Chapter 7 Flashcards
(229 cards)
1
Q
NAs should know the resident’s _______ at the time of discharge
A
Condition
2
Q
Vital signs order
A
Temp
Pulse
Resp
BP
Pain
O2 sat
Pulse ox
3
Q
What are vital signs?
A
Show how well organs are working
4
Q
Which changes in vitals require nurse attention
A
1.Temp outside of normal range
- Too rapid or too slow resp rate
- Abnormal pulse
- Changes in BP
5
Q
Ranges: mouth (oral) temp
A
97.6-99.6
6
Q
Temp rectum (rectal)
A
98.6-100.6
7
Q
Temp Armpit (axillary)
A
96.6-98.6
8
Q
Temp ear (tympanic)
A
96.6-99.7
9
Q
Temporal artery (forehead) temp
A
97.2-100.1
10
Q
Normal pulse rate
A
60-100 bpm
11
Q
Normal resp rate
A
12-20
12
Q
Blood pressure normal systolic
A
90-119 systolic
13
Q
Body temperature is normally very close to ___
A
98.6
14
Q
Body temperature is a balance between
A
The heat created by the body, and the heat lost to the environment
15
Q
Factors that affect body temperature
A
Age
Illness
Stress
Environment
Excercise
Circadian rythym
16
Q
What should you do if a resident has just done done something with their mouth, eating, drinking, smoking EXCERCISED etc
A
Wait 20 minutes and come back
17
Q
True or false: body temperature fluctuates?
A
True
18
Q
When is body temperature lower?
A
Morning
19
Q
Increases in body temperature may indicate an ___or____
A
Infection or disease
20
Q
Which is the most common way of taking body temperature
A
Oral
21
Q
Which is the most accurate way of taking body temperature
A
Anal
22
Q
Places where you can take temperature
A
Oral
Rectal
Axillary
Tympanic
Temporal artery
23
Q
Types of thermometers
A
Digital
Electronic
Tympanic
Temporal artery
Mercury-free
24
Q
What color is a rectal thermometer
A
Red
25
What color is an oral thermometer?
Blue or green
26
Which temperature is least accurate
Axillary
27
Who should not have an oral temperature recorded?
1. Unconscious
2. Had facial surgery
3. Is younger than 5
4. Is confused or disoriented
5. Is heavily sedated
6. Is likely to have a seizure
7. Is coughing
8. Is using oxygen
9. Has facial paralysis
10. Has a nano gastric tube
11. Has soreness, redness, swelling or pain
12. Has injury to face or neck
28
Rectal temp should be a last resort?
Yes
1.oral
2. Axillary
3. Rectal
29
How to use a digital thermometer
1. Put on sheath
2. Turn on thermometer
3. Wait until ready sign appears
30
How to use electronic thermometer?
Remove probe from base unit.
Put on probe cover
31
Mercury free thermometer
1. Hold thermometer by stem
2. Shake thermometer before inserting it in resident's mouth. Shake thermometer down to lowest #. Below 96 f
3. Hold it at end opposite with bulb with thumb and 2 fingers. Stand away from furniture and walls.
32
Digital thermometer
Insert end of the thermometer into the resident's mouth, under the tongue and to one side.
33
Electronic thermometer
Insert the end of the thermometer into the resident's mouth, under the tongue and to one side.
34
Hold thermometer in until it
Beeps
35
How long should a mercury free thermometer stay in?
At least 3 minutes
36
How should residents breathe while getting oral temp taken?
Through nose
37
Should resident talk while getting temp checked
No
38
Should resident bite on thermometer?
No
39
Why should you never let go of a thermometer during rectal temperature?
It can get lost or puncture the colon
40
On what side should a resident lie for a rectal temperature assessment?
Left side
41
How far does the thermometer go in for rectal temperatures?
1/2 inch to 1 inch
42
What should you do if you feel resistance during rectal temperature?
Stop
43
In what direction should you pull an ear for adult when taking tympanic temp
Up
44
In what direction should you pull an ear when taking tympanic temp for child?
Down
45
Pulse
Number of heartbeats per minute
46
Beat
Wave of blood moving through artery as result of heart pumping
47
When do you add a superscript to a temperature
Rectal or axillary
Superscript R for rectal
Superscript Ax for axillary
48
Radial pulse
Inside of wrist, using radial artery
49
Brachial pulse
Pulse inside the elbow. 1- 1&1/2 inches above the elbow
50
Normal Pulse range for children
100-120 bpm
51
Newborn pulse rate
120-180 bpm
52
What affects pulse rate
Excercise,
Fear
Anger
Anxiety
Heat
Infection
Illness
Medications
Pain
53
A rapid pulse could indicate
Fever
Dehydration
Heart failure
54
Slow, weak pulse could indicate
Infection
55
Respiration
One inhale one exhale
56
Inspiration
Breathe in
57
Expiration
Breathe out
58
Infant respiratory rate
30-40
59
Should you report irregular pulse rythym even if the bpm are normal?
