question

Describe an airborne precautions room

answer

private room with monitored negative air pressure with 6 to 12 changes per hour, keep door closed and client in room, can place client with another but only if same organism, place mask on client if being transported

question

Name diseases that would require airborne precautions (4)

answer

measles, varicella, tuberculosis, and shingles until the lesions are crusted over.

question

What does nurse wear into an airborne precautions room?

answer

Use respiratory protection, like a protective mask, that is fit-tested. Do not share with other providers.

question

describe droplet precautions

answer

-used with pathogens transmitted by infectious droplets, involves contact of conjunctiva or mucous membranes of nose and mouth -happens during coughing, sneezing, talking, or during procedures such as suctioning or bronchoscopy

question

Describe droplet precautions room

answer

-private room or cohort with client with same infection but no other infection -maintain spatial separation of 3 feer between infected client and visitors or other clients -door may remain open -place mask on client if being transported

question

Name diseases that would require droplet precautions (4)

answer

streptococcal pharnygitis, pneumonia, meningitis caused by Haemophilus influenzae type B, mumps

question

What does nurse wear into a droplet precautions room?

answer

everything.

question

neutropenic precautions

answer

-used for clients at increased risk for infection, such as immunosuppressed with neutrophil count under 5000

question

interventions for neutropenic precautions

answer

-private scrupulously cleaned -meticulous handwashing and use of personal protective equipment by all -restriction of visitors -no fresh fruit of vegetables -avoid invasive procedures, such as catheterization, unless essential

question

How do you ambulate with a cane?

answer

Cane should be held in hand opposite affected extremity. Advance cane and affected leg, about 4 to 12 inches. To go upstairs, step up with good extremity and then place cane and affected extremity on step. Reverse when going downstairs.

question

cane lenght

answer

should be equal to the distance between the greater trochanter and the floor;

question

straight leg cane

answer

-used to support and balance a patient with decreased leg strength (keep on strong side of the body) -walk placing cane 15-25cm forward, keeping weight on both legs

question

quad cane

answer

-provides most support -used when there is partial or complete leg paralysis or some hemiplegia

question

walkers

answer

-must be waist high -patient must be able to lift the walk unless they have been fitted with wheels or short runners

question

4 point crutch walk

answer

-used when weight-bearing is allowed for both legs -slow, safe -right crutch, left foot, left crutch, right foot

question

2 point crutch walk

answer

-used when weight-bearing is allowed for both legs; less support than 4-point -faster, safe -right crutch and left foot advance together, then left crutch and right foot advance together

question

3 point crutch walk

answer

-used when weight-bearing is allowed on one leg -faster gait, safe -advance weaker leg and both crutches simultaneously, then advance strong leg

question

swing-to-swing thru crutch walk

answer

-used when partial weight-bearing is allowed on both legs; requires coordination -fast gait but requires more strength and balance -advance both crutches then both legs

question

Before ambulation, what should you assess?

answer

Activity tolerance of the patient, strength, mobility status, mental status, degree of personnel and equipment assistance needed. Assess safety of environment and adequacy of clothing, including nonslip shoes.

question

Before ambulation, what should you talk to the patient about?

answer

Inform patient of rationale and specific goals for walking. Tell them to report any dizziness, weakness, or shortness of breath.

question

Describe how to ambulate in progressive stages

answer

First sit on the bed and dangle, then stand to side of bed, then progressively walking. Nurse can use gait belt to support patient. If patient is dizzy or unsteady, return patient to close bed, chair, or gently lower to the floor.

question

Name some ambulatory assistance devices

answer

Gait belt, crutches, walker, cane

question

Purpose of ambulation

answer

Allows for muscle movement and joint flexibility. Improves respiratory and GI function. Rules risk of complications of immobility.

