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Fundamentals Exam 1
| Question | Answer |
|---|---|
| Safety | freedom from psychological and physical injury prevention of injury |
| Fall | sudden, unintentional change in position, coming to rest on the ground or other lower areas most commonly reported |
| Physical Restraints | Any manual method, physical or mechanical device, or material or equipment that immobilizes or reduces the ability of a patient to move arms, legs, or head freely |
| Chemical Restraint | medications used to alter a patient's behavior Not standard practice |
| Restraint Alternatives | Equipment or device put into place to avoid restraints |
| Restraint ordering | clinically justified, based on a face-to-face assessment, current, detailed (how long, type, why), and renewed as indicated |
| Patient comfort | food, hydration, toileting, and ROM |
| how often are you supposed to check a patient's comfort | every 2 hours |
| patient safety/ sign of an injury | vitals, circulation checks, skin integrity, correct application |
| how often should you check a patients safety | every 15 minutes |
| Which of the following patients is at a grater risk of experimenting a fall? a.) A confused patient with a history of falls b.) A patient who ambulates by holding onto furniture c.) A recently admitted patient d.) A patient who wears readers | a.) a confused patient who has a history of falls |
| Hygiene | impacts a patients comfort, safety, and well-being |
| Purpose of bathing | cleansing skin, stimulates circulation, improves self-image, reduced body odor, and promotes ROM |
| Hygiene is never ____ | routine... everyone is different follow a patients normal day-to-day bathing technique |
| how to bathe direction wise | distal to proximal |
| Mobility | ability to move freely, easily, rhythmically, and purposefully in an environment |
| When a patient can assist in transfer... | widen the base of support, lower center of gravity, and face direction of movement of patient |
| When a patient isn't able to assist in transfer... | divide the work between arms and legs to reduce back injury, leverage/rolling/turning is required |
| Metabolic changes that relate to immobility | decreased appetite equals negative nitrogen balance (weight loss, decreased muscle mass, and weakness), hypercalcimia (pathological fractures), and decreased GI mobility (constipation) |
| Nursing interventions for metabolic changes related to immobility | Check I&O's, monitor food intake, high protein diet and high calorie diet, monitor weight, monitor labs, and monitor elimination |
| Respiratory system that relate to immobility | atelectasis and hypostatic pneumonia |
| Respiratory system nursing interventions | Monitor RR and how they are breathing, monitor breath sounds every 2 hours, positioning to provide better lung expansion, deep breathing, adequate fluid intake |
| cardiovascular changes that relate to immobility | orthostatic hypotension and thrombus |
| cardiovascular nursing interventions | monitor increase HR, decreased pulse, and decreased BP, monitor patient as soon as possible dangle, OOB, gait belt, call light, SCDs, and anticoagulation |
| Musculoskeletal changes that relate to immobility | disuse osteoporosis, joint contraction, foot drop |
| musculoskeletal nursing interventions | assess/screenings, calcium supplements and food, up when able, ROM, splints/boots, promote neutral alignment |
| Urinary changes that relate to immobility | urinary status and renal calculi |
| nursing interventions for urinary changes | fluids and semi-Folwer bed mattress |
| Route | how it enters the body |
| absorption | from site into blood |
| distribution | from blood into cells, tissues, and muscle |
| action | how medication acts/physiological function |
| metabolism | changed to prepare for excretion |
| excretion | how it exits body |
| caplet | coated for easier swallowing |
| capsule | powder, liquid, or oil in a gelatin shell |
| tablet | compressed powder |
| enteric coated | dissolved in small intestines |
| time released | granules with different coatings, or some tablets, that dissolve slowly |
| lozenge | dissolves in mouth |
| elixir | mixed with water or alcohol and a sweetener |
| syrup | sugar solution |
| Therapeutic effect | expected or predicted |
| side effect | unintended, secondary effect |
| adverse effect | severe response to meds |
| toxic effect | med accumulation into blood stream |
| idiotsyncratic reaction | over or under reaction to medication |
| allergic reaction | unpredictable reaction to meds |
| synergistic effects | combined with another medication is greater than effect of just one medication |
| half life | time for med concentration to be halfed |
| onset | time it takes med to produce a response |
| peak | time med reaches max concentration |
| trough | time med take to be at min concentration |
| duration | time for when med is at peak concentration and how long it takes for a response to occur |
Created by:
molrando