NUR 111 Written Final.txt

  1. How many inches do you lubricate a Foley catheter for the female patient?
  2. How many inches do you lubricate a Foley catheter for the male patient?
  3. Once you see urine in the tubing during insertion of an indwelling Foley what do you do?
    Advance 2 more inches
  4. What is important to remember to do after catheterizing a male who is uncircumcised?
    Replace foreskin if retracted earlier.
  5. What is the problem called when there is swelling of the glans penis from not Replace foreskin if retracted earlier?
  6. If the patient complained of severe pain when you tried to inflate the Foley balloon, what is happening?
    The balloon is being inflated in the urethra, not in the bladder.
  7. What nursing intervention would you do to decrease sudden Pt pain while inflating a Foley balloon?
    Deflate the balloon fully.
  8. How far must the Foley catheter be inserted for a male client?
    Experts recommend insertion to the "Y" bifurcation.
  9. What supplies are needed to remove a Foley catheter?
      • Basin
      • disposable towel
      • clean gloves
      • sterile syringe
  10. Sterile Dressings: What must you do before changing the dressing?
    Remove binders and tapes.
  11. What supplies are needed before changing a sterile dressing?
    Surgical dressing kit & sterile gloves
  12. How do you clean a sterile incision?
    For lengthwise incisions, the first swab is on the incision and along its length. Then each subsequent swab (minimum 2 and up to 4) on alternating sides of the incision and parallel to it.
  13. How do you clean an incision with a Penrose drain?
    Starting around the drain and spiraling out from there.
  14. What do you assess when looking at the wound for a dressing change?
      • # of sutures or staples
      • approximation - it will be "approximate" (closed) or "open" (e.g. 5 mm, middle of distal half)
      • swelling
      • redness
      • drainage: amount, odor and color/clarity.
  15. What do you write when you are done changing the dressing?
    Date, time, initials on an extra piece of tape, then affix on existing tape.
  16. What is the proper position used to suction an unconscious client?
    Lateral position facing you.
  17. How do you test the suction equipment before using?
    Kink the hose to verify suction.
  18. How do you suction the alert client?
    Semi-fowlers with head turned to one side.
  19. How soon must you change the Yankeur suction catheter?
    Q 24 hrs.
  20. When do you rinse the suction catheter?
    After each use.
  21. What is the mmHg for wall suction?
    60-80: neonate, 80-100: children, 80-120: adults
  22. What is the mmHg for portable suction?
    • 10-15 inches Hg was taught I believe. My wife, who has done plenty of ICU suctioning, says to always use the least amount of pressure that will get the job done to avoid any trauma to the mucosal
    • or other tissues.
  23. At what flow rate is supplemental humidity necessary for oxygen therapy? and why?
    • Above 4 L/min
    • Dry gasses dehydrate respiratory mucous membranes
  24. At what flow rate is supplemental humidity NOT necessary for oxygen therapy? and why?
    • From 1-2 L/min via cannula
    • There is sufficient humidity inhaled from the atmospheric air.
  25. List the safety precautions for oxygen therapy safety precautions
      • "No smoking, Oxygen in Use" signage
      • Adherence to no smoking
      • Instruct client and visitors to hazards of smoking with oxygen use
      • Make sure all electrical devices are in good working order to prevent sparks.
      • Avoid wool and synthetics that can create static discharge. Wear cotton clothes and use cotton bed clothes
      • Avoid alcohol, acetone, and nail polish in Pt room.
      • Make sure all electrical medical equipment is grounded.
      • Know location and use of fire extinguishers.
  26. A Simple oxygen mask delivers...
    5-8 L/min @ 40-60%
  27. Partial rebreather mask delivers...
    6-10 L/min @ 60-80%
  28. Non rebreather mask delivers...
    10-15 L/min @ 95-100%
  29. Venturi mask delivers...
    4-10 L/min @ 24-50%
  30. Nasal Cannula delivers...
    1-6 L/min @ 24-45%
  31. Face tent provides...
    4-8 L/min @ 30-50%
  32. List the (5) physiological effects of heat therapy
      • Vasodilatation
      • Increased cellular metabolism
      • Increased capillary permeability
      • Increased inflammation
      • Sedative effect
  33. Heat is used for clients with: (list 3) Musculoskeletal problems
      • Joint stiffness
      • Muscle spasms
      • Contractures
  34. List the physiological effects of cold therapy
      • Vasoconstriction
      • Decreases inflammation, slows bacterial growth
      • Decreases capillary permeability
      • Decreases cellular metabolism
      • Local anesthetic effect
  35. Cold is used for clients with sport injuries (list 3):
    • Sprain - torn ligament (bone to bon)
    • Strain - torn tendon (bone to muscle)
    • Fracture
  36. Cold limits, i.e. when contraindicated
      • Open wounds
      • Impaired circulation
      • Allergy or hypersensitivity to cold
  37. Heat Therapy, i.e. when contraindicated
      • The first 24 hours after a traumatic injury. Heat increases bleeding and swelling.
  38. Important elements of an Incident Report
    • It is usually written to document accidents. Sometimes infections or loss of personal effects.
      • Identify Pt by name (and initials) and MRN
      • Date, time and place
      • Describe only FACTS as YOU SAW them - no conclusions.
      • State clients comments using direct quotes.
      • ID all witnesses
      • ID and equipment by serial #
      • ID and meds by name and dose

