Foundations Final Jersey College Questions and Answers

Foundations Final Jersey College Questions and Answers Hypoxia deficiency in the amount of oxygen reaching the tissues Auscultation to listen Palpation an examination technique in which the examiner's hands are used to feel the texture, size, consistency, and location of certain body parts percussion tapping on a surface to determine the difference in the density of the underlying structure Piece of equipment is used to perform the Weber test and Rinne test Tuning Fork Weber's test and Rinne's test are performed in order to assess Sound Conduction (deafness) When assessing a "PT" eye, which instrument would the nurse use to visualize the retina Ophtalmoscope ophtalmoscope instrument for examining the interior of the eye, especially the retina percutaneous through the skin The nurse performs a comprehensive assessment of a newly admitted client. What is the primary purpose of this admission assessment Identify baseline data Comprehensive assessment The comprehensive assessment is conducted when a client first enters the health care setting to obtain baseline information that can be used for comparison to later assessments. When assessing the glossopharyngeal nerve, it is most important for the nurse to implement which intervention The clients ability to swallow cranial nerves 12 pairs of nerves that carry messages to and from the brain Cranial Nerve 1 Olfactory (smell) Cranial Nerve 2 Optic - vision Cranial Nerve 3 Oculomotor (eye movement) Cranial Nerve 4 Trochlear (eye movement) Cranial Nerve 5 Trigeminal Cranial Nerve 6 Abducens (motor) Cranial Nerve 7 facial nerve Cranial Nerve 8 Vestibulocochlear Cranial Nerve 9 Glossopharyngeal Cranial Nerve 10 Vagus Cranial Nerve 11 Accessory (motor) Cranial Nerve 12 Hypoglossal (tongue movement) popping sounds heard on auscultation of the lungs crackles Hepatitis inflammation of the liver Hepatitus B Virus Virus caused by contact with bodily fluids and can cause scarring of the liver, liver failure, cancer, or death. Assessment Before the nurse can determine what care a person requires, the nurse must determine the client's needs and problems. This requires the use of assessment skills and data collection, which include interviewing, observing, and examining the client, and in some cases, the client's family. Following the assessment, the nurse can also use the client's medical record and contact other healthcare providers. When using an interpreter The nurse should observe the cues the client expresses with body language, and listen to the tone of voice. Tugor skins elasticity; poor elasticity seen when skin remains pinched (slowly unfolds) sign of dehydration Chlorhexidine an antibacterial compound with substantial residual activity that is used as a liquid antiseptic and disinfectant arterial blood pressure Arterial blood pressure (ABP), a basic hemodynamic index, is often used to guide therapeutic interventions in critically ill patients peripheral venous catheter a peripheral venous catheter, peripheral venous line or peripheral venous access catheter is a catheter placed into a peripheral vein for intravenous therapy such as medication fluids. Upon insertion, the line can be used to draw blood Edema happens when there is which fluid volume imbalance? extracellular fluid volume excess Anemia a deficiency of red blood cells pallor Extreme or unnatural paleness Appropriate Levels Potassium 3.5-5.0 Phosphorus 2.5-4.5 Magnesium 1.3-2.3 Sodium 135-145 Chloride 97-107 Calcium 8.6-10.2 Bicarbonate 25-29 Packed Red Blood Cells (PRBCs) To increase oxygen-carrying capacity in patients with anemia, in patients with substantial hemoglobin deficits, and in patients who have lost up to 25% of their total blood volume administered as 1 unit over 2-3 hours not to exceed 4 hours Potassium sparing diuretics Potassium-sparing diuretics such as spironolactone, amiloride, and triamterene all have the potential to cause hyperkalemia. Pediatric IV sites foot NPO nothing by mouth Furosemide loop diuretic decreases potassium levels Hypovolemia decreased blood volume How is control over the extracellular concentration of potassium within the human body is exerted aldosterone. phlebitis vein inflammation Prealbumin a thyroxin-binding protein measured to evaluate the nutrition status of critically ill patients who are at high risk for malnutrition Braden Scale 10-12 is high risk 19-23 no risk at all 15-18 low risk 13-14 moderate risk Normal respiratory rate 12-20 breaths per minute Normal oxygen levels 95-100 Normal pulse rate 60-100 bpm Normal blood pressure range 120/80 Normal temperature range 97-100 Implementing Carrying out plans and helping employees to work effectively. indirect care intervention treatment performed away from the patient but on behalf of a patient or group of patients nursing intervention any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes; there are nurse-initiated, physician-initiated, and collaborative interventions standing orders document that details the nursing care to be implemented in specific nursing situations, frequently when a physician is not present; may expand scope of nursing responsibilities unlicensed assistive personnel (UAPs) individual who is trained to function in an assistive role to the licensed registered nurse in the provision of patient activities as delegated by and under the supervision of the registered professional nurse Alfaro's rule Assess, re-assess, revise, record: Assess patients before performing nursing actions. Re-assess them to determine their responses after you perform nursing actions. Revise your approach as indicated. Record patient responses and any changes you made in the care plan. NIC Nursing Interventions Classification direct care intervention is a treatment performed through interaction with the patients include both physiologic and psychosocial nursing actions and include both the "laying on of hands" actions and those that are more supportive and counseling in nature. nurse variables Nurse variables that influence the implementation of the care plan include levels of expertise, creativity (ability to match patient needs with specific nursing strategies), willingness to provide care, and available time. Protocols written plan that details the nursing activities to be executed in specific situations *Nursing Intervention An important nursing intervention is ongoing data collection. In every patient encounter, it is important to be sensitive to both subtle and dramatic changes in the patient's condition *Nursing Intervention Another vital nursing intervention is ongoing risk management. While monitoring the patient's responses to the care plan, nurses are also alert to the development of new problems that may result in the identification of new diagnoses or collaborative problems. Remembering the legal truth "It wasn't done if it wasn't documented," each nurse carefully documents all nursing interventions. Alveoli small air sacs at the end of the terminal bronchioles that are the site of gas exchange in the lungs atria upper chambers of the heart atrioventricular bundle a bundle of modified heart muscle that transmits the cardiac impulse from the atrioventricular node to the ventricles causing them to contract bradypnea abnormally slow breathing dyspnea difficult or labored breathing endotracheal tube polyvinyl-chloride airway that is inserted through the nose or the mouth into the trachea, using a laryngoscope as a guide expiration breathing out (exhalation) inspiration breathing in (inhalation) Respiration gas exchange between the atmospheric air in the alveoli and blood in the capillaries sinoatrial (SA) node A specialized area of cardiac tissue, located in the right atrium of the heart, which initiates the electrical impulses that determine the heart rate; often termed the pacemaker for the heart. Pacemaker of the heart wheezes continuous high-pitched whistling sounds produced during breathing ventricles Lower chambers of the heart oxygen and carbon dioxide must move through the alveoli as part of the oxygenation process. Thus, an adequately functioning respiratory system is vital for the exchange of gases. The airway begins at the nose and ends at the terminal bronchioles, is a pathway for the transport and exchange of oxygen and carbon dioxide.. upper airway composed of pharynx, larynx, and epiglottis. Its main function is to warm, filter, and humidify inspired air. The lower airway, known as the tracheobronchial tree Includes the trachea, right and left main stem bronchi, segmental bronchi, and terminal bronchioles (Fig. 39-1). Its major functions are conduction of air, mucociliary clearance, and production of pulmonary surfactant.