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107 Cards in this Set
- Front
- Back
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Nursing Process
The state board examiniations for professional nursing now use the nursing process rather than medical specialties as an organizing concept |
true
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Nursing Process
asking a pt how she feels today is demonstrating which characteristic of the nursing process? |
interpersonal
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Nursing Process
a RN says that clinical is second nature and not to study - what is a good response |
Intuition alone alows increased risk and fewer benefit. Intuition often moves problem solving forward quickly but it might result in a lot of trial and error approaches
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Nursing Process
Nursing works best when each nurse competently uses the Intellectual, Interpersonal, Technical and Ethical/Legal skills demanded in each situation. This is based upon the notion of ______ ________ |
blended skills
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Nursing Process
evidence based descriptions of behaviors that demonstrate the knowledge characteristics standards and skills that promote critical thinking in clinical practice is known as |
Critical Thinking Indicators CTI's
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Nursing Process
Angela has blurted out that she had been raped when she first came home and has refused to verbalize about it, she has stopped attending all classes and has nightmares. The RN activity represented is |
Assesing
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Nursing Process
after analzying data , you beleive angela may be experiencing rape-trauma syndrome, silent reaction The RN activity represented is |
Diagnosing
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Nursing Process
You speak to Angela To develop treatment goals that you formulate as ouctomesa nd begin to thinka bout the types of nursing intervetntions most likely to yield the best outcomes The RN activity represented is |
Planning
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Nursing Process
you encourage angela to express feelingsand help her to identify personal coping strategies and strengths the RN activity represented is |
Implementing
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Nursing Process
you decide to meet with angela in one week to assess her progress towards targeted outcomes The RN activity represnted is |
Evaluating
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Medication
the name selected by the pharmaceutical company selling the drug and protected by trademark is the drugs |
trade name
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Medication
the process by which a drug is transferred from its site of entry into the body to the bloodstream is known as |
absorption
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Medication
a patient with an abnormal, unexpected response to a drug is called |
an idiosynchratic effect
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Medication
a life-threatrening immediate response to a drug is called |
an anaphylactic reaction
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Medication
Two ways to check identification of a patient |
Ask his name
Check ID bracelet |
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Medication
you are administering a med through a nasogastric tube, before giving the medication, you should |
Check the proper placement of the NGT
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Medication
a Med that has an overfilled cartirdge may need some of the med to be discarded, you must always check the volume needed to provide the correct dose with the volume in syringe t/f |
true
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Medication
The correct sequence when mixing insulins is |
Inject air into the regular insulin vial - being careful not to allow the solution to touch the needle.
Next, inject air into the NPH insulin vial and withdraw of each desired amt of insulin separetely. |
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Medication
If a patient is allergic to a drug ordered by a doctor, the correct response is to |
Call the doctor and ask for a medication change due to the PT allergy.
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Medication
a Nurse manager asks you to administer medication that she prepared... the correct answer to this is |
tell the RN manager you cant administer it because you did not pour the medication.
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Medication
what is the correct technique for administering heparin SUBCUTAENOUSLY? |
do not aspirate or massage before or after injection, as to not cause trauma or bleeding in tissue
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Medication
a pt refuses her noon medication, what do you tell her |
tell her you will return the medication to the cart but should address the patients reasons for refusal, document them, and report them to physician
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Medication
if you make a medication error, your FIRST response is to |
Check the patients condition immediately to note any effects of error.........., then after record error and make incident report.
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Medication
your PT tells you to leave medication on table she will take it later, your response is |
tell them you cannot leave the medication but will return with it when breakfast arrives, etc....
meds should never be left at PT bedside. |
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Documenting
what is the correct documentation guideline? |
Enter Info in complete accurate concise factual and organized manner
Date and time each entry |
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Documenting
you must document nursing interventions as closely possible to the time of their execution t/f |
true
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Documenting
according to HIPA , patients have a right to |
see and copy health record
to update health record to get a list of disclosures to request restriction on certain uses or disclosures to choose how to recieve health info |
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Documenting
if a friend calls to ask you about ifnormation on a patient you tell them |
sorry but im not able to give information about patients to the public - even when my best friend or family members asks.