question

Describe how to use a walker from the bed

answer

Set walker in front of seated patient. Have patient stand with assistance as needed. Have patient hold walker's handgrips firmly. Stand slightly behind patient, on one side. Have patient move walker forward 6 to 8 inches and set it down, making sure all feet on the floor. Tell patient to step forward with either foot into the walker, support self. Follow through with other leg. Continue pattern.

question

Describe proper position of crutches

answer

Hold crutches 6 inches in front of and 6 inches to the side of each foot. Should be 1.5 to 2 inches below armpits. Elbows are flexed at a 15 degree angle

question

Purpose of anti embolism stockings

answer

Reduces risk of DVT and pulmonary embolism. Helps prevent phlebitis.

question

how do aniembolism stockings work?

answer

Exert external pressure on lower extremity muscles and superficial leg veins, thus preventing stasis and promoting venous return in lower extremities by maintaining external pressure.

question

When should anti embolism stockings not be worn?

answer

Do not apply if skin lesions or gangrene present.

question

When should anti embolism stockings be put on?

answer

In the morning before patient out of bed

question

Teach patient to recognize possible indicators of DVT or phlebitis, such as:

answer

-redness, tenderness, -pain on dorsiflexion (postiive Homans sign) -calf pain -localized edema of one extremity -possible warm skin over the affected leg -possible fever, chills, and perspiration

question

When patient in on anti embolism stocking, when would they notify provider? What are abnormal symptoms?

answer

skin irritation and breakdown, abnormal color, warm or cool temperature, unusual sensations, swelling, changes in movement

question

Can patient wear anti embolism stockings with nonskid socks?

answer

Yes, but skid resistant socks on patient prior to ambulation

question

Apical pulse is the best site location in which instances?

answer

best pulse site in infants and young children and if patient is taking a medication that affects the heart rate

question

Pulse deficit: how is it calculated?

answer

Compare radial and apical heart rates. Normally are the same. If radial is slower there is a perfusion issue.

question

PMI

answer

point of maximal impulse, the apical pulse, which is where the impulse of the left ventricle is felt more strongly; 5th intercostal space at the mid clavicular line on the left side

question

2 types of aseptic technique

answer

medial asepsis is clean technique and surgical asepsis

question

Describe medical asepsis, or clean technique

answer

Focuses on reducing number of microorganisms and preventing them from spreading

question

Surgical asepsis

answer

Sterile technique and focuses on eliminating the microorganisms from an area; including sterile objects and rules therein; prevents introduction or spread of pathogens from environment to patient

question

Surgical asepsis principles

answer

Sterile object touched by nonsterile is contaminated Only sterile objects on the sterile field Out of range of vision or below waist is contaminated long exposure to air is contaminated in contact with wet ifs contamined

question

Primary cause of falsely elevated reading of blood pressure

answer

Cuff is too narrow

question

How do you get false-high readings with blood pressure cuffs?

answer

Cuff too small, cuff wrapped too loosely, cuff deflated too slowly, ensure going 2 mm Hg

question

Cuffs come in how many standard sizes?

answer

6; ranging from newborn to extra-large adult

question

Normal adult BP values

answer

systolic 90 to 140 and diastolic 60-90

question

If you have trouble hearing the sound as it is low and indistinct, what can you do?

answer

raise patient's arm over her head with cuff intact to cause blood to enter the lower arm. Hold position for 15 seconds before rechecking pressure. Infalte the cuff while arm is elevated. Support arm while it is beign lowered.

question

Nursing proper body mechanics to prevent injury

answer

Bed to proper working height Lower side rail on side of patient contact Bend knees when lifting Assess weight before lifting Determine if assistance needed Hold lifted object close to body Don't twist Push rather than pull Low center of gravity Wide base of support

question

Is informed consent required for bone marrow biopsy?

answer

yes

question

What does bone marrow biopsy examine?

answer

number, size, and shape of red blood cells, white blood cells, and platelet precursors in the bone marrow

question

Where are bone marrow biopsy specimens obtained?

