Exam Week 9 part 2

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Author:
alicia0309
ID:
240356
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Exam Week 9 part 2
Updated:
2013-10-13 23:48:00
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nursing 102
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Diagnostics/Blood Administration
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  1. what are the phases of diagnostic testing
    • Pre-Test: Assessment and Evaluation
    • Intra-Test: Obtain Specimen (Assist/Support)
    • Post-Test: Compare, Report & Follow up
  2. if blood is present hemoccult what color is
    blue = blood
  3. normal urine specific gravity
    1.010-1.025
  4. normal urinary pH
    slightly above 7
  5. normal urinary glucose
    • negligable
    • used to Dx but not to treat DM
  6. normal urine Ketones
    • not present
    • if present:
    • poorly controlled DM
    • Alcoholism
    • Starvation
    • high protein diet
  7. Specific Gravity in urine High
    Fluid Deficit
  8. Specific Gravity in urine LOW
    fluid excess
  9. Normal Urinary Protein
    • Not Present
    •  
    • Present = Glomerular Membrane Damage
  10. normal urine osmolarity (amount of particles to water)
    500-800mOsm/L

    • high = fluid deficit
    • low = fluid excess
  11. normal hemoglobin
    • male 14-18
    • female 12-16
  12. normal hematocrit
    • male 37-49%
    • female 36-46%
  13. normal Sodium
    135-145 mEq/L
  14. normal Potassium
    3.5-5.0mEq/L
  15. normal Calcium
    4.5-5.5mEq/L
  16. norma Chloride
    95-100mEq/L
  17. normal Magnesium
    1.5-2.5mEq/L
  18. what is Nurses role in lumbar puncture?
    pre and intra
    • explain, empty bladder/bowel
    • position and drape
    • open puncture kit
    • support neck/knees, reassure pt, observe pt color, resp, pulse
    • label and send to lab
  19. nurses role post lumbar puncture
    • place sterile dressing
    • assist to dorsal recumbent position 1 pillow (must remain 1-12 hrs)
    • give meds if needed and ordered
    • offer liquids freq to restore CSF
    • Monitor Pt (swelling, bleeding, numbness tingling)
    • document procedure
  20. blood type compatibility
    • A -- A, O
    • B -- B,O
    • O -- O
    • AB -- A,B,O,AB
    • + -- + or -
    • -      only -
  21. nursing role in liver biopsy
    Pre-Test
    • give preprocedural meds as ordered
    • Explain, Pt fast 2 hrs prior
    • give sedative 30mins prior
    • supine position w/ RUQ exposed
  22. Nursing Role Liver Biopsy
    Intra-test
    • monitor and support
    • instruct to take few breaths and hold after exhale
    • needle in and breath when removed
    • apply pressure & small dressing
  23. nursing role liver biopsy Post-Test
    • position client o right side w/small pillow or folded towel
    • monitor and assess VS every 15 mins for 1st hr and then every hr for 24
    • check for abdominal pain
    • check for bleeding
    • document and transport
  24. what labs would be ordered to check renal function
    BUN and Creatinine
  25. what lab values reflect patient's hydration?
    Hgb & Hct
  26. blood transfusion reactions
    • sepsis
    • circulatory overload
    • Allergic-severe
    • Allergic-mild
    • Febrile
    • Hemolytic
  27. what to do in the case of hemolytic reaction?
    • Stop
    • remove tubing (must send to lab with blood and urine sample)
    • KVO NS
    • Notify Physician
    • Monitor VS
    • Monitor I&O
  28. S/S Hemolytic reaction
    • chills
    • H/A
    • fever
    • back ache
    • dyspnea
    • cyanosis
    • CP
    • tachycardia
    • hypotension
  29. nursing action
    Febrile reaction
    • D/C blood
    • Give antipyretics
    • KVO w/NS
    • Notify Physician
  30. S/S Febrile
    • fever
    • chills
    • warm flushed skin
    • H/A
    • anxiety
    • muscle pain
  31. Nursing action Allergic - mild
    • stop or slow (protocol)
    • Notify Physician
    • Adm Antihistamines as ordered
  32. Nursing actions
    Allergic -severe
    • stop
    • KVO w/NS
    • Notify Physician
    • Monitor VS-CPR if necessary
    • Adm meds/O2 as needed
  33. Nursing actions
    Circulatory Overload
    • place client upright
    • adm diuretics & O2
    • Notify Physician
    • Stop or Slow
  34. which 2 reactions is slow or stop transfusion
    • Allergic -mild
    • Circulatory Overload
  35. which reactions need nurse to KVO
    • allergic -severe
    • Febrile
    • Hemolytic
  36. what BT reactions does nurse need to monitor VS
    • Allergic -severe
    • hemolytic
  37. when would you need to stop transfusion and send tubing to the lab
    • Hemolytic
    • Sepsis
  38. nursing action Sepsis
    • Stop
    • Send remaining and tubing to lab
    • obtain blood specimen
    • Adm IV fluids, antibiotics
  39. S/S Sepsis
    • high fever
    • chills
    • V&D
    • hypotension
  40. what are blood outcomes
    • admin 1 unit of blood or PRBC
    • Hgb goes up 1gm
    • Hct goes up 3%
    • platelets go up 5,000-10,000
  41. what is Dx testing
    • to monitor illness
    • provide info pertaining to treatment
    • confirm Dx
  42. Nursing interventions to Dx Testing
    • proper collection
    • explain pt role, purpose
    • read report know normal
  43. ABG
    • arterial stick
    • radial, brachial, femoral artery
    • Hold pressure 5-10min
    • put in ice and transport
  44. capillary blood glucose
    • obtain approp site
    • record on flow sheet
    • clean with alcohol let dry
    • extremely high or low recheck or draw and send to lab
  45. after visual procedure what is nurse responsible for
    make sure gag reflex is present before eating or drinking
  46. nursing actions for xray
    • check to see if female is pregnant
    • with barium increased fluids and give laxative
  47. laryngoscope an bronchoscope
    sterile procedures
  48. untrasound
    no pain gel is cold tell patient
  49. nuclear test
    involve nuclear isotopes
  50. obtaining 24 hr urine
    • have pt void at start time and throw away
    • collect all urine
    • at end time have pt void and keep
    • label containers, keep in ice in bathroom
    • post signs
  51. how do females clean before urine collection
    • front to back
    • outer to inner
  52. males clen prior to urine collection
    circular motion out
  53. clean catch instructions
    sterile container
  54. mid stream catch
    • sterile container with lid
    • start urine in toilet then catch mid stream

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