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35 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Tracheostomy care should be performed at least every _______. |
8 hours |
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A nurse is caring for a client that is high risk for aspiration. The nurse should instruct the patient to do which of the following? A) drink thin liquids B) tuck the chin when swallowing C) use a straw D) Lie down after meals to prevent nausea |
B) tuck the chin when swallowing |
Rationale: tucking the Chin when swallowing helps force food down the esophagus and helps close off the respiratory tract to prevent aspiration. Drinking thin liquids and using a straw both increase the risk of aspiration. |
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What instructions are important to include when teaching a diabetic patient about foot care? |
- do NOT soak feet due to risk of infection - nails should be filed straight across - dry feet thoroughly, ensure space between toes is dry - apply lotion/moisturizer to feet, do not apply lotion in space between toes - inspect feet daily for any injury, pain, or signs of infection - apply clean cotton socks - never go barefoot due to risk of foot injury |
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A patient with COPD presents with altered LOC, increased respirations, elevated BP, and tachycardia. What should be suspected? |
Carbon Dioxide Toxicity
Patient will eventually become Stuporous. Monitor O2 sat, provide Ventilatory support via CPAP/BiPap, and avoid excessive O2 concentrations/rate. |
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What condition is a potential complication of COPD that causes s/s of right-sided heart failure (JVD, extreme dyspnea, cyanosis, dependent edema)? |
Cor Pulmonale
= right-sided heart failure that occurs as a result of pulmonary disease. |
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What teaching should be provided to patients with COPD regarding strategies to manage symptoms and decrease the occurrence of acute exacerbations? |
1. Avoid environmental respiratory irritants (cigarettes, pollution, smoke) 2. Positioning: Upright & leaning forward (tripod position) to promote drainage of secretions & improve breathing. 3. Activity: Schedule activities to avoid over exhaustion, take frequent rest periods. 4. Breathing pattern: Purse-lipped breathing technique to promote CO2 expulsion. 5. Infection prevention: frequent hand washing, mouth care, etc. 6. Diet: high calorie, high protein foods in order to compensate for increased caloric demands caused by increased metabolic demand that results from increased work of breathing. 7. Medication: Strict medication compliance. |
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When reading the results of a Mantoux test, a positive result is indication by a palpable induration that is greater than ______ mm. |
Positive TB Test = induration of greater than or equal to 10 mm |
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The nurse is assessing a patient post chest tube insertion. The nurse observes crackling and determines that the patient has Subcutaneous emphysema. What is the correct nursing intervention?? |
The nurse should mark the affected area on the patient and monitor for its spread. If after an hour the affected area has spread, the nurse should notify the physician. |
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What preventative measures are used for immobile patients at risk for DVT due to limited mobility? |
• Elastic Anti-embolic Stockings or TED hose • SCDs & IPC • Positioning: to reduce compression on leg veins • ROM exercises • Anti-coagulants [Lovenox, Heparin] |
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What instructions are given to patients using a cane for the first time? |
• hold the cane on the STRONG (unaffected) side • keep TWO points on the ground at all times to maintain stability •advance the cane 6 to 10 in • then advance the AFFECTED side toward the cane. • Lastly advance the STRONG leg past the cane. |
Cane = strong side Maintain two points Cane 6-10 in first, then Weak LEG, last Strong Leg Past Cane |
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When instructing a patient on the proper use of crutches, the nurse should instruct the patient to position the crutches on the (STRONG/WEAK) side when sitting or rising from a chair. |
= position the crutches on the STRONG (unaffected) SIDE when sitting down or standing up. |
SITTING = STRONG |
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An older adult is brought to the ER by ambulance after collapsing while gardening. An assessment reveals that the patient is confused, tachycardic, tachypnic, hypotensive, and he has hot dry skin. What diagnosis is consistent with these s/s and what interventions should be used to treat this patient? |
The patient has s/s of heat stroke (confusion, increased HR & RR, hot dry skin). Interventions are aimed at rapidly cooling the patient. • remove pt's clothing • place ice pack's over major arteries [axillae, groin, chest, neck]. •immerse in cold-water bath • after patient is wet, use fan to rapidly move air over body. |
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The nurse is d/c a patient with chronic respiratory issues that requires portable oxygen. What teaching should the nurse provide the pt and their family regarding oxygen safety measures? |
