Brain Quiz 1.Auditory association area: temporal lobe, process impulses from ears 2.

Basal Nuclei ganglia caudate nucleus lentiform nucleus amygdaliod nucleus: grey matter inside cerebrum, central centers relay center from cortex to spinal cord important in starting, stopping an monitoring movements made by cortex regulate dopamine levels 3.Brain Stem: Regulates involuntary actions 4.Broca's area: motor speech area 5.Central Sulcus: separates frontal and parietal lobe 6.Cerebellum: muscle coordination and integration 7.Corpus callosum: connects right and left sides of cerebrum, allows communication 8.Dentate nuclei: the cerebellar nuclei of the lateral hemisphere involved in motor planning 9.Frontal lobe: motor areas control movements of voluntary skeletal muscles 10.Hypothalamus: integrates involuntary response and links nerves and endocrine system 11.Inferior peduncle: brings sensory information concerning actual positions of body parts to cerebellum via spinal cord and medulla oblongata 12.Insula: perception of bodily sensations, emotional states, empathy, and addictive behavior 13.Lateral fissure: separates frontal and temporal lobe 14.Longitudinal fissure: separates right and left hemispheres 15.Medulla Oblongata: conects spinal cord to brain; cardiac, respiratory, vasomotor control center 16.Midbrain: auditory and visual reflex center, location where pain is registered 17.Middle peduncle: transmits info from cerebral cortex about desired position of body parts 18.Occipital lobe: sensory area responsible for vision 19.Parietal lobe: provides sensations of temperature, touch, pressure and pain 20.Parietaooccipital fissure: separates parietal and occipital lobes 21.Pons: respiration control; links cerebrum and cerebellum 22.Premotor, prefrontal: concentration, planning, problem solving, general association areas 23.Sensory association area: makes sense of impulses 24.Somatic motor area: central voluntary muscles 25.Somatic sensory area: primary area for general somatic senses, integrate impulses with association areas 26.Superior peduncle: carries efferent information to the mibrain and thalamus 27.Temporal lobe: sensory area responsible for hearing 28.Thalamus: the structure of the brain that relays messages from the sense organs to the cerebral cortex 29.Visual association area: help interpret what you see 30.Visual cortex: receives impulses from the eyes 31.Wernicke's area: sensory speech area

1. Nursing practice in the twenty-first century is an art and science that is centered on the A. Client B. Health care facility C. Nursing process D. Cultural diversity 2. Who decreased mortality by improving sanitation in the battlefields, resulting in a decrease in illness and infection? A. Florence Nightingale B. Clara Barton C. Dorthea Dix D. Lillian Wald 3. The professional nurse responsible for increasing the respect for the individual and awareness of cultural diversity was:

A. Client

A. Florence Nightingale

B. Mary Mahoney

A. Harriet Tubman B. Mary Mahoney C. Isabel Hampton D. Mary Adelaide Nutting 4. The document that developed goals and objectives to meet the health of the public is known as: A. Notes on Nursing B. Last Acts Campaign C. Healthy People 2010 D. Nursing Principles and Practice 2010 5. A nurse who uses critical thinking in the decision-making process providing effective quality care to individuals is known as a(n): A. Advanced care nurse B. Clinical decision maker C. Evidence-based practitioner D. Multidiscipline practice 6. The document that assures clients that they will receive quality care from a competent nurse is the: A. Standards of care B. Nurse Practice Act C. Accreditation certification D. National council licensure 7. The regulation of licensure and practice of nursing is accomplished by the: A. NCLEX-RN B. Certification examination C. Nurse Practice Act D. ANA Congress for Nursing 8. A nurse who has been in a position on the same unit for 2 years understands the organization and care of the clients on that nursing unit. Benner defines this nurse as able to anticipate nursing care and to formulate long-range goals; this nurse is given the title: A. Expert B. Proficient C. Competent D. Advanced beginner 9. An advanced practice nurse (APN) is the nurse most independently functioning of all professional nurses. All of the following are examples of clinically focused APNs except: A. Nurse specialist B. Nurse practitioner C. Case manager D. Care provider 10. An APN is pursuing a job change. Which of the following positions would the APN be unable to pursue without meeting additional criteria? A. Nurse educator B. Certified registered nurse anesthetist C. Nurse manager D. Case manager

