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What does the medical term STAT mean?
One time order right now!
An 82-year-old male patient is admitted with vomiting and diarrhea. On assessment, you note that he is apprehensive, and his skin is cool, dry, and pale. His pulse is rapid, and his blood pressure is lower than normal. These symptoms are indicative of:
1.Fluid overload.
2.Electrolyte imbalance.
3.Dehydration.
4.Intestinal flu.
3!
Apprehension; cool, dry, pale skin; a rapid pulse; and lower blood pressure are indicative of dehydration.
how do you properly administer eardrops to adults or children over the age of 3
Pull the auricle upward and outward
A patient, 1 day postoperative, is receiving an analgesic via PCA pump. The patient reports that the pain is not being controlled adequately. The first action the nurse should take is:
1.Contact the surgeon to increase the dose.
2.Try nonpharmacologic comfort measures,
3.Deliver the bolus dose per standing orders.
4.Assess the pain for location, quality, and intensity.
4
The first step should be to assess the pain for location, quality, and intensity of biofeedback. Depending on the assessment findings, either comfort measures can be instituted or a rescue bolus as ordered may be administered.
What needle should be used for an IM injection?
What needle should be used for a SUB-Q injection?
IM- 1.0 - 1.5 inch needle
SUB-Q- 3/8 5/8 or 1/2 inch needle
While passing out morning meds, the nurses patient states " I have never taken a round yellow pill before.", what should the nurse do next?
Re-check the medication against the order to ensure this is the right medication and to reassure the patient.
When instructing a patient about an MRI test, you would explain that:
1. it is necessary to hold very still during the test
2. heavy sedation is provided before the test
3. loud noise will be heard during the test
4. Communication with the technician is possible
5. relaxation is achieved using soft music
1, 3, 4
An MRI requires that the patient remain very still during the test; loud noises will be heard during the test; and communication is possible with a speaker system inside the scanner. Although the patient is offered music choices, soft music will be inaudible due to the noisy clicks and banging the MRI machine produces.
A patient insists on leaving against medical advice, what are the nurses priorities in this situation
Notify PHCP asap.Offer to ask the MD to talk to the patient, listen to what they have to say. Obtain a signature stating that the patient understands that this is going to affect their health, the MD will not be able to write a prescription and insurance may refuse to pay the hospital bill which will leave them responsible for paying out of pocket.
TIP: if Pt. refuses to sign AMA form, Document the refusal, names of witnesses and reason for Pt. leaving AMA!
What occurs when fluid volume deficit, causes loss of water from the cells in our body?
Dehydration!
Before administering a IM injection the patient states " I'm scared of needles. I don't want this to hurt. Im not ready." What should the nurse say next to reassure the patient.
1. Your doctor ordered me to give you this shot at 1400 and it is now 1405 I am now going to have to give this to you right now
2. Its okay, it won't hurt, just think positively
3. Im very experienced, I know how to give painless injections
4. Its okay, it will hurt, but it will be over before you know it
5. im ordered to give this regardless of your opinion
4!
Injections will always hurt! it is important we refrain from lying or giving false reassurance to our patients.
Factors that can adversely affect sleep include: (Select all that apply.)
1. Alcohol consumption near bedtime.
2. A rotating shift schedule.
3. A very quiet environment.
4. Watching television in bed.
5. Reading a book in bed.
6. A cool bedroom.
1, 2, 4
Factors that can adversely affect sleep include alcohol consumption near bedtime, a rotating shift work schedule, and watching television in bed.
How do you properly administer eardrops to a patient under 3 yrs. of age?
Straighten the external ear canal by pulling down and back
What are the main indicators of pain via the Pt.
Moaning, crying, irritability, inability to sleep, grimacing or frowning.
How do you properly administer eyedrops?
Gently pull down the skin below the eye to expose the conjunctival sac
Administer drops into the center of the conjunctival sac
Apply gentle pressure to the lacrimal duct with tissue fro 1-2 minutes to prevent systemic absorption
Instruct Pt. to keep eye closed for an additional 1-2 minuets
Which action by the nurse indicates proper technique for performing ACCU-check
1. Leaving the patient with an alcohol swab incase of excess bleeding
2. Wiping the first drop of blood with cotton
3. Sticking the needle on the flat part of the finger
4. Only sanitizing the finger when done obtaining blood
2!
wiping the first drop of blood with alcohol can contaminate the blood
orders are verified and signed off by:
1. the unit secretary
2. the licensed nurse
3. the physician
4. the nursing supervisor
2
Orders are transcribed by the charge nurse or unit secretary but are verified and signed off on by the RN or LVN.
Glucose, Proteins, Fatty acids, and Amino acids are all considered Electrolytes or non-electrolytes?
NON-Electrolytes!
They remain bound together when dissolved in body fluid. Whereas Electrolytes break up into ions in body fluid.
When does discharge planning start?
At admission!
Discharge planning starts at admission to ensure Pt. will reach all goals by discharge
in caring for a patient receiving opioids, it is most important to monitor for what?
1. Nausea and vomiting
2. Respiratory depression
3. Hypotension
4. Constipation
4
Constipation is the most common side effect of opioid analgesics and can cause bowel impaction if not treated early.
What is the normal blood pH?
7.35-7.45
The older adult is at greater risk for dehydration than the middle-aged adult because: (Select all that apply.)
1.Older adults have a diminished sense of thirst.
2.Older adults have less muscle mass as years advance.
3.The older adult's body is almost 80% water.
4.Compensatory mechanisms work less efficiently.
5.Older adults have increased surface area and more evaporative losses.
1,4!
The older adult does have a diminished sense of thirst; compensatory mechanisms work less efficiently in older adults and don’t quickly correct dehydration
What are the main types of pain?
Acute, Chronic, nociceptive, neuropathic, and phantom
Which action from the nurse ensures that the nurse knows proper PEG tube medication administration:
1. The nurses mixes all PEG tube meds to give at once to decrease discomfort of the Pt.
2. Administers PEG tube meds by gravity 17 feet above the stoma
3. Mixing each med with water and administering separately
4. Flushing the tube only before administering feed to reduce patient discomfort
3!
Meds should never be mixed together. Meds should always be mixed with water
What should a nurse recommend to a patient with insomnia?
1. Increase activity 30mins to an hour before bedtime
2. Decrease consumption of sugary foods throughout the day
3. Implement daily exercise into lifestyle
4. Avoid taking naps throughout the day
5. Encourage waking up at 11am to increase hours of sleep
4
avoiding naps throughout the day can reduce insomnia
What is the purpose go an occult stool specimen test
To check for occult blood in the stool frequently caused from GI bleeds