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HESI TERM 1
FUNDAMENTALS
135
Health Care
Not Applicable
10/25/2010

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Cards

Term
what is located in the abdominal cavity?
Definition
spleen
stomach
gull bladder
small intestine
large intestine
appendix
liver
Term
where is the abdominal cavity located?
Definition
below the diaphram above the hip bone
Term
that are the names of the 4 quadrants?
Definition
right upper quadrant
right lower quadrant
left upper quadrant
left lower quadrant
Term
what are the names of the 9 quadrants?
Definition
(R)hypochondriac,epigastric,(L)hypochondriac
(R) lumbar, umbilical, (L) lumbar
(R) inguinal, hypogastric, (L) inguinal
Term
how do you document abuse in the nursing note?
Definition
write the incjuries objectively on the patient & thier vitals always factual never personal
Term
how does diffusion work in regards to the respiratory system (the transfer of O2 and CO2)?
Definition
high to low
Term
how does diffusion work?
Definition
high concentration to low concentration

(there is no force to stop diffusion and particles distribute themselves evenly an example is how ink spreads in water)
Term
how does osmosis work?
Definition
from low concentration to high concentration
Term
how does filtration work?
Definition
water and solutes move across capillary membranes driven by fluid pressure
Term
how does active transport work?
Definition
allows molecules to move across cell membrane into an area of higher solute concentration
Term
what do you do if someone is stuck with a dirty needle
Definition
clean with soap and water
flush splashes to nose, mouth or skin with clean water
report incident to your supervisor
complete an incident report
immediately seek treatment
Term
what do you do if you accidently re-stick a patient with a needle?
Definition
nothing theres no risk of catching infection just wipe area
Term
what are sordes?
Definition
thier brown and hairy usually in the gums and are caused due to accumulation of food, microrganisms
Term
what do you have to do for sordes?
Definition
perform good oral hygeine
Term
describe the epiglottis and what it does and its location
Definition
prevention of aspiration
directs food and water to esaphagus
sits below your vocal cords
Term
what is false imprisonment?
Definition
false imprisonment is when you withhold someone from any physical movement or lessen thier conciousness with medication
Term
give some examples of false imprisonment
Definition
hold them against thier own will with restraints, medication (adivan) or locking pt in a room
Term
how do you give an intradermal injection?
Definition
10-15 degree angle
Term
what is an intradermal injection used for?
Definition
to give TB test
Term
how do you asses your client?
Definition
head to toe assesment
or a focused assesment
Term
what are normal vital signs?
Definition
BP: 110-130/60-85
T: 96.8 -100.4
P: 60-90
R: 12-20
Term
if the patient request last rights what should the nurse do?
Definition
ask whom they want to contact
Term
describe the structure of the ear
Definition
external ear
middle ear
internal ear
Term
how do you take an adults temperature from the ear?
Definition
pull pinna up and back
Term
how do you take a childs temperature from the ear?
Definition
pull pinna down and back
Term
how would you provide ear drops for an adult?
Definition
clean the pinna and meatus of ear canal warm med in hands then pull pinna up and back &instill the # of drops
Term
how would you provide ear drops for a child?
Definition
clean the pinna and meatus of ear canal warm med in hands then pull pinna down and back &instill the # of drops
Term
what does vitamin A do for the body?
Definition
bone growth
improves night vision
Term
what does vitamin c do for the body?
Definition
improves wound healing
collagen formation
promotes absorption
prevents scurvy
Term
why does our body need vitamin D and where does the body get vitamin Dfrom?
Definition
the sun,
promotes calcium and phophorous absorption
helps bone deminirilazation
deficiency would cause rickets and osteonolacia
Term
why does our body need protein?
Definition
repairs body tissue and regenerates it
Term
what does our body need to heal itself?
Definition
high protein and high carbs diet
Term
what provides energy for the body and which source is the best for the body to utilize?
Definition
protien, carbohydrates and fats
but the primary is cabohydrates
Term
how can the nurse advocate for a client?
Definition
try to meet the needs for the pt.
including advanced directives
Term
what are different types of cholesterol?
Definition
god cholesterol LDL bad cholesterol HDL
Term
which is the good cholesterol?
Definition
HDL helps clear the LDL cholesterol out of the blood and reduces risk for heart disease
Term
which is the bad cholesterol?
Definition
LDL most likely to clog blood vessels increasing your risk for heart disease
Term
what is the best position for a client to cough for a sputum collection and when is it mostly recommended?
