NURS 305 - Exam 3 Flashcards
(54 cards)
1
Q
Normal ranges of serum pH; terms for states higher and lower than that
A
7.35-7.45
Higher: Alkalosis
Lower: Acidosis
2
Q
Type of grieving that occurs before the actual loss
A
Anticipatory grief
3
Q
Lack of sleep can put a client at increased risk for _______
A
Infection
4
Q
Leininger’s _______ model focused on providing care within the differences and similarities of the beliefs, values, and patterns of culture.
A
Transcultural
5
Q
The specific accountability or liability associated with the performance of duties of a particular role
A
Responsibility
6
Q
Major regulator of acid-base balance
A
Kidneys
7
Q
Type of evidence that is scientific based
A
Empirical
8
Q
One who expresses and defends the cause of another
A
Advocate
9
Q
Signs of this complication of IV therapy include: redness, warmth, and swelling at the IV site
A
Phlebitis
10
Q
Being answerable to oneself and others for one’s own actions
A
Accountability
11
Q
This moral principle refers to the “right to make one’s own decisions”
A
Autonomy
12
Q
Excessive gastrointestinal losses can lead to this electrolyte balance
A
Hypokalemia
13
Q
Prolonged immobilization can cause imbalances of this electrolyte
A
Calcium
14
Q
Acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, or sexual orientation
A
Social justice
15
Q
Parenteral administration of this electrolyte supplement cannot exceed 10 mEq per hour
A
Potassium
16
Q
Any event or stimulus that causes an individual to experience stress
A
Stressor
17
Q
Type of loss experienced by one person but cannot be verified by others
A
Perceived
18
Q
Practicing within an appropriate code of ethics and accepted standards of practice
A
Integrity
19
Q
Blood and blood products: know the basics of administration…set up with what type of fluids, transfusion reactions, how long it can hang?
A
Basics of administration: - Requires 18 or 20 gauge I.V. catheter - Verify physician order - Obtain pt consent first - Get vital sign baseline before administering - Begin transfusion slowly - Check blood type to pt’s blood type - Must be checked by second RN - Cannot be delegated to UAP - NS (normal saline) piggybacked into blood tubing (no other solutions or medicine) MAX hang time: 4 hrs
20
Q
Blood transfusion reactions
A
Transfusion reactions can happen quickly Allergic: - Local – hives, pruritus, urticaria - Resp – distress, wheezing - Anaphylactic – loss of consciousness (life threatening) Bacteria: - Increased temp - Decreased BP - Dry, flushed skin - Abdominal pain - Headache - Sudden chills
21
Q
The amount of fluid as feeding provided to the client should be recorded on the _____ record.
A
The amount of fluid as feeding provided to the client should be recorded on the patient record.
- Exact amount must be recorded, transfusion amount included.
22
Q
What is an institutional ethics committee?
A
- Ethical Standards of the Joint Commission mandate that health care institutions provide a committee to provide education, counseling, and support on ethical issues
- Include nurses and can be asked to review a case and provide guidance to a competent client, an incompetent client’s family, or health care providers
- Ensure relevant facts of a case are brought out, provide a forum in which diverse views can be expressed, provide support for caregivers, and can reduce the institution’s legal risks
23
Q
Moderate alcohol consumption is considered:
A
1/day women and 2/day men
24
Q
Know examples of what should be included in the I&O measurements (what would you document as intake and output)
A
Intake:
- Oral fluids (include water taken with medications)
- Ice chips (record fluid volume as one-half the volume of the ice chips),
- Foods that are or become liquid at room temperature (not foods that are pureed)
- Tube feedings (including volume of water used for flushes before/after medication administration, intermittent feedings, residual checks, or any other water given via a feeding tube)
- Parenteral fluids (including blood transfusions)
- IV medications
- Catheter or tube irrigants
Output:
- Urine
- Vomitus and liquid feces
- Tube drainage (gastric or intestinal)
- Wound and fistula drainage.
25
Nurses are expected to provide culturally competent nursing care. Know the four examples of health beliefs and practices provided in the book. (Pg. 321-322)
* Magic-religious health belief: Health and illness controlled by supernatural forces. Illness may be punishment.
* Scientific or biomedical health belief: Life is controlled by physical and biomedical processes that can be manipulated by humans. Illness caused by germs, viruses, bacteria, etc.
* Holistic health belief: Health based on balance. When balance compromised, illness occurs. Balance between the physical, mental, emotional, and spiritual.
* Folk medicine: Beliefs and practices relating to illness prevention and healing derive from cultural traditions rather than modern medicine. Considered more humanistic than biomedical health care.
