Nursing Process/Documentation
The step in the nursing process that is the development of goals for care and possible activities to meet them.
What is planning
The lowest intensity of a stimulus that causes the subject to recognize pain.
What is pain threshold
The timespan that includes the preparation for, the process of, and the recovery from surgery
What is perioperative
Normal range for pH, CO2 and HCO3
What is pH - 7.35-7.45, CO2 - 35-45, HCO3 - 22-26
Minimum oxygen flow rate for oxygen delivery using a simple mask
The description of a wound that has drainage composed of a great deal of blood
What is sanguieous drainage
The step in the nursing process that is the giving of actual nursing care.
What is implementation
Type of pain often has unknown cause and is defined as discomfort that continues for a long period(6 months or longer)
What is chronic pain
Surgery that is necessary at some time, but the client has some choice as to when the procedure will be done.
What is required/nonelective
Complex and designed primarily to prevent acid-base imbalances within the body:
What is the buffer system
Resonance over a lung with percussion is indicative of this
What is a desired finding
What is a homograft
Guidelines for effective recording and reporting: (must name all 3)
Pain originating in one body part, but perceived elsewhere
What is referred pain
Blocks all body sensations and cause unconsciousness, relaxation and loss of reflexes.
What is general anesthesia
The drug of choice for tetany
What is calcium gluconate
Oxygen delivery system that is widely used in home care settings for its safety and convenience
What is a concentrator
Burn involves entire epidermis into deep layers of the dermis from a radiant burn
What is deep partial thickness burn
Nursing actions that are based on orders or specific directions from the healthcare provider.
What are dependent actions
Medications that relieve pain
What are analgesics
Stage of general anesthesia where there are active reflexes, increased heart rate, irregular breathing, increased BP, pupils widely dilated.
What is stage 2
Observable edema that dents under slight finger pressure for 3 seconds.
What is +3 pitting edema
Essential before suctioning the client with a tracheostomy tube
What is preoxygenating the client
Pressure ulcer that extends to the muscles, tendons and bones
What is stage IV
How to document when a client refuses to take medication.
What is circle the time the drug was to be administered and document the reason not administered.
Chemicals and foods that decrease production of endorphins by the body: (must name 3)
What is caffeine, sugar, nicotine, alcohol, salt
Given preop to help inhibit body secretions, so the client produces less mucus, reducing the likelihood of aspiration and atelectasis.
What is atropine or a drying agent
Acid base imbalance caused by vomiting, gastric suctioning, bulimia, etc.
What is metabolic alkalosis
Kussmaul respirations are often seen in these patients
What is diabetic patients
The helpful rule for evaluating a mole and what it stands for
What is ABCD or ABCDE rule - Asymmetry, border, color, diameter, evolving
What is assessment, planning, intervention, evaluation
What is adjuvant
What is circulating nurse
Plays a key role in acid-base balance and helps to maintain water balance
What is chloride
A positive PPD reading is indicative of this
What is the patient has been exposed to TB
Test that can confirm the diagnosis of varicella
What is Tzanck's smear
Data that consist of the client's opinions or feelings about what is happening.
What is subjective data
Process through which the client receives a suggestion to concentrate on an image to control pain or discomfort
What is guided imagery
Procedure when operative site is cleansed with an anti-infective and sometimes shaved is called:
Major component of bones and teeth, affects permeability of cell membranes, plays a role in blood coagulation and maintenance of heartbeat and affects nerve function
What is calcium
The term for collapse of a lung
What is Jackson-Pratt, Hemovac and Davol
Shorthand method for documenting normal findings and routine care based on clearly defined standards of practice and pre-determined criteria for nursing assessments and interventions. Requires nurse document only significant findings to the pre-defined norms.
What is charting by exception
Pain scale that is most effective for gathering data regarding a 2 year old child and what does it stand for.
What is FLACC scale; face, legs, activity, cry, consolability.
The amount of time client told to stay NPO before operation if having spinal or general anesthesia.
What is 8-10 hours.
The acid base imbalance and compensation this client is experiencing:
pH 7.32
PaCO2 - 45
HCO3 - 18
What is metabolic acidosis, uncompensated.
Condition that may occur if an endotracheal tube is incorrectly placed
What is gastric distention
Three types of skin cancer
What is basal cell carcinoma, squamous cell carcinoma and malignant melanoma
The 3 parts of a NANDA approved nursing diagnosis: (must state what they are and how they are placed into the nursing diagnosis)
What is problem related to etiology(cause) as evidenced by signs and symptoms
The 4 phases of pain transmission
What is transduction, transmission, perception, modulation
The 3 phases of perioperative nursing and what each consist of:
What is preoperative - nursing care before surgery
intraoperative - nursing care in the OR and PACU
postoperative - nursing care after surgery
Electrolyte imbalance client is experiencing with positive Chvostek and Trousseu's sign.
What is hypocalcemia or hypomagnesemia
Has a barrel chest, cyanotic appearance, using a handkerchief and cup for excess sputum production
What is a blue bloater
The 3 phases of burn injury management
What is Resuscitative, acute and rehabilitative
The 5 steps of the nursing process.
What is nursing assessment, nursing diagnosis, planning, implementation and evaluation
COLDSPA stands for this
What is character, onset, location, duration, severity, pattern, associated factors
Signs of shock (must list how blood pressure, pulse, body temp would be along with at least 1 other sign)
What is hypotension, tachycardia, hypothermia, narrowed pulse pressure, restless, anxiety, dyspnea, cyanosis, extreme thirst, cold, clammy skin, low O2 sat, slowed cap refill, ringing in ears, difficulty seeing
Client is experiencing this acid based imbalanced based on these results: pH 7.32, PaCO2 50, HCO3 30.
What is respiratory acidosis, partial compensation
Mask of choice for client requiring oxygen concentration of 70% with flow rate around 12 LPM.
What is non-rebreathing mask
The 3 types of wound healing and describe each
What is first intention - minimal tissue loss, such as surgical incisions - scarring and infection rates are low
2nd intention - wound edges widely separated in injuries such as deep lacerations, burns and pressure wounds. Scarring often occurs and risk of infection greater.
3rd intention - delay in time between injury and closure of wound. Deep scarring almost always occurs.