Fundamentals of Nursing Test 3

• Pretest-prep for test
• Intratest-specimen collection, etc, during test
• Post test-care after test

Any test that requires entering the patient's body

any invasive test

typically the patient is premedicated and health care providers and staff performing test are on high alert

• Client is provided with detailed information.
• Client and family are provided a time frame for the procedure.
• Client and family are encouraged to ask questions.
• Client is provided with any preparation instructions like NPO or NPO x meds or bowel prep.

• Gather supplies and have them ready.
• Provide emotional and physical support for patient.
• Be discreet.
• Monitor patient as needed.
• Properly deliver specimen.

Cerebrospinal fluid or other difficult to obtain or time sensitive specimen.

• Follow flowheet for nursing care of client
• Perfom follow up activities and observations
• Modify interventions for patient as necessary
• Report results to appropriate health team members as appropriate in a timely maner.

• RBC Count
• RBC Indices
• WBC Count
• WBC Differential
• H and H
• Platelet

High bicarbonate level and alkalinity

Blood Urea Nitrogen

normal ranges from 10:1 to 20:1--higher ratios can indicate dereased blood flow to kidneys, congestive heart failure, gastrointestinal bleeding, increased protein in the diet, or liver disease

• Digoxin
• Theophylline
• Anti-seizure medications

The nurse is responsible for making sure they are completed, even if the nurse is not the one drawing them.

• Radial
• It can be brachial, femoral, or from an arterial line
• Respiratory typically draws it.

It must be placed immediately on ice and carried to the lab quickly.

• brain natriuretic peptide-a hormone for which production increases when the ventricles of the heart are stretched
• it is used to detect and evaluate extent of congestive heart failure

Liver function

enzyme used frequently as a Cardiac marker

liver function

Glycosated hemoglobin (Hemoglobin A1C-HmgA1C)

• phenylketonuria (PKU)
• Congenital hypothyroidism
• Sickle cell
• Galactosemia

fingerstick by nurse or fingerstick blood sugar for capillary glucose

• provide comfort, privacy, and safety
• explain the purpose of the procedure
• use correct procedure or make sure the patient of staff perform correct procedure
• note relevant information on lab requisition slip
• transport specimen to lab
• report abnormal findings to health care provider in timely manner and document

• stool culuture may not be delegated to UAP--it is sterile
• Stool specimen-client defecates in bedpan or bedside commode and notifies nurse after defecation
• Stool culture-sterile swab is dipped into the specimen-using sterile technique it is then placed in a sterile test tube.

red meat, raw fruit (melon) and raw vegetables (raddishes), iron, aspirin, anticoagulants

vitamin C

Blue is positive for occult blood. Any other color is negative.

a sign on the bathroom door

• usually first-morning urine
• free of fecal contamination
• free of contamination from toilet paper
• lid placed tightly on specimen
• clean-catch/midstream
• Can be collected by UAP

• culture and sensitivity of microorganisms
• cytology-orgin, structure, function and pathology of cells/cancer
• acid-fast bacillus (AFB)-TB test-to identify and asses the effectiveness of TB

to evaluate treatment

1-2 T or 15-30 mL

in a negative pressure room

• gloves
• have patient say "ahh" depress tounge
• insert swab into oropharynx
• run swab along tonsils and areas that are reddened or contain exudates
• place swab in sterile test tube
• label and send to the lab
• document

• Indirect-non-invasive-nothing enters the patient's body-x-rays, ultrasound, KUB
• Direct-invasive-Anoscopy, Proctoscopy, Colonoscopy, Cystoscopy

• uses idodine dye to detect urinary alterations
• check for shellfish allergies--if they exist premedication and close monitoring will most likely be ordered
• provides better visualization of kidneys ureters and bladder- strictures, stones and other abnormalities

x-ray kidneys/ureters/bladder-typically only good to see any existing stones

• ECG/EKG
• Stress EKG
• Angiography
• Echocardiogram-ultrasound
• Lung scan V/Q Scan

