Term
| What are some indications that trach sx should be performed? |
|
Definition
| Audible/noisy secretions, Coughing, Decreased O2 sat, Rhonci heard on auscultation |
|
|
Term
| What should you never document? |
|
Definition
|
|
Term
| Why is military time preferred by many facilities? |
|
Definition
| It avoids confusion because no number is ever duplicated and "AM/PM" is not needed |
|
|
Term
| What are the purposes of performing a physical assessment? |
|
Definition
| Evaluate pt's current physical condition, Detect early signs of developing health problems, Est. a baseline for future comparison, Evaluate pt's response to medical & nursing interventions |
|
|
Term
| What is the overall goal of physical assessment? |
|
Definition
| To obtain objective data about pt |
|
|
Term
| What is considered brisk, equal, & simultaneous constriction of both pupils after shining a light into 1 eye & then the other? |
|
Definition
|
|
Term
| What is considered purposeful observation? |
|
Definition
|
|
Term
| What is the most frequently used assessment technique? |
|
Definition
|
|
Term
| What are the steps for assessing the abdomen? |
|
Definition
| Inspect first, then auscultate, then palpate/percuss |
|
|
Term
| Why would you not want to palpate the stomach before listening to it? |
|
Definition
| Manipulation of the abdomen can alter bowel sounds |
|
|
Term
| What should all urine specimen containers be labeled with? |
|
Definition
| Pt's name, date & time of collection, nurses name/title who collected it |
|
|
Term
| How much urine needs to be collected for a specimen? |
|
Definition
|
|
Term
| What should you do with the specimen if it cannot be sent to the lab within 1 hour after collection? |
|
Definition
| Refrigerate the specimen or put it on ice |
|
|
Term
| Before sending the urine specimen to the lab, what should you place it in? |
|
Definition
|
|
Term
| What should a nurse always be wearing when handling urine? |
|
Definition
|
|
Term
| What is important when regarding a 240hour urine specimen? |
|
Definition
| That the urine within the collection bottle represents every drop of urine voided within 24 hours |
|
|
Term
| What do you do with the very first morning void at the beginning of a 24-hour ruine specimen collection? |
|
Definition
|
|
Term
| Where should specimen collection always be included? |
|
Definition
|
|
Term
| What are some general post procedures concerning the removal of a Foley cath? |
|
Definition
| ensure pt is comfortable with personal items has call light within reach, SR raised, bed in lowest position |
|
|
Term
| What should you document after the removal of a Foley cath? |
|
Definition
| Date/time, Procedure, Urine clarity/color/amt, Pt education given & pt response/understanding, How pt tolerated procedure |
|
|
Term
| What are some things you are to tell a pt when educating them after their Foley cath is removed? |
|
Definition
| May have some frequency & experience discomfort the first time you void, Call nurse the first time you void so output can be measured & recorded, Need for reporting prolonged discomfort or no voiding in 6-8 hours, Push fluids (unless contradicted) to flush bacteria out of urinary tract & ensure they can void |
|
|
Term
| What is involved when performing trach care on a pt? |
|
Definition
Cleaning the skin around stoma, changing dsg, & cleaning inner cannula
|
|
|
Term
| Before sx a trach, how long sould you hyperoxygenate? |
|
Definition
|
|
Term
| How long should sx while withdrawing last? |
|
Definition
|
|
Term
| Each sx procudure should not exceed ___ seconds total |
|
Definition
|
|
Term
| what is the maximum sx level for an adult? |
|
Definition
|
|
Term
| When sx a trach, how far should you insert the cath? |
|
Definition
| approx 4-5 inches or until resistance is felt |
|
|
Term
| What should you do if during sx, cath feels stuck/attached to tracheal wall? |
|
Definition
| stop sx & pull back 1 inch |
|
|
Term
| What should you do if pt becomes distressed during sx? |
|
Definition
1. stop procedure immediately
2.ask pt if he is okay
3.administer ventilation using manual resuscitation bag/O2 source as necessary
4. monitor VS |
|
|
Term
| when is sx performed on a pt? |
|
Definition
|
|
Term
| how often is trach care performed? |
|
Definition
|
|
Term
| why is trach care performed? |
|
Definition
