Nu 313 Test 1

Front 1

1 oz = ___ T

Back 1

2

Front 2

1 g = ____ mg

Back 2

1000

Front 3

1 mg = ____mcg

Back 3

1000

Front 4

1 L = ___ mL

Back 4

1000

Front 5

1 mL = ___ L

Back 5

0.001

Front 6

gr 15 = ___ g

Back 6

1

Front 7

60 mg =____ gr

Back 7

1

Front 8

1 t = ___ mL

Back 8

5

Front 9

1 T = ___ mL

Back 9

15

Front 10

1 oz = ___ mL

Back 10

30

Front 11

1 kg (1000 g)= ___ lb

Back 11

2.2

Front 12

conversion equation

Back 12

D/H x Q = X

Front 13

What is the ANA definition of Nursing?

Back 13

The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and popu.

Front 14

What is the nursing model?

Back 14

1. holistic approach
2. focueses on human respones to actual and potential problems.
3. health promotion and prevention
4. includes family, community, public

Front 15

What is the medical model?

Back 15

1. Focuses on diagnosis
2. treatment of disease
3. patient oriented

Front 16

what 4 things does the scope of practice look at?

Back 16

1. Health promotion
2. Illness prevention
3. Health restoration
4. End of life care

Front 17

3 roles of a professional nurse

Back 17

1. provider of care
2. designer/manager of care
3. member of the profession

Front 18

LCSC BSN Philosophy
Page 61-66 of handbook)

Back 18

1. science of nursing
2. art of nursing
3. teaching/learning environment

Front 19

the nursing proces is what type of a process

Back 19

a critical thinking process or circular process

Front 20

The ANA Nursing Process 6 standards

Back 20

I: assessment
II: diagnosis
III: planning outcome
IV: planning intervention
V: implemenation
VI: evaluation

Front 21

Types of assessments

Back 21

initial, ongoing, comprehensive, focused, specialized (nutritional, pain, cultural)

Front 22

When documenting data make sure you

Back 22

do it ASAP, write just the facts, record only pertinent information and data

Front 23

A health problem is

Back 23

any condition that requires intervention in order to promote wellness or to prevent or resolve disease/illness

Front 24

Nursing Diagnosis provides

Back 24

the basis for selection of nursing interventions to achieve outcomes

Front 25

what is the process for selecting an intervention

Back 25

1. reveiw the nursing diagnosis
2. review the desired pt outcomes
3. ID several actions
4. choose the best interaction for this pt
5. individualize the standardized actions

Front 26

How do you evaluate client progress

Back 26

1. review outcomes
2. collect reassessment data
3. judge goal achievement
4. record the evalutive statement
5. evaluate collaborative problems

Front 27

Standard precautions on every patient

Back 27

wash hands, clean gloves, face/eye protection,

Front 28

How long to you wash your hands?

Back 28

At least 15 seconds with warm water and soap

Front 29

U.S. drug legislation (FDA) does what

Back 29

1. Sets official drug standards
2. defines Rx drugs
3. Regulates controlled substances
4. improves safety
5. requires proof of efficacy

Front 30

What is the stock supply

Back 30

it is not locke dand is not patient specific. It is usually in a multi-dose container like tylenol

Front 31

What is Unit Dose medication system

Back 31

the pills are divided into specific dose size

Front 32

What is pixis

Back 32

machine that houses meds and automatically dispenses. Purpose was to increase safety but they are only as safe as the people that stock and use them

Front 33

What are some Self-administration medication systems

Back 33

PCAs, insulin, nitroglycerin, eyedrops

Front 34

Drug classification involves

Back 34

1. clinical use
2. body system it works on
3. chemical/pharmacological traits

Front 35

pharmakokinetics

Back 35

what happens to the drug in the body

Front 36

pharmakodynamics

Back 36

how the drug affects the body

Front 37

types of medication orders

Back 37

written, automatic stop date, STAT order, standing order, PRN order

Front 38

How orders can be communicated

Back 38

hand writing, pre-printed, oral/telephone, fax

Front 39

RVVO and RVTO

Back 39

Return Verified Verbal Order
and
Return Verified Telephone Order

Front 40

Components of an order

Back 40

clients full name, date and time, medication name, dosage size frequenec and number of doses, route, and signature of prescriber

Front 41

The 7 Rights

Back 41

Patient, Medication, Dose, Route, Time, Teaching, Documentation

Front 42

Different routes

Back 42

oral, sublingual, buccal (cheek), parenteral (IV, IM, SQ, ID), insertion, instillation, inhalation, intranasal, topical, transdermal, otic

