client who has diarrhea for the past four days. When assessing a client, the nurse should expect which of the following findings? Select all that apply.

The specimen cannot be contaminated with urine. For fecal occult blood testing at home, the stool specimens cannot be contaminated with water or urine. The fecal occult blood test (FOBT) is a diagnostic test to assess for occult blood in the stool. This test has commonly been used for colorectal cancer screening, especially in developed nations. When used correctly for screening, this testing modality has established associations with decreased morbidity and mortality. When performing at home, the stool should be collected in a dry, clean container.

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client?

Position commode at bedside

A nurse is caring for a debilitated female patient with nocturia. Which nursing intervention is the priority when planning to meet this patient's needs?

Insert tube 3-4 inches; place pt in sims; warm enema solution; hold 12-18" above

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all that apply.

Fresh food and whole-wheat toast.

A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?

Tachycardia

A nurse obtained a client's pulse and found the rate to be above normal. The nurse document these findings as:

comprehensive physical assessment

A nurse performing a health history interview and a complete head-to-toe examination of every body system is performing what kind of assessment?

ongoing assessment

A nurse who is Repeating the initial assessment, repeating vitals, repeat focused assessment, & checks interventions is doing what kind of assessment?

Observe the emesis. After a patient has vomited, the nurse must inspect the emesis to document color, consistency, and amount.

A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first?

A focused physical assessment

A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing?

His 24-hour output is adequate. *A 24-hour urine output of less than 500 ml in an adult is considered inadequate and may indicate kidney failure*. This must be corrected while the patient is in the acute state so that appropriate fluids, electrolytes, and medications can be administered and excreted. *Indwelling catheterization is not needed to diagnose trauma, urinary tract infection, or residual urine*.

A patient is catheterized with a #16 indwelling urinary (Foley) catheter to determine if:

Return shortly to the patient's room and remain there until the patient takes the medication

A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do?

0.5 ml

A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1 ml. How many milliliters should the nurse administer?

insoluble fiber bulks: Kale, wheat, nuts, green beans, corn, broccoli/cauliflower, potatoes

A patient with the diagnosis of diverticulosis is advised to eat a diet high in fiber. What should the nurse recommend that the patient eat to best increase the bulk and fecal material?

Below 95%

A person with pulmonary emboli will MOST LIKELY have oxygen saturation levels _____.

*Lower the solution container after instilling about 150 mL* of solution. Lowering the container of solution creates a siphon effect that pulls the instilled fluid back out through the rectal tube into the solution container. The *return flow promotes the evacuation of gas from the intestin. This technique is used only with a return flow enema.

A practitioner orders a return flow enema (Harris flush drip) for an adult patient with flatulence. When preparing to administer this enema the nurse compares the steps of a return flow enema with cleansing enemas. What should the nurse do that is unique to a return flow enema?

Lower the solution container after instilling about 150 mL of solution.

A practitioner orders a return flow enema (Harris flush drip) for an adult patient with flatulence. When preparing to administer this enema the nurse compares the steps of a return flow enema with cleansing enemas. What should the nurse do that is unique to a return flow enema?

Making changes after evaluating the situation and having discussions with the staff. A new assistant nurse manager should not make changes until she has had a chance to evaluate staff members, patients, and physicians. Changes must be planned thoroughly and should be based on a need to improve conditions, not just for the sake of change.

A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:

Numbness

A terminally ill patient usually experiences all of the following feelings during the anger stage *except*:

inductive reasoning

A type of logic in which generalizations are based on a large number of specific observations. Facts,observations, reasoning moves from *specific to general*

Semi-Fowler's

The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How should she position the patient to begin and perform most of the physical examination?

Phlebitis

After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the I.V. site reveals that it is warm and erythematous. This usually indicates:

Weak, rapid pulse + poor skin turgor

An elderly nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect which assessment finding?

Normal dietary intake

An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects that the child has iron-deficiency anemia. Because iron deficiency anemia is suspected, which of the following is the most important information to obtain from the infant's parents?

