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NR226 NR-226 Final Exam Review & Study Guide (Latest Update) Fundamentals [Patient Care], Exams of Nursing

NR226 NR-226 Final Exam Review & Study Guide (Latest Update) Fundamentals [Patient Care]

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2023/2024

Available from 07/08/2024

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Download NR226 NR-226 Final Exam Review & Study Guide (Latest Update) Fundamentals [Patient Care] and more Exams Nursing in PDF only on Docsity! NR-226 Final Exam Review & Study Guide • Review your nursing process, priorities, and safety o ADPIE ▪ Assessment, Diagnosis, Planning, Implementation, Evaluation o Priorities ▪ First-level Priority ▪ ABC’s (Airway, Breathing, Circulation), and Vital Sign concerns ▪ Second-level Priority ▪ Requiring your prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security). ▪ Third-level Priority ▪ Problems with lack of knowledge, activity, rest, or family coping o Patient Safety First ▪ Ex. In case of fire, get patient out of the room first; keep patients with high fall risk near nursing station • Review calculations (ALL) o 1 oz = 30 ml o 1tbs = 15 ml o 1 tsp = 5 ml o 1 cup = 8 oz o 1 kg = 2.2 lb • Review pain management, PCA pumps o Patient-controlled analgesia (PCA) ▪ Medication delivery system that allows clients to self administer safe dose of opioids ▪ Small, frequent dosing ensures consistent plasma levels. ▪ Clients have less lag time between identified need and delivery of medication, which increases their sense of control and can decrease the amount of medication they need. ▪ Morphine, hydromorphone, and fentanyl are typical opioids for PCA delivery ▪ Clients should let the nurse know if using the pump does not control the pain NR-226 Final Exam Review & Study Guide ▪ To prevent inadvertent overdosing the client is the only person who should push the PCA button. • Review expected physiological changes for older adults o Integumentary ▪ Decreased skin turgor, subcutaneous fat, and connective tissue (dermis), which leads to wrinkles and dry, transparent skin ▪ Loss of subcutaneous fat, which makes it more difficult for older adults to adjust to cold temperatures. ▪ Thinning and graying of hair, as well as a more sparse distribution ▪ Thickening of fingernails and toenails o Cardiovascular/ Pulmonary ▪ Decreased chest wall movement, vital capacity, and cilia, which increases the risk for respiratory infection ▪ Reduced cardiac output ▪ Decreased peripheral circulation ▪ Increased blood pressure o Neurosensory ▪ Slower reaction time ▪ Decreased touch, smell, and taste sensations ▪ Decreased saliva production ▪ Decline in visual acuity ▪ Decreased ability for eyes to adjust from light to dark leading to night blindness, which is dangerous when driving. ▪ Inability to hear high-pitched sounds (Presbycusis) ▪ Reduced spatial awareness o GI ▪ Decreased digestive enzymes ▪ Decreased intestinal motility, which can lead to increased risk of constipation ▪ Increased dental problems o Neuromuscular ▪ Decreased height due to intervertebral disk changes ▪ Decreased muscle strength and tone ▪ Decalcification of bones ▪ Degeneration of joints o Genitourinary ▪ Decreased bladder Capacity NR-226 Final Exam Review & Study Guide ▪ Surgery • Complications ▪ Aspiration of gastric content ▪ Adenocarcinoma of esophagus ▪ Esophagitis ▪ Barrett’s esophagus ▪ Strictures • Teaching ▪ Maintain weight below BMI of 30 (Normal Range 18.5- 25) ▪ Stop smoking ▪ Limit or avoid alcohol and tobacco use ▪ Eat a low-fat diet ▪ Avoid foods that lower the LES (Lower esophageal sphincter) pressure (fatty and fried foods, chocolate, caffeinated beverages, peppermint, spicy foods, tomatoes, citrus fruits, and alcohol) ▪ Avoid eating or drinking 2 hr before bed ▪ Avoid tight-fitting clothes ▪ Elevate the head of the bed 6 to 8 inches ▪ ADVISE PATIENT WHEN SLEEPING, TO LAY ON RIGHT SIDE • Risk Factors ▪ Obesity ▪ Older age (delayed gastric emptying and weakened LES tone) ▪ Sleep apnea ▪ NG Tube o • Review bowel assessment, constipation, diarrhea o Bowel assessment: • Inspect → Auscultate → Percuss → Palpate o Constipation • Monitor for ▪ Abdominal bloating ▪ Abdominal cramping ▪ Straining at defecation NR-226 Final Exam Review & Study Guide ▪ Presence of dry, hard feces at defecation. ▪ Irregular bowel movements, or reduced frequency from client’s normal pattern. ▪ hypoactive bowel sounds • Nursing Care ▪ Increase fiber and water consumption (unless contraindicated) before more invasive interventions ▪ Give bulk-forming products before stool softeners, stimulants, or suppositories ▪ Enemas are last resort for stimulating defecation. o Diarrhea • Monitor for ▪ Frequent loose stools ▪ Abdominal cramping ▪ Stool of water consistency ▪ hyperactive bowel sounds • Nursing Care ▪ Help determine and treat the cause ▪ Administer medications to slow peristalsis ▪ Provide perineal care after each stool, and apply moisture barrier ▪ After diarrhea stops, suggest eating yogurt to help re- establish an intestinal balance of beneficial bacteria • Review acid-base imbalances, signs/symptoms (see chart) o Normal Values ▪ pH = 7.35 - 7.45 ▪ PaCO2 = 35 - 45 ▪ HCO3 = 21- 28 o Respiratory Acidosis : HYPOventilation ▪ Results from: ▪ Brain tumors, cerebral aneurysm, stroke, or overhydration, trauma, or neurologic diseases ▪ Inadequate chest expansion due to muscle weakness, pneumothorax/ hemothorax, flail chest, obesity, sleep apnea, tumors, or deformities. ▪ Airway obstruction from neck edema, localized lymph node enlargement, foreign bodies or mucus ▪ Alveolar-capillary blockage secondary to a pulmonary embolus, thrombus, acute respiratory distress NR-226 Final Exam Review & Study Guide syndrome, chest trauma, drowning, or pulmonary edema ▪ Inadequate mechanical ventilation ▪ Results in ▪ Increase CO2 ▪ Decreased pH ▪ S&S ▪ Vitals: Tachycardia, tachypnea, increased blood pressure ▪ Dysrhythmias ▪ Anxiety, Irritability, confusion ▪ Ineffective shallow, rapid breathing ▪ Pale or cyanotic ▪ Seen in clients with COPD, pulmonary disease, sleep apnea, and obesity. o Respiratory Alkalosis: HYPERrventilation ▪ Results From: ▪ Hyperventilation due to fear, anxiety, intracerebral trauma, salicylate toxicity, or excessive mechanical ventilation ▪ Results in: ▪ Decreased CO2 ▪ Increased pH ▪ S&S ▪ Vitals: Tachypnea ▪ Inability to concentrate, numbness, tingling, tinnitus, and possible loss of consciousness ▪ Tachycardia, ventricular and atrial dysrhythmias ▪ Rapid, deep respirations o Metabolic Acidosis ▪ Results From: ▪ Excess production of hydrogen ions ▪ Diabetic Ketoacidosis (DKA) ▪ Lactic Acidosis ▪ Heavy exercise ▪ Seizure Activity ▪ Hypoxia ▪ Excess intake of acids ▪ Ethyl alcohol ▪ Methyl alcohol NR-226 Final Exam Review & Study Guide osmolality are administered through central IV catheter and low osmolality are administered peripherally. ▪ The goal is to correct or prevent fluid and