Review for N172:(
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Difference between a persons apical pulse and radial pulse.
Tells if a patient has A Fib and early diastolic ventricular ectopic beats.
Difference between systolic and diastolic
irregular breathing characterized by hyperventilation alternating with apnea lasting 10-20 seconds
rapid deep respirations associated with ketoacidosis
gasping, irregular, infrequent breaths....end of life.
How do you tell if a person has orthostatic hypotension
when they have a 15mm or more drop in SBP or 10mm or more drop in DBP.
An increase of 15 BPM in patients HR may occur
When seeing a patient what do I assess with their IV?
- Is there any.....
Is the site clean, dry and without signs of complications.
ID solution, rate and the volume remaining along with the equipment/pump used for the infusion
Before I remove an IV what 2 things do I need to do?
- Turn off the pump/or clamp tubing
- Note how much of the solution is left
Assess LOC by asking
Orientation to person, place, time and situation/event
- What's your name
- Where are you
- Whats the date
- What brought you here
Pupils Equal, Round, Reactive to light/Accommodation
- Provoked-what brought it on
- Radiating/Region-from 1 place to another
- Time-for how long
How high do you hold the enema bag?
18 inches above the rectum and they will hold for 2-5 minutes.
How long does it does it take for a stoma to shrink to it's permanent size?
How large do you cut the bandage to go over the stoma?
- 2-3 months
- 1/8-1/16 inches larger than the stoma
When do you empty a stoma bag?
What do you clean it with?
What don't you want to get on to a new stoma?
- when it is 1/2 full or inflated with gas
- water only
- don't get water on a new stoma
ounces to mL's
x it by 30
3 ounces x 30= 90mL
Heard in the lung bases
Heard on inspiration and expiration
High pitched musical sound
Heard over larger airways
Heard on inspiration and expiration
Heard over large airways
1 ounce = how many mL's
1 mcg = how many mg's?
1 kg = how many grams
1 litre = how many mL's
1 tbsp = how many mL's
1 tsp = how many mL's
1 mg = how many mcg's?
Soft bland diet
no fried foods, raw fruits and veggies
decreased amounts of fiber
Sodium restricted diet
- limits sodium to 1000-2000
- (1-2 grams)
Full liquid diet
anything liquid at room temperature...jello, ice cream, creamed soups, milk shakes
Clear liquid diet
jello, tea, cranberry juice
3 ways to test placement of NG tube placement
inject 20-30mL's of air and ausculate for sound
Aspirate for gastric secretions....should be >4 and be acidic
Before I feed somebody with a G Tube what do I do
check for residual....should be 20-100mL's. If more than 100 tell nurse cuz not digesting/eliminating food
Always put what you took out back in.
When administering tube feedings....what do I flush with before and after feeding?
What do I put in between each crushed or liquid medication?
10-100mL's of water
5-10mL's of water
**remember to record these amounts of water in the I&O!!
When measuring distance for NG tube, prior to insertion, what are the markers?
Nose to ear to xiphoid process
What do I irrigate a NG tube with?
Normal Saline....document amount in I&O's
When I am feeding somebody through their NG tube what do I flush with to maintain patency?
20-30mL's of water....prior to feeding and at completion of feeding
Which oxygen mask delivers the highest concentration of O2?
Normal blood glucose
Signs of hypoglycemia
- full/bounding rapid pulse
Rapid onset and progression....dangerous!!
Signs of hyperglycemia
- Flushed skin
- Weak/Rapid pulse
- Deep labored breathing
Slow onset and progression
How do you treat hypoglycemia and hyperglycemia?
hypo-give them carbs in liquids or foods
Where do you collect a urine specimen from a catheter bag?
from the needle-less port in the tubing....not the bag
When do you obtain a sputum specimen?
1-2 hours after a meal or 1 hour before.....and after oral care.
Collect 2-10mL's of sputum
When taking a wound culture.....
Where do you find aerobic cells and anaerobic cells?
