Unit 1
The radial pulse is slower than your apical pulse.
What is a pulse deficit?
My patient has tuberculosis. What PPE should be worn?
Name 4 out of 6 listed.
N95
Gown
Eye Protection
Gloves
Shoe covers
Hair bonnet
When a nurse suspects consolidation, what breath sounds might she hear?
Absent breath sounds.
a low BUN is commonly caused by this fluid imbalance.
Fluid volume excess.
What is the average residual amount of urine for younger and older adults?
50 mL to 100 mL
Early signs of hypoxia putting a patient at risk for hypoxemia may include
Confusion
Restlessness
Tachypnea
Tachycardia
Pallor
Give an example of when a nurse CAN NOT delegate vital signs to a CNA.
New admission to facility.
Unstable after surgery.
When receiving an IV that can affect vital signs.
If the patient is pale, cold, and clammy.
After a cardiac catheterization, a nurse should place her patient in what position?
Reverse Trendelenburg's
How does a nurse assess edema?
Apply pressure over a bony prominence for 2 seconds.
A common electrolyte imbalance when administering furosemide and causes muscles weakness.
Hypokalemia (Low potassium levels)
A patient who performs self-catheterization MUST always wash their hands before donning gloves.
True or False
True
What is ethnocentricity?
Recommending one's own favorite foods.
Offer the patient fluids at least every 2 hours.
Assist the patient with toileting at least every 2 hours.
Remove it and reposition every 2 hours.
Guidelines for a patient who is restrained.
Stimulates circulation.
Prevents pressure ulcers.
Can stimulate the vagus nerve.
Can cause bradycardia.
What can the nurse establish from heart sounds? Name 3 things.
Intervals between heartbeats.
Compare the radial and apical pulse.
To be able to chart distinct heart sounds when clearly heard.
To listen to apical pulse for a full minute.
To document the rate for the apical pulse.
This is an unexpected symptom of hypocalcemia.
Constipation
Renal stones
A diversion that prevents constant draining of the urine is called what?
Continent urostomy
What is the recommendation from the My Pyramid food management system is given for fruits and vegetables?
Half of our plate should be fruits and vegetables, with the majority of that half being vegetables.
A vest restraint, when applied properly, the crossover will be located where?
In the front.
Some signs of acute pain may include (Name 3 responses)
Dilated pupils
Syncope
Increased heart rate
Reduced attention span
Name 3 interventions for a patient with fluid volume overload.
Monitor the effects of diuretic therapy.
Obtain daily weights on the same scale.
Assess intake and output every shift.
Encourage compliance with fluid restriction.
Educate about hidden sodium in foods.
Respirations seen in a patient with Respiratory Alkalosis
Hyperventilation
(The body responds by slowing the respirations down)
A bowel segment that loses its blood supply places the patient at highest risk for needing this surgical procedure.
a Colostomy
Rapid respirations are the body’s natural compensation for this pH imbalance.
What is alkalosis (Ph over 7.5)
Name one aspect of an outcome statement.
It should be realistic with specific actions.
It should have measurable actions that can be evaluated.
It should contain a definite time frame for completion of the goals.
Inserting an indwelling urinary catheter.
Establishing an intravenous (IV) line.
Administering subcutaneous medication.
Procedures that require sterility.
What will you assess in a patient at risk for respiratory failure every 4 hours? Name 4 things
Color of skin, mucous membranes, and nailbeds.
Respiratory effort and sternal retractions
Oxygen saturation
Oxygen status (orientation, restlessness, irritability, confusion)
Cough and sputum
Lab results of a patient with fluid volume deficit. Name 2
Elevated urine specific gravity.
High hematocrit level.
Elevated BUN
What type of urinary catheter is expected in a patient who has a blockage in the urethra?
Suprapubic
What is the name of the solution that must be hung with blood?
Normal Saline
0.9% Sodium Chloride
NS
What class of insulin is Humulin N (NPH)?
Intermittent
When edema is suspected, the nurse first presses over a bony prominence for this number of seconds.
2 seconds
Nursing measure to prevent urinary complications related to immobility in patients.
Monitor urinary output.
Have the patient void at least every 8 hours.
Assist in a comfortable position to void (Standing if able, high Fowler's if a bed pan is used)
Encourage and ensure patient consumes 8 ounces of fluid every 2 hours.
Gastrointestinal complication prevention in an immobile patient include
Ambulating patient at least 4 times a day.
Giving a laxative or stool softener as needed.
Have patient drink at least 8 ounces of fluid every 2 hours.
Reposition in the bed every 2 hours.
Encourage increased intake of fiber in their diet.
Have them use a shower chair.
Teach them to alternate activity with rest periods.
Encourage small, frequent meals.
Assess their respiratory effort and use of accessory muscles.
Name one of the purposes of Intravenous therapy
Maintain or provide daily body fluid and electrolytes
Replace abnormal or excess loss of fluids and electrolytes
Provide an avenue to IV administration of medications