WGU - Foundations of Nursing D439 with 109 questions and answers

What is the nursing process?

Assessment

Diagnosis

Planning

Implementation

Evaluation

Maslow's Pyramid of Needs

1. basic needs

2. safety and security needs

3. belonging and love needs

4. esteem needs

5. self-actualization needs

ABC's of nursing

airway, breathing, circulation

what is a SMART goal?

Specific, Measurable, Attainable, Realistic, Timely

alectasis

collapsed alveoli

What is ventilation?

movement of air into and out of the lungs

hypokalemia

serum potassium level below 3.5 mEq/L

ss: paralysis, heart arrhythmia, respiratory failure, decreased muscle contractility, numbness and tingling in extremities

hyperkalemia

serum potassium level greater than 5 mEq/L

ss: heart palpitations, numbness, abdominal pain, NVD

hyponatremia

serum sodium level less than 135 mEq/L

ss: confusion, stupor, anuria, convulsions/seizures, coma, low bp, weakness

hypernatremia

serum sodium level greater than 145 mEq/L

ss: irritability, xerostomia, polydipsia, edema, high bp, seizures

hypomagnesemia

serum magnesium level less than 1.5 mEq/L

ss: tetany, tremors, convulsions/seizures, delirium, ekg changes

hypermagnesemia

serum magnesium level greater than 2.5 mEq/L

ss: hypothyroidism, slurred speech, flushing, lethargy, NVD, decreased deep tendon reflex

hypocalcemia

serum calcium level less than 8.5 md/dL

ss: nervousness, excitability, tetany, Trousseau's sign, Chvotek's sign, seizures

hypercalcemia

serum calcium level greater than 10.5 mg/dL

ss: coma, somnolence, anorexia, immobilization, ECG changes

BUN

blood urea nitrogen levels (10-20mg/dL)

Creatinine

nitrogenous waste excreted in the urine (0.6-1.3mg/dL)

Albumine

3.5 - 5.5 g/dL

when do you measure peaks and troughs?

Peaks: 1 hour after IM injection, 30 minutes after IV infusion

Troughs: 30 minutes before next dose

What are the levels of Maslow's Hierarchy of Needs from bottom (most important) to top?

physiological needs, safety and security, love and belonging, esteem, self-actualization

Patient rights

Right to continuity of care

Right to be treated respectfully

Right to refuse or consent

Right to information

Right to privacy and confidentiality

Right to review medical records

Right to consent or refuse research

Right to health alternatives

Right to the explanation of charges

Adult vital signs (normal ranges)

Bp: 120/80

Pulse: 60-80

RR: 12-20

Temp: 96.8 - 100.4

O2: 95-100

Pain: fifth vital sign is subjective

Temperature taking techniques form most accurate to least accurate

Rectal, tympanic, oral, axillary, temporal

Neurovascular assessment

6 P's

pain

pallor

peripheral pulse

paresthesia

pressure

paralysis

Glasgow Coma Scale

< 8 = coma (score between 3-15)

eye opening 1-4

verbal response 1-5

motor response 1-6

Pain assessment

"OPQRST"

onset: chronic or acute

provoking: what makes it better or worse

quality: stabbing, throbbing, aching

radiating: where pain beings and ends

severity: 1-10

timing: intermittent, continuous, when it occurs

I-SBAR-R

Identify

situation

background

assessment

recommendation

read back order

5 Rights of delegation

Right task

Right circumstance

Right person

Right directions/communication

Right supervision/evaluation

wheezes

(mainly on expiration)

high-pitched, throughout lungs, air through narrow airways (asthma)

Crackles

heard in lower lobes, fine/coarse, collapsed small airway and alveoli "popping open"

(pneumonia, pulmonary edema, congestive heart failure)

Rhonchi

trachea and bronchi, low pitched rumbling, gurgling, narrowed airway with increased secretions, or bronchospasms (mucus blockage)

Pleural friction

anterior lateral lung, dry, rubbing or squeaking, inflamed pleura (sounds like rubbing balloon with fingers)

stridor

high pitched whistling/gasping on inspiration (epiglottis, inflammation of vocal cords, tonsilitis)

