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What effects does immobility have on the musculoskeletal system? 1. Osteoporosis 2. Muscle Atrophy 3. muscles become to tight 4. stiffness of joints
What effects immobility have on the cariovascular system? 1. Angina 2. decreased blood flow 3. use of valsalva maneuver 4.orthostatic hypotension 5.Venous stasis 6. dependent edema 7.thrombus 8.embolus
What are the causes of immobility? 1. sedentary lifestyle ( couch potato) 2. Prolonged inactivity 3. illness/injury
What are the effects of immobility on the Respiratory system? 1. restricted expansion of lungs 2. pooling of secretions 3. secretions in alveoli (inflammation) 4. collapsed lung
What effects does immobility have on the urinary system? 1. Urinary stasis 2. Renal calculi 3. Urinary retention
What effects does immobility have on the Integumentary system? It leads to poor skin turgor. It creates pressure ulcers.
What effects does immobility have on your metabolism? It slows gastric motility which leads to constipation
Why is it not good to ignore the urge to defecate? It weakens the defecation relex
What is Urinary stasis? Urine does not move out of the bladder
What is Hypostatic pneumonia? secretions in the alveoli
What is Atelectasis? lung collapse
What is Ankylosis? stiffnes of a joint due to abnormal adhesion
What is ischemia? insufficient blood supply to tissues
What is necrosis? Death of cells due to lack of blood supply
The nurse, caring for a client confined to bed, recognizes which of the following conditions as the priority concern? RAMONT 530 1. Contractures 2. Orthostatic hypotension 3.Osteoporosis 4. Disuse atrophy
The nurse is caring for a client in respiratory distress and must position the client. What is the best position for reducing the clients respiratory effort? RAMONT 530 1.Dorsal recumbent 2.Semi-Fowlers 3.Orthopneic 4.Sims
The nurse is assined to take morning vital signs on several clients on a medical surgical unit. Of the following vital signs, which would the nurse immediately report to the RN?RAMONT 467 1.99.6(R),86,24,140/88 2.97.2(O),110,18,110/78 3.101.8(A),72,18,90/60 4.98(O),100,26,148/80
The nurse's assigned client has a history of mastectomy of the right breast, 1 year ago.She has been admitted with a fracture of her left humerus. The nurse would measure blood pressure by; RAMONT 467 1. Applying the cuff to the right arm, being careful not to pump it above 150mm 2.Using a large cuff and assessing BP using her thigh. 3.Placing the cuff below her left elbow and palpating her radial pulse. 4. chart that you were unable to assess the B
The nurse receives an order to administer Tylenol (acetaminophen) for a temp over 101F. When measuring the temp the nurse gets a reading of 38C and converts this temp to what on the F scale? RAMONT 467 1.100.6 2.104 3.103.2 4.101.5
The nurse admits a 30-month old toddler to the pediatric care unit and measures pulse rate using what site? RAMONT 467 1.Radial 2.Carotid 3.Brachial 4.Apical
The client is being discharged home. The physician has ordered MS Contin for pain control. The nurse would teach the client and support people to do which of the following prior to administering the medication? RAMONT 467 1.Measure BP prior to administration 2.Measure BP 20 minutes after administration. 3.Assess respiration following administration. 4.Assess apical pulse prior to admnistration
The nurse prepares to assist a client with personal hygiene. The client has a number of personal preferences for how and when hygiene should be performed. The nurse's best action would be to: pg.431 Ramont 1.Follow the clients preferences 2.Tell the client that as a nurse you will provide hygiene in an efficient manner. 3.Delegate this client to a UAP who has time to deliver care 4. smile and agree with the client, but provide hygiene care as usual
The nurse is changing linen on an occupied bed and begins by: pg.431 Ramont 1.Removing the top bedding 2.moving the mattress up on the bed 3.turning the client toward the side where the linen will be changed 4.loosening the foundation of the bottom linen on the side of the bed nearest the linen supply.
