Fundamentals Final

Signs/Symptoms of Hypoglycemia

Shakiness, sweating, confusion, dizziness, irritability, and hunger.

Normal Blood Glucose Range

70–100 mg/dL (fasting)

Midstream Urine Specimen Collection

Meatus Cleansing Direction: Cleanse the urinary meatus from front to back.

Massage Contraindications

Patients with impaired skin integrity, such as those with open wounds, burns, or fractures.

Apical Pulse Location

At the apex of the heart, typically at the 5th intercostal space, midclavicular line.

Protective Isolation purpose

To protect immunocompromised patients from infections.

Who is protective isolation used for

Patients with compromised immune systems, such as those undergoing chemotherapy or with HIV/AIDS.

Needle Safety

Use retractable or safety-engineered needles.

Needle disposal

Immediately dispose of needles in a puncture-resistant sharps container.

Two-Tenths in Decimal Form

0.2

Assault

Threatening harm to a person.

Battery

Actual physical contact without consent.

Negligence

Failure to provide standard care, leading to patient harm.

False Imprisonment

Unlawful restraint or confinement of a person.

Needle Stick Injury Protocol

Immediate Actions: Clean the wound with soap and water, report the incident, and follow institutional protocols for post-exposure prophylaxis.

Inhaler Use Instructions

1. Shake the inhaler.

2. Exhale fully.

3. Place the inhaler in the mouth or use a spacer.

4. Inhale deeply while pressing the inhaler.

5. Hold breath for 10 seconds.

6. Exhale slowly.

Passive Needle Safety Device

A device that automatically covers the needle after use, reducing the risk of needlestick injuries.

Passive Needle Safety Device function

Activates without direct contact, enhancing safety.

When to Perform Three Medication Checks

1. Before removing the medication from storage.

2. Before preparing the medication.

3. Before administering the medication to the patient.

Best Position for Rectal Suppository

Left lateral or Sims' position.

Who do you contact if prescribing dr is not available

another provider or supervising physician or charge nurse (follow facility protocol)

If Wrong Medication Administered

Assess the patient, notify the healthcare provider, monitor for adverse effects, and document the incident.

Drawing Medication from an Ampule

1. Snap off the neck of the ampule.

2. Use a filter needle to withdraw the medication.

3. Change to an appropriate needle for injection.

Intramuscular (IM) Injection Angle

90 degrees to the skin surface

Patient Identification Methods

Ask the patient to state their name and date of birth, and verify against the medical record

Ear Position for Young Child

Pull the ear downward and backward

Ear Position for Adult

Pull the ear back and upwards

Postoperative Priority Action

First Step: Assess the patient's airway, breathing, and circulation

Nurse's PPE During Medication Administration

Wear gloves and ensure a clean environment to minimize the risk of medication errors.

Signs of Infiltration

Swelling, pallor, coolness, and pain at the IV site.

1 teaspoon (tsp)

5 milliliters (mL)

1 tablespoon (tbsp)

15 milliliters (mL)

1 ounce (oz)

30 milliliters (mL)

1 cup

240 milliliters (mL)

Application for Ophthalmic Medications

Apply pressure to the inner canthus (punctal occlusion) to prevent systemic absorption.

Synovial Joint

A joint characterized by a synovial cavity filled with fluid, allowing for free movement (e.g., knee, elbow)

interventions for Decreasing Constipation

Increase dietary fiber, encourage fluid intake, and promote regular physical activity

Correct Posture for Patient Transfer

Maintain a wide base of support, bend at the knees, and keep the back straight.

Age-Related Changes in the Elderly

Changes: Decreased skin elasticity, reduced muscle mass, slower metabolism, and diminished sensory perception.

Purpose of Passive Range of Motion (ROM)

To maintain joint flexibility and prevent contractures in patients unable to move independently.

Action if Evisceration Occurs

Cover the wound with a sterile dressing moistened with saline, and notify the healthcare provider.

Monitoring During Total Parenteral Nutrition (TPN)

Monitor blood glucose levels, electrolytes, and signs of infection.

Adverse Effect of Hypothermia Blanket

Shivering, which can increase metabolic rate and oxygen consumption.

Knot for Wrist Restraints

Use a quick-release knot to ensure safety and compliance with restraint protocols.

Delegation to Assistive Personnel AP (Delegable Tasks)

Activities of daily living, routine vital signs, and non-invasive procedures.

Medication Form Not Given to Ileostomy Patients

Extended-release or enteric-coated medications, as they may not be absorbed properly.

Monitoring After Catheter Removal

Observe for signs of urinary retention, infection, and ensure adequate voiding.

Steps for Catheterization

1. Perform hand hygiene and gather equipment.

2. Explain the procedure to the patient.

3. Maintain sterile technique throughout.

4. Insert the catheter and secure it properly.

5. Document the procedure and patient's response.

Signs/Symptoms of Obstructive Sleep Apnea

Loud snoring, choking during sleep, excessive daytime sleepiness, and difficulty concentrating.

