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FUNDAMENTALS

everything

QUESTIONANSWER
What are the techniques in interviewing process. What are the techniques in interviewing process. Problem Seeking & Problem Solving, Direct & Open-Ended Questioning
What are the three phases of a basic interview. What are the three phases of a basic interview. Orientation, Working, and Termination Phase
What is the first step in nursing assessment. What is the first step in nursing assessment. Nursing Health History
Basic components of the nursing health history. Basic components of the nursing health history. Bio. Info. Reasons for seeking hxcare Pt. expectations Past Hx Hospitalization Treatment Outcomes Family Environmental Psychosocial Present Hx State & R.O.S.
What is the focus of nursing history. What is the focus of nursing history. Effect of CHANGE in Hx state in meeting basic human needs.
A statement of potential or actual patient problems. A statement of potential or actual patient problems. Nursing Diagnosis
Nursing diagnostic involves four elements. Nursing diagnostic involves four elements. Analysis & Interpretation of data, Clustering of Data, Identification of Pt. Problems, Formulation of Nsg. Dx.
It requires validation and clustering of data. It requires validation and clustering of data. Interpretation of data
Determining whether data gathered is complete and accurate. Determining whether data gathered is complete and accurate. Validation of data
Grouping related data, usually sx & sy, indicating a general problem. Grouping related data, usually sx & sy, indicating a general problem. Clustering of data
A hx care problem that is currently perceived by the pt. or assessed by the nurse. A hx care problem that is currently perceived by the pt. or assessed by the nurse. Actual Hx Care Problem
A hx care problem in which the patient is at risk. A hx care problem in which the patient is at risk. Potential Hx Care Problem
When planning, a nurse should consider the level of potential pt. involvement, time limit and what? When planning, a nurse should consider the level of potential pt. involvement, time limit and what? Available Hx care system resources
In implementation of the NCP, what actions are taken. In implementation of the NCP, what actions are taken. Assist Pt. on ADL, Counsel & support Pt. & family, Guide Pt., Teach Pt. & Family, Provide care to achieve NCP, Provide Environment that is conducive.
Interventions based on instructions or written directives given by another professional. Interventions based on instructions or written directives given by another professional. Dependent Intervention
Aspects of care encompassed by licensure and law. Aspects of care encompassed by licensure and law. Independent Intervention
Interventions that the nurses carry out in collaboration with another professional. Interventions that the nurses carry out in collaboration with another professional. Interdependent Intervention
True or False. The NCP is modified as the Pt's state of Hx changes and as needs for care changes. True or False. The NCP is modified as the Pt's state of Hx changes and as needs for care changes. True
In evaluation of NCP, outcomes of nursing interventions maybe used for. In evaluation of NCP, outcomes of nursing interventions maybe used for. Malpractice suits Staff Evaluations Reviews Promotions Nursing Research Quality Improvement
What are the enrivonmental fire safety precautions? What are the enrivonmental fire safety precautions? Mark fire exits Dont use elevator Turn off O2 machines Move pt's. by bed, stretcher, or wheelchair
What are environmental radiation safety precautions? What are environmental radiation safety precautions? Label radioactive materials Limit time spent Distance yourself from the source Use lead apron Never touch dislodged implants
What are environmental precautions for disposing infectious wastes? What are environmental precautions for disposing infectious wastes? Needles should not be recapped, bent or broken Yellow for infectious Green for biodegradable Black for nonbiodegradable Red for blood, sharp items, contaminated
It is to restrict client movement through the application of a device? It is to restrict client movement through the application of a device? Physical restraints
Medications given to inhibit specific behavior? Medications given to inhibit specific behavior? Chemical restraints
Restraints should have? Restraints should have? Reason & method Date & time of use Duration & release from it Assessment of pt's response & further need of use Half bow or safety knot & secured to the bedframe or chair
Restraints should not be? Restraints should not be? P.R.N. & without consent from the pt. & family
Neurovascular, circulatory & skin integrity is assessed in using restraints when? Then removed at least every? Neurovascular, circulatory & skin integrity is assessed in using restraints when? Then removed at least every? Every 30 minutes Removed @ least q 2 hrs. to promote circulation
Who are those prone to accidental poisoning? Who are those prone to accidental poisoning? Toddlers Preschoolers Young school age
In older adults, poisoning & overdose of prescribed medz. will yield? In older adults, poisoning & overdose of prescribed medz. will yield? Diminished eyesight Impaired memory
If lye, grease, petroleum or household cleaner is ingested, a nurse should? If lye, grease, petroleum or household cleaner is ingested, a nurse should? Never induce vomit especially to an unconscious person If vomit occurs, bring vomitus to CDC
Nosocomial infections can be transmitted by a healthcare personnel by? Nosocomial infections can be transmitted by a healthcare personnel by? Improper handwashing Unchanged gloves between clients
Standard precautions apply to? Standard precautions apply to? Blood Non-intact skin Mucous membrance All body fluids except sweat
Diseases under transmission based precautions are? Diseases under transmission based precautions are? Measles Chickenpox (varicella) Disseminated varicella zoster T.B.
Droplet precautions diseases are? Droplet precautions diseases are? Adenovirus, Influenza Sepsis, Scarlet Fever Epiglottitis, Mumps Meningitis
Barrier protection for transmission based droplet precautions is? Barrier protection for transmission based droplet precautions is? Placing client in private room or cohort client Mask
Transmission based contact precautions diseases are? Transmission based contact precautions diseases are? Clostridium Difficle INFxN with multidrug resistant org. Wound infections Cutaneous diptheria Herpes simplex Impetigo Pediculosis Scabies Staphylococcus Varicella Zoster Conjunctivitis
Smallpox is a droplet type with S&S of fever, back pain, vomiting, malaise, headache & papules that turn into? Smallpox is a droplet type with S&S of fever, back pain, vomiting, malaise, headache & papules that turn into? Pustular vessicles in the face & extremities
In case of fire, a nurse should R- A- C- E- In case of fire, a nurse should R-rescue A-alarm C-confine E-extinguish
Head tilt-chin lift is used in B.L.S. but if pt. has a neck injury, what do you use? Head tilt-chin lift is used in B.L.S. but if pt. has a neck injury, what do you use? Jaw thrust maneuver
A.B.C.D.'s of B.L.S. are: A.B.C.D.'s of B.L.S. are: Airway Breathing Circulation Defibrilation or Definitive Treatment Each step begins with ASSESSMENT always
Apical & radial pulse will always yield? Apical & radial pulse will always yield? Identical result
In assessing for a pulse to an infant < 1 yr old? a child > 1 yr old? In assessing for a pulse to an infant < 1 yr old? a child > 1 yr old? Brachial (<1yr) Carotid (>1yr)
For infants on B.L.S., chest compression is 1/2 - 1 inch deep @ least 100 times/min using? For infants on B.L.S., chest compression is 1/2 - 1 inch deep @ least 100 times/min using? 2-3 fingers Child 1-1.5 inches deep
When performing a Heimlich Maneuver to an obese or pregnant, what do you do? When performing a Heimlich Maneuver to an obese or pregnant, what do you do? Chest thrusts
For unconscious adult (B.L.S.), you do a? For unconscious adult (B.L.S.), you do a? Tongue jaw lift Fingersweep object
For unconscious pregnant, a pillow or rolled blanket is placed on the right side to? For unconscious pregnant, a pillow or rolled blanket is placed on the right side to? Displace uterus to the left of the abdomen
Unconscious pregnant needing defibrilation should have the paddles placed 1-rib higher than the usual because? Unconscious pregnant needing defibrilation should have the paddles placed 1-rib higher than the usual because? Heart is displaced during pregnancy
This is used to convert ventricular fibrilation into a perfusing rhythm? This is used to convert ventricular fibrilation into a perfusing rhythm? Automated External Defibrillator
Automated External Defibrilator is C/I to? Automated External Defibrilator is C/I to? < 8 yrs old Child weighing < 25 kgs.
