General Nursing

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Questions and Answers

The #1 priority in nursing is to manage the ______, ______, and ______.

Airway, Breathing, Circulation

In Maslow’s Hierarchy, the second concern after ABC’s is ______.

Safety

The acronym RACE stands for Rescue, Activate alarm, ______ fire, and Extinguish fire if able.

Contain

The ______ Degree burn is characterized by blisters and edema.

<p>2nd</p> Signup and view all the answers

The formula to calculate total fluid requirement after a burn is 4ml x Total Burn Surface Area x ______.

<p>body weight (kg)</p> Signup and view all the answers

The Glasgow Coma Scale is used to assess a patient's level of ______.

<p>consciousness</p> Signup and view all the answers

Patients with Rh ______ should NOT receive Rh positive blood.

<p>negative</p> Signup and view all the answers

After a blood transfusion starts, you must stay with the patient for the first ______ minutes.

<p>15</p> Signup and view all the answers

In children, the order of assessment should go from least to most ______.

<p>invasive</p> Signup and view all the answers

In case of a transfusion reaction, the first step is to ______ the transfusion.

<p>STOP</p> Signup and view all the answers

Increased pressure and restricted blood flow to an extremity can cause pain and ______.

<p>paresthesia</p> Signup and view all the answers

Damage from increased pressure is irreversible after ______ to ______ hours.

<p>4, 6</p> Signup and view all the answers

The 5 P’s of assessing for compartment syndrome include pain, paresthesia, paralysis, ______, and pulselessness.

<p>pallor</p> Signup and view all the answers

When dressing a sucking stab wound, tape it on ______ sides to allow air to escape.

<p>3</p> Signup and view all the answers

If a chest tube is accidentally removed, cover the site with an occlusive dressing taped on ______ sides.

<p>3</p> Signup and view all the answers

To manage a disconnected chest tube, place the end of the tube in a container of sterile ______.

<p>saline</p> Signup and view all the answers

Fluctuations in a chest tube setup indicate that the tube is ______.

<p>working</p> Signup and view all the answers

Continuous bubbling in the chest tube system indicates an ______ leak.

<p>air</p> Signup and view all the answers

Having all ______ side rails up is considered a form of restraint.

<p>4</p> Signup and view all the answers

For contact precautions, don gloves and a ______.

<p>gown</p> Signup and view all the answers

Flashcards

Compartment Syndrome

Increased pressure in an extremity restricting blood flow, causing pain and numbness.

5 P's of Compartment Syndrome

Pain, paresthesia, paralysis, pallor, pulselessness—signs of compartment syndrome.

Sucking Stab Wound

A penetrating wound that allows air to enter the chest.

Occlusive Dressing

A dressing that prevents air from entering or exiting.

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Chest Tube Disconnection

If disconnected, do NOT clamp the chest tube.

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Chest Tube Fluctuations

Up and down movements in the chest tube signify proper drainage.

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Chest Tube Bubbling

Continuous bubbling indicates an air leak.

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Patient Room Safety

Ensure bed rails are up, wheels are locked for safety.

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Pressure Ulcer Stages

Categorization of pressure ulcers according to severity.

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Don and Doff Order

Specific order for putting on and taking off protective equipment.

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ABCs in Nursing

Airway, Breathing, and Circulation; the first priorities in assessing a patient.

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Maslow's Hierarchy

A pyramid of human needs, from basic physiological needs to self-actualization, used in planning patient care.

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Parkland Formula

A calculation for the total fluid volume needed for burn patients in the first 24 hours.

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Rule of Nines

A method for approximating the extent of a burn injury by dividing the body into sections.

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Primary Prevention

Actions to prevent diseases or injuries from ever happening.

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Secondary Prevention

Treating illnesses or injuries to minimize harm and complications.

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Tertiary Prevention

Ongoing care focused on rehabilitation and recovery to prevent further complications after a disease or injury.

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Allen's Test

A test to evaluate adequate blood flow to the hand before drawing blood from an artery in that area.

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Blood Transfusion Reaction

Adverse effects experienced during a blood transfusion, requiring immediate medical intervention.

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Compartment Syndrome

A serious condition where pressure builds up inside a muscle compartment, cutting off blood flow to the affected area, requiring emergency care.

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Study Notes

General Nursing Priorities

  • ABCs: Airway, Breathing, Circulation are the top priorities in emergencies.
  • Maslow's Hierarchy: Physiological needs (like ABCs) take precedence over higher-level needs in stressful situations. Safety, comfort, psychological, social, and spiritual needs follow.
  • Fire Safety: RACE (Rescue, Alarm, Contain, Extinguish) is the protocol for fire emergencies involving patients.
  • Prevention Types: Primary prevention aims to prevent disease or injury (education, first aid). Secondary prevention focuses on treating injuries (emergency room triage). Tertiary prevention involves follow-up care.

Nursing Process

  • Assessment: Gathering information about the patient's condition.
  • Diagnosis: Identifying the problem.
  • Outcome/Planning: Creating a plan of care.
  • Implementation: Carrying out nursing interventions.
  • Evaluation: Assessing the effectiveness of interventions.

Order of Assessment

  • Adults: Inspection, auscultation, palpation, percussion.
  • Children: Inspection, auscultation, percussion, palpation (least to most invasive).

Burns

  • Priority: Maintain a patent airway.
  • Rule of Nines: A method of estimating the surface area of a burn.
  • Parkland Formula: A calculation for fluid resuscitation after a burn.
  • Burn Degrees:
    • 1st Degree: Red, painful, superficial, heals quickly (3-7 days).
    • 2nd Degree: Blisters, edema, heals within 21 days.
    • 3rd Degree: Deep tissue damage, no pain (nerve damage), requires skin grafting.
    • 4th Degree: Extends to muscle, bone, tendon.

Glasgow Coma Scale

  • Used to assess level of consciousness. Higher scores indicate better neurological function. Low scores signal severe impairment.

Cranial Nerves

  • A list of the 12 cranial nerves and their functions.

Cultural Considerations

  • Specific cultural beliefs should be considered when providing care.

Blood

  • Universal donor = O-
  • Universal recipient = AB+
  • Patients with Rh-negative blood should not receive Rh-positive blood.

Blood Transfusions

  • Monitor the patient closely for the first 15 minutes.
  • Multiple transfusions can increase the risk of hyperkalemia.
  • Transfusion reactions present with symptoms such as fever, shortness of breath, and hypotension.

Compartment Syndrome

  • Increased pressure in a tissue compartment, causing pain, and other detrimental symptoms. Requires immediate care since it results in permanent damage.

Chest Tube

  • Continuous bubbling indicates a leak.
  • Fluctuations in the chest tube provide good evidence that the chest tube is working correctly.

Precaution

  • Contact Precautions:
    • Used for patients with infections spread by direct contact
    • Handwashing, gloves, gowns are important to prevent spread.
  • Droplet Precautions:
    • Used for diseases spread through respiratory droplets
    • Masks, eye protection, and gown are necessary.
  • Airborne Precautions:
    • Used for diseases spread through the air
    • N95 masks and respiratory protection are critical.

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