FINAL Flashcards
(198 cards)
1
Q
what are the normal ranges for older adults for temperature ?
A
36-38 degrees Celsius
2
Q
above 38 degrees Celsius would be what
A
hyperthermia
3
Q
below 36 degrees Celsius its called or known as what
A
Hypothermia
4
Q
average temperature for oral or tympanic is..
A
37 degrees Celsius
5
Q
average temp for rectal is…
A
37.5 degrees Celsius
6
Q
what is the average for axillary
A
36.5 degrees Celsius
7
Q
when would you take vital signs for your patient
A
- after a fall
- before certain medications
- when patient voices a change
- during admission
- before and after nursing interventions
8
Q
what does pyrexia mean
A
fever
9
Q
how do you measure temp in the body
A
through the body’s hypothalamus that regulates the body’s temperature by sweating or shivering when cold
10
Q
what are nursing interventions for a temp of 35
A
- warm blankets
- extra layers
- socks
- warm drinks
- change environments
11
Q
what is the balance between the heat produced and heat lost in the body called?
A
thermoregulation
12
Q
what happens when the body experiences diaphoresis (excessive sweating), radiation, convection, conduction, evaporation
A
heat loss
13
Q
amount of blood the heart pumps in one minute
a. stroke volume
b. cardiac output
A
B
14
Q
what are the 3 different types of thermometers used when taking temp
A
- electronic (we use in labs settings must be changed according to what site you are testing)
- chemical strip (single use or reusable)
- glass
15
Q
- eating or dinking 30 mins before
- circadian rhythm
- environment
- age and hormone levels like in women menopause
- neurological conditions affecting the hypothalamus
- fever (pyrexia)
are all factors that will increase what
a. blood pressure
b. temperature
c. heart rate
A
B
16
Q
what are normal ranges for older adults and pulse
A
60-100 bpm
17
Q
when documenting VS or pulse and respirations what factors do you NEED to include
A
rate: numerical value
rhythm: regular/irregular
strength: strong, weak, thready, bounding, diminished
equality: bilaterally
18
Q
what are the 10 different pulse sites on the body
A
- temporal
- carotid (on the neck below the jawline)
- apical (between the 4th or 5th intercostal space nipple line)
- brachial (ringer finger up or inner arm side)
- radial (on wrist at thumb side)
- ulnar (on wrist on pinky side)
- femoral
- popliteal (behind the knee)
- dorsalis pedis (foot pulse)
- posterior tibial (foot pulse)
19
Q
- caffeine
- exercise
- medications
- emotions like fear, stress, pain
- health conditions conditions
are all factors that increase what VS
A
factors that affect pulse
20
Q
when measuring pulse what are we checking
A
the circulatory system and the electrical force sent from the SA node felt at different points through the body
21
Q
The nurse notices that an 18-year-old male has an irregular pulse. What would be the nurse’s best course of action?
A. Read the history and physical of the patient.
B. Assess the apical pulse rate for one full minute.
C. Auscultate for the strength and depth of the pulse.
D. Ask the patient if he feels any palpations.
A
B
22
Q
what are the normal rates of respirations
A
12-20
23
Q
what is measured when assessing respiration
A
ventilation process of inhaling and exhaling controlled by the medulla oblongata and the chemoreceptors that monitor the co2 and o2
24
Q
when measuring respirations what do we assess?
A
the ventilation process of inhaling and exhaling controlled by the medulla oblongata and the chemoreceptors that monitor the co2 and o2
25
where is the apical pulse found
4-5 intercostal space
26
what does blood pressure measure?