electrolyte disturbances ▪ High in sugar ▪ Allows for direct access to vascular system and permits continuous infusion of fluids over time ▪ Change every 24 hours due to increased sugar content and clogging ▪ If patient complains of nausea - slow down the feeding ▪ You want to gradually build up feeding to prevent HYPERglycemia ▪ S&S: Polyuria, Polydipsia, Polyphagia ▪ If interrupted HYPOglycemia can occur (Taper down - Don’t just stop.) ▪ S&S: Diaphoresis, shakiness, confusion, Pallor, Polyphagia, ▪ Complications of TPN ▪ Infection & Sepsis: Indicated by fever or elevated WBC; due to contaminated catheter, solution, or long-term indwelling catheter. ▪ Metabolic Complications: Hyperglycemia, Hypoglycemia, Hyperkalemia, Hypophosphatemia, Hypocalcemia, Dehydration, Fluid overload. ▪ Mechanical Complications: Catheter misplaced causing pneumothorax or hemothorax (evidenced by SOB, diminished or absent breath sounds), arterial puncture, catheter embolus, air embolus, thrombosis, obstruction ▪ Nursing Actions ▪ Monitor redness around catheter, fever,chills, elevated WBC ▪ Use strict aseptic technique ▪ Monitor blood glucose ▪ Administer sliding scale insulin to TPN to treat hyperglycemia ▪ Administer dextrose (D10) to TPN to treat hypoglycemia ▪ Monitor I&O, weight • PEG (percutaneous endoscopic gastrostomy): percutaneous endoscopic gastronomy -- a flexible feeding tube is placed through the abdominal wall and into the NR-226 Final Exam Review & Study Guide stomach. It allows nutrition, fluids, and medications to be directly administered into the stomach; bypassing the mouth and esophagus. o Common in stroke patients o Seen in patients who need long-term care o Seen in patients who have difficulty swallowing o Complications ▪ infection ▪ aspiration ▪ bleeding and perforation • NGT ( Nasogastric Tube): put the patient in high fowler's position to help prevent aspiration. measure tube from tip of nose to the ear and then down to the end of the sternum, o Curve the tube around finger for flexibility and lubricate (7.5-10 cm) 3-4 inches with water soluble lubrication o Verify placement by testing the ph of gastric content (1- 4) o Verify placement by also using a chest x-ray o Irrigate with saline • Urinary catheterization: ensure there is no iodine or latex allergy o Males : positioned supine with legs slightly abducted ▪ Retract foreskin and cleanse the meatus with iodine in a circular motion ( 3 times with different cotton balls) ▪ Have pt bare down then insert catheter 7-9 inches or until flash of urine is seen ▪ Then replace foreskin and secure tubing to inner thigh o Females: position supine ( cant remember name of position) with legs bent and abducted ▪ Separate labia with non dominant hand and cleanse side away from you, then the side close to you and then down the middle. ▪ As they bear down advance catheter until flash of urine is seen and then go another 1-2 inches ( 2.5- 5 cm) • Isolation precautions: NR-226 Final Exam Review & Study Guide o Contact ▪ Gloves and Gown ▪ A private room or room with patients with the same infection ▪ EX. MRSA, Herpes Simplex, Impetigo, Scabies, Wound infection, Shingles, bags/tubes, fluid drainage o Airborne ▪ N95 and negative pressure room (air moves from in the room to outside environment). ▪ Private Room ▪ EX. Tuberculosis, Varicella, Measles o Droplet ▪ Face Masks ▪ A private room or room with patients with the same infection ▪ EX. Flu, Scarlet Fever, Rubella, Pertussis, Mumps, Pneumonia o Protective ▪ Positive pressure room ▪ Private room ▪ Face mask for patient when out of room ▪ EX. Stem cell transplant, Immunocompromised • Review informed consent (who is responsible for what), HIPAA o Legal process by which a client or client’s legally appointed designee has given written permission for a procedure or treatment. o Roles ▪ Nurse ▪ Witness informed consent ▪ Ensure that provider gace the client the necessary information. ▪ Ensure that the client understood the information and is competent to give informed consent. ▪ Have client sign informed consent document. ▪ Notify provider if the client has more questions or appears not to understand any of the information. The provider is then responsible for giving clarification ▪ Document questions the client has, notification of the prover, reinforcement of teaching, and use of an interpreter. NR-226 Final Exam Review & Study Guide ▪ Provide means of good hygiene and elimination ▪ Monitor vitals ▪ Offer range of motion exercises of extremities ▪ Pad bony prominences to prevent skin breakdown ▪ Use a quick release knot (loose knot that is easy to remove) to tie the restraints to the bed frame where they will not tighten when raising or lowering the bed. ▪ Make sure restraints are loose enough for range of motion and there is enough room to fit 2 fingers between the restraint and the client ▪ Remove or replace restraints frequently to ensure good circulation to the area and allow full range of motion to the limbs ▪ Regularly determine the need to use the restraints ▪ Never leave the alone without the restraints. ▪ Obtaining orders ▪ Provider must conduct a face-to-face assessment within 1 hour of application ▪ In Emergency situations where there is an immediate risk to the client or others, the nurse may place restraints on the client. The nurse must obtain a prescription from the provider as soon as possible according to the facility’s policy (Usually within 1 hour). ▪ Prescription must include type, reason, location, duration, and warranting behavior ▪ Prescription only allows ▪ 4 hr of restraints for an adult ▪ 2 hrs for clients ages 9 to 17 ▪ 1 hr for clients younger than age 9. ▪ Providers may renew these prescriptions within a maximum of 24 consecutive hours. ▪ Cannot be a PRN prescription ▪ Indications ▪ Confused ▪ Wandering ▪ Fall risk ▪ Disoriented ▪ Removing medical devices NR-226 Final Exam Review & Study Guide ▪ Threat to themselves or others ▪ Discontinuing ▪ DC at earliest possible time or reassess after 24 hours o IMMOBILITY o AMBULATION o ISOMETRIC EXERCISES. • Nursing ethics and torts o TORTS ▪ Negligence: ▪ A nurse fails to implement safety measures for a client at risk ▪ Malpractice (Professional Negligence): ▪ A nurse administers a large dose of a medication due to a calculation error. The client has a cardiac arrest and dies ▪ Breach of Confidentiality ▪ A nurse releases client’s medical diagnosis to member of the press. ▪ Defamation of Character ▪ A nurse tells a coworker that she believes the client has been unfaithful to her partner ▪ Assault: ▪ The conduct of one person makes another person fearful/ and apprehensive ▪ A nurse threatens to place a NG tube in a client who is refusing ▪ Battery ▪ Intentional and wrongful physical contact with a person that involves an injury or offensive contact ▪ A nurse restrains a client and administers an injection against her wishes ▪ False Imprisonment ▪ A person is confined or restrained against his will. ▪ A nurse uses