Flow sheets

Are comprehensive charting forms that integrate assessments and nursing actions organized by body systems. The nurse checks the box corresponding to the current assessment findings. Nursing actions, such as wound care, treatments, or IV fluid administration, are also included. This is simply a one- or two-page form that gathers all the important data regarding a patient's condition. It is housed in the patient's chart and serves as a reminder of care and a record of whether care expectations have been met.

storage;micturition

Low bladder volume activates the pontine___ center which activates the sympathetic nervous system and inhibits the parasympathetic nervous system cumulatively allowing the accumulation of urine in the bladder. High bladder volume activates the pontine____ center which activates the parasympathetic nervous system and inhibits the sympathetic nervous system as well as triggers awareness of a full bladder; consequently leading to relaxation of the internal sphincter and a choice to relax the external urethral sphincter once ready to void.

High protein diet, cranberry, systemic acidosis, diabetes, starvation, diarrhea, phenylketonuria

Low urinary pH (acidic 4.5 or lower) is seen in these circumstances

oil retention enema

Lubricating Enema that lubricates the rectum and colon so the feces will absorb the oil and become softer and easier to pass.

Deductive reasoning in nursing

Making a clinical nursing diagnosis by testing hypotheses based on systematically collected data; information gathering method- nurse constructs a hypothesis first then finds supporting or refuting facts from the data

sepsis, fever over 100[degrees]F, nausea or vomiting, sickle cell crisis, HIV crisis, a complicated or high-risk pregnancy, crepitus, edema, thrombocytopenia, or meningitis.

Massage only the hands, feet, or scalp of patients with

Place pt in Fowler's position

Nurse CJ is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?

Tachypnea, restlessness, & cyanosis, tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds

Nurse Stephanie is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are *early* indications that should alert the nurse that the client is developing hypoxemia?

Reflecting on the significance of death

Nurses and other healthcare providers often have difficulty helping a terminally ill patient through the necessary stages leading to acceptance of death. Which of the following strategies is most helpful to the nurse in achieving this goal?

Have the patient take a 30- to 60-minute nap in the afternoon.

Nursing interventions that can help the patient to relax and sleep restfully include all of the following *EXCEPT*:

ST wave

On a heart monitor, one heartbeat is reflected as a PQRST wave. The wave that represents ventricular repolarization (rest)?

Anal sphincter muscles

One of the main mechanisms behind fecal incontinence is the inappropriate function of the

Problem focused assessment

Ongoing process integrated with nursing care, to determine a status of a specific problem identified in an earlier assessment.( hourly assessment)

Palpation, percussion, and auscultation should be performed in that order, except when performing an abdominal assessment

Order of assessment

Inspect, auscultation, percussion, palpate

Order of physical assessment for the abdomen

Maslow's 1.Physiological Needs

Oxygen, water, food elimination, temperature, sexuality, physical activity, and rest demonstrates which stage of Maslow hierarchy of needs

Be lowered

Pain tolerance in an elderly patient with cancer would:

It improves interdisciplinary collaboration that improves efficiency in procedures.

Patient Z asks Nurse Toni why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system?

speech therapy

Paul Jake suffered a stroke and has difficulty swallowing. Which healthcare team member should be consulted to assess the patient's risk for aspiration?

Help maintain open airways

Pursed-lip breathing involves deep inspiration and prolonged expiration against slightly closed lips. The pursed lips create a resistance to the air flowing out of the lungs, which prolongs exhalation and maintains positive airway pressure, thereby _____ _____ ____ ____ and preventing airway collapse. Pursed lip breathing is beneficial for people with chronic lung disease. It can help strengthen the lungs and make them more efficient.

Severity questions

Questions addressing the pts pain severity, pain scale

Quantity questions

Questions asking how bad the pain is, moderate, severe, intermittent

Timing questions

Questions asking the pt what they were doing when their pain started, when it started and how long it's been bothersome, duration

Quality questions

Questions asking what a pts pain feels like (stabbing, aches, burning)

Palliative Questions

Questions asking what makes a pts pain better

provocative question

Questions asking what makes a pts pain/ symptoms worse

Region/ radiation questions

Questions asking where a pts pain is, does it radiate anywhere else?

