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fundamentals exam 3 > fundamental exam > Flashcards

fundamental exam Flashcards

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1
Q

What are ways that a nurse can assess a patient’s oxygenation// breathing?

A

Pulse ox
Listening to lungs
Respiration Rate

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2
Q

What assessmet finding would lead to an intervention of applying oxygen to a patient?

A

Pulse ox falls below 89%
Aterial oxygen pressure falls below 60mmHg

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3
Q

What is Atelectasis?

A

Collapse of partial or full lung

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4
Q

What are some nursing interventions that can help prevent atelectasis?

A

Deep Breathing
Proper use of incentive spirometer
Chest physiotherapy

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5
Q

What is normal respiratory rate?

A

Between 12-20

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6
Q

What is dyspnea?

A

Shortness of breath

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7
Q

What happens to the respiratory rate if the body has an increased demand for oxygen?

A

Breathing rate increases
Heart beats faster

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8
Q

If someone is dyspenic & has an elevated respiratory rate, what simple interventions could you offer?

A

Deep breathing
Changing positions

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9
Q

How would you manage care for patients with poor oxygenation?

A

Coughing techniques
Deep breathing
Supple of oxygen through nasal cannula or face mask

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10
Q

What does a nursing diagnosis of impaired gas exchange mean?

To make this nursing diagnosis, what may we assess?

A

a disruption of oxygen and carbon dioxide exchange in the lung tissues

Assess: pulse ox, cardiac function, bloodwork, arterial blood gasses

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11
Q

What is right-sided heart failure?
What are the symptoms of it?

A

Right ventricle is too weak to pump enough blood to the lungs

Symptoms: shortness of breath, swelling in your ankles, dizziness, fatigue, swelling

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12
Q

What is left-sided heart failure?
What are the symptoms of it?

A

Left ventricle of the heart no longer pumps enough blood around the body

Symptoms: coughing, shortness of breath, swelling in your ankles, & weight gain

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13
Q

When do we use a nasal cannula vs face mask to deliever oxygen to a patient?

A

Nasal cannula: experiencing minimal respiratory distress

Face mask: for patients who need LARGE amounts of oxygen at once; needs constant level of oxygen

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14
Q

What are some interventions to help thin secretions?

A

Deep breathing
Chest physiotherapy
Supplemental humidication
Changing positions
drinking fluids

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15
Q

What is intracellular space?

A

Everything inside of the cell membrane

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16
Q

What is extracellular space?

A

everything outside of a cell

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17
Q

What are signs & symptoms of specific electrolyte imbalances?

A

Cold clammy skin
Hypotension
Dizziness
Sudden weight loss
Tachycardia

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18
Q

What are the normal rangs of lab values for electrolytes?

A

Potassium: 3.5-5.0
Sodium: 135-145
Calcium: 8.6-10.3
Magnesium: 1.7-2.2

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19
Q

What is clinical dehydration? And nursing interventions for it

A

Absence of sufficient amount of water in your body

Nursing interventions: encourage fluid intake & IV fluids

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20
Q

What are nursing interventions for fluid retention?

A

Record intake & output
Administer diuretics
Enforce fluid restrictions

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21
Q

What is respiratory acidosis?

A

Lungs cannot remove all of the carbon dioxide produced by your body

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22
Q

What is respiratory alkalosis?

A

low carbon dioxide levels disrupt your bloods acid-base balance

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23
Q

What is metabolic acidosis?

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A

Buildup of acid in the body due to kidney disease or kidney failure

24
Q

What is metabolic alkalosis?