restraints on a competent client to prevent leaving the health care facility. o ETHICS ▪ Basic Principles of Ethics ▪ Advocacy ▪ Support of clients’ health, wellness, safety, and personal rights, including privacy NR-226 Final Exam Review & Study Guide ▪ Responsibility ▪ Willingness to respect obligations and follow through on promises ▪ Accountability ▪ Ability to answer for one’s own actions ▪ Confidentiality ▪ Protection of privacy without diminishing access to high-quality care ▪ Ethical Principles for Client Care ▪ Autonomy ▪ The right to make one’s own personal decisions, even when those decisions might not be in that person’s own best interest. ▪ Beneficence ▪ Action that promotes good for others, without any self interest. ▪ Fidelity ▪ Fulfillment of promises ▪ Justice ▪ Fairness in care delivery and use of resources. ▪ Nonmaleficence ▪ A commitment to do no harm ▪ Veracity ▪ A commitment to tell the truth • Kubler-Ross’s stages of grief, types of losses o Kubler-Ross Model ▪ Denial ▪ Client has difficulty believing terminal diagnosis or loss ▪ Anger ▪ The client lashes out at other people or things ▪ Bargaining ▪ The client negotiations for more time or a cure. ▪ Depression ▪ The client is overwhelmingly saddened by the inability to change the situation ▪ Acceptance ▪ The client acknowledges what is happening and plans for the future by moving forward. NR-226 Final Exam Review & Study Guide o • Standard precautions apply to blood, blood products, all body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes. o • Perform hand hygiene before, after, and between direct contact with patients. (Examples of between-contact activities are cleaning hands after a patient care activity, moving to a non–patient care activity, and cleaning hands again before returning to perform patient contact.) o • Perform hand hygiene after contact with blood, body fluids, mucous membranes, nonintact skin, secretions, excretions, or wound dressings; after contact with inanimate surfaces or articles in a patient room; and immediately after gloves are removed. o • When hands are visibly soiled or contaminated with blood or body fluids, wash them with either a nonantimicrobial or an antimicrobial soap and water. o • When hands are not visibly soiled or contaminated with blood or body fluids, use an alcohol-based, waterless antiseptic agent to perform hand hygiene (WHO, 2009). o • Wash hands with nonantimicrobial soap and water if contact with spores (e.g., Clostridium difficile) is likely to have occurred. o • Do not wear artificial fingernails or extenders if duties include direct contact with patients at high risk for infection and associated adverse outcomes. o • Wear gloves when touching blood, body fluids, secretions, excretions, nonintact skin, mucous membranes, or contaminated items or surfaces is likely. Remove gloves and perform hand hygiene between patient care encounters and when going from a contaminated to a clean body site. o • Wear personal protective equipment (PPE) when the anticipated patient interaction indicates that contact with blood or body fluids may occur. o • A private room is unnecessary unless the patient's hygiene is unacceptable (e.g., uncontained secretions, excretions, or wound drainage). o • Discard all contaminated sharp instruments and needles in a puncture- resistant container. Health care facilities must make available needleless devices. Any needles should be disposed of uncapped, or a mechanical safety device is activated for recapping. o • Respiratory hygiene/cough etiquette: Have patients cover the nose/mouth when coughing or sneezing; use tissues to contain respiratory secretions and dispose in nearest waste container; perform hand hygiene after contacting respiratory secretions and contaminated objects/materials; contain respiratory secretions with procedure or surgical mask; spatial separation of at least 3 feet away from others if coughing. • Donning PPE (putting on) o Gown---mask----goggles --- gloves( from book) • Doffing PPE (taking off) o Gloves/gown- goggles- mask NR-226 Final Exam Review & Study Guide • Hand hygiene o use warm water o not too much water pressure you do not want splashing o rub hands 15-20 + seconds o keep hands lower than elbows (less cbontaminates --> most) o dry hands from fingers --> wrist o SURGICAL Handwashing ▪ Washing hands with hands higher than elbows • Range of motion, active and passive, when indicated Active - patient is able to performs the ROM activity by themselves Passive - health care provider performs ROM exercise for patient (coma pt) Exam 2 Skin Integrity/Wound Care: • What food provide the most protein for wound healing? o Beans o Animal Source • Which lab indicates affects wound healing? o Albumin (normal 3.4 to 5.4) ▪ <3.4 = increase risk for delay in wound healing • What are the risks for skin breakdown/pressure ulcer? o Impaired sensory o Alteration of LOC o Shear o Friction o Moisture • Describe wound drainage o Serous: clear, watery, plasma o Purulent: Thick, yellow, green (infection) o Serosanguineous: Pale pink, watery, mixture of clear and red fluid, blood-tinged, streaked o Sanguineous: Bright red, acute bleeding • What is evisceration/dehiscence? Treatment? o Evisceration: Total separation occurs; protrusion of visceral organs through wound opening. o Dehiscence: partial or total separation of wound layers. ▪ Risk: poor wound healing qualities, obesity • What dressing would you use for a stage 1? NR-226 Final Exam Review & Study Guide o Transparent • How do you obtain a wound culture? o Obtain wound AFTER it has been cleaned with normal saline (0.9% sodium chloride) • What are the subscales of the Braden Scale? o Risk of pressure ulcer ▪ Scale 6 to 23 ▪ Low = high risk for pressure ulcer/ High = low risk for pressure ulcer o 6 Subscales ▪ Sensory Perception 1(yes) to 4 (no) ▪ Moisture 1(moist) to 4 (dry) ▪ Mobillity 1(immobile) to 4 (mobile) ▪ Nutrition 1(bad) to 4(good) ▪ Friction & Shear 1(yes) - 3(rarely) ▪ Activity 1(no) to 4(yes) • Sterile Field, maintaining o Prolonged exposure to airborne microorganism can make sterile items nonsterile ▪ Avoid coughing, sneezing, talking directly over a sterile field ▪ Advise clients to avoid sudden movements, refrain from touching supplies, drapes, or the nurses gloves and gown, and avoid sneezing, coughing, talking directly over sterile field. o Only Sterile items can touch sterile items ▪ Outerwrapping and 1-inch edges of packaging containing items are not sterile. Inner surface of the sterile drape or kit, except the 1-inch border, are the sterile field where sterile items can be added. To position the field on table surface, grasp 1- inch border before donning sterile gloves. Discard any object that comes in contact with the 1-inch border. ▪ Touch Sterile items only with sterile gloves ▪ Any object below the waist or above the chest is contaminated ▪ Sterile material can come in contact with other sterile surfaces or