answer

iliac crest and sternum

question

Nursing responsibilities with bone marrow biopsy

answer

Cleanse site with alcohol to remove povidone iodine, apply pressure with sterile gauze pad for several minutes to control bleeding, apply STERILE pressure dressing by having patient lie on back, continually assess for bleeding and drainage, give an analgesic as necessary

question

Life threatening complications of bone marrow biopsy

answer

Infection and bleeding

question

What is bone marrow biopsy used to diagnose?

answer

multiple myeloma, all types of leukemia, some lymphomas, some solid tumors

question

What can you do to enhance patient comfort and cooperation before a bone marrow biopsy?

answer

Explain the test: takes 5-10 minutes, taken from iliac crest, get consent, tell which bone will be sampled, small incision, provide a sedative as ordered

question

bone marrow biopsy (other info)

answer

- fever, yellow drainage=osteomyletis; -no sports 48 hours. -Ileac older than 2. 1 year old use tibia. no sternum or scapula.

question

Bronchoscopy procedure

answer

Bronchoscopy is a procedure that allows your doctor to look at your airway through a thin viewing instrument called a bronchoscope. During a bronchoscopy , your doctor will examine your throat, larynx , trachea , and lower airways. Can get a specifimen collection, do biopsy, suction mucous plugs and remove foreign objects. can diagnose lung issues;

question

Things to do before bronchoscopy

answer

Instruct patient to be on NPO status 6-12 hours before the procedure. Obtain signed permit. Give sedative if ordered. Inspect mouth for infection, remove dentures, prepare client for sore throat afterwards

question

Things to do after bronchoscopy

answer

Keep patient NPO until gag reflex returns. Monitor for recovery from sedation. Blood-tinged mucous is normal. Monitor for hemorrhage and pneumothroax if biopsy was done. Instruct patient to sit or lie on side afterwards. Observe respirations carefully.

question

Change dressings when

answer

They become wet

question

How can you promote healing with any wound?

answer

Keep it moist, clean, and free from debris

question

dressing change

answer

-know type of dressing, placement of drains, and equipment needed -prepare patient for a dressing change: evaluate pain, describe procedure steps, gather supplies, recognize normal signs of healing, answer questions about the procedure or wound -perform hand hygiene and don appropriate gloves -change gloves between dirty and clean steps of the procedure -assess the wound and peri-wound (measure if required per agency protocol)

question

Tips for removing an old dressing

answer

Wear gown, face shield, and gloves Loosen by holding patient's skin and pulling dressing toward the wound Slowly remove Loosen with sterile normal saline Observe dressing for drainage color, odor, etc Discard dressing and gloves in waterprofoof trash

question

Caring for a wound

answer

Sterile procedure if fresh wound or open wound Saturate sterile gauze pads with cleaning agent Wipe incision closest to open wound and then away to least clean area Check for signs of infection, like heat, redness, swelling, odor Irrigate as ordered Pack the wound if ordered

question

wound irrigation

answer

flushing of an open wound using a medicated solution, water, sterile saline. they are ordered to clean the area of pathogens and other debris and to promote wound healing., Done just before applying new dressing, Best used when granulation tissue has formed, should be done gently to prevent disturbing healthy cells

question

Open wounds

answer

exposed to environmental factors, potential injury, and infection; more likely to heal at slower pace

question

Who might be on a clear liquid diet

answer

Surgical clients, those with acute vomiting or diarrhea, used to empty GI tract to prevent aspiration, maintain fluid balance; Not for calories, GI stim., or nutrients.

question

Clear liquid diet includes

answer

Gelatin, popsicles, tea, ginger ale, fruit juice without pulp, bouillon. Milk and juice with pulp are prohibited.

question

Progression of diets from clear liquid diet

answer

Clear liquid diet, then full liquid diet, soft diet, and then normal or modified

question

What do contact lenses correct

answer

refractive errors of the eye or abnormalities in the shape of the cornea

question

Why must all contact lenses be removed periodically?

answer

to prevent infection and corneal ulcers or abrasions

question

What indicates contact lens overwear?

