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NUR 160-Hondros Exam 1, HONDROS NUR
160 EXAM 1, Spring hondros college
Nursing 160, HONDROS NUR 160 EXAM 1,
Hondros Nur160 exam 1, Nursing 160-Exam
1, Hondros- Nursing 160 exam 1
just culture - (ANS ) workers are protected from disciplinary action when they report injuries, errors, or near misses close-ended question - (ANS ) What is your name? false reassurance - (ANS ) Everything will be fine Why Assess? - (ANS ) To identify changes in pt condition, to help foresee areas of concern RN - (ANS ) who does the initial assessment? Within 24 hours - (ANS ) When should an initial assessment be done? discharge planning - (ANS ) What should we pay attention to when a pt is post op knee replacement and they live on 2nd floor Steps of an assessment - (ANS ) 1. Introduce self
- Explain procedure
- wash hands
- Identify pt
- Provide privacy
- Inspect, auscultate, palpate Correct, then continue - (ANS ) If a concern arises during assessment (Ex: pt c/o SOB. Sit up, apply O2 or check tubing, teach inhale through nose, exhale through mouth) Order of assessmet - (ANS ) Subjective then Objective (helps to identify ares of focus) Inspect airway, auscultate lungs - (ANS ) If pt c/o sore throat or recent cold Serous Drainage - (ANS ) Clear(Good or indifferent) Sanginous Drainage - (ANS ) Blood-red(a little is ok, alot is bad) Serosanginous Drainage - (ANS ) Pink-mix of blood and serous(This is ok) Purulent Drainage - (ANS ) Puss (assess for infection and notify MD) Absent Bowel Sounds - (ANS ) Auscultate 5 mins per quadrant (Silence means NOTHING) ( minute total) assess for an obstruction and notify MD
Symptoms of Hyperglycemia - (ANS ) extreme thirst, frequent urination, dry skin, hunger, blurred vision, drowsiness, nausea Symptoms of Hypoglycemia - (ANS ) shaking, tachycardia, sweating, anxious, dizzy, hunger, impaired vision, weakness, fatigue, headaches, irritable insulin - (ANS ) NPH-longer lasting (cloudy) Regular- faster acting (clear) Order of Insulin Draw - (ANS ) cloudy(air), clear(air),clear(insulin), cloudy(insulin) 70-110 - (ANS ) Normal BS Vision Intervention - (ANS ) Annual Eye Exam Vision Assessment - (ANS ) PERRLA, peripheral testing, snellen chart, Hx (changes in vision?, dark spots?, flashes?, issues in certain lighting?) Vision pt education - (ANS ) Certain drops can burn eyes, burning is better than being blind (miotics) Hearing interventions - (ANS ) 1. Face to face
- Speak clearly, slowly and directly
- Eliminate background noise Hearing Treatment - (ANS ) audiology Cataract Assessment - (ANS ) 1. dimness
- misty vision
- blurriness (milky haze) Glaucoma - (ANS ) High IOP Timolol - (ANS ) Glaucoma Tx ARMD risks - (ANS ) 1. depression
- ignoring Sx
- injuries, falls, accidents, mobility ARMD sight - (ANS ) Loss of central vision- can see on side(may place things to one side or other) Glaucoma Sight - (ANS ) Loss of peripheral vision-side vision Deafness Intervention - (ANS ) hearing aid care
Age prevention - (ANS ) sunscreen, antiaging products, lotions, hydration Nutrition Hx - (ANS ) What do you eat? Vitamins? OTC? Restrictions? BMI- high? Low? Constipation or Diarrhea? Nutrition prevention - (ANS ) Meal planning, diet, exercise, see dietician, if pt has cancer increase protein, low fat, increase calories Physical activity Hx - (ANS ) How much? Weight bearing? Intensity? ROM problems? Pain? Aerobic or Anaerobic? Physical Activity prevention - (ANS ) increased activity with plan, buddy system, classes, pain management for exercise if needed (1 hr before) Carcinogen Exposure Hx - (ANS ) radiation (time, distance, shielding), asbestos, led, pollution, sun or tanning, coal miner, Agent Orange?
Carcinogen prevention - (ANS ) PPE, avoidance, move if needed, remove lead, no tanning, stay out of sun Genetics Hx - (ANS ) family Hx, current Dx-past medical Hx, genetics testing (BRACAA1 or 2), blood tests, saliva Genetics prevention - (ANS ) proper screenings. good chronic Disease care prophylactic Tx, if indicated(mastectomy, Oophorectomy) Racial/Social Hx - (ANS ) poverty, food ingestion, BMI, alcohol, smoking, Sexual Hx, location of family home, work location, type of work, Sickle cell (AA), clotting factors (Caucasian) Racial/Social Prevention - (ANS ) education, screenings, dietary changes, routine medical care, changing jobs, abstaining Primary Prevention - (ANS ) PPE Secondary Prevention - (ANS ) Self Breast Exam Tertiary Prevention - (ANS ) Pulmonary Rehab
2 - (ANS ) two cells, one site 3 - (ANS ) invading>two sites adjacent 4 - (ANS ) two or more separate sites Types of errors - (ANS ) Diagnostic Treatment Preventative Communication Diagnostic error - (ANS ) delay in diagnosis Treatment error - (ANS ) gave 10,000mg of medicine instead of 1000 Preventative error - (ANS ) did not use bed alarm and pt fell communication error - (ANS ) failure to communicate Active error - (ANS ) error made during care provided Latent error - (ANS ) flaws in system (they did not update policy,etc.)
