Review for N172:(

  1. Ad lib
    As Desired
  2. SX
    Signs and Symptoms
  3. Pulse deficit
    Difference between a persons apical pulse and radial pulse.

    Tells if a patient has A Fib and early diastolic ventricular ectopic beats.
  4. Pulse Pressure
    Difference between systolic and diastolic
  5. Cheyne Stokes
    irregular breathing characterized by hyperventilation alternating with apnea lasting 10-20 seconds
  6. Kussmaul's
    rapid deep respirations associated with ketoacidosis
  7. Agonal
    gasping, irregular, infrequent breaths....end of life.
  8. How do you tell if a person has orthostatic hypotension
    when they have a 15mm or more drop in SBP or 10mm or more drop in DBP.

    An increase of 15 BPM in patients HR may occur
  9. Describe IV infiltration
    • cool skin
    • painful
    • edema
  10. Describe phlebitis
    • warm
    • painful

    inflammation of a vein
  11. When seeing a patient what do I assess with their IV?
    • Is there any.....
    • Redness
    • Edema
    • Drainage
    • Pain

    Is the site clean, dry and without signs of complications.

    ID solution, rate and the volume remaining along with the equipment/pump used for the infusion
  12. Before I remove an IV what 2 things do I need to do?
    • Turn off the pump/or clamp tubing
    • Note how much of the solution is left
  13. TPR
  14. Assess LOC by asking
    Orientation to person, place, time and situation/event

    • What's your name
    • Where are you
    • Whats the date
    • What brought you here
  15. PERRLA
    Pupils Equal, Round, Reactive to light/Accommodation
  16. P

    • Provoked-what brought it on
    • Quality-describe
    • Radiating/Region-from 1 place to another
    • Scale/Severity-0-10
    • Time-for how long
  17. How high do you hold the enema bag?
    18 inches above the rectum and they will hold for 2-5 minutes.
  18. How long does it does it take for a stoma to shrink to it's permanent size? 
    How large do you cut the bandage to go over the stoma?
    • 2-3 months
    • 1/8-1/16 inches larger than the stoma
  19. When do you empty a stoma bag?
    What do you clean it with?
    What don't you want to get on to a new stoma?
    • when it is 1/2 full or inflated with gas
    • water only
    • don't get water on a new stoma
  20. Insensible losses:

    • stool-200mL
    • lungs-300mL
    • skin-600mL
  21. ounces to mL's
    x it by 30

    3 ounces x 30= 90mL
  22. Fine Crackles

    Heard where?
    When heard?
    Heard in the lung bases

    Heard on inspiration and expiration
  23. Wheezes

    Where heard
    When heard
    High pitched musical sound

    Heard over larger airways

    Heard on inspiration and expiration
  24. Course Crackles

    Where heard
    Heard over large airways

    aka Rhonci
  25. 1 ounce = how many mL's
  26. 1 mcg = how many mg's?
    0.001 mg
  27. 1 kg = how many grams
    1000 grams
  28. 1 litre = how many mL's
    1000 mL
  29. 1 tbsp = how many mL's
    15 mL's
  30. 1 tsp = how many mL's
    4-5 mL's
  31. 1 mg = how many mcg's?
    1000 mcg
  32. Soft bland diet
    no fried foods, raw fruits and veggies

    decreased amounts of fiber
  33. Sodium restricted diet
    • limits sodium to 1000-2000
    • (1-2 grams)
  34. Full liquid diet
    anything liquid at room temperature...jello, ice cream, creamed soups, milk shakes
  35. Clear liquid diet
    jello, tea, cranberry juice
  36. dysphagia
    difficulty swallowing
  37. 3 ways to test placement of NG tube placement
    inject 20-30mL's of air and ausculate for sound

    Aspirate for gastric secretions....should be >4 and be acidic

  38. Before I feed somebody with a G Tube what do I do
    check for residual....should be 20-100mL's.  If more than 100 tell nurse cuz not digesting/eliminating food

    Always put what you took out back in.
  39. When administering tube feedings....what do I flush with before and after feeding?