• distinguishes minor differences in the density of tissues
• produces a 3D image of organ or structure
• more sensitive than an x-ray

• noninvasive scanning
• magnetic field-may burn tattoos
• clients with implanted metal devices may not undergo MRI
• provides better contrast between normal and abnormal tissue than CT

• Bone scan-common with breast and prostate cancer
• Creates-"hotspots" of hyperfuntion and "coldspots" of hypofunction

• non-invasive
• injection of inhalation of radioisotope
• images created as the isotope is distributed throughout the body
• allows study of various aspects of organ funtion
• may include evaluation of blood flow and tumor growth

• Withdrawal of fluids that have collected abnormally
• to obtain a specimen
• invasive procedure requires strict sterile technique

• removal and examination of tissue
• invasive procedure
• requires strict sterile technique

Ruling out meningitis with high fever, high WBC count, and headache

Left lateral/Sim's Position

to drain fluid associated with liver failure

fluid in the abdomen

• Call sterile and get sterile tray with the appropriate tools delivered
• check the hospital intranet for procedures
• get collection jars

intercostal space

• in a position that allows easy access to intercostals
• sitting on one side with arm held to the front and up
• or
• sitting and leaning forward over a pillow

posterior superior iliac crest

• Exhale and hold breath
• to prevent movement of liver and other abdominal organs

after applying pressure to the biopsy site, position patient on the biopsy site--a pillow can be placed below

Control IIs

the desired effect the reason the drug is prescribed

• secondary effect
• uninted, usually predictable
• may be harmless of harmful

• more sever side effect
• may justify discontinuation of a drug

result from overdose

• immunologic reaction to a drug
• mild to severe

unusually low physiologic response to a drug

one drug alter the effect of one or both drugs

effect of one or both drugs is increased

the effect of one or both drugs is decreased

when two drugs increase the action of one or another drug

mechanism of drug action and relationships between drug concentration and the body's responses

study of absorption, distribution, biotransformation, and excretion of drugs

• developmental
• sex
• cultural, ethnic, genetic
• diet
• environment
• psychological
• illness and disease
• time of administration

• response/treatment for chest pain
• morphine, oxygen, nitroglycerin, aspirin

• buccal
• rectal
• vaginal
• sublingual

• oral
• topical
• transdermal

the date, time, and initals must be written on the tube

now

ambien 10 mg po hs before surgery

• multiple vitamin daily
• KCl 40 meq po twich daily X 2 days

• as needed
• Maalox 15 mL po prn q6hrs for indigestion

• full name of client
• date and time
• name of drug
• doseage of drug
• frequency of administration
• route of administration
• signature of the person writing the order
• sometimes provider #

• descriptive info on client
• date on which it was written
• Rx symbol meaning "take thou"
• Med name, dosage, and strength
• Route
• Dispensing instructions for pharmacist
• quantity of med to dispense

• thirty rather than 30
• written in words rather than numerically

• ID Patient-name and DOB
• Inform the patient-drug name and action
• "Do you have any allergies?:
• Provide adjunctive interventions as indicated
• Administer drug
• Record drug administered
• evaluate client's response to drug

• Right medication
• Right dose
• Right time
• Right route
• Right patient
• Right client education
• Right documentation
• Right to refuse
• Right assessment
• Right evaluation

lower dose needed

increased dose

crush only appropriate medications

• dissolve in at least 30 mL warm water
• aspirate--stomach contents and measure residual
• volume-typically if greater than 100mL leave off for a while then give meds

administer one at a time, flushing after each with 15-30 mL of warm water to clear tube

15-16 minims

insulin only

• -hub
• -cannula or shaft
• -bevel

• slant or length of bevel
• length of the shaft
• gauge

• roll NPH
• insert air into NPH
• insert air into regular
• draw regular
• draw NPH
• give injection