    Do not refer to incident rpt in Pt records

    Person who identifies that an incident has occurred writes report, e.g. nurse who finds med error even if they did not administermed.
  39. What are the documentation systems currently in use?
      • Source-oriented record
      • Problem-oriented record
      • PIE - Problems, Interventions, Evaluations model
      • Focus charting
      • CBE - Charting by Exception
      • Case Managent

    All can be implemented via computer or paper
  40. Source Oriented Charting is...
    Each person or department making notations is a seperate section of Pt chart
  41. Narrative Charting characteristics...
      • Not usually used by itself
      • Usually chronological in nature
      • Questions usually answered:
        • Assessments
        • Interventions
        • My eval or Pt response to interventions
  42. Problem-Oriented Medical Record (POMR): Definition and components?
    Charting is done by all participants for each problem the client has, e.g. all of the charting (docs, nurses, etc.) for a "broken leg" is done in the broke leg section. If there is another prblem, e.g. deep laceration to arm, it is charted in its own section.

    Drawbacks include assessments and interventions affecting two problems must be repeated.

      • Database
      • Problem List
      • Plan of Care
      • Progress Notes
  43. How are progress notes in a POMR chart headed?
    Like the plan of care, entries are made by docs, nurses, etc. In the Progress notes, they are numbered (if on paper) to correspoind to the problem from the problem list, and they are also, whether paper or computer, coded by type of entry, i.e. SOAP and SOAPIER, as follows:

      • Subjecxtive
      • Objective
      • Assessment
      • Plan
      • Intervention
      • Evaluation
      • Revision
  44. Summarize Focus Charting
    Makes client and clients concerns/strength the focus of care.

    • Usually 3 columns:
      • Date/Time
      • Focus
      • Progress Notes

    The Progress Notes follow the DAR format:

      • D-Data (e.g. assessment)
      • A-Action
      • R-Response
  45. Case Management Characteristics?
      • Cost-effective model
      • Uses Critical pathways with established times for care
      • Work best for Pts with 1 or 2 diagnosis and few individualized needs
      • Pts with multiple problems or unpredictable course of symptoms, e.g. neurologic, are difficult to doc on critical path.
  46. Kardexes: Key elements?
    Flow Sheets with