    What do I put in between each crushed or liquid medication?
    10-100mL's of water

    5-10mL's of water

    **remember to record these amounts of water in the I&O!!
  40. When measuring distance for NG tube, prior to insertion, what are the markers?
    Nose to ear to xiphoid process
  41. What do I irrigate a NG tube with?
    Normal Saline....document amount in I&O's
  42. When I am feeding somebody through their NG tube what do I flush with to maintain patency?
    20-30mL's of water....prior to feeding and at completion of feeding
  43. Which oxygen mask delivers the highest concentration of O2?
    Non-rebreather mask
  44. Normal blood glucose
  45. Signs of hypoglycemia
    • Irritable
    • weak/shaky
    • sweaty
    • full/bounding rapid pulse

    Rapid onset and progression....dangerous!!
  46. Signs of hyperglycemia
    • Drowsy/Lethargic
    • Flushed skin
    • Thirsty
    • Weak/Rapid pulse
    • Deep labored breathing

    Slow onset and progression
  47. How do you treat hypoglycemia and hyperglycemia?
    hypo-give them carbs in liquids or foods

    hyper-administer IV
  48. Where do you collect a urine specimen from a catheter bag?
    from the needle-less port in the tubing....not the bag
  49. When do you obtain a sputum specimen?
    1-2 hours after a meal or 1 hour before.....and after oral care. 

    Collect 2-10mL's of sputum
  50. When taking a wound culture.....

    Where do you find aerobic cells and anaerobic cells?

    Which do you collect first?
    aerobic on the edge of a wound

    anaerobic on the center of a wound

    Obtain anaerobic first
  51. Lipping
    pouring out a little of the first part of a sterile solution
  52. R
    • Redness
    • Edema
    • Approximation
    • Drainage/Dressing
    • Size, site, sutures/staples/steristrips
  53. Pressure Ulcers

    Stages 1, 2, 3, 4
    • 1-in tact skin, red
    • 2-blister or skin loss of dermis/epidermis
    • 3-loss down to subcutaneous layers/necrosis
    • 4-full thickness with damage to muscle/bone/supporting structures
  54. What do I clean skin tears with?
    Normal Saline
  55. Characteristics to be assessed during a dressing change....
    • size and color of the wound
    • drainage
    • granulating
    • depth
    • approximation
    • odor
  56. What is the panic level for WBC?
    <500  at a high risk for infection.....neutropenic
  57. 4 components of a CBC
    • RBC
    • WBC
    • Hct
    • Hgb
  58. Sedimentation rate tells you....
    if a person has inflammation
  59. Hemoglobin is used for
    oxygen transportation
  60. Hematocrit tells you if a person is
    • dehydrated/overhydrated
    • anemic
  61. Panic value for platelets
    <20,000...they are at risk for bleeding out
  62. What is a sign that a person may be hemmoraghing?
    Increased HR and Decreased BP
  63. 7 Rights of patient medication admin....
    • Right...
    • Drug
    • Dose
    • Documentation
    • Time
    • Route
    • Approach/Allergy
    • Patient
  64. Prior to giving a medication injection I need to check...
    • 7 rights
    • check order
    • expiration on the bottle
    • time of last injection
  65. When drawing up medication from a vial, make sure to
    put the same amount of air in to the bottle that I will be withdrawing from the bottle....pressurize it
  66. IM Injections

    Fluid amount and location
    Needle size
    Angle of injection
    3mL in large muscles of an adult or 1mL in the deltoid or in to thin elderly adults

    21-23 gauge and 1-1.5 inches long

    90 degrees
  67. With an IM injection to pushing the medication don't forget to....
    aspirate to make sure I am not in a blood vessel
  68. What kinds of medications are given intramuscularly
    • antibiotics
    • antiemetics
    • narcotics
    • sedatives
    • vitamins
    • tetanus
    • iron
  69. Z track injections

    Used for?
    draw up technique
    after injection I will.....
    But don't....
    Irritating IM medications...Vistaril, Iron, B12 and some antibiotics

    • add 0.2 mL of air
    • Aspirate
    • Count to 10 after injection
  70. Subcutaneous Injections

    Needle size
    • Loose connective tissue, fatty back of arm or belly
    • 1-3 mL's or 0.5mL for infants
    • 25-27 gauge  and 1/2 to 5/8 inch
    • 45-90 degrees
  71. What sort of injection is used for insulin and heparin?
  72. What not to do after these injections....