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Documenting
what is the corrected abbreviation for AS NEEDED |
PRN
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Documenting
to look for trends in a patients vital signs you should first consult |
graphic sheet
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Documenting
this method of documentation uses categories data , action and response (DAR) to facilitate charting |
Focus Charting
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Documenting
a doctor tells you a verbal order and to document it on the order sheet, you should tell the doctor |
i am sorry but verbal orders can only be given in an emergency situation that prevents us from writing them out. i'll bring the chart to you and we can quickly do it.
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Documenting
abbreviation for past medical history |
PMH
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Documenting
abbreviation for temparature, pulse, respiration |
TPR
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Hygiene
when developing a plan of care for an older patient - you must pay attention to pts skin based on an understanding of what? |
the skin becomes increasingly DRY as we age.
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Hygiene
a patient wearing antiembolism stockings must |
have legs measured according to manufacturors direction before applying
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Hygiene
during a bath, you notice the PT has dry skin - what is the best action needed |
use an emollient on the dry skin
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Hygiene
a adolescent pt with acne should be recommended ... |
wash the skin frequently to remove dirt oil and debris
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Hygiene
what is a marked inflammation of gums, with recession and bleeding called |
Periodontis
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Hygiene
what is an inflammation of the tongue called |
Glossitis
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Hygiene
What is an ulceration of the lip called |
Cheilosis
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Hygiene
what is priority action when admininstering oral care to a dependant patient |
wear disposable gloves
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Hygiene
your pt has an eye infection with a moderate amt of discharge, what action wouldbe most appropriate to use when cleaning his eyes |
positioning pt on the same side as the eye to be cleansed
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Hygiene
when providing foot care to an older pt, you must |
bathe pt feet at least daily
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Hygiene
Providing perenial care to pt requires |
using a clean portion of the washclothe for each stroke
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Hygiene
an 80 year old pt needs total assistance with personal and oral hygiene - he is thin, has few visitors, prefers to remain in bed in a semisitting position.... what is a PRIORITY diagnosis |
Risk for impaired skin integrity - a break in his skin could lead to life threatening infection.
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Hygiene
an older pt with an unsteady gait, walk, requests tub bath - what would be most appropriate |
assist patient in and out of tub to prevent falling
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Hygiene
before shaving PT , you must |
use a electronic razor if finding out that the pt is taking anticoagulants
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Hygiene
to remove gas permable contact lenses from an unresponsive patient - you would |
ensure that the lens is centered on cornea before gently manipulating the lids to release it
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Hygiene
when pt has an IV line and needs a bath, you must |
thread the bag and tubing through the gown sleeve keeping line intact
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Hygiene
When making occupied bed, what is most important to do |
use a bath blanket or top sheet for warmth and privacy
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Hygiene
what is the best position for shaving a patient in order to prevent soap and wate from running behind the patients head |
Fowler, semi Fowler position
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Hygiene
an inflammation of the oral mucosa causes bacteria , virus... |
stomatisis
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Hygiene
infestation with lice is called |
pediculosis
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Skin
after a surgical incision, a pt often has an elevated body temperature and generalized malaise - these manifestations most often occur during what phase of wound healing |
Inflammatory Phase
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Skin
thick, odorous, green wound drainage is called |
Purulent
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Skin
a pt with a large abdominal wound suddenly calls out for help bc she feels as though something is falling out of her incision - inspection reveals a gaping open wound with tissue bulging outward - you immediately report this as |
wound dehiscence with evisceration
(open wound with viscera protruding) |
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Skin
what is the most useful action to prevent wound infections |
performing careful hand hygiene
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Skin
new reddish pink tissue composed of many small blood vessels in the wound is likely |
granulation tissue
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Skin
a moist heat application is called a |
sitz bath
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Skin
when asessing a pt at risk for pressure ulcer formation - which site would you identify as most common |
sacrum
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Skin
what is a key contributing factor to pressure ulcers? |
pressure
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Skin
an older pt with a broken hipwith age related skin changes and immobility is most likely to have |
pressure ulcers
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Skin
you document prescence of a reddish area that has Blistered, what stage ulcer is it? |
stage 2
(uclers, abrasions, crater) |
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Skin
an older pt sits and slumps in chair all day,. she will most liekly develop a pressure ulcer due to |
shearing forces
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Skin
an open lesion with subcutaenous tisuse exposed is what stage ulcer |
stage 3
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Skin
a reddened area with abrasion is what stage |
stage 2
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name the first and second layer of skin
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epidermis (1) and dermis (2)
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Skin
what is the PRIORITY action to prevent a pt having pressure ulcer |
use a mild cleansing agent when cleansing skin
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Skin
what treatement would be necessary for a stage 2 pressure ulcer |
a moisture retentive dressing provides a moist environment for wound healing which is correct!