C. Healthy People 2010

B. Clinical decision maker

A. Standards of care

C. Nurse Practice Act

C. Competent

D. Care provider

B. Certified registered nurse anesthetist

Front Back 11. Which of the following professional organizations was created to address concerns of members in the nursing profession? A. NLN

A. NLN

B. MSN C. PHA D. NIH NURSING HAS A CODE OF ETHICS THAT PROFESSIONAL rn'S FOLLOW: 1. DEFINES THE PRINCIPLES BY WHICH NURSES' PROVIDE CARE TO THEIR CLIENTS 2. ENSURES IDENTICAL CARE TO ALL CLIENTS 3. PROTECTS THE CLIENT FROM HARM 4. IMPROVES SELF-HEALTH CARE 2. THE FOUNDER OF MODERN NURSING IS: 1, DORTHEA DIX 2. FLORENCE NIGHTINGALE 3. CLARA BARTON 4. HARRIET TUBMAN THE FOUNDER OF THE AMERICAN RED CROSS: 1. FLORENCE NIGHTINGALE 2. DORTHEA DIX 3, CLARA BARTON 4. MARY MAHONEY 4. EVIDENCE-BASED PRACTICE IS DEFINED AS: 1. THE INTERGRATION OF THE BEST RESEARCH WITH CLINICAL EXPERTISE AND PATIENT VALUES 2. SCHOLARLY INQUIRY OF NURSING AND BIOMEDICAL RESEARCH LITERATURE 3. NURSING CARE BASED ON TRADITION 4. QUALITY NURSING CARE PROVIDED IN AN EFFICIENT AND ECONOMICALLY SOUND MANNER 5. THE STANDARDS OF CARE DESCRIBED IN THE ANA STANDARDS OF CLINICAL PRACTICE, SECOND EDITION INCLUDE: 1. THE NURSING PROCESS: ASSESSMENT, DIAGNOSIS, OUTCOME IDENTIFICATION, AND PLANNING, IMPLEMENTATION, AND EVALUATION. 2. ADMINISTRATION OF MEDICATIONS, PERSONAL HYGIENE, AND GROOMING 3. CARE OF VULNERABLE POPULATIONS 4. CARE OF PERSONS IN FINANCIAL CRISIS 6. REGARDLESS OF EDUCATION PREPARATION, THE EXAMINATION FOR THE RN LICENSURE IS EXACTLY THE SAME IN EVERY STATE IN THE UNITED STATES, THIS: 1. PROVIDES A STANDARDIZED MINIMUM KNOWLEDGE BASE FOR THE CLIENT POPULATION NURSES SERVE 2. GAURENTEES SAFE CARE FOR ALL CLIENTS 3. ENSURES IDENTICAL CARE FOR ALL CLIENTS 4. ENSURES AND HONEST CARE GIVER 7. CONTEMPORARY NURSING REQUIRES THAT THE NURSE POSSES KNOWLEDGE AND SKILLS FOR A VARIETY OF PROFESSIONAL ROLES AND RESPONSABILITIES. EXAMPLES INCLUDE: 1. AUTONOMY AND ACCOUNTABILITY 2. FOLLOWING PHYSICIANS ORDERS 3. PROVIDING BEDSIDE CARE 4. INCREASED EMPHASIS ON HEALTH PROMOTION AND ILLNESS PREVENTION 8. ADVANCED PRACTICE NURSES GENERALLY: 1. WORK IN THE UNIVERSITY SETTING 2. FUNCTION INDEPENDENTLY 3. WORK IN ACUTE CARE SETTINGS 4. FUNCTION AS UNIT DIRECTORS

