FUNDAMENTALS 1&2 NOTES Flashcards
REFRESHER (163 cards)
1
Q
A client is restless, grimacing, and unable to sleep, even though they deny pain verbally. What do these non-verbal cues likely indicate?
A
Pain
2
Q
This type of pain is usually associated with injury, medical conditions, or surgery and typically lasts hours to days.
A
Acute Pain
3
Q
: A patient describes their pain as coming and going sporadically, with “flare-ups” that can last for hours or days. What type of pain is this?
A
Episodic Pain
4
Q
A patient reports pain that has been present for 4 months, which they associate with a long-term illness. What type of pain is this?
A
Chronic Pain
5
Q
what crucial principle of pain management is highlighted by always accepting a patient’s and their family’s reports of pain?
A
BELIEVE
Always believe the patient and family when they report pain
6
Q
When using the “PQRST” nursing assessment questions for pain, what factor are you trying to identify when asking “What makes the pain worse or what makes it better?”
A
Palliative or Provocative factors
7
Q
When a nurse asks a patient to “describe the pain,” which aspect of the PQRST pain assessment is being addressed?
A
Quality of pain
8
Q
For a non-verbal patient, you observe their facial expression, leg movements, activity level, whether they are crying, and how easily they can be comforted. Which pain scale are you likely using?
A
FLACC SCALE
(Face, Legs, Activity, Cry, Consolability)
9
Q
Identifying the exact spot where a patient feels discomfort relates to which component of the PQRST pain assessment?
A
Region (Location of the Pain)
10
Q
When utilizing a numerical scale from 0 to 10 or a descriptive scale of No pain, Mild, Moderate, Severe, what aspect of pain is being measured?
A
Severity (Pain Scale)
11
Q
Asking a patient if their pain is worse in the morning, at night, or at other specific times throughout the day helps you assess what aspect of their pain?
A
Timing
12
Q
What noninvasive test measures the oxygen saturation of a client’s hemoglobin?
A
Pulse oximetry
13
Q
The normal capillary oxygen saturation (Sao2) for a healthy individual typically falls within what percentage range?
A
95% to 100%
14
Q
This vital sign reflects the balance between heat produced and heat lost from the body.
A
Body temperature
15
Q
Which type of body temperature refers to the temperature of deep tissues, such as those in the abdominal or pelvic cavity, and remains relatively constant?
A
Core temperature
16
Q
You are assessing an adult’s temperature. What is the typical normal range in Fahrenheit?
A
97 to 99 F
17
Q
While accessible, which common temperature measurement site is considered the least accurate?
A
Axilla
18
Q
To obtain the most accurate body temperature, a nurse would typically use which measurement site?
A
Rectal
19
Q
When taking a rectal temperature, what position should the client be placed in, and in which direction should the lubricated thermometer be inserted?
A
Left Side Lying position, inserted towards the umbilicus.
20
Q
For an infant, how deep should a lubricated thermometer be inserted for a rectal temperature?
A
0.5 inches
20
Q
When taking a tympanic temperature on a child who is less than 3 years old, how should the ear canal be manipulated?
A
Down and Back
20
Q
A patient has a constant body temperature continuously above 38°C (100.4°F) with little fluctuation. What type of fever is this?
A
Sustained
21
Q
A patient’s fever spikes and falls within a 24-hour period, returning to acceptable temperature levels at least once. What type of fever is this?
A
Intermittent
22
Q
A patient’s fever spikes and falls, but never returns to acceptable temperature levels. What type of fever is this?
A
Remittent
23
A patient experiences periods of febrile episodes and periods of acceptable temperature values that are often longer than 24 hours. What type of fever is this?
Relapsing
24
What is the normal pulse rate range for an adult?
60bpm-100bpm
25
A pulse described as "strong and bounding" would be assigned what grade on the grading scale for pulses?
4+
26
A pulse that is "normal and easily palpable" would be assigned what grade?
2+
27
You are unable to locate a pulse on a patient. What grade would you assign?
