Term
Can a diabetic patient soak their feet?
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Definition
| Yes, but you have to ensure you dry inbetween the toes afterwards to prevent denudment and open areas |
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Term
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Definition
First do no harm:
Let a more experienced nurse put in the foley or do the IV - if you are not skilled, then you might harm the patient |
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Term
| What would you do if the patient stated he had a latex allergy? |
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Definition
| Remove all latex from room; change plan of care to replace latex tapes with silk tape; remove latex dressings and replace with cotton non-allergic dressings |
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Term
| Who is at highest risk of developing a nosocomial infection? |
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Definition
| Immunosuppressed patients; patients on chemotherapy or those taking antirejection drugs (such as those with a transplant) |
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Term
| What does orthopnea mean? What should the nurse do FIRST! |
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Definition
Orthopnea- difficulty breathing when lying flat.
SIT THE PATIENT UP! |
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Term
| Describe the safety factors when ambulating a patient |
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Definition
Wear non skid shoes, rubber soles
gait belt
1 person assist if the patient is unsteady
Determine weight bearing precautions to make sure it is safe! |
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Term
What are the diet recommendations for someone in need of wound healing?
What kinds of foods would you recommend? |
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Definition
High protein, vitamin C, Zinc
Eggs, meat, legumes, orange juice |
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Term
| Should the nurse express sympathy to a family when a patient dies? |
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Definition
Yes
Sympathy can be expressed in this situation |
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Term
| What patient population is best served by using ROLL PLAYING? |
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Definition
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Term
| If a patient needs assistance in writing their advanced directives, who should the nurse direct their attention to? |
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Definition
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Term
| Describe a stage I pressure ulcer |
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Definition
| Redded skin that does not blanch |
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Term
| Describe a stage II pressure ulcer |
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Definition
| shallow open area with red/pink wound bed |
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Term
| Describe a stage III pressure ulcer |
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Definition
| Deep full thickness wound involving fascia |
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Term
| Describe a stage IV pressure ulcer |
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Definition
| Deep full thickness pressure ulcer where bone or underlying structures can be visualized |
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Term
| What is an unstagable pressure ulcer |
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Definition
| An ulcer over a bony prominence that the wound bed can not be visualized |
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Term
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Definition
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Term
| What should the nurse do if the initial vital signs are abnormal? |
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Definition
| Validate. Repeat the vital signs in 15 minutes to make sure the vital signs are accurate |
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Term
| What should the nurse do if she feels the patient is anxious and having sensory overload during the teaching session |
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Definition
| close the door and allow the patient to relax. Come back to repeat the teaching session later when the patient has calmed |
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Term
| What is the most important step in processing an ethincal dilemma |
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Definition
| Recognizing your own values as compared to the situation |
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Term
| How can you maintain infection control when taking an oral, axillary or rectal temperature |
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Definition
| place a protective sheath over the probe |
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Term
| If the patient is in need of going for a test and is in isolation precautions what should the nurse do to maintain these precautions and decrease the prevalence of infection? |
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Definition
| Place a mask and gown on the patient before transport |
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Term
| How can you insure communication when a patient is anxious? |
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Definition
| Give the patient written direction |
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Term
| Why is marking allergies on a bracelet important ? |
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Definition
| Anyone interacting with the patient can ready identify the patient's needs |
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Term
| If a patient is unable to roll side to side, what other options does a nurse have to make the bed? |
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Definition
| Have the patient sit up and make the bed from top to bottom instead of side to side. |
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Term
| What should the nurse do FIRST in a medication error? |
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Definition
| Assess the patient then contact the healthcare provider (physician) |
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Term
| What is log rolling and why do we do it for our patients? |
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Definition
| Maintains spinal allignment |
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Term
| What would be excluded in a CLEAR LIQUID DIET? |
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Definition
Patient can have PLAIN (no cream or sugar) coffee, jello, broth (that does not have solids)
Just make sure you can SEE THROUGH IT! |
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Term
| Why would a pedal pulse be absent? |
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Definition
| maybe due to peripheral vascular occlusion but sometimes the provider presses too hard. Lighten up on the pressure to see if there is a faint pulse. |
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Term
| What should you do first if the oxygen saturation is low? |
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Definition
| Validate the test. Reposition the oxygen nasal cannula and retest the oxygen saturation on another finger or elsewhere on the body |
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Term
| What is the risk associated with an enlarged, distended bladder? |