force against the arterial walls
27
normal range for SpO2 (pulse oximeter)
95-100% or 92-100%
28
a normal range for SpO2 for a pt with COPD would be
88%, don't go above 92% oxygen because risk of over oxygenating the person 88-92%
anything below 85% is red flags
29
you would avoid checking SpO2 on the fingers when patient is...and what other sites can you check
cyanotic
acrylics on or nail polish
cold
fidgety
confused
other sites include
- toes
- earlobes
30
what are negative effects of body temp
- frostbite
- fever
- heatstroke
- heat exhaustion
31
total amount of blood in the body, if blood becomes thicker it becomes harder for it to be pushed out increasing blood pressure
blood volume
32
what is hypertension
high blood pressure anything above 140/90
33
what is hypotension
low blood pressure anything below 90/60
34
what are the s/s for heatstroke
- confusion
- delirium
- excessive thirst
- visual disturbances
35
when ventricles relax is called
a. systolic
b. diastolic
diastolic
36
when the heart contracts and pushes blood into the body
a. systolic
b. diastolic
systolic
37
what are factors for hypertension
- high sodium diet
- diabetes
- atherosclerosis
- stress
- smoking, weight, and amount of activity
38
what is orthostatic hypotension
BP dropping when you change positions like from laying to standing
39
When assessing the BP of a
school-age child, using a normal-size adult cuff will affect
the reading and produce a(n) _______ value.
A. Accurate
B. Indistinct
C. Falsely low
D. Falsely high
C
40
what is measured when assessing SpO2
hemoglobin attached to the blood in the arterial blood
41
what is the class for acetaminophen and action
class
- non opioid analgesic
action
- reduces pain and fever
42
when one is sweating what does that do to temp?
sweating lowers body temp while shivering regulates more
43
nurses always believes who's perception about pain
a. patients
b. patients family member
c. doctors
A, patient only knows what they feel even when showing no physical signs of pain
44
what medication is a CNS depressant, is a opioid- analgesic, and stops the perception of pain by binding with opioid receptors, also has an antidote of naloxone
morphine
45
how does hypertension affect the organs
- eyes, retinopathy and weak capillaries
- kidneys can lead to AKD or CKD due to damaged capillaries
- brain can cause a stoke
46
what are common hypertension drugs
ACE inhibitors
ARBS
Beta blockers
Calcium channel blockers
Diuretics
vasodilators
47
which of the 3 detects pressure changes in major arteries like carotid
a. proprioceptors
b. baroreceptors
c. chemoreceptors
B
48
which of the 3 allows one to be aware of their movements and body parts
a. proprioceptors
b. baroreceptors
c. chemoreceptors
A
49
which of the 3 monitor the co2, o2, and pH
a. proprioceptors
b. baroreceptors
c. chemoreceptors
C
50
what do adrenergic medications do and name 3 types of adrenergic medications
- stimulate the fight or flight
- constricting blood vessels and bringing up BP
medications:
- norepinephrine
- epinephrine
- dopamine
51
where do beta 1 drugs act
one the heart
52
where do beta 2 drugs act
on the lungs
53
what does creatine clearance mean
it is lab work that tells us how well the kidneys are working to eliminate the medication
54
type 1 diabetes how it works and s/s
- absence of endogenous (insulin created inside the body) insulin
- autoimmune process (bc body starts to fight itself)
- pancreas doesn't make insulin
- person becomes insulin dependent lifelong
s/s
- polyuria
- polydipsa
- polyphagia
55
type 2 diabetes
- more common in older adults
- body creates insulin but cells don't use it or become resistant to it
- based on diet, lifestyle, and obesity
56
normal ranges of blood sugar are
4-7
57
what are the complications that arise with diabetes
- neuropathy: nerve damage
- nephropathy: kidney damage
- retinopathy: vision damages, creates blurry vision and dark spots in vision
- atherosclerotic changes (plaque buildup in the blood vessels making it harder to pass blood through)
58
foot complications and diabetes
- problems may be linked with neuropathy (thats why patients dont know what happen becasue they cant feel it)
59
neuropathic ulcers could be caused by
- mechanical irritations: (caused by physical rubbing or pressure) like tight shoes, cutting toenails, or shaving calluses
- thermal irritations: caused by burns or heating pads
- chemical irritations: salicylic acid that's in corn plasters
60
what is a foot doctor called
podiatrist
61
DKA means
diabetic ketoacidosis
- caused by extreme hyperglycemia
- too much of everything is present in the body
- organs are cording bc of the acid present in the body
- body starts to breakdown fat and lipids instead of glucose (ketones are produced bc of fat breakdown)
62
what are the fasting blood glucose tests
3.9-6.1 mmol/L
63
what are the findings for oral glucose tolerance test
7.8-11.0 mmol/L
64
what are hemoglobin A1C tests
- blood test that assesses the blood glucose levels of the past 3 months, levels should be below 7%
65
what is the treatment for diabetes mellitus
type 1
- insulin therapy
type 2
- lifestyle changes (diet, reducing weight, physical activity)
- oral drug therapy like metformin
- insulin when no other methods work
66
antidiabetic drugs do what....