Yes you also should if breathing is irregular
60
Blood pressure
Pressure of blood in heart. Input/output rate. Pressure on walls and arteries
61
How is BP recorded?
Fraction mmHg
62
Systolic
Heart contractions. Filling the bucket.
Top number.
Pushes blood from left ventricle
63
Diastolic
Heart relaxes.
Blood leaves bucket.
64
Hypertensive
Blood pressure is constantly high
65
Sphygmomanometer
Used alongside stethoscope to take BP
66
Systolic pressure is the ____ sound
First
67
Diastolic pressure sound
Last sound. Soft muffled thump
68
On which arms shouldn't you take BP
IV
Dialysis shunt
Arms with medical equipment
Cast
Recent burns
Trauma or mastectomy
69
Pulse oximeter
Measures percentage of oxygen in blood. Uses light. Also measures pulse.
70
Less than ___% O2 saturation must be reported
95%, but re check first
71
Is pain a vital sign?
No it isn't, but some refer to it as the fifth vital sign
72
Is pain a normal part of aging?
No
73
What should an NA ask about pain?
Where is the pain?
When did the pain start?
How long does the pain last?
How often does it happen?
Rate it on 1-10
Can you describe pain?
Use resident's exact words
What makes pain better?
What makes pain worse?
What were you doing when you started?
74
Which changes in weight must be reported?
All of them
75
Restraint
Physical or chemical way to restrict voluntary movement or behavior
76
Physical restraints
Anything that restricts a person's freedom of movement
77
Chemical restraints
Medications that control someone's mood or behavior
78
Enabler
Equipment that promotes safety, comfort, independence and mobility.
Person must be able to remove it independently
79
LTCs are prohibited from using restraints unless they are ___ _______
Medically necessary
80
NAs can't use physical restraints unless
1. Doctor ordered it in care plan and they have been trained in the restraint's use
81
Restraint free care
Restraints are not kept or used for any reason
82
Restraint alternatives
Measures in place instead of using restraints
83
How often must a restrained resident be checked on
At least every 15 minutes
84
Output
Urine, feces, vomit, sweat, perspiration, moisture that a person exhales and wound drainage
85
Fluid balance
Maintaining equal input an output. Taking in and eliminating an equal amount of fluids
86
Specimen
Sample that's used for analysis
87
Routine urine specimen
Collected every time resident voids
88
Void
Urinate
89
Hat
Container that's sometimes used to measure urine or stool
90
Seal must be ____ before specimen collection
Intact
91
Clean catch specimen
Mid stream specimen.
Does not include first and last urine voided in the sample
92
Purpose of a clean catch specimen
Detect bacteria in the urine
93
True or false: you shouldn't touch the inside of the container or the inside of the lid when collecting specimens
True
94
Should you clean perineal area first when collecting a clean catch?
Yes
95
Why can't residents also urinate when you're taking a stool sample?
It ruins it
96
When is the best time to collect sputum?
Early morning
97
How much sputum should an NA collect?
1 teaspoon
98
Catheter
Thin tube inserted into bodies used to drain or inject fluids
99
Urinary catheter
Drains urine from bladder
100
Oxygen therapy
Administering oxygen to increase the supply of oxygen to the lungs
101
Do nursing assistants stop, adjust or administer oxygen?
No, they never stop, adjust or administer oxygen
102
Water temperature should be no higher than ___ when providing catheter care?
105
103
Indwelling catheter
Remains in bladder for periods of time
104
Indwelling catheter is also known as
Foley catheter
105
Condom catheter is also called
Texas catheter
106
Condom catheter.
External, goes on penis. Fastened with special tape. Has leg bag.
107
Should bag hang above catheter opening
No! Can cause infection. Bag should never flow back into water
108
Drainage bag must be ___ the floor
Off
109
Is it okay for catheter tubing to touch the floor?
No! Catheter tubing should never touch the floor
110
How do you prevent accidentally dislodging the catheter tube?
Keep it as straight as possible. No kinks
111
Things to report about catheters
-blood or unusual urine
-cathether bag doesn't fill after several hours
-cathether bag fills suddenly
-cathether is not in place
-urine leaks from catheter
-resident reports pain or pressure
-odor is present
112
Should the spout and clamp touch the graduated container?
No
113
Oxygen therapy
Administering oxygen to increase the supply of oxygen to lungs
114
Combustion
Burning
115
Can you use oil based lubricants on resident or any part of the cannula or mask?
