Nutrition
Elimination
Tissue Integrity
Sensory Perception
Fundamental Concepts
100

BMI Classifications

Underweight: below 18.5

Healthy Weight: 18.5-24.9

Overweight: 24-29.9

Obesity: 30 and above 

100

Minimum hourly urine elimination 

30 mL/hr

100

Serous drainage

clear, thin & watery drainage from a wound site 

100

Nursing interventions for the client who have vision loss

Call clients by name before approaching to avoid startling them, identify yourself, stay within clients’ visual field if they have a partial loss, give specific information about the location of items or areas of the building, explain interventions before touching clients, before leaving, inform clients of your departure

100

Informed consent

The legal process by which a client or the client’s legally appointed designee has given written permission for a procedure or treatment.

200

Manifestations of Malnutrition

Dry, brittle hair & nails; poor dental health; weakness & fatigue; flaccid muscles; prominent protrusions in bony areas; loss of appetite; mental status changes

200

what is CAUTI

catheter-associated urinary tract infection 

200

The Glasgow Coma scale

assessment used to obtain baseline assessment of the client’s level of consciousness and for ongoing assessment.

200

Rosenbaum test

type of eye examination to screen for presbyopia (impaired near vision or farsightedness)

200

Maslow’s Hierarchy of Needs

Guides the delivery of nursing care and priority setting when they identify a preferential order of client problems: physiological, safety and security, love and belonging, self-esteem, and self actualization. 

300

Risk factors for obesity

lack of physical activity, lack of sleep, genetics, medications, calorie intake, limited access to healthy foods, easy access to fast food and socioeconomic status

300

Nursing interventions for constipation

1. increase fiber & water consumption

2. give bulk-forming products 

3. administer stool softeners, stimulants, or suppositories as ordered by the physician 

4. encourage regular exercise 

300

Negative pressure wound therapy

vacuum-assisted closure system that removes pressure of a injury and aids in healing process 

300

Nursing interventions for sensory overload

Provide a private room, reduce lights and noises, offer the client earplugs and dark glasses if needed, provide orientation cues (calendars, clocks), limit visitors, reduce unpleasant odors, assist the client with stress reduction, ensure pain is adequately managed, schedule sleep to minimize interruptions.

300

Flow rates for Nasal cannula, Simple face mask, Partial rebreather mask, Non- rebreather mask & Venturi mask

Nasal cannula: 1-6 L/min

Simple face mask: 5-10 L/min

Partial rebreather mask: 10-15 L/min

Non-rebreather mask: 10-15 L/min

Venturi mask: 4-15 L/min

400

Cultural factors that affect nutrition

Islam: pork, alcohol, shellfish prohibited; Judaism: Kosher diet; Mormonism: alcohol/tobacco, coffee/tea discouraged; Catholicism: avoid meat on Friday's during lent

400

Client education for fecal occult blood specimen 

1. defecate in clean bedpan/bedside commode 

2. do not contaminate stool with urine

3. do not place toilet tissue in bedpan 

4. notify nurse as soon as possible after defacation

400

Cranial nerve assessment

assessment to determine all 12 cranial nerves functionality 

400

Define decorticate posturing

abnormal posturing that manifests as flexion and internal rotation of upper extremity joints and legs

400

pH levels of Metabolic acidosis vs. Metabolic alkalosis

Metabolic acidosis: pH > 7.45, loss of bicarbonate

Metabolic alkalosis: pH < 7.35, antacid overdose

500

Difference between enteral nutrition and parenteral nutrition 

Enteral: tube placed into the stomach/small intestine

Parenteral: tube inserted into a vein for nutrients to enter directly into the bloodstream

500

Steps for obtaining a catheter-urine specimen 

perform hand hygiene and don gloves, clean port with alcohol swab, insert needle and withdraw desired urine amount, transfer urine sample to specimen container avoiding contamination, then remove gloves, perform hand hygiene, label the specimen container and transfer to lab

500

Staging of pressure ulcers

stage 1: non-blanched, intact red skin

stage 2: open, shallow wound with red/moist wound base

stage 3: open wound, visible adipose tissue

stage 4: deep wound with exposed muscle, tendon and bone visible 

500

Patient education for the client with a new hearing aid

1. Use the lowest setting that allows hearing without feedback, 

2. To clean the ear mold, use mild soap and water while keeping the hearing aid dry.

3. When the hearing aid is not in use for an extended length of time, turn it off and remove the battery to conserve battery power and avoid corrosion of the hearing aid. Keep replacement batteries on hand.

500

Requirements for alcohol based waterless antiseptics vs. soap and water

Soap and water: if contamination with spores is suspected, visibly soiled or contaminated with blood or body fluids, c. diff. 

Alcohol based waterless antiseptics: preferred unless the hands are visibly dirty, because the alcohol-based product is more effective in removing micro-organisms

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