1. DEFINES THE PRINCIPLES BY WHICH NURSES' PROVIDE CARE TO THEIR CLIENTS

2. FLORENCE NIGHTINGALE

3. CLARA BARTON

1. THE INTERGRATION OF BEST RESEARCH EVIDENCE WITH CLINICAL EXPERTISE AND PATIENT VALUES

1. THE NURSING PROCESS: ASSESSMENT, DIAGNOSIS, OUTCOME IDENTIFICATION, AND PLANNING, IMPLEMENTATION, AND EVALUATION.

1. PROVIDES A STANDARDIZED MINIMUM KNOWLEDGE BASE FOR THE CLIENT POPULATION NURSES SERVE

4. INCREASED EMPHASIS ON HEALTH PROMOTION AND ILLNESS PREVENTION

2. FUNCTION INDEPENDENTLY

I NORTH AMERICA THE MAJOR PROFESSIONAL NURSING ORGANIZATIONS IS ARE: 1. THE NATIONAL INSTITUTE OF HEALTH AND CRITICAL CARE NURSE 2. NATIONAL LEAGUE FOR NURSING AND THE AMERICAN NURSES ASSOCIATION 3. NATIONAL COUNCIL LICENSURE EXAMINATION 4. THE AMERICAN MEDICAL ASSOCIATION 10. AS LONG AS NURSES MAINTAIN INVOLVEMENT IN HEALTH CARE POLICY AND PRACTICE: 1. NURSES WILL HAVE SIGNIFICANT INCREASES IN SALARIES 2. OUTSIDERS WILL NOT IMPOSE THEIR WILL ON NURSING AND NURSING PRACTICES 3. MAJOR HEALTH PROBLEMS WILL SUBSIDE 4. PHYSICIANS WILL HAVE MORE CONTROL OVER NURSING AND NURSING FUNCTIONS Cards

2. NATIONAL LEAGUE FOR NURSING AND THE AMERICAN NURSES ASSOCIATION

2. OUTSIDERS WILL NOT IMPOSE THEIR WILL ON NURSING AND NURSING PRACTICE.

Term What are the five ethical principles?

Definition Autonomy-ability of client to make personal decisions, even if they arent in their best interest Beneficence-care given is in best interest of the client Fidelity-keeping ones promise about care offered Justice-fair treatment Nonmalificence-avoidance of harm or pain as much as possible

Term Malpractice

Definition Professional negligence - nurse administers large dose of med due to calc error and the client dies

Term The core of nursing practice is regulated:

Definition state law: Can revoke/issue license; define nursing practice parameters (standards of care) [ANA]; regulate practice; adopt rules and regulations for this; set standards for nursing programs

Term Five elements to prove negligence

Definition 1. duty 2. breach of duty-not meet standard 3. forseeability of harm 4. breach of duty has potential to cause harm 5. harm

Term Formal Chain of Command

Definition should be used to verbalize concerns related to assignment in light of current legal scope of practice, job description and area of competence

Term Advance Directives

Definition -required by PSDA Living will: clients wished for treatment if incapacitated or facing end of life issues Durable POA: proxy authorized for decisions when client is unable Providers Orders: DNR/AND

Term Mandatory Reporting

Definition abuse suspicion, communicable disease, -ensures med treatment -monitors for outbreaks -plan/evaluate control/prevention plan -determine health priorities from trends

-identify outbreaks

Term Included in a chart and why

Definition Assessments; medication administration; treatments given and the clients responses; client education For: communication, legal documentation, financial billing, education, research, monitoring

Term Change of shift report

Definition significant objective info report is given at the conclusion of each shift by the nurse leave to the nurse assuming responsibility for the client; face-toface, audio-taped, presents on rounds

Term Five rights to delegation

Definition Task, circumstance, person, communication, supervision/evaluation

Term LPN delegation

Definition monitor client findings, reinforce teaching, perform tacheostomy care, suctioning, NG patency check, administer enteral feeding, insert urinary catheter, administer meds

Term AP delegation

Definition ADLS, bathing, grooming, dressing, toileting, ambulating, feeding (without precautions), positioning, bed making, specimen collection, I&O, vital signs for the stable

Term Common infection risks

Definition hand hygiene, compromised health/defenses against it, poor asepsis, poor hygiene/nutrition, stress, corwded living environment, older adults, poor lifestyle choices, recent exposure (poor sanitiation, mosquito born/parasitic disease, endemic in visited area)

Term Nosocomial

Definition Infection in hospital from exogenous (outside pt) or endogenous (altered flora); most commonly UTI; from e.coli or s.aureus or enterococci

Term systemic infection s/s

Definition Fever Increased pulse and RR Malaise Anorexia N/V Enlarged lymph nodes (waste)

Term localized infection

Definition first stage of 3 in inflammatory response Redness warmth edema pain/tenderness loss of use of affected part

Term Infection Lab results

Definition WBC above 10,000/uL and left shift from neutrophil increase Elevated ESR rate Positive culture