Front 43

3 times to check before giving meds

Back 43

1. before you pour
2. After you pour
3. at the bedside

Front 44

Applying eye drops

Back 44

gloves, high-Fowler, right hand on forehead with drops, left hand pull down lower lid, dropper 1/2-3/4 inch above eye, ask pt to look up, drop into sac

Front 45

applying eye ointment

Back 45

apply thin 1 inch strip to conjunctive sac

Front 46

Applying eardrop

Back 46

side lying position, gloves pull pinna up and back, instill drops alond side of ear canal, do not touch ear at all, massage or press on traus of ear, pt to remain on side for 5-10 minutes

Front 47

Nasal med administration

Back 47

Have pt blow nose, gloves, position pt head down and foreward, close one nostril and exhale, give spray for drops while pt breathes trhough mouth, remain in postion for 1-5 and do not blow nose

Front 48

Administering topical and transdermal meds

Back 48

Where gloves, remove prior medication and patches, find hair free area, date and sign

Front 49

Needle gauges

Back 49

the smaller teh number the bigger the needle. So, a 14 is huge. IV is usually 18-20. 30 is small

Front 50

Intradermal injection site

Back 50

Ventral surface of forearm and upper back/chest

Front 51

Intradermal injection equipment

Back 51

1 mL syringe
1/4 to 5/8 needle; 27-30 gauge
alcohol wipes
clean gloves
usual dose: 0.01-0.1

Front 52

Intradermal injection technique

Back 52

With bevel of needle up, hold syringe parallell to skin at 5-15 degree angle, stretch skin taut, go in enough to cover bevel, inject slowly to create wheel, do not massage

Front 53

Subcutaneous injection site
(insulin, heparin, lovenox)

Back 53

abdomen (heparin and lovenox are always here), lateral adn posterior aspect of upper arm, upper buttocks just below waist, anterior aspect of thigh

Front 54

Subcutaneous injection equipment

Back 54

Insulin syringe
1 mL syringe
3/8 to 5/8; 25-30 gauge
alcohol wipes
clean gloves
maximum vol is 1 mL

Front 55

Subcutaneous injections technique

Back 55

pinch skin to inject, hold like a dart btw thumb and forefinger, insert needle at a 45 or 90 angle, inject med, hold needle for 10 seconds for heparin and lovanox

Front 56

Insulin injections

Back 56

assess BG, wipe site with ETOH, do not move from body area to area, but do rotate within same area, always check onset, peak, and duration

Front 57

Intramuscular (flu, pain)Injection Sites 1

Back 57

deltoid. Locate lower edge of acromion process, go 2 fingers below and make triangle. max volume is 1 mL

Front 58

Intramuscular (flu, pain)Injection Sites 2

Back 58

Vastus lateralis. Locate greater trochanter. Use middle third and anterior lateral aspect of thigh. max vol: 3 mL. Preferred for children

Front 59

Intramuscular (flu, pain)Injection Sites 3

Back 59

ventrogluteal. Locate greater trochanter, anterior superior iliac spine, iliac crest. Place Middle of angle btw midle and index fingers. Max vol = 3 mL. Do not use Dorsogluteal site

Front 60

Intramuscular injection equipment

Back 60

1-3 mL syringe
1" to 1.5" needle
21-25 gauge
alcohol wipes
clean gloves
max vol: 1 or 3 mL

Front 61

Intramuscular injection technique

Back 61

clean with ETOH, spread skin or pinch, z-track if needed, insert at a 90 angle, aspriate, if blood appears start over, inject medication slowly, withdrawal needle quickly and massage area with swab.

Front 62

what is documentation

Back 62

the act of recording client care in written form

Front 63

why document

Back 63

communication
legal requirement
legal protection
education/research
reimbursement

Front 64

what are the 2 types of documentation systems

Back 64

problem-oriented and source-oriented

Front 65

Problem-oriented documentation

Back 65

organized around client problems
4 components: databse, problem list, plan of care, progress notes

Front 66

advantages/disadvantage of problem-oriented documentation

Back 66

A: easy to monitor, easy to access, and encourages collaboration
D: requires cooperation from everyone, can take dillagence to maintain

Front 67

source-oriented documentation

Back 67

disciplines chart separately with a variety of sections

Front 68

advantages/disadvantage of source-oriented documentation

Back 68

A: info is easy to find, lots of complete info.
d: data is scattered and fragmented

Front 69

Types of charting

Back 69

narrative, SOAP, focus, PIE, charting by exception (CBE)