0 (Absent, not palpable)
27
A patient's breathing is regular but abnormally fast, with a respiratory rate greater than 20 cycles per minute. What is this called?
Tachypnea
27
A patient's breathing is regular but abnormally slow, with a respiratory rate less than 12 cycles per minute. What is this called?
Bradypnea
28
hat term describes a normal respiratory rate, typically 12-20 cycles per minute, with normal depth and no adventitious breath sounds?
Eupnea
29
A patient is experiencing labored breathing with an increase in both depth and rate (faster than 20 cpm with deep breathing). What is this alteration in breathing pattern called?
Hyperpnea
30
This alteration in breathing is characterized by an increase in both rate and depth, leading to a low level of carbon dioxide.
Hyperventilation
31
Which alteration in breathing pattern involves a decrease in both rate and depth, resulting in hypercarbia?
Hypoventilation
32
A patient's respirations are irregular in rate and depth, with alternating periods of apnea (cessation of breathing) and slow, shallow breaths. What type of respiration is this?
Cheyne-Stokes Respirations
33
A patient exhibits abnormally shallow breaths for 2-3 breaths, followed by irregular periods of apnea. What is this breathing pattern called?
Biots Respiration
34
This breathing pattern is characterized by abnormally deep and regular increases in respiratory rate, often described as "sawtooth" breathing.
Kussmauls Respiration
35
What is the force exerted by pulsating blood on the walls of an artery under pressure from the heart called?
Blood pressure
36
What is the peak of maximum pressure when the heart's contraction forces blood into the aorta?
Systolic pressure
37
The force exerted by the blood remaining in the arteries when the ventricles relax is known as what?
Diastolic pressure
38
What is the term for the difference between the systolic and diastolic pressures?
Pulse pressure
39
What are the five phases of Korotkoff sounds heard during blood pressure measurement?
Phase 1 (Tapping Sound, Systolic BP), Phase 2 (Softer, Swishing Sound), Phase 3 (Crisp, Louder Sound), Phase 4 (Muffling sound), Phase 5 (Disappearance of the Sound: Diastolic)
39
A patient's blood pressure is 120/80 mmHg. What is their pulse pressure?
40 (120 - 80 = 40
40
If a patient has a narrow pulse pressure (less than 30 mmHg), what might this indicate?
Decrease cardiac output, heart failure, and blood loss.
41
A patient presents with a wide pulse pressure (greater than 60 mmHg). What could this suggest?
Stiffness of arteries, high stroke volume, hypertensive
42
What key indicator of organ perfusion, crucial for brain and kidney health, represents the average pressure in a patient's arteries during one cardiac cycle?
MAP (Mean ARTERIAL Pressure)
43
A patient has a blood pressure of 120/80 mmHg. Calculate their Mean Arterial Pressure (MAP).
93 mmHg (120+(2×80)=280; 280/3=93)
44
What MAP range indicates adequate perfusion to organs?
70-100 mmHg
45
A patient's MAP is less than 60 mmHg. What does this low perfusion indicate?
Risk for hypo perfusion, possible organ damage.
46
A patient's blood pressure is 125/78 mmHg. How would you categorize this reading?
Elevated Blood Pressure
47
A patient's blood pressure is 135/85 mmHg. This falls into which hypertension stage?
High Blood Pressure (Hypertension) Stage 1
48
A patient presents with a blood pressure of 190/110 mmHg. What immediate action is required based on this reading?
Hypertensive Crisis (consult your doctor immediately
48
A patient's blood pressure is consistently 150/92 mmHg. This indicates which blood pressure category?
High Blood Pressure (Hypertension) Stage 2
49
What is the system that includes all fluid enclosed within cells by their plasma membranes?
Intracellular fluid (ICF
50
This fluid surrounds all cells in the body and has two primary constituents: the fluid component of blood (plasma) and interstitial fluid.
Extracellular fluid (ECF)
51
The total normal daily fluid output from the skin (insensible and sweat), insensible lungs, gastrointestinal tract, and urine is estimated to be within what range?