material; however, contact with non-sterile items at anytime contaminates a sterile field. o Microbes can move by gravity from a non-sterile item to a sterile field. ▪ Do not reach across a sterile field ▪ Do not turn your back on a sterile field ▪ Hold items to add to a sterile field, 6-inches above the field. o Any sterile, non-waterproof wrapper that comes in contact with moisture becomes non-sterile ▪ Keep all surfaces dry ▪ Discard any sterile packages that are torn, or punctured , or wet. o Sterile Field Set-up: ▪ Open cover away from body NR-226 Final Exam Review & Study Guide • Urinary incontinence, types and management of o Stress: Loss of small amounts of urine from increased abdominal pressure without bladder muscle contraction with laughing, sneezing, or lifting ▪ Instruct patient in pelvic muscle exercises o Urgency: Inability to stop urine flow long enough to reach the bathroom due to an overactive detrusor muscle with increased bladder pressure ▪ Ask about UTI ▪ Instruct pelvic muscle exercises or bladder training o Functional: Loss of urine due to factors that interfere with responding to the need to urinate, such as cognitive, mobility, and environmental barriers ▪ Toileting program ▪ Mobility aid (raised toilet seats, toilet grab bars) ▪ Toilet area cleared to allow access for wheelchair or walker ▪ Call bell within reach o Reflex: Involuntary loss of a moderate amount of urine usually without warning due to hyperreflexia of the detrusor muscle, usually from spinal cord dysfunction. ▪ Follow schedule for bladder emptying though voiding or intermittent catheterization o Overflow: Urinary retention from bladder overdistention and frequent loss of small urine due to obstruction of the urinary outlet oe an impaired detrusor muscle ▪ Timed voiding ▪ Double Voiding ▪ Intermittent catheterization ▪ Indwelling catheterization • Urinary tract infection (UTI), signs and symptoms o Caused by E.coli o Upper urinary tract: Kidney o Lower urinary tract: Bladder, Urethra o Treat with antibiotics o Lower UTI symptoms ▪ Burning or pain in urination (dysuria) ▪ Irritation of bladder (cystitis) ▪ Urgency Incontinence, Frequency incontinence, suprapubic tenderness, foul-smelling cloudy urine. o Upper UTI leads to pyelonephritis and bloodstream infection o Blood in urine o Upper UTI s/s ▪ Fever, chills, diaphoresis, flank pain (due to kidneys) o Catheter Associated UTI’s (CAUTI) ▪ Increased hospitalization ▪ Increased morbidity & mortality ▪ Increased hospital stays ▪ Increased hospital cost • Indwelling catheter, insertion/removal and management NR-226 Final Exam Review & Study Guide Tell the patient you are “coming” and put in the catheter - nooooo Men are positioned Supine with legs extended and slightly abducted, hold penis at 90° angle after looping catheter advance at 7 to 9 inches or until urine flow. Women are placed in the dorsal recumbent position after cleaning catheter is advanced until year in appears then advance another 1 to 2 inches. For both male and female you would ask them to bear down as you insert the catheter For removal you would deflate the balloon allow it to drain and then pull the catheter out slowly while twisting it inside of your hand For maintenance of a indwelling catheter you need to ensure there’s no obstructions in the tubing or Any irritation or skin breakdown around the perineal area • Cystoscopy post-op care, what client should expect (teaching) o Expect blood-tinged urine, blood clots in urine, hematuria, dysuria, frequent urination. • Bladder retraining o Hydrate patient and monitor ▪ 6 ro 8 glasses a day ▪ Avoid caffeine ▪ Avoid fluids 2 hours before bedtime o Kegel exercises o Hand in glass of water/ Running water stimuli o Nutrition: • NG tube insertion/removal and management, pH of secretions o Ph of secretions 1-4 good , 6 and up bad o X- ray for checking placement primarily. • What foods are included on a clear liquid diet? o Clear fruit juice, Gelatin, Broth, Bouillon, Carbonated beverages, Coffee, Tea, Fruit ice, popsicles • How do you initiate a continuous enteral feeding? Typically tube feedings start at full strength at slow rates (see Skill 45-3 on pp. 1090-1094; Box 45-12). Increase the hourly rate every 8 to 12 hours per health care provider's order if no signs of intolerance appear (high gastric residuals, nausea, cramping, vomiting, and diarrhea). Studies have demonstrated a beneficial effect of enteral feedings compared with PN. Feeding by the enteral route reduces sepsis, minimizes the hypermetabolic response to trauma, decreases hospital mortality, and maintains intestinal structure and function (Khalid et al., 2010). EN is successful within 24 to 48 hours after surgery or trauma to provide fluids, electrolytes, and nutritional support. If the patient develops a gastric ileus, it prevents instituting nasogastric feedings. Nasointestinal or jejunal tubes allow successful postpyloric feeding because the formula instills directly into the small intestine or jejunum or beyond the pyloric sphincter of the stomach (Hodin et al., 2014). NR-226 Final Exam Review & Study Guide 1. Start formula at full strength for isotonic formulas (300 to 400 mOsm) or at ordered concentration. 2. Begin infusion rate at designated rate typically at 10 to 40 mL/hr (Stewart, 2014). 3. Advance rate slowly (e.g., 10 to 20 mL/hr every 8 to 12 hours) to target rate if tolerated (tolerance indicated by absence of nausea and diarrhea and low gastric residuals) (Stewart, 2014). • What is the client at risk for if TPN is interrupted? Signs and symptoms? Hypoglycemia if interrupted Catheter related infections that are associated with increased morbidity and mortality probriged hospitalization and increased medical cost. Signs and Symptoms of TPN • Changes in heartbeat\Confusion • Convulsion or Seizure • Fast weight gain or loss • Fatigue • Fever or Chillis • Increased urination • What is a complication of TPN? o At risk for pneumothorax, dyspnea, NVD, Aspiration, skin irritation o Dehydration and electrolyte imbalances o Thrombosis (blood clots) o Hyper/Hypoglycemia (too much or too little sugar in the blood) o Infection o Liver failure o Micronutrient deficiencies (vitamin and minerals) • Peristalsis? How do you know it’s returned? o Wavelike movements in the GI Tract o Returned ▪ Bowel sounds heard ▪ Patient passes flatus (gas) • Albumin indicative of what? What is the preferred energy source? o Albumin measures protein in body o Preferred source of energy are Carbohydrates • Remember what you would do first and what tasks you can delegate to a UAP or AP Five rights of delegation: Right task Right circumstance Right person Right direction and communication NR-226 Final Exam Review & Study Guide Do not use on new traumas or injuries Apply heating pad for 30 minutes at a time, put a barrier between heat and skin. Asses skin for temp, color, sensation, edema and integrity before use. Cold therapies: Vasoconstriction decreases blood flow and stops