Term Chain of infection

Definition infectious agent (bacteria, virus, fungi, protozoa); reserboir to grow (wound drainage, food, o2 tubing); exit portal; means of transmission; entry portal to a susceptible host

Term proper coughing adequate

Definition cover mouth and nose using a favial tissue to contain secretions, turn head and stay a minimum of 3 ft away from others, mask if continual, hand hygiene

Term Standard (tier 1) precautions

Definition all body fluids, mucous, intact skin gloves, masks, eye/ shields if spraying

Term Transmission Precautions (Tier 2)

Definition Airborne - <5um (TB [special mask], measles, varicella), private room, negative air pressure exchanged every 6 hours, masks Droplet - > 5um (pneumonia, mumps, rubella, pertussis, SF) private/same disease room, masks Contact (resp virus, wound, enteric, herpes simplex), private/same disease room, gloves/gowns for all, proper disposal

Term Fall risk prevention

Definition fall-risk assessment upon admission; document risks and implement safety measure: -call light/respond quick -orient to setting -place near nursing station -ensure things are in reach -low bed, rails up if compromised -avoid full bedrails for those who attempt to get up -clutter free; locks; sensors -educate

Term Seizure Precautions

Definition rescue equipment at bed, remove unsafe items in event, assist ambulation, advise: nothing in mouth, do not restrain, lower to floor with space, protect head and flex fwd, body on side, loosen clothes; Stay with/call for help Explain/provide comfort

Term Restraints order

Definition face-to-face assessment then prescription in writing Emergency: obtain order ASAP Include: Reason, type of restraint, location, how long to be used, and type of behaviors demonstrated that warrant use and rewrite order every 24 hours

Term Restraint responsibility

Definition Food, fluid, safety and comfort assessments performed and documented every 15-30 minutes Quick release knot fitting two fingers, pad bony prominences, regularly assess, never leave unattended w/o Document: Behaviors, actions causing, when applied/removed, location, type, care, meds, response when removed

Term Fire

Definition RACE R-rescue A-alarm C-contain E-extinguish (A-paper/wood/trash fire; B-flammable liquids/gas fire, Celectrical fire)

Term Home Safety

Definition nurses often collaborate to promote safety to initiate a plan of care, the nurse must identify risk factors using a risk assessment tool, and complete a nursing history, a physical examination and a home hazard appraisal

Term Bed/Client positions

Definition semi-fowler - 30d; prevent tube regurgitation and aspiration fowler 45 - NG, suctioning, vent, abdomen surgery drainage high-fowler 90 - lung expansion; sever dyspnea prone - abdomen, oral/throat surgery drainage lateral - side, 3 pillows, sleep sims - oral drainage between sims/lateral orthopneic - sit; arms on bed table (copd) trendelenburg - head below feet; venous return Reverse T - feet below head; gastric emptying, esophogeal reflux

Term Mobility assessment sequence

Definition ROM, Moving from supine to sitting on the side of the bed, Gait, Exercise tolerance

Term Triage classes/ categories during mass casualty events

Definition I - Emergent - highest priority; life threatening injuring with high possibility of survival when stabilized II - Urgent - major injurys, not yet life threatening; can wait 45-60 for treatment III - Nonurgent - minor injuries, do not need immediate attention IV - Expectant - not expected to live and will be allowed to die naturally; provide comfort not restorative care

Term Disease Prevention tests

Definition routine starting at age 20 dental - every 6 months BP - 2 years starting at 20 BMI - each routine Cholesterol - every 5 starting at 20 Glucose - every 3 starting at 45 Colorectal - FOBT starting at 50, colonoscopy every 10 Pap - every 2y from 20-30 then 1-3years Breast - every 3y @ age 20; yearly @ 40 Mammogram - @ 40 then yearly Testicular - 20, yearly Prostate/digital rectum - males above 50

Term Older Adult health risks

Definition Cardiovascular disease: CAD, hypertension, stroke Mobility: arthritis, osteoporosis, falls Mental health: depression, dementia, suicide DM, Cancers, Incontinence, Abuse/neglect, cataracts, alcoholism, pain

Term Categories of CAM

Definition Alternative medical philosophy (acupuncture, homeopathy, Chinese meds)