A surgeon is responsible for getting consent & a nurse can be a witness provided the pt. understood the procedures explained by the doctor. What is the next step? A surgeon is responsible for getting consent & a nurse can be a witness provided the pt. understood the procedures explained by the doctor. What is the next step? Document the witnessing of consent signing
In general anesthesia, solid & liquid foods are withheld for? In general anesthesia, solid & liquid foods are withheld for? 6-8 hrs. prior Local anesthesia - 3 hrs. prior
When is enema or laxative performed in clients for surgery? When is enema or laxative performed in clients for surgery? The night prior surgery
If client has a Foley catheter before surgery, it should be emptied & document the? If client has a Foley catheter before surgery, it should be emptied & document the? Amount & characteristics of the urine
3 levels of moral development (premoral or preconventional level, conventional level, postconventional level).   3 levels of moral development (premoral or preconventional level, conventional level, postconventional level). Lawrence Kohlberg  
4 conservation principles (conservation of energy, structural integrity, personal integrity, and social integrity).   4 conservation principles (conservation of energy, structural integrity, personal integrity, and social integrity). Myra Levine  
4 types of personality (sanguine, melancholic, phlegmatic, choleric).   4 types of personality (sanguine, melancholic, phlegmatic, choleric). Galen  
5 hierarchy of needs (physiological, safety & security, love & belonging, self esteem, self actualization).   5 hierarchy of needs (physiological, safety & security, love & belonging, self esteem, self actualization). Abraham Maslow  
Adaptation model. Each person is a unified biopsychosocial system in constant interaction with changing environment.   Adaptation model. Each person is a unified biopsychosocial system in constant interaction with changing environment. Sister Calista Roy  
All behavior is learned.   All behavior is learned. B.F. Skinner  
Believed that nurse helps patients meet a perceived need that the patient cannot meet themselves.   Believed that nurse helps patients meet a perceived need that the patient cannot meet themselves. Ida Jean Orlando  
Birth trauma.   Birth trauma. Otto Rank  
Care, Core, Cure. Care, Core, Cure. Lydia Hall  
Cognitive development (sensorimotor, peri-operational thought, concrete operations, formal operations).   Cognitive development (sensorimotor, peri-operational thought, concrete operations, formal operations). Jean Piaget  
Conceptualized the behavioral system model. Each person is composed of 7 subsystem (ingestive, eliminative, affiliative, aggressive, dependence, achievement and sexual).   Conceptualized the behavioral system model. Each person is composed of 7 subsystem (ingestive, eliminative, affiliative, aggressive, dependence, achievement and sexual). Dorothy Johnson  
Developed self-care and self-care deficit theory.   Developed self-care and self-care deficit theory. Dorothea Orem  
Developmental task.   Developmental task. Robert Havighurst  
Focused on manipulating the environment for the patient's recovery.   Focused on manipulating the environment for the patient's recovery. Florence Nithingale  
Founded psychobiology. Believes in totality of man/holistic approach.   Founded psychobiology. Believes in totality of man/holistic approach. Adolf Meyer  
Goal attainment theory. Nursing as a helping profession.   Goal attainment theory. Nursing as a helping profession. Imogene King  
Health as expanding consciousness. Humans are unitary beings in whom disease is a manifestation of the pattern of health.   Health as expanding consciousness. Humans are unitary beings in whom disease is a manifestation of the pattern of health. Margaret Newman  
Health care system model. Nursing is concerned with all the variables affecting an individual's response to stress, which are interpersonal, intrapersonal, and extrapersonal in nature.   Health care system model. Nursing is concerned with all the variables affecting an individual's response to stress, which are interpersonal, intrapersonal, and extrapersonal in nature. Betty Neuman  
Human becoming. Emphasized free choice of personal meaning in relating value priorities.   Human becoming. Emphasized free choice of personal meaning in relating value priorities. Rosemarie Rizzo Parse  
Human caring model. Nursing is the application of the art and human science through transpersonal caring.   Human caring model. Nursing is the application of the art and human science through transpersonal caring. Jean Watson  
Humanistic nursing practice theory. Nursing is an existential experience.   Humanistic nursing practice theory. Nursing is an existential experience. Josephine Paterson & Loreta Zderad  
Identified 14 basic needs. Nurse functions to assist client in performing activities contributing to health, recovery, or peaceful death.   Identified 14 basic needs. Nurse functions to assist client in performing activities contributing to health, recovery, or peaceful death. Virginia Henderson  
Identified 21 nursing problems. Defined nursing as service to individuals and families, therefore, society.   Identified 21 nursing problems. Defined nursing as service to individuals and families, therefore, society. Faye Abdellah  
Interpersonal model. Nursing is an interpersonal process of the therapeutic interactions between sick and nurse.   Interpersonal model. Nursing is an interpersonal process of the therapeutic interactions between sick and nurse. Hildegard Peplau  
Interpersonal theory (anxiety occurs due to poor interpersonal relationship).   Interpersonal theory (anxiety occurs due to poor interpersonal relationship). Harry Stack Sullivan  
Introversion and extroversion - persona/anima   Introversion and extroversion - persona/anima Carl Jung  
Modeling and role-modeling theory.   Modeling and role-modeling theory. Helen Erickson, Evelyn Tomlin & Mary Ann Swain  
Nurse's individual philosophy lends credence to nursing care.   Nurse's individual philosophy lends credence to nursing care. Ernestine Weidenbach  
Presented grand theory of nursing. All persons are caring and nursing is a response to unique social call.   Presented grand theory of nursing. All persons are caring and nursing is a response to unique social call. Anne Boykin & Savina Schoenhofer  
Psychosexual theory (oral, anal, phallic, latent, genital stage). Psychoanalytical theory (Libido is the psychic reservoir of psychic energy, id, ego, & superego).   Psychosexual theory (oral, anal, phallic, latent, genital stage). Psychoanalytical theory (Libido is the psychic reservoir of psychic energy, id, ego, & superego). Sigmund Freud  
Psychosocial development (trust vs. mistrust, autonomy vs. shame/doubt, initiative vs. guilt, industry vs. inferiority, identity vs. role confusion, intimacy vs. isolation, generativity vs. stagnation, integrity vs. despair).   Psychosocial development (trust vs. mistrust, autonomy vs. shame/doubt, initiative vs. guilt, industry vs. inferiority, identity vs. role confusion, intimacy vs. isolation, generativity vs. stagnation, integrity vs. despair). Erik Erickson  
Superinferiority and inferiority complex / birth order.   Superinferiority and inferiority complex / birth order. Alfred Adler  
The science of unitary human beings. Human beings are more than and different from the sum of their parts.   The science of unitary human beings. Human beings are more than and different from the sum of their parts. Martha Rogers  
Theory based on bodily characteristics (endomorphic, mesomorphic, ectomorphic).   Theory based on bodily characteristics (endomorphic, mesomorphic, ectomorphic). William Sheldon  
Transcultural nursing. Nursing is a humanistic and scientific mode of helping a client through specific cultural caring process.   Transcultural nursing. Nursing is a humanistic and scientific mode of helping a client through specific cultural caring process. Madeleine Leininger  
Pulsating abdominal mass Pulsating abdominal mass Abdominal Aortic Aneurism  
Painful board-like abdomen Painful board-like abdomen Abruptio Placenta  
Uremic frost on skin   Uremic frost on skin Acute Renal Failure  
Bronze pigmentation of skin   Bronze pigmentation of skin Addison's Disease  
Outburst laughter or cry fasciculations   Outburst laughter or cry fasciculations Amyotrophic Lateral Sclerosis (ALS)  
Pain upon exertion   Pain upon exertion Angina Pectoris  
Mc Burney's sign   Mc Burney's sign Appendicitis  
Boutonnier deformity, swan neck deformity, ulnar drift, Bouchard's nodes   Boutonnier deformity, swan neck deformity, ulnar drift, Bouchard's nodes Arthritis  
Murmur heard high on chest   Murmur heard high on chest Atrial Septal Defect  
Rocking, spinning, routines   Rocking, spinning, routines Autism  
Grayish white discharge, malodorous   Grayish white discharge, malodorous Bacterial Vaginosis  
Raccoon's eye   Raccoon's eye Basilar Fracture  
Meconium staining   Meconium staining Breech Birth  
Russel's sign, binge eating   Russel's sign, binge eating Bulimia Nervosa  
Cherry pink flushed face   Cherry pink flushed face Carbon Monoxide Poisoning  
Jack hammer syndrome   Jack hammer syndrome Carpal Tunnel Syndrome  
Cloudy vision   Cloudy vision Cataract  
Gluten sensitivity, water, pale, foul smelling stool   Gluten sensitivity, water, pale, foul smelling stool Celiac Disease  
Maculopapulovesiculo rash   Maculopapulovesiculo rash Chicken Pox  
Rice water stools   Rice water stools Cholera  
Pulling up of arms & legs, red-face crying   Pulling up of arms & legs, red-face crying Colic  
Barrel chest, clubbing of fingers   Barrel chest, clubbing of fingers C.O.P.D.  
Moon face, buffalo hump   Moon face, buffalo hump Cushing's Syndrome  
Homonymous hemianopsia   Homonymous hemianopsia CVA  
Feeling of fullness at vagina   Feeling of fullness at vagina Cystocele & Rectocele  
Recent and past memory defect   Recent and past memory defect Delirium  
Recall or learning memory impairment   Recall or learning memory impairment Dementia  
Flashes of light, vein in line of sight Flashes of light, vein in line of sight Detached Retina  
3 P's: polydipsia, polyphagia, polyuria   3 P's: polydipsia, polyphagia, polyuria Diabetes Mellitus  
Pseudomembrane   Pseudomembrane Diptheria  
Cramping, colicky pain in left lower abdominal quadrant   Cramping, colicky pain in left lower abdominal quadrant Diverticular Disease  
Saddle nose, Brushfield's spot's (Trisonomy 21)   Saddle nose, Brushfield's spot's (Trisonomy 21) Down Syndrome  
Ortolani's sign, Galeazzi's sign, asymmetry of gluteal, popliteal & thigh folds   Ortolani's sign, Galeazzi's sign, asymmetry of gluteal, popliteal & thigh folds Dysplasia of Hip  
Cullen's sign   Cullen's sign Ectopic Pregnancy  
Premenstrual pain decreasing as menstrual flow decreases   Premenstrual pain decreasing as menstrual flow decreases Endometriosis  
Exposed bladder, appears to be turned inside out   Exposed bladder, appears to be turned inside out Exstrophy of Bladder  
Radar gaze   Radar gaze Failure to Thrive (FTT)  
Barret esophagus   Barret esophagus G.E.R.D.  