    Heparin...don't pinch or massage

    Insulin...don't massage
  73. Intradermal Injection

    Used for?
    Needle size
    • Allergy testing and TB Tests
    • 10-15 degrees
    • 26-27 gauge 3/8-5/8 inch needle
  74. When do you read a TB test?
    48-72 hours after the injection
  75. Prior to administering medication I need to do 3 checks....
    • Check before removing from the drawer/cassette
    • Before dispensing
    • Recheck at bedside before opening-tell the patient what you are giving
    • After pouring and before disposing of the empty container
  76. Prior to giving any medication it is crucial to check....
    the expiration date
  77. Medications that shouldn't be crushed
    • Sustained Released
    • Long Acting
    • Controlled release
    • Extended Length
    • Enteric Coated
  78. What's the time frame of the administration of medication?
    Within 30-60 minutes of the written order
  79. Prior to giving Digoxin make sure....
    • the Potassium level is btwn 3.5-5.1
    • chk the serum dig level....hold if 2+
    • take apical prior to admin....hold if below 60
  80. Before giving potassium make sure the serum level is not above
  81. Prior to giving anithypertensives check the persons _______ and hold it if the _______
    • Blood pressure and Heart Rate 30 prior to administration
    • SBP is <90
  82. Prior to giving anticoagulants what do I check?
    platelet level

    PT and INR for Coumadin

    don't want platelets <100,000
  83. Never give insulin if the BS is below
  84. What is dangerous about narcotics and sedatives?
    it depresses a persons respirations
  85. Prior to administering medications to a patient always....
    • Wash Hands
    • ID patient with 2 ID's
    • Ask about allergies
    • Explain why they are getting each medication
    • Don't leave until it is all gone
    • Wash Hands and clean up wrappers
    • Document!!!
  86. 2 medications that require a 2nd RN to check
    Heparin and Insulin
  87. 1 g = how many mg?
    1000 mg
  88. 1 Tbsp = how many tsp?
    3 tsp
  89. Normal RBC

    • Male 4.6-6
    • Female 4.0-5
  90. Normal Hgb

    • Male 13.5-18g/dL
    • Female 12-16g/dL
  91. Normal Hct

    • Male 40-54%
    • Female 36-46%
  92. Normal Platelet Levels
    150,000-400,000 uL
  93. Normal WBC
    4,500-10,000 uL
  94. Normal Sodium
    135-145 mEq/L
  95. Normal Potassium
  96. Normal Calcium
  97. Normal pH
  98. Normal HCO3
    22-26 mEq/L
  99. Normal PaCO2
    48-32 mmHg
  100. Normal PaO2

    Tells if person is Hypoxic
  101. Normal SaO2

    O2 Saturation/Pulse Ox
  102. If this measurement is out of whack the person has metabolic acidosis/alkalosis
  103. If this measurement is out of whack the person has respiratory acidosis/alkalosis
  104. How do Beta Blockers work?
    reduces bp by reducing heart rate, heart workload and hearts output of blood
  105. How do ACE Inhibitors work?
    cause the body to produce less angiotensin which allows the vessels to relax and open up...causing a lower bp
  106. How do Calcium Channel Blockers work?
    it prevents calcium from entering the muscle cells of the heart causing the hearts contraction to be less forceful
  107. Maslows
    • Physiologic
    • Safety
    • Love/Belonging
    • Esteem
    • Self Actualization
Card Set
Review for N172:(
Review of all of the crap I forgot in 3 short months!!!