| to keep secretions from becoming dried & narrowing or occluding the airway |
|
|
Term
| What are some indications that trach care should be perfomed? |
|
Definition
1. audible, noisy secretions,
2. coughing
3. decreased O2 sat
4. rhonci heard on auscultation |
|
|
Term
| What position should pt be placed in when performing trach care? |
|
Definition
|
|
Term
| When performing trach care, what is used to clean inside & outside of plastic cannula? |
|
Definition
|
|
Term
| Which way should you turn when replacing cannula during trach care? |
|
Definition
|
|
Term
| What do you use to rinse clean cannula in when performing trach care |
|
Definition
|
|
Term
| When performing trach care, what do you use to clean around the stoma? |
|
Definition
| applicator moistened with diluted peroxide |
|
|
Term
| What should you do after you have already cleaned one area around the stoma with an applicator & need to go back over it? |
|
Definition
| wipe same area again with another moistened applicator with saline |
|
|
Term
| When performing trach care, should you ever re-wipe over an area that has already been cleaned with the same applicator? Y/N |
|
Definition
|
|
Term
| When performing trach care, where should you place the stoma dsg? |
|
Definition
| beneath flanges & outeer cannula of trach tube |
|
|
Term
| When performing trach care, how should you go about changing the trach ties? |
|
Definition
| Wait to remove old ties until new ones are in place & tie securely |
|
|
Term
| What stimulates COPD pt's to breathe? |
|
Definition
low O2 levels
(hypoxic drive to breathe) |
|
|
Term
| Which breathing technique is most desirable for pt's with COPD? |
|
Definition
|
|
Term
| What is a breathing technique that helps clients eliminate more than the ususal amt of CO2 from teh lungs? |
|
Definition
|
|
Term
| What type of O2 delivery system is ideal for hypoxic pt's with COPD? |
|
Definition
|
|
Term
| What can depress breathing in a pt with COPD? |
|
Definition
| giving high % of O2; no more than 2-3 L is safe unless pt is mechanically ventilated |
|
|
Term
| How does one perform pursed-lip breathing? |
|
Definition
1. inhale slowly thru nose while counting to 3
2. purse lips as though to whistle
3. contract abdominal muscles
4. exhale thru pursed-lips for a count of 6 or more |
|
|
Term
| What is a technique for deep breathing using a calibrated device? |
|
Definition
|
|
Term
| What are some reasons for using an incentive spirometer? |
|
Definition
- helps nurse evaluate effectiveness of pt's breathing efforts
- encourages pt to reach a goal-directed vol of inspired air |
|
|
Term
| What is a technique for evacuating air or blood from the pleural cavity? |
|
Definition
| water-seal chest drg system |
|
|
Term
| What is used to help restore negative intrapleural pressure & re-inflate lungs? |
|
Definition
| water-seal chest drg system |
|
|
Term
| Why is a chest tube inserted? |
|
Definition
| to remove air/blood from pleural cavity when lung is deflated as a result of a trauma such as a blunt force to the chest, stabbing, or gunshot |
|
|
Term
| What is a chest tube connected to? |
|
Definition
| drg system with 3 chambers |
|
|
Term
| Which chest tube compartment collects blood or acts as an exit route for air? |
|
Definition
|
|
Term
| Which chest tube compartment is known as a water-seal? |
|
Definition
|
|
Term
| What is the function of the 2nd chest tube compartment? |
|
Definition
| to prevent air from re-entering pleural space |
|
|
Term
| Should there be any tidaling in the 2nd chest tube compartment? Y/N |
|
Definition
|
|
Term
| What would bubbling in the 2nd chest tube compartment indicate? |
|
Definition
|
|
Term
| Which chest tube compartment is responsble for sx? |
|
Definition
|
|
Term
| Why is sx applied within the 3rd chest tube compartment? |
|
Definition
|
|
Term
| What must you do if you are going to separate a chest tube from the drg system? |
|
Definition
|
|
Term
| Why should you oly keep chest tube & drg system separated very briefly? |
|
Definition
| a tension pneumothorax can develop |
|
|
Term
| When working with a chest tube drg system, what should always be kept @ the bedside? |
|
Definition
|
|
Term
| Where should the Pleur-evac be placed for the chest tube/drg system? |
|
Definition
| always lower than the chest |
|
|
Term
| What is the slowest & least dependable rate of absorption & why? |