answer

Pain, tearing, discomfort, and redness of the conjunctivae

question

Encourage contact lens wearing patient to remember the acronym RSVP

answer

redness, sesnitivity, vision problems, and pain. Remove contact lenses immediately if any of these problems.

question

Things to keep in mind with documentation

answer

do not leave blank lines, draw horizontal lines so nothing can be added do not use correction fluid, cross out and write error legal document document everything appropriately reflect only what saw or told, not interpretation or opinion

question

SOAP system of documentation

answer

subjective, objective, assessment, plan

question

When is EKG a standard of care?

answer

during general anesthesia and strongly encouraged during deep sedation

question

What makes the P wave on an EKG?

answer

right and left atria

question

What makes the QRS complex on an EKG?

answer

ventricles make QRS complex.

question

What makes the T wave on an EKG?

answer

electrical recovery or return to a resting state for the ventricles, or ventricle repolarization

question

To determine the heart rate from a rhythm strip what do you do?

answer

Obtain a 6 second strip, count the complexes, multiply by 10, this is for regular rhythms. So if 14 complexes on a strip, it is 140 beats per minute.

question

PR interval

answer

passage through AV node

question

What should a patient not do 24 hours before EKG?

answer

drink, or smoke, or caffeine

question

What to tell patient about EKG?

answer

Do not drink caffeine or smoke 24 hours before test Only takes about 10 minutes No discomofrt Lie still, relax, breathe normally Helps with treatment

question

EEG

answer

asleep some, may be sleep deprived prior, flickering lights

question

Hyperthermia

answer

Core body temp elevate above normal range

question

Causes of hyperthermia

answer

hyperthyroidism, thyroid storm, central nervous system disorders, heat stroke, infections

question

Nursing considerations for hyperthermia

answer

cool environment with tepid baths, hypothermia blankets, antipyretics, increase fluid intake, oral hygiene, cough and deep breathe if immbiolity exists, avoid shivering as will increase temperature

question

Signs of hyperthermia

answer

increased pulse, decreased blood pressure, disorientation

question

Hyperthermia treatment

answer

fluid replacement

question

Enema

answer

introduction of a Solution into the rectum and sigmoid colon for cleaning or therapeutic purposes

question

Types of enemas

answer

Oil retention, soapsuds, tap water, barium enema for xrays

question

Nursing responsibilities with enemas

answer

Position patient on left side use tepid solution hold irrigation set no more than 18 inches above rectum insert tube no more than 4 inches instruct client as to how long to retain solution

question

When should you NOT give an enema?

answer

in presense of abdominal pain, anausea, vomiting, or suspected appendicitis

question

Purposes for enemas

answer

Stimulates peristalsis, lubricates and softens stool, expels flatus, cleans colon, used for medicaton administration

question

Food temperature for enteral tube feedings

answer

room temperature or warmed in a basin of water = diarrhea if food too cold, too much; to-do = elevate HOB, check residual, flush, feed, flush.

question

Nursing considerations for epilepsy and seizures

answer

Document type and progress and behavior, oxygen and suction at bedside, position on back with head turned to side or position on side to prevent aspiration and promote drainage of secretions. highest incidence for younger than 10, older than 65. falls is main concern.

question

Impaction

answer

accumulation of hardened feces wedged in rectum or sigmoid colon

question

Inidcations of impaction

answer

no bowel movement for several days despite urge, diarrhea of liquid part goes through, loss of appetite, distended and cramping abdomen, rectal pain, urinary incontinence from pressure on baladder

question

Risk factors for fecal impaction

answer

Long periods of bed rest, dehydration, nutritional depletion, confusion, unconcious, medications with constipation effects, barium xrays

question

Interventions for impactions

answer

Oil and cleansing enemas, using a gloved finger to digitally remove

question

Things to consider when feeding a patient

answer

maximize independence support dignity encourage social aspects offer toilet before provide hygiene Choose own foods risk for aspiration and impaired swallowing