Halos around light Halos around light Glaucoma  
Dysuria, genital discharge   Dysuria, genital discharge Gonorrhea  
Exopthalmia   Exopthalmia Grave's Disease  
Hemarthrosis   Hemarthrosis Hemophilia  
Asterixis   Asterixis Hepatic Disease  
Ribbon-like, foul smelling stool   Ribbon-like, foul smelling stool Hirschprung's Disease (megacolon)  
Grapelike growth, large abdomen   Grapelike growth, large abdomen H-mole  
Bossing's sign, setting sun eyes   Bossing's sign, setting sun eyes Hydrocephalus  
Trousseau's sign   Trousseau's sign Hypocalcemia  
High pitch cry   High pitch cry Increased Intracranial Pressure (ICP)  
Doll's eye   Doll's eye Increased Intraoccular Pressure  
No passage of meconium   No passage of meconium Intestinal Obstruction  
Dance sign, currant jelly-like stool, sausage like   Dance sign, currant jelly-like stool, sausage like Intussesception  
Activity intolerance   Activity intolerance Iron Deficiency Anemia (IDA)  
Strawberry tongue   Strawberry tongue Kawasaki  
Red gelatinous sputum   Red gelatinous sputum Kleibsella Pneumonia  
XXY in males   XXY in males Klinefelter's Syndrome  
Pulmonary manifestations (i.e. orthopnea, crackles, cyanosis, etc.)   Pulmonary manifestations (i.e. orthopnea, crackles, cyanosis, etc.) Left Ventricular Heart Failure  
Less than 2.5 kgs or 5 1/2 lbs   Less than 2.5 kgs or 5 1/2 lbs Low Birth Weight  
Red-ringed circular rash (erythema chronicum migrans)   Red-ringed circular rash (erythema chronicum migrans) Lyme Disease  
Blackwater fever   Blackwater fever Malaria  
Whirling, vertigo, tinnitus   Whirling, vertigo, tinnitus Meniere's Disease  
Kernig's sign, Brudzinki's sign   Kernig's sign, Brudzinki's sign Meningitis  
White "cheesy" discharge   White "cheesy" discharge Moniliasis  
Gower's sign   Gower's sign Muscular Dystrophy  
Charcot's triad: intention tremor, nystagmus, scanning speech (clipped)   Charcot's triad: intention tremor, nystagmus, scanning speech (clipped) Multiple Sclerosis  
Nasal smile Nasal smile Myasthenia Gravis  
Nonproductive that progresses to mucoid sputum   Nonproductive that progresses to mucoid sputum Mycoplasmal Pneumonia  
Viselike or crushing pain radiating to shoulder, arms, jaw or back   Viselike or crushing pain radiating to shoulder, arms, jaw or back Myocardial Infarction  
Purulent conjunctivitis (N. Gonorrhea)   Purulent conjunctivitis (N. Gonorrhea) Opthalmia Neonatorum  
White patches on tongue (Candida Albicans)   White patches on tongue (Candida Albicans) Oral Thrush  
Kyphosis   Kyphosis Osteoporosis  
Ringing or buzzing   Ringing or buzzing Otosclerosis  
Steatorrhea   Steatorrhea Pancreatitis  
Machinery-type murmur throughout the heartbeat in the left 2nd or 3rd interspace   Machinery-type murmur throughout the heartbeat in the left 2nd or 3rd interspace Patent Ductus Arteriosus  
Pill rolling Pill rolling Parkinson's Disease  
Abdominal muscle rigidity with rebound tenderness   Abdominal muscle rigidity with rebound tenderness Peritonitis  
Beefy red tongue   Beefy red tongue Pernicious Anemia  
Paroxysmal cough ending with a whoop   Paroxysmal cough ending with a whoop Pertussis  
Nikolsky sign   Nikolsky sign Phemphigus Vulgaris  
Fever, vaginal discharge, lower abdominal cramping   Fever, vaginal discharge, lower abdominal cramping Pelvic Inflammatory Disease (PID)  
What is the purpose of IV fluid therapy?   What is the purpose of IV fluid therapy? Maintenance, to replace or correct deficits, to restore ongoing loss, for meds, nutrition, phlebotomy, transfusions or blood product therapy.  
What is oncotic pressure?   What is oncotic pressure? Colloids, plasma proteins, albumin  
What is hydrostatic pressure? What is hydrostatic pressure? Blood pressure  
What is normal serum osmo?   What is normal serum osmo? 280 - 295 or approx. twice that of the serum Na level.  
What can expand the intravascular compartment?   What can expand the intravascular compartment? Hypertonic fluids.  
What is the problem with using hypertonic fluids?   What is the problem with using hypertonic fluids? If done too fast will draw too much fluid into the intravascular, dehydrating intracellular, especially the brain?  
What is a S/sx of fluids administered too fast?   What is a S/sx of fluids administered too fast? decreased LOC / Confusion.  
What happens if you expand the intra Cellular compartment too fast?   What happens if you expand the intra Cellular compartment too fast? Deplete the intravascular, decreasing BP and causing edema.  
What are the two basic types of parenteral fluids?   What are the two basic types of parenteral fluids? Crystalloid and Colloid  
What is a crystalloid fluid?   What is a crystalloid fluid? An Electrolyte containing solution.  
What are the three basic types of crystalloid fluids?   What are the three basic types of crystalloid fluids? Isotonic, Hypotonic and Hypertonic  
Why are crystalloid fluids called true solutions?   Why are crystalloid fluids called true solutions? Because they can pass through semipermeable membranes.  
What is a Colloid fluid?   What is a Colloid fluid? Contains proteins and starches.  
What can't a Colloid fluid do?   What can't a Colloid fluid do? Pass between compartments. They draw the fluid to them.  
Name three problems with IV fluid therapy.   Name three problems with IV fluid therapy. Phlebitis, extravasation and incompatabilities.  
What three things can an LVN NOT do?   What three things can an LVN NOT do? cannot hang, flush or change bags on a central line even if certified.  
What can an RN NOT do with a central line.   What can an RN NOT do with a central line. Cannot assign to LVN or supervise LVN with anything to do with a central line.  
How do you determine whether it is a central line or a peripheral line?   How do you determine whether it is a central line or a peripheral line? Ask the doctor for an x ray order to determine.  
Name some isotonic fluids   Name some isotonic fluids D5W, LR and NS  
Why do you need to be careful with LR and dehydration?   Why do you need to be careful with LR and dehydration? It is hard for the renal system to process the electrolytes.  
What does the liver do to lactate? (LR)   What does the liver do to lactate? (LR) It metabolizes the lactate to bi-carbonate which buffers acidosis  
What are two common uses for Normal Saline (NS)?   What are two common uses for Normal Saline (NS)? To treat hyponatremia and intravascular dehydration.  
Name a Hypotonic solution?   Name a Hypotonic solution? 0.45 NS ( 1/2 NS)  
What is a problem with Hypotonic solutions?   What is a problem with Hypotonic solutions? Use too long and it will lower BP. It is low in solutes so fluid will move out of the vascular space.  
What makes Hyper tonic fluids different than the others?   What makes Hyper tonic fluids different than the others? It has more dissolved particles than body fluid.  
What does a hypertonic fluid do?   What does a hypertonic fluid do? It moves fluid out of the intracellular and interstitial compartments into the intravascular.  
What are hypertonic fluids used for?   What are hypertonic fluids used for? Hydration and nutrition  
What is dangerous about hypertonic dextrose saline solutions?   What is dangerous about hypertonic dextrose saline solutions? they can move fluids very quickly.  
What is a hypertonic dextrose saline fluid solution used for?   What is a hypertonic dextrose saline fluid solution used for? TPN and PPN. Nutrition.  
What type IV line do you use with Hypertonic dextrose saline?   What type IV line do you use with Hypertonic dextrose saline? 10% solutions can go peripheral but all others 20% and above must use a central line?  
Why must most hypertonic dextrose saline solutions be used with a central line?   Why must most hypertonic dextrose saline solutions be used with a central line? Because the fluids are very irritating to veins.  
How do you infuse hypertonic dextrose saline solutions?   How do you infuse hypertonic dextrose saline solutions? You must use an infusion pump.  
Plasma expanders are not considered what?   Plasma expanders are not considered what? Blood products.  
What do you NOT have to do with plasma expanders?   What do you NOT have to do with plasma expanders? Type and cross match.  
Which of the two main categories of fluids do plasma expanders fall into?   Which of the two main categories of fluids do plasma expanders fall into? Colloid.  
What are Colloids used for?   What are Colloids used for? Maintenance of blood volume, hypovolemic shock, dialysis.  
In which patients do you need to use colloid product with cautiously?   In which patients do you need to use colloid product with cautiously? renal insufficiency and CHF  
PPN is used in what type of line?   PPN is used in what type of line? Peripheral  
TPN is used in what type of line?   TPN is used in what type of line? Central  
What are the components of TPN?   What are the components of TPN? H2O, PRO, CHO, fat, vitamins, trace minerals.  
TPN usually come in a _____hour supply.   TPN usually come in a _____hour supply. 24 hour supply  
Name some indications for TPN.   Name some indications for TPN. Non-function GI, Bowel obstruct., acute inflam, colitis, Crohns, malabsorption, chemo, burns, sepsis, ooncology, pancreatitis.  
How do you know TPN is working? How do you know TPN is working? By weighing daily.  
What is the consideration with IVs and glucose?   What is the consideration with IVs and glucose? Must use the appropriate IV access for concentration of glucose, must use pump, don't play catch up, taper TPN, accu-checks, used micron filters  
What should you monitor with TPN?   What should you monitor with TPN? I & O, weight, liver and renal function and electrolytes.  