Front 70

Charting needs to describe

Back 70

patient, response, meet legal requirements, be adequate

Front 71

Narrative Charting

Back 71

Can use with POR or SOR.
A; tracks pt changing status and useful to construct a timeline of events
D: some people ramble

Front 72

Problem Intervention Evaluation Charting (PIE)

Back 72

Use with POR, establishes an ongoing plan of care, D: focus is on problem rather than the pt as a whole

Front 73

Subjecitve, Objective, Assessment, Plan Charting (SOAP)

Back 73

used with SOR and POR made for nursing

Front 74

Focused charting

Back 74

highlights the clients concerns, problems, or strengths. 3 columns (time/date, focus/problem, charting in DAR format)
A: holistic
D: no problem list

Front 75

DAR means

Back 75

data, action, response

Front 76

flowsheet charting

Back 76

use to record routine care (hygiene, I/O, VS, ADLs) use to trach pt response to care.

Front 77

Medication Administration record (MAR)

Back 77

includes drug name, dose, route, time, signature, frequence, pt, allergies

Front 78

Kardex

Back 78

used to summarize plan of care. Includes: name, age, diagnosis, allergies,diet, labs, active ordrs, transfers, safety precautions, DNR

Front 79

What to chart

Back 79

assessment, plan of care, communication, education, any changes in condition, interventions and their outcome, refusals

Front 80

What not to chart

Back 80

care you have not given yet, opinions or interpretations, content that suggests a risk or unsafe practice

Front 81

1. Complete Blood Count (CBC)

Back 81

evaluates parts of the blood, general health status, aids in diagnosis of anemia, infection. Used for c/o of fatigue, weakness, Temp, inflammation, bruising or bleeding

Front 82

CBC includes

Back 82

White Blood Cell (WBC)
Red Blood Cell (RBC)-shows anemia
Hemoglobing (HGB)
Hematocrit
Platelet count

Front 83

White Blood Cell Differential uses and components

Back 83

Used to classify the WBC into types

Neutrophils, Eosinophils, Basophils, Monocytes, Lymphocytes. See elevated levels with infection

Front 84

2. Chemistry Panel

Back 84

Routine tests that show health status. Eval electrolyte imbalance and body organs, nationally standarized, best if draw after 10-12 hr fast.

Front 85

Chemistry Panel - Basic Metabolic Panel (BMP) includes

Back 85

glucose
clacium
electrolytes (Na, K, CO2, Cl)
BUN
Creatinine
-R/t kidneys, acid/base, hydration status

Front 86

Chemistry Panel-Complete Metabolic Panel (CMP) BMP +others for liver function and includes

Back 86

ALP, ALT/SGPT, AST/SGOT (liver enzymes), Bilirubin liver waste), total protein, albumin

Front 87

3. Arterial Blood Gas (ABG)
Used to

Back 87

asses distrubances of the acid base balance, monitor effectiveness of O2 therapy, monitor O2 and CO2 levels

Front 88

ABG ordered for symptoms including:

Back 88

difficulty breathing, SOB, hyperventilation, decreased LOC. Blood is drawn from an artery and must go immediately to the lab

Front 89

ABG includes

Back 89

pH, PaCO2, PaO2, HCO3
O2 sat, Base excess

Front 90

4. Coagulation Studies

Back 90

used to determine the level of clotting factors especially when heparin and lovenox are used.

Front 91

Coagulation studies are ordered for:

Back 91

prolonged bleeding, screening for a hereditary clotting deficiency, monitor severity of deficiency, GI bleed, monitor effectiveness of medication trt.

Front 92

Coagulation studies include

Back 92

Activated Partial thromboplastin time, Prothrombin time, international normalized ratio

Front 93

Activated partial Thromboplastin Time (APTT)

Back 93

measures anti-thrombin III, used to investigate abnormal bleeding or clotting, part of heparin anticoagulation therapy, part of pre-surgical screen

Front 94

Prothrombin Time (PT)

Back 94

To check how well blood-thinning medication are working to prevent clots (coumadin), can detect and diagnose a bleeding disorder

Front 95

International Normalized Ratio (INR)

Back 95

part of teh PT used for standardized reporting of results

Front 96

5. Kidney function is ordered when

Back 96

Bad BMP, Meds (ABs, diuretics, CT scans bc of x-ray contrast that is put in to the body)

Used to monitor and trt problems related to kidney function

Front 97

Kidney Function: Urinary analysis (UA)

Back 97

measures color, appearance, pH, protein, crytalis, gravity, RBC, WBC, Glucose, Nitrites, Ketones,

