Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
fund test 2
| Question | Answer |
|---|---|
| What are the legal aspects of medication administration (8) | Nurse must follow legal provisions when administering narcotics, responsible for 1) knowing action 2) dose, 3)therapeutic affects, 4) side effects, 5) adverse reactions, 6)drug interactions, 7) contraindications, 8) precautions |
| What are the parts of a medication order (6) | 1. Name; 2) DOSE; 3) Frequency; 4) Route 5) dATE, 6) Signature |
| STAT | Immediate administration of measure or med |
| NOW | ASAP (usually within an hour or as soon as medication can be prepared BUT 90 MIN. AT OUTSIDE |
| PRN | As needed by patient, (always should have cause) |
| Standing | CARRIED OUT UNTIL THE PRESCRIBER CANCELS OR UNTIL A PRESCRIBED NUMBER OF DAYS ELAPSE |
| Intramuscular works | 3ML SYRINGE, 1-11/2" LONG 21-25 GAUGE |
| subcutaneous works | 1 ml OR 50-100 UNIT 25-27 Ga 3/8-5/8" long |
| Intradermal works | 1 Ml 25-27 GA 1/4-5/8 (tuberculin needle) |
| What are the 7 rights of medication administration | Right drug, dose, patient, route, time, form, documentation, |
| Intramuscular sites | Ventrogluteal, vastus laterallis, deltoid, |
| subcutaneous sites | Outer aspects of upper arms, abdomen (avoid umbilicus) , anterior aspect of thighs, scapula, upper ventral or dorsogluteal areas |
| Intradermal sites | Select area on inner aspect of forearm that is not heavily pigmented or covered with hair. Upper chest or upper back beneath the scapulae also are sites for intradermal injections. |
| Intramuscular administration | Spread skin with fingers, or use Z track technique, inject at 90 degree angle, aspirate, if no blood, inject medication |
| subcutaneous administration | Pinch skin together (around 2 inches) inject at 45 deg. Angle, do not aspirate, |
| Intradermal administration | Inject at 5-15 deg. Angle. Should be able to seee needle tip. Inject, look for bleb |
| Opiods.what is the most important nursing assessment to perform before administration | Respiration rate |
| What medication should be available in the event of adverse reactions to opiods | Naloxone, 4 mg diluted in 4 ml of Saline |
| Describe types of pain | Acute, chronic, referred, somatic, phantom, visceral |
| Acute pain | Moderate to severe, rapid onset |
| Chronic pain | Ongoing pain (arthritis) may be moderate to severe |
| Referred pain | Pain in a part of the body separate from source of pain |
| Visceral pain | Pain resulting from stimulation of internal organs |
| Phantom pain | Pain from severed limb, brain centers initiate |
| Somatic pain | Tissue, joint bone, localized |
| Pain assessment, objective data | Limited range of motion, grimacing |
| Pain assessment, subjective data | Patient pain assessment, scale |
| medication used to treat itching (common side affect of many drugs) | Benydryl? |
| Pain scale 0-10, moderate, mild, severe | 1-3, milds; 3-6, moderate, 7-10 severe |
| asepsis | freedom from infection; the methods used to prevent the spread of microorganisms |
| medical asepsis | (Noun) the practice of techniques and procedures designed to reduce the number of microorganisms in an area or on an object and to decrease the likelihood of transfer hand hygiene |
| surgical asepsis | refer to destruction of organisms before they enter the body that can be carried by open wound or surgical procedures. Surgical technique |
| principles of surgical asepsis | 1. Sterile to sterile, is sterile, 2) only sterile objects can be placed on a sterile field,3) out of site, not sterile,4) hands below waist, not sterile, 5) prolonged exposure, not sterile, 6) wet sterile not sterile, edges (1" border ) to sterile fiel |
| Chain of infection | Agent, reservoir, Portal of entry, susceptible host, port of exit, mode of transmission |
| Systemic infection | Fever, malaise, enlarged lymph nodes |
| Localized infection | Localized swelling, pain, heat, edema |
| describe the infectious process | Incubation, prodromal, illness |
| defenses against infection | Normal flora, body defenses, tissue repair, inflammation, vascular and cellular responses |
| actions to reduce infection | aseptic technique, |
| actions to reduce reservoir | Bathing, hygiene, dressing changes, Bedside unit, |
| difference between systemic and localized infection | Local/entire body |
| follow a client with skin problems through nursing process (ADPIE) | Assess skin integrity, diagnose, plan , implement evaluate |
| Key points of standard precautions | Hand washing, gloves, masks, gowns, clean equipment |
| Isolation Guidelines | As ordered PPE changed after contact |
| transmission base precautions | Airborn, droplet, contact, protective equipment |