Why do you monitor liver and renal function with TPN?   Why do you monitor liver and renal function with TPN? To make sure that they are excreting electrolytes.  
Why do you use a micron filter with TPN?   Why do you use a micron filter with TPN? to filter out bacterial growth.  
Why do you taper TPN?   Why do you taper TPN? To avoid hypoglycemic shock from cutting of the sugar.  
Can you run other things in the TPN IV tubing?   Can you run other things in the TPN IV tubing? No, don't mix with anything else.  
What is an important consideration with albumin? What is an important consideration with albumin? May cause anaphylaxis  
What are some potential complications with TPN?   What are some potential complications with TPN? Fluid imbalances, metabolic acidosis, liver dysfunction, hyperglycemia and infection.  
Nursing process   Nursing process systematic, rational method of nursing care  
Decision making process   Decision making process identify purpose, set criteria, weigh criteria, seek alternatives, examine alternatives, project, implement, evaluate  
Assessing   Assessing collect, organize, validate,document data  
Diagnosing   Diagnosing analyze data, identify risks & strengths, formulate diagnostic statements  
Planning   Planning Prioritize,formulate goals and outcomes,select interventions, write orders  
Implementing   Implementing reassess,implement interventions,delegate,document  
Evaluating   Evaluating compare data to outcomes, draw conclusions, modify care plan  
subjective data   subjective data symptoms only the pt. can verify  
objective data   objective data signs detectable to observer  
directive interview   directive interview highly structured, elicits specific info  
Non directive interview   Non directive interview rapport building interview  
Cephalo caudal approach   Cephalo caudal approach head to toe approach  
Maslow's Theory   Maslow's Theory hierarchy of needs  
validation   validation double checking data to confirm accuracy  
cues   cues what pt. says or nurse sees  
inferences   inferences nurses interpretation  
diagnosis   diagnosis statement regarding the nature of problem  
risk factors diagnosis   risk factors diagnosis indicates a problem that could develop  
wellness diagnosis   wellness diagnosis readiness for enhancement of wellness  
possible diagnosis   possible diagnosis evidence is incomplete  
syndrome diagnosis   syndrome diagnosis associated with a cluster of other diagnoses  
diagnostic 3 part statement diagnostic 3 part statement PES  
Problem   Problem statement of clients response  
Etiology   Etiology factors contributing to probable cause of response  
Signs and Symptoms   Signs and Symptoms defining characteristics manifested by pt.  
nursing intervention   nursing intervention any treatment based on clinical judgment that a nurse performs  
formal care plan   formal care plan written or computerized guide  
informal care plan   informal care plan strategy that exists in the nurses mind  
standardized care plan   standardized care plan formal plan for all individuals with same etiology  
individualized care plan   individualized care plan tailored for specific pt.  
Nursing Care Classification (NOC) standardized nursing language indicator   Nursing Care Classification (NOC) standardized nursing language indicator concrete observable state of behavior  
Using Silence   Using Silence Accepting pauses or silences that may last several seconds or minutes without any verbal response.  
Sitting quietly (or walking with PT) and waiting attentively until client is able to put thoughts and fments or questions that (a) encourage the client to verbalize, (b) choose a topic of conversation, and feelings into words   Sitting quietly (or walking with PT) and waiting attentively until client is able to put thoughts and fments or questions that (a) encourage the client to verbalize, (b) choose a topic of conversation, and feelings into words Using Silence (example)
Providing general leads   Providing general leads Using statements or questions that (a) encourage the client to verbalize, (b) choose a topic of conversation, and facilitate continued verbalization.  
"Perhaps you would like to talk about..." ; "would it help to discuss your feelings?"; "and then...."; "I know what you are saying"   "Perhaps you would like to talk about..." ; "would it help to discuss your feelings?"; "and then...."; "I know what you are saying" Providing General leads (example)  
Using specific and tentative   Using specific and tentative making statements that are specific rather than general, tentative rather than absolute  
"You scratched my arm" instead of "you are clumsy as an ox" OR "you seem concerned about mary" rather than "you don't care about mary"   "You scratched my arm" instead of "you are clumsy as an ox" OR "you seem concerned about mary" rather than "you don't care about mary" Specific & Tentative (examples)  
Open-ended question   Open-ended question ASKING BROAD QUESTIONS that lead or invite the client to explore, elaborate, clarify, define, and describe thoughts or feelings. Client's answers are longer than 1 or 2 words  
"I'd like to hear more about that"; "What brought you to the hospital today?"; "you said you were frightened yesterday, how are you feeling today?"   "I'd like to hear more about that"; "What brought you to the hospital today?"; "you said you were frightened yesterday, how are you feeling today?" Open-ended question (example)  
Using Touch   Using Touch Providing appropriate forms of touch to reinforce caring feelings.  
Putting arm over client's shoulder OR placing hand over client's hand   Putting arm over client's shoulder OR placing hand over client's hand Using touch (example)  
Restating   Restating using the same words as the client  
Client: "I couldn't manage to eat any dinner last night- not even dessert" Nursing- "you couldn't manage to eat any dinner last night- not even dessert?"   Client: "I couldn't manage to eat any dinner last night- not even dessert" Nursing- "you couldn't manage to eat any dinner last night- not even dessert?" Restating (example)  
Paraphrasing   Paraphrasing Restating in different form with implied feeling or observation  
Client: " I have trouble talking to strangers" Nurse "You find it difficult talking to people you don't know"   Client: " I have trouble talking to strangers" Nurse "You find it difficult talking to people you don't know" Paraphrasing (example)  
Seeking clarification   Seeking clarification Making the clients overall meaning of the msg understandable. It is used when paraphrasing is difficult or when communication is rambling or garbled. To clarify, the RN may restate the msg or confess confusion & ask PT to repeat
Nurse: "I'm puzzled" Nurse: "I'm not sure what you mean by ___ Would you please repeat that again?"   Nurse: "I'm puzzled" Nurse: "I'm not sure what you mean by ___ Would you please repeat that again?" Seeking Clarification (example)  
Perception Checking/ Consensual Validation   Perception Checking/ Consensual Validation A method similar to clarifying that verifies the meaning of specific words rather than the overall message  
C: "it just won't stop" N: "I'm not sure what you mean - it won't stop" OR C: "my husband never gives me presents" N: "He never gives you gifts for your birthday or christmas?" C: "it just won't stop" N: "I'm not sure what you mean - it won't stop" OR C: "my husband never gives me presents" N: "He never gives you gifts for your birthday or christmas?" Perception Checking/ Consensual Validation (example)  
Offering Self   Offering Self Suggesting ones' presence, interest, or wish to understand the client without making any depands or attaching conditions that the client must comply with to receive nurse's attention  
"I'll stay with you till your daughter arrives"; "we can sit here quietly for awhile, we don't need to talk unless you would like to"   "I'll stay with you till your daughter arrives"; "we can sit here quietly for awhile, we don't need to talk unless you would like to" Offering Self (example)  
Giving Information   Giving Information Providing, in simple and direct manner, specific factual information the client may or may not request. When information is not known, the nurse states this and indicates how the nurse will obtain the information.  
"Your surgery is scheduled for 11am tomorrow"; I don't know the answer to that, but I'll find out from the unit manager, when she comes in"   "Your surgery is scheduled for 11am tomorrow"; I don't know the answer to that, but I'll find out from the unit manager, when she comes in" Giving information (example)  
Acknowledging   Acknowledging Giving recognition, in non judgmental way, of change in behavior.  
