Final Exam Flashcards
(37 cards)
ADPIE
Assessment Nursing Diagnosis Planning Intervention Evaluation
Subjective Data
Info the pt or client tells the nurse
Objective Data
info that is measurable & observable
Which of the following best describes the responsibilities nurses have for educating clients?
- Legally, the client must be told detailed information about the medical diagnosis.
- Teaching is the primary role for the registered nurse.
- Because of short hospital stays, nurses attempt to teach clients about discharge.
- The American Hospital Association formalized the client’s right to information.
Number 2
Role of the nurse in client education is a legal mandate. The Nurse Practice Act in each state indicates that teaching is the primary role for the registered nurse
Actual Nursing Diagnosis
current problems that the pt has
Priority Nursing Diagnosis
determining which problem is most important for the pt
Risk for Nursing Diagnosis
a health problem that may develop if preventive actions aren’t taken
What are the parts of a Nursing Diagnosis?
Nursing Diagnosis
Related to (r/t)
As evidence by (aeb)
What is the classification of Heparin?
What are common side effects of Heparin?
Nursing consideration/interventions…
- anticoagulant
- bleeding
- no aspiration, no massage
Needle sizes:
- Intradermal
- Subcutaneous
- Intramuscular
- Intradermal: 1 cc/ml, 3/8-5/8” needle
- Subcutaneous: 3/8-5/8” needle
- Intramuscular: 1-1.5” needle (21-23 gauge)
Mixing Insulin
-wipe rubber seals of vials
-roll NPH
-inject air into NPH
-inject air into Reg & draw it up
-draw up NPH
-have 2nd nurse verify before removing
(clear to cloudy)
The nurse is preparing to administer 0.9% NS to infuse at 100 ml/hour per the physician orders. A.)What would the nurse program into the infusion pump? There are two (2) items to answer this question. B.) How would the nurse check the infusion pump to make sure it is correct?
A) 100 ml VTBI
B) count the drips per minute
4 most common sites for Intramuscular injections (IM)
- deltoid
- vastus lateralis
- ventrogluteal
- dorsogluteal
What are the 3 categories for Central Venous Access Devices (CVAD)?
- central (triple lumens)
- peripheral (PICC)
- implanted ports (Port-a-cath)
3 common complications associated w/CVAD’s
- air embolism
- bleeding
- catheter occlusion/damage
- Sepsis (CLABSI)
- Hematoma
- Hemothorax/ pneumothorax
- Phlebitis (PICC)
- How often should nurse flush a CVAD?
- How many ml flush does evidence-based practice recommend to use w/CVAD?
- How often should the nurse assess the site of a CVAD?
- Who is responsible to change the CVAD site dressing?
- flush every 12 hours
- 10 ml NS
- Assess site every 2 hrs If infusing IVF; every 4 hrs if adapted
- specially trained nurse of IV team changes site dressing
When setting up a PCA pump, what is needed/considered?
- 2nd nurse to double check
- Narcan available
- allergies checked
- pt must be able to push trigger button & understand the pump
- running IV
- program pump
- provide education
What are some interventions/ nursing care for pt receiving TPN/PPN?
- I & O
- monitor electrolytes
- blood glucose checks (every 6 hours)
- assessments
- change tubing every 24 hrs
- submit TPN orders daily
- D10 available
- assess IV site/infusion pump every 2 hrs
- *DO NOT CATCH UP
Isotonic Solution
osmotic pressure that is equal of plasma….no net movement (PERFECT)
- Normal Saline
- Ringer’s Lactate
Hypertonic Solution
Electrolytes leave cell; less water, more solutes -fluid moves from less solutes to more solutes **cell shrivels** DEXTROSE -D5LR -D5NS -D50 -D5.1/2NS
Hypotonic Solution
Electrolytes enter cell; more water, less solutes
- fluid moves from less solutes to more solutes
- *cell swells
- 0.2% saline
- 0.45 saline
- D2.5 W
- D5W
Oliguria
diminished/small amount of urine
Anuria
absence of urine
Polyuria
excess amount of urine