bleeding Helps with pain relief, reduces fever, inflammatory response and bacterial growth Relaxes muscles Asses skin for pallor or mottling (blue spots) every 10-15 minutes • Remember what is involved in telephone/verbal orders (repeat back, clarify unclear orders, transcription to medical record/MAR) • Ethical principles (autonomy, beneficence, veracity, confidentiality) o Autonomy: the right to make one’s own personal decision, even when those decisions might not be in that person’s own best interest. o Beneficence: actions that promotes good for others, without any self-interest o Veracity: truthfulness o Confidentiality: protection of privacy. • Who is responsible for the consent? The doctor or person performing the procedure is responsible for having the client sign the consent form and nurse confirms consent form in the clients chart and answer any questions about the form. Asses whether the patient understands what they are signing for and make sure they are acting voluntarily • What should you do first after a needle stick? Clean the Site after disposal of needles and wash this site with soap and water for a minimum of 30 seconds next report the incident to immediate supervisor then report directly to a licensed healthcare provider for medical evaluation • Labs that indicate infection (wbc, neutrophils, etc.) Leukocytes: Increased white blood cell count >10,000 Increased ESR (Erthrocyte sedimentation rate ) >20 mm/hr increase indications active inflammatory response or infection Increase in specific types of WBCs on differential (left shift = an increase in neutrophils) Presence of microorganisms on culture of the specific fluid/area Laboratory Value Normal (Adult) Values Indication of Infection White blood cell (WBC) count 5000-10,000/mm3 Increased in acute infection, decreased in certain viral or overwhelming infections Erythrocyte sedimentation rate Up to 15 mm/hr for men and 20 mm/hr for women Elevated in presence of inflammatory process NR-226 Final Exam Review & Study Guide Iron level 80-180 mcg/mL for men 60-160 mcg/ml for women Decreased in chronic infection Cultures of urine and blood Normally sterile, without microorganism growth Presence of infectious microorganism growth Cultures and Gram stain of wound, sputum, and throat No WBCs on Gram stain, possible normal flora Presence of infectious microorganism growth and WBCs on Gram stain Differential Count (Percentage of Each Type of White Blood Cell) Neutrophils 55%-70% Increased in acute suppurative (pus-forming) infection, decreased in overwhelming bacterial infection (older adult) Lymphocytes 20%-40% Increased in chronic bacterial and viral infection, decreased in sepsis Monocytes 2%-8% Increased in protozoan, rickettsial, and tuberculosis infections Eosinophils 1%-4% Increased in parasitic infection Basophils 0.5%-1.5% Normal during infecti EXAM 1 NR226 1) Review your nursing process a) ADPIE i) Assessment, Diagnosis, Planning, Implementation, Evaluation 2) What you can and cannot delegate a) Five rights of delegation: i) Right task - delegate tasks that are repetitive, require little supervision, relatively noninvasive, have predictable results and minimal risk (specimen collection, ambulating stable patient and preparing room for pt admission) ii) Right circumstance- consider the appropriate pt setting, available resources and other relevant factors ( usually delegate chronic pts vs acute) iii) Right person- the right task needs to be given to the right person to be performed on the right person iv) Right direction and communication- give clear,concise description of the task including objective, limits and expectations v) Right supervision and evaluation- give appropriate monitoring, evaluation, intervention and feedback b) To LPN: the nurse can delegate monitoring findings as input to the RNs are already ongoing assessment, reinforce client teaching, perform tracheostomy care and suctioning, checking NG tube patency, administer enteral feeding, insert urinary catheter and administering medications. NR-226 Final Exam Review & Study Guide c) To APs: Nurses can delegate activities of daily living like bathing, grooming, dressing, toileting, ambulating, feeding, positioning. As well as routine tasks such as bedmaking, specimen collection, intake and output, and vital signs for stable clients i) For example a nurse can delegate to the AP to assist a client who has pneumonia to use a bedpan but cannot delegate in AP to administer a nebulizer treatment ii) Another example a nurse can delegate an AP to measure vital signs of a client who is stable versus a patient who is not 3) Priorities a) First-level Priority i) ABC’s (Airway, Breathing, Circulation), and Vital Sign concerns b) Second-level Priority i) Requiring your prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security). c) Third-level Priority i) Problems with lack of knowledge, activity, rest, or family coping 4) Review calculations (ALL) a) 5) Review Infection Precautions (which precautions are indicated for which diseases) a) Contact i) Gloves and Gown ii) A private room or room with patients with the same infection iii) EX. MRSA, Herpes Simplex, Impetigo, Scabies, Wound infection, Shingles, bags/tubes, fluid drainage, C-Diff b) Airborne i) N95 and negative pressure room ii) Private Room iii) EX. Tuberculosis, Varicella, Measles c) Droplet i) Face Masks ii) A private room or room with patients with the same infection iii) EX. Flu, Scarlet Fever, Rubella, Pertussis, Mumps, Pneumonia d) Protective i) Positive pressure room ii) Private room iii) Face mask for patient when out of room iv) EX. Stem cell transplant, Immunocompromised 6) Review all elements of pain and pain assessment a) Pain Assessment (pain elements) (added stuff found in book page 1023) (?) i) PQRSTU (1) Provoked: What causes pain?, What makes it better or worse? (2) Quality: What does it feel like? Dull? Sharp? Stabbing? Burning? Crushing? (3) Relief measures: what do you take at home to gain pain relief? NR-226 Final Exam Review & Study Guide vi) vi) b) Safety : avoid skin trauma by keeping it clean, dry and intact, use pressure relieving surfaces and devices, maintain skin hygiene and encourage proper nutrition intake. c) Interventions: (a) stage 1: transparent dressing on wound, relieve pressure with devices, frequent repositioning, keep client dry, clean well nourished and hydrated (b) stage 2: maintain moist healing environment with saline or apply hydrocolloid dressing, promote natural healing, provide nutritional supplements and administer analgesics (c) stage 3: clean and/or debrid wound.use of prescribed dressings, possible surgical intervention or proteolytic enzymes. nutritional supplements, analgesics and antimicrobials (d) stage 4:clean and/or debrid wound.use of prescribed dressings, possible surgical intervention or proteolytic enzymes. nutritional supplements, analgesics and antimicrobials. perform non adherent dressing changes every 12 hours. treatments could include skin grafting or hyperbaric chamber (e) unstageable: debride until staging is possible. 