WGU D439 FOUNDATIONS OF NURSING OA
88 COMPREHENSIVE STUDY GUIDE
◉ no radial pulse at 90.
Answer: PUMP TO 120
◉ how much to pump cuff.
Answer: at least 30 mm Hg above the point the radial pulse
disappears
◉ potassium levels involved.
Answer: heart: helps the heart squeeze
◉ high potassium levels.
Answer: high apical pulse rate and rhythm
◉ nursing charts by exception- lungs.
Answer: LUNG SOUNDS DIMINISHED IN LEFT LUNG not normal
◉ nasal cannula care: if patient has reddened areas around
cheekbones.
Answer: PLACE PADDING AROUND THE CANNULA TUBING
,◉ nasal cannula care: if patient's O2 readings improve with
movement.
Answer: place the nasal cannula in the nose securely
◉ nasal cannula care: O2 levels low.
Answer: VERIFY PLACEMENT OF PULSE OXIMETER
◉ Oxygen chamber.
Answer: store in a cool area
◉ Fall Prevention "H".
Answer: Hourly rounds: check on patient HOURLY
◉ Fall prevention "O".
Answer: Organize belongings: use bed alarms
◉ Fall Prevention "P".
Answer: Position changes slow: ensure slow position changes and
keep everything needed within reach
◉ Fall Prevention "E".
,Answer: Ensure lighting is sufficient: For elderly patients keep a well
lit room
◉ patient has sleep apnea and given sedative.
Answer: MAKE SURE AIRWAY PRESSURE DEVICE IS ON
◉ restraint types.
Answer: chemical & physical
◉ restraint knot.
Answer: slip knots
◉ restraint tying area.
Answer: BED FRAME ONLY
◉ chemical restraints.
Answer: meds such as benzos
◉ first thing to assess after restraint.
Answer: CAPILLARY REFILL
◉ when to check capillary refill when restrained.
, Answer: immediately and every 15 mins
◉ other checks when restrained.
Answer: skin integrity, vital signs, ROM every 2 hours; offer
bathroom every 2 hours
◉ restraint documentation.
Answer: reasoning, mental status, care offered, time in restraints
◉ restraint order time.
Answer: ONLY last 24 hours
◉ urine specific gravity test use.
Answer: identify dehydration, kidney problems, conditions like
diabetes insipidus
◉ urine specific gravity test & range.
Answer: concentration of particles in urine; 1.005- 1.030
◉ high urine specific gravity test.
Answer: HIGH = YOU'RE DRY/ DEHYDRATED =
VOMITING/DIARRHEA
88 COMPREHENSIVE STUDY GUIDE
◉ no radial pulse at 90.
Answer: PUMP TO 120
◉ how much to pump cuff.
Answer: at least 30 mm Hg above the point the radial pulse
disappears
◉ potassium levels involved.
Answer: heart: helps the heart squeeze
◉ high potassium levels.
Answer: high apical pulse rate and rhythm
◉ nursing charts by exception- lungs.
Answer: LUNG SOUNDS DIMINISHED IN LEFT LUNG not normal
◉ nasal cannula care: if patient has reddened areas around
cheekbones.
Answer: PLACE PADDING AROUND THE CANNULA TUBING
,◉ nasal cannula care: if patient's O2 readings improve with
movement.
Answer: place the nasal cannula in the nose securely
◉ nasal cannula care: O2 levels low.
Answer: VERIFY PLACEMENT OF PULSE OXIMETER
◉ Oxygen chamber.
Answer: store in a cool area
◉ Fall Prevention "H".
Answer: Hourly rounds: check on patient HOURLY
◉ Fall prevention "O".
Answer: Organize belongings: use bed alarms
◉ Fall Prevention "P".
Answer: Position changes slow: ensure slow position changes and
keep everything needed within reach
◉ Fall Prevention "E".
,Answer: Ensure lighting is sufficient: For elderly patients keep a well
lit room
◉ patient has sleep apnea and given sedative.
Answer: MAKE SURE AIRWAY PRESSURE DEVICE IS ON
◉ restraint types.
Answer: chemical & physical
◉ restraint knot.
Answer: slip knots
◉ restraint tying area.
Answer: BED FRAME ONLY
◉ chemical restraints.
Answer: meds such as benzos
◉ first thing to assess after restraint.
Answer: CAPILLARY REFILL
◉ when to check capillary refill when restrained.
, Answer: immediately and every 15 mins
◉ other checks when restrained.
Answer: skin integrity, vital signs, ROM every 2 hours; offer
bathroom every 2 hours
◉ restraint documentation.
Answer: reasoning, mental status, care offered, time in restraints
◉ restraint order time.
Answer: ONLY last 24 hours
◉ urine specific gravity test use.
Answer: identify dehydration, kidney problems, conditions like
diabetes insipidus
◉ urine specific gravity test & range.
Answer: concentration of particles in urine; 1.005- 1.030
◉ high urine specific gravity test.
Answer: HIGH = YOU'RE DRY/ DEHYDRATED =
VOMITING/DIARRHEA