      • Graphic Record - vitals, etc.
      • I&O
      • MAR
      • Skin assessment (Branden)
  47. Abbreviations
      • ug - mcg
      • IU - international unit
      • QOD - every other day
      • QD - every day
      • SC or SQ - subq or subcutaneous
      • AS - left ear
      • AD - right ear
      • AU - both ears
  48. Format of information for telephone reports
    • SBAR Communication
      • S-Situation
        • Your name unit
        • Pt name & problem
      • B-Background
      • A-Assessment
      • R-Recommendation
  49. Disadvantages/Risks of heat therapy
      • Increased cappilaqry permeability may lead to edema or an increase in preexiting edema.
      • When applied to a large area, it could cause excessiove peripheral vasodialation leading a drop on BP and subsequent fainting.
  50. Arteriosclerosis
    refers to a stiffening of arteries.
  51. Atherosclerosis
    a condition in which an artery wall thickens (and the lumen gets smaller!!!) as a result of the accumulation of fatty materials such as cholesterol.
  52. Conditions that necessitate precautions in the use of hot and cold applications:
      • Neurosensory impairment
      • Impaired mental status
      • Impaired circulation
      • Immediately after injury or surgery - NO HEAT - increases bleeding and swelling
      • Open wounds - NO COLD decresed blood flow inghibits healing
  53. What is the HOT/COLD Rebound Phenomena?
      • HEAT - max vasodialation occurs in 20-30 minutes, BEYOND 30-45 results in tissue conjestion and vasoconstriction occur for unknown reasons at which point burns are a risk because heat cannot be dispelled adequately via blood circulation.
      • COLD - Vasoconstriction occurs up to about 15C(60°F), but below that vasodialtion occurs as a protection against freezing, e.g. red (lots of flowig blood) ears and nose in winter.
  54. How does heat help joint stiffness?
    By deacreasing the viscosity of synovial fluid and increasing tissue distensibility.
  55. Follow up for any hot/cold therapy?
    Return to Pt after 15 minutes and eval skin for any untoward signs, e.g. redness
  56. Hot Water Bottle Temp Therapy ranges?
      • Normal adult and child over 2: 115-125°F
      • Debilitated or unconcious adult or child under 2: 105-115°F
  57. Sitz Bath...
      • To soak perineal or rectal area
      • 105-110°F
  58. Cooling Sponge Bath...
      • ONLY for Pt with temps above 104°F
      • 80-98°F
  59. Incentive Spirometry...
      • Use 10X per hour
  60. Room air contains how much oxygen?
  61. How to tell when an IV needle is NOT in the vein?
      • Infiltration- nonvesicant
      • Coolness of skin around site
      • Skin blanching
      • Edema at, above or below
      • Leakage
      • Absense of "pinkish" blood return
      • Extravasation - escape of vesicant (blister causing, sever tissue injury or necrosis OUTSIDE of vein)
      • Pain, tenderness or discomfort
      • Change in temp of skin
      • Burning at insertion site
      • Phlebitis - inflammation of the vein (mechanical, chemical or bacteriological)
      • Redness at site
      • Paslpable cord along vein
      • Increase in temperature
  62. If oxygen saturation is less than 85%...
    Nurse can treat with oxygen and THEN get an order
  63. Green leafy foods will...
    inactivate CUMADIN
  64. How does STRESS increase your risk of infection?
    It releases the steroid Cortisol (hydrocortisone) from the adrenal gland, which increases blood glucose levels, which provides a "better" growth medium for bacteria.
  65. How often do we need to change various parts of an IV?
      • Bag - Q24 hrs
      • Tubing - Q72 hrs
      • Sites - Q72 hrs
      • Dressing(transparent) Q72 hr or with Site change
  66. What is a Saline or Heparin Lock?
    IV access, no continuous fluid
  67. IV Flush Protocols
      • SL or Saline Lock or Heparin Lock (all same thing): 1-2 mL NS Q8-12 hrs
      • PICC lines or Central lines (Central line is shorter term than PICC): 10 mL NS folowed by 300 units heparin, after each use or daily
  68. Oxygen Flow