22) Review clear liquid versus full liquid diet a) Clear Liquid (liquids that leave little residue) i) Clear fruit juice, Gelatin, Broth, Bouillon, Carbonated beverages, Coffee, Tea, Fruit ice, popsicles b) Full Liquid i) Clear liquids plus smooth textured dairy products, custards, refined cooked cereals, vegetable juice, pureed vegetables & all fruit juices. 23) Review medication administration (ALL), disposal of, counting narcotics, etc. a) Rights of Safe Medication Administration i) Right Client/ Right Medication/ Right Dose/ Right Time/ Right Route/ Right Documentation/ Right Client Education/ Right to Refuse NR-226 Final Exam Review & Study Guide ii) check medication 3 times: check on MAR sheet, check when retrieving medication and check at patients bedside. you need to stay at the bedside until patient takes medication. iii) telephone orders: must have another nurse listen into call, verify orders and receive physician signature within 24 hours (?) iv) polypharmacy: happens when a patient takes multiple medications that are potentially inappropriate or unnecessary (?) v) Hour window to give medication; 30 minutes before time suppose to give or 30 minutes after time to give. vi) Medication routes (?): 1. oral routes: sublingual or buccal 2. parenteral routes (injections): i. intradermal: injection into dermis ii. subcutaneous: injection into tissue just below dermis iii. intramuscular: injection into muscle iv. intravenous: injection into vein b) Disposal: 1. needles: do not recap needle after injection, there is usually a sheath or guard, dispose of needles into sharps disposal container using one hand. 2. medications (ex: pills): put in medication disposal box with another nurse around to verify c) Counting Narcotics: 1. count before taking narcotics from medication machine and count after removal. Note any discrepancies. If you are “wasting something” properly dispose of it and make sure another nurse is there to watch 24) Review urinary catheterization a) Check patients LOC and if allergic to latex or iodine. ask about prior experience, check bladder for fullness. b) for women have them positioned in the ( i forgot the name) bend knees and spread legs. for men position supine with legs slightly abducted c) for women: hold the labia with non dominant hand, then clean with iodine on the farthest side, the side near you and then straight down the middle. for men: retract foreskin and grasp penis lightly and hold at right angle to body, then clean the meatus 3 times in a circle motion d) Lubricate foley cath 1-2 in for female & 5-7 in for males e) Sterile procedure used f) French sizes (standard is 14 french, 10 ml) i) 14-16 adult ii) 8-10 children iii) 5-6 infants g) Men (ask to bear down first) i) Insert 7-9 in or until flash of urine -- advance to bifurcation h) Women (ask to bear down first) i) Insert 2-3 in until flash of urine -- advance another 1-2 in. i. inflate balloon and gently tug to check for resistance NR-226 Final Exam Review & Study Guide (2) j. secure tubing to inner thigh and place bag on side of the bed, lower than the bladder 25) Review bowel elimination (what happens when straining, positioning). a) Straining i) Hemorrhoids- engorged dilated blood vessels inside of the rectum ii) Hernias iii) Anal fissures iv) Valsalva Maneuver (straining while bearing down) (1) Bradycardia (2) Hypotension (3) Syncope b) Positioning for Enema i) Sim’s Position (Side lying position, leg hiked) ii) before giving enema do an abdominal assessment iii) high fowler position over bed pan. Bed raised to 60-90 degrees 26) Review restraints (indications, obtaining orders, discontinuing) a) DO NOT TIE TO SIDE RAILS b) Use seclusion/restraints for the shortest duration and only if less restrictive means were unsuccessful (Last resort) c) They can cause complications or death d) Inappropriate use of restraints i) Convenience of the staff ii) Punishment for the client iii) Clients who are extremely physically and mentally unstable. iv) Clients who cannot tolerate the decreased stimulation of a seclusion room e) Restraints should i) Never interfere with treatment ii) Restrict movement as little as is necessary iii) Fit properly and be discreet as possible iv) Be easy to remove and change f) Nursing Responsibilities i) Assess skin integrity at least every 2 hrs ii) Offer food and fluids iii) Provide means of good hygiene and elimination iv) Monitor vitals v) Offer range of motion exercises of extremities vi) Pad bony prominences to prevent skin breakdown vii) Use a quick release knot (loose knot that is easy to remove) to tie the restraints to the bed frame where they will not tighten when raising or lowering the bed. viii) Make sure restraints are loose enough for range of motion and there is enough room to fit 2 fingers between the restraint and the client ix) Remove or replace restraints frequently to ensure good circulation to the area and allow full range of motion to the limbs x) Regularly determine the need to use the restraints NR-226 Final Exam Review & Study Guide 32) over the sternum you will hear bronchovesicular 33) over pleural space you will hear vesicular in adults but bronchovesicular in children 34) Review acceptable abbreviations (look at page 614 table 32-3 and page 622 table 32-7). NR226 Fundamentals Exam 2 REMEMBER SAFETY, PRIORITIES, AND NURSING PROCESS 1) Review your nursing process, priorities, and safety a) ADPIE i) Assessment, Diagnosis, Planning, Implementation, Evaluation b) Priorities i) First-level Priority (1) ABC’s (Airway, Breathing, Circulation), and Vital Sign concerns ii) Second-level Priority (1) Requiring your prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security). iii) Third-level Priority (1) Problems with lack of knowledge, activity, rest, or family coping c) Patient Safety First (ex. In case of fire, get patient out of the room first,) (a) keep patients with high fall risk near nursing station 2) Review calculations (ALL) a) 1 oz = 30 ml b) 1tbs = 15 ml c) 1 tsp = 5 ml d) 1 kg = 2.2 lb 3) Review pain management, PCA pumps a) Pain Management Strategies i) Non-pharmacological (1) Cognitive-behavioral measures: (a) changing a way someone perceives pain, and physical approaches to improve comfort (2) Cutaneous Stimulation: (a) Heat (increase blood flow, and reduce stiffness), cold (decrease inflammation), therapeutic touch, massage (3) Distraction: (a) Decrease attention to the presence of pain can decrease pain level. ex. music, ambulation, deep breathing, visitors, television, video games, prayer. NR-226 Final Exam Review & Study Guide (4) Relaxation: (a) Includes meditation, yoga, and progressive muscle relaxation. (5) Imagery: (a) Focusing on a pleasant thought to divert focus. Requires ability to concentrate. (6) Acupuncture or Acupressure (7) Reduce pain stimuli from environment (8) Elevation