No
116
IV therapy
Giving medication, nutrition or fluids through a vein
117
Port
Permanent IV opening
118
Closed bed
Bed completely made with the bedspread and blankets in place.
119
Who is a closed bed made for?
Residents who will be out of bed most of the day
120
Open bed
Folding linen down to foot of bed. Bed ready to receive a resident
121
Sterile dressings
Cover new, open or draining wounds. Nurse changes these
122
Non sterile dressings
Applied to dried, closed wounds that have less chance of infection. Depending on state regulations
123
Which changes in weight should NAs report?
NAs must report every change in weight, no matter how small
124
1 lb is equal to ___ oz
16
125
1 kg is equal to ___ grams
1000
126
1 kg equals ___ lbs
2.2
127
Can you put your hand on a resident's back while weighing?
No, resident must be able to fully hold themselves up on scale without any help
128
Can a resident hold, touch or lean on something while weighing?
No
129
What kind of shoes should a resident wear before walking on the scale?
Nonskid
130
Which things should stay the same when weighing a resident?
1. Amount of clothes
2. Time of day
3. Scale used
131
Residents shouldn't gain more than __ lbs per day
3
132
Which scale is the least accurate
Bed scale
133
How often are height and weight measured
Height: once
Weight: at least monthly
134
What should you do if a resident can't stretch out to be measured?
Get the nurse
135
Examples of restraints
belt restraints, vest restraints, wrist/ankle restraints
136
Examples of enablers
Wheelchairs, geriatric chairs, cushions and pillows, assistive devices
137
Are side rails restraints?
Sometimes
138
Are geriatric chairs restraints?
Sometimes
139
Doctor's note for restraints has to be signed within __ to __ hrs
24-48
140
Does family have to be notified if their resident is restrained?
Yes
141
Why is it important to document what you did to prevent using restraints
Because restraints are a last resort! Document everything you did to keep from putting on restraints. Offered backrub. Document everything done to patient
142
How often do residents have to be released from restraints?
Every 2 hours for 10 minutes
143
Restraints can easily cause
Pneumonia
Incontinence
Pressure sores
Constipation
Blood clots
144
What is a good way to distract a resident instead of restraining them?
Giving them a repetitive task
145
An NA cannot use a restraint unless the _______ ______ has approved it &
Charge nurse
NA has been trained to use it properly
146
How do you give a restrained resident proper care
1. Help with elimination often. Check for incontinence and give skin care
2. Offer fluids and food
3. Measure vital signs
4. Check for irritation, bruising or odd marks
5. Check for swelling
6. Reposition the resident
7. Ambulate resident
147
1 oz= ___ml
30
148
How much water should we drink a day
64 oz
149
1/4 cup= __oz
2
150
1/2 cup = __ oz
4
151
Older women should drink
Just over 1.5 quarts /1.6 liters
152
Older men should drink
2 L about 2 quarts
153
Specimen
Sample that is used for analysis to make a diagnosis
154
Urine breaks down after ___ seconds
15
155
You should make sure hats and pans have been ____ before getting resident to go again
Cleaned
156
Where should you label a specimen?
On the side of the cup
157
Can you get a urine sample from a diaper
No
158
Can you get a stool sample from a diaper?
Sometimes. Not for worms. Just for blood
159
Anything that comes from the body should go in a
Biohazard bag
160
What does rusty sputum sometimes indicate
TB
161
Is sputum spit?
No
162
The NA should ask ___ to find out a resident's personal preferences and ___
Questions
Routines
163
The NA should always call the resident by their _____ name
Formal
164
The NA should not____ the admission process or the resident
Rush
165
New residents must be given a copy of their _____
Rights
166
It is important for the NA to ___ the resident in case something important was missed
Observe
167
T/F the resident will pack their own belongings for a transfer
False
168
T/F an NA writes discharge order for resident
False
169
What may changes in vital signs indicate
Issues with health
Worsening condition
170
What changes should be immediately reported to the nurse
1. Fever
2. Abnormal pulse/resp
3. Changes in BP
4. Pain is worse
171
Apical pulse
Pulse on chest, most accurate
172
Femoral pulse
Groin
173
Pedal pulse
Foot
174
8 things you can do to reduce resident's backpain?