Biological and botanical therapies (naturopathic therapy, diets, vitamins, minerals, herbal) Body manipulation (massage, touch, chiropractic therapy) Mind-body therapies (biofeedback, art therapy, meditation, yoga, psychotherapy) Energy therapies (Reiki, therapeutic touch)

Term Specialized license versus nursing CAM therapy intervention

Definition SL: acupuncture/pressure, homeopathic medicine, naturopathic medicine, chiropractic medicine, massage therapy, biofeedback, therapeutic touch Nursing: guided imagery/visualization therapy, healing intention, breath work, humor, mediation, simple touch, music therapy, therapeutic communication

Term Specialized License CAM Interventions

Definition Acupuncture/pressure alters body function or produces analgesia Homeopathic medicine healing remedies Naturopathic med diet, exercise, environment and herbal promote natural healing Chiropractic med treated by manipulation of the spine Massage therapy relaxation/circulation improved stretching/loosening muscles Biofeedback - increase awareness of body responses to minimize extremes Therapeutic touch hands to help bring clients energy fields into balance

Term Nursing CAM interventions

Definition Guided imagery/visualization therapy healing/relaxation by focusing on images Healing intention healing through caring, compassion and empathy in prayer Breath work breathing patterns to reduce stress and increase relaxation Humor reduce tension and improve mood coping mechanism Meditation calm mind and body Simple touch communicates presence, appreciation and acceptance Music therapy relaxation with distraction from pain; concentration Therapeutic communication verbalize/become aware of emotions and fairs

Term Systolic BP versus Diastolic BP

Definition Systole contraction Diastole relaxation Systolic BP occurs during ventricular systole of the heart, when ventricles force blood into the aorta and represents the maximum amount of pressure exerted on the arteries Diastole BP occurs during ventricular diastole of the heart, when the ventricles relax and exert minimal pressure against arterial walls, and represents the minimum amount of pressure exerted on arteries

Term Temperature

Definition balance between heat lost and heat produced: Results from basal metabolic rate, muscle activity, thyroxine output, sympathetic stimulation, dehydration, injury/illness (fever response) Oral: 4+ in sublingual pocket 36-38; no trauma to face, do not use if bite Rectal: .5d less than oral; not with bleeding precautions/stool, second measure if above 37.2 Axillary: clean/dry with arm over/held down; use under 3m Tympanic: pull ear up and back(a)/down and back(c); outer ear canal Temporal: wipe lens with alc; scan/hold against flat forehead moving gently over to temporal artery, touching skin behind ear; release and read Fever not harmful unless past 39

Term Hyperthermia

Definition abnormally elevated temperature

Obtain specimen for WBC/ESR/electrolytes Antibiotics from culture Fluids/rest Antipyretics (tylenol/motrin/aspirin-not children) Prevent shivering; head covered Oral hygiene

Term Hypothermia

Definition temp below 35 Heated humidified O2 Warming blanket Warmed fluids Cardiac monitoring with emergency resuscitation on standby

Term Pulse

Definition rate/rhythm of heart 0-4/absent to bounding scale; 2 is normal Apical may be faster in pulse deficit then radial and only appear during dysrhythmia - use for irregularities, before cardiac meds, rapid rates and infants(normal is 120-160 bpm)

Term Heat transfer mechanisms

Definition Conduction: heat from body to surface (submerged in cold water); convection: heat by air currents; evaporation: heat through water vapor (sweat/diaphoresis); radiation: one object to another without contact (heat loss to cold room)

Term Tachycardia/Bradycardia measuring

Definition Tachycardia Assess/monitor: for other s/s: pain, anxiety, restlessness. Fatigue, low BP, low o2 sats, for potential side/adverse effects of medications Bradycardia Assess/monitor: s/s: hypotension, chest pain, syncope, diaphoresis, dyspnea, altered mental status

Term Respiratory Rate factors

Definition Age - decreases with age (infants 30-60; school-aged 20-40; 12-20) Pain - increases before stabilizing; decreases depth Brainstem injury - decreases rate and rhythm impaired 02 (95-100% norm, below 85% abnorm) Check RR in semi-fowlers

Term Blood Pressure

Definition Determined by CO: BP = CO x SVR (systemic vascular resistance d/c)

