Reduction of Risk Potential Flashcards
What is the most appropriate comparison for vital signs: the standard acceptable ranges or the client’s baseline?
the client’s baseline
If the client has a baseline that is higher than the standard acceptable range, a vital sign reading considered high may actually be acceptable for the client.
Kidney function is best assessed using which laboratory value?
creatinine
While both BUN & creatinine are collected when testing kidney function, creatinine is more indicateive of kidney failure. BUN alone is not significant but should be used in conjunction with creatinine results.
When is a glucose reading most accurate & indicative of glucose homeostasis?
when fasting
A fasting glucose reading is most indicative of glucose homeostasis as glucose levels naturally rise after meals & fall as the pancreas secretes insulin.
Which group typically has a higher concentration of red blood cells in the blood, males or females?
males
The normal range for hematocrit is higher for males compared to females. This also leads to higher normal ranges for hemoglobin
For a client who is having a heparin drip started, what is the most critical lab value to monitor?
aPTT
When starting a heparin drip, aPTT tests are performed typically Q6H so that the client’s response to the dose can be measured & the dose can be adjusted if needed.
___ is the most appropriate laboratory test to assess for diabetes mellitus.
HgbA1C
When diabetes is suspected, a test of the client’s hemoglobin A1C (HgbA1C) will determine long-term control of the client’s glucose levels. A normal HgbA1C ranges between 4 & 5.6%. Levels greater than 6-4% can be indicative of poor glucose control due to diabetes.
What segment of the EKG waveform indicates ventricular repolarization or relaxation?
ST segment
The ST segment is the segment between the QRS-complex & the T-wave, & it represents the time where the ventricles are relaxing or repolarizing to prepare for the next contraction.
What is the expected time for capillary refill in a healthy client?
less than 3 seconds
If the client’s capillary refill is greater than 3 seconds, they may have impaired circulation to that limb.
Which cranial nerve is responsible for visual acuity?
Cranial Nerve II
Cranial Nerve II is the optic nerve, & it is responsible for vision & visual acuity.
The client has been diagnosed with a UTI, & the primary care provider has ordered Bactrim & a urine culture. Which should be completed first, the medication administration or the urine culture?
the urine culture
The urine culture should be collected prior to administering Bactrim, since Bactrim may alter the test results.
When administering medication through a nasogastric tube, when should the tube be irrigated?
prior to & following medication administration
To check for tube placement & maintain patency of the nasogastric tube, the tube should be irrigated both prior to & following medication administration.
Is suctioning of a tracheostomy tube a sterile procedure, clean procedure, or a dirty procedure?
sterile procedure
Due to the infection risk that could lead to pneumonia, suctioning of a tracheostomy tube is a sterile procedure. Sterile technique must be maintained to keep this risk as low as possible.
Are all clients required to be NPO prior to a surgical procedure?
no
The necessity for the client to be NPO is dependent upon the planned anesthesia type for the procedure. For a client undergoing general anesthesia, NPO is required to prevent aspiration. However, if the procedure will be done under local anesthesia, the client may not be required to be NPO.
Nurses should encourage post-operative clients to reach a target volume of ___ when using an incentive spirometer.
600-900
Following surgery, the client will use the incentive spirometer to encourage a return to baseline of the respiratory system. When using the incentive spirometer, the client should be instructed to inhale slowly & consistently, aiming for a value between 600-900.
How often should the injection caps on the lumen of a central venous access device be changed?
7 days or anytime there is leakage
For a client with a central venous access device, the injection caps should be changed every 7 days or when there is a leak.
