Term
| Nursing action to facilitate expectorate of thick secretions |
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Definition
| offer liquids,percusion, chest pt, ambulate |
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Term
| nursing assessment for dyspnea |
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Definition
| auscultate, clear lung sound, air flow, odor of skin (cynosis) cips, ears, 02 saturation. |
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Term
| management of wrist IV site |
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Definition
| put brace so it wont bend, check for enema, 7'ps |
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Term
| evaluation of clients understanding of deep breathing & coughing instruction |
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Definition
| pt should demonstrate your teachings, take a deep breath exhale, the cough |
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Term
| teaching instructions about a low fat diet to a client who seems preoccupied |
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Definition
| get pt's attention, the start teaching, ask PT what he wants to eat, then suggest alternative MCH |
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Term
| Problems associated w/ excessive fat-soluble vitamin ingestion |
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Definition
| vitamin E, D, K, A (FAT SOLUABLE) the liver, kidney, renal. |
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Term
| positioning a client who is receiving a NGT feeding |
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Definition
| Semi-fowlers, 30-45 degree(above) aspiration precaution, elevate head. |
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Term
| Nurse's role in obtaining a client's consent |
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Definition
| explain everything if pt ask opinion bring it to the MD (objective) |
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Term
| correcct technique to clean dentures |
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Definition
| clean technique on removie it to the pt, put denture cup w/ name & room # paper towel, kidney basin to brush it, warm h20 |
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Term
| Instructions on when to perform breast self examination |
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Definition
| during shower, check for lump. |
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Term
| Nursing care of a client who is in protective isolation |
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Definition
| wash hands, PPE, standard, no flower, no fresh stuff, fruits, no sick family, children under 14. |
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Term
| 1st step in managing a fire in a clients waste basket |
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Definition
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Term
| client teaching related to orthostatic hypotension. |
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Definition
| they feel dizzy, fall risk, teaching, change position slowly or while standing up. Meds from MD |
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Term
| Foods restricted for a client who has edema |
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Definition
| NAS, (processed foods NO, no salt, no soysauce, ketchup, tomatoes) |
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Term
| nursing measure to increase a client's oral fluid intake |
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Definition
| Offer juices or whatever they like for as long as they're liq. PAGE 399 (box), call light pitcher in reach. |
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Term
| Food for vegetarian (VEGAN) |
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Definition
| beans, nuts, tofu, fruits, b12-vitamin supplement, fortified cereals. |
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Term
| nursing measure to increase client food intake |
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Definition
| assessment what kind of diet or kind of texure, know problem first offer variety of food. |
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Term
| Food to eliminate on a sodium-restricted diet |
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Definition
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Term
| Communication technique for client who misinterprets instruction |
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Definition
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Term
| nursing response to a client is confused |
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Definition
| simple Q's & clear tell who you are, eye contact, avoid distractions, turn off IV, radio ask for help if PT being combative, put pts safety. |
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Term
| Discussing the plan of care with a 78-yr old client |
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Definition
| explain everything to your pt, discuss with all the healthcare team, goal, attainable goals( REALISTIC), cant start NCP, but LVNS add up. |
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Term
| Result of a nurse who grimaces while changing a clients dressing |
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Definition
| damaging the pt's self esteem & Dignity |
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Term
| Communication technique to encourage a clients verbalization regarding fears |
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Definition
| assurance, no false assurance. |
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Term
| Calculation NOF clients fluid intake |
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Definition
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Term
| Rationale for applying a cold pack for possible fracture |
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Definition
| to prevent swelling.Warm-you want blood to flow |
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Term
| Need for a physician order prior to caring for a client who is diabetic |
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Definition
| 1-Accucheck, 2-MEDS, INSULIN, FOOD (DIET) |
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Term
| Nursing suggestion to stimulate a client’s senses in nursing home |
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Definition
| music, tv, activities, snacks |
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Term
| correct suctioning technique |
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Definition
| 10-|15| seconds, sterile technique, head up 45 degrees semi fowler face sideways. No suction when going in. |
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Term
| When to use surgical aceptic technique |
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Definition
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Term
| Type of client exercise exemplified by asking client to make fist. |
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Definition
| PT with muscle witness (stroke), CVA, nerve damage PT, [R][L] general weakness |
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Term
| expected outcome of the effective treatment for fluid volume excess |
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Definition
| edema ( not suppose to have) lung is clear. |
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Term
| Appropriate documentation of a wound & dressing |
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Definition
| site, dressing type, wound color, wound size, odor, pain, edema, pus, temp. |
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Term
| Nursing measure for a client who is bedridden and has edema |
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Definition
| Elevate the affected extremities higher than your c3, no sodium |
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Term
| Manifestation of high levels of stress |
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Definition
| V/S is elevated besides temp. psychological- [Forgetful]-decrease focus, irritability. |
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Term
| Assesment for thrombophebitis |
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Definition
| painful when you touch. S/Sx of infection, edema, wheeping (fluid oozing out) discoloration. |
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Term
| Appropriate hydration to promote wound healing |
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Definition
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Term
| Incorrect technique for collecting a stool speciment for the presence of OVA & parasites |
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Definition