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Definition
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Term
| Why would a pedal pulse be absent? |
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Definition
| maybe due to peripheral vascular occlusion but sometimes the provider presses too hard. Lighten up on the pressure to see if there is a faint pulse. |
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Term
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Definition
| maintain spinal alignment |
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Term
| what are the risks of an enlarged, distended bladder? |
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Definition
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Term
| What are nocturnal emissions? |
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Definition
| Nighttime ejaculation. Normal in the adolescent population. |
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Term
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Definition
| Due to void. Important to record and communicate this as we need to watch the patient after removal of the foley to ensure there is no urinary retention |
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Term
| What should your recommend if the wound has tan, purlulent drainage? |
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Definition
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Term
| If a patient can't sleep, assess for pain |
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Definition
| recommend pain medications |
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Term
| How should you prepare the skin for a topical administration of medication? |
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Definition
| Soap and water. Do not use an alcohol prep pad. |
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Term
| patient out comes and goals need to be: |
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Definition
| SMART! Make sure they are timed! ... will complete in 2 days, by tomorrow, by discharge etc! |
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Term
| The order of procedures are: |
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Definition
1. Sterile
2. Clean
3. Dirty |
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Term
| What surface should the weight be for crutch walking? |
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Definition
| weight should be on the palm of the hands |
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Term
| Who should be rounded on the most during night shift? |
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Definition
| Sleep apnea, copd, respiratory conditions |
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Term
| how far do you advance the catheter on a male? |
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Definition
| For both circumsized and uncircumsized- insert the catheter to the bifurcation |
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Term
| Therapeutic communication |
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Definition
Be nice!
Ask therapeutic questions like :
tell me about .....
What do you think about .....
How can I help you..... |
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Term
| What is the most imporatant aspect of checking the patient in restraints? |
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Definition
| Constantly assess to determine the need to reapply |
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Term
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Definition
| teach the patient to wash their hands and use disposable gloves |
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Term
| Death/Dying regimes that are unusual? |
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Definition
| allow for family to express needs and complete rituals as much as possible |
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Term
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Definition
| Keep your promise. Come back when you say you are going to |
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Term
| give a nonmedical regime to stimulate the bowels |
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Definition
warm prune juice
ambulation |
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Term
| what is QD, QID, BID, TID |
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Definition
QD (every day),
QID (four times a day),
BID (twice a day),
TID(three times a day) |
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Term
| what are the isolation precautions for someone with TB |
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Definition
Face mask (N 95)
gown gloves |
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Term
| When should you use a DOPPLER? |
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Definition
| when you can not manual feel a pedal pulse |
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Term
| What is your concern for a patient with chronic pain? |
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Definition
| Is the patient able to complete their ADL's sufficient to meet their needs |
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Term
| Who can translate for the nurse? |
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Definition
| A hospital approved translator |
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Term
| what is the goal for imporving physical activity? |
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Definition
| Obtain normal heart rate, blood pressure and respiratory ranges |
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Term
| what should be used to clean a wound? |
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Definition
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Term
| If potassium levels are abnormal |
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Definition
| expect to replace as potassium has cardiac implications |
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Term
| What is the method of wasting a narcotic medication? |
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Definition
| Have 2 registered nurses witness and sign the waste |
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Term
| what is the best way to open an ampule? |
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Definition
| Put a cotton gauze or protective covering to prevent cuts |
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Term
| What are the infection control concerns with eye drops? |
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Definition
| Wash hands, apply gloves, do not let the tip of the bottle touch the patients eye |
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Term
| what is the proper position for the ear when using a tympanic thermometer? |
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Definition
| Pull the auricle up and back on an adult |
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Term
| what does RACE stand for? |
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Definition
Rescue, Alarm, Confine, Evacuate
Close the door to the room with the fire! |
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Term
| What is your concern for the patient with vomiting or diarrhea? |
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Definition
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Term
| why do we use normal saline to cleans wounds? |
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Definition
| cleans the wound without destroying tissue |
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Term
| how do we dress dry wounds? |
