Fundamentals/
Health Assessment
Health Assessment
List the steps in the nursing process
Assessment
Diagnosis
Planning
Implementation
Evaluation
What are the five rights of medication administration?
Right person
Right medication
Right dose
Right route
Right time
Part of the brain that is also known as the "emotional brain". It is responsible for feeling of anger, love, hate, joy, and fear.
Limbic system
The first day of TW's last menstrual period was February 1st 2021. Calculate her EDD.
November 8th, 2022.
Hand washing
Priority intervention for patient experiencing blood transfusion reaction
Stop the transfusion
Antidote for heparin overdose
Protamine sulfate
Name the type of defense mechanism being used in the following example.
A person who dislikes animals does volunteer work for the Humane Society.
Reaction formation
A nullipara with uterine overdistention is being prepared for induction after having consistently ineffective contractions during her first stage of labor. Shortly after receiving Pitocin, the fetal monitor begins to show the nadir of the FHR occurring after the peak of each contraction. What is the priority intervention for this patient?
Turn her to the left lateral position
Name the components of Cushing's triad.
Widened pulse pressure, bradycardia, and abnormal respirations.
What is the correct order to don PPE
Gown
Mask
Goggles/face shield
Gloves
How is intermediate (NPH) and regular insulin mixed and drawn up?
Air into NPH
Air into regular
Draw up regular
Draw up NPH
Which is the priority nursing diagnosis for a patient with schizophrenia who has solely paced back and forth for last 12 hours?
A. Impaired nutrition: less than body requirements
B. Risk for activity intolerance
C. Risk for dizziness related to walking around in circles
D. Altered mental status as evidence by schizophrenia
A. Impaired nutrition: less than body requirements
Scheduled vaccinations for a child who is 12 months old
Hep A, Hib, MMR, DTap, PCV, Varicella, Influenza
Priority intervention for patient presenting with acute pancreatitis
Implement NPO status
Determine the type of acid base imbalance and its compensation from the following ABG:
pH: 7.5
HCO3: 22
PaCO2: 13
Uncompensated Respiratory Alkalosis
The doctor orders Heparin 50 units/kg/dose SQ qd. The patient weighs 64 kg. Heparin is supplied in a vial that reads 5,000 units/mL. How many mL/dose will you administer?
0.64 mL/dose
Priority teaching for patient taking Monoamine Oxidase Inhibitors
Avoid eating foods containing tyramine (raisins, beer, caffeinated foods/beverages)
You're assessing the one minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 150, pink body and hands with cyanotic feet, some flexion of arms and legs, and cries when stimulated. What is your patient's APGAR score?
8
A patient with Type 1 diabetes mellitus is admitted to the Emergency Department. Upon arrival, his blood glucose level is 500. He informs you that he has been sick for the past few days with a common cold and does not remember the last time he took his prescribed insulin. Additionally, he states to be extremely thirsty and has recently been going to the restroom more often. What can the nurse expect that this patient is experiencing and what is anticipated nursing intervention?
Diabetic Ketoacidosis and administration of IV fluids.
-Do not take with ED medications
-Rise slowly/change positions slowly
-Do not stop abruptly (may cause rebound HTN)
-Teach lifestyle modifications
-Measure blood pressure and heart rate before administration
Digoxin 10 mcg bid is ordered for a 6 month old with congestive heart failure weighing 14 lbs. The safe dosage range for this medication is 7.5-12 mcg/kg/day. Is this a safe dose for this patient?
If not, is it too high or too low?
No, it is too low.
HF, a 23 year old male, was diagnosed with bipolar disorder when he was 18 years old and has been in and out of the psychiatric facility since. He becomes suspiciously attached with the nurses taking care of him, but when he doesn't get his way, he tells the charge nurse that the nurse hasn't given him food in 3 days. Additionally, since his girlfriend was discharged from the facility, he has threatened to commit suicide, but is found a week later with another girlfriend. Not only that, but he has recently begun pinning nurses against each other to create tension.
What type of personality disorder is HF displaying?
Borderline personality disorder
SF, a 26 year old woman, is scheduled for her routine checkup. She is currently 16 weeks pregnant and has been anticipating finding out the gender of her baby. When looking through her past medical history, you find that she had an elective abortion at 4 weeks when she was 16 years old. Additionally, she miscarried at 10 weeks when she was 22 years old. SF has a very supportive husband who helps her take care of their 2 year old triplet girls who were born at 34 weeks.
G: 4
T: 0
P: 1
A: 2
L: 3
A 35 year old patient weighing 130 lbs is admitted to the Emergency Department after experiencing deep partial thickness burns to the front and back both arms and the anterior face and torso. Using the Parkland Burn Formula, calculate the total amount of Lactated Ringers that the patient will receive over the next 24 hours.
Round to the nearest tenth.
9,572.7 mL.