question

Femoral angiogram (for PAD)

answer

peripheral vessel blood flow is assessed by injecting contrast media into the appropriate arteries and veins. Can see atherosclerotic plaques, occlusion, aneurysms, venous abnormalities, or traumatic injury. - get written consent; - NPO after mindnight

question

Nursing interventions for femoral angiogram

answer

Check for allergy to contrast media, give milk sedative if ordered, check extremity with puncture site for pulsation, warmth, color, and motion after procedure inspect insertion site for bleeding or swelling, observe patient for allergic reactions. Be sure to assess pulses. pt will have to keep the leg straight for at least 6 hrs after the procedure to prevent bleeding from the femoral artery;

question

Allergic reaction signs from contrast media from femoral angiogram

answer

dyspnea, nasuea, vomiting, sweating, tachycardia, numbness of extremities

question

Treatment for femoral angiogram contrast media allergy

answer

epinephrine, antihistamines, steriods

question

PAD foot care

answer

warm water, dry, lotion, wear clean socks.

question

PVD

answer

cool, brown skin. edema, decreased pulses. -- BEDREST, ELEVATE LEGS, WARM/MOIST PACKS, ELASTIC HOSE (6-8 WEEKS), AMBULATE, ANTICOAGS.

question

Semi Fowler's

answer

30 to 45 degrees; promotes lung expansion especially with ventilator, used when patients receive gastric feedings to reduce regurgitation and risk of aspiration

question

Fowler's

answer

45 to 60 degrees; use while patient is eating, during NG tube insertion and tracheal suction, promotes lung expansion, eases breathing

question

What do hazards of immobility include?

answer

contracture, pressure ulcers, osteoporosis, hypercalcemia, negative nitrogen balance, increased cardiac workload, orthostatic hypotension, statsis of respiratory secretions, urinary stasis, constipation, thrombus, boredom, depression

question

Nursing considerations for hazards of immobility

answer

-contracture = frequent position changes/ ROM exercises; -pressure ulcers = turn, clean, dry, ambulate, diet (protein, vitamin, carbs), air matress, moving bed, watch for low albumin; -osteoporosis = weight bearing, diet; - hypercalcemia = - negative nitrogen balance - increased cardiac workload = don't hold breath, no Valsalva, rise slowly; - orthostatic hypotension = rise from bed slowly; - statsis of respiratory secretions = turn, cough and deep breathe; postural drainage, incentive spirometer - urinary stasis =void normal, increase fluids, low calcium diet, watch I&O; - constipation = ambulate, increase fluids, privacy, stool softeners; - thrombus = leg exercises, ambulate, turn, avoid gatching bed, use TED hose; -boredom, depression = tv, visitors; Turn frequently, provide good skin care, given high-protein diet with small frequent feedings,,

question

What is hemoptysis?

answer

Expectoration or coughing up of blood from respiratory tract, including larynx, trachea, bronchi, or lungs.

question

Disorders related to hemoptysis?

answer

bacterial pneumonia, bronchitis, TB, lung abscess, lung cancer, pulmonary emboli

question

Nursing considerations with hemoptysis?

answer

determine where it is from--respiratory tract or GI tract; may pH test to help tell where it is from; hemoptysis will be alkaline where stomach will be acidic; describe hemoptysis according to amount and color and wehter mixed with sputum

question

Some hypoxia causes

answer

decreased hemoglobin level, high altititude, cyanide poisoning, pneumonia, poor tissue perfusion, impaired ventilation

question

Signs and symptoms of hypoxia

answer

apprehension, restless, decreased LOC, dizzy, behavioral changes, cant lie flat, increased pulse, increased rate and depth of respirations, blood pressure elevated early on, cyanosis and respiratory decline are late stages

question

Nursing intervention for hypoxia

answer

2 L oxygen per nasal cannula if O2 less than 95%, call provider then

question

To obtain urine sample from indwelling foley catheter

answer

Apply calamp to drainage tube distal to injection port, clean port with antiseptic, insert sterile needle and syringe into the port, aspirate quanity or urine needed, inject urine in sterile specimen container, remove clamp

question

What must be explained before giving informed consent?