Front 98

Kidney function: BUN and Creatinine

Back 98

waste products flitered out fo teh blood by the kidneys. Increased C may indicate a decrease in kidney function.
Creatinine: better indicator of renal function
BUN: affected by hydration

Front 99

7. Electrolytes

Back 99

order with heart failure, kidney and liver disease.
Ca, Na, K, Mg

Front 100

8. Culture

Back 100

used to detect presence of infection by bacteria or yeast in blood/sputum/urine/wound

Front 101

What is infection

Back 101

successful invasion of the body by a pathogen

Front 102

nosocomial infection

Back 102

infection acquired in a healthcare facility

Front 103

Chain of infection includes

Back 103

Infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

Front 104

Stages of infection

Back 104

incubation
prodromal
illness
decline
convolesence

Front 105

What is incubation stage

Back 105

from teh time of infection until manifestation of symtoms, can infect others

Front 106

what is prodromal stage

Back 106

appreance of vague symptoms, not all diseases have this stage

Front 107

what is illnes stage

Back 107

signs and symptoms present

Front 108

what is the decline stage

Back 108

number of pathogens decline

Front 109

what is the convolescence stage

Back 109

tissue repair and return to health

Front 110

Infection is classified by ____ and _______

Back 110

location and duration

Front 111

location classification

Back 111

localized-occurs in limited region
systemic-affects many regions

Front 112

duration classification

Back 112

acute-rapid onset of short duration
chronic-slow development, long duration
latent-infection present with no discernible symptoms

Front 113

Exogenous nosocomial infection

Back 113

pathogen acquired from healthcare environment

Front 114

endogenous nosocomial infection

Back 114

normal flora multiply and cause infection as a result of treatment (yeast infection)

Front 115

Primary Lines of defense

Back 115

Anatomical features-limit pathogen entry
(skin, mucous membrane, tears, normal flora in GI tract, normal flora in urinary tract)

Front 116

Secondary lines of defense

Back 116

biochemical processes activated by chemicals released by pathogens.
(phagocytosis, complement cascade, inflammation, fever)

Front 117

Tertiary line of defense

Back 117

humoral and cell mediated immunity. an Ab is produced in response to the presence of and antigen

Front 118

Factors that increase Risk

Back 118

1. Developmental stage
2. medications that inhibit immune response
3. nursing.medical procedures
4. Skin breakdown
5. illness/injury/disease
6. smoking
7. sex with many ppl

Front 119

Factors that support host defense

Back 119

1. adequate nutrition to maintain immune cells
2. balanced hygiene
3. rest/exercise
4. immunization

Front 120

Medical asepsis

Back 120

a state of cleanliness that decreases the potential for the spread of infection that is promoted through: a clean environment, hands, and CDC guidelines

Front 121

hand washing guidelines

Back 121

wash for at least 15 seconds in nonsurgical setting and 2-6 minutes in a surgical setting.

Front 122

Contact precautions

Back 122

pathogen is spread by direct contact.
Private room, gown, gloves, double bag

Front 123

Sources of Contact precautions

Back 123

open/draining wound, secretions, supplies, MRSA, C-difficile, VRE, intestinal tract pathogens

Front 124

Droplet Precautions

Back 124

pathogen is spread via moist droplet via sneezing, coughing, talking. Use private room, gown, gloves, double bag, plus mask and eye protection

Front 125

Droplet precaution pathogens

Back 125

large particle droplets (> 5 microns) pertussis, flu, adenovirus, rhinovirus, Group A Strept, Nesseria meningitides

Front 126

Airborne precautions

Back 126

pathogen is spread via air current and is < 5 microns. Useprivate room, gown, gloves, double bag, plus special mask and (-) pressure ventilation

Front 127

Airborne Precaution pathogens

Back 127

small particles: measles, chickenpox, TB, SARS

Front 128

Protecive Isolation or reverse isolation

Back 128

We are protecting the pt from us. use with immune compromised population. Precautions include: private room, nurse not assigned to pt with active infection, mask, handwashing, gown, gloves

Front 129

Antibiotic-Resistant Organisms (ARO)

Back 129

MRSA, VRE, MDRO

Front 130

Methicillin-Resistant Staphylococcus Aureus (MRSA)

Back 130

bacteria is normally found on skin/nares but get into body and cause infection. Can live on surfaces for months, may lead to sepsis

Front 131

Vancomycin-Resistant Enterococci (VRE)

Back 131

normally in intestines, but can cause infection. Spread by contact.