Morphine - (ANS ) For severe pain, schedule II, binds to opiate pain receptors, BBB Percocet - (ANS ) moderate to high pain, acetaminophen with oxycodone, BBB Norco - (ANS ) moderate pain, acetaminophen with hydrocodone Acetaminophen - (ANS ) mild to moderate pain, BB, resets hypothalamus, Acetaminophen warning - (ANS ) Do not exceed 4000mg per day. Acute liver failure, consider other sources of acetaminophen Forms of communication - (ANS ) 1. open-ended
- close-ended
- restating
- clarifying
- review/summary 6.stating
- paraphrasing Factors affecting Communication - (ANS ) 1. false assumption
- false reassurance
- giving advice
- defensiveness
Ceftriaxone - (ANS ) Broad-spectrum antibiotic Populations at risk for surgical complications - (ANS ) the very young and the very old, nutritional needs, chronic disease, people under stress (fear or anxiety), certain cultures, people on multiple medications and herbal remedies Immunodeficiency - (ANS ) healing slow and prone to infections Chronic disease - (ANS ) body is under stress, infection can easily occur medications - (ANS ) some cause immunodeficiency; some interact with anesthesia, some cause bleeding malnutrition - (ANS ) does not promote healing, protein is good for healing Pre-op testing - (ANS ) glucose level, EKG, blood counts, liver and kidney function, serum electrolytes, blood chem profile. Does the pt have any chronic conditions? Pt education in surgical cases - (ANS ) Infection control, signs of an infection, what to do if infection is suspected, when to call provider Concerns for education - (ANS ) level of cognition, How does the person learn?,
Informed Consent teaching - (ANS ) 1. Pt is competent and agrees to have procedure stated on form
- Risks should be explained by provider
- Make sure pt can see and hear what they are consenting to GI prep for surgery - (ANS ) 1. When pt should start NPO status Bowel prep, if ordered
- May have oral care
- Which meds will be taken, which will be held Skin Prep for surgery - (ANS ) 1. When and how to cleanse skin and with what
- If shaving is ordered, when, how, where
- What not to use on cleansed skin Latex allergy and surgery - (ANS ) 1. Screening for latex allergy risk
- Identified to all staff involved
- Allergy bracelet placement
- What kind of reaction? Respiratory Prep for surgery - (ANS ) 1. How to use incentive spirometer
- What sputum should and should not look like
- Why incentive spirometer is important, what symptoms do they need to report
Pre-operative checklist - (ANS ) Ensures all required care has been performed and that the patient is properly prepared for surgery Respiratory Prep for surgery - (ANS ) NARCOTICS - (ANS ) BIND TO OPIOID RECEPTORS IN THE CENTRAL NERVOUS SYSTEM BLACK BOX WARNING - (ANS ) FDA ISSUED WARNING AS SEVERE LIFE THREATENING EFFET SHCEDUALING OF DRUGS - (ANS ) DEFINED AS THE STRENGTH OF DRUGS I => HIGHEST II =>MOST COMMON NON SHCEDUALED => OVER THE COUNTER MAX DOSE OF ACETAMINOPHEN - (ANS ) 4G OR 4000MG
- DAMAGE TO LIVER ALL CONTAIN ACETAMINOPHEN - (ANS ) ACETAMINOPHEN PERCOCET
NARCO
VICODIN
MORPHINE - (ANS ) -OPIOID NARCOTIC
-SHCEDUAL II
-DOES NOT CONTAIN ACETAMINOPHEN
-SIDE EFFECTS
*DECREASES MENTAL ALERTNESS
*EUPHORIA
*DYSPOHRIA
**** RESPIRATORY DEPRESSION*****
*NAUSEA
*VOMITING
*BRONCHOCONSTRICTION
*DECREASED URINATION
*BRADYCARDIA
WHAT TO DO IF PATIENT THINKS MEDS ARE WRONG - (ANS ) CHECK AGIAN
WHAT TO DO IF PATIENT VOMITS 5 MIN AFTER MEDS - (ANS ) CALL DOC
WHY NPO - (ANS ) TO REDUCE APSERATION
MALIGNANT TUMORS - (ANS ) -RATE OF GROWTH VARIES
-METASTASIZES
-RARELY CONTAINED IN A CAPSULE
-IRREGULAR MORE IMMOBILE WHEN PALPATED
-LITTLE RESEMBLANCE TO PARENT TISSUE
-INVADES NORMAL TISSUE
-MAY RECUR AFTER REMOVAL
-FATAL WITHOUT TREATMENT
OBJECTIVE - (ANS ) Information written or read that is based on facts rather than feelings or opinions. SUBJECTIVE - (ANS ) Based on personal opinions, feelings, and attitudes; not objective ANTICOAGULANTS - (ANS ) substances that prevent blood clotting CANCER STAGING - (ANS ) 1-4 =>LEVEL OR DEGREE OF PROBLEM X =>CANT ASSES O =>NONE IS => INSITU T =>TUMOR N => NODE
M => METASTASIS (SPREADING
INSITU - (ANS ) GROUP OF ABNORMAL CELLS THAT COULD TURN INTO CANCER
** PRECANCER
NEUTROPENIC PRECAUTIONS - (ANS ) Isolation procedures to protect an immunocompromised patient from infections. AVOID FRESH FRUIT VEGIES AND FLOWERRS FACTORS THAT EFFECT WOUND HEALING - (ANS ) -NUTRITION -SMOKING
- DIABETIC PRE OP - (ANS ) -CHECK LIST -NO JEWELRY -LIVING WILL
- ALLERGIES WHAT THEY ARE AND WHAT THEIR REACTION IS -IF THEY HAVE AN ALERGEY TO LATEX NO STRAIGHT RAZOR FOR HAIR REMOVAL -RESPIRATION INFECTION BEFORE SURGERY=>CALL DOC -INFORMED CONCENT