of edematous extremities to promote venous return and decrease swelling. ii) Pharmacological (1) Opioid Analgesics (a) Morphine, Fentanyl, Codeine (i) Monitor: 1. Respiratory depression 2. Sedation: Monitor LOC and take safety precautions 3. Orthostatic hypotension 4. Urinary Retention 5. N/V 6. Constipation (2) Nonopioid Analgesics (a) NSAIDS (i) Monitor: 1. Upset stomach 2. Bleeding with long-term use b) PCA Pumps i) Patient-controlled analgesia (PCA) (1) Medication delivery system that allows clients to self administer safe dose of opioids (a) Small, frequent dosing ensures consistent plasma levels. (b) Clients have less lag time between identified need and delivery of medication, which increases their sense of control and can decrease the amount of medication they need. (c) Morphine, hydromorphone, and fentanyl are typical opioids for PCA delivery (d) Clients should let the nurse know if using the pump does not control the pain (i) To prevent inadvertent overdosing the client is the only person who should push the PCA button. 4) Review expected physiological changes for older adults a) Integumentary i) Decreased skin turgor, subcutaneous fat, and connective tissue (dermis), which leads to wrinkles and dry, transparent skin ii) Loss of subcutaneous fat, which makes it more difficult for older adults to adjust to cold temperatures. iii) Thinning and graying of hair, as well as a more sparse distribution iv) Thickening of fingernails and toenails b) Cardiovascular/ Pulmonary NR-226 Final Exam Review & Study Guide i) Decreased chest wall movement, vital capacity, and cilia, which increases the risk for respiratory infection ii) Reduced cardiac output iii) Decreased peripheral circulation iv) Increased blood pressure c) Neurosensory i) Slower reaction time ii) Decreased touch, smell, and taste sensations iii) Decreased saliva production iv) Decline in visual acuity v) Decreased ability for eyes to adjust from light to dark leading to night blindness, which is dangerous when driving. vi) Inability to hear high-pitched sounds (Presbycusis) vii) Reduced spatial awareness d) GI i) Decreased digestive enzymes ii) Decreased intestinal motility, which can lead to increased risk of constipation iii) Increased dental problems e) Neuromuscular i) Decreased height due to intervertebral disk changes ii) Decreased muscle strength and tone iii) Decalcification of bones iv) Degeneration of joints f) Genitourinary i) Decreased bladder Capacity ii) Prostate hypertrophy in men iii) Decline in estrogen or testosterone production iv) Atrophy of breast tissue in women g) Endocrine i) Decline in Triiodothyronine (T3) production, yet overall functions remain effective ii) Decreased sensitivity of tissue cells to insulin 5) Review nutrition, complete and incomplete proteins, carb sources, etc. a) Complete Protein (Contain all of the essential amino acids;Usually from animal sources) i) Beef ii) Whole milk iii) Poultry b) Incomplete Protein (Do not contain all the essential amino acids; Generally come from plant sources) i) Nuts ii) Legumes iii) Grains iv) Fruit v) Vegetables c) Carbohydrate Sources i) Whole grain breads ii) Baked potatoes NR-226 Final Exam Review & Study Guide 9) Review acid-base imbalances (see chart) (got information from ati and chart. ranges are from ati) i) Calcium: total calcium 8.4-10.5 mg/dl (1) Hypercalcemia: >10.5 (a) causes: calcium shift from bone to ECF, bone cancer, hyperparathyroidism, excessive vitamin D (b) S&S: decreased neuromuscular excitability- hypoactive deep tendon reflexes, lethargy, impaired memory, slurred speech, kidney stones (c) interventions: increase fluid to decrease stone formation, limit calcium intake, use loop diuretics, administer phosphate (2) Hypocalcemia: (a) causes:calcium shift from ECF to bone, decreased calcium intake, parathyroid removal, renal failure, alcoholism, acute pancreatitis, pregnancy (b) S&S: neuromuscular irritability, hyperactive deep tendon reflex, positive chvosteks sign (facial twitching when tapped in front of ear), Positive Trousseaus sign (hand or finger spasms when BP cuff applied), tingling in fingers and toes, cardiac dysrhythmias prolonged QT interval and ST segment, diarrhea and possible seizures. ii) Magnesium: 1.3-2.1 mEq/L (1) Hypermagnesemia: (a) causes: renal failure or increased magnesium intake (b) S&S: weak deep tendon oreflexes, decreased respiratory rate, hypotension, lethargy-coma, dysrhythmias, prolonged PR and QRS intervals with tall T waves (2) Hypomagnesemia: (a) causes: prolonged malnutrition, alcoholism, laxative use, diabetes mellitus, diarrhea, renal failure (b) S&S: increased nerve impulse transmission, hyperactive deep tendon reflexes, positive chvostek's and trousseau's signs, tetany, seizures, tremors iii) Sodium: 136-145 mEq/L Major cation in ECF (1) Hypernatremia: (a) causes: decreased fluid intake leading to increased serum concentration, diabetes insipidus, excessive sodium retention, cells are dehydrated (b) S&S: weight gain over time, excessive thirst, tachycardia, dry mucous membranes, oliguria, orthostatic hypotension, muscle weakness, disorientation, restlessness, reduced- absent deep tendon reflexes, edema (2) Hyponatremia: (a) causes: increased fluid intake that lead to decreased serum concentrations, decreased renal function. CHF, vomiting, diarrhea, burns (b) S&S: hypothermia, tachycardia, hypotension, weight loss, poor skin turgor, dry mucous membranes, confusion, lethargy, decreased deep tendon reflexes, hyperactive bowel sounds, cramping, anorexia, nausea iv) Potassium: major cation in icf, 3.5 - 5 mEq/L NR-226 Final Exam Review & Study Guide (1) Hyperkalemia: (a) S&S: cardiac arrhythmias, hyperactive bowel sounds, bladder irritability, skeletal muscle twitching, acidosis, prolonged QRS and PR interval with tall T wave, slow irregular pulse, hypotension confusion (2) Hypokalemia: (a) S&S: cardiac arrest if less than 2.0 mEq/L, hypoactive bowel sounds, constipation, skeletal muscle weakness, alkalosis, flat ST segment and Q wave, shallow respirations, muscle cramping, weak irregular pulse v) Phosphate: 2.4- 4.1 mg/dl (a) Hypophosphatemia: (b) S&S: related to hypercalcemia vi) Hyperphosphatemia: (a) S&S: related to hypocalcemia, decreased energy due to the inability to produce atp 10) 10) 11) Review lab values: hgb, hct, BUN, specific gravity, expected findings (hypo/hypervolemia) a) Expected Lab Values i) Hgb (Hemoglobin): (1) Male: 14-18 g/dL (2) Female: 12-16 g/dL ii) Hct (Hematocrit) (1) Male: 42-52% (2) Female: 37-47% iii) BUN (Blood urine nitrogen): (1) 10-20 mg/dL iv) Urine Specific Gravity: (1) 1.010 to 1.030 b) HYPERvolemia i) Hgb (hemoglobin) (1) Decreased ii) Hct (hematocrit) (1) Decreased iii) BUN (blood urea nitrogen) (1) Decreased iv) Urine Specific Gravity (1) Less than 1.010 c) HYPOvolemia i) Hgb (hemoglobin) (1) Increased ii) Hct (hematocrit) (1) Increased iii) BUN (blood urea nitrogen) (1) Increased NR-226 Final Exam Review & Study Guide