- reduce blood sugar levels to maintain normal levels
include oral and insulin medications
67
A patient with type 2 diabetes mellitus tells the nurse that he has been testing his own blood glucose level six times per day for the past 3 years. What is the most appropriate action for the nurse to take?
a. Observe the patient's testing technique for accuracy.
b. Advise the patient that he is not permitted to perform his own blood glucose testing.
c. Check with the patient's health care provider concerning the patient's self testing.
d. Explain to the patient that a nurse must complete blood glucose testing.
A
68
can insulin be given orally?
no because it must reach the blood stream for effective use by taking it orally it passes the GI track meaning beaks down by the stomach become useless
69
insulin is given what route?
- sub-q
- only regular insulin can be given IV
- inhalation form (puffer) like afrezza
70
rapid acting insulin give me the types of insulins that are rapid acting, what route it can be given nd onset
onset 15-30 mins
peak 30-90 mins
duration 3-5 hrs
insulin aspart
insulin lispro
insulin glulisine
can be given sub-q and sub-q pump
71
short acting insulin give me the types of insulins that are rapid acting, what route it can be given nd onset
onset 30 mins- 1 hr
peak 2-4 hrs
duration 5-8 hrs
insulin regular (humulin R, novolin R)-> clear vial
only insulin that can be given sub-q and IV
72
intermediate acting insulin give me the types of insulins that are rapid acting, what route it can be given nd onset
onset 1-3 hrs
peak 6-10 hrs
duration 12-16 hrs
insulin NPH (humulin-N, novolin-N)-> cloudy vial appearance
given sub-q
73
long acting
onset 60 mins (1 hour)
peak minimum
duration up to 24 hours
insulin glargine (lantus)
insulin detemir (levemir)
given sub-q
74
what are important things to teach with insulin
- wipe the area clean for 30 secs
- eat within a 15 min window to avoid a low
- teach patient how to administer like pinch sink then administer
- importance of switching sites to avoid fatty deposits
75
how to draw up 2 insulins in one syringe?
cloudy, clear, clear, cloudy!
put air into cloud and clear
draw up clear
draw up cloudy
don't mix long lasting
76
are typically used for hospitalized diabetic patients or for patients on total parenteral nutrition (TPN) or enteral tube feedings based on their blood sugar levels... called what
sliding scale
77
insulin syringes are always measured in what units? U-100 insulin has how many units
units, has 100 units
for U-500 syringes they are used for critical patients like patients who are in DKA
78
what is the difference between glucose and glycogen
glucose is the active form of sugar what the body can use for energy
glycogen is the stored form when body needs energy
79
when does the body go through the glycogenolysis process
when the blood sugar is low body breaks glycogen to glucose to bring blood sugar levels back up
80
81
When do diabetics take medication to lower blood sugar?
Before meals, in the morning, or as a corrective measure to lower high blood sugars
82
what do beta cells produce in the pancreas
insulin
83
A hormone produced by alpha cells in the pancreas, it helps to control blood glucose by raising the blood glucose levels also comes in a injectable form 50ml
glucagon
84
how do you treat hypoglycemia
15/15 method
give a 15 g snack wait 15 mins and check patients blood glucose levels
- juice
- candy
- dextrose tabs
- tablespoon of honey or sugar
85
what are sites you can rotate
- abdomen
- thighs
- back of arms
- love handles
86
insulin pump
- gives insulin on its own
- good for 7 days and then must be rotated
87
what are some oral hypoglycemics
- metformin
- sulfonylureas
- biguanides
88
what is important a patient know when prinking their finger
- dont poke the pad of the finger, assess the side as the pad has many nerve endings
89
what is hypoglycemia (blood sugar values)
anything below 4 mmol/L
90
s/s of hypoglycemia
- dizziness
- sweating
- cold and clammy
- blurry vision glucose blocks arteries in retina
- confusion
- excessive hunger
- loss of consciousness in extreme cases
91
what is the biggest managing tool in diabetes
assessing ones blood sugar levels
92
glucosuria/glycosuria
is called glucose in the urine
93
what are some tests to diagnose diabetes
- hemoglobin A1C
- oral glucose tolerance test
- random blood glucose test
94
Which action would the nurse carry out first when performing a blood glucose test on a patient with type 1 diabetes mellitus?