•Storage: Follow manufacturer directions regarding storage of O2 containers (upright) • smoking: post a "no smoking" sign on front door, instruct family to smoke outside • electrical safety: ensure that all electrical devices are grounded, no frayed cords, etc • static electricity: remove all bedding capable of creating static electricity & combustion (wool, nylon, & other synthetics), replace with cotton. • flammable materials: heating oil, nail polish, alcohol, acetone should not be used near pt •Fire Safety: install smoke detectors, & fire extinguishers; plan an escape route. |
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A nurse caring for a patient in the second stage of labor who is experiencing repetitive and prolonged variable decelerations. The nurse prepares to assess the patient's labor progression and observes a portion of the umbilical cord protruding from the vaginal opening. What nursing interventions are indicated? |
NI's for Umbilical Prolapse: 1) call for help and stay with patient 2) notify the provider 3) Administer 100% O2 by facemask 4) Reposition the pt: knee-chest, trendelenburg, or left-lateral position 5) Continuously monitor FHR 6) Apply a warm moist sterile dressing/gauze to protruding portion of cord to prevent drying & maintain blood flow. 7) Initiate IV (if not already in place) & administer IV fluid bolus to increase BP 8) If decals continue, attempt to relieve compression of cord by inserting two sterile gloved fingers & applying pressure to the fetal presenting part 9) prepare for emergency c-section |
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Each unit of PRBC's increases Hemoglobin by ______ g/dL and Hematocrit level by _____ %. However, it takes approximately ______ to ______ hrs for levels to increase. |
Each unit of PRBC's increases HGB by 1 g/dL and Hematocrit by 3%. However, it takes 4 to 6 levels to rise. |
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A nurse who initiated the infusion of 2 units of PRBCs 10 Minutes ago and is monitoring the patient for s/s of immediate transfusion reaction. What signs should the nurse be assessing the patient for ? |
•chills & diaphoresis • rapid thready pulse • back pain, chest pain, aches • hives, rash, itching • SOB & wheezing •numbness & tingling • pallor, cyanosis • N/V/D & Abd cramping |
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The nurse is taking a health history for a newly admitted patient. The patient states that she is a vegetarian and strictly adheres to a vegan diet. What nutritional deficit is this patient at risk for based on her dietary choices? |
• Vitamin B12 • Vitamin D *vegan diet = no meat, no eggs, no milk or dairy. |
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Small pox, anthrax, hemorrhagic fevers & plague are all what category of Biologic agent? |
Category A = highest priority due to ease of transmission, high mortality rate |
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What are the manifestations of Ebola? |
Fever, hemorrhage, Vomiting, diarrhea, cough, jaundice, shock |
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What is the difference between a consultation and a referral? |
A consult = the expert opinion of an individual regarding the level of care needed to treat the patient
Referrals - provide the patient with access to specific health services, community resources, and specialty care.
*ex/ a patient presenting with cough and SOB would receive a consult by respiratory/pulmonology department that would make recommendations for the patient's treatment. Referrals would then be made (based on that consult) to specific services such as RT, smoking cessation, infectious disease if TB is suspected, ryc |
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What is the nurse's role regarding patient valuables? |
At Admission: • nurse inventories client's personal items including: dentures, clothing, money, credit cards, cell phones, assistive devices, medications, religious articles. • the patient signs a form acknowledging what is being kept at bedside, valuables being placed in safe, medications being secured in pharmacy, articles being sent home with family members. • nurse documents in patient chart that inventory has been completed
D/C: nurse ensures that items locked up are returned to patient & patient acknowledges receipt of these goods. |
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A nurse is performing an admission assessment on a patient. After gathering data & performing a ROS which of the following is the priority action? A) orient pt to room B) conduct a care conference C) review patient's medical orders D) develop Plan of Care |
A) orient patient to room - this is the priority because it poses the greatest SAFETY risk to patient (falls, injury, use of call bell to call for help) |
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What information should be provided when transferring a patient to another unit or facility? |
- demographics (age, gender, religion, etc) - medical DX & PCP - overview of health status, POC, recent progress (stable, chronic disease, etc) - immediate concerns regarding alteration in condition - most recent v/s and meds - allergies - specialized equipment or adaptive devices [oxygen, cane, suction, wheelchair] - advance directive & code status - family involvement |