Definition
1st thing in the morning and pt must be on high fowlers
Term
what can a nurse do to promote coughing for a client that is post-op & in pain to allow the client to cough forcefully?
Definition
give them a pillow teach them how to splint to prevent the incision from opening
Term
what should the nurse do to intervene for a client suffering from deppresion?
Definition
ask open ended questions and report it if pt is potention to harm them selves
Term
how can a nurse asses pain?
Definition
facial expressions of the client
grimmicing
using the faces scale
or 0-10 scale
Term
what does a nurse have to be aware with codeine?
Definition
its a respiratory depressant
constipation occurs
nausea
depresses the cough reflex
Term
what does the nurse need to be aware of with cough syrups with codeine added to them?
Definition
also increases chances for pnemonia and fluid retention
Term
name the IM injection sitesand how many MLS can be injected in each site
Definition
deltoid 2MLs
ventral gluteal 3mls
dorsal gluteal 3 mls
vastuas lateralas 3mls
Term
what are the lenghts and sizes of the needles used for IM injections?
Definition
1/2- 1 1/2 inches
Term
what is the normal protein intake?
Definition
0.8g/per kilo body weight
(not exceed 15-20% of your daily caloric intake)
Term
what is the normal fat intake?
Definition
20-30% or 30% of your daily caloric intake
- less than 7% saturated
- less than 8% poly
- less than 18% mono
Term
what is the normal carbohydrate intake?
Definition
50 to 100 grams/day
or 80% to 100% caloric intake
Term
what does the body use protein for?
Definition
healing
rebuilding
cellular regeneration and repair
Term
what does the body use fats for?
Definition
energy
supports for organs and bones
vitamin absorption
Term
what does the body use carbohydrates for?
Definition
energy only
Term
how does the nurse identify the client prior to giving medications?
Definition
name
check MAR
ask for thier name
look at id band
Term
what are the sixs rights of medication administration?
Definition
right medication
right route
right dose
right time
right client
right documentation
Term
what is fish oils used for by the body?
Definition
fish has omega -good for heart health
lowers cholesterol levels
Term
what should a nurse do for a crying patient?
Definition
listen why is pt. sad or depressed
talk to encourage feelings
Term
where is the center of gravity on a child, young adult and an elderly client?
Definition
young child: head
young adult: hips
olderly adult: upper tortal
Term
what does the body use calcium for and when a patient is recieving calcium what does the nurse need to be aware of?
Definition
bones
teeth
could cause kidney stones
if phosphorous is high calcium is low
if calcium is high, phophorous is low
Term
what does the nurse need to be aware of when administering enteric coated medications?
Definition
cant crush
(advil is an example of enteric coated orange pill)
absorbed slower in the small intestine
Term
if a patient refuses to take a bath what can the nurse do?
Definition
ask for the best time to take a bath
ask open ended questions to find out why they dont want a bath
ask for a perferred day or time of day
Term
what are some short term goals in relationship to nutrition?
Definition
ex client will gain 2 pounds in the next 2 days
2 days or a week is considered to be a short term goal
Term
what type of food would a client get for a low cholesterol diet?
Definition
low fat diet
no cheese or eggs
Term
what foods should be avoided by a client on a low sodium diet?
Definition
bacon
smoked meat
processed foods
prepacked foods
Term
a client with heart failure would be on what type of diet? and why? what food should this client avoid?
Definition
low sodium
low cholesterol
low fluids
amounts of cc watched
Term
what type of diet should a client with decubs be on?
Definition
protein diet for healing of wound
carbohydrates for body energy preserved
Term
when caring for a client with bed sores what should the nurse assess for?
Definition
drainage
color
depth
wide
lenght
secretions
odor
consistency
blood envolved
Term
describe the stages of decubitus ulcers and what they look like:
Definition
1: nonblanchin redness
2: skin breakdown, blister
3: subcutaneous
4: muscle and bone(necrotic tissue should be viewable)
Term
how would you asses the site for an IM injection?
Definition
scars
tattoes (recent)
muscle mass
swelling
Term
how can iron be given?
Definition
po
tablets
liquid
IM
IV
Term
children on liquid iron should take the medicine how?
Definition
30 min on benadril for alergic reaction, and drink it with a straw to prevent teeth from staning
Term
what liquid is perfered to be given with iron?
Definition
orange juice
Term
why is orange juice perfered to be given with iron?