answer

Explanation of risks, benefits, expectations, and alternatives to procedure; can be withdrawn at any time

question

Intake and output should be within _____ to ____ milli liters of each other

answer

200 to 300 ml

question

I&O

answer

measured each shift, 24 hrs., and hourly in ICU. output=urine, liquid stool, vomit, fluids from suction, drainage. input=oral, semisolid, ice, parenteral, enteral fedings, irrigations.

question

Isometric exercises

answer

performed by patient; alternate contraction and relaxation of muscle without moving join; maintains strength when joint immoblized, such as with a cast; can also do resistive isometric exercises with patient pushes or pulls like pushing hands together or pushing against a wall

question

Purpose of isometric exercises

answer

increases muscle mass, tone, and strength in bedridden patients, and increases circulation to the exercised body part

question

Criteria for TPN (total parental nutrition)

answer

inability to absorb nutrients from the GI tract for more than 10 days Illness for more than 2 weeks; loss of 10% or more of preillness weight Albumin level less than 3.5 grams Excessive nitrogen loss from wound infection Kidney or liver failure nonfunction of GI tract for 5-7 days

question

Some things to know with TPN

answer

- lipds are administered through separte tubing; - Consistent rate (start at 50ml/hr to 100-125ml/hr); -Change every 24 hours; -Vital signs every 4 hours; -Monitor glucose every 6 hours; -Assess electrolytes; -No meds through this; -USE: large vessel, RAPID dilution, watch for infection, hyperglycemia and fluid overload. -monitor weight, labs, I&O

question

TPN

answer

peripheral=supplements oral, less than 2 weeks central=into subclav vein, ~4 weeks, can be PICC, percutaneous, single or triple lumen.

question

What should patient do during TPN tubing and cap changes

answer

use the valsalva maneuver

question

Low-residue diet description

answer

Minimizes intestinal irritation and activity by reducing fiber and cellulose; for those with temporary GI elimination problems such as a lower bowel surgery and for diverticulitis, crohn's disease

question

Low-residue diet foods

answer

foods need to be easily digested. Foods are high in carbs. roast lamb, buttered rice, sponge cake, bananas, cooked vegetables and fruit, lean tender meats, white breads, canned fruits and veggies, cereal, pasta; NO nuts; seeds, skin on fruit (high fiber), dairy, whole wheat, bran.

question

Low-residue diet foods prohibited

answer

whole wheat, corn, bran, raw fruits and vegetables, seeds

question

Low fat diet description

answer

Reduces calories from fat and minimizes cholesterol intake; used for conditions such as atherosclerosis, coronary heart disease, obesity, cystic fibrosis; liver & gallbladder diseases.

question

Sample menu items for low fat diet

answer

Fruit, vegetables, cereals, lean meat

question

Sample prohibited foods for the low fat diet

answer

marbled meats, avocados, whole milk, bacon, egg yolks, butter

question

Good fats to choose

answer

fish, nuts, vegetable oils

question

Fat and vitamins

answer

Fats are necessary for absorption of A, D, E, K vitamens so strict followers of low fat diet can be deficient in these vitamins

question

Describe lumbar puncture

answer

Insertion of needle into subarachnoid space to obtain specimen of cerebral spinal fluid; relieve pressure, inject dye or medications

question

Preparation for lumbar puncture

answer

Explain procedure Informed consent Position client in lateral recumbent fetal position at edge of bed

question

Postprocedure care for lumbar puncture

answer

neurological assessment every 15 to 30 minutes until stable; position flat for 4-12 hours with first laying prone 2-3 hours to prevent CSF leakage then side for 2-3 hours and then supine for 6 hours, encourage oral fluids to 3,000 ml, observe sterile dressing at insertion site for bleeding or drainage, headache is biggest issue after lumbar puncture so lay flat to reduce CSF and therefore headache

question

MRI

answer

magnetic resonance imaging. A diagnostic radiography using electromagnetic energy

question

Nursing care for MRI

answer

Explain procedure, assessing client for claustrophobia, removing all metal jewelry and metal, asking if patient has metal implanted in body; tell pt they have to lie still.