| Range of motion activities for neck | Chin to chest, tilt side to side, rotate (flexion, extentsion, hyperextension, lateral flex, rotation) |
| Range of motion activities for shoulder | |
| Range of motion activities for elbow | Flexion, extension, hyperextension |
| Range of motion activities for forearm | Pronation, supination |
| Range of motion activities for wrist | Flexion, extension, hyperextension, adduction, abduction |
| Range of motion activities for fingers | Flex, ext, hyper, ad, ab |
| Range of motion activities for hip | Flex, exte, hyp, ab, ad, internal rot external rotation, circumduction |
| Range of motion activities for knee | Flex, extend |
| Range of motion activities for ankle | Plantar flex, dorsal flex |
| Range of motion activities for foot | Inver, evert, flex, extend, ab, ad |
| Passive ROM | assisted |
| Active rom | unassisted |
| EFFECTS OF IMMOBILITY ON MUSCULOSKELETAL SYSTEM | Atrophy of muscles and stiffening of joints |
| EFFECTS OF IMMOBILITY ON CARDIOVASCULAR | Circulation to periphery is compromised |
| EFFECTS OF IMMOBILITY ON gi System | Bowel blockages, |
| EFFECTS OF IMMOBILITY ON Integumentary | Pressure ulcers |
| Assessment for vision | Subjective: vision difficulties, pain, strabismus or diplopia, reddness. Objective: Snellen, cardinal, confrontation light reflex, accommodation |
| diplopioa | Double vision |
| Snellen | 2o feet away, |
| Confrontation | Measures peripheral vision, cover one eye pring object in from side |
| Light reflex | Darken room and bring light across, look for equal and reactive response of pupils to light |
| accomodation | Focus on distant object then close |
| Cardinal position of gaaz | Muscle weakness, hold finger 6-12" go out and back |
| Assessment for hearing | Subjective data, earache, tinnitis, verigo, discharge, hearing loss. Objective, tuning fork, Webber test rinne test |
| Weber test | Tuning fork on head (side to side differential) |
| Rinne Test | Tuning fork next to ear then on bone (air vs. solid) count |
| assessment for head | Subjective: headaches, injuries, Dizziness, neck pain, lumps: Objective, palpate determine size, shape, t |
| assessment for neck | Assess rom, check lymph nodes look for tracheal shifts |
| flexion | Bending at joint |
| extension | Straightening at joint |
| abduction | Moving limb away from body |
| adduction | Moving limb into body |
| pronation | Turning forearm palm down |
| supination | Turning forearm palm up |
| Circumduction | moving arm in a circle around shoulder |
| inversion | Moving sole of foot toward ankle |
| eversion | Moving sole of foot outwards at ankle |
| rotation | Moving head around a central axis |
| protraction | Forward and parallel to ground |
| retraction | Backwards and parallel |
| elevation | raising |
| depression | lowering |
| inversion | |
| assessment for nose | |
| assessment for throat | |
| assessment for musculoskeletal | |
| assessment for skin hair nails | |
| method to apply sterile gloves | |
| performing dry sterile dressing | |
| applying wet to dry sterile dressing | |
| Wound staging for pressure ulcers | |
| Stage 1 characteristics | Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. |
| stage 2 characteristics | Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. |
| stage 3 characteristics | Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. |
| stage 4 characteristics | Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. |
| risk factors for developing pressure ulcers | Impaired sensory perception, Alteration in LOC, impaired mobility, shear, friction, moisture |
| types of wounds | |
| wound color | |
| wound healing | |
| exudates | Serous, sanguineous, serosanguinous, purulent |
| Serous exudate | Yellow clear |
| Sanguinous exudate | red |
| Serosanguinous exudate | Pale red |
| Purulent | Yellow greeniush, pussy |
| and complications | |
| closure designation for suterued, stapled, taped wound | Primary intention |
| closure designation for pressure ulcer | Secondary intention |
| complications of wound healing | |
| dihiscence | Total disintegration of mechanical bonding of wound brought about by influences not totally understood. |
| evisceration | An organ protruding through a wound site |
| what to do if evisceration is discovered by nurse | Call doctor, medical emergency |
| methods to reduce effects of shearing force or skin trauma on pt when moving pt confined to bed | |
| Nursing action to promote wound healing and preventing pressure ulcers | |
| what are types of wound dressing | |
| what are the functions of different wound dressings | Protect, |
Created by:
jrjct1
Popular Science sets