2200 to 2500ml
51
Fluid loss that can be measured, such as urine, feces, and vomit, is categorized as what type of fluid loss?
Sensible fluid loss
52
What is the normal total daily fluid intake from ingested fluids (orally), foods, and metabolism?
2200 to 2700ml
52
Fluid loss that cannot be easily measured, such as sweat and respirations, is referred to as what?
Insensible fluid loss
53
What term describes the movement of water only through a semipermeable membrane from an area of low solute concentration to an area of high solute concentration to balance things out?
Osmosis
54
These ions are found in body fluids, help conduct electricity and energy, and control body fluids.
Electrolytes
55
What term describes the balance or equilibrium, a self-regulating process, maintained in the body?
Homeostasis
56
What is the normal range for Potassium?
3.5−5 mEq/L
57
A patient is experiencing nerve and muscle dysfunction. Which electrolyte, important for nerve impulse conduction and proper muscle activity, might be out of balance?
Potassium
57
What is the normal range for Sodium?
135−145 mEq/L
57
Which electrolyte is crucial for maintaining blood volume, blood pressure, and pH balance?
Sodium
58
What two hormones primarily regulate sodium levels in the body?
Antidiuretic Hormone and Aldosterone Hormone
59
What is the normal range for Calcium?
9.0−10.5 mg/dL
60
A patient is exhibiting issues with bone density, blood clotting, and heart rhythm. Which electrolyte plays a significant role in these three "B's"?
Calcium
60
Which two electrolytes have an inverse relationship, meaning that as one increases, the other tends to decrease?
Calcium and Phosphorus
61
What is the normal range for Magnesium?
1.3−2.1 mEq/L
62
This electrolyte is essential for protein synthesis, nerve function, and blood sugar regulation
Magnesium
63
What is the normal range for Phosphate?
3.0−4.5 mg/dL
64
This electrolyte is crucial for bone and teeth formation, regulating calcium, and is necessary for ATP production.
Phosphate
65
Which electrolyte shares similar functions with sodium, including contributions to blood volume, blood pressure, and pH balance?
Chloride
65
What is the normal range for Chloride?
98−106 mEq/L
66
When assessing skin turgor and elasticity using the pinch method, you observe a slight pitting of 2mm that disappears rapidly. What grade of pitting edema is this?
1+
67
After pressing on a patient's skin, you notice a deeper pit of 4mm that takes 10 to 15 seconds to disappear. What grade of pitting edema is this?
2+
68
You observe a noticeably deep pit of 6mm on a patient's skin that takes more than a minute to disappear. What grade of pitting edema is this?
3+
69
Upon assessment, you find a very deep pit of 8mm that takes 2 to 5 minutes to resolve. What grade of pitting edema is this?
4+
70
This diagnostic test assesses the ability of the kidneys to filter wastes and excess fluids, with a normal range of 90-120ml/min/1.73m2, and requires a urine specimen.
GFR (Glomerular Filtration Rate)
71
Which kidney function test involves a 24-hour urine collection and is always partnered with serum creatinine to assess the kidney's ability to clear waste products?
Creatinine Clearance
71
This waste product is formed in the liver, and its blood levels (normal range 8-20mg/dl) are indicative of kidney dysfunction, dehydration, or heart/liver problems when elevated.
BUN (Blood Urea Nitrogen
72
A patient's BUN level is low. What could this indicate?
Liver Disease, Malnutrition or Overhydration
73
This urine test measures the concentration of solutes like electrolytes, urea, and creatinine, with a normal range of 1.005-1.030.
Urine Specific Gravity
74
A patient's urine specific gravity is high. What does this "lapot" or concentrated urine suggest?
Kidney Dysfunction
75
This blood test measures the concentration of solutes in blood, including glucose, sodium, and urea, and has a normal range of 270-295mosmol/kg.
Serum Osmolality
76
A patient's serum osmolality is high ("concentrated/lapot"). What conditions could this indicate?
Hypernatremia, Dehydration, Hyperglycemia
77
A patient's serum osmolality is low ("diluted/labnaw"). What could this suggest?