question

Maslow's 5 levels of need

answer

physiological, safety or security, love and belonging, esteem, and self-actualization; -basic physiological needs (oxygen, water, food, temperature, elimination, sexuality, physical activity, and rest) -safety and security needs (effective handwashing and sterile technique, proper use of electrical equipment, proper administration of medications, effective transfer techniques) -love and belonging needs (family and friends, trusting nurse-patient relationship, special support groups) -self-esteem needs (respect his or her values, setting reasonable goals, support from family and friends) -self-actualization needs-highest level of the hierarchy (to achieve full potential, focus on patient's strengths rather than on his weaknesses)

question

Most common reason for insertion of a NG tube in a postop client diagnosed with a duodenal ulcer includes which reason?

answer

decompress the stomach

question

Would irrigation procedure

answer

warm solution, position patient for gravity drainage, use sterile filed, allow a slow, steady stream of solution with a syringe and sterile catheter, solution must flow away from wound, continue until solution is clear, and try to time with doctor visit she he can inspect at the same time

question

Wound healing diet

answer

high in protein, fat, and carbs. High in vitamins A, C, and E. High in zinc. -sample menu items: 30 grams powdered skim milk and one egg in 100ml water or roast beef sandwich and skim milk -common medical problems: burns, infection, hyperthyroidism -to reestablish anabolism to raise albumin levels

question

Minimal urine output per hour

answer

30 ml

question

Minimal urine output per 24 hours

answer

800 ml

question

Normal urine output per day

answer

1,500 ml

question

Normal urine pH

answer

4.6 to 8.0

question

Normal specific gravity of urine

answer

1.010 to 1.030

question

Oliguria is less than _____ ml per 24 hours

answer

400

question

Oliguria is caused by

answer

dehydration, acute kidney injury, increased ADH secretion

question

Thoracentesis

answer

Aspiration of intrapleural fluid for diagnostic and therapeutic purposes; This is when a needle is inserted in the thoracic cavity (between ribs) into the pleural space to remove fluid or air.

question

Patient position for thoracentesis

answer

patient sits on edge of bed and leans forward over a bedside table.

question

Pre-procedure prep for thoracentesis

answer

take vital signs, shave area around needle insertion site, position patient sitting with arms on pillow or over bed table or lying on side in bed, teach patient to expect stinging sensation with injection of local anesthetic and feeling of pressure when needle inseted

question

Nursing responsibilities after thoracentesis procedure

answer

auscultate breath sounds frequently, monitor vital signs frequently, check for leakage of fluid, location of puncture site, client tolerance, secure a sterile dressing on the puncture site after procedure Look out for respiratory distress; Check for Crepitis (air under tissue) when assessing patient.

question

Therapeutic communication

answer

active listening site facing client observe open posture lean toward client establish and maintain eye contact share observations, empathy, hope, humor, feelings, use touch, use silence, provide information, clarify, focus, paraphrase, ask questions, summarize

question

Risk factors for pressure ulcer development

answer

impaired sensory perception, impaired mobility, altered level of consciousness, shear, friction, moisture

question

Presbycusis

answer

age-related hearing loss; do not hear high pitches anymore; damage to hair cells of the organ of corti; be sensitive to these patients and communicating with them

question

Postural drainage

answer

Uses gravity to facilitate removal of bronchial secretions; client placed in variety of positions to facilitate drainage into larger airways, basically from lungs and bronchi into trachea; secretions may be removed by coughing or suctioning; prevents complication of statsis of respiratory secretions

question

Postural drainage positions

answer

various positions; normally head down position; chosen position maintained for about 5 minutes during percussion and vibration; commonly done 2-4 times a day; 1 hour before meals and 3 hours post meals

question

What is normally done before postural drainage?

