Skin Integrity
Mention the vitamins that promote wound healing
What is Vitamin A promotes healing through epithelization, collagen formaiton
Vitamin C promote healing through collagen
Protein major structural component of cell reproduction
Mention components when assessing respiratory system
what is inspection, palpation, percussion, aucultation
What is counting respirations, assessing lungs, pulse oxymetry,
Mention nursing interventions prior to performing oropharyngeal or endotracheal suctioning?
What is assess respiratory rate, pulse oxymeter, assess lungs, hyperoxygenate patient?
What are the nursing interventions the nurse should do before administering regular insulin?
What is check expiration date, ensure is clear without any crystal or sediments. Inject the amount of air before of desired insulin.
What is perform accu check, clean site with alcohol
select site.
mention the correct methods when cleaning a wound?
what is cleaning wound 0.9% (NS) lightly before collecting specimen
Mention the areas in the body that increase for decubitus ulcer
What is all bony prominences; shoulders, elbows, coccyx, heels
Mention manifestation of hypoxia
Early signs of hypoxia
what is tachypnea, tachycardia, restlessness, anxiety, confusion
pale skin mucous
Late signs: stupos, cyanotic, bradypnea, ATI pg 324)
Client presents with chest pain, what are the diagnostic test healthcare provider will order?
What is cbc, check blood count
sma7, check labs; NA, K, C02, HC02, Bun, creat. glucose
cardiac enzymes, check degree of damage of heart EKG- electrical conductivity
What are the effects of opiods on cardiovascular clients?
Opiods help decrease pain,
facilitates deep breathing respirations improving tissue perfussion
Which laboratory test indicate poor wound healing?/dl
What is serum albumin of less than 3.5 g
What is evisceration?
What is a dehiscence that involve protrusion of the visceral organ through wound opening?
Mention nursing interventions when doing chest physiotherapy
schedule treatments 1 hour before or 2 hours after meals
administer bronchodilators or nebulizer 30 min. to 1 hour before
apply percussion
ATI pg 328 Nursing interventions
Mention nursing interventions for chest congestion?
What is chest physiotherapy?
What is increase fluid intake?
What is effect of calcium channel blockers?
Name a few of the calcium channel blocker
What is decrease blood pressure?
what are the types of isolation and provide one example
what is Droplet- via droplet transmission meningococal pneumonia
What is contact- VRE, direct contact, Vancomycin resistant enterococci (VRE)
What is airborne- varicella/chicken pox, TB
Protective- what is weakened immune system, cancer, HIV
mention nursing interventions to prevent skin trauma
what is to reposition client in bed q 2 hours
keep head of bed at least 30 degree angleraise heels off the bed
Ambulate client as soon as possible
instruct client to shift their weight q 15
Keep client from sliding down avoid friction
Use supportive devices to move clients
mention steps of nasotracheal suctioning
use sterile technique, suction pressure of 120-150 mg/hg
limit each attempt to no longer of 10 -15 seconds apply intermittent suction
do not pass more than two passes witht he catheter Allow one min between passes ATI pg. 328-329
What nursing action must a nurse do prior to giving digoxin?
What is check apical pulse?
Mention some of the nursing action the nurse should perform prior to medicate calcium channel blocker
what is check Identifiers x2?
What is check expiration date?
What is checking 5 rights?
What is check vital signs esp. blood pressure?
Mention foods high in protein
poultry, grilled salmon, eggs, fish, are complete proteins
Mention the types of drainage noted when cleansing a wound
what is serous drainage- portion of blood ( serum) thick and reddish
sanguineous contains both serum and blood
serosanguineous contains both both serum and blood. looks pink and pale due to mixture
purulent- indicates infection, contains debri and bacteria
purosanguineous- mixed drainage pus and blood
Mention the physiological changes of fluid overload?
What is increased respirations, increased blood pressure, increased tachycardia?
What are nursing interventions the nurse should have before taking a blood pressure?
What is checking right size of blood pressure cuff,
what is legs uncrossed, what is keeping both arms above heart
What is checking equipment is working well?
What are the nursing actions the nurse should do when administering nitroglycerin?
What is checking Pt's ID x2,
What is expiration date, take vital signs?
Recheck blood pressure after 5 minutes, repeat if pain continues.
May repeat medications x3 doses
mentioned complications from immobility
what is contractures
what is crackles in lungs
what is pressure ulcer
What is constipation
What are different types of wound drain?
What is jackson pratt (prevent fluid accumulation)
What is wound vacccum help remove fluid
what is a pen rose drain remove drain
What are classical signs and symptoms of emphysema?
What is barrel chest, nail clubbing, dyspnea, purse lip, decreased pulse oxymeter?
Mention some of the signs and symptoms a client with left heart failure will present with?
What is hacking cough, shortness of breath, orthopnea, cyanosis,tinged blood sputum
mentioned nursing instructions when teaching a client on the use of metered dose with inhaler
Breathe out completely.
what are the signs of symptoms of Right heart failure?
What is hepatomegaly, ascites, splenomegaly, anorexia
jugular vein distention