While caring for a client with impaired circulation of the lower extremities, the nurse assesses the clients feet and finds that the skin is very dry and the heels have reddened areas. the nurses priority action is to pg.431 1.ensure that the bottom sheet is taut and free of wrinkles 2.massage the feet and allow them to air dry 3.bathe the feet and dry briskly 4.apply extra blankets over the leg and feet to keep them warm
Order:Prilosec 40mg PO once daily for 4 weeks. The available strength is 10mg per capsule. Determine the # of capsules of this antacid drug that you would administer to the patient over the entire treatment period. 112 tabs pg179 Dosage
Keftab (cephalexin) 50 mg/kg PO in two equally divided doses is prescribed for an elderly patient who weighs 40 kilo grams. If each tablet contains 500mg, how many tablets of this cephalosporin antibiotic will the patient receive per dose? 4tab/2tab per dose pg.179 Dosage
The physician orders Coumadin 6.5mg PO every other day from Monday through Sunday. How many mg of Coumadin will your patient receive in the week? 26mg pg181
Paxil 50mg PO daily has been ordered for your patient. Only 10mg, 20mg and 30mg strength tabs are available. Which combination of tabs contain the exact dosage using the smallest # of tabs? 50mg pg.179 dosage
The prescriber ordered precose 75mg PO t.i.d with meals. The medication is available in 25mg tablets. How many tablets of this glucosidase inhibitor will you give your patient in 24 hours? 9 tab pg.179 Dosage
Troprol-XL extended release tabs 200 mg PO daily has been prescribed for a patient. The label reads 200mg per tab. Calculate the number of tabs of this antihypertensive drug the patient would have received after 7 days. 7 tab pg.179 Dosage
The nurse, caring for a debilitated bed-ridden client, notes nonblanchable erythema of intact skin on the coccyx. The nurse's priority action is to: pg562 Ramont 1.Document the size, location,stage of the wound. 2.Position the client to remove pressure from the site and reposition at least every 2 hours. 3.Place the client on an airflow mattress 4.Apply protective pads and adhesive dressings over the site.
The nurse examines the clients wound on the thigh close to the knee and documents the wounds location as: Pg390 Ramont 1.superior to the knee 2.Medial to the knee 3.Distal to the knee 4.Proximal to the knee
In the admission assessment of a client who has been living alone and is unable to provide for his own care.You examine the skin and notice red lesions, which appear as "red tracks" under the skin. Which of the following would be the nurses action? 1.Don gloves prior to cont. your assessment 2.Postpone your assessment until the CNA has bathed the client 3.Place the client in isolation 4.Proceed with the assessment but do not touch the client. pg.390 Ramont
The nurse is providing oral hygiene for an unconscious client and places the client in what position? 1High fowlers 2.side-lying 3.prone 4.supine pg.431 Ramont
The nurse is meeting the cleints hygienic needs, which include all of the following except: pg. 431 Ramont 1.skin,hair,nail and oral care 2.Care of the nasal cavities, eyes and ears 3.Bed making 4.apply extra blankets over the leg and feet to keep them warm
The nurse is teaching the client about foot care and instructs the client to: pg431 Ramont 1. Use the hottest water tolerable 2.Allow the feet to air dry to avoid injury 3.Soak the foot for 3to5 min prior to trimmin the toe nails 4.Rub callused areas of the foot with a washcloth to remove dead skin.