Importance of Consistent Sleep/Wake Times

To regulate circadian rhythms and improve sleep quality.

Medications to Hold Before Fecal Occult Blood Test

Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and anticoagulants, as they can cause gastrointestinal bleeding.

Purpose of Laxative After Barium Swallow

To facilitate the elimination of barium and prevent constipation.

What patient teaching should be provided after a barium swallow test?

○ Increase fluid intake to help expel the barium from the gastrointestinal tract.

○ Expect white or light-colored stools for 1–3 days as the barium is eliminated.

○ Take a laxative if prescribed or as advised to prevent constipation or impaction.

○ Notify the healthcare provider if no bowel movement occurs within 2–3 days or if abdominal pain, bloating, or changes in bowel habits occur.

Items Not Allowed Inside an MRI

Metal objects, including jewelry, credit cards, hearing aids, and any electronic devices.

Steps for Obtaining a Blood Glucose

1. Wash hands and prepare equipment.

2. Cleanse the puncture site with an alcohol swab and allow it to dry.

3. Prick the fingertip with a lancet.

4. Wipe away the first drop of blood.

5. Place the second drop onto the test strip.

6. Read and record the result.

Steps for a 24-Hour Urine Specimen

1. Discard the first void of the 24-hour period.

2. Collect all urine for the next 24 hours in a designated container.

3. Keep the container refrigerated or on ice during the collection period.

4. At the end of 24 hours, void one last time and add this to the collection.

5. Ensure the total volume is recorded and sent to the laboratory promptly.

Subjective

Information reported by the patient, such as symptoms and feelings.

Objective

Observable and measurable data, like vital signs and physical examination

findings

What to Place Around a Penrose Drain

A sterile, absorbent dressing should be placed around the drain to absorb

drainage and prevent infection.

Duration for Wound Irrigation

Irrigate the wound until the solution runs clear or as ordered by the healthcare provider.

Finding to Report Immediately for a Patient in a Cast

Signs of compartment syndrome, such as severe pain, swelling,

numbness, or tingling.

How Weights Should Hang for a Patient in Skeletal Traction

freely without touching the floor or bed, ensuring continuous traction.

Skeletal Traction

Used for long-term immobilization and alignment of bones

Skin Traction

Applied to the skin for short-term immobilization and pain relief.

Care for the Unaffected Limb in Buck’s Traction

Regularly assess for circulation, movement, and sensation; perform

range-of-motion exercises as tolerated.

Monitoring for a Patient in Buck’s Traction

Check for signs of skin breakdown, circulation issues, and ensure the

traction setup remains intact.

Which Side of the Body Should a Patient Use a Cane

on the stronger side of the body to provide support.

 Other Body Parts to Assess Oxygen Saturation

Assess oxygen saturation using the earlobe or forehead if finger readings are unreliable.

Oxygen Concentration and Masks

Concentrations:

○Nasal cannula: 24–44%

○Simple face mask: 40–60%

○Non-rebreather mask: up to 90%

 Adverse Effect of Oxygen Therapy

Oxygen toxicity, which can lead to lung damage if administered at high

concentrations for extended periods.

Early Sign of Inadequate Oxygenation

Restlessness, confusion, or changes in respiratory rate and pattern.

Instructions for Home Oxygen Use

○ Ensure proper setup and maintenance of equipment.

○ Avoid smoking near oxygen sources.

○ Regularly check oxygen levels and refill as needed.

Safe Clothing During oxygen Therapy

Cotton fabrics are recommended.

Clothing During Oxygen Therapy Avoid

Wool, synthetic, or static-prone materials that can ignite.

Vitamins Needed for Wound Healing

Vitamin C, Vitamin A, and Zinc are essential for effective wound healing

Serous

Clear, watery fluid.

Sanguineous

Bright red, bloody drainage.

Serosanguineous

A mix of clear and bloody drainage.

Purulent

Thick, yellow or greenish fluid indicating infection.

First Phase of Wound Healing

Hemostasis, where blood clotting occurs to stop bleeding.

Healing by First Intention

Wound edges are approximated, leading to minimal scarring

Action Before Obtaining a Wound Specimen

Cleanse the wound with normal saline to remove debris before collecting a

specimen.

Position if Dehiscence Occurs

Place the patient in a low Fowler's position to reduce tension on the wound.

Wound Healing by Second Intention

Wound edges are not approximated, leading to more granulation tissue and

scarring.

Assessing Effectiveness of Oxygen Therapy

Monitor oxygen saturation levels, respiratory rate, and the patient's overall

comfort and alertness.

Proper Fit of a Non-Rebreather Mask

 fits snugly over the nose and mouth with no leaks, and that the

reservoir bag is inflated before use.

Signs of Oxygen Toxicity

Substernal discomfort, paresthesia, dyspnea, restlessness, fatigue, and malaise.