Tracheal

high pitched, harsh, loud

Bronchial

high pitched, hollow, loud, inspiration < expiration

bronchovesicular

medium pitched (normal breath sounds) medium amplitude, inspiration = expiration

vesicular

low pitched, blowing, soft, inspiration > expiration

Piaget's stages of cognitive development

sensorimotor, preoperational, concrete operational, formal operational

Standard precautions

hand hygiene, ppe when appropriate, gloves, discarding sharps, and coughing etiquette

contact precautions

private room, hand hygiene, gloves and gown, limit patient exposure, special linens, leave equipment in room, prevention education

droplet precaution

private room, surgical mask, face shield, >5 microns, within 3 feet of patient

influenza, meningitis, pertusis

airborne precautions

private room AIIR, N95, <5 microns

TB, measles, varicella

6 rights of medication administration

Right patient

Right medication

Right dose

Right route

Right time

Right documentation

* 3 checks; receive order, preparation of medication, before administration

Subcutaneous needle use

3/8 to 5/8 in

45-90 degree insertion angle

upper arm, abdomen, anterior thigh

insulin or heparin

Intramuscular needle use

1-1.5 in

90 degree insertion angle

deltoid, ventrogluteal, vastus lateralis

immunizations or antibiotics

Intradermal needle use

3/8 - 3/4 in

0-15 degree insertion angle

forearm

TB, allergies

eye medication administration

1) position patient supine W/hyperextended neck

2) wash away crusts

3) place cotton ball on cheek

4) drops: instill in conjunctival sac, repeat if missed or pt blinks, wait 5 minutes before 2nd medication

ointment: apply thin stream along inner edge of lower eyelid, inner canthus to outer canthus

ear drop medication administration

*earwax buildup or ear infection

child: pull ear down and back

adult: pull ear up and back

1) position patient on side w/ needed ear up

2) instill medication and remain on side for 2-3 minutes

3) keep medication @room temperature to avoid vertigo

transdermal medication administration

*patch or disc directly on skin of arms, chest or upper back

Avoids first pass metabolism

sustained administration of medication

1) clean and dry skin

2) rotate sites of patches

3) apply to dry, intact skin

*avoid shaved skin and heat

total parenteral nutrition

used for patient who cannot have nutrients introduced directly to the GI tract (IV)

se/ hyperglycemia, hyperlipidemia, refeeding syndrome, nausea and vomitting

nursing considerations: slow IV infusion rate, use large central vein, NO added meds should enter the TPN line

Slow infusion: if infused too quickly, TPN solution can cause hyperosmolar diuresis, dehydration, NVD, hypovolemic shock, seizures, coma, and death

nasal cannula

most commonly used oxygen delivery device

add humidity at 3L

MAX 6L

simple face max

used in mild respiratory distress 6-12L

non-rebreather mask

8-15L up to 95% FiO2

*ensure reservoir is 1/2 full on inspiration

venturi mask

allows providers to set a specific FiO2

contain air entrainer (mixes O2 w/RA)

FiO2 24%-60%

hypoxia

lack of oxygen circulation to the body

Early symptoms: diaphoresis, restlessness, tachypnea, dyspnea, tachycardia, HTN, arrhythmia, decreased urine output, fatigue

Late symptoms: cyanosis, cool, clammy skin, use of accessory muscles, retractions, hypotension, arrhythmia, diaphoresis, fatigue, decreased urine output

Hypotonic IV solutions

(<280 mOm/L)

0.225% NaCl

0.45% NaCl

Isotonic IV solutions

(280-300 mOm/L)

Normal Saline 0.9% NaCl

Lactated Ringer

Dextrose 5% in water D5W

Hypertonic IV solutions

(>300mOm/L)

3% or 5% Nacl

Dextrose 5% in 0.45% NaCl

Dextrose 10% in water D10W

Diet progression

clear liquid, full liquid, pureed, mechanical soft, soft, regular

immobility

Assessment: mobility continuum

Complications: cardiovascular, decreased respiratory capacity, muscle atrophy, peristalsis, urinary stasis

Nursing considerations: turn, cough, deep breathes (TCDB), range of motion (ROM), skin care, fluids, balanced diets

Interventions for impaired skin integrity

reposition every 2 hours, pressure relief, remain clean/dry skin, remain adequate hydration and nutrition

Signs of skin breakdown

redness, swelling, warmth, cracks, discoloration, rashes, scabs, blisters, dry, raised, shiny, painful, decreased skin turgor (dehydration), bleeding, bony prominence

pressure ulcers

stage 1 : intact

stage 2 : partial thickness

stage 3 : full thickness w/o fascial involvement

stage 4 : full thickness with fascial involvement

*sacrum, hips, heels, elbows are the most common sites

Stage 1 pressure ulcer

intact skin with nonblanchable erythema

Stage 2 pressure ulcer

partial thickness skin loss (open or closed) Blister

Stage 3 pressure ulcer

Full thickness skin loss without fascial involvement. Fat could be visible w/sloughing