Front 132

Clostridium-Difficile

Back 132

Spore forming bacillus. Spread by contact, cure via donor stool transplant, trt: stop offering AB start metronidazole,

Front 133

Surgical Asepsis

Back 133

create a sterile environment/equipment

Front 134

layers of the skin

Back 134

epidermis
stratum corneum
stratum germinativum
dermis
subcutaneous layer

Front 135

factors affecting skin integrity

Back 135

age, mobility status, nutrition/hydration, sensation level, impaired circulation, medications, moisture, fever, infection, lifestyle

Front 136

classification of wounds

Back 136

open/closed
acute/chronic
clean/contaminated/infected
superficial/parital or full thickness
penetrating

Front 137

Serous exudate

Back 137

consists of serum, appears clear to yellowish

Front 138

Sanguineous

Back 138

bloody drainage, indicates damage to vessels

Front 139

Serosangineous

Back 139

mix of bloody and straw colored

Front 140

Purulent

Back 140

yellow to green; contains pus (leukocytes, liquified dead tissue, dead and living bacteria

Front 141

inflammatory wound phase

Back 141

begins immediately after injury, lasts 4-6 days, small vessels dilate adn become permeable, serous fluid leaks into traumatized tissue, result of histamine release

Front 142

proliferative wound phase

Back 142

begine 1-4 days after injury and lasts 14-21 days. rapid growth of epitheilial cells to produce protective covering around wound, rebuilding of vascular capillaries, tissue is very fragile

Front 143

Maturation-wound remodeling phase

Back 143

begins 14-21 days after injury and lasts upto 2 yrs. scar shrinks and thins, decreased redness, wound edges move towards center, healed scar is only 70% as strong

Front 144

wound healing process

Back 144

regeneration
Primary intention
secondary intention
tertiary intention

Front 145

regeneration

Back 145

when wound affects only epidermis, no scar, new epithelial cells can not be distinguished from intact skin

Front 146

Primary intention

Back 146

Simplest form of healing
clean surgical incision
edges clearly approximated
sutures or staples
top layer healing in 72 hours
surface seals
minimal scarring

Front 147

secondary intention

Back 147

heals by granulation
closes from bottom up
edges not approximated
sutures not used
tissue loss
heals more slowly, more prone to infection and scarring
burns, open wounds, pressure ulcers

Front 148

tertiary intention

Back 148

method that leaves wouldn open to heal
wound usually is infected an needs frequent irrigation and dressing change
granulating tissue brought together
delayed closure of edges

Front 149

factors affecting wound healing

Back 149

mobility, nutrition, high BG, low, hemoglobin, obesity, sensation, moisture, tobacco, medications, immunosuppressed

Front 150

Complications of wound healing

Back 150

hemorrhage, infection, dehiscence, eviseration, fistual formation

Front 151

what is dehiscence

Back 151

partial or toal rupture of a sutured wound. Usualy occurs within 4-5 days postop before extensive collagen is deposited

Front 152

What is evisceration

Back 152

protrucion of internal viscera through an incision

Front 153

goals of wound care

Back 153

remove necrotic tissue, prevent/control infection, absorb drainage, amintain a moist environment, protect the wound fron further injury, protect the surrounding tissue

Front 154

Nursing interventions: skin

Back 154

prevention, meticulous skin care, adequate nutrition, frequent reposition (q2h, prn), therapeutic mattresses, teaching

Front 155

nursing interventions: wound

Back 155

cleanse/irrigate, caring for drainage device, debriding a wound, dressing a wound, support/immobilize a wound, apply heat/cold

Front 156

Pressure ulcer

Back 156

main cause = unrelieved pressure to an area, results in ischemia

Front 157

Intrinsic factors in pressure ulcer development

Back 157

immobility
impaired sensation
inadequate nutrition
aging/fever
incontinence

Front 158

Extrinsic factors in pressure ulcer development

Back 158

friction, shearing, exposure to moisture

Front 159

Treating Pressure Ulcers RYB Code. RED

Back 159

usually in the late regeneration phase, gentle washing, protect with ETOH free barrier film, fill dead space, cover, change dressingas infrequently as possible

Front 160

Treating Pressure Ulcers RYB Code. Yellow

Back 160

liquid to semiliquid, often purulent. remove non-viable tissue, irrigate, absorbent dressing material

Front 161

Treating Pressure Ulcers RYB Code. Black

Back 161

covred with necrotic tisue or eschar, require debridement. sharp scaple or scissors, mechanical-more selective than sharp (enzyme agent used), autolytic-dressing with body's own enzyme to break down tissue