"You trimmed your beard and mustache" OR "you walked twice as far today with your walker"   "You trimmed your beard and mustache" OR "you walked twice as far today with your walker" Acknowledging (example)  
Clarifying time or sequence   Clarifying time or sequence Helping the client clarify and event, situation, or happening in relationship to time  
C: "I puked this morning" N: "before or after breakfast?"   C: "I puked this morning" N: "before or after breakfast?" Clarifying time or sequence(example)  
It is a style or process of persuading a group of people, usually his followers to attain a desired objective.   It is a style or process of persuading a group of people, usually his followers to attain a desired objective. Leadership  
A leader that is chosen by the administration or a group which are given the official capacity to act.   A leader that is chosen by the administration or a group which are given the official capacity to act. Formal / appointed / elected / designated  
A leader that does not have official appointments or designations but is usually chosen by the group itself.   A leader that does not have official appointments or designations but is usually chosen by the group itself. Informal  
It states that leaders are born and not developed because some people are born with characteristics to be great.   It states that leaders are born and not developed because some people are born with characteristics to be great. Great Man Theory  
A person can be an effective leader if he has all the intellectual, emotional, physical and other personal traits of an effective leader.   A person can be an effective leader if he has all the intellectual, emotional, physical and other personal traits of an effective leader. Trait Theory  
He is a leader who makes other people feel better in his/her presence which is an inspirational quality that the leader possessed.   He is a leader who makes other people feel better in his/her presence which is an inspirational quality that the leader possessed. Charismatic Theory  
It states that there is no personality, traits to be a good leader, but rather leadership is the relationship that exists among people in a social situation.   It states that there is no personality, traits to be a good leader, but rather leadership is the relationship that exists among people in a social situation. Situational Theory  
A leader that can immediately resolve a sudden crisis, emergency or critical situation.   A leader that can immediately resolve a sudden crisis, emergency or critical situation. Contingency Theory  
A leader that knows how to determine the maturity of his followers.   A leader that knows how to determine the maturity of his followers. Life-Cycle Theory  
A leader who uses a support system method.   A leader who uses a support system method. Path Goal Theory  
A style where the leader makes all the decisions and disallows his members to influence him. Followers dislike this leader and leader has little trust to his members. His aim is to develop Self. Uses trial & error and a critic.   A style where the leader makes all the decisions and disallows his members to influence him. Followers dislike this leader and leader has little trust to his members. His aim is to develop Self. Uses trial & error and a critic. Authoritarian  
A leadership style where it is loose and permissive. His approach is "Do your own thing". His reference is "You" and has the desire to develop only "Friendship".   A leadership style where it is loose and permissive. His approach is "Do your own thing". His reference is "You" and has the desire to develop only "Friendship". Laissez-Faire  
A leader whose authority is from the group. Gives importance to participation, involvement and development of the group. He is a helper and uses "We" as his reference of leadership.   A leader whose authority is from the group. Gives importance to participation, involvement and development of the group. He is a helper and uses "We" as his reference of leadership. Democratic  
A leadership style that uses repetition and tries to develop the system as his objective. His reference is "they" and acts as a ruler and a regulator type of leader.   A leadership style that uses repetition and tries to develop the system as his objective. His reference is "they" and acts as a ruler and a regulator type of leader. Bureaucratic  
A power whereby the leader has the official capacity to exercise rights and demand obligations from subordinates.   A power whereby the leader has the official capacity to exercise rights and demand obligations from subordinates. Legitimate Powers  
I - olfactory (sensory) I - olfactory (sensory) sense of smell  
II - optic  (sensory) II - optic (sensory) visual acuity  
III - oculomotor  (motor) III - oculomotor (motor) extraocular eye movement, pupil constriction and dilation  
IV - trochlear  (motor) IV - trochlear (motor) upward/downward movement of eyeball  
V - trigeminal  (sensory/motor) V - trigeminal (sensory/motor) sensory nerve to skin of face, motor nerve to muscles of jaw  
VI - abducens (motor) VI - abducens (motor) lateral movement of eyeballs  
VII - facial  (sensory/motor) VII - facial (sensory/motor) facial expression, taste  
VIII - auditory  (sensory) VIII - auditory (sensory) hearing  
IX - glossopharyngeal  (sensory/motor) IX - glossopharyngeal (sensory/motor) taste, swallowing  
X - vagus  (sensory/motor) X - vagus (sensory/motor) sensation of pharynx, movement of vocal cords
XI - spinal accessory  (motor) XI - spinal accessory (motor) movement of head and shoulders  
XII - hypoglossal  (motor) XII - hypoglossal (motor) position of tongue  
Trust vs. Mistrust   Trust vs. Mistrust Infancy (0-18 mos)  
Autonomy vs. Shame & Doubt   Autonomy vs. Shame & Doubt Early Childhood (18mos-3yrs)  
Initiative vs. Guilt   Initiative vs. Guilt Preschool (3-6yrs)  
Industry vs. Inferiority   Industry vs. Inferiority School-age (6-12yrs)  
Identity vs. Role Confusion   Identity vs. Role Confusion Adolescence (12-18yrs)  
Intimacy vs. Isolation   Intimacy vs. Isolation Young Adult (18-25yrs)  
Generativity vs. Stagnation   Generativity vs. Stagnation Adulthood (25-45yrs)  
Integrity vs. Despair   Integrity vs. Despair Late Adulthood (45-death)  
Teaching that is Dependent on environment Needs security   Teaching that is Dependent on environment Needs security Infant (0-18mos)  
Teaching focused on Separation anxiety Self exploration Environment   Teaching focused on Separation anxiety Self exploration Environment Infant (0-18mos)
Teaching focused on Natural curiosity Separation Intrusive procedure   Teaching focused on Natural curiosity Separation Intrusive procedure Toddler (18mos-3yrs)  
Teaching focused on Ego Body mutilation (pain) believes illness is self caused & punitive   Teaching focused on Ego Body mutilation (pain) believes illness is self caused & punitive Preschooler (3-6yrs)  
Teaching focused on Limited time Active imagination (animistic thinking, fearful)   Teaching focused on Limited time Active imagination (animistic thinking, fearful) Preschool (3-6yrs)  
Teaching focused on Reality Objectivity Separation anxiety (tries to appear brave)   Teaching focused on Reality Objectivity Separation anxiety (tries to appear brave) School Age (6-12yrs)  
Teaching focused on Cause & effect Concrete Information (passive coping strategy)   Teaching focused on Cause & effect Concrete Information (passive coping strategy) School Age (6-12yrs)  
Teaching focused on Abstract hypothetical thinking Logic & scientific principles   Teaching focused on Abstract hypothetical thinking Logic & scientific principles Adolescence (12-18yrs)  
Teaching focused on Body image Self esteem & identity (feel invincible)   Teaching focused on Body image Self esteem & identity (feel invincible) Adolescence (12-18yrs)  
Teaching focused on Autonomy Self direction Critical thinking   Teaching focused on Autonomy Self direction Critical thinking Young adult (18-25yrs)  
Teaching focused on Competency based learner (can make decision personally & socially)   Teaching focused on Competency based learner (can make decision personally & socially) Young Adult (18-25yrs)  
Teaching focused on Physical changes Alternative lifestyle Sense of well developed (questions achievements & contributions to family & society, confident)   Teaching focused on Physical changes Alternative lifestyle Sense of well developed (questions achievements & contributions to family & society, confident) Middle Adult (25-45yrs)  
Teaching focused on Cognitive & physical changes No formal learning (decreased S.T.M., risk taking, easily fatigue)   Teaching focused on Cognitive & physical changes No formal learning (decreased S.T.M., risk taking, easily fatigue) Older Adult (45-death)  
For a hospitalized Child, focus on   For a hospitalized Child, focus on Separation  
For a hospitalized Toddler, focus on   For a hospitalized Toddler, focus on Separation & Intrusive procedure  
For a hospitalized Preschooler, focus on   For a hospitalized Preschooler, focus on Body mutilation & Pain  
For a hospitalized School-age, focus on   For a hospitalized School-age, focus on Loss of control  
For a hospitalized Adolescent, focus on   For a hospitalized Adolescent, focus on Body image  
PRE-OPERATIVE CARE, a parent or a legal may sign the consent of a MINOR, while the OLDER client may need whom? Legal Guardian
PRE-OPERATIVE CARE, a nurse can be a witness in consent signing & document the same only if the client understood surgeon's explanations and the client? Acknowledges understanding of the procedure
PRE-OPERATIVE CARE, NPO is 6-8 hrs. before Gen. Anesthesia, while for Local Anesthesia is? 3 hours before surgery
PRE-OPERATIVE CARE, prepare ___ administration for malnourished, with protein or metabolic deficiencies or cannot ingest food client. Total Parenteral Nutrition
PRE-OPERATIVE CARE, if client has a Foley Catheter, drain before the surgery and note the? Amount of urine & characteristics
PRE-OPERATIVE CARE, what do you use to clean the surgical site? Mild Antiseptic Soap
PRE-OPERATIVE CARE (client teaching), inform the client what to expect POST-OP like pain & discomfort, and that he/she can request what? Narcotic Drugs as pain reliever, note it will not make the client an addict to such
PRE-OPERATIVE CARE (client teaching), demonstrate what to the client? Patient Controlled Analgesic (PCA)
PRE-OPERATIVE CARE (client teaching), instruct not to what? 24 hours before the surgery. Smoke
PRE-OPERATIVE CARE (client teaching), instruct to do Deep Breathing & Coughing Exercises, use of Incentive Spirometry for the prevention of? Pneumonia & Atelactasis
PRE-OPERATIVE CARE (client teaching), instruction of let & foot exercises will prevent what? Facilitate what? Venous Stasis / Venous blood return
PRE-OPERATIVE CARE (client teaching), instruct the client on how to splint an incision by? Placing a pillow, or one hand with the other hand on top, over the incisional area.
PRE-OPERATIVE CARE (checklist), ensure the client is wearing identification bracelet and assess for what? Allergies for latex
PRE-OPERATIVE CARE (checklist), ensure that informed consent forms were signed for the operative procedure and for what other reasons? PRE-OPERATIVE CARE (checklist), ensure that informed consent forms were signed for the operative procedure and for what other reasons? Blood transfusions, disposal of a limb, or for surgical sterilization procedures.
PRE-OPERATIVE CARE (checklist), ensure that history, P.E., consultation requests, prescribed laboratory results, EKG, chest radiography are documented & recorded plus? PRE-OPERATIVE CARE (checklist), ensure that history, P.E., consultation requests, prescribed laboratory results, EKG, chest radiography are documented & recorded plus? Blood type, screened & cross matching is performed.
PRE-OPERATIVE CARE (checklist), after removing everything unnecessary, documented it, kept or given to family members, the nurse must document the? PRE-OPERATIVE CARE (checklist), after removing everything unnecessary, documented it, kept or given to family members, the nurse must document the? Last time client ate or drank, voided before surgery, medications given prior surgery then monitor V.S.
PRE-OPERATIVE CARE (medications), instruct client about the desired effects and then what? PRE-OPERATIVE CARE (medications), instruct client about the desired effects and then what? Keep client in bed with side rails up.