26
_________ is being aware of one's relationship to others; sharing their joys, sorrows, pain, and accomplishments; and participating in the experience of another.
Compassion
27
________ is having the knowledge, skills, energy, experience, and motivation to respond adequately to others, within the demands of the professional responsibilities.
Competency
28
_______ is focused on morals, ethics, and an informed sense of right and wrong. Awareness of personal responsibility is part of conscience.
Morality
29
TPN is delivered via ______ and is very high in _______.
TPN is delivered via a venous catheter and is very high in glucose. There is a very high risk for infection.
30
Know hospice and palliative care (what they are, who they serve, and when each is appropriate) (Pg. 1112-1113)
- Hospice: When death predicted within 6 mos. Focuses on support and care of dying pt and family. Based on holistic concept of quality of life instead of cure. Supports family after pt death.
- Palliative: Different than hospice in that patient is not necessarily believed to be dying. Provides pain relief; Regards dying as part of normal process; Neither hastens nor prolongs death; Holistic care; Support system for family; Enhances quality of life; Applicable early in course of disease.
31
Acting in accordance with an appropriate code of ethics and accepted standards of practice is _______.
integrity
32
Nutrition and exercise are necessary for a healthy lifestyle, but key words to remember are balance and moderation. In order to qualify as a low-calorie food in a 2,000-calorie diet, the food must have less than ? calories per serving.
- Low cal: 40 calories
- Moderate cal: 100 calories
- High cal: 400 calories
33
What assessment findings are associated with excess fluid volume?
- Weight gain
- Fluid intake greater than output
- Full, bounding pulse and tachycardia
- Increased BP & CVP
- Distended neck veins
- Crackles in lungs
- Dyspnea, shortness of breath
- Confusion
34
Parenteral potassium should be well ______ and given _____.
Parenteral potassium should be well diluted and given IV.
- Never given bolus
- Monitor heart rate and rhythm
35
Know the complications of IV fluid therapy (fluid volume excess/deficit, phlebitis, infiltration, extrasavation) (Pg. 1460, 1500)
- Fluid volume deficit: Isotonic loss of water and electrolytes. Hypovolemia. Occurs from abnormal loss of fluids from skin, GI tract, or kidney; Decreased fluid intake; Bleeding; 3rd spacing.
- Fluid volume excess: Body retains both water and sodium. Hypervolemia. Caused by excessive intake of NaCl; Administering sodium-containing infusions too quickly; Diseases that alter regulatory mechanisms (HF, renal failure, cirrhosis of the liver). Risk factor is edema.
- Phlebitis: Inflammation of a vein. Mechanical phlebitis (from too large a catheter in a small vein); Chemical phlebitis (from irritating I.V. fluid); Bacterial phlebitis (Bacterial infection, could be from poor aseptic technique during I.V. insertion).
- Infiltration: Unintended administration of nonvesicant (does not cause blisters) fluid or drug into SQ tissue.
- Extravasation: Unintended administration of vesicant (causes blisters) drugs or fluids into the SQ tissue.
36
5 measures to help prevent infiltration and extravasation
1. Selection of the venipuncture site. Areas of joint flexion should be avoided.
2. Gauge of catheter should be the smallest that can deliver the prescribed therapy in the appropriate size vein.
3. Knowing osmolality and pH of medications and fluids is important (e.g. hypertonic fluids and medications should not be infused through a peripheral vein)
4. Using a manufactured catheter stabilization device prevents unnecessary movement of the catheter in the vein
5. Assessing patency of catheter and vein frequently
37
What are the four types of knowledge in nursing? (p. 452)
- Empirical knowledge is systematic and helps to describe, explain, and predict phenomena.
- Aesthetic knowledge is the art of nursing and is expressed by nurses in their creativity and style in meeting the needs of clients.
- Personal knowledge promotes wholeness and integrity in the personal encounter, achieves engagement rather than detachment, and denies the manipulative or impersonal approach.
- Ethical knowledge focuses on matters of obligation or what ought to be done, and goes beyond simply following the ethical codes of discipline.
38
Prior to administering a feeding through a gastrostomy tube, the nurse should assess for ________.
placement
Nurses are responsible for verifying tube placement before each intermittent feeding and at regular intervals (e.g., at least once per shift) when continuous feedings are being administered.