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Maintaining Sterile Field: - top flap: open away from body - open side flaps with same hand (right flap/right hand) - set up with items being used first closet and items to be used last the furthest away - open packaged items and add directly to field maintains 6 inch distance above - pouring solutions: open cap and place cap face up on clean, non-sterile surface *hold bottle with label in Palm *first pour 1-2 mL into receptacle, then without splashing pour solution directly into gauze, dressing or site. |
Sterile Gloves 1) use bare non-dominant hand to pick up dominant glove, touching only inside of cuff 2) use dominant sterile gloves hand to pick up non-dominant hand gloves touching only the outer under side of cuff |
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Strategies for lifting heavy objects or patients |
- Use major muscles groups - tighten abdominal muscles - distribute weight between arms and legs - when lifting from floor: flex hips, knees, and back. Lift to thigh level keeping knees bent and back straight. Stand, keeping object as close to body as possible. |
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Ergonomic principles for: Pushing and pulling |
- Widen base of support by spreading feet - pull objects rather than push if possible - pushing: move front foot forward - Pulling: move rear leg back - use own body weight as counterweight to increase stability - avoid twisting the thoracic spins or bending back when knees are bent |
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What are the health risks for Asian-American, African-American, and Latin-American patients based on traditional diet and food preparation techniques? |
Asian American- High SODIUM African American- high in FAT, Animal PROTEIN, and SODIUM and low in potassium, calcium, and fiber Latin-American - frying in LARD, increased use of butter & oil, substitution of traditional fruit drinks for sugar laden drinks. |
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Although albumin is most frequently used as a means of assessing a patient's nutritional status, _____________ is actually more representative of current nutritional level and less affected by non-nutritional factors such as injury & kidney disease. |
Prealbumin NR = 23-43 mg/dL *not commonly used because it is a more expensive test than the widely used albumin. |
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What nutritional education should the nurse provide a pregnant patient in the first trimester regarding the need for additional caloric intake in the first, second, and third trimester? |
First Trimester = no need for increased caloric intake. Second Trimester = intake should be increased by approx 350 calories/day Third Trimester = an additional 450 calories is recommended |
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A nurse is talking with a client at her first prenatal visit. The patient asks how much weight she should gain through out the pregnancy. The patient is a normal weight and height with a BMI of 22. How should the nurse respond? |
25 - 35 lbs is recommended gain for women of average size and healthy pre-pregnancy BMI. |
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A nurse working in a OBGYN office is caring for a 26 year old women with the metabolic disease PKU. The woman is recently married and states that she and her husband were planning to start a family this year. What information should the nurse provide the patient regarding PKU and pregnancy? |
• Women with PKU disease who plan to become pregnant should be instructed to resume the PKU diet at least three months prior to pregnancy and t/o the pregnancy. |
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Primary Prevention strategies aimed at reducing violence in the home & community include: |
• teaching conflict resolution & anger management • parenting classes to provide anticipatory guidance on expected age appropriate parental responses & discipline • preventing elder injury by educating community on ways to provide safe environment • respite services for primary care givers of elder adults to reduce stress and decrease social isolation • make support services known to individuals most likely to need assistance & reinforcing that no one deserves to be abused |
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The screening of ALL pregnant patients for potential abuse is what level of preventative care? |
= Secondary Prevention * this level of care addresses needs of individuals who are specifically at risk - domestic violence frequently occurs for the first time during pregnancy or increases if already occurung. |
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Providing grief Counseling services for families of suicide or homicide is what level of healthcare? |
= Tertiary prevention * this level focuses on long term treatment of individuals that have already experienced violence, have already lost a loved one, those who have committed acts of abuse ... In order to facilitate recovery, and minimize the effects. |
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What are primary, secondary, & tertiary prevention strategies to address the issue of substance abuse? |
Primary - increasing public awareness of the dangers of drug and alcohol abuse, provide education to young people Secondary - screening of individuals for maladaptive behaviors associated with substance abuse. Tertiary - providing emotional support to families dealing with substance abuse, referring individuals with substance d/o to community programs such as AA or NA or ALANoN |
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