Unit 1 Flashcards
(28 cards)
Rhonchi
Low-pitched, snoring sound. Heard during inspiration or expiration. Clears with coughing.
Crackles
Crackling, popping sound. Heard when blocked airway opens. Common during inspiration.
Wheezing
High-pitch, whistling sound. Heard on inspiration and expiration. Loudest during expiration.
Stridor
Intense, high-pitched, and continuous monophonic wheeze or crowing sound. Loudest during inspiration when airways collapse due to low internal lumen pressure
The RN is unable to note any bowel sounds. What’s the next step?
Auscultate for 5 min in each quadrant
RN cares for a pt with type 1 DM. Pt is non-complaint with current treatment. Which nursing diagnosis/problem the rn identifies as most appropriate?
Knowledge deficit
Term added for the nursing process in 1991
Outcome identification
If a pt does not meet a goal, it has to be revised. This is called
Outcome oriented
The nursing process to care for a pt with coronary artery disease who eats high fats from a restaurant.
Adaptability
Auscultate the heart of a patient to confirm palpitations is part of which step in the nursing process?
Assessment
Short temp goal for a pt after surgery
Walk to the bathroom without experiencing SOB within 48 hours after surgery
Pt has generalized itching and red rash after being touched with latex gloves. Document written by MD for this type of reaction?
Standing order
All nursing interventions need to be documented. Proper documentation leads to what positive outcome?
Facilitated communication with all members of the health care team.
Rn realizes pt is not able to meet goal. What’s the next action?
Modify care plan in response to the patients condition and wishes.
Which characteristics do the nursing diagnosis have?
Nursing do require naming pts pronlemes using nursing labels & identifying actual or potential problems as well as responses to the problem
Rn completes health and physical assessment on a patient w fracture pelvis. What is the rn doing next?
Analyze and cluster the assessment information
A pt that has leukemia is going to receive an experimental drug. Rn is worried it will cause reduction of platelets and lead to intestinal bleeding. Nursing diagnosis?
Risk
Macule
Flat, not detectable with palpation
Papule
Solid raise lesion with distinct borders
Nodule
Raised solid mass with defined borders that extent into the dermis level
Tumor
Solid mass that extends through the subcontaneous tissue.
Vesicle/Bulla
Circumcised, raised lesions- filled with serous fluid
Pustule
Circumcised, elevated lesion fluid is pus
Wheal
Irregular shaped area of edema, varies in color and size