|
Definition
-oral route
- due to frequent changes of GI environment |
|
|
Term
| When should you avoid giving MEDs via oral route? |
|
Definition
- if pt is vomiting, unconscious, or likely to aspirate
- if pt has gastric/intestinal sx or difficulty swallowing |
|
|
Term
| What are small, cylindrical gelatin containers that hold dry powder, granules, or liquid medicinal agents? |
|
Definition
|
|
Term
| What is a convenient method for giving drugs with an unpleasant odor or taste? |
|
Definition
|
|
Term
| What provides a gradual, but continuous relesase of drug because granules inside capsule dissolve @ different rates? |
|
Definition
|
|
Term
| What are flat disks containing a medical agent in a suitably flavored base such as hard sugar candy or the combo of sugar with sufficient mucilage to give it form? |
|
Definition
|
|
Term
| Why are lozenges held in mouth? |
|
Definition
| to dissolve slowly, thus releasing the therapeutic agents |
|
|
Term
| What is an obsolete dosage form that refers to tablets & capsules? |
|
Definition
|
|
Term
| What are dried powdered drugs that have been compressed into smaller disks? |
|
Definition
|
|
Term
| What are tablets with an indentation that may be used to divide the dosage? |
|
Definition
|
|
Term
| Why must enteric-coated tablets never be crushed? |
|
Definition
| the active ingredients will be released prematurely & be destroyed in the stomach |
|
|
Term
| What are clear liquids that are made of drugs dissolved in alcohol & water? |
|
Definition
|
|
Term
| When is an elixir primarily used? |
|
Definition
| when the drug will not dissolve in water alone |
|
|
Term
| What are tablets containing a special coating that resist dissolution in acidic pH of the dtomach but are dissolved in the alkaline pH of the intestines? |
|
Definition
|
|
Term
| What are dispersions of small dropplets of water in oil/oil in water? |
|
Definition
|
|
Term
|
Definition
| to mask bitter tastes or provide better dolubility to certain drugs |
|
|
Term
What are liquid dosage forms that contain solid, insoluable drug particles dispersed in a liquid base?
|
|
Definition
|
|
Term
| Why should suspensions be shaken well before administration? |
|
Definition
| to ensure through mixing of particles |
|
|
Term
| What is a sm paper cup for transporting medication forms such as capsules of tablets to the pt to prevent contamination from handling? |
|
Definition
|
|
Term
| What is a glass/plastic container that has 3 scales for the measurement of liquid medications? |
|
Definition
|
|
Term
| When using a medicine cup, where should you read the volume of the liquid? |
|
Definition
|
|
Term
| What is a meniscus on a medicine cup? |
|
Definition
| the concave or holowed curvature on the surface of the solutio |
|
|
Term
| Should liquid medications in a medicine cup be read at the highest or lowest point of the concaved curve? |
|
Definition
|
|
Term
| Where should you place the medicine cup before reading the volume of liquid? |
|
Definition
|
|
Term
| Which medication is always administered to a pt first? |
|
Definition
|
|
Term
| When do you document your medication administration on the MAR? |
|
Definition
| after administering medication |
|
|
Term
| Should you initial/document on MAR prior to pt actually taking the medication? Y/N |
|
Definition
|
|
Term
| What should nurse be aware of prior to giving any medications to a pt? |
|
Definition
| what nursing interventions must be performed prior to their administration |
|
|
Term
| What are adhesive structures that allow the tablet to stick together? |
|
Definition
|
|
Term
| What are substances that encourage dissolution in body fluids? |
|
Definition
|
|
Term
| What are required for effective manufacturing? |
|
Definition
|
|
Term
| Whar are inert ingredients that make the tablet size convenient? |
|
Definition
|
|
Term
| What are the 8 routes for topical medication? |
|
Definition
1. cutaneous
2. opthalmic
3. otic
4. nasal
5. sublingual
6. buccal
7. vaginal
8. rectal |
|
|
Term
| Why should you always put on gloves while administering topical applications? |
|
Definition
| because some medicines can be absorbed through the skin |
|
|
Term
| What is the term used to describe lotion, ointment, gel, or cream that is administered by rubbing into the skin? |
|
Definition
|
|
Term