1. Backrub
2. Comfortable position
3. Distract them
4. Notify nurse
5. Align pillows
6. Help resident to restroom
7. Calm, quiet environment
8. Ask if they want bath
175
Why must an NA report weight losses
Could indicate health problems
176
Restraint free care means that
Restraints are never used for any reason
177
What 8 care tasks need to happen every 2 hours when resident is restrained
1. Moving around
2. Bathroom/incontinence/skin
3.bruises
4. Measure vitals
5. Offer fluids &food
6. Swelling
7. Check for bruising and signs of irritation
8. Reposition resident
178
7 things that can disrupt resident's sleep
1. Other residents
2. Fear/anxiety
3. Stress
4. Diet
5. Noise
6.medication
7.Illness
179
Things affected by lack of sleep
Decreased mental function
Reduced reaction time
Irritability
Compromised immune system function
180
T/f: urinals and bedpans are normally stored on the over bed table
False
181
When a resident cannot get out of bed,
The bed should be raised to a safe height before making it
182
A bed made with the bedspread and blankets in place is called a
Closed bed
183
Sterile dressings cover
Open or draining wounds
184
Elastic bandages are also known as
Non sterile bandages
ACE bandages
ACE wraps
185
How soon should an NA check on a resident after applying a bandage?
10 minutes
186
T/f: Soiled linens should be placed on the over bed table when changing a resident's bed
False
187
How many inches down should you clean a catheter
At least 4
188
Can NAs turn off oxygen in case of fire?
Yes, but they can't adjust setting or dose
189
Can you use oil based lubricants on resident or on cannula?
No
190
Which fabrics can cause electric discharges ?
Nylon and wool
191
Can oxygen tubing or cords for under rugs or furniture?
No
192
Can you use an extension with an oxygen concentrator?
No
193
Examples of fire hazards
Electric equipment
Electric razors
Hair dryers
Cigs
Flammable liquids
Alcohol and nail polish remover
194
Intravenous Therapy
Delivery of medication, nutrition or fluids through a vein
195
What is the NAs responsibility in regards to IV
Report and document problems with the IV line
196
What should you report about IV therapy
1.Tube/needle falls out
2. Tubing disconnects
3. Dressing around IV is loose or not intact
4. Blood is in tubing or around IV site
5. Site is swollen or discolored
6. Bag is broken
7. Amount of fluid doesn't decrease
8. IV fluid doesn't drip or leak
9. IV fluid is almost out
10. Pump beeps indicating a problem
11. Pump is dropped
12. Resident complains or has trouble breathing
197
Can you wet an IV site?
No
198
Can you catch IV tube on anything?
No
199
Can an NA lower an IV bag below the IV site?
No, it should be at least 3 ft above heart so the fluid has enough pressure to infuse
200
Why shouldn't an NA disconnect the IV pump or turn off the alarm?
Will hurt resident's treatment
201
Why shouldn't you touch the IV clamp
It controls the flow rate
202
What goes on top of bedside stand?
Water pitcher, cup
Phone, radio, photos, other items
203
What is the over bed table used for
Meals,
Personal care,
Must be kept clean
Uncluttered
(No contaminated items)
204
Do privacy curtains block sound?
No
205
What should an NA do when she doesn't know how to use equipment?
Ask for help
206
When should over bed table be cleaned?
After each use.
207
Where should over bed table be before leaving?
Within resident's reach
208
Temperature range required by obra
71-81f
209
When should meal trays be removed?
Right after meals
Check for bread crumbs
210
Do wrinkled linens have to be changed?
Yes
211
Why should you check to see if resident can lift pitcher and cup
So they always have access to water
212
Who cleans bathrooms?
Housekeeping
213
Is it okay to move a resident's belongings?
No
214
What should be reported about sleep issues
1.Sleeping too much
2.Eating or drinking caffeinated items late in day
3. Wearing night clothes during day
4. Eating heavy meals late at night
5. Refusing to take sleep meds
6. Taking new meds
7. Having TV, radio, computer on late at night
8. Having pain
215
Linens should be changed after:
1.Bedbath
2. Personal care
3. Damp sheets/soiled/need straightening
216
Sheets that don't lie flat increase the risk of
Pressure injuries
217
Bag soiled linen at:
Point of origin
218
When making the bed the NA should
Use a wide stance and bend her knees. Bending at the waist should be avoided. Especially when tucking sheets under mattress
219
Always work from _____ to ____ area of bed
Cleanest
Dirtiest
220
Hospital corners prevent
Residents feet from getting tangled when getting in and out of bed
221
Should resident see soiled side of dressing?
No
222
What should you note when changing a dressing
Color
Odor
Drainage
223
What do ace bandages do?
Help decrease swelling
Hold dressings in place
Secure splints
Support and protect body parts
224
How should bandage be wrapped?
In figure 8 pattern
So no part of wrapped area is pinched
225
Why shouldn't you tie a bandage?
Cuts off circulation
226
Signs and symptoms of poor circulation
1. Swelling
2. Pale gray cyanotic skin
3. Shiny, tight skin
4. Skin that is cold to touch
5. Sores
6. Numbness
7. Tingling
8. Pain or discomfort
227
What should do in case of poor circulation?
Loosen bandage and notify nurse
228
Normal diastolic BP
60-79 diastolic
229
What is sims position
Resident lying on left side to straighten colon for rectal temp