Normal 120/80 Prehypertension: S 120-139 D 80-99 Stage 1 hypertension: S 140-159 D 90-99 Stage 2 hypertension: greater than 160/100 based off highest reading; difference = pulse pressure infants-low; children/fat-higher; adults increase w age; OA-increase systolic due to d.elasticity; higher in AA; lowest in early morn

Term Measuring BP

Definition Rest 5m before; no caffeine/smoking 30m before Not on side with IV/mastectomy or shunt Use arm with higher vascular reading

Sit, feet flat, arm at heart level Inflate to 30mmHg above palpated systolic and release at 2/3mmHg per sec Measure standing after initial; 2m apart

Term Hypertension

Definition Factors: renal or thyroid disease, meds, constriction of BV, increased fluid Potassium, Calcium and Magnesium can help lower BP Restrict sodium, carb, and saturated fat intake

Term Cultural Barrier

Definition can lead to stress disorders or depression Language, communication, culturally inappropriate tests and tools that lead to misdiagnosis, and ethnic variations in drug metabolism related to genetics Nurses should always accommodate cultural beliefs and values except in direct conflict w essential health practices

Term Subcultures

Definition Factors within the culture that may be held differently based on: age, gender, sexual orientation, marital status, family structure, income, education level, religious views, life experiences

Term Spirituality

Definition Connectedness with a higher power, achieve balance in life, maintain health, to seek health care, and to deal with illness and injury as well as give hope(anticipation/optimism; provides comfort), faith(religion or culture) and transcendence

Term Muscoskeletal System

Definition examination includes looking at the structure and function of the system; examining each joint and muscle, the surrounding tissues and comparing symmetric parts Inspection and palpation: height, posture, spine/back, ROM, muscle symmetry and strength

Term Neurological system

Definition examination can evaluate the major indicators of neurological function and assist with recognizing dysfunction; integrated with other assessments Level of consciousness and general state of health (motor function and mental status for cerebral function, cranial nerve assessment, sensory function and reflexes)

Term Levels of Consciousness

Definition Alert - responsive, fully responds Lethargy - open eyes and respond but is drowsy and falls asleep repeatedly Obtundation - needs to be lightly shaken Stupor - painful stimuli to achieve brief response, sometimes not verbally Coma - 3 on Glasgow Coma scale, no response, abnormal posturing

Term Mini-Mental Exam

Definition Orientation of time and place Attention and calculation of counting backwards by 7 Registration and recalling of objects Language, inculding naming of objects, following of commands and ability to write

Term Bowel

Definition Collect stool specimen for serial fecal occult test (guaiac) Fiber requirement 25-30 Foods high: whole grains, fruits, veggies

Term Hemorrhoids

Definition dilated BV in rectal wall from straining, can be caused by heart failure, liver disease and pregnancy itchy, painful, bloody moist wipes to cleanse; moisture creams/ointments may help

Term Fun urine control facts

Definition Full bladder control 4-5 years, prostate enlargement after 40 years, Older: fewer nephrons, loss of blader muscle tone, inefficient emptying, nocturia; childbirth kegel exercises; pregnancy increases circulatory volumve/renal workload up to 50%, relaxin relaxation of sphincter, sodium leads to decrease, spinal cord injury, suppression of the urge whith pain, alterations in glomerular filtration rate from anesthesia/opiod analgesics causes decrease, meds

Term If found with an evisceration:

Definition You will see protrusion of organ from wound caused by seosanguineous fluid. Call for help Stay with the client Position supine Cover with sterile towels/sterile saline dressings Observe for shock

Term Would Healing Stages

Definition - Inflammatory 3 days control bleeding with clot formation; deliver O2, WBC, nutrients - Proliferative: 3-24 days: replace lost tissue with connective/granulated; contract wound edges; resurface new epithelial cells - Maturation/Remodeling: strengthening collagen scar/restoration of normal appearance; one year plus depending on extent

Term Feeding Complications

Definition oGR above 100mL: withhold, notify, semi-Fowler, recheck in 1 hour oDiarrhea 3+ in 1 day: notify, dietitian, skin care oNausea/vomiting: withhold, turn to side, notify, check patency, aspirate residual; auscultate oAspiration: withhold; notify; x-ray; o2 as indicated; turn to side; suction; temp; auscultate oSkin irritation: skin barrier; monitor placement