| What is the term used to describe a drug that is incorporated into a patch or paste? |
|
Definition
|
|
Term
| Where are transdermal applications applied? |
|
Definition
| to an area with adequate circulation, usually the upper body (above the waist) |
|
|
Term
| When administering a transdermal application, should you change sites with every application? Y/N |
|
Definition
|
|
Term
| How long might it take for some birth control disks to being working? |
|
Definition
|
|
Term
| How often are patches such as Fentanyl replaced? |
|
Definition
|
|
Term
| How long might it take for some patches such as Fentanyl to begin working? |
|
Definition
|
|
Term
| What must you be sure to do when you apply patches? |
|
Definition
| date & initial when you apply them |
|
|
Term
| What should be done along with removing an old patch when applying a new one? |
|
Definition
| clean area well with soap and water |
|
|
Term
| What contains a drug within a thick base that is not rubbed into the skin? |
|
Definition
|
|
Term
| What is Nitroglycerine ointment used for? |
|
Definition
|
|
Term
| What type of topical application refers to applying drugs to the mucous membranes of one of both eyes (conjunctival sac)? |
|
Definition
|
|
Term
| What should you do when administering an opthalmic application to avoid damaging the eyeball? |
|
Definition
| never drop application directly on eyeball |
|
|
Term
| Why might otic applications be used? |
|
Definition
| to moisten cerumen or treat a local bacterial or fungal infection |
|
|
Term
| How long must you wait between instilling different types of eye drops? |
|
Definition
|
|
Term
| Which 2 types of topical applications require you to warm the solution to room temperature for comfort? |
|
Definition
|
|
Term
| How do you straighten the ear canal of an adult? |
|
Definition
|
|
Term
| How do you straighten the ear canal of a child? |
|
Definition
|
|
Term
| What instructions must you follow before instilling an otic solution in to both ears? |
|
Definition
| turn head to opposite side, have pt lie still for 5 minures after administration, wait 15 minutes before instilling into the opposite ear |
|
|
Term
| What procedures should you follow when instilling a nasal application? |
|
Definition
| have pt tilt head back or place a rolled towel under the neck, instruct then to breathe thru their mouth (not hold their breath) |
|
|
Term
| What causes "rebound effect" in pt's using nasal decongestant sprays? |
|
Definition
| overuse of spray -- may use plain saline instead |
|
|
Term
| What is the term used for applying medications under the tongue? |
|
Definition
|
|
Term
| What is the term used to describe placing medications against the mucous membrane of the inner cheek (between cheek & gum) |
|
Definition
|
|
Term
| What are some common S/S of yeast infection? |
|
Definition
| white, cheese-like, odorous discharge |
|
|
Term
| What are some conditions in which douching may be needed? |
|
Definition
| if there is an infection or discharge present |
|
|
Term
| Are douches necessary for female hygeine? Y/N |
|
Definition
|
|
Term
| When should douches not be used? |
|
Definition
|
|
Term
| What should you instruct pt to do prior to vaginal application administration? |
|
Definition
|
|
Term
| When inserting a vaginal application, how far should you insert the applicator into the vagina? |
|
Definition
|
|
Term
| What are 2 types of inhalers? |
|
Definition
1. metered dose
2. dry powder/turbo inhaler |
|
|
Term
| Which kind on inhaler contains medicine that is under pressure? |
|
Definition
|
|
Term
| Which type of inhaler contains a powder that is distributed upon inhalation as a propeller in device spins? |
|
Definition
|
|
Term
| What must the pt have in order to use a dry powder/turbo inhaler? |
|
Definition
|
|
Term
| How long should you wait between each medication if more than 1 inhaled medication is to be administered? |
|
Definition
|
|
Term
| What can inhaled bronchodilators cause? |
|
Definition
|
|
Term
| What should you always monitor in pt's using inhaled bronchodilators? |
|
Definition
|
|
Term
| why is military time preferred in many facilities? |
|
Definition
| helps to avoid confusion because no number is ever duplicated and AM/PM is not needed |
|
|
Term
| What are used to shorten the length of documentation? |
|
Definition
|
|
Term
