Lab Values, Fluids, & Acid-Base
This electrolyte has a normal range of 3.5-5 mEq/L and plays a crucial role in cardiac and neuromuscular function.
What is potassium?
This syndrome/state is best described as the body's tissue receiving inadequate oxygen.
This acronym that forms the logical, problem-solving approach of nursing is the framework of the care that is provided.
What is ADPIE(Assessment, Diagnosis, Planning, Implementation, and Evaluation)/
What are education and research?
This federal statute provides rights to patients with their privacy and security in regard to protected health information(PHI).
What is Health Insurance Portability and Accountability Act (HIPAA)?
This should be obtained before any sedation is administered.
Informed Consent
This is how aa person interprets the impact of a stressor.
What is appraisal?
This electrolyte imbalance frequently seen in alcoholics is best known by its tendency to cause tremors, hyperactive deep tendon reflexes, and confusion.
What is HYPOmagnesemia?
What is Chronic Obstructive Pulmonary Disease?
This method of teaching is paramount in patient education and is supported in Evidence Based Practice/Research.
What is the teach-back method?
This electronic documentation format/system only focuses on a single encounter with a patient.
This best describes conduct that falls below the standard of care in comparison to someone who is reasonably prudent.
What is negligence?
This nurse manages the overall operating room outside of the sterile field.
What is a circulating nurse?
These are the three stages of physiological processes that prepare the body for danger.
What are the alarm, resistance, and exhaustion stage?
This compartment in an adult comprises neither the most, nor the least amount of fluid found in the body.
What is the interstitial space?
This bedside device used by the patient ideally will resolve fine inspiratory crackles post-surgically.
What is an incentive spirometer?
Measuring of success within the evaluation phase of the nursing process should begin by doing this.
What is patient-centered evaluation?
This is the specialty in nursing that specifically looks at nursing science when integrated with computer science and another interdisciplinary specialty.
What is nursing informatics?
These laws at the state level exist to protect citizens and hold nurses accountable for their actions.
What is reverse Trendelenburg or side-lying?
These are the five stages of grief in order.
What are denial, anger, bargaining, depression, and acceptance?
This physical assessment is one of the most critical and obvious indicators of fluid status.
What are daily weights?
Obesity, trauma, and central nervous system alterations are all examples of factors that affect this which will then potentially impact oxygenation.
What is chest wall movement?
You walk into a patient's room and introduce yourself while preparing to educate them on the at-home maintenance of their pressure injury. The patient responds to your introduction with "Hello. Nice see you. Why you here?" This is the priority next step that the nurse should take before educating this patient.
What is assess their orientation, English proficiency, and cognitive abilities.
A nurse documents the following on a patient:
"Pt receives 2tqhs po when BP WDL on DNO. WMF."
This is an example of what standard of quality documentation being ignored.
What is appropriate use of information?
This federal statute requires that healthcare institutions provide patients with written information to make decisions about their care, including the right to formulate an advance directive.
This scale is used post-operatively to assess consciousness after being medicated intra-operatively.
What is the Pasero Opioid-Induced Sedation Scale?
A 42-year-old patient with metastatic breast cancer is beginning a new chemotherapy regimen. She reports severe anxiety about her symptoms, difficulty sleeping, chronic pain that is poorly controlled by her current medications, and increasing strain on her family who is struggling to coordinate her appointments. She states, “I want to keep fighting the cancer, but I need help managing everything else that’s going on.”
This interdisciplinary approach should be recommended and can be provided alongside curative treatment and focuses on symptom management, psychosocial support, and improving quality of life.
What is palliative care?
These are the four key properties of bodily fluid balance.
What are volume, osmolality, electrolyte concentration, and pH?
A patient presents to the emergency department with a gun shot wound and profuse hemorrhaging. This physiological factor is precipitated by the trauma leading to oxygenation issues.
What is hypovolemia?
Planning and outcome identification is best facilitate when these three key portions of planning are present.
What are patient participation, setting priorities, and teamwork/collaboration?
When claims of malpractice or negligence are brought onto a nurse, this will be used in court to defend against the claims as a central source of information.
What is a legal record of care?
After being given education by the physician and signing the informed consent form pre-surgically, the patient states that they want to know the name of their anesthesiologist. This will be the response of the nurse.
What is "I will contact the provider/anesthesiologist to make sure that you are fully informed"?
You walk into a patient’s room and find food trays spilled on the floor, IV pump alarming, bed alarm going off, oxygen tubing disconnected, urinal spilled, linens soiled, call light on the ground, and the patient halfway out of bed grasping the side rail with labored breathing. This is the nurses priority action upon entering the room.
What is assess the patient’s immediate physiological safety by evaluating airway, breathing, circulation, and preventing active harm?
What is complicated grief that is masked?
A 42-year-old patient arrives with severe anxiety, tingling around the mouth, hand tremors, and a single episode of vomiting earlier in the day. They have a history of asthma and current respirations are 32.They present to the ED with lab-evidenced over-release of carbon dioxide. This bodily response is the most likely pseudo-compensatory response.
Fainting
A patient with a baseline O2 of 88% and a history of COPD is desatting to less than 80% and is unresponsive. After successful resuscitation and placing the patient on 6L oxygen, the nurse receives an order to suction the patient and introduce the suction catheter 3 times at bedside and proceeds to do so. This is the priority education point that the charge nurse intends to provide in this situation.
What is “Suctioning should never exceed two passes and must only be done when secretions are present, because each pass can worsen hypoxia in a recently unstable COPD patient"?
While assessing a large, deep pressure injury on the patient’s sacrum, the nurse notes that the wound appears very deep with a strong odor and thick drainage. The wound edges are rolled, and there is a central black eschar with surrounding yellow slough that completely obscures the wound bed. Upon palpation, the nurse believes they feel firmness. This would be the stage of this PI.
What is unstageable?
When requesting for reimbursement of care, this document will be provided in order to account for the costs appropriately.
A nurse is shopping at a mall and sees that a man is on the ground with a large group of people around them. The nurse runs over and finds that the man is unconscious with an obstructed airway. The nurse remembers that when they work in the ED, an emergency tracheotomy is performed in order to allow for ventilation. The nurse performs this on the patient with a hollow writing utensil tube and the patient lives. Later on, the patient comes back and sues the nurse. The likely outcome of this case will be this due to this state statute.
What is "the nurse would lose in court" and Good Samaritan Law due to the procedure being outside of her scope?
A patient presents to a neuro-surgical unit after brain surgery with a productive, barking cough. Upon assessment, the patient is A&Ox4, unable to hear out of right ear, is able to distinguish scents between both nostrils, and their bed is in the lowest position. This is the priority action for the nurse providing care for this patient.
What is reach out to the physician to discuss cough-management techniques due to potential for increase of pressure in head post-surgically?
The following is an example of this: A 29-year-old patient who recently lost a parent describes persistent insomnia, headaches, and difficulty concentrating. He reports that in his culture, openly expressing grief is discouraged and considered a sign of weakness. Although he continues working, he says he feels “numb,” increasingly fatigued, and unable to relax. Physical assessment shows elevated blood pressure and tachycardia despite no medical history of hypertension. Before planning interventions, the nurse must determine whether the patient’s ongoing physiological arousal is causing cumulative strain on the body due to chronic, unrelieved stress.
What is allostatic load?