final exam Flashcards
(69 cards)
1
Q
safety precautions
A
- lock wheels of the wheelchair to prevent it from moving on the client when sitting down
- call bell should be within reach @ all times, teach client to use call bell
- keep clients bed in low position
- put fall risk id on clients wrist
2
Q
dirty linen
A
- all linen that touches floor should get put in linen bag
3
Q
location of pt
A
pt at risk for fall should be near the nursing station
4
Q
history of falls precuations for showers
A
put a bath seat in it
5
Q
gait belt
A
helps support the client while walking. gait belt keeps the client center of gravity stable and helps prevents falls
6
Q
precautions
A
- 95 mask is required for airbone precautions
- gloves are required when coming in contact with bodily fluids
- hand hygiene should be preformed in between every glove use
7
Q
hippa
A
- when complying with hippa remember that documentation provides info to facilitate communication amoung members of the health care team and plan appropriate therapies when evaulating progress
8
Q
insurance
A
- health care facilites hvae insurance that covers all employees
- recommended that nurses obtain their own professional liability insurance
9
Q
violations of hippa
A
- sharing a computer password with coworkers would violate hippa
- sharing lab findings with a client family would be a violation of hippa unless the family is considered an authorized person
10
Q
documentation provides
A
info to facilitate communication among all members of the healthcare team
11
Q
interprofessional team
A
- an occupational therapist can assist with clients who have physical challenges with adaptive devices to help with self care activities
12
Q
applying critical thinking skills
A
helps pt focus on their values and beliefs within their mangement of care
13
Q
what does a nurse consider whom is critically thinking
A
immediate action with a pt condition worsens
14
Q
a nurse who improves plan of care….
A
while thinking back on interventions and their effectiveness is critically thinking
15
Q
what does concept map promote
A
clinical decisions and critical thinking -
16
Q
nursing process and exploring other option for pt care
A
promote critical thinking
17
Q
cane
A
- instruct client to move a cane an advance their weak leg forward to the cane followed by the advancing strong leg past the cane
- provides clients body weight to be distributed between the cane and the stronger leg
18
Q
where should height of the cane be
A
equal distance between the floor and the hip
19
Q
which side should the cane be on
A
strong side of pt. body
20
Q
how should the elbows be when holding cane
A
keep their elbow slightly flexed when they use their cane
21
Q
walker
A
client should lift the walker in advance it and then set it down
- nurse should walk slightly behind client who is using a walker in case they need assistance
22
Q
how should the client move feet with walker?
A
the client should move one foot up to the walker and move the walker first
23
Q
where should the walker land on a person body
A
below the level of the clients waste
24
Q
nursing process first step
A
assessment
includes:
- organizing clients data
- nurse should assess the client’s date first and then analyze the data to determine what is a priority
25
steps of nursing process
```
assessment
analysis
planning
implementation
evaluation
```
26
nursing plan of care
comes after implementation of care
| - plan following by evaluation to determine the effectiveness of the interventions that the nurse has done
27
sterile field
- open package over a sterile package over the middle of sterile field
- pull flaps of the package away from body, grasping it from side to side to avoid reaching over the sterile field and contaminating
- label into palm of hand so that the solution doe snot drip down the label in ruin it
28
restraints
- use a quick release tie fro easy removal in emergency
- two fingers should fit under restraint
- padding should be applied against bony promises with restraints to prevent friction and potential skin breakdown
29
how often should restraints be removed
remove every two hours according to facilities policy
| - assess skin and whether or not the restraint is too tight
30
where should restraints be secured to
an area of the bed frame that moves with the client when repositioning
- not to the siderail
- head of bed is okay
31
how often does provider renew prescription for restraints
every four hours
32
what should a nurse do before restraints
consider alternative methods versus restraints
| - restraints will physically help a client for moving freely however, they are a last resort
33
being in bed immobile increases
breakdown of bone tissue
| - results in high calcium
34
complications of immobility
- contractures of the extremities
- extra fluid in lungs
- pressure ulcers
- constipation
- not able to cough affectively
- low oxygen levels
- feet cant flex
35
foot board
feet not flex helpful to prevent foot drip in bed
36
proving hygiene
- make sure personal items are used when changing linens
- do not make the bath water too hot
- move with direction of growth when shaving to prevent burns
37
oral care
- head should be turned so pt does not aspirate