PRE-OPERATIVE CARE (medications), after administering medications, next to the client, place what? PRE-OPERATIVE CARE (medications), after administering medications, next to the client, place what? Call bell, instruct client not to get out of bed and call for assistance if needed
PRE-OPERATIVE CARE (inside O.R.), after verifying identification bracelet & verbal response, the nurse will review chart and then confirm what? PRE-OPERATIVE CARE (inside O.R.), after verifying identification bracelet & verbal response, the nurse will review chart and then confirm what? Operative procedure & site
PRE-OPERATIVE CARE (inside O.R.), the clients chart will be reviewed for completeness and taking a note about what? PRE-OPERATIVE CARE (inside O.R.), the clients chart will be reviewed for completeness and taking a note about what? Allergic reactions information
POST-OPERATIVE CARE (immediate), what is the period of this stage? POST-OPERATIVE CARE (immediate), what is the period of this stage? 1-4 hours after surgery
POST-OPERATIVE CARE (immediate), monitor airway patency & adequate ventilation because prolonged mechanical ventilation during anesthesia may affect what? POST-OPERATIVE CARE (immediate), monitor airway patency & adequate ventilation because prolonged mechanical ventilation during anesthesia may affect what? Postoperative Lung function, extubated patients may not be able to maintain airway
POST-OPERATIVE CARE (immediate), the client maybe unable to clear his/her airway, that is why it is important to monitor what? POST-OPERATIVE CARE (immediate), the client maybe unable to clear his/her airway, that is why it is important to monitor what? Secretions
POST-OPERATIVE CARE (immediate), encourage Deep Breathing & Coughing exercises, monitor pulse oximetry, O2 administration and then observer for? POST-OPERATIVE CARE (immediate), encourage Deep Breathing & Coughing exercises, monitor pulse oximetry, O2 administration and then observer for? Chest movements for symmetry and use of accessory muscles.
POST-OPERATIVE CARE (immediate), note rate, depth & quality of respirations, RR should be? POST-OPERATIVE CARE (immediate), note rate, depth & quality of respirations, RR should be? >10 and not <30 BPM
POST-OPERATIVE CARE (immediate), a breath sound of stridor, wheezing or crowing indicates what? POST-OPERATIVE CARE (immediate), a breath sound of stridor, wheezing or crowing indicates what? Partial obstruction, bronchospasm, laryngospasm
POST-OPERATIVE CARE (immediate), a breath sound of crackles or ronchi may indicate? POST-OPERATIVE CARE (immediate), a breath sound of crackles or ronchi may indicate? Pulmonary Edema, monitor signs of Atelectasis or Pulmonary embolism
POST-OPERATIVE CARE (immediate), check capillary refill, assess the skin, peripheral pulses & edema and monitor for bleeding. A bounding pulse may indicate what? POST-OPERATIVE CARE (immediate), check capillary refill, assess the skin, peripheral pulses & edema and monitor for bleeding. A bounding pulse may indicate what? Hypertension, Fluid overload, or excitement.
POST-OPERATIVE CARE (immediate), unless contraindicated, client is placed on Fowler's position after surgery to increase? POST-OPERATIVE CARE (immediate), unless contraindicated, client is placed on Fowler's position after surgery to increase? Size of the thorax for lung expansion
POST-OPERATIVE CARE (immediate), what type of positioning is avoided if the pharyngeal reflexes have not yet returned? POST-OPERATIVE CARE (immediate), what type of positioning is avoided if the pharyngeal reflexes have not yet returned? Supine
POST-OPERATIVE CARE (immediate), if comatose or semicomatose, what type of positioning? POST-OPERATIVE CARE (immediate), if comatose or semicomatose, what type of positioning? Side lying & keep an oral airway in place.
POST-OPERATIVE CARE (immediate), assess L.O.C., wake client periodically until awaken and if awaken? POST-OPERATIVE CARE (immediate), assess L.O.C., wake client periodically until awaken and if awaken? Orient client to the environment in a soft tone
POST-OPERATIVE CARE (immediate), main body temperature and prevent heat loss by? POST-OPERATIVE CARE (immediate), main body temperature and prevent heat loss by? Blanketing & raise room temperature
POST-OPERATIVE CARE (immediate), an exposed skin, cool OR, or maybe from anesthesia may result to? POST-OPERATIVE CARE (immediate), an exposed skin, cool OR, or maybe from anesthesia may result to? Hypothermia, keep blanket on & continue O2 if shivering
POST-OPERATIVE CARE (immediate), assess surgical site, drains & wound dressings for? POST-OPERATIVE CARE (immediate), assess surgical site, drains & wound dressings for? Redness, abrasions or breakdown
POST-OPERATIVE CARE (immediate), record I&O, monitor for Fluid & Electrolyte imbalance, N&V, NGT patency, abdominal distention and the return of what? POST-OPERATIVE CARE (immediate), record I&O, monitor for Fluid & Electrolyte imbalance, N&V, NGT patency, abdominal distention and the return of what? Bowel sounds
POST-OPERATIVE CARE (immediate), how many hours is it that the client is expected to void urine after the surgery? POST-OPERATIVE CARE (immediate), how many hours is it that the client is expected to void urine after the surgery? 6-8 hours, note color, quantity & quality
POST-OPERATIVE CARE (immediate), assess for pain, PRE-OP & POST-OP medz, then inquire about the type & location of pain by asking the client to? POST-OPERATIVE CARE (immediate), assess for pain, PRE-OP & POST-OP medz, then inquire about the type & location of pain by asking the client to? Rate the pain from 1-10, note facial expression, body gestures, increase PR, BP & RR.
POST-OPERATIVE CARE (immediate), inquire effectiveness of last medication, if on a Narcotic drug, assess every 30 minutes for? POST-OPERATIVE CARE (immediate), inquire effectiveness of last medication, if on a Narcotic drug, assess every 30 minutes for? RR & pain relief
POST-OPERATIVE CARE (intermediate), how many hours is this stage after surgery? POST-OPERATIVE CARE (intermediate), how many hours is this stage after surgery? 4-24 hours
POST-OPERATIVE CARE (intermediate), monitor airway patency, encourage Deep Breathing & Coughing exercises, monitor circulatory status encourage the use of what? POST-OPERATIVE CARE (intermediate), monitor airway patency, encourage Deep Breathing & Coughing exercises, monitor circulatory status encourage the use of what? Antiembolism stockings if not C/I
POST-OPERATIVE CARE (intermediate), assess for mobility on all extremities & encourage early ambulation by first sitting on the edge of the bed with feet supported. But if client is unable to move, what do you do next? POST-OPERATIVE CARE (intermediate), assess for mobility on all extremities & encourage early ambulation by first sitting on the edge of the bed with feet supported. But if client is unable to move, what do you do next? Turn the client every 1-2 hours.