Overhydration, Hypoglycemia, water intoxication
78
A solution with the same osmolarity as blood, resulting in equal transfer of water without affecting cell size, is known as what?
Isotonic solution
79
What term refers to the amount of solutes within a specific fluid?
Osmolarity
80
You need to administer an IV fluid to a patient experiencing significant fluid loss due to vomiting, diarrhea, burns, or hypovolemic shock. What type of solution would be appropriate?
Isotonic Solution
81
This isotonic solution contains water, sodium, and chloride, and is the only fluid compatible with blood transfusions.
PNSS (0.9% Sodium Chloride)
82
This isotonic solution contains water, sodium, chloride, calcium, potassium, and lactate, which helps the blood pH by converting to bicarbonate
Lactated Ringers (Ringers Lactate Solution)
83
This solution starts as an isotonic solution but ends up as a hypotonic solution because the dextrose is metabolized, leaving a low osmolality.
5% Dextrose in Water (D5W)
84
What type of solution has a higher osmolarity than blood, causing water to leave the intracellular space and the cell to shrink?
Hypertonic solution
85
Which type of solution has a lower osmolarity than blood, causing water to move from the extracellular space into the intracellular space, resulting in cell swelling?
Hypotonic solution
86
What is the general osmolarity range for isotonic solutions?
270-300
87
Before initiating IV therapy, what crucial step involves reviewing the physician's orders?
Verify Doctors Order
88
Which of the following areas are generally not suitable sites for IV insertion due to an increased risk of thrombus formation?
Legs and Feet
89
For infants, which sites are suitable for IV insertion?
Scalp and Feet
90
When selecting an IV site, why is it advisable to start at the distal area?
To provide Options
91
How often should a venipuncture site be changed?
Every 72 hours to 96 hours
92
How often should an IV dressing be changed if it is a transparent gauze?
7 Days or as specified by the Agency Policy
93
What is the general recommended frequency for changing IV tubings?
Every 96 Hours
94
How often should an IV bag or bottle be changed?
Every 24 Hours
95
What is the administration of whole blood, its components, or plasma-derived products for therapeutic purposes via IV called?
Transfusion Therapy or Blood replacement
96
A primary purpose of blood transfusion is to restore the oxygen-carrying capacity of blood. Which blood component is primarily responsible for this function?
Hgb (Hemoglobin)
97
In the ABO blood group system, which blood type is considered the universal donor because it lacks A and B antigens on the surface of its red blood cells?
Type O
98
Which blood type is considered the universal recipient because it lacks anti-A and anti-B antibodies in its plasma?
Type AB
99
A patient's own blood is collected and then reinfused back into the same patient at a later time. What type of transfusion is this?
Autologous
100
A patient with leukemia is not a candidate for which type of transfusion, as it would increase the risk of disease transmission and complications?
Autologous
101
When blood is donated by another person, it is referred to as what type of transfusion?
Homologous / Allogeneic
102
Before connecting the IV tubing to the IV cannula during a blood transfusion, what step involves filling the blood filter?
Spike PNSS bag, Prime tubing for the Blood Filter
103
After connecting the IV tubing, for the first 15 minutes, how should the infusion pump be set to deliver blood?
At a slow rate (more than 2 mL per minute)
104
Which diet emphasizes increasing fiber intake from whole grains, fruits (especially with the skin), and vegetables, and is often recommended for managing hypertension?
DASH diet (Dietary Approaches to Stop Hypertension)
105
A patient diagnosed with hypertension or congestive heart failure is advised to limit their intake of processed meats, salty snacks, and canned goods. Which dietary restriction is the primary focus for these conditions?
Low Sodium
106
A diabetic patient is educated to prioritize complex carbohydrates (60% of their intake) and lean protein (20%), while avoiding saturated and trans fats. What type of diet is this patient following?