iv) Urine Specific Gravity (1) Greater than 1.030 12) Review TPN, PEG, NGT, isolation precautions/PPE, urinary catheterization TPN (total parenteral nutrition): IV administration of a complex highly concentrated solution containing nutrients and electrolytes that is formulated to meet the patients needs. PN solutions with high osmolality are administered through central IV catheter and low osmolality are administered peripherally. a) The goal is to correct or prevent fluid and electrolyte disturbances b) High in sugar c) Allows for direct access to vascular system and permits continuous infusion of fluids over time d) Change every 24 hours due to increased sugar content and clogging e) If patient complains of nausea - slow down the feeding f) You want to gradually build up feeding to prevent HYPERglycemia i) S&S: Polyuria, Polydipsia, Polyphagia g) If interrupted HYPOglycemia can occur (Taper down - Don’t just stop.) i) S&S: Diaphoresis, Pallor, Polyphagia, h) Complications of TPN i) Infection & Sepsis: Indicated by fever or elevated WBC; due to contaminated catheter, solution, or long-term indwelling catheter. ii) Metabolic Complications: Hyperglycemia, Hypoglycemia, Hyperkalemia, Hypophosphatemia, Hypocalcemia, Dehydration, Fluid overload. iii) Mechanical Complications: Catheter misplaced causing pneumothorax or hemothorax (evidenced by SOB, diminished or absent breath sounds), arterial puncture, catheter embolus, air embolus, thrombosis, obstruction i) Nursing Actions i) Monitor redness around catheter, fever,chills, elevated WBC ii) Use strict aseptic technique iii) Monitor blood glucose iv) Administer sliding scale insulin to TPN to treat hyperglycemia v) Administer dextrose (D10) to TPN to treat hypoglycemia vi) Monitor I&O, weight 13) PEG (percutaneous endoscopic gastrostomy): percutaneous endoscopic gastronomy -- a flexible feeding tube is placed through the abdominal wall and into the stomach. It allows nutrition, fluids, and medications to be directly administered into the stomach; bypassing the mouth and esophagus. a) Common in stroke patients b) Seen in patients who need long-term care c) Seen in patients who have difficulty swallowing d) Complications i) infection ii) aspiration iii) bleeding and perforation NR-226 Final Exam Review & Study Guide b) Disposal: i) needles: do not recap needle after injection, there is usually a sheath or guard, dispose of needles into sharps disposal container using one hand. 1. medications (ex: pills): put in medication disposal box with another nurse around to verify c) Counting Narcotics: i) count before taking narcotics from medication machine and count after removal. Note any discrepancies. If you are “wasting something” properly dispose of it and make sure another nurse is there to watch d) Do Not Break Up: i) Potassium ii) Aspirin Questions from Class • If a client refuses treatment and wants to be discharged. And you notify provider and provider says restrain to stop them/ o o False Imprisonment. • As a nurse you have several roles, giving client information about disease process. o Educator • Client is going to be discharged. Adult child request information about home health service. o Nurse should discuss resources and options and concerns. • Nursing processes what should you do first for a pt who doesn’t feel well. o Ask to describe current health concerns. • Pt with CVA unable to move r side. Nursing Diagnosis? o Impaired mobility. • Teaching group of clients who smoke about hypertension. ANA Standards what are you doing o Implantation • New nurse providing care on another unit. Another nurse ask about medical diagnosis of a patient with you. You decide not to share info. o Confidentiality • Nursing Process o Personalize plan of care that consist of dynamic process to meet pt holistic needs NR-226 Final Exam Review & Study Guide • Pt has acute pancreatitis. Which of the provider prescription should the nurse implement o Pantoprazole (proton pump inhibitor) 8mg IV Bolus. To calm down • Suspected cervical cord injury of a conscious client. What is patient risk of. o Weaken Gag reflex o Hypotension o Absent Bowel Sounds • Client who has heart failure digoxin 125 mcg po daily. Comes in Digoxin po 0.25mg. How much do you give. o 0.5 mcg • TB. Negative Pressure Room o Air exhaust into outside environment. • Bronchovesicular sounds o Near Sternal Border • Food High Fiber o Sweet Potatoes • Osteoporosis. Supplements to take. o Calcium • Looking at medical record. Look at older adult with BMI 17. How would you identify a pt at risk of malnutrition o Someone who has COPD. (since they are short of breath, they do not eat well and they burn more calories trying to breath = malnourished) • Type 1 diabetes. Hypoglycemia when exercising o Eat carbohydrates before exercise • ·Dietary guidelines, 2000 cal a day diet. What do you include o Include 4 and a half cups of fruits and vegetables. • NG Tube. TO administer 3 meds w/ suction. You should? o Pinch tube prior to administer meds (if you don’t pinch the suction tube or clamp it will be suctioned up when you administer medications) • New Diagnosis of urolithiasis. Risk Factor? o Family History • Vegetarian. Eats milk products but does not eat beans. Suggestion for lunch? o Peanut butter and jelly sandwich • Diuretic with Potassium Chloride Extended release tablet. How would you give the medication o Take the Potassium extended release tablet whole. • Nasal Decongestant drops o Tell patient to blow nose before instilling. • Nurse is preparing to administer 1000 ml lactate ringer IV over 6 hours. Comes in 10 gtt/ml. Set manual IV at how many gtt/min o 28 • Nursing is performing Trach care. What to do when suctioning o Suction 2 to 3 times with 60 second intervals between. • Pt has difficulty swallowing pills. Pt asks can you crush enter coated aspirin to make it easier to swallow? NR-226 Final Exam Review & Study Guide o Crushing will cause stomach ache • Client with congestive heart failure, take digoxin daily, doesn’t take medication because it makes them feel nausea and weak. o Check vital signs • Wrist restraints o Secure restraint using quick release tie. • Older client found wandering brought to ER. Palpating abdomen the pt flinches. Ask if they feel pain? What type of barrier? o Confusion • Inserts IV and pt experiences pain at insertion site o Take it out. • Guaiac Test o Test blood in stool • Iron Anemia should increase intake of which foods o Green vegetables. Broccoli • GERD o Avoid eating 3 Hours before bedtime. • Decreased breath sounds o Atelectasis • Sudden interruption of TPN o Hypoglycemia ▪ Confusion ▪ Diaphoresis • Which pt at for Risk for hypokalemia o PT with NG Tube to suction o Dehydration • Know electrolyte values. • Stool specimens o Store in sterile container • Best source of calcium o Cup of Milk • Hypotonic Solution o Know which fluids to treat patient with hypernatremia o 0.45 saline
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