Name 7 steps of 24 hour urine collection 1.Let the patient know to save urine 2.Keep cold 3.let healthcare team know 4. label container 5.1st urine sample collect BUT discard 6.last voided urine SAVE 7.If one sample is discarded in the process start over
What is the differences between a foley catheter and a straight catheter? a straight catheter is temporary (in and out) a foley stays for hours or days
Jennifer weights 115lbs 8oz. What is her weight in kilograms? 52.5 lbs pg.134 dosage
A medication cup contains 22.5ml of a solution. How many tbls are in the medication cup? 1.5 tbls pg129 Dosage
A patient weights 150lbs. What is the patients weight measured in kilograms? 68.18kg pg.130 dosage
An infant weights 4kg. What is the infants weight measured in lbs and oz? 8lbs 13oz pg. 130 dosage
Change 2 1/4 hours to an equivalent amount of time in minutes 135min pg.90 dosage
When do you take Vital Signs? 1.Client admission 2.prior to transfer to another unit 3.prior to discharge 4.prior to calling MD 5.Before and after surgery, medication administration, diagnostic procedures 6. change in pt's condition 7.at least every 4 hours
Where is the Apical pulse located? Left mid clavicular line 5th intercostal space
What is a pulse? it is the indicator of circulatory status
What factors affect pulse? Age,Exercise,Fever, medication, blood loss, stress, position change, gender
what are the 4 ways to describe a pulse? Absent, difficult to feel, strong, normal
where are the 9 pulse points and what are they called? 1.Temporal 2.Carotid 3.Facial 4.Brachial 5.Radial 6.Femoral 7.Popliteal 8.Pedal 9.Posterior Tibialis
What are the 5 assessments you take when doin Vital signs? Blood pressure, Respiratory rate, pain, pulse,
What is debridement? It is the process of removing dead or infected tissue from wounds
Why do we use debridement on patience? improves the healing of the remaining healthy tissue
What does PERRLA mean? Pupils Equally, Round, Reactive to Light and Accomodation
What are the 4 assessment techniques? 1.Inspection 2. Auscultation 3.Palpation 4.Percussion
What is pitting edema and non pitting edema? Pitting edema- applying pressure to the swollen area by depressing the skin and causes indentation Non pitting edema-pressure applied to the skin but does not leave indentation.
What is normal pulse range? 60-100 beats/min
What is normal respiratory ranges? 12-20 breaths/min
What is normal systolic range? 90-140
What is normal diastolic range? 60-90
What is the meaning of Dx? Diagnose
What does H and P stand for? History and physical
What is LOC? Level of consciousness
What is q4h? every 4 hours
What is BID? twice a day
What is TID? 3 times a day
What is Stat? immediately
What is PRN Whenever necessary
What is AMA? against medical advice
What is necrosis? Death of cells due to lack of blood supply
what is ischemia? insufficient blood supply to tissues
What is urinary stasis? urine does not move out of the bladder
What is urinary retention? Static urine causes bacterial infection
What is Renal Calculi? Prolonged horizontal position
What is the braden scale and norton scale used for? It is used to assess pressure ulcers
What is the difference between the braden scale and the norton scale? braden scale is more detailed and used to predict pressure sores the Norton scale is more simplified
How is the braden and norton scale used? The lower the number the Higher you are at risk for an ulcer
Describe pressure ulcer stage 1 Non blanchable erythema (skin redness remains) of intact skin
Describe pressure ulcer stage 2 Can be an abrasion or blister. Affects down to the dermis
What are the 6 categories that is used to assess in the braden scale? 1.Sensory perception (ability to feel) 2.moisture 3. Activity (ability to move) 4. mobility (control body positions) 5. nutrition 6. Friction and shear (how often one slides)
If i score a 6 on the Braden scale am I more or less at risk of a pressure ulcer? Why give examples More at risk because the braden scale is assess from 6pts-20pts if i score all ones in every catergory i have a bad pressure ulcer.
What are the 5 categories of Norton scale? 1.physcial condition 2.mental state 3. activity 4.mobility 5.incontinent
Describe pressure ulcer stage 3 full thickness skin loss involving damage, necrosis can have a deep crater
describe pressure ulcer stage 4 damage to muscle bone
What is evisceration? When your wounds open up and organs are exposed
What is dehiscene? When your wounds open up again but no organ exposure
What is prognosis? predicting the outcome of a disease
Created by: tyvinson