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Skin
what stage has a necrotic area extending through the fascia to the bone |
stage 4
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Skin
bacteria in a wound that increase stress on the body, requiring large amounts of energy from immune system to fight microorganisms. |
infection
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Skin
what interferes with the blood supply to the area, resulting in inadequate supply of O2 and nutritnets to the tissue |
edema (swelling)
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Skin
what is the prcoess of drying up cells , aka dehyrdration |
dessication
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Urinary
when collecting a urinalisis from a pt, you must keep in mind |
results may be altered if sample is left standin at room temp too long
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Urinary
what will best promote a teaching plan for a pt to produce healthy urinary functioning |
caffeeine intake should be monitored and limited bc it is damaging to bladder mucosa
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Urinary
a pt with fever or diaphoresis has a urine ouput that is |
decreased and highly concentrated
(due to kidneys retaining body fluids due to fever) |
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Urinary
an indwelling catheter in a male pt is more vulnerable bc |
the male urethra is larger and more vulnerable to injury
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Urinary
care for a pt with an indwelling catheter is |
irrigation of catheter with 30ml saline solution every 4 hours
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Urinary
your pt is having difficulty voiding/peeing, the last thing you want to do is have the pt |
ignore the urge to void
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Urinary
an 80 year old male pt with a UTI and an indwelling catheter is most likely due to |
the indwelling catherer
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Urinary
the inability to void even though the pt kidneys are producing urine that enters the bladder is called |
Retention
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Urinary
difficulty urinating is called |
dysuria
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Urinary
your pt is alert and walking and voids frequently but cant make it to bathroom in time, her planning careshould take note that |
kegal excercises be performed at regular intervals during day
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Urinary
a patient taking pyridium may experience her urine color change to |
bright orange/red
must make pt aware! |
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Urinary
your pt is timid and relucatant to talk about his urinary retention process, what could create stress for your pt and possibly increase his inability to urinate |
staying with him while voiding
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Urinary
a PRIORITY when caring for a male pt with condum catheter is |
prevent the tubing from kinking to maintain free urinary drainage
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Urinary
a diagnosis of impaired urinary elimination due to maturational enuresis - this would tell you that the PT is .... |
a child older than 4 years of age who has involuntary urination
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Urinary
involuntary urination after an age when continence should be present is called |
maturational enuresis
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Urinary
medication, state of physical mobility, age of patient, incontinence pattern WHICH of these is least important for evaluating an older PT to reduce urinary incontinence |
Incontinence pattern
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Bowel
what foods should your pt avoid to prevent a laxative effect |
alchohol
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Bowel
what occurs with amoxicilin clavulanate use about 20 percent of the time? |
diarreah
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Bowel
how do you administer an oil-retention enema |
administer and instruct the pt to retain enema for at least 30 minutes
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Bowel
your pt is having a newly created ileostomy, you must advise her that |
fecal drainage will be liquid
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Bowel
what class of laxactive causes the stool to absorb water and sweel? |
bulk forming
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Bowel
what lubricates the stool making it easier to pass |
emmolients
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Bowel
what allows visual examination of the large intestine |
colonoscopy
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Bowel
what allows visual examiniaton of esophogus and stomach |
esophagastroduodenscopy EGD
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Bowel
what is the radiographic examination of the large intestine called |
barium enema
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Bowel
why should a barium enema be done before an upper GI because |
retained barium may cloud colon
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Bowel
why should you avoid habitual use of laxatives? |
they will cause chronic constipation
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Bowel
what is the basis for action for a hypertonic solution enema? |
osmosis of water INTO colon
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Bowel
why should you not use rectal indwelling catheters |
rectal necrosis can occur
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Bowel
during removal of fecal impacation, what could occur cause of vagal stimulation |
Bradycardia or decreasing heart rate
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Bowel
what is a common diagnosis for patient with ileostomy |
disturbed body image
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Bowel
what positon will help with flatulence |
Knee-Chest positon because gas rises
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Bowel
a food that is responsible for excess flatulence is |
cauliflower
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