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Flashcards in Fundementals Deck (65)
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1

post tonsillectomy interventions

1.discourage coughing/clearing throat as it can lead to bleeding 2.ice collar for pain 3.analgesics 4.avoid milk products (pudding) b/c they coat the mouth and promote clearing of the throat

2

interventions for fall risk

1.room close to nursies station 2.clutter free and good lighting at night 3.call light near reach 4.bed in lowest position

3

restraints interventions

1.notify the provider immediately 2.assess every 2 hours 3.always tie to bed frame 4.max 24 hours

4

what are the different classes of fire

Class A: paper, wood, cloth, or trash Class B: flammable gas or liquid Class C: electric fire

5

transfering from bed to chair to vice versa

position client so that client is moving toward the strong side

6

moving clients in bed

ask them to raise their head and cross their arms across their chest

7

semi fowlers

30 degrees 1.feeding 2.head injury/surgery 3.increased ICP

8

fowlers

45-60 1.post abdominal surgery

9

high fowlers

90 degrees 1.dyspnea 2.NG tube insertion

10

supine

lying on back with a small pillow 1.spinal cord injury (no pillow though)

11

prone

lying on abdomen with head to side 1.post lumbar puncture 6-12 hours 2.post myelogram 12-24 hours (oil based dye) 3.post tonsillectomy and adenoidectomy 4.immobilized or unconscious

12

side lying

most body weight on lateral aspect of lower ilium 1.post abdominal surgery 2.post tonsillectomy and adenoidectomy 3.post liver biopsy (right side) 4.unconscious

13

Sims

lying on left side with most weight on anterior aspect of ilium, humerus and clavicle 1.enema administration

14

lithotomy 

1.perineal, rectal, vaginal procedures 

15

trendelenburg

head and body lowered while feet are elevated

1.during labor if umbilical cord pressure is trying to be relieved

16

modified trendelenburg

supine with legs elevated

1.shock

17

reverse trendelenburg

head elevated while feet are lowered

1.cervical traction

2.feeding clients restricted to supine position such as post cardiac cath

18

dorsal recumbent

1.urinary catheterization (females)

2.abdominal assessment

3.wound evisceration 

19

crutches

1.correct fit (3 finger widths between axilla and top of the crutch 

2.elbows flexed 

3.do not bear weight on axilla

4.6-10 inches

20

non weight bearing crutches 

means that you have one leg that can not bear any weight 

1.advance both crutches and the affected extremity while balancing on the good leg

2.move good leg forward beyond crutches

3.move both crutches then the affected extremity

21

4 point gait

used when you have partial weight bearing on both legs

1.move right crutch forward (6-10 inches)

2.move the left leg to even it with the left crutch

3.move left crutch foward

4.move right foot forward to even with right crutch

22

3 point gait

used for people that have one leg that can not bear weight

1. move both crutches forward with weight on unaffected leg

2.shift weight to crutches and move unaffected leg forward

23

2 point gait

opposites move at the same time

1.right foot and left crutch forward

24

walking up and down stairs with crutches

good foot heaven bad foot hell

1.when going up unaffected leg goes up first and the crutches move with the affected leg

2.affected leg goes down first and crutches still move with the affected leg 

25

canes

1.size is measured from greater trochanter to floor

2.goes with unaffected side

3.moves forward 6-10 inches

4.move cane forward first while bearing weight on good leg. move the bad leg forward shift weight to cane then move good leg forward past the cane.

26

walkers

for sizing the clients wrists should be even with the hand grips on the walker while the arms are dangling downward

1.advance walker 12 inches

2.move the affected lower limb then the good one

3.do not use a rolling walker if support is needed due to weakness or for parkinsons 

27

sterile field

the 1 inch border is nonsterile. 

all objects stay above waist and within vision

28

airborne diseases

measles, varicella, TB

1.Negative pressure room with HEPA filter

2.must wear FIT tested N95

3.apply a small particulate mask to client if they wanna leave the room for a medical reason only

29

droplet precautions

1.for droplets larger then 5 mcg

2.can put with another person with same organism

3.keep door closed

4.mask is required when personnel is within 3 ft of client

30

protective isolation

clients who have bad immune systems

1.no fresh flowers, fruits or veggies

2.for max protection positive pressure room