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Definition
| with moisture donating dressings: hydrocolloid gel dressings |
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Term
| how do we dress saturated wounds? |
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Definition
| Moisture reducing dressings: seaweed, cotton gauze |
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Term
| do we have to turn a patient on a specialty mattress? |
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Definition
| No, specialty mattresses frequently do not need sheets and they are usually beds that move the patients |
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Term
| How do you determine the basline for a blood pressure for a patient who does not know their usual baseline? |
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Definition
| Use the palpation method: Inflate the cuff while palpating the radial pulse, inflate until you it is obliterated (goes away), then inflate the cuff 30 mm HG above that as your HIGH number. Allow the cuff to deflate noting the blood pressure. |
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Term
| Who determines the scope of practice? |
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Definition
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Term
| What are the 6 links to the chain of infection |
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Definition
host
microbe
portal of exit
portal of entry
reservoir
mode of transmission |
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Term
|
Definition
| a parasites: mosquitos, ticks, flies |
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Term
|
Definition
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Term
| what are the 3 typical types of drainage |
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Definition
serous- clear
sanginous-bloody
serosanginuous- pink/tinged fluid |
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Term
| what are the principles of sterile technique? |
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Definition
sterile to sterile
do not reach over the sterile field
nothing below the waste
dry
1 inch boarders
open packages away from you |
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Term
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Definition
| a specially fitted mask for use with airborne precuations such as suspected TB |
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Term
| what is normal temperature |
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Definition
|
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Term
| what is malignant hyperthermia? |
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Definition
| a hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anethetic drugs |
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Term
| what is the result of a blood pressure if the cuff is too wide? |
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Definition
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Term
| what is z-track used for? |
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Definition
| to prevent deposit of medications into sensitive tissue, prevents staining or medication seeping out of the sinus track |
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Term
| how should oral liquid medications be poured? |
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Definition
| into a calibrated cup at eye level |
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Term
| what is a nebulizer spacer used for? |
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Definition
| inhaling medications for those that are not coordinated enough to used the MDI |
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Term
| how long should the 'hub' be 'scrubbed' |
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Definition
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Term
| how should toenails be trimmed? |
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Definition
straight across
A podiatrist is recommended for diabetic patients |
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Term
| what does pursed lip breathing do? |
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Definition
| prevents alveolar collapse |
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Term
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Definition
| collapse of the alveoli that prevents normal exchange of oxygen and co2 |
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Term
Analyze these ABG's
pH 7.25
PaCO2 48
HCO3 29 |
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Definition
| Partially compensating Respiratory Acidosis |
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Term
Analyze these ABG's
PH 7.49
PaCO2 33
HCO3 18 |
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Definition
| Respiratory Alkalosis, partially compensating |
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Term
| How do you correct Hypophosphatemia? |
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Definition
| Correct the Calcium imbalance. There is a reverse relationship. |
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Term
Analyze these ABG's
PH 7.31
PaCO2 32
HCO3 20 |
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Definition
| Metabolic Acidosis, Partially compensating |
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Term
| For IV selection, you should start looking for a vein |
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Definition
| At the most distal end of the arm. |
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Term
| Give an example of Justice |
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Definition
| Organ transplant list, based on health needs |
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Term
| What does the Good Samaritian Act cover |
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Definition
| a health care professional acting within their scope of practice |
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Term
What amount of urine is indicative that the kidneys are working?
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Definition
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Term
| What should you do if the patient complains of cramping during an enema ordered for a surgical procedure? |
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Definition
Lower the infusion bag to decrease the rate of the fluid entering the bowel. This will decrease cramping.
Understand, the patient HAS to have this enema or he CANNOT have the surgery. |
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Term
| What is a meant by "splinting" when you splint, cough and deep breath? |
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Definition
| Splinting refers to holding on to a pillow or stuffed object to 'press' on the area to decrease the pain associated with coughing |
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Term
What is dehiscence?
What is evisceration? |
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Definition
| Dehiscence is the wound opening, evisceration is protrusion of visceral organs through a wound opening |
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Term
| what is the first thing a nurse should do when a pressure ulcer is recognized? |
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Definition
| remove the source of the pressure |
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Term
| what is the best score for the BRADEN SCALE? What is the worst? |
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Definition
| Best score is 23, worst score is 6. DO SOMETHING AT 18!!! |
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