Stage 4 pressure ulcer

Full thickness skin loss with fascial involvement. Bone is exposed, sloughing of skin, eschar formation, undermining or tunneling, surgery is indicated

Braden Scale

(the higher the score, the less risk for pressure ulcer formation)

Sensory 1-4

Moisture 1-4

Activity 1-4

Mobility 1-4

Nutrition 1-4

Friction & shearing 1-3

serous fluid

clear-yellow, watery; early stages of healing

serosanguineous

light pink, watery fluid; early healing

sanguineous

bright red; active bleeding or poor healing

purulent

green, dark yellow, brown pus; infection

T-tube

Cholecystectomy

Penrose

typically limbs, small amounts of drainage are anticipated

jackson pratt

bulb creating negative pressure suction

hemovac

similar to jackson pratt but on a larger scale

Superficial thickness burn

1st degree burn

epidermis layer is affected, redness, pain, tender, no blisters

Sunburn

superficial partial thickness burn

2nd degree burn

epidermis and some dermis, pink/red, wet looking, blister, blanches

deep partial thickness burn

2nd degree burn

entire epidermis and most of dermis, dry, white/red, decreased sensation, little to no blanching

full thickness burn

3rd degree burn

damage to all layers of skin and muscle, white/yellow/black, decreased pain sensation

Parkland formula

TBSA% x body weight in kg x 4

* half of fluid calculated should be given within the first 8 hours

enema administration

1) Provide education

2) Don PPE

3) Position patient in the Sims position

4) Lubricate and gently insert tip

5) Ask patient to relax and take deep slow breaths

6) Begin flow slowly, STOP with discomfort

*Potential for Vagus response (decreased bp, decreased pulse)

Tap water/ soap suds enema

hypotonic, should not be repeated to avoid water toxicity

Normal saline

Isotonic, safest type of enema

Fleet enema

hypertonic, should not be given if patient is dehydrated; fleet enema works by drawing fluids into the colon to soften stool and promote peristalsis

Medication enemas

Kayexalate: increase potassium

Neomycin: clear before surgery

Lactulose: increase ammonia

Vancomycin: used for C.Diff

Oil retention enema

lubricates colon/rectum, softens stool

postoperative fevers

5 W's

Wind: Pneumonia, atelectasis (day 1-3)

Water: UTI from urinary catheter (day 3-5)

Walk: DVT, pulmonary embolism (day 4-6)

Wound: Incision site infection (day 5-7)

Wonder: fever caused iatrogenically by drugs including serotonergics (ss) or antipsychotics/antiemetics (nms) (7+ days)

clubbing of nails

nail bed softening with nail flattening; often enlargement of fingertips

Causes: chronic lack of oxygen: heart or pulmonary disease

beau lines on nails

transverse depressions in nails indicating temporary disturbance fo nail growth

Causes: systemic illness such as severe infection or nail injury

Koilonychia (spoon nails)

concave curves

Causes: Iron deficiency anemia, syphilis, use of strong detergents

Splinter hemorrhages in nails

red or brown linear streaks in nail bed

Causes: minor trauma, subacute bacterial endocarditis, trichinosis

Paronychia

Inflammation of skin at the nail base

Causes: local infection, trauma

Macule

flat discoloration that is blue, red, brown or hypopigmented ( <0.5cm)

ex: freckles, petechiae, measles, vitiligo

Papule

elevated, solid lesion (<0.5cm) Color varies

ex: Wart, moles, lipoma, basal cell carcinoma

Plaque

Circumscribed, elevated, superficial, solid lesion, (>0.5cm)

ex: psoriasis, seborrheic and actinic keratoses

Pustule

Elevated, superficial lesion filled with purulent fluid

ex: acne, impetigo

vesicle

(blister) circumscribed, superficial, collection of serous fluid (0.5cm)

ex: varicella, herpes zoster, second-degree burn

wheal

firm, edematous, irregularly shaped area with varied size, may only last a few hours

ex: insect bite, urticaria, angioedema

What actions make the sterile field no longer sterile?

- If the sterile field becomes wet it is no longer sterile

- Longering of sterile gloves below the waist make the gloves no longer sterile

- Reaching over the sterile field brakes the sterile field

- If the sterile drape becomes punctured or torn it is no longer sterile

How do you estimate the length for an NG tube?

Measure from the tip of the nose, to the earlobe, and from the earlobe to the xiphoid process of the sternum