Balanced Diet
106
For a patient with Chronic Kidney Disease (CKD) or End-Stage Renal Disease (ESRD) experiencing fluid retention, which dietary modifications are crucial to manage electrolyte balance?
ow Sodium, Low Potassium, Low Phosphorus, Moderate Protein
106
A patient diagnosed with Celiac Disease must completely eliminate specific grains from their diet due to an inability to metabolize a certain protein. Which protein must they avoid?
Gluten
106
A patient with liver disease and hepatic encephalopathy is advised to limit protein intake to a moderate level and avoid alcohol and red meat to prevent the buildup of a neurotoxin. Which diet focuses on reducing this toxin?
Low Sodium, Moderate Protein (to manage Ammonia levels)
107
Following a severe burn injury, a patient requires a diet rich in calories and protein, often supplemented with Vitamin C and Zinc, to support tissue repair and immune function. What is the primary focus of this dietary approach?
High Calorie, High Protein with Supplements
108
A patient with a peptic ulcer is advised to avoid caffeine, spicy foods, alcohol, and citrus fruits, while opting for oatmeal and non-citrus fruits. What type of diet is recommended for this condition?
Bland Diet, Low Acid, Low Fat
108
To minimize the risk of infection in a patient undergoing chemotherapy, which food preparation guideline is crucial to prevent the consumption of harmful microorganisms?
Avoid Raw Produce and Unpasteurized Foods
108
A patient suffering from Gout is told to avoid organ meats, sardines, shellfish, and beer. This dietary restriction aims to reduce the body's production of what substance?
Purine
109
For a patient with dysphagia, thin liquids are strictly avoided, and their meals are often pureed or thickened. What is the primary concern when managing the diet for this condition?
Difficulty in Swallowing
110
A patient with neutropenia or a compromised immune system is advised to avoid raw foods, uncooked meat, and unwashed produce. What type of diet is recommended to protect them from infection?
Neutropenic Diet
111
A patient with pancreatitis, experiencing malabsorption, is instructed to avoid high-fat meals. Which type of diet is typically recommended to manage this condition?
Low Fat, High Calorie with Enzyme Support
112
Before an Esophagogastroduodenoscopy (EGD), a patient is given a local anesthetic, conscious sedation, and kept NPO to prevent aspiration. What is the purpose of this diagnostic procedure?
Endoscopy of the Upper Gastrointestinal Tract (Esophagus, Stomach, Duodenum)
112
Following an upper endoscopy, a nurse must ensure the patient's gag reflex has returned before allowing oral intake. Why is this assessment critical post-procedure?
To Avoid Aspiration
113
After a barium swallow, a patient is encouraged to increase fluid and fiber intake and may be given a laxative. What is the main goal of these post-procedure interventions?
To Excrete Barium from the Body
113
For a colonoscopy, a patient must adhere to a low-residue diet and remain NPO to ensure the bowel is completely clear. What is the primary objective of this procedure
Examination of the Lower Colon
114
What is the term for the process that involves percussion, vibration, and specific patient positioning to facilitate the removal of sputum from the lungs?
Chest Physiotherapy
115
A nurse is performing suctioning on a patient with excessive sputum. If the patient is unconscious, what position should they be placed in to prevent aspiration?
Side Lying Position
115
During suctioning, the nurse applies suction only while withdrawing the catheter in a spiral, twisting, or circular motion. What is the maximum duration for applying suction during each pass?
10 seconds
115
A patient is undergoing removal of pleural fluid from their lungs, a procedure that can be either diagnostic or therapeutic. What is this procedure called?
Thoracentesis
116
After a thoracentesis, the nurse applies a pressure dressing and positions the patient on the unaffected side. Why is positioning on the unaffected side important?
So that the fluid won't leak and the lungs can expand
117
What is the normal finding for the water seal chamber of a Chest Tube Thoracostomy (CTT) drainage system during inspiration and expiration?
Tidaling / Intermittent Bubbling
118
If continuous bubbling is observed in the water seal chamber of a chest tube drainage system, what does this indicate?
Air Leak
119
When providing tracheostomy care, the inner cannula is removed for cleaning due to mucus buildup. With what solutions can it be cleaned?