a. Apply clean gloves to minimize the risk for contamination.
b. Assess the patient's skin for possible puncture sites.
c. Ask the patient to wash his or her hands and forearms with warm, soapy water.
d. Determine the patient's preferred puncture site.
C, particles of food can be on the hands still giving you a false reading
95
medications used to wash out a body cavity given through a stream of solution like normal saline or sterile water is called what
irrigation
96
when is a spacer or space chamber used
in older adults or kids, it traps the medication in the chamber allowing the patient to get to full dose
97
why are inhalation medications used for what patients
- pt's with respiratory conditions like COPD, asthma, emphysema, bronchitis
98
what route of medications are applied through lotions, ointments, drops, mucus membranes, and always with applicators or gloves to avoid contamination?
a. subcutaneous
b. inhalers
c. topical
C
99
true or false suppositories are considered a topical medication, and what is the best position for a rectal medication
true, left sims always
100
what are some things a nurse would do when giving a medication rectally
- tell pt to be in left sims position
- double glove adn wear all PPE
- breath in out (when pt breaths out inset medication)
- remind the patient the medication will act fast and to hold it in ring the call bell, bring commode closer to patient
101
how would do administer ear drops in children
pull gently down on the auricle and backwards this is because children's ear canals haven't fully developed
102
how would you administer ear drops in an older adult
pull auricle upwards and out
103
when administering any topical medication what is the nurse required to do!
assessment of the area
eyes check for drainage/ redness
nose assess for broken area, dryness, drainage
ear assess for bleeding or drainage
rectal and vaginal assess for skin around the area
104
when administering eye drops where do you administer
eye drops always go better in the conjunctival sac of the eye, putting them at the top of the eyes will be ineffective as the medication will drip out
105
how would you want to administer an eye medication
have the patient lay head back
106
what does INDURATION mean
hard or firm tissue caused by edema, inflammation and tumor
107
Debridement is
removing dead tissue (necrotic tissue) to be able to stage the wound
108
what are the 6 Braden scale assessment components
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction and shear
109
what does undermining mean
when there is a tunnel under the skin of the wound
110
what are the four kind of wound drainages
purulent - indicates infection yellow, green drainage
serous - watery plasma
sanguineous - bloody
serosanguineous - watery blood, pinkish red in colour
111
what is the most cautioned side affect common with nasal medications
rebounding affect, where the symptoms worsen
112
what's the positioning for nasal sprays vs nasal drops
nasal drops or any drops always but your head back to fully have the medication be absorbed so in a supine position
nasal sprays be in a high or semi fowlers position
113
The nurse is preparing to apply a topical oil-based medication to a patient's forearms. What should the nurse do to minimize the risk of contamination during the application?
a. Encourage the patient to self-apply the medication.
b. Wear treatment gloves during the entire application process.
c. Change gloves between prepping the skin and applying the medication.
d. Perform effective hand hygiene before and after applying the medication
B
114
what are common skin application patches
- nitroglycerin
- fentanyl
- nicotine
115
what are primary and secondary intention
primary intentions wound edges are approximated mean they are brought closer together
secondary wound is like a D one side is ready to approximate while other is not so wound is healed with granulation tissue
116
what are the 3 wound healing stages
- primary intention (surgically closed wound that's done with staples or sutures)
- secondary intention (wound edges aren't approximated so the wound heals on its own with granulation tissue)
- tertiary intention wound is left open to heal for many days then wound edges are approximated
117
inflammatory: takes 0-3 days causes erythema and vasodilation (open blood vessels) casing tender, red, and warmth to area
proliferative phase: 3-21 days wound starts to close and becomes a light pink colour
remodeling phase: up to 2 years to fully heal the wound scaring may occur
are the...