Definition
orange juice helps absorption
Term
what can you do to make bad tasting medication more easier to take?
Definition
mix medication with something that will mix its taste
Term
what is chemical digestion?
Definition
chemical breakdown of the food into smaller particles such as amino acids, glucose, (fatty accids break down for for digestion)
Term
what should the nurse do for grieving spouse or family member when death of a loved one happens?
Definition
understand stages of grief
use theraputic communication
Term
describe the proper method of instilling a rectal suppository and what instructions will need to be given to the client?
Definition
ask if pt has had a bm
lay them to left lateral with upper leg flexed
for an adult insert 4 inches
for chil 1-2 inches
press buttocks
and let them sit for 5 minutes and ask them to retain the suppossitory for 30 min
Term
describe the proper method of instilling a vaginal medication and what instructions will need to be given to the client?
Definition
ask pt to hold suppository for 5-10 min
client should be on dorsal recumbent position
inspect vagina for any discharge odor before and after suppository
insert suppository 3-4 inches along the posterior wall
Term
why whould a client recieve calcium after a trasfusion?
Definition
since blood has been sitting in a bag for a while the calcium stays at the bottom of the bag and when transfusion occurs hardley any calcium gets transfused therefore calcium plays an important role in blood
Term
what does blood need when you have a blood transfusion to prevent it from clotting?
Definition
iron and calcium
Term
list the foods high in iron:
Definition
clams
oysters
mussels
pork
chicken
beef
liver
lean red meats
dark green leafy vegetables like kale, mustard anf green spinach
breakfast cereals
Term
what foods are high in protein?
Definition
most fish fillets
steak
pork
chicken
eggs
dairy
beans
nuts
soy
seeds
Term
what are the foods low in salt
Definition
fresh foods
fresh vegetables
unprocessed meats, fish and poultry
breads
cereals
mustard
spices
herbs
sugar
syrup
some chesses like monterrey mozzarella
milk non dairy creamer
Term
what are foods with low cholesterol?
Definition
lean cuts of meats and turkey without skin
all varieties of fish
egg whites
non fat dairy products
1% milk
whole grain breads
Term
what are opened ended questions and why are they perferred?
Definition
designed to encourage a full meaningful answer using the subjects own knowledge and or feelings
Term
what should the nurse do if a medication error happens?
Definition
tell the supervisor and complete an incident report
Term
what can a nurse do to minimize the chance of a medication error?
Definition
6 rights and 3 checks
Term
what should the nurse do if she hears someone breaching HIPAA?
Definition
try to stop them and report them with supervisor or charge nurse
Term
whats the proper use of a cane?
Definition
put cane on the strong side of the body and move cane along with the weak leg
Term
whats the proper use of crutches?
Definition
weight of the body should be on the arms rather than the armpits
pt should have 2-3 inches space available from armpit to the top of crutch
Term
whats the proper use of a walker?
Definition
walker should be 3-4 inches away from you feet so you could step inside walker and always move walker first
Term
what the proper use of a wheelchair?
Definition
pt uses arms to move the wheels in thier desired direction
Term
describe kegel exercises and what are they used for?
Definition
bladder used to strengthen the caginal mucosal
Term
whats the pulloccygeus muscle?
Definition
a muscle females have used to do kegel exercises
Term
what category does omega 3 fall under?
Definition
polyunsaturated fats
Term
what are the different types of suctioning?
Definition
nasal pharanx
oral pharanx
endotracheal
nasopherengeal
oral suction
Term
what does the nurse need to be aware of when suctioning?
Definition
the pt is deprived from breath when suctioning and suction for only 10-15 secs with 30-60 secs in between for rest
Term
what are the suction rates for wall unit?
Definition
infant 50-95
child 95-110
adult 100-120
Term
what are your gagues for im, subq, and id injections?
Definition
IM 20-23
subq 23-25
ID 25-27
Term
what is the suction rates for adults children and infants with a portable suction monitor?
Definition
infant 2-5
child 5-10
adult 10-15
Term
what are the sizes of the suctions for infants chidren and adults?
Definition
infants 5-8
children 8-10
adults 12-18
Term
how would the nurse measure NG tube for proper lenght for a client?
Definition
start from the nose
then to the back of the ear
and across to the stomach
Term
what is the lithotomy position used for?
Definition
papsmear
pelvic exam
speculum exam
Term
what are the different medication administration locations in the mouth?
Definition
buccal
sublingual
oral
Term
what are the 5 stages of grieving?