POST-OPERATIVE CARE (intermediate), reinforce wound with sterile dressing if necessary and always keep it? POST-OPERATIVE CARE (intermediate), reinforce wound with sterile dressing if necessary and always keep it? Dry & intact, notify physician if bleeding occurs
POST-OPERATIVE CARE (intermediate), monitor I&O, N&V and if vomiting, have a suctioning equipment available and ready to use. NPO status is observed until? POST-OPERATIVE CARE (intermediate), monitor I&O, N&V and if vomiting, have a suctioning equipment available and ready to use. NPO status is observed until? Gag reflex & peristalsis returns
POST-OPERATIVE CARE (intermediate), when oral fluids are permitted, start with? POST-OPERATIVE CARE (intermediate), when oral fluids are permitted, start with? Ice chips & water, then advance to Clear Liquids up to Regular Diet as prescribed
POST-OPERATIVE CARE (intermediate), after NPO order is lifted, what do you assess for? POST-OPERATIVE CARE (intermediate), after NPO order is lifted, what do you assess for? Bowel sounds on all four quadrants
POST-OPERATIVE CARE (intermediate), how many mL per hour should a client void? POST-OPERATIVE CARE (intermediate), how many mL per hour should a client void? Should be > 30 mL/hr
POST-OPERATIVE CARE (intermediate), if with Foley Catheter, client is expected to void within 6-8 hours. Ensure that the amount is at least? POST-OPERATIVE CARE (intermediate), if with Foley Catheter, client is expected to void within 6-8 hours. Ensure that the amount is at least? 200mL
POST-OPERATIVE CARE (extended), what is the period of this stage? POST-OPERATIVE CARE (extended), what is the period of this stage? 1-4 hours after surgery
POST-OPERATIVE CARE (extended), on this stage, you monitor for signs of infection such as? POST-OPERATIVE CARE (extended), on this stage, you monitor for signs of infection such as? Redness, swelling, & tenderness at the surgical site, fever & leukocytes
POST-OPERATIVE CARE (extended), the client is advised to do R.O.M. exercises every 2 hours and encourage ambulation to promote? POST-OPERATIVE CARE (extended), the client is advised to do R.O.M. exercises every 2 hours and encourage ambulation to promote? Peristalsis & passage of flatus
POST-OPERATIVE CARE (extended), the client is encouraged to perform A.D.L. & eat foods that will promote wound healing. What are the foods? POST-OPERATIVE CARE (extended), the client is encouraged to perform A.D.L. & eat foods that will promote wound healing. What are the foods? Protein & Vitamin C
Inflammation of the alveoli caused by an infectious process that may develop as a result of infection, aspiration or immobility? Inflammation of the alveoli caused by an infectious process that may develop as a result of infection, aspiration or immobility? Pneumonia, usually around 3-5 days postoperatively
Collapse of the alveoli with retained mucous secretions and is the most common postoperative complication? Collapse of the alveoli with retained mucous secretions and is the most common postoperative complication? Atelectasis, usually around 1-2 days postoperatively
POST-OPERATIVE CARE (Pneumonia & Atelectasis) Assessment / increase risk for dyspnea/ elevated temperature/ productive cough/ and what more? POST-OPERATIVE CARE (Pneumonia & Atelectasis) Assessment / increase risk for dyspnea/ elevated temperature/ productive cough/ and what more? Increased R.R. & chest pain
POST-OPERATIVE CARE (Pneumonia & Atelectasis) Nsg Inter / assess for lung & breath sounds/ reposition client every 1-2 hour/ inc O.F.I. / early ambulation and what more? POST-OPERATIVE CARE (Pneumonia & Atelectasis) Nsg Inter. / assess for lung & breath sounds/ reposition client every 1-2 hour/ inc O.F.I. / early ambulation and? Deep breathing & coughing exercises/ incentive spirometer/ chest physio/ postural drainage
An inadequate concentration of oxygen in arterial blood? An inadequate concentration of oxygen in arterial blood? Hypoxia
POST-OPERATIVE CARE (Hypoxia) Assessment / cyanosis/ dyspnea/ hypertension/ tachycardia and what else? POST-OPERATIVE CARE (Hypoxia) Assessment / cyanosis/ dyspnea/ hypertension/ tachycardia and what else? Restlessness & Diaphoresis
POST-OPERATIVE CARE (Hypoxia) Nursing Intervention, monitor signs of hypoxia/ eliminate cause/ monitor lung sounds/ administer oxygen/ D.B. & C. E. and what more? POST-OPERATIVE CARE (Hypoxia) Nursing Intervention, monitor signs of hypoxia/ eliminate cause/ monitor lung sounds/ administer oxygen/ D.B. & C. E. and what more? Monitor pulse oximetry & reposition client
It blocks the pulmonary artery and disrupts blood flow to one or more lobes of the lung? It blocks the pulmonary artery and disrupts blood flow to one or more lobes of the lung? Pulmonary Embolism
POST-OPERATIVE CARE (Pulmonary Embolism) Assessment / dyspnea/ cyanosis/ tachycardia and what more else? POST-OPERATIVE CARE (Pulmonary Embolism) Assessment / dyspnea/ cyanosis/ tachycardia and what more else? Decreased blood pressure & sudden chest or upper abdominal pain
POST-OPERATIVE CARE (Pulmonary Embolism) Nursing Intervention / what is the first thing that you should do? POST-OPERATIVE CARE (Pulmonary Embolism) Nursing Intervention / what is the first thing that you should do? 1)Notify the physician 2)Monitor V.S. 3)Administer O2 & medications
Loss of large amount of blood externally or internally in a short time? Loss of large amount of blood externally or internally in a short time? Hemorrhage
POST-OPERATIVE CARE (Hemorrhage) Assessment / restlessness/ hypotension/ cool, clammy skin and what other else? POST-OPERATIVE CARE (Hemorrhage) Assessment / restlessness/ hypotension/ cool, clammy skin and what other else? Weak rapid pulse & reduced urine output
POST-OPERATIVE CARE (Hemorrhage) Nursing Intervention / provide pressure to the site of bleeding immediately and then what? POST-OPERATIVE CARE (Hemorrhage) Nursing Intervention / provide pressure to the site of bleeding immediately and then what? Notify the physician, administer O2, IV fluids & blood as prescribed & lastly prepare client for surgery if needed
Loss of circulatory fluid volume, which usually is caused by hemorrhage? Loss of circulatory fluid volume, which usually is caused by hemorrhage? Shock
POST-OPERATIVE CARE (Shock) Assessment / / restlessness/ hypotension/ cool, clammy skin and what other else? POST-OPERATIVE CARE (Shock) Assessment / / restlessness/ hypotension/ cool, clammy skin and what other else? Weak rapid pulse & reduced urine output
POST-OPERATIVE CARE (Shock) Nursing Intervention / elevate legs only if the client did not have Spinal Anesthesia/ determine & treat cause of shock/ administer O2/ monitor V.S., L.O.C./ monitor I & O. and what if the client had Spinal Anesthesia? POST-OPERATIVE CARE (Shock) Nsg Inter / elevate legs (w/o Spinal Anes.)/ treat cause of shock/ adm. O2/ monitor V.S., L.O.C./ monitor I&O. & if client had Spinal Anes.? Elevate legs not higher than pillow/ assess skin turgor, moisture and mucous membra
Inflammation of a vein, leg veins commonly affected, often accompanied by clot formation? Inflammation of a vein, leg veins commonly affected, often accompanied by clot formation? Thrombophlebitis
POST-OPERATIVE CARE (Thrombophlebitis) Assessment / vein inflammation/ aching or cramping pain/ elevated temperature and what? POST-OPERATIVE CARE (Thrombophlebitis) Assessment / vein inflammation/ aching or cramping pain/ elevated temperature and what? (+) Homan's Sign
POST-OPERATIVE CARE (Thrombophlebitis) Nursing Intervention / monitor leg/ encourage antiembolism stockings – removed 2x/day for washing & inspection of leg/ give heparin sodium or warfarin (coumadin)/ the leg is elevated by 30 degrees & do not? Apply pressure on popliteal area. No leg dangling & sitting on one position for long periods
Involuntary accumulation of urine in the bladder as a result of loss of muscle tone? Involuntary accumulation of urine in the bladder as a result of loss of muscle tone? Urinary Retention
POST-OPERATIVE CARE (Urinary Retention) Assessment / inability to void/ restlessness & diaphoresis/ lower abdominal pain/ distended bladder and what else? POST-OPERATIVE CARE (Urinary Retention) Assessment / inability to void/ restlessness & diaphoresis/ lower abdominal pain/ distended bladder and what else? Hypertension & Drumlike sound upon bladder percussion
POST-OPERATIVE CARE (Thrombophlebitis) Nursing Intervention / monitor voiding/ assess distended bladder/ encourage inc. O.F.I./ provide privacy and what? Pour warm water on the perinium, allow pt to hear running water then CATHETERIZE if all non invasive attempts fail
Failure of appropriate forward movement of bowel contents and maybe due to anesthetic medications or manipulation of the bowel during the surgical procedure? Failure of appropriate forward movement of bowel contents and maybe due to anesthetic medications or manipulation of the bowel during the surgical procedure? Paralytic Ileus
POST-OPERATIVE CARE (Paralytic Ileus) Assessment / abdominal distention/ absence of bowel sounds, bowel movement or flatus, what is the first indication of this condition? POST-OPERATIVE CARE (Paralytic Ileus) Assessment / abdominal distention/ absence of bowel sounds, bowel movement or flatus, what is the first indication of this condition? Nausea & Vomiting immeidately postoperatively
POST-OPERATIVE CARE (Paralytic Ileus) Nursing Intervention / monitor I & O/ maintain NPO until bowel sounds return/ patency of NGT/ early ambulation/ administer IVF or TPN, medications and what is the noninvasive action? NGT insertion and connected to intermittent or constant suction for bowel decompression
Caused by poor aseptic technique or a contaminated wound before surgical exploration? Caused by poor aseptic technique or a contaminated wound before surgical exploration? Wound Infection
POST-OPERATIVE CARE (Wound Infection) Assessment / fever & chills/ edematous skin at incision site & tight skin sutures/ increased WBC and what is the order of the inflamed incision site? POST-OPERATIVE CARE (Wound Infection) Assessment / fever & chills/ edematous skin at incision site & tight skin sutures/ increased WBC and what is the order of the inflamed incision site? 1)Warm, 2)Tender, 3)Painful
POST-OPERATIVE CARE (Wound Infection) Nursing Intervention / monitor temperature/ maintain patency of drains & note amount, color, consistency/ change dressing/ give antibiotics and what are the signs of infection? REEDA- Redness, Erythema, Ecchynosis, Drainage, Approximation for wound edges
Separation of the wound edges at the suture line? Separation of the wound edges at the suture line? Wound Dehiscence, usually occurs 6-8 days after