| - turning pt head to side during mouth care is better than putting the nurses thumb or fingers into the mouth
38
activities of daily living (ADLs)
- performing oral hygiene, bathing oneself and getting dressed
- occupational therapist assist the most with activities of daily living
39
urine specimen collection
female:
- client should clean area of the perineum from front to back to avoid bacteria entering specimen
- client should begin a stream of urine and then pass the container intoto the urine stream when obtaining the sample
- wash off bacteria at the distal urethra that may contaminate sample
40
what contributes to constipation
- excessive laxatuve use
- ignoring the need to use bathroom
- inadequate fluid
41
what results in hardening of stool
reducing fluid flows the passage of food through the intestine
42
what promotes bowl emptying
- increase fiber in diet
| - increasing activity
43
what prevents constipation
increasing vegetables
44
urinary incontience
- assit client every 2 hours creates regular pattern of toleting to prevent incontience
- protect pt. skin
45
discontinuing catheter
pt should be laying down in a supine position
46
when incontienence is suspected what should u do
bladder scan
47
pressure ulcers
reposition client every 2 hours especially when sore is at stage 3
- transparent dressing is first choice for stage 1 ulcer
- stage 3 pressure ulcer has necrotic sub c tissue
48
when assessing a pt. fluid status the nurse should reveiw
- health history
- lab data
- clinical assessment
49
adult water ratio
50-60% of total body weight
50
infants water ratio
75-80% of total body weight
51
2/3 of body fluid is
intracellular
52
1/3 of body fluid is
extracellular
53
factors to fluid volume deficit
- excess gi loss
- diaphoresis
- fever
- hemmorrhage
- insufficient intake
- burns
- diuretic therapy
- aging: older adults have less body water and decreased thirst
54
fluid volume deficit clinical manifestations
- weight loss
- dry mucus membranes
- increased heart rate and respirations
- thready pulse
- capillary refill less than 3 sec
- weakness, fatigue
- orthostatic hypotension
- poor skin turgor
55
late symtoms of fluid deficit
- oliguria
- decreased cvp
- flattened neck veins
56
diagnostic procedures
- serum electrolytes
- bun/creatinine
- hct
- urine specific gravity and osmolarity
57
fluid volume deficit nursing interventions
- monitor vital signs
- monitor skin turgor
- maintain strict i&o
- weight pt. daily
- monitor lab are ordered
58
fluid replacement as ordered
- increase oral fluid intake
- initiate oral rehydration solution
- anticipate giving iv fluids for severe dehydration/maintain as ordered
- initiate fall precautions
59
medications for fluid volume deficit
- electrolyte replacement
| - intravenous fluids
60
fluid volumem excess
fluid intake or retention is greater than the body needs
61
volume excess contributing factors
- kidney failure
- heart failure
- cirrhosis
- interstitial to plasma fluid shifts: burns, hypertonic fluids
- excessive water intake
62
fluid volume excess clinical manifestations
- cough, dyspnea, crackles
- increased blood pressure
- tachypnea and tachycardia
- bounding pulse
- weight gain (1L= 1kg)
- increased urine output
- increased central venous pressure
- edema
63
fluid volume excess diagnostic procedures
- serium: electrolyte, bun, creatinine, hct
- urine: specifc gravity and osmolality
chest x-ray if respiratory complications are present:
- increased work of breathing
- tachypnea
- low o2 saturation
64
nursing interventions volume excess
monitor respiratory rate, symmetry and effort
- monitor heart sounds
monitor for edema:
1. measure on scale
2. 1+ (minimal) to 4+ (severe)
3. monitor dependent edema by measuring circumference of extremities
65
fluid volume excess nursing interventions
- monitor for ascites
- measure abdominal girth
- weight pt. daily
- maintain strict i&o
- monitor vital signs
- administer diuretics
- limit fluid intake
- provide frequent skin care
- semi fowlers position: reposition pt. minimum of evert 2 hours
- restrict sodium intake
66
hypovolemia
occurs when there is a decrease in blood volume within the bidy due to loss of body fluids or blood
- excessive sweating, large burns, diuretics, inadequate fluid intake, and increased urination can lead to hypovolemia
- causes nose, mouth, other mucous membranes to dry out, the skin to lose elastivity, and urine output to decrease
- body then tries to compensate for volume loss by increasing the heart rate and strength and contractions
67
hypovolemia untreated
- blue discoloration of lips and nails beds
- change in alertness or level of consciousness
- chest pain, tightness, or pressure
- palpitations
- no urine production
- tachycardia- increased heart rate
- tachypnea- rapid breathing
- decreased bp
- weak pulse
68
hypovolemic shock
which is when the body has lost 20 % or 1/5 of its blood or fluid supply
- treatment is aimed at controlling fluid or blood loss, replacing those components and restoring overall circulation
69
Hypervolemia
- fluid overload, is a condition where the body has too much water.
- caused by: problems with the kidneys as they are responsible for balancing the salt and fluid in the body.
- The goal of treatment is to rid the body of excess fluid.