Definition
denial
anger
barganing
depression
acceptance
Term
whare are the different locations of the mucous membrane in regards to the renal system?
Definition
in the lining of the ureter in the bladder into the urethra
Term
whats the first thing a nurse should do in regards to medication administration?
Definition
use the 6 rights 3 checks
pt id band
chart
and ask pt thier name
Term
how would a nurse asses peripheral circulation?
Definition
check with capillary refils
color of pt skin
Term
is suction yonker sterile?
Definition
no
Term
if you need to suction 2 different tubes for the same client, how many suction tubes would you need and why?
Definition
you would 2 because its supposed to be sterile technique
Term
what do you do to provide oral care for an unconsious client?
Definition
side laying position to prevent aspiration and so drainage can come out, dont use any water because client can choke on water when unconcious
Term
what should a nurse asses if there is peripheral cyanosis?
Definition
cap refil
pulses
color of skin
skin temperature
compare pulses to extremities
Term
what should the nurse do for a pt that is angry?
Definition
theraputic communication
ask open ended questions
dont take personal
Term
when should a pt be ambulated after surgery?
Definition
immediately after doctors order
Term
what assesment should the nurse do prior to ambulating a patient after surgery?
Definition
asses conciousness
vital signs rom
make sure anesthesia is worn off and know strong and weakness side and make sure you know about any attached machines or any drainages the pt has
Term
why would a pt be put on a NPO diet?
Definition
to prevent aspirations for a client going to surgery
Term
when positioning a wheelchair for a client to transfer into it where should it be?
Definition
on the patients strong side at the foot of the bed or head of the bed depending on strong side
Term
wher should a foley urine collection bag be attached on to the bed?
Definition
on the frame of the bed so it could move along with the bed when moved
Term
how do you take orthostatic bp?
Definition
supine , wait 2-3 min take bp sit them up wait 1-2 minutes take bp, stand pt up wait 1-2 minutes take bp again
Term
describe how to count respirations
Definition
rise and fall of the chest, if having a hard time put hand on chest and feel for rise and fall of chest
Term
what assesments would you perform on a client that is in restariants and how often?
Definition
cap refill cyanosis
skin break down
pluses
rom (remove on hand at a time)every 2 hrs
Term
what do you do if pt is on retraints and thier capillary refills arent normal?
Definition
loosen restraints and asses pt again
Term
what precautions need to be taken when working with a client who has c-diff?
Definition
gloves
Term
where is c-diff found?
Definition
in stool
Term
what PPE do you wear if pt has diarrhea?
Definition
gloves
mask
gown and goggles incase of splash
Term
what is a vagal reaction?
Definition
drop in blood pressure and drop in heart rate
Term
what type of diet should a patient with diarrhea be placed on and why?
Definition
bananas
rice
toast
lots of water intake
soft and low residual diet to keep form stimulating the intestines
Term
what is the location and name of different pulse points in the body?
Definition
temporal
coratid
apical
brachial
radial
popiteal
femoral
post-tib
Term
what orders would you anticipate being ordered for a client about to have surgery?
Definition
NPO- nothing by mouth to prevent aspiration during surgery
Term
what does a clear liquid diet consist of?
Definition
water
tea
coffe
clear broths
gingerate
carbonated beverages
clear juices and plain gelatin
Term
what is ment by a full liquid diet?
Definition
anything solid that becomes liquid at room temerature such as water, icecream
Butter/cream/oil/margarine
Carbonated beverages
Cheese soup
Coffee/Tea
Fresh or frozen plain yogurt
Fruit drinks
Fruit punch
Honey/jelly/syrup
Term
what is a soft diet?
Definition
a diet that is easily chewed and digested for clients who have difficulty swallowing and chewing
Term
why would a client be put on an NPO status?
Definition
before anesthesia or surgery
until bowel sounds return to prevent vomiting
Term
list the different body plains and describe how they divide the body
Definition
frontal plane: runs from oneside of the body to the other separating body into front and back
sagital plane: runs from from to back seperate into left and right
transverse plane: divides body into a top and bottom
Term
what are the different client positioning in bed?
Definition
high fowlers
semi fowlers
dorsal recumbent
left lateral position
sims
supine
Term
whats anatomical position?
Definition
a standing position with legs slightly separated and face front arms to the side with palms faced foward
Term
what does RICE stand for in soft tissue or muscle injury?
Definition
Rest
Ice
Compression
Elevation
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