| are abbreviations a priority? |
|
Definition
|
|
Term
| what should you do if you do not know the proper abbreviation? |
|
Definition
|
|
Term
| what is the purpose of TJC issuing a "do not use" list? |
|
Definition
| to protect the safety of clients |
|
|
Term
| Who required HC agencies to safeguard written, spoken, & electronic health info? |
|
Definition
|
|
Term
| according to HIPPA, what must all pts be given? |
|
Definition
| a written statement of how their info will be used |
|
|
Term
| according to HIPPA, what type of disclosure should facilities use? |
|
Definition
|
|
Term
| what type of disclosure would include giving only information that needs to be known in order to take care of a specific issue at hand? |
|
Definition
|
|
Term
| what type of dusclosure gives exemptions when agencies can release private health info without pt's prior authorization? |
|
Definition
|
|
Term
| What are some exemptions for beneficial disclosure? |
|
Definition
1. reporting vital statistics
2. informing USDA of adverse reactions to drugs/medical devices
3.disclosing info for tissue donation
4. notifying public health dept about communicable diseases |
|
|
Term
| what is a method of improving pt outcomes by continuing to ensure they have the services they need when discharged so they don't return for the same problem or are placed in facilities if can't return home |
|
Definition
|
|
Term
| when does discharge planning begin? |
|
Definition
|
|
Term
| what is the goal of the discharge process?to keep pt for as short of time as possible |
|
Definition
|
|
Term
| when does authorization for discharge occur? |
|
Definition
| when MD examines pt, says they are well enough to leave & writes an order for their discharge |
|
|
Term
| Why are discharge instructions so important? |
|
Definition
| they can have legal consequences |
|
|
Term
| What do nurses need to ensure concerning the pt during discharge instructions? |
|
Definition
| that pt has knowledge, skills, & resources to ensure they can care for themselves after discharge |
|
|
Term
| What occurs when pt's leaves before physician authorizes their discharge? |
|
Definition
|
|
Term
| what is a reason that a pt might sign out AMA? |
|
Definition
| because he is unhappy with an aspect of care |
|
|
Term
| what should the nurse do when a pt is trying to sign out AMA? |
|
Definition
| call nursing supervisor & MD to notify them |
|
|
Term
| Who does an AMA form protect & how? |
|
Definition
| releases hospital, staff, & MD from any complications that occur after pt leaves the building |
|
|
Term
| What should you do if pt refuses to sign AMA form? |
|
Definition
| let them leave, but note in medical record that they were given the form but refused to sign it & have a witness sign, as well |
|
|
Term
| when educating a person that has a hx constipation, the nurse needs to instruct him to eat more of what tpes of foods? |
|
Definition
1. raw nuts
2. nuts
3. vegetables |
|
|
Term
| what pt position is best for administering an enema? |
|
Definition
|
|
Term
| what is one of the greatest challenges in Ostomy care? |
|
Definition
| preventing skin breakdown for pt |
|
|
Term
| what is a typical symptom of fecal impaction? |
|
Definition
|
|
Term
| what is unintentional tort? |
|
Definition
| a situation that results in an injury although the person did not intend to cause harm |
|
|
Term
| if a pt wishes to leave the hospital without being medically discharged, what would be an appropriate nursing action? |
|
Definition
| notify Dr & have pt sign AMA form |
|
|
Term
| what defines the legal scope of nursing practice? |
|
Definition
|
|
Term
| what SC agency is responsible for the Nurse Practice Act? |
|
Definition
| The State Board of Nursing |
|
|
Term
| what is an example of an open-ended question? |
|
Definition
| "what does it feel like?" |
|
|
Term
| what skin change is a common finding in dark-skinned people? |
|
Definition
|
|
Term
| which american culture is at high risk for sickle cell anemia? |
|
Definition
|
|
Term
| what would be an appropriate long-term diet from an elderly pt that has difficulty chewing? |
|
Definition
|
|
Term
| what are some food sources that will help a pt with a lactace deficienct obtain calcium? |
|
Definition
1. green, leafy vegetables
2. whole grains
3. dried peas
4. beans
5. canned sardines |
|
|