• TB skin test
• Allergy testing

5-15 degree

• if you can pinch 2", 90 degrees
• if you can pinch 1", 45 degrees

• ventogluteal-no blood vessels, no nerves1-3 mL
• vastus lateralis- 1-2 mL
• dorsogluteal-risky, preferred for Z-track, 1-3mL; 5mL of gamma globulin
• rectus femoris-infant .5-1 mL
• deltoid-vaccinations, no more than 1 mL

dorsogluteal

• always check expiration date
• place hand on forehead
• instill into lower lacrimal sac

waste the first bead

• pull up and back
• pull down and back for babies and toddlers

warm water

• client blows nose first
• seated position with head tilted back
• client hold the tip of the container just inside the nares
• inhales and the spray enter the nasal passage

• Left Sims' position
• upper leg flexed
• gloves
• lubricate suppository and fingers
• encourage client to relax by breathing through mouth
• insert 4 inches for adult, 2 inches for child
• avoid embedding in feces
• press buttocks together for a few minutes
• client remain in left lateral or supine position at least 5 min
• client retain for at least 20 min

• -always give bronchodialator
• -wait 5-10 minutes
• -then give steroid

• Growth of actualization
• a process that develops over time
• having potential and the need to grow

• knowing
• alternating rhythms
• patience
• honesty
• trust
• humility
• hope
• courage

nurses must understand different cultures to really show caring

• Basis for nursing's role in society
• Commitment to care of the whole person

• one feels a person sense of commitment
• caring processes as nursing interventions
• five caring processes

• Empirical-science of nursing
• Personal-therapeutic use of self
• Ethical-moral component
• Aesthetic-the art of nursing

• Knowing the client
• Nursing presence
• Empowering the client
• Compassion
• Competence

• Caring
• Compassion
• Competence

• to be able to properly provide care for others
• You can not give to other our of your emptiness

Using matching verbal and non-verbal cues.

• clarify--I see..........what does this mean?
• validate--It seems...........am I right?

A person's experiences that influence him in interpreting what is being said.

caustic and sarcastic

• need to recognize
• failure to listen
• improperly decoding client's intended message
• placing the nurse's needs above the client's needs

problem solving

Honest, Appropriate, Direct

• claimed that most learning comes from observation
• would like return demonstration

• learning is based on learner's behavior
• response when traced to the effects of a stimulus
• conditioning
• positive reinforcement

• praise correct behavior and provide positive feedback
• provide role models of the desired behavior

• Cognitive
• Affective
• Psychomotor

Bloom, Piaget, Lewin

discussed change and what is needed for change to occur

Assess develpmental and individual readiness to learn

• provide social, emotional, physical environment conducive to learning
• encourage positive teaching-learning relationships
• select multisensory teaching strategies
• recognize personal characteristics have impact on how cues are perceived

big focus on feelings, active learning,and self motivation of the learner

• Acheiving full potential
• automonmy and sef-determination
• learner is an active participant and takes responsibility for meeting learning needs

• Encourage patients to find out as much as they can and to visit their doctor to confirm, validate, and clarify
• Caution about misinformation and bad websites

Typically at a 6th grade level

Evaluation/assessment of learning and documentation of assessmenet of learning

No

• influence others to work together to accomplish a specific goal
• visionary
• outstanding interpersonal skills
• exellent listeners and communicators
• innovate change, motivate, facilitate, and mentor
• guide teams that assess effectiveness of care
• implement evidence-based practice
• construct process improvement strategies

• First Level
• Charge Nurse or Team Leader

• middle level
• manage first level management
• responsible for activities of departments supervised

• Upper Level
• Establish goals and develop strategic plans
• responsible for management of nursing and practice of nursing

the nurse

• Preceptor-person with experience assiting a new nurse with skills
• Mentor-more longterm, provides nurturing

NO

• -assess client
• client must be medically stable
• task routine for this client
• nor require a substantial amount of scientific knowledge or technical skill
• considered safe for this client
• have a predictable outcome

• right task
• right circumstances
• right person
• right directions and communication
• right supervision and evaluation

• need for change recognized
• moving make a plan in detail
• change is integrated