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Concepts 3: Final!!
Final Review
| Term | Definition |
|---|---|
| Posterior auscultation sequence begins with the | Right middle lobe |
| A cardio focused assessment includes: | Blood pressure, equality of pulses, skin color, skin temperature, skin moisture, capillary refill time |
| A cardio focused assessment does NOT include: | Accessory muscle use (respiratory assessment) |
| Pyuria | Pus in urine |
| Polyuria | Increased urine output |
| Oliguria | Very little urine output |
| Anuria | Absence of urine, inability to void |
| Dysphasia | Difficultly coordinating and organizing words in sentences |
| Dysphagia | Difficulty swallowing |
| Aphasia | |
| Your patient falls. What is your first priority nursing action? | Check for injuries! |
| "Most older adults are too ill or disabled to live independently." | False |
| "Most older adults are uninterested in sex." | False |
| "Older adults are still lifelong learners." | True |
| "Most older adults remain independent." | True |
| Most expected result of a patient's dehydration? | Little urine output |
| Voiding every hour while awake | Frequency |
| Kausmall respirations | Deep, rapid labored breathing |
| What position do you put the patient in to listen to breath sounds? | High Fowlers |
| "Store the catheter drainage bag at the client's waist." | False |
| "Secure the catheter tubing to the bed rail." | False |
| Patient is on Furosemide (Lasix), what is your concern? | Hypokalemia (low potassium) |
| Indications for catheterization? | Open perineal wound, comfort measures for hospice, urinary retention |
| NOT an indication for catheterization? | Anuria, staff convenience, stress incontinence |
| You find a patient's IV site to be warm and red, etc. What is your first priority nursing action? | Remove the IV |
| Types of catheters? | Texas/Condom cath, Indwelling (foley) cath, Alock (3-way) cath, Coude cath |
| Your patient has hearing loss. What is your first question? | Do you use hearing aids? |
| Female clean catch specimen guidelines: | Place the cup in the stream, hold labia open while cleaning and collecting |
| Phlebitis symptoms | Warm & Red |
| Infiltration symptoms | Cool & Pale, Edema, Tightness |
| "Keep the cath drainage bag above the heart." | False |
| "Leave the cath drainage bag on the bed." | False |
| "Empty the cath drainage bag every 220 mL." | False |
| "Remove the cath at the first sign of infection." | False |
| Can an AP (authorized personnel) monitor a blood transfusion? | No, the nurse must monitor the first 15 mins |
| If a patient has a reaction to a blood transfusion, what is one priority action the nurse must take? | Save all tubing and supplies to send out for testing |
| Glasgow Coma Scale: | Points are 3-15, 12 is a moderate deficit, it assesses eye, motor, and verbal responses to determine LOC (level of consciousness) |
| Hospice care is | End-of-life care, 'less than 6 months' diagnosis to qualify |
| Palliative care is | Comfort measures at any point in care |
| Your patient has severe vomiting. What imbalance might you expect? | Metabolic alkalosis |
| Your patient has excessive sodium retention. What complication might you expect? | Hypervolemia |
| Once you receive the bag of blood, how long do you have to administer it? | Maximum of 4 hours |
| Symptoms of Hypovolemia | Dry, cracked lips, tented skin turgor, tachycardia, oliguria |
| Your patient appears normal & healthy, but pulse ox reading comes back as 70%. What is your first priority nursing action? | Reposition the pulse ox |
| Patient's potassium level is 3.5. They have a prescription for K. What do you do? | Administer it |
| Trach emergency supplies to always keep at bedside? | Oxygen, suctioning equipment, ventilator, ambu bag, obturator, trach of the same size, trach size one smaller |
| You flush a patient's IV and NS leaks from the site. What is your priority action? | Remove the IV and restart it at an unaffected location |
| Do you suction a patient's mouth and then suction their trach? | No |
| A positive Trousseau sign or Chvostek sign indicates what | Low calcium, hypocalcemia |
| True or False: "Your patient's stoma should be dark purple or black." | False |
| Your patient is complaining of pressure and discomfort in their lower abdomen. What is your first action? | Perform a bladder scan |
| Normal pH range of blood: | 7.34 - 7.45 |
| Normal range of PaCO2: | 35 - 45 |
| Normal range of HCO3: | 22 - 26 |
| What % of the body is composed of water? (Average adult) | 60% |
| Venipuncture guidelines: | Pick a stable, nonrolling vein. Apply tourniquet proximal to elbow |
| Butterfly needles are often used for | Short infusions |
| Nebulizer treatments: | Use compression tubing, fluid can be seen in the cup, mist comes out, and patient breaks out thru mouth |
| ABGs | Use an artery (arterial blood gas) |
| Simple Face Mask provides how much O2? | 5-10L |
| Symptoms of Hypervolemia: | Jugular vein distention, third spacing (aka edema), shortness of breath, weight gain, sudden coughing, fear/anxiety |
| A straight cath is used for: | an In & Out cath |
| Your patient is on Spironolactone. What are they at risk for? | Hyperkalemia, this is a potassium-sparing diuretic, so you retain K |
| How much residual urine in the bladder is normal? | 50 to 100 mL |
| Is suctioning a sterile procedure? | Yes |
| Crackles | Wet, fluid |
| Rhonchi | Gurgles |
| Stridor | 911, airway completely obstructed |
| Wheezing | Whistling sound, musical sound, airway narrowed |
| Head to Toe assessment: abdomen then lower extremities? | True |
| Respiratory Acidosis is caused by: | drug overdose, hypoventilation, low pH (eg. 7.21) |
| What tool for oral suctioning? | Yaunker |
| Most common UTI medication? | Bactrim |
| Pink, frothy sputum | Pulmonary edema (emergency) |
| Clear, white sputum | Viral infection |
| Green sputum | Bacterial infection |
| Rusty sputum | Pneumonia or TB |
| I.S.B.A.R | Introduction, Situation, Background, Assessment, Recommendation |
| True or False: "When you exhale, your ribs become smaller and your intercostal muscles relax." | True |
| Your patient is hypotension and has calorie deficits. Which IV solution do you give? | D5W |
| Listening to a patient's heart sounds is considered what type of space? | Intimate |
| What are the learning styles? | Visual, Auditory, Kinesthetic |
| Parts to a Nursing Diagnosis | Problem, Etiology ("related to"), Signs ("as evidenced by") |
| Hyponatremia | Low blood pressure, seizures |
| HIPAA | Health Insurance Portability and Accountability Act |
| Potassium - think: | arrythmias, EKG |
| Bronchovesicular sounds are | Normal breath sounds |
| Living Will | |
| Durable Power of Attorney | |
| True or False: "When checking the carotid, check both sides of the neck at the same time." | False |
| Cranial Nerve 7 | Facial (VII) |
| Patient has nosebleeds and requires oxygen. Which intervention do you apply? | Oxygen humidifier |
| Cyanosis | Blue, Hypoxia |
| When do you suction- when going in, or withdrawing? | Withdraw |
| Venturi Masks provide how much oxygen? | 5-15 L |
| IV solution most like blood? | Isotonic |
| Hemolytic shock during a transfusion can manifest as: | Shock, low back pain, fever |
| Which IV solution to initiate or discontinue a blood transfusion? | 0.9% NS |
| Which IV solutions to replace blood? | D5W, LR |
Created by:
hannamalec
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