Which do you collect first?
aerobic on the edge of a wound
anaerobic on the center of a wound
Obtain anaerobic first
pouring out a little of the first part of a sterile solution
- Size, site, sutures/staples/steristrips
Stages 1, 2, 3, 4
- 1-in tact skin, red
- 2-blister or skin loss of dermis/epidermis
- 3-loss down to subcutaneous layers/necrosis
- 4-full thickness with damage to muscle/bone/supporting structures
What do I clean skin tears with?
Characteristics to be assessed during a dressing change....
- size and color of the wound
What is the panic level for WBC?
<500 at a high risk for infection.....neutropenic
Sedimentation rate tells you....
if a person has inflammation
Hemoglobin is used for
Hematocrit tells you if a person is
Panic value for platelets
<20,000...they are at risk for bleeding out
What is a sign that a person may be hemmoraghing?
Increased HR and Decreased BP
7 Rights of patient medication admin....
Prior to giving a medication injection I need to check...
- 7 rights
- check order
- expiration on the bottle
- time of last injection
When drawing up medication from a vial, make sure to
put the same amount of air in to the bottle that I will be withdrawing from the bottle....pressurize it
Fluid amount and location
Angle of injection
3mL in large muscles of an adult or 1mL in the deltoid or in to thin elderly adults
21-23 gauge and 1-1.5 inches long
With an IM injection to pushing the medication don't forget to....
aspirate to make sure I am not in a blood vessel
What kinds of medications are given intramuscularly
Z track injections
draw up technique
after injection I will.....
Irritating IM medications...Vistaril, Iron, B12 and some antibiotics
- add 0.2 mL of air
- Count to 10 after injection
- DONT MASSAGE
- Loose connective tissue, fatty back of arm or belly
- 1-3 mL's or 0.5mL for infants
- 25-27 gauge and 1/2 to 5/8 inch
- 45-90 degrees
What sort of injection is used for insulin and heparin?
What not to do after these injections....
Heparin...don't pinch or massage
- Allergy testing and TB Tests
- 10-15 degrees
- 26-27 gauge 3/8-5/8 inch needle
When do you read a TB test?
48-72 hours after the injection
Prior to administering medication I need to do 3 checks....
- Check before removing from the drawer/cassette
- Before dispensing
- Recheck at bedside before opening-tell the patient what you are giving
- After pouring and before disposing of the empty container
Prior to giving any medication it is crucial to check....
the expiration date
Medications that shouldn't be crushed
- Sustained Released
- Long Acting
- Controlled release
- Extended Length
- Enteric Coated
What's the time frame of the administration of medication?
Within 30-60 minutes of the written order
Prior to giving Digoxin make sure....
- the Potassium level is btwn 3.5-5.1
- chk the serum dig level....hold if 2+
- take apical prior to admin....hold if below 60
Before giving potassium make sure the serum level is not above
Prior to giving anithypertensives check the persons _______ and hold it if the _______
- Blood pressure and Heart Rate 30 prior to administration
- SBP is <90
Prior to giving anticoagulants what do I check?
PT and INR for Coumadin
don't want platelets <100,000
Never give insulin if the BS is below
What is dangerous about narcotics and sedatives?
it depresses a persons respirations
Prior to administering medications to a patient always....
- Wash Hands
- ID patient with 2 ID's
- Ask about allergies
- Explain why they are getting each medication
- Don't leave until it is all gone
- Wash Hands and clean up wrappers
2 medications that require a 2nd RN to check
Heparin and Insulin
1 g = how many mg?
1 Tbsp = how many tsp?
- Male 13.5-18g/dL
- Female 12-16g/dL
Normal Platelet Levels
Tells if person is Hypoxic
O2 Saturation/Pulse Ox
If this measurement is out of whack the person has metabolic acidosis/alkalosis
If this measurement is out of whack the person has respiratory acidosis/alkalosis
How do Beta Blockers work?
reduces bp by reducing heart rate, heart workload and hearts output of blood
How do ACE Inhibitors work?
cause the body to produce less angiotensin which allows the vessels to relax and open up...causing a lower bp
How do Calcium Channel Blockers work?
it prevents calcium from entering the muscle cells of the heart causing the hearts contraction to be less forceful
- Self Actualization
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