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Term
| When to obtain a sputum culture |
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Definition
| gargle then cough, 1st thing morning |
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Term
| how to obtain urine speciment from foley CATH |
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Definition
| clamp it normal urine 100 ML/HR, clean alcohol on the port. |
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Term
| Nursing response to angry client |
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Definition
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Term
| Evidence of age-related hearing loss in an 80-year old client |
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Definition
| they cant hear, they ignore you, they get angry. |
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Term
| Nursing suggestion in increase a clients resistance for infection |
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Definition
| exercise, nutrition, fluid environment (clean), food, rest. |
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Term
| Nursing measure for a client who is immobilized |
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Definition
| q2h turning, liq (hydration), ROM, DIet, BOdy alignment, Contracture-Foot board, curl towel on hand, pillows, tennis shoes |
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Term
| Procedure necessitating that a nurse wear gloves |
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Definition
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Term
| Behavior modification for a 10 yr old to encourage exercise |
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Definition
| Encourage them to play, sports, behavioral modification. |
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Term
| Assisting a client to W/C |
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Definition
| LOCK W/C, bed. Stand on weak side, explain procedure, body mechanics. |
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Term
| Sequelae CVA w/ damage to [R] hemisphere |
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Definition
| [L] side weakness paralysis, weakness, let them have freedom to do self activities on [R] |
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Term
| Nursing management of a client who is preoperative and febrile |
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Definition
| Double check the temp x2, inform MD. |
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Term
| Manifestation of dehydration |
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Definition
| Increase temp, increase pulse, pain-headache,skin dry, no turgor, park color urine, decrease urine output, concentrated, oliguria, dry tongue, no tears. |
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Term
| client instruction related to low erythrocyte count |
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Definition
| diet green leafy vegetable, meat, iron,rest, vitamins, rest, exercise. |
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Term
| expected appearance of stool is in a client who has hemmorhoids |
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Definition
| Bright red blood, food high in fiber & fluid intake. |
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Term
| factor in elderly that increases the risk of burns |
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Definition
| Sense of touch,smell, decrease in the senses, poor mobility |
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Term
| Initial nursing action when changing a postoperative dressing |
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Definition
| Doctors order, explain to PT, (sterile procedure) |
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Term
| Client teaching related to lancet use for glucose monitoring |
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Definition
| Lancet= disposable (1time), for 1 PT only, throw on sharps |
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Term
| assessments for a Homan’s sign |
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Definition
| push the patient foot if they feel pain(then if its (+) they have OVT) heart (MI), PE(LUNG), BRAIN(CVA) |
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Term
| Leg exercises for client w/ a cast |
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Definition
| check capiliary refil, 7's then its only toes exercises, ROM, if itchy (HAIRDRYER) |
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Term
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Definition
| green leafy vegetables, peas & beans, depression: FOlate |
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Term
| Evaluation PT teaching related to bed controls |
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Definition
| demonstrate then have pt demonstrate |
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Term
| Analysis of the cause for having amber colored urine |
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Definition
| dehydration, poor urinary output, PH-ACIDIC. |
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Term
| Client teaching about vitamin C |
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Definition
| WATER SOLUBLE VITAMIN C, LOW VITAMIN C-BLEEDING OF GUMS, DECREASE = RICKETTS |
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Term
| FOod containing riboflavin |
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Definition
| Milk dairy product, whole grain, meat, eggs - Helps W/ Blood |
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Term
| Food combination to make a complete protein |
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Definition
| Beans, Legumes+green leafy vegetable= combination. Meat is a complete protein |
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Term
| Nursing action related to medication administration that had been prepared by another nurse |
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Definition
| DONT GIVE MEDS IF YOU DID NOT PREPARE IT |
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Term
| Amount of calories in 60 grams of proteins |
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Definition
| 240 calories, carbohydrate is absorb in Stomach. |
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Term
| Evaluation of a clients understanding for performing arm exercises for crutch walking. |
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Definition
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Term
| Correct administration of eye ointment OS |
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Definition
| From top pull bottom pour eye drops, put pressure on inner cantus so wont go to blood stream. Wash hands, clean blood stream technique. |
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Term
| Correct interpretation of food label information |
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Definition
| just look on the nutrional facts, based on 24 hours intake. 2000 calorie diet. |
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Term
| Nursing action when client says he/she is unsure of having surgery |
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Definition
| tell the MD to reexplain it again to the PT |
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Term
| Nursing action when client refuses a medication |
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Definition
| ask for a reason, encourage, find alternative, talk to the MD. |
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Term
| Nursing action for a client who is admitted for same day surgery |
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Definition
| DO your assessments. Subjective & objective, eaten? When? |
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Term
| Nursing response when a cliet is "angry at god" |
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Definition
| ask them why...(verbalize why) |
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Term
| Analysis of effectiveness of oxygen administration |
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Definition
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Term
| Nursing action for client who is immunosuppressed |
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Definition
| Reverse isolation, Protect them, no fresh fruit, dont visit someone sick, Dont play w/ kids, no flowers, pet. |
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Term
| Assessment of a 5- year old child who has difficulty sleeping |
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Definition
| ask them what makes them sleep, warm milk, soft music, assurance. maybe the lights |
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