      • Nasal Cannula: 1-6 L/min @ 24-45%
      • Face tent: 4-8 L/min @ 30-50%
      • Venturi mask: 4-10 L/min @ 24-50%
      • Simple face mask: 5-8 L/min @ 40-60%
      • Partial rebreather: 6-10 L/min @ 60-80% (bag to remain inflated on inspiration otherwise increase flow rate)
      • Non rebreather: 10-15 L/min @ 95-100%
  69. Name Vital Signs
      • Temp
      • Pulse
      • BP
      • Respirations
      • Pain
  70. Low or Semi Fowler's angle
  71. Fowler�s angle
  72. High Fowler's angle
  73. Correct Application of Fowler's?
    People who have difficulty breathing and for some people with heart problems
  74. Correct Application of Orthopneic
    Client who have problems exhaling because they can press the lower part of their chest against the edge of the over bed table
  75. Correct Application of Dorsal Recumbent (Supine)
    Provide comfort and to facilitate healing following certain surgeries or anesthetics e.g. spinal
  76. Correct Application of Prone
    • Only position that allows full extension of the hip and knee joints. When used periodically it helps prevent flexion contractures of the knees and hips.
    • Promotes drainage of the mouth so it is good for unconscious patients as well as those recovering from mouth or throat surgery.
    • Significant lordosis is a problem.
    • Because neck is rotated to a significant degree, it is not good for clients with cervical or lumbar spine problems.
    • Some cardiac and respiratory patients find the position suffocating because it inhibits chest expansion.
  77. Correct Application of Lateral
    Helps relieve pressure on the sacrum and heels of patients who spend much of the day sitting or in Fowler's or dorsal recumbent.
  78. Correct Application of Sim's
    • Promotes drainage of the mouth so it is good for unconscious patients as well as those recovering from mouth or throat surgery.
    • Good for paralyzed clients because it reduce pressure over the sacrum and greater trochanter.
    • Good for those getting enemas or exam/treatments of the perennial area.
  79. Lateral Pressure Ulcer Risk Areas
    • Pressure Ulcer Risk Areas
    • Parietal and Temporal
    • Ear
    • Acromial Process (shoulder)
    • Ilium
    • Greater Trochanter
    • Medial and Lateral Condyles (knee)
    • Malleolus, medial and lateral (ankles)
  80. Prone Pressure Ulcer Risk Areas
    • Pressure Ulcer Risk Areas
    • Zygomatic bone (cheek and ear) Occipital
    • Acromial Process (shoulder)
    • Women's breast
    • Men's genitalia
    • Patellas (Knees)
    • Phalanges (toes)
  81. Fowler's Pressure Ulcer Risk Areas
    • Pressure Ulcer Risk Areas
    • Vertebrae
    • Sacrum
    • Pelvis
    • Calcaneus (heels)
  82. BP Normal
    < 120 / < 80
  83. BP prehypertensive
    120-139 / 80-89
  84. BP Hypertension state 1
    140-159 / 90-99
  85. BP Hypertension state 2
    >= 160 / >= 100
  86. Normal temperature range
    • 98.6° - 99.5° F
    • 36° -37.5° C
  87. When is a Pt Pyrexic?
    Above 38° C or 100.4° F
  88. Typical Pulse
    80 (60-100)
  89. Typical Respirations
    16 (12-20) Bradypea < 10, Tachapnea > 24
  90. How to test for Orthostatic Hypotension?
      1. Supine for 10 min
      2. Take BP and pulse
      3. Sit or stand and immediately take BP and pulse
      4. Pulse rise of 15-30 or S drop of 20 or D drop of 10
      5. Check BP & pulse after 3 minutes to insure Pt returns to base
  91. These conditions can lead to Erroneously LOW BP readings
      • Cuff to WIDE
      • Arm above the heart
      • Deflating cuff too quickly - LOW S, but HIGH D
      • Failure to ID ascultatory gap
    • All other possibilities can lead to Erroneously HIGH BP readings
  92. What is Ascultatory Gap?
      • Paticularly in hypertensive Pts, there can be a disappearance of BP sounds from the later parts of Karaotkoff phase 1 or 2 and lasting for as much as 40 mmHg.
      • To prevent a erroneously low Systolic reading, a palpatory systolic estimate should be taken and then inflate to that + 30.
  93. Subcutaneous Needle
    • 3/8 - 5/8
    • 1 inch if obese