Temperature/ fever spike

Rapidly rising temp to fever then normalizes & then completely normal after a few hours

Prevent a patient from becoming confused or disoriented.

Restraints can be used for all of the following purposes except to:

32 drop per minute Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of milliliters per minute: 125/60 min = X/1 minute 60X = 125X = 2.1 ml/minute To find the number of drops/minute: 2.1 ml/X gtts = 1 ml/15 gtts X = 32 gtts/minute, or 32 drops/minute

The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of:

Death

The further down the health continuum a pt is, the closer they are to

Caring for the back by means of massage

The goal when performing this procedure is to enhance relaxation, reduce muscle tension and stimulate circulation.

take a deep breath, hold for 2 seconds, and cough two or three times in succession

The most convenient way to remove most secretions is coughing. It is necessary to assist the patient during this activity. Deep breathing, on the other hand, promotes oxygenation before controlled coughing.Teach the patient the proper ways of coughing and breathing:

Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas.

The most important nursing intervention to correct skin dryness is:

Maslow's -4. Self-Esteem Needs

The need for a person to feel good about oneself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments is part of what stage of Maslow's hierarchy of needs?

Sims' (left lateral)

The nurse administers a cleansing enema. The common position for this procedure is?

*Return flow: relief of postoperative flatus*, stimulating bowel motility. A *return-flow enema, or Harris flush*, is used to remove intestinal gas and stimulate peristalsis. A *large volume fluid* is used but the fluid is instilled in *100-200 ml increments*. Then, the *fluid is drawn out by lowering the container below the level of the bowel*. This brings the flatus out with the fluid.

The nurse assesses a client's abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling "bloated" . The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema?

Under weight

The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the physician's office for a college physical. This patient is considered:

Inspection

The nurse in charge is assessing a patient's abdomen. Which examination technique should the nurse use first?

Helps the patient dangle the legs After placing the patient in High Fowler's position and moving the patient to the side of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed

The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer?

38.9°C

The nurse in charge measures a patient's temperature at 102 degrees F. what is the equivalent Centigrade temperature?

Sims

The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip replacement 2 weeks ago. Which position should the nurse avoid when examining this patient's rectal area?

Patient's description of pain

The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data?

Sitting Upright

The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment?

Exercise weight bearing activity

The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to

The stoma color is a deep red purple. An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. A stoma is the exteriorization of a loop of bowel from the anterior abdominal wall, done during a surgical procedure.

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?

Charting that Separates the health record according to discipline

The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting:

Axillary

The nurse is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client's temperature?

Check the syringe to verify that the nurse has removed the prescribed insulin dose

The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for self-injection. The patient's first priority concerning self-injection in this situation is to:

actual diagnosis

a client problem that is present at the time of the nursing assessment

health promotion nursing diagnosis

a clinical judgement of a pts motivation, desire, and readiness to enhance well-being and actualize human health potential

heat stroke

a condition caused by too long an exposure to high temperatures, causing high fever, headaches, hot, dry skin, physical exhaustion and sometimes physical collapse and coma. Temp 106

functional nursing model

a method of providing patient care by which each licensed and unlicensed staff member performs specific tasks for a large group of patients (may be seen during a mass casualty event)

Fowler's position

a semi-sitting position; the head of the bed is raised between 45 and 60 degrees

crede's maneuver

a technique used to void urine from the bladder of an individual who, due to disease, cannot do so without aid. The maneuver is executed by exerting manual pressure on the abdomen at the location of the bladder, just below the navel Because the bladder muscles will not contract to increase the intra-bladder pressure to promote urination, the process is initiated manually.