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A

the body pH is greater than 7.45 secondary to some metabolic process

25
How do we assess electrolytes & acid-base imbalances?
Labwork, ABG & serum electrolytes to determine acid-base imbalances
26
How do we assess sleep; what would you ask a patient?
Sleep study Has anyone told you snore? What is your sleep schedule? Sleep pattern? Do you snore?
27
What are some risk factors & signs for obstructive sleep apnea? How is it treated?
Loud snoring Daytime sleepiness Type 2 Diabetes High blood pressure Obese Males Congestive heart failure Treated - CPAP machine
28
What are some nursing interventions used to promote sleep in care setting?
Provide comfort setting Encourage using the bathroom before sleeping Make sure the environment is dark & quiet
29
Examples of bad communication
Being insensitive Not letting the patient express how they are feeling Shrugging them off Not being sympathetic
30
Examples of good communication
Active listening Showing respect Presence Honesty Showing sympathy Acknowledge the patients feeling
31
Types of grief
Normal Anticipatory Disenfrachised Complicated
32
What makes complicated grief a concern for clients?
Someone can become depressed & more anxious Physical & mental health could become worse
33
Types of Loss
Actual loss: loosing someone, loosing a part of body Perceived loss: loss of independence; less obvious to people
34
What is palliative care?
Focuses on the prevention,relief, and reduction of symptoms Goal is to help achieve the best possible quality of life Patient can opt to get treatment of care
35
What is hospice care?
6 months or less to live Focuses on the care of terminally ill patients Goal is to manage pain, provide comfort, ensure quality of life Prioritize care according to patient wishes
36
What is advanced directive?
A written statement of a persons wishes regarding medical treatment when they become incapable ( example: DNR)
37
What are the 5 stages of grief & the behaviors shown?
Denial: you go numb, do not believe anything in your life Anger: mad at everything Bargaining: false hope Depression: feel isolated, sad Acceptance: emotions stable; you re-enter reality; come to accepting
38
What are some physical signs of impeding death?
Irregular/shallow breathing Lowered blood pressure Loss of sensation in arms & legs Rapid pulse urinating less/ difficutly to urinate
39
How would you approach/ communicate with unconscious patient who is dying?
Open-ended questions Therapeutic communication Talk to them
40
What is General Adaptation Syndrome?
the process your body goes through when you are exposed to any kind of stress
41
What are the stages of general adaptation syndrome?
Alarm stage: fight or flight - Dilated pupils, increased heart rate, rapid breathing Resistance stage; your body tries to repair itself after a shock of stress - Headache, bowel issues, poor concentration, sadness Exhaustion stage: dealing with stressors without relief to the point where your body cannot cope with stress - burnout, fatigue, decreased stress tolerance
42
What are some general reactions to stress?
Coping & defense mechanism
43
What is a caregiver burden?
Stress associated with the demands of caring for someone with physical or mental impairments
44
What are some nursing interventions for clients with stress/ anxiety?
Let them talk out how they are feeling Acknowledge how they are feeling Provide active listening
45
Examples of healthy coping strategies
Exercising Support systems Journal writing Drawing Relaxation techniques
46
Examples of non-healthy coping strategies
Isolating Drinking Self harm Drug use
47
What is anxiety (nursing diagnosis)
vague, uneasy feeling of discomfort or dread accompanied by an autonomic response; a feeling of apprehension caused by anticipation of danger
48
What is sensory deprivation?
Inadequate quality or quanity of stimulation example: being isolated, not having enough of something
49
What is sensory overload?
Reception of multiple sensory stimuli example: too much lights, too much music
50
How cognitive response for a patient with sensory deprivation?
Depression & loneliness & be more confused
51
How cognitive response for a patient with sensory overload?
Anxiety & feeling overwhelmed
52
What interventions can a nurse offer for each?
Dim the lights & reduce noises Talk to patients so they do not feel isolated
53
What are some examples of sensory deficits & how can we improve communication with patients who have these deficits?
Examples of sensory deficits: deaf, blind, hearing impairement, vision impariment Turn your face towards the patient, Speak clearly, do not shout or over exagggerate words or lip movements
54
What is the difference between dementia & delirium?
Dementia: more permanent; gradually progressives over time Delirium: temporary; medication can cause someone to be delirium
55
types of loss
actual loss ( loosing someone, loosing your breast due to breast cancer, loosing ur limb) perceived loss ( loss of independence) situational loss ( loss of job)
56
Sensory deficits: Deficit in the normal function of sensory reception & perception (example: someone that cannot hear or see) Sensory deprivation Inadequate quality or quantity of stimulation (example: someone who is on bedrest, being isolated, not having enough of something) Sensory overload Reception of multiple sensory stimuli (example: too much happening at once) (anxiety is a concern when it comes to sensory overload)

fundamentals exam 3 (1 decks)

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