Term NG Complications

Definition - Excoriation of nares and stomach: apply lubricant as needed; asses color of drainage. REPORT DARK/COFFEE-GROUND OR BLOOD STREAKED DRAINAGE immediately - Discomfort: rinse mouth with water for dryness; throat lozenges; oral hygiene frequently - Occlusion of NG leading to distention: irrigate per facility protocol to unclog; tap water with enteral feedings; change position in case the tube is against the stomach wall

Term Documentations when discontinuing an NG tube

Definition tubing removal/condition of the tube, volume and description of the drainage, abdominal assessment including inspection, auscultation,

palpation and percussion; last and next bowel movement and urine output

Term Accidental Decannulization

Definition Emergency in first three days Ventilate with manual resusitation bag call for help immediately hyperextend the neck with obturator inserted into treacheostomy tube Quickly and gently replace tube and remove obturator Secure tape, assess placement with bilateral auscultation If fail: o2 through stoma. If fail: cover stoma and o2 through mouth/nose

Term IV catheter sizing

Definition Trauma client 16 gauge rapid fluid volume Surgical client - 18 gauge rapid blood Other 22-24 gauge children/adults theater

Term IV guidelines

Definition Never give in bolus if it can cause serious adverse reactions; IV pump; potassium chloride Never administer IV meds through tubing that is infusing blood, blood products or nutritional solutions Fragile veins, anticoagulants, elderly: no tourniquets, use BP cuff, do not slap extremity Edema: Digital pressure with alcohol pad over selected vein to displace it Fluids should not hang more than 24 hours

Term Needle sizes, gauge and degree entering

Definition Intradermal: tuberculin/allerfy/canver immunotherapy: 3/8 to 5/8 inch 2627, .01 to .1mL; 10-15degrees Subcutaneous(pinch an inch)[heparin/insulin]: max 1.5mL; 5/8 to 1/2 inch 25-27n, 45-90 d Insulin 25,26,27 Intramuscular: 1 to 1 1/2 inch, 18 to 27n, 22-25 gauge; 1-3ml injected Z-track: Type of IM injection that prevents medication from leaking into subq; stains

Term Preventing error in the nursing process

Definition A: Obtain necessary preadministration data (HR/BP) Question prescriptions that seem unclear or inappropriate or not gradual! P: Set priorities, identify client outcome I: No distractions during med prep. Double check labels, measurements, amount, 6 rights Educate client then omit/delay if client questions size or appearance or as indicated by their condition Discarding controlled substance must be witnessed E: Evaluate response, document, and report Recognize side/adverse effects document and report Errors report (not part of permanent record)

Term Six Rights to safe administration

Definition 1. verify identification each time, check allergies by bracelet, asking and med administration record Jco requires two identifiers (personspecific)Right Client 2. check label 3 timesRight Medication 3. calculate and check drug reference to ensure its within usual rangeRight Dose 4. on time to maintain consistent therapeutic blood levelRight Time 5. Right Route 6. immediately record pertinent info, including response to medRight Documentation

Term Medication Reconciliation

Definition JCo requires this. Nurse should compile list of current medications ensureing all are included, with correct dosages and frequency. Compare list with new medication prescriptions and reconcile to resolve any discrepancies. This list becomes current for administration. This should be done: on admission, when transferring between units/facilities and at discharge.

Term Prescription components

Definition Components: client name, date and time, name of med, dosage, route, frequency, signature

Term Types of prescriptions

Definition routine/standard(regular schedule), single/one time(certain time or as soon as possible), stat(once, immediately), PRN(per needed with clinical judgement; prescription says what doage, what frequency and under what conditions), standing(for specific circumstances/units)

Term Nurses legal responsibility to med administration

Definition - Preparing, administering and evaluating client responses to meds - Maintaining up to date knowledge including: uses, mechanisms of action, routes of administration, safe dosage range, side effects, adverse responses, precautions and contraindication - Determining accuracy of med orders

Term just some parental facts/locations

Definition Parenteral vastus lateralis site < 2 years of age, >2 can use ventral gluteal up to 2mL or deltoid up to 1mL Tuberculin syringe for solution colunes < 0.5 mL

Term Disoriented clients

Definition o Call by name and identify yourself o Maintain eye contact at eye level o One question/one direction at a time said briefly and slowly with time for response o Avoid lengthy conversations o Adequate sleep and pain management