wound healing stages
118
what does epithelialization mean
skin rebuilds over wound
119
what does dehisced mean
the wound has re-opened
120
what does a VAC (Vacuum-Assisted Closure) do
pulls fluid out of the wound promoting healing of the wound
121
when doing wound care and patient is feeling pain when is a good time to give PRN pain meds
- 30 mins before wound care go back and assess pain levels and start wound care
122
when measuring a wound what do you gather
length
depth
width
123
what is DARP
data
action
response
plan
124
125
what drug is INR used with
warfarin
126
what does INR mean
international normalized ratio, its a blood test that measures how fast blood can clot
127
what is the INR time without warfarin (anticoagulant)
0.9-1.1low INR time more chance of clotting
128
what is INR with warfarin (anticoagulant)
3.6 higher the INR time higher risk of bleeding out
129
what does PTT stand for
Partial Thromboplastin Time
130
what medication is PTT used for
heparin
131
what is PTT time WITHOUT heparin
25-40, without the medication
132
what is PTT time WITH heparin
60-70 with heparin (takes longer to clot, blood is thinner)
133
what points must be included in documentation
- accurate
- comprehensive
- flexible
- reflect nursing standards
134
nurses are ethically and legally required to keep clients information
confidential
135
how do you correct a documentation error?
a. tell the charge nurse you made a mistake
b. white out the area and continue writing over the area to fix your mistake
c. draw a line through and writer error beside it, write initials and date, write correct entry
C
136
what is the story-like format used in documentation called
narrative
137
SOAP (subjective-objective-assessment-planning_
SOAPIE (subjective-objective-assessment-planning-intervention-evaluation)
PIE (problem-intervention-evaluation)
DAR (data-action-response)
are all methods of recording what
a. progress notes
b. care plan
c. database
A
138
where members from the patients care team have their own section to document is called
a. problem oriented medical record (POMR)
b. charting by exception
c. source records (sections)
C
139
what method of documentation includes
database
problem list
care plan
progress notes
(POMR)- problem oriented medical record
140
patient meets all care standards unless documented
is what type of documentation style
charting by exception, focuses more on documenting the abnormal
141
involves the health care team (interdisciplinary team) in the care plans and management
case management and critical pathways
142
the time it takes for a medication to produce a response in the body
onset
143
total time it takes for the medication to work after that time medication no longer works in body
duration
144
feel the strongest effect of the medication
peak
145
what are the 10 rights to med admin
patient
dose
drug
route
time/frequency
reason
documentation
patient teaching
to refuse
evaluation
146
medications are excreted by what parts of the body
- liver
- kidney
- bowels
- lungs
- exocrine glands (sweating)
147
blood test done that assess the toxic affect through blood work
trough
148
medication has reached lowest form patient is ready to ask for more
plateau
149
what does parenteral medications mean
injections meds like IV, IM, ID, SC
150
what do percutaneous meds mean
through the skin like topical, or transdermal
151
needle stuff for subcutaneous
needle length: 1/2-5/8
needle gauge: 25-27
angle of injection: 45-90 degrees depending on pt's subcutaneous fat
152
needle stuff for intramuscular
needle length: 1-1.5
needle gauge: 20-24
angle of injection: 90 degrees
153
what is the max volume of fluid you an give through subcutaneous
2 mL
154
when using a ampule what is one thing you must do to filter glass particles
- use a filter needle
155
heprain should be given where to reduce pain
left side of abdomen and 2 inches away from the umbilicus
156
if person starts to bleed after heparin what should nurse do
hold gauze there for one minute
157
where is the deltoid site landmark
acromion process
158
what site should you be careful because of the sciatic nerve
Dorsal gluteal: buttocks
159
where is the landmark for the vastus lateralis
greater trochanter (sexy bone) or pubis symphysis and patella
160
where is the landmarking for the ventrogluteal
greater trochanter (sexy bone), anterior superior iliac spine, iliac crest
161
needle stuff for intradermal
needle length: 3/8-5/8
needle gauge: 26-28
angel of injection: 15 degrees flat as possible (bc you want it to go into the dermis)