tactile fremitus

a tremulous vibration of the chest wall during speaking that is palpable on physical examination

sagittal plane

a vertical plane that divides the body into right and left parts

IgE antibodies

bind to mast cells and basophils and are involved in allergic reactions; monomer. defense against different parasitic infections which include Strongyloides stercoralis, Trichinella spiralis, Ascaris lumbricoides, and the hookworms Necator americanus and Ancylostoma duodenal

hyperpyrexia

body temperature of more than 106.7°F or 41.5°C

Integrated plans of care (IPOC)

combined charting and care plan format. It is care that is planned with people who work together to understand the service user and their carer(s), puts them in control, and coordinates and delivers services to achieve the best outcomes

heat exhaustion

condition resulting from exposure to heat and excessive loss of fluid through sweating; paleness, dizziness, N/V, fainting, temp 101-102

urinary retention

evidenced by supra pubic distention and lack of voiding or small, frequent voiding (overflow incontinence)

Condom Catheter (Texas Catheter)

external catheter that has an attachment on the end that fits over the penis

functional urinary incontinence

involuntary loss of urine related to impaired function. If the *urinary tract is functioning properly* but *other illnesses* or *disabilities* are preventing one from staying dry. For example, if an illness rendered the client unaware or unconcerned about the need to find a toilet, the client would become incontinent. Medications, dementia, or mental illness can decrease awareness of the need to find a toilet.

compartment syndrome

involves the compression of nerves and blood vessels due to swelling within the enclosed space created by the fascia that separates groups of muscles can be confused or differential diagnosis with phlebitis

ventrogluteal site IM

located by placing the palm of the hand over the greater trochanter of the patient's hip with the wrist perpendicular to the femur, pointing the thumb toward the patient's groin and the index finger toward the anterior superior iliac spine, and extending the middle finger back along the iliac crest toward the buttock.

Percussion: Hyperresonance

louder and lower pitched than resonant sounds are normally heard when percussing the chests of children and very thin adults may be heard when lungs are hyperinflated with air or pts having an acute asthma attack (COPD, Pneumothorax)

*Midline: divides body into two parts in equal halves*-pass through midline structures such as the navel or spine, and all other sagittal planes (also referred to as *parasagittal planes*)

midsagittal/median plane

diastolic pressure

occurs when the ventricles are relaxed; the lowest pressure against the walls of an artery

Pyrexia (fever)

or fever, occurs because heat-loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature. Usually not harmful if it stays below 39°C (102.2°F)

parturition

process of giving birth term

Title VII of the Civil Rights Act of 1964

prohibits employment agencies, employers, and unions from discriminating against applicants and employees on the basis of race, color, religion, national origin, or sex.

PQRST

provocative/palliative, quality, region/radiation, severity, timing

carotid pulse

pulse felt between the scm and the trachea at the level of the cricoid cartilage

Tachypnea

rapid breathing > 20 /min

Diarrhea

reversal of the net absorption of water and electrolytes in the intestinal tract to their secretion and excretion out of the body, meaning, instead of absorbing water and electrolytes into our body, we are now ridding ourselves of more of them.

portal hypertension

s/s prominent abd wall veins (caput medusa) hemorrhoids, enlarged spleen, anemia, GI bleeding, esophageal varices. Rx: balloon, vasopressin, nitro, TIPS. Nursing: assess bleeding, no alcohol, monitor for infection: Dx?

IgG antibodies

the most prevalent in serum; provide naturally acquired passive immunity; neutralize bacterial toxins, participate in complement fixation and enhance phagocytosis.the only immunoglobulin that crosses the placentae as its Fc portion binds to the receptors present on the surface of the placenta, protecting the neonate from infectious diseases.the most abundant antibody present in newborns

flatulence/flatus

the passage of gas out of the body through the rectum

Lateral recumbent

the patient is lying on his side

Habit training

the process of teaching a child to eliminate on the toilet at routine times. involves teaching children to eliminate on the toilet by developing a toileting routine/habit.

dorsogluteal site

the upper outer quadrant of the buttocks is a common location for intramuscular injections. this site is avoided in clients under the age of 3 because their muscle is not sufficiently developed. if not identified correctly, can cause damage to the sciatic nerve.

right middle lobe of lung

this lobe of the lung is only accessible in the anterior aspect inferior to the breast and in midaxillary region for fremitus, percussion, and auscultation

Code of nursing ethics principles

•Describes obligation to the pt •the role of the RN in the HC team •duties of the RN to the profession & to society •advocacy, responsibility, accountability, confidentiality