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NURS 221 Final Exam
"Atelectasis" - ansCollapse of the alveoli that prevents the normal exchange of O2 and CO "Diffusion" - ansExchange of respiratory gases in the alveoli and capillaries "Hemothorax" - ansThe collection of blood/fluid in the pleural cavity "Hypoxia" - ansInadequate tissue oxygenation at the cellular level -cyanosis is seen in late stages "Perfusion" - ansThe ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs "Pneumothorax" - ansThe collection of air in the pleural space "Ventilation" - ansThe process of moving gas in and out of the lungs "Work of Breathing" - ansThe effort required to expand/contract the lungs 2 Chamber System - ansThe fluid collector and water seal each have their own chamber (more accurate, used when more drainage is expected) Airborne Precautions - ans(measles, TB, varicella) -Requires: a respirator when caring for the patient, negative-airflow, private room Carminative enema - ansRelief from gaseous distention Cataplexy - ansA medical condition in which strong emotion or laughter causes a person to suffer sudden physical collapse though remaining conscious Central cyanosis - ansSeen in: -Tongue -Soft palate -Conjunctiva Chest tube - ansremoves air/fluid from the pleural space to prevent air from re-entering or to re-establishing intrapleural/intrapulmonic pressure Clean-voided (mid-stream) - anscollected during normal voiding, catheter or diversion using specimen cup
Cleansing enema - anspromote the complete evacuation of feces from the colon (tap water/soap spuds) Daily fluid intake - ans2300mL Diabetic footcare - ans-Assess feet and wash/dry daily -Apply lotion to the top/bottom of the foot, not between toes -Keep nails short with emery board -Wear properly fitting shoes -NEVER soak Doff - ans-Gloves -Goggles -Gown -Mask Don - ans-Gown -Mask -Goggles -Gloves Droplet Precautions - ans(pneumonia, rubella, mumps, sepsis, scarlet fever) -Requires: mask, private room or room with a patient who has the same disease Dry Chest Drainage System - ansUses automatic control valve (ACV) instead of water in suction chamber Durable Power of Attonery - ansA legal document that designates a healthcare proxy to make healthcare decisions for a patient should the be able to do so themselves Ear Drops - ansWarm if refrigerated -Assess external canal for discomfort and hearing -Patient is side-lying -Gently massage tragus after administration and have patient remain in position for 2- 3min Falls Risks - ans-Poor vision -Cognitive dysfunction -Urinary frequency -Physical condition/impaired mobility -Hx of falls -The elderly
-S/S: hypothermia, increased HR, hypotenstion ID needle - ans-25-27g -5-15 degree angle -3/8-5/8 inch IM injection sites - ans-Deltoid (2mL) -Vastis Lateralis (medial, lateral aspect of thigh) -Ventrogluteal (turn patient on side with knee flexed, palm on greater trochanter, index finger anteriosuperior iliac spine, middle finger along iliac crest) IM injections - ansZ track -Faster drug absorption -May give 2-5mL, typically not more than 3mL -Children and the elderly should only be given 2mL, infants only 1mL IM needle - ans-18-27g -90 degree angle -5/8-1 and half inch Impact of pain on vital signs - ansIn acute pain: BP, HR and resp. rate increase Informed Consent - ansA legal process by which a patient or the patient's legally appointed designee has given written permission for a procedure/treatment -consent is considered informed if the provider explains and the patient understands Informed Consent Includes - ansExplanation of -Why the patient need the procedure -The benefits and the risks -Other options Inhalers - ansshake before use -Instruct patient to inhale for 2-3 seconds, then hold for 10
-Use spacer if ordered, but only for pressurized-metered dose inhalers Insomnia - ansHabitual sleeplessness; inability to sleep -not feeling rested after sleeping Intradermal Injection - ans-Used for TB skin test on the inner arm -Slow absorption -(Bevel up) If no bleb, then not given correctly Isotonic, Hypertonic, Hypotonic - ans Living Will - ansA legal document that expresses the patient's wishes should they become incapacitated and facing end-of-life issues Medicated enema - ans- Kayexalate: for dangerously high serum potassium -used to reduce bowel bacteria before surgery Metabolic Acidosis - ansKidneys unable to excrete enough bicarbonate Metabolic Alkalosis - ansKidneys excrete too much bicarbonate Narcolepsy - ansParoxysmal attacks of sleep or excessive sleepiness while awake Nasal Canula - ans1-6 L/min Nasal Installation positions - ansPosterior Pharynx: patient supine, head tilted back Frontal/Maxillary sinuses: tilt head over edge or bed and tip to the effected side Ethmoid/Sphenoid processes: tilt head over edge of bed, support neck Nasal Installations - ansAssess nares/septum and palpate sinuses -Have patient breathe through mouth and administer towards mid-line Non-rebreather - ans10-15 L/min (delivers highest amount of O2) Nurse Practice Acts - ansState laws that determine and define the responsibility and scope of practice of nurse Nursing interventions for sensory alterations - ans-Promote function
-Transmission of pathogens PPE - ans-Hand hygiene before applying and after removing PPE -Tie gown at neck and waist -Leave personal items outside room R.A.C.E. - ansR-Rescue A-Alarm C-Confine E-Extinguish Range for Calcium - ans8.4-10. Range for Chloride - ans98- Range for Magnesium - ans1.5-2. Range for Phosphate - ans2.7-4. Range for Potassium - ans3.5-5. Range for Sodium - ans136- Range for total CO2 - ans22- Range for Venous bicarb. - ans24- Ranger for Arterial bicarb. - ans22- Rectal Suppository - ansDrape patient -Position patient in L Sims -Lubricate suppository, retract buttock and insert 4inches (adult) -Patient will hold position for 5 min Respiratory Acidosis - ansLungs unable to excrete enough CO Respiratory Alkalosis - ansLungs excrete too much CO Routine Urinalysis - ans(pH 4.6-8) -protein -glucose -ketones -specific gravity
-RBCs/WBCs -Bacteria -Casts -Crystals Seizure Precautions - ans-Always stay with the patient -Lower the patient to the floor if they are standing -Turn the patient on their side -Not the start and stop time of the seizure -Maintain patency of airway -Do not place anything in the patient's mouth -Provide privacy Single Chamber Unit - ansThe chamber serves as both the water seal and collection chamber Sleep apena - ansMore than 5 breathing cessations, each longer than 10 seconds, per hour during sleep. -Central -Obstructive -Combination Stages of sleep - ansStage 1 NREM: Light sleep, lasts a few minutes, easily awake Stage 2 NREM: Deeper, 10-20 min, longer to wake up Stage 3 NREM: Initial deep sleep, 15-30 min, difficult to wake up Stage 4 NREM: Delta sleep (deepest sleep), 15-30 min, very difficult to awaken REM: Vivid dreaming, longer with each sleep cycle, vital sign changes, cognitive restoration Standards of Care - ans-Legal guidelines for defining nursing practice and identifying minimum acceptable nursing care
- Outline the scope, function and role of the nurse -Reflect the values and priorities of the nursing profession Sterile Urine collection - anscollected from urinary catheter Subcutaneous Injection - ans-Abdomen is most used site -0.5-1mL
