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131 Cards in this Set

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What is the prefered injection site for a 1 year old child?
ventrogluteal
morphine
respritory depression and decreased urinary output
intradermal
TB Test
Sub Q
insulin
factors to consider when choosing routes of med admin.
ex. client is nauseated, vomiting for several hrs., & needs antiemetic med. the nurserecognizes...
a parenteral route is the route of choice
Order:6mg morphine sulfate ever 3-4 hrs prn for a client's post-op pain. the unit does of the med dispenser has 15 mg in 1 ml. how much sol. should be given
dose ordered/dose on hand * amt on hand
6mg/15mg * 1ml = 2/5 ml
the nurse is teaching the client how to prepare 10U of regular insulin and 5U of NPH insulin for injection. the nurse instructs the patient to
inject into both vials withdraw the regular insulin first
the client has an order for 30U of U-500 insulin. the nurse is using a U-100 syringe and will draw up and admin...
5 times as strong as U-100 insulin. 30 units of U-500 insulin/6
prescriber
must be a documented Dx, condition, or indication for each med ordered
Pharmacist
responsible for filling prescriptions acurately and for being sure the are valid
the 6 rights
med
dose
client
route
time
and documentation
10:00, 2:00, and 6:00
TID (3 times a day)
If you have blood when you aspirate you
throw away the needle in the sharps container & start over
which documentation method would the phrase "Client is wheezing and experiencing some dyspnea on exertion
P for PIE
how much time does it take for regular insulin to take effect
2-4 hours
where to inject heparin?
abdomen
calculate a medication order from 80mg/tsp to the correct amount of ml
5ml
interpret an order that reads ii gtts OD
2 drops to the right eye
where patient teaching is documented
discharge summary form
how to correct a documentation error
draw a straight line through error and initial it
Can an LPN take a telephone order from a physician?
no
53-year-old client is seen at the clinic for a yearly physical exam, that evaluating the client's weight, the nurse also considers the age and height
comparing data with normal health patterns
how would I calculate an insulin order of 30U of U500 and convert that to a dosage in a U100 syringe
6U
the long-term goal would be for a tailor who is admitted for eye surgery
returning to sewing
during an admission history you have a client that has trouble breathing at night. In obtaining data for a problem-oriented database, the nurse should first question the client about
The onset and duration of his present breathing problem
how to recognize a nurses statement that reflects the scientific method
"The client doesn't look the same today. I think something is wrong"
aspects of critical thinking
religion
language
intuition
levels of critical thinking
basic
complex
commitment
components of critical thinking
knowledge base
experience
competence
attitudes
standards
nursing process
assessment
diagnosis
planning
implementation
evaluation
assessment steps
approach
collection and verification of data
analysis of data
documentation
types of data
objective data
subjective data
objective data
what you and see and measure
subjective data
what the patient says
nursing is about
thinking
cognitive
what you know
psychomotor
what you do
effective
what you feel
5 types of nurses
1.novice
2.advaced beginner
3.competent
4.proficient
5.expert
reflection
when you think about something you gain insight
language
communication is essential
intuition
innersensing-art of nursing- takes skill and knowledge
can;t havbe with out science
basic
you so specifically
becomes second nature
complex
analyze, be creative
make decisions about what you want by weighing optins
commitment
choose action and accept accountability for it
purpose of the scientific method
to fin whats real and what is truth
problem solving
use information to develop a solution
diagnostic reasoning and inference
determine health status from patient symptoms
clinical decision making
drawing a conclusion based on pieces of evidence
attitudes
must convey confidence
think independently and interdependently
be humble
skills
interpretation
analysis
evaluation
inference
explanation
self-regulation
Source Records
patients chart is organized so that each discipline has a section
current
timely immediate documentation
utilization review
people that look at medical record and check to see if it meets the standards
Charting by exception
used to eliminate redundancy, ensure concise documentation of routine care, emphasize abnormal findings, and identify trends in care
Acuity recrd
provides a method of determining the hours of care and staff required
Nursing Documentation must be: ACFCTSO
Accurate, Concise, Factual, Complete, Timely, Specific, Organized
critical pathways
tool used in managed care that incorporates the treatment interventions from all disciplines.
unit dose
current system, uses portable carts containing 24 hour supply of patients medications
what affects circulation?