    • 24 - 26
    • 26 - 30 for insulin

    0.5 - 1.0 mL
  94. Deltoid IM
    1 inch

    23 - 25

    0.5 - 1.0 mL
  95. Dorsal Gluteal, Ventral Gluteal or Vastus Lateralis
    • 1 1/2
    • 2 inch if obese

    20 - 22

    Up to 3.0 mL
  96. Intradermal
    1/4 - 5/8

    25 - 27

    up to 0.1 mL
  97. Deltoid landmarks
    • 1. Acromion Process
    • 2. Top of axilla
  98. Dorsal Gluteal landmarks
    • 1. Posterior superior iliac spine (note: towards the spine)
    • 2. Greater trochanter (note: lateral side of leg)
  99. Ventrogluteal landmarks
    • 1. Greater trochanter
    • 2. Anterior superior iliac spine (note: towards umbilicus)
    • 3. Iliac crest (note: lateral leg above greater trochanter)
  100. Vastus lateralis landmarks
    • 1. Greater trochanter
    • 2. Lateral femoral condyle
  101. Subcutaneous upper arm landmarks
    • 1. Acromion process (hand breath below)
    • 2. Elbow (hands breath above)
  102. Subcutaneous abdomen landmarks
    • 1. 2 inches away from umbilicus
    • 2. Above level of iliac crest
  103. Sublinqual meds for NPO Pt OK?
  104. What are the RIGHTS med Administration?
      1. Medication
      2. Dose
      3. Time
      4. Route
      5. Client
      6. Education
      7. Documnetation
      8. Refusal
      9. Assessment, e.g. specific assessment (not for BP < 60) BEFORE dose
      10. Evaluation
  105. What are the 3 blood gasses that can trigger chemoreceptors that drive respirtation?
    • Hydrogen
    • Oxygen
    • Carbon dioxide
  106. Which of the 3 blood gasses that can trigger chemoreceptors that drive respirtation has the strongest effect?
    Carbon dioxide
  107. What is Hypoxic Drive?
    COPD Pts such as those with emphysema have chronically elevated CO2 often have desensitized receptors such that increasing oxygen levels decreases respiratory rate, thus Hypoxic Drive. Traditionally, O2 has been administered to COPD Pts at low flow rates. However, 2008 studies indicate that not all COPD Pts have desensitized CO2 receptors so that low flow O2 may not be enough for these Pts, and that chronic hypoxemia shortens survival and quality of life.
  108. What SaO2 rate is considered Hypoxia?
    92% and below
  109. Name 3 activities of Protein metabolism?
      1. Anabolism - building tissue
      2. Catabolism - breaking down tissue
      3. Nitogen Balanace (nitogen is the element that distinguishes protein from lippids and carbs)
  110. Local Infection indicators?
      1. Swelling
      2. Redness
      3. Pain or tenderness with palpation or movement
      4. Palpable heat
      5. Possible loss of function of body part
  111. Systemic Infection indicators?
      1. inc Pulse and respirations for high fever
      2. Anorexia (loss of appetite) and in some cases nausea and vomiting
      3. Malase
      4. Large & tender lymph nodes
      5. WBC > 11k/mm3
  112. Yellow biohazard bag for...
  113. Why might an infant with an infection not have a temperature?
    underdeveloped immun system
  114. Above what temperature should children be treated with measures other than comfort measures?
    39° C, 102.2° F
  115. What actions enhance circulation of lymph?
      1. slow deep breathing
      2. ambulation
      3. movement
  116. Disinfectant v Antiseptic?
    inanimate surface v body tissue
  117. Use STANDARD Precautions for...
    • Contact with:
      1. Blood