POST-OPERATIVE CARE (Wound Dehiscence) Assessment / increased drainage/ opened wound edges and? Appearance of underlying tissues through the wound
POST-OPERATIVE CARE (Wound Dehiscence) Nursing Intervention / low Fowler's position to avoid abdominal tension/ cover with NSS dressing and then immediately? Notify physician & prevent wound infection, antiemetics is given to avoid abdominal tension as well, splint incision when coughing
Protrusion of internal organs through an incision. Common on obese, with past abd. surgery or who have poor wound healing. Protrusion of internal organs through an incision. Common on obese, with past abd. surgery or who have poor wound healing. Wound Evisceration, usually occurs 6-8 days after. It is an Emergency
POST-OPERATIVE CARE (Wound Evisceration) Assessment / serosanguinous discharge from dry wound/ with loops of bowel or other abdominal contents through the wound and the client is reporting? POST-OPERATIVE CARE (Wound Evisceration) Assessment / serosanguinous discharge from dry wound/ with loops of bowel or other abdominal contents through the wound and the client is reporting? A feeling of popping after coughing or turning
POST-OPERATIVE CARE (Wound Evisceration) Nursing Intervention / Fowler's position/ cover wound with sterile NSS and ? POST-OPERATIVE CARE (Wound Evisceration) Nursing Intervention / Fowler's position/ cover wound with sterile NSS and ? Notify DR & prevent wound infection, antiemetics is given to avoid abdominal tension as well, splint incision when coughing
In ambulatory surgery, the criteria for client discharge are the following, he/she is alert and oriented/ has voided/ not in respiratory distress/ vomiting & in minimal pain and also the client is able to? In ambulatory surgery, the criteria for client discharge are the following, he/she is alert and oriented/ has voided/ not in respiratory distress/ vomiting & in minimal pain and also the client is able to? Ambulate, swallow & cough
POST-OPERATIVE CARE (Discharging) assess pt's readiness to learn, educ. level, & desire modify lifestyle/ demo incision care/ written guide to pt & family &? POST-OPERATIVE CARE (Discharging) assess pt's readiness to learn, educ. level, & desire modify lifestyle/ demo incision care/ written guide to pt & family &? Instruct PT to cover incision with plastic when showering & give a 48 hour of dressing suppl
Formula for IV Calculations Formula for IV Calculations CC's per hour X Drop Factor / 60
Ordered 1000 cc 5% D/ 0.45 NS at 100cc/hr. Drop factor is 60 Ordered 1000 cc 5% D/ 0.45 NS at 100cc/hr. Drop factor is 60 100
Ordered: 1500 ML0.9% NS to infuse 90 cc/hr. Drop Factor: 20 gtt/ml Ordered: 1500 ML0.9% NS to infuse 90 cc/hr. Drop Factor: 20 gtt/ml 30
ORDERED: Ampicillin 500 mg in 50 cc 0.9% NS to infuse 1hour. Drop Factor: 10 gtts/ml ORDERED: Ampicillin 500 mg in 50 cc 0.9% NS to infuse 1hour. Drop Factor: 10 gtts/ml 8
Ordered 1250 cc 2.5 % D/W to infuse from 12 noon to 6 pm. The Drop Factor is 15 gtts/ml. Ordered 1250 cc 2.5 % D/W to infuse from 12 noon to 6 pm. The Drop Factor is 15 gtts/ml. 52
ORDERED: 1000 cc RLS adn 1000 cc 5% D/LRS and 1000 cc 0.9% NS to infuse over 24 hours. DROP FACTOR: 12 gtt/ml ORDERED: 1000 cc RLS adn 1000 cc 5% D/LRS and 1000 cc 0.9% NS to infuse over 24 hours. DROP FACTOR: 12 gtt/ml 25
ORDERED: 1000 cc 5%D/0.45% NS with 40 mEq of KCL to infuse in 8 hours. DROP FACTOR: 12 gtts / ml ORDERED: 1000 cc 5%D/0.45% NS with 40 mEq of KCL to infuse in 8 hours. DROP FACTOR: 12 gtts / ml 25
ORDERED: An infant weighs 18 # has an IV of 500 cc 10% D/W to infuse over 24 hours. DROP FACTOR: 60 gtts/ml ORDERED: An infant weighs 18 # has an IV of 500 cc 10% D/W to infuse over 24 hours. DROP FACTOR: 60 gtts/ml 20-21
___% of the average adult's weight is fluid ___% of the average adult's weight is fluid 60%
Intracellular fluids (ICF) Intracellular fluids (ICF) all fluid w/in body cells
What % of body weight is ICF? What % of body weight is ICF? 40%
Extracellular fluid (ECF) Extracellular fluid (ECF) fluid outside of a cell; divided into 3 parts, Interstitial fluid, intravascular fluid, and transcellular fluids
What % of ECF makes up body weight? What % of ECF makes up body weight? 20%
What is interstitial fluid? What is interstitial fluid? contains lymph, fluid between cells and outside blood vessels
What is Intravascular fluid? What is Intravascular fluid? blood plasma
Electrolytes Electrolytes minerals or salts; when melted or dissolved in water it separates into ions and is able to carry an electrical current
Cation Cation + charged electrolytes EX: Na+ K+ Ca+
Anion Anion - charged electrolytes EX: Cl- HCO3- SO4-
Solute Solute dissolvable in water
Solvent Solvent dissolvable in plasma
Osmosis Osmosis movement of a pure solvent, through a semipermeable membrane, from an area of lesser solute concentration to an area of greater solute concentration to try to equalize concentrations on both sides of a membrane
Osmotic pressure is: Osmotic pressure is: the drawing power for water & depends on the number of molecules in solution
A solution with the same osmolarity as blood plasma is called: A solution with the same osmolarity as blood plasma is called: isotonic
Movement of a solute in a solution across a semipermeable membrane from an area of higher concentration to an area of lower concentration is: Movement of a solute in a solution across a semipermeable membrane from an area of higher concentration to an area of lower concentration is: diffusion
Filtration Filtration water and diffusable substances move together in response to fluid pressure, moving from an area of higher pressure to an area of lower pressure
Hydrostatic pressure Hydrostatic pressure movement of water from interstitial space into the intravascular space by filtration
Increased hydrostatic pressure causes what? Increased hydrostatic pressure causes what? edema, as with CHF
Active transport Active transport movement of materials across cell membranes requiring metabolic activity
Homeostasis Homeostasis physiological balance
Osmoreceptors Osmoreceptors continually monitor the serum osmotic pressure, when osmolality increases, hypothalamus is stimulated
ADH ADH Antidiuretic hormone; stored in pituitary gland; works directly on kidney tubules and collecting ducts making them more permeable which returns water to systemic circulation
Aldosterone Aldosterone released by adrenal cortex in response to increased K+ levels; it increases the reabsorption of Na+ and secretion of K+
Insensible water loss Insensible water loss continuous and not perceived by person
Sensible water loss Sensible water loss through excessive perspiration
The lungs expire____ml of water a day The lungs expire____ml of water a day 400ml
What are the major cations? What are the major cations? Na+ K+ Ca+ Ions
What are the major anions? What are the major anions? chloride, bicarbonate, phosphate
__% of sodium is in the ECF? Function of Na+? __% of sodium is in the ECF? Function of Na+? 90%, maintain water balance
__% of K+ in ECF. What's it's function? __% of K+ in ECF. What's it's function? 2%; regulates metabolic activity
1% of Ca+ is in blood, 99% in bone; what is the function? 1% of Ca+ is in blood, 99% in bone; what is the function? blood clotting, bone/teeth formation
Magnesium is essential for: Magnesium is essential for: enzyme activities, neurochemical activities, cardiac and skeletal excitability
__% of magnesium in ECF. Na plasma concentration is: __% of magnesium in ECF. Na plasma concentration is: 1%; 1.5-2.5 mEq/L
Bicarbonate, a chemical base buffer, is regulated by: Bicarbonate, a chemical base buffer, is regulated by: the kidneys
Buffer Buffer a substance or group of substances that can absorb or release H+ to correct an acid-base balance
What is the largest chemical buffer in ECF? What is the largest chemical buffer in ECF? carbonic acid and bicarbonate buffer system; reacts to change in pH of ECF within seconds
Biological regulation Biological regulation occurs when H= ions are absorbed and released by cells, occurs only after chemical buffering and takes 2-4 hrs
Fluid volume deficit (FVD) Fluid volume deficit (FVD) water & electrolytes lost in equal or isotonic proportions
Fluid volume excess (FVE) Fluid volume excess (FVE) water and sodium retained in isotonic proportions
Hyperosmolar imbalance Hyperosmolar imbalance dehydration
Hypoosmolar imbalance Hypoosmolar imbalance water excess
TPN or total parenteral nutrition TPN or total parenteral nutrition nutritionally adequate hypertonic solution of glucose, electrolytes, and other nutrients given through an indwelling or central IV
IV fluid and electrolyte therapy IV fluid and electrolyte therapy crystalloids
Colloids Colloids blood and blood component
Vascular access devices include: Vascular access devices include: catheters, cannulas, infusion ports,
the breakdown of RBC's is called: the breakdown of RBC's is called: hemolysis
Autologous transfusion collection of clients own blood (pre-op) Autologous transfusion collection of clients own blood (pre-op) Safest and done before surgery
One of the most common electrolyte imbalances is: One of the most common electrolyte imbalances is: hypokalemia
The client most at risk for FVD's is: The client most at risk for FVD's is: an infant
One reason older adults experience fluid and electrolyte imbalance and acid-base imbalances is they: One reason older adults experience fluid and electrolyte imbalance and acid-base imbalances is they: have a decreased thirst sensation
Output recorded on an I & O record includes: Output recorded on an I & O record includes: urine, diarrhea, vomitus, gastric suction, and drainage from wounds and tubes
Health promotion activities in the area of fluid and electrolyte imbalances focuses primarily on: Health promotion activities in the area of fluid and electrolyte imbalances focuses primarily on: client teaching
TPN is delivered by: TPN is delivered by: indwelling or central IV catheter
As a safety alert the RN is aware the following med is never given directly through IV: As a safety alert the RN is aware the following med is never given directly through IV: Potassium chloride, it will burn the vein
Indications of IV fluid infiltration include: Indications of IV fluid infiltration include: pallor and coolness
CDC recommends replacing peripheral venous catheters and rotating sites should occur at least every: CDC recommends replacing peripheral venous catheters and rotating sites should occur at least every: 72-96 hours
Created by: akosipidro on 2007-08-15



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