Term Aphasia defecit (speech/language) clients

Definition o Greet client and call them by name o Speak clearly, slowly and short without shouting o Pause between statements to allow understanding o Check for comprehension o Minimize background noise o Ask questions that requires simple answers and allow for time o Match verbal with nonverbal o Picture charts or other speech therapist measures (writing) may improve communication o Acknowledge and frustration expressed

Term visually impaired client

Definition o Call by name before approaching and introduce yourself, staying within visual field o Give specific information on location of items in area of building or food on tray leaving o Explain interventions before touching o Inform client of your departure o Appraise clothing and suggest changes if soiled or torn o Made a radio, television, compact disc, or digital audio file player available for use

Term

Definition

hearing impaired client

o Sit and face client without covering mouth while speaking o Hearing devices o Speak slowly and clearly without shouting, try lowering pitch o Brief sentence/simple words, write down if not understood o Sign language interpreter if necessary

Term Catheter Irrigation

Definition - Prepare a sterile syringe - Clamp catheter between injection port/extension tubing - Cleanse injection port with antiseptic swab/wipe - Insert needle of syringe with irrigant into injection port - Inject slowly - Withdraw and remove clamp; allowing irrigant to drain into drainage bag

Term Catheter size

Definition 8-10 for children 14-16 for women 16-18 for men

Term Urinary elimination diagnostic tests

Definition Bedside sonography/bladder scan ultrasound scanner noninvasively measures bladder volume after voiding KUB kidneys/ureters/bladder xray to determine size, shape, and position of kidneys IVP contrast to ciew ducts, renal pelvis, uterters, bladder and urethra, Iodine is used check for a shellfish allergy Renal scan renal blood flow and anatomy of kidneys without contrast Renal Ultrasound view of gross renal structures Cystoscopy endoscope to visualize bladder/urethra Urodynamic testing tests bladder muscle function by filling with Co2 ot .9% sodium chloride and comparing pressure readings with clients reported sensations

Term Urine - med changes

Definition Pyridium orange Amitriptyline green/blue Levodopa (dopar) brown/black Chemotherapy toxic for kidneys

Term hypovolemia data

Definition Causes: GI loss, diaphoresis, renal loss, third spacing, hemorrhage, altered intake Vitals: hyperthermia, tachycardiam thready pulse, hypotension, orthostatic hypotension, decreased central venous pressure, tachypnea, hypoxia dizzy, syncope, confused, weak, tired decreased production of urine, flattened neck veins

Term hypovolemia care

Definition assess respiratory status SOB, dyspnea Check urinalysis, O2 sat, CBC and electrolytes Measure client weight daily at same time, same scale Vitals LOC heart rhythem IV Shock position (back with legs elevated) Fluid replacement I&O-alert under 30 hour assess gait

Term hypovolemia care

Definition assess respiratory status SOB, dyspnea Check urinalysis, O2 sat, CBC and electrolytes Measure client weight daily at same time, same scale Vitals LOC heart rhythem IV Shock position (back with legs elevated) Fluid replacement I&O-alert under 30 hour assess gait

Term Lab values

Definition Tylenol max of 4 g/day Fiber: 25-30 Blood glucose: 70-250 Potassium: 3.5-5 Serum Sodium: 136-145 Calcium 9-10.5 Mg: 1.3-2.1

Term Pressure Ulcer Risk Lab Values

Definition Norton below 14 Braden Below 18 Serum below 3.5

Term Standard conversions

Definition 1 mg = 1000mcg 1g = 1000mg 1kg = 1000g 1oz = 30mL 1L = 1000mL 1tsp = 5mL 1tbsp = 15mL 1tbsp = 3tsp 1kg = 2.2lb 1gr = 60mg

Term Math dose

Definition what you have of the quantity Have/Quantity = Desire/X desired*quantity/have = amount to be given by weight: Amount prescribed*kgweight (mg*kg) = TDD TDD/# of doses per day = amount per dose ^use this as desired

Term Manual and Electronic pump math

Definition Electronic: mL/hr Volume(mL)/Time(hr) = IV flow rate Volume(mL)/Time(min) = XmL/60min Manual: Volume to be infused/Time(min)*drop factor drop factor*Volume(mL)/Time(hr)*(1hr/60m)