Water/Normal Saline Solution (NSS) or Half-Strength Hydrogen Peroxide
120
When inserting an NGT, the nurse measures the length from the patient's nose to the earlobe, and then to which anatomical landmark, before inserting the tube?
Xyphoid Proces
121
After inserting an NGT for feeding (gavage), how can the nurse confirm proper tube placement, besides an X-ray?
Aspirating Gastric Content and Checking pH (1-4), or Auscultating Air (30 mL) for Gurgling Sound
121
A patient receiving NGT feeding has a residual volume greater than 400 mL. What nursing action should be taken?
Hold the Feeding
122
Before a paracentesis procedure, the nurse ensures the patient's bladder is empty. Why is this preparation step crucial?
To Avoid Bladder Puncture
123
Following a liver biopsy, the patient is positioned on their right side (affected side) at a 4-degree angle and kept on bed rest for 24 hours. What is the primary reason for this specific positioning and activity restriction?
To Apply Pressure and Prevent Bleeding/Hemorrhage
124
For a patient with an ileostomy, if the volume of liquid stool increases significantly, what common problem might this indicate?
Obstruction
125
When assessing a newly created stoma, you observe it to be edematous and reddish-pink. What color would indicate ischemia or compromised blood supply to the stoma?
Bluish/Dusky or Black
126
When caring for a stoma, how much larger than the stoma should the wafer size of the appliance be cut?
1/8 inch larger
127
To prevent odor and gas, a patient with a colostomy should avoid certain foods. Which foods are known to reduce odor?
Parsley, Buttermilk, Yogurt, Cranberry, Orange Juice, Tomato Juice
128
When performing a standard physical assessment, which sequence of techniques should be followed for all body systems except the abdomen?
Inspection, Palpation, Percussion, Auscultation (IPaPeA)
129
When assessing a patient's abdomen, what is the modified sequence of physical assessment techniques to avoid altering bowel sounds?
Inspection, Auscultation, Percussion, Palpation (IAPePa)
130
During an abdominal assessment, you listen for bowel sounds. What is considered the normal range of bowel sounds per minute?
5 to 30 bowel sounds in one minute
131
In the Weber's test for hearing, a tuning fork is placed in the middle of the forehead, and the patient is asked to identify which ear hears the sound louder. If the sound is localized to the "poor" ear, what type of hearing loss does this indicate?
Conductive Hearing Loss
132
If, during a Weber's test, the sound is localized to the "good" ear, what type of hearing loss is suggested, often associated with Meniere's Disease or ototoxicity?
Sensorineural Hearing Loss
132
When collecting a 24-hour urine specimen, what is the first step at the start time (e.g., 8 AM)?
Discard the First Urine
132
A patient is undergoing a Snellen's Test, where they stand 20 feet from a chart and can read the letters typically read at 20 feet. What is considered a normal visual acuity measurement?
20/20
133
A Guaiac test is performed on a patient's stool after they have avoided red meat, raw fruits, and vegetables for 2-3 days. What is the purpose of this test, and what does a bluish reaction indicate?
To detect Hidden Blood in the Stool (diagnose Colorectal Cancer or Peptic Ulcer); Bluish reaction indicates a Positive Result
134
A patient is using a cane for ambulation. When going upstairs, the instruction is "Good goes to heaven, Bad goes to hell." Which leg should move first?
Good Leg, then Cane and Bad Leg
135
When using crutches, how many finger breadths below the axilla should the crutch height be adjusted to prevent nerve damage?
2-3 finger breadths
136
What is the primary expected finding in the drainage from a Continuous Bladder Irrigation (CBI) via a 3-way Foley Catheter?
Bloody, with Normal being Light Pink with Few Clots
137
What common side effect should a nurse anticipate and manage in a patient receiving opioid medications like Fentanyl, Morphine, or Demerol?
Constipation
138
A patient with venous insufficiency is instructed to apply elastic compression stockings. When is the best time to apply these stockings to optimize their effectiveness?
Before Getting Out of Bed