162
higher the scale on the Braden scale means what
lower risk of pressure sores
163
lower score on the Braden scale means
higher the risk is for patient to have pressure sore
164
what does decubitus ulcer mean
pressure sore, pressure ulcer, bed sore
165
what happens in stage 1 of pressure sore
- skin still intact
- non-blanchable erythema
- can happen to healthy people on couple of hours
166
what happens in stage 2 of pressure sore
- partial thickness skin loss meaning the epidermis is gone
- skin looks like blister or abrasion
167
what happens in stage 3 of pressure sore
- full thickness gone epidermis and dermis, subcutaneous layers affected
- slough maybe present
- may or may not have undermining
168
what happens in stage 4 of pressure sore
- full thickness lost plus exposure of bones muscles, tendons, and ligaments
- eschar present
169
what happens in stage 5 of pressure sore
- unstageable bc we can't see how deep the wound goes due to the necrotic tissue
- debridement needs to be done
170
what is a arterial ulcer
- lack of oxygenated blood in that site like the toes or feet
- happens becasue the arterial site is blocked meaning no oxygenated blood can pass through
171
what is a venous ulcers
- caused by pooling of the blood in lower legs because there's trouble promoting blood flow back up to the heart
172
what is a diabetic ulcers
- caused by vascular and neuropathy changes
- caused by damages to the capillaries because of the excessive sugar
173
what is a enteral nutrition
- food going directly to the stomach or intestines
different types
- gastrostomy or nasogastric (NG) goes directly to the stomach
- nasointestinal (NI) or jejunostomy go into the intestine or small intestine
174
Through an opening in the abdominal wall in the stomach. Long term, Surgically created under general anesthesia. Must have an intact GI tract
gastrostomy tube
175
what is the best way to verify a patients tube placement
by a x-ray
176
when a patient is being administered a tube feed what is the best position for them to be sitting in
semi or high fowlers
177
what is a central line
- it rests at the superior vena cava
- usually for long term use
- inserted into a large vein
178
what is the peripheral
- inserted into a small vein
- for short term use
179
reasons for patients to be on enteral nutrition
- stroke
- people who can't swallow or are at risk for dysphagia
- oral cancer
- anorexia
180
true or false intestinal fluids are stained yellow
true
181
can the follow medication be crushed
extended release
sustained release
controlled release
long acting
enteric coated
NOOOOO! medication will not be effective if crushed
182
when can an ostomy pouch be changed
every 3-7 days
183
what should the stoma look like
beefy red
moist
raised
184
what is the last sensory change to go
hearing
185
what is rigor mortis
body becomes stiff stone like
happens within 2-4 hours of death
186
algor mortis
body begins to cool down usually after 24 hours
187
liver mortis
breakdown of red blood cells causing bruising on skin purple reddish bruising within 30 mins to 2 hours
188
can LPN's pronouns death
no
189
Signs and symptoms of approaching death
- loss of muscle tone: pt will become bed bound, peristalsis slows down, loss of fecal and urinary control
- circulatory and respiratory changes: Cheyne-stokes long pauses between breaths, legs and feet become cool to touch core stays warmest for long
- sensory changes: hearing stays the longest, pt may lose their reflex to blink
190
some ways to document death
- patient is unresponsive to verbal, tactile, or pain stimuli
- pupils are fixed
- pulse and respirations are absent
- pt expired at 1400
191
when should the tube feed be flushed
- before administering formula
- after formula
- if tube seems blocked
- before and after medications
192
what does hypoxia mean
low O2 in the tissues at the cellular level
193
what does hypoxemia mean
low O2 in the blood
194
difference between SA and AV node
SA
- located in the right atrium
- bodies natural pacemaker, sends electrical impulses to start a heartbeat
AV
- passes electrical signals from the atrium to the ventricles
195
what is cyanosis
- starts at the lips blue discoloration
196
Used when the patient can cough effectively
but is not able to clear secretions
oropharyngeal and nasopharyngeal
197
Used when the patient is unable to manage
secretions
orotracheal and nasotracheal
198
what tubes remove air and fluid from pleural spaces when theres fluid or blood trapped
chest tubes