      2. Body fluids
      3. Secretions
      4. Excretions, except sweat
      5. non-intact skin
      6. mucous membranes
  118. Use AIRBORN + STD Precautions for...
    • Pts with transmits via droplets less than 5 microns:
      1. measles
      2. varicella
      3. tubercluosis
  119. Use DROPLET + STD Precautions for...
    • Pts with transmits via particle droplets greater than 5 microns:
      1. diphtheria
      2. mycoplasma pneumonia
      3. etc.
  120. Indirect Infection transmission modes?
    • Vehicle - inanimate object
    • Vector - animal or flying/crawling insect
  121. Methods of Direct infection transmission?
    • touching
    • kissing biting
    • sexual intercourse
    • Droplet (< 5 microns) spread within 3'
  122. Question Pt before taking BP...
    • Mastectomy because the cuff may cause lymphedema
    • smoke or caffiene in last 30 minutes
  123. Types of Exercise
    • Isotonic - walking, swimming...
    • Isometric - muscle contraction but NO joint movement
    • Isokinetic - isometric against a resistance(machine) instead of a solid object
  124. Turn Pts at risk of pressure ulcers every...
    2 hours: left lateral, supine, right lateral
  125. When to take vital signs?
    • 0700-0800
    • Change in status or rpts pain, hot, faint
    • Before and/or after meds that could affect resp or cardio
    • B&A surgery
    • B&A nursing intervention that could affect vitals like ambulating a Pt who has been on bed rest
  126. HYPO v HYPERTHERMIA sympton overlap
    • Temp down - PO
    • Heart Rate down - PO
    • Heart rate up - PER
    • Resp down - PO
    • Resp up - PER
    • Sever shivering (initially) - PO/PER
    • Feeling cold - PO/PER initially, but not severe
    • Pale, cool, waxy skin - PO
    • Frostbite - PO
    • Hypotension - PO
    • Decreased unrinary - PO
    • Lack of muscle coord - PO
    • Disorientation - PO
    • Drowsiness to coma - PO
  127. Diet Characteristics
    • Clear Liquid: 24-36 hours
    • Full Liquid: liquid @ body temp; not long term, but if so Ensure
    • Soft: low-fiber pureed
    • Diet as Tolerated (DAT): e.g. first day post-op->clear; if bowel sounds then advance
  128. Medical v Surgical Asepsis
    • Medical - limit amount (few but not 0) and location of microbes
    • Surgical - ZERO microbes or spores
  129. Restraints
      • PRN orders for restraints are prohibited
      • ONLY AFTER every other means of safety has been unsucessfully documented (1-area where they can be seen, 2-lowest bed pos, 3-rocking chairs to use up energy)
      • Safety or to allow a medical procedure to proceed
      • Nurse may apply if safety is issue, BUT must have face-to-face eval by 2nd level within 1 hour
      • Attending must be notified
      • Behavioral (hard/leather) order good for 4 hours, reassess, monitor q15 min
      • Med Surg (soft) order good for 12 hours , reassess, monitor q1 hour
      • Perfusion: Pulse, Temp, Capillary refill, Color
  130. Antipyretics?
    Tylenol & motrin
  131. Anti Inflammatory?
    Montrin, but not Tylenol
  132. Pulse Pressure & Diagnostic
    • Systolic - Diastolic
    • If below 25, inficative of heart failure
  133. Hematacrit?
    Viscosity of blood
  134. IRIS
    I Require Intensive Surveilence
  135. RACE
    Rescude Alarm Contain Extinguish
  136. Post Ictal
    Period AFTER seizure
Card Set
NUR 111 Written Final.txt