answer

aerosolized bronchodilators and hydration therapy, as well as percussion and vibration

question

Preoperative care

answer

Ensuring informed consent signed and attached to chart, all lab tests, chest xray and EKG have been completed, perform skin and bowel prep, NPO, administer pre-op meds such as sedation and antibiotics, removing dentures, jewelry, and nail polish

question

Preoperative exercises

answer

deep reathing, coughing, leg exercises, how to move in bed, how to use an incentive spirometer

question

incentive spirometer

answer

pts. with atelectasis, pnuemonia, had abdominal/chest/pelvic surgery, prolonged bedrest, hx of lungs probs.

question

The nurse understands that psoriasis is

answer

A chronic autoimmune reaction.

question

fears of surgery by age:

answer

Toddler fear - separation Preschool fear - mutilation - allow them to play with a model and encourage questions; School age - losing control Adolescent - losing independence

question

The nurse knows that serum albumin is used as an indicator of malnutrition because

answer

Serum albumin is easy to measure, and can indicate a protein deficiency that may not be detected on physical examination.

question

The nurse is caring for a patient beginning intermittent heparin therapy. The nurse knows which of the following lab tests are used to monitor the effectiveness of heparin?

answer

Partial thromboplastin time. Anticoagulant is working if PTT is 1.5-2 times the control. PTT must be measured at least once a week.

question

The nurse understands that which of these common foods are most likely to cause eczema and should be eliminated form the diet?

answer

Milk, wheat, egg whites.

question

position changes prevent...

answer

-to prevent contractures -to promote circulation -to promote pulmonary function -to promote pulmonary drainage -to relieve pressure on body parts

question

supine

answer

minimize hip flexion

question

sims

answer

drain oral secretions. good for enema, perineal care.

question

fowlers

answer

increase venous return, allow lung expansion. good for heart and lungs. normal = 45-60 semi=30 high=90

question

head and knees elevated

answer

venous return, pressure off lumbar-sacral

question

lithotomy

answer

gyno

question

prone

answer

promote extension of hip joint. allows mouth to drain. use for unconscious.

question

transfering pt

answer

basics: move pt. toward stronger side, use large muscles, use drawsheet, have assistance

question

heat and cold therapy

answer

-heat causes vasodilation when you want inflammation to begin healing. -Cold causes vasoconstriction to limit bleeding. Use cold within first 48 hours. -Must apply heat and cold every 20 minutes

question

incontinence

answer

Inability to control bladder and/or bowels. -urge-strong, sudden urge -stress-sneeze -overflow-constant dribbling -reflex-large amt. urine retained. CNS disease

question

good samaritan law

answer

This law deals with the rendering of first aid by health care professionals at the scene of an accident or sudden injury. It encourages health care professionals to provide medical care within the scope of their training without fear of being sued for negligence

question

paracentesis

answer

is a procedure for withdrawing fluid from the abdominal cavity. Generally done when fluids are crowding the lungs

question

suctioning

answer

wear eyewear, hyperoxygenate, semi fowlers. do not apply suction in and intermittently out.

question

elastic stockings

answer

-to prevent postural hypotension -assess the skin before applying -tape measurer to assess size needed -do not massage the legs -check for wrinkles, rolls, and binding -remove once per shift -assess toes for circulation -can be delegated to NAP

question

protein sources

answer

-meat, fish, nuts, cheese, protein powder, and peanut butter, whole wheat bread, rice, red beans, spaghetti and meat sauce

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drain purpose

answer

-placed to provide an exit route for air, blood, or other material following surgery -keeps tissues close together so that healing can occur

question

nursing considerations for drains

answer

-monitoring characteristics and volume of drainage and recording in output records -preventing skin contact -securing placement -monitoring for infection

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