Fluid and Electrolyte
Name the normal ranges for
Sodium, Potassium, Chloride, Calcium, Bicarbonate, Magnesium, and Phosphorous.
Sodium- 135-145 Potassium- 3.5-5
Chloride- 95-105 Calcium- 8.5-10.5
Bicarbonate- 22-26 Magnesium- 1.6-2.6
Phosphorous 2.5-4.5
What are the 10 rights
Medication Education
Dose Assessment
Patient Evaluation
Route Refusal
Time
Documentation
What is the difference between friction and shearing?
SHEARING:
INJURY OF DEEPER LAYERS
FRICTION:
TOP LAYER OF SKIN IS AFFECTED
The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?
A: Antibiotics
B: Frequent change of position
C: Oxygen humidification
D: Chest physiotherapy
B: Frequent change of position
True or False: An RN delegates to the LPN to administer a scheduled tube feeding to a patient. The RN has now transferred full accountability to the LPN for the task getting done, and the RN is no longer accountable for the task.
False
Insensible fluid losses include:
perspiration (sweat)
What is the use of a pill splitter and what meds cannot be split?
The use of a pill splitter is for a clean cut
Capsules
Enteric-coated
Extended release
What are the 4 phases of wound healing?
1. Hemostasis -first 60 minutes
2. Inflammatory Phase or Defensive Phase -Lasts 1-5 days
3. Proliferative Phase - 5-21 days
4. Maturation Phase -21 days to 3-6 month
Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient?
A: Postural drainage
B: Chest percussion
C: Incentive spirometer
D: Suctioning
C: Incentive spirometer
List the Five Rights of Delegation
Right task
Right circumstance
Right person
Right direction/communication
Right supervision
Etiologies associated with hypocalcemia may include all of the following except:
renal failure
inadequate intake calcium
metastatic bone lesions
vitamin D deficiency
metastatic bone lesions
What are the Medication MAR Three checks?
Pull med and compare information on unit dose package or on label of bottle to MAR (FIRST CHECK)
THIRD CHECK is completed in the room with the patient and the MAR
Which of the following characteristics are most likely that of a stage 4 pressure ulcer?
A. eschar
B. blister
C. shallow crater
D. nonblanchable redness
A. eschar
A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status?
A: Increased breathlessness but increased activity tolerance
B: Decreased breathlessness and decreased activity tolerance
C: Increased activity tolerance and decreased breathlessness
D: Decreased activity tolerance and increased breathlessness
D: Decreased activity tolerance and increased breathlessness
On your unit there are two RNs: one is a new RN while the other is an experienced RN. In addition, there are three LPNs and two nursing assistants. Which tasks delegated to one of the nursing assistants by the new RN needs to be re-evaluated?
A and B
Marie Joy’s lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated?
In a client with hypocalcemia, a positive Trousseau’s sign refers to carpopedal spasm that develops usually within 2 to 5 minutes after applying and inflating a blood pressure cuff to about 20 mm Hg higher than systolic pressure on the upper arm.
The nurse is giving morning medications to patient who refuses to take an oral dose of docusate (Colace).What is the nurse's best response?
a. your prescriber ordered that you must take this drug twice a day.
b. docusate will soften your bowel movements so that you do not strain
c. this drug will help prevent constipation while you are on bed rest.
d. can you tell me why you do not want to take the docusate?
D. can you tell me why you do not want to take the docusate?
What term refers to pale, red and watery drainage from a wound?
A. serous
B. sanguineous
C. serosanguineous
D. purulent
C. serosanguineous
serous - clear, watery, plasma
sanguineous - bright red, active bleeding
purulent - thick, yellow, green, tan or brown (pus)
Which of the following statements made by a student nurse indicates the need for further teaching about suctioning a patient with an endotracheal tube?
A: "Suctioning the patient requires sterile technique."
B: "I'll apply suction while rotating and withdrawing the suction catheter."
C: "I'll suction the mouth after I suction the endotracheal tube."
D: "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."
D: "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."
What are the 3 types of communication in an effective team?
Hint- a non effective team could have 2 people talking but no one receiving the info.
Sender
Receiver
Feedback
Khaleesi is admitted in the hospital due to having lower than normal potassium level in her bloodstream. Her medical history reveals vomiting and diarrhea prior to hospitalization. Which foods should the nurse instruct the client to increase?
The client with hypokalemia needs to increase the intake of foods high in potassium. Orange juice and bananas are high in potassium, along with raisins, apricots, avocados, beans, and potatoes.
In which of the following ways can a nurse prevent injury from a needlestick?
a. recap the needle before disposal
b. remove the needle from the syringe
c. immediately discard the needle and syringe in a puncture-proof container
d. stick it into the patient's mattress until it can be disposed of.
c. immediately discard the needle and syringe in a puncture-proof container
Which of the following are functions of dressings? (select all that apply)
A. promote hemostasis
B. keep wound bed dry
C. wound debridement
D. prevent contamination
E. increase circulation
A. promote hemostasis
C. wound debridement
D. prevent contamination
We don't want to keep the wound bed dry and dressings don't increase circulation
What is the special circumstance with patients with COPD?
Giving too much oxygen can cause hypoventilation because the drive to breath is decreased
8. Select all the task you could delegate to a nursing assistant as the RN:
C, D, and E