PN1 Final Exam - N/A PDF

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1. Best Practice (Pg.5) a. To promote client safety and continuity of care excellent practice is for a nurse to use I-SBAR-R when contacting a health care provider for an order i. I=Identification of self and client ii. S=Situation iii. B=Background iv. A=Assessment v. R=Recommendation vi. R=Read back 2. Inter-Generational Families (Pg. 18) a. Also called multigenerational families b. 2 or more related generations living together as a functioning family. (Sometimes 3-4 generations) c. Reasons- economic support, child care, emotional support 3. Lab data for malnutrition (Pg. 675) a. Have a BMI of less than 20 when undernourished b. Decreased Albumin level of 26 mEq/L b. Metabolic acidosis (pg. 234): An acid-based imbalance that results in arterial pH decreasing below 7.35. i. Result of either bicarbonate reserves decreasing below 22 mEq/L or production of acid due to metabolism. ii. pH7.45 PCO3 26 mEq/L 81. Who is at risk for dehydration a. Elderly 82. What are signs and symptoms of left sided heart failure (Pg. 445-446) a. Caused by left ventricular myocardial infarction, aortic valve stenosis, prolapsed valve complications and hypertension. i. Lungs become congested with fluid ii. Patient becomes cyanotic, dyspneic, restless and coughs up blood-tinged sputum. Breath sounds have moist crackles iii. Patient has tachycardia and low BP iv. Client becomes confused 83. Know all about PPE a. Gloves, gowns, mask, face shield/mask 84. Know the difference between

a.

Pulmonary edema (pg. 380) i. Life threatening condition characterized by a rapid shift of fluid from plasma into pulmonary interstitial tissue and alveoli. ii. Gas exchange is impaired, generally has cardiac cause such as

left ventricular failure or MI. iii. Excess fluids in the lungs, collects in numerous air sacs in lungs 1. Cough, pink/frothy sputum, Dyspnea b. Peripheral edema (Pg. 215) i. Excess fluid in either tissues or extremities 1. Symptoms: Pitting edema in extremities, Edematous area are tight, smooth, dry. Shiny, pale, cool skin, Puffy eyelids, Weight gain 85. Know about these of nutrition a. Calcium: Aids in bone and teeth formation i. Provides muscle contraction and relaxation ii. Aids blood clotting iii. Aids in nerve transmission iv. Promotes normal heart rhythm v. Sources are Milk, Cheese, Green leafy veggies b. Vitamin (Pg. 669): Main source of vitamins are fruits and vegetables. Water-soluble vitamins B and C are not stored in the body; however, fat-soluble vitamins A, D, E and K are stored in the body and if taken in excess can become toxic to the body. c. Minerals: Necessary for tissue building and protection of skin, bone, hair and nails (Pg. 670). There are 7 of them: Look at pgs. 678-679 Table 33-4 for more detailed explanation of them i. Calcium ii. Chloride iii. Magnesium iv. Phosphorus v. Potassium vi. Sodium vii. Sulfur 86. Know about IV infusion (Pg. 247-253)

a. Purpose of an IV is to correct fluid and electrolyte imbalances, administer meds, blood products and provide nutritional supplements. b. Infusion set includes insertions spike with protective cap, drip chamber, tubing with slide clamp and regulating (roller) clamp, an injection port and a protective cap over the needle adapter. c. PICC line is inserted for long IV therapies d. Select vein for an IV that is most distal end to maintain integrity of vein e. Calculating hourly the flow rate Number of hours i. Total volume mL infuse ¿ infusionrate ¿ hour ii. Calculate actual infusion rate (per min) total fluid volume Drop factor Drop per min Total time (min)

87. Know how to write an objective nursing diagnosis (Pg. 76) a. Gathered information through physical examination and the diagnostic and laboratory findings b. Physical exam includes systematic physical exam, head to toe, check ROM, if there is redness/warmth anywhere, fever with increased pulse, secretions ore exudate of skin, Auscultation of the lungs 88. When do you document a. Right after the medication is given b. Right after cares are done 89. Know what to teach a patient about quitting smoking (Pg. 1273) a. Nicotine replacement therapy by patch, nasal spray, inhaler or gum helps break habit but it is important that the patient DOES NOT smoke while using the patch b. Exercise program will help with stress management and minimize weight gain, relaxation techniques will help too c. Support of family and friends are very important

d. Relapse is highest in the first few weeks and diminishes considerably after 3 months 90. Know how to determine what kind of environment to teach in a. When there is minimal distractions b. When the patient is rested and focused...