hypertension in diabetes
1 reason for toxic effects (accumulation of a med beyond therapeutic index):
hydration level
medication formed determines
route of administration and there are 20 diff. forms
meds have 3 classifications
1. systemic 2. organ 3. symptom
drug names
1. generic -- official name 2. chemical 3. trade -- pharmaceutical co has a patent of the name
gather data
subjective=what the patient says; what can't be measured objective=measurable
care plan
to-do list
nursing diagnosis
to tell you why you need to do the things in your care plan
Neuman
systems model: we are a system of parts, all parts important, if one part goes wrong, the whole system is affected; primary, secondary, tertiary care
benner
personal experience; 5 nursing competencies
watson
connecting patient caring
Leinninger's sunrise model
culturally congruent care
common method of selecting priorities
Maslow's Hierarchy of basic human needs is a:
components of critical thinking
1. specific knowledge base 2. experience 3. competencies 4. attitudes 5. standards
assessment
systematic data collection, validation, and interpretation
purpose of a nursing process
to provide individualized, holistic, safe, quality, effective, and efficient care to clients
process
a series of steps or acts that leads to accomplishment of some goal or purpose
nursing process
a systematic and scientifically based process used by nurses to identify and make decisions about client needs
five types of nurse levels
. novice 2. advanced beginner 3. competent 4. proficient 5. expert
skills that are necessary of a nurse
1. interpretation 2. analysis 3. evaluation 4. inference 5. explanation 6. self regulation
self regulation
reflecting on experiences and how to improve
explanation
presenting arguments
inference
considering alternatives
evaluation
assessing results
analysis
critiquing
interpretation
assess
three parts of a diagnosis
1. nanda 2. related to 3. as evidenced by
drawing a conclusion based on pieces of evidence
clinical decision making
determine health status from patient's symptoms
diagnostic reasoning and inference
using info to develop a solution
problem solving
scientifin method
to find out what's real and what's truth
when a client-centered goal has not been met in a projected time frame, the most appropriate action would be to:
repeat the entire sequence of the nursing process to discover needed changes
the primary source of data for elevation is the:
client
medications used to wash out a body cavity delivered with a stream of solution
Irrigation
tetrogenetic effect
adverse affect on fetus
computer controlled
automated medicine dispensing systems used primarily for narcotics
unit dose
current system, uses portable carts containing 24 hour supply of patients medications
stock supply
historical, medications are available in large multidose containers
single orders
only once
standing orders
til dr. changes it or has stop order
nurse
responsible for knowing what medications are prescribed, their therapeutic and nontherapeutic effects, and the associated nursing implications
presaline
antihypertensive
Pharmacodynamics
the drug's action on body
Pharmacokinetics
the body's action on drugs -absorption -distribution -metabolism -excretion
proprietary patent (good for how long?)
7 days
synergistic effect
two meds combines better than 1
what would a patient who's toxic on morphine look like?
respiratory depression and decreased urinary output 0.675
how is insulin administered?
subQ
subQ
15 degrees
client is nauseated, has been vomiting for several hours, and needs to receive an antiemetic medication. the nurse recognizes that which is accurate?
parenteral route is the route of choice -parenteral=intradermal, subQ, intramuscular, intravenous
given mass dissolved in a known volume
solution
preprinted, established guidelines that are used to care for patients with similar health problems
standardized care plan
provides a method of determining the hours of care and staff required
Acuity recrd
provides current orders, treatments, and diagnostic testing that are ongoing
Client care summary or KARDEX
allow quick and easy assessment of patient status
Flow Sheets and graphic record
tool used in managed care that incorporates the treatment interventions from all disciplines
critical pathways
the case manager advises nursing staff on specific nursing care issues, coordinates the referral to services provided by other disciplines, and ensures client education is completed
Case Management
used to eliminate redundancy, ensure concise documentation of routine care, emphasize abnormal findings, and identify trends in care
Charting by exception
patients chart is organized so that each discipline has a section
Source Records
logical order
organized
timely immediate documentation
Current
thorough communication
complete
exact, precise, concise, spelling, and abbreviations
Accurate
objective and subjective data are:
Factual
an effective way to learn the nature of an illness and the patients response is to read the medical record
Education
how is the patient's needs and progress communicated?
through progress notes and nurse's notes
a confidential, permanent legal documentation of information relevant to a patients health care
Medical Record
Nursing Documentation must be: ACFCTSO
Accurate, Concise, Factual, Complete, Timely, Specific, Organized
people that look at medical record and check to see if it meets the standards
utilization review
non governmental or legal agency/professional organization that gives recognition to an institution
Accredidation
Permanent document of all information relevant to health care
Record
anything written/printed that can be used as record or proof for authorization
Documentation