Methods nurses use to check tube placement include the following:
1. Aspirate gastrointestinal secretions (gastric secretions tend to be a grassy-green, off-white, or tan color)
2. Measure the pH of the aspirated fluid (gastric aspirates tend to have a pH of 1 to 4 – may be as high as 6 if pt is receiving meds to control gastric acid) * recommended method
3. Auscultate the epigastrium while injecting 5 to 20 mL of air (air injected into the stomach produces whooshing, gurgling, or bubbling sounds over the epigastrium and upper LQ)
4. Confirm the length of tube insertion with the insertion mark.
39
Know what assessments are involved with tube feedings. (pg. 1289)
o Inspect insertion site (if through abd)
o Inspect residual to ensure digestion
o Tube placement (can aspirate GI secretions to inspect color, Measure pH of aspirated fluid [recommended method], Auscultate the epigastrium while injecting 5-20 mL of air, Confirm length of tube inserted with an insertion mark).
40
__________ strategies can reduce stress to a tolerable limit temporarily, but are ineffective ways to deal with reality permanently. They can even have a destructive or detrimental effect on the person.
Short-term coping
- Examples of short-term coping strategies: Alcohol or drugs; Daydreaming and fantasizing; Relying on belief everything will work out; Giving in to others to avoid anger
- Three approaches to coping with stress are to: alter the stressor, adapt to the stressor, or avoid the stressor.
- Coping can be adaptive or maladaptive (ineffective coping results in maladaption).
- Effectiveness of individual’s coping is influenced by a number of factors including:
o The number, duration, intensity of stressors
o Past experiences of the individual
o Support systems available to the individual
o Personal qualities of the person
41
pH values lower than 6.8 or higher than 7.8 are generally considered ______.
fatal
42
________ is the right to self-determination, and professional practice reflects autonomy when the nurse respects patients' rights to make decisions about their health care.
Autonomy
43
The nurse's first loyalty is to the ______
client
Conflicts among obligations to families, physicians, employing institutions, and clients may arise because of the nurse's unique position. It is not always easy to determine which action best serves the client's needs.
- Legal before ethical
44
Know the primary symptom of electrolyte imbalances for calcium, potassium, and sodium
Calcium: neuromuscular
o Hypotetany with muscle spasms & panesthesias
o Chvostek’s – cheek twitch; Trousseau – arm flex
Sodium: neuro
o Confusion primary manifestation in either
Potassium: cardiac
o High = cardiac arrest, bowel
o Low = leg cramps, decreased bowel activity, slow pulse, slow reflexes
o Never IV push
o Lost by vomit & diarrhea
45
How does an increased respiratory rate affect the level of CO2 in the blood?
- Increased resp rate blows off more CO2 / lowering it in blood causes respiratory alkalosis
- Carbonic acid levels decrease and pH increase
46
Renal regulation is slow, but powerfully effective in _____-______ ________.
acid-base regulation
47
Transcultural nursing focuses on providing care within the differences and similarities of the beliefs, values, and patterns of cultures
- Incorpoate individual’s cultural beliefs, values or practices
- Sensitive to individuals normal environment
- Often more diversity in group
- Madeline Leininger – transcultural nursing
48
The loss of ___?____ sleep causes immunosuppression, slows tissue repair, lowers pain tolerance, triggers profound fatigue, and increases susceptibility to ___?____. The best outcome statement for this client is to report getting sufficient sleep to provide energy for daily activities.
NREM
infection
(REM sleep loss = psych disturbances)
49
The concept of death matures and most understand that death is an inevitable part of life at age? Toddlers fear _____ and preschoolers view death as ___?___.
separation
| temporary
50
What is the best intervention is to have the client establish and maintain a regular bedtime and wake-up time for all days of the week?
- Reduce lighting and environmental distractions
- Provide for periods of uninterrupted sleep (bundle care)
- Promote bedtime rituals
- Teach stress reduction, relaxation techniques
- Promote comfort measures
51
Know how sleep (or lack thereof) affects a person.
- Disturbs thinking patterns.
- Makes you more susceptible to disease
- Mood swings, accidents on the road
- Increased stress levels
- Increased depression
- Leads to weight gain. Sleep deprived do not burn calories as efficiently.
52
What are the five essential nursing values?
Altruism - concern for welfare and well-being of others.
Autonomy - right to self-determination
Human dignity - respect for inherent worth and uniqueness of individuals and populations
Integrity - acting in accordance with an appropriate code of ethics and accepted standards of practice
Social justice - acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation
53
When an ethical issue arises, one of the most important nursing responsibilities in managing client care situations is which of the following?
1. Be able to defend the morality of one's own actions.
2. Remain neutral and detached when making ethical decisions.
3. Ensure that a team is responsible for deciding ethical decisions.
4. Follow the client and family's wishes exactly.
1. Be able to defend the morality of one's own actions.
54
What is the usual concentration of IV potassium?
20 to 40 mEq/L
