Nursg 200 exam 2

15 mL

How many ml in a tbsp?

5 mL

How many ml are in a tsp?

30 mL

How many ml in a oz?

240 mL

How many ml in a cup?

8 oz

How many oz in 1 cup?

16 oz

How many oz in a lb?

oral, NGT, IV, irrigation

What 4 things are considered in input?

urine, liquid stool, drainage

What 3 things are considered in output?

burns, recent surgery, diuretics, renal failure, CHF, NGT

What 6 conditions (not obvious) make it mandatory to monitor fluid status?

oral intake, urine, stool

When is it fine to delegate I & O?

weight loss, depressed orbital space, dizzy, weak pulse

What are 4 clinical findings that indicate fluid deficit (not obvious findings)?

weight gain, orbital edema, rales, distended neck vein

What are 4 clinical findings that indicate fluid excess (not obvious findings)?

hypoventilation

This increase CO2

hyperventilation

This decreases CO2

hypovolemia, pregnancy, obesity, increased metabolic rate

what are 4 factors that affect oxygenation?

tachypnea

a abnormally fast respiration rate

bradypnea

a abnormally slow respiration rate

Biot’s respirations

shallow breaths that are marked with periods of apnea seen in CNS disorders

Cheyne-Stokes respirations

breathing that goes from very shallow to very deep marked with periods of apnea

apneustic respirations

deep gasping breathing

agonal respirations

long periods of apnea broken up by periods of breathing (gasping)

air trapping respirations

when a person has difficulty exhaling

Kussmaul’s respirations

hyperventilation associated with metabolic acidosis

cyanosis

a condition that can be present with hypoxemia whereby the skin and nails get a bluish tint

1-6 L

how much oxygen can a nasal canula provide?

5-8 L

how much oxygen can a simple face mask provide?

4-12 L

how much oxygen can a venturi mask provide?

15 L

how much oxygen can a nonrebreathing mask provide?

collect data, organize data, document data

what are 3 things you do in assessment?

analyze data, identify health problems, risks, strengths, diagnostic statments

what are 5 things you in diagnosising?

prioritize problems, formulate goals, write interventions

what are 3 things you do in planning?

reassess client, implement interventions, document

what are 3 things you do in implementation?

collect data, compare data to goals,

what are the 2 things you do in evaluation?

actual nursing diagnosis

the problem based diagnosis: client problem that is present at the time of assessment

risk nursing diagnosis

clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene

health promotion nursing diagnosis

related to clients’ preparedness to implement behaviors to improve their health condition

syndrome diagnosis

a cluster of nursing diagnosis with similar interventions

label, related to, defining characteristics (as evidenced by)

what are the 3 things that make up a nursing diagnosis (except if it’s a risk diagnosis then you’d exclude the last part)?

specific, measurable, attainable, relevant, time-bound

What makes a goal SMART?

actual, risk, health promotion

how do you choose which problems to fix first in the planning phase?

potentiation effect

when a drug interaction causes and increase in one of the drug’s effects

inhibiting effect

when a drug interaction causes and decrease in one of the drug’s effects

iatrogenic

a condition that is caused by medical treatment

rotate sites, clean skin, wear gloves

what are 3 things to consider when giving medicine topically?

90

what degree do you use for a IM injection?

45, 90

what degree do you use for a SQ injection?

15

what degree do you use for a ID injection?

client information, drug name, dose, route, frequency, date, time, and signature of provider

What are 8 things that need to be on a medication order?

client, drug, dose, route, time

What are the 5 rights?

when removing drug, when preparing drug, before administration

What are the 3 checks that ensure you have your 5 rights?

CBC, chem 7, CT scan, MRI, ultrasound

what are 5 routinely preformed tests?

WBC differential, HgB, Hct, platelets

What is looked at in a CBC?

MCV

a part of the RBC indices that measures the size of RBCs

MCH

a part of the RBC indices that measures the amount of Hgb inside of RBCs

MCHC

a part of the RBC indices that measures the proportion of Hgb inside of RBCs

Na, K, Cl, CO2, BUN, creatinine, glucose

What does a Chem 7 look at?

albumin, ALP, ALT, AST, bilirubin, NH3, hepatitis

what are 7 tests we can preform to test liver function?

aPTT

this assesses the intrinsic system and common pathways for clotting used to test heparin, liver disease, and clotting factors

PT

this assesses the extrinsic system and common pathways for clotting

INR

you use this to monitor warfarin therapy, hemophilia, and liver disease

therapeutic drug levels, cardiac enzymes, BNP, lipid panel, TSH

What are 5 other blood tests?

urinalysis, culture, electrolytes, hormone levels, toxicology, 24-hour urine collection

What are 6 urine tests we can preform?

10 mL, first morning collection for routine analysis, random samples at any time

what are 3 things to take into consideration for urine collection?

Guaiac, steatorrhea, parasites

what are 3 things tested for in stool?

Cytology, culture, AFB

what are 3 things tested for in sputum?

remove metal, determine pregnancy status, bowel prep

what are 3 things to consider during pre-procedure of an X-ray?

full bladder for pelvis, NPO for gallbladder, empty bowels, before barium exam

what are 4 things to consider pre-procedure for a ultrasound?

endoscopy

a light, flexible instrument is passed into internal structures for direct visualization

bowel prep, NPO, functioning IV for sedation

what are 3 things pre-procedure to consider for a endoscopy?

monitor VS and LOC, keep NPO until reflexes return

what are 2 things to consider post-procedure for a endoscopy?

lumbar punture

CSF collected from the subarachnoid space with a needle inserted between L3/L4 or L4/L5, can be used for analysis, relieving pressure, or administering medication

client’s trunk flexed, walk specimen to lab

what are 2 things to consider pre-procedure and during the procedure of a lumbar puncture?

supine for 8 hours, monitor VS and LOC, give fluids, meds for headaches, monitor site and bedding for halo

what are 5 things to consider post lumbar puncture?

CAT scan

this combines a series of X-ray views from different angles to produce cross-sectional images

contrast allergies, pregnancy, NPO, no barium or bismuth

What are 4 things to consider pre CT scan?

aspiration

the removal of fluid, requires consent

biopsy

the removal and examination of tissue, requires consent

bleeding times, hold anticoagulants, NPO, IV, prep site

what are 5 things to do pre biopsy and aspirations?

monitor VS and LOC, NPO until reflexes return, monitor site

what are 3 things to consider post biopsy and aspiration?

95-105

normal Cl levels?

10-20

normal BUN levels?

0.5-1.5

normal creatinine levels?

70-100

normal glucose levels?

4-5.6%

normal Hgb A1C levels?

3.5-5

normal K levels?

1.3-2.2

normal mg levels?

135-145

normal Na levels?

8.5-10.6

normal Ca levels?

M: 42-52%, F: 37-47%

normal Hct levels?

M: 14-18, F: 12-16

normal Hgb levels?

80-95

normal mean corpuscular volume (MCV) levels?

4,500-10,000

normal WBC count?

150,000-400,000

normal platelet count?

55-70%

normal neutrophil count?

20-40%

normal lymphocyte count?

2-8%

normal monocyte count?

1-4%

normal eosinophil count?

0.5-1%

normal basophil count?

30-40

normal PTT?

11-12.5

normal PT