Exam 2 Content - Nursing Exam PDF

38 Questions - 100 points - 4 DA Questions - Conversion - Abbreviations - 1 Select All that Apply - 7 Short 2 Lab Values Calcium RANGE: 9-11 ​ Fxn: ​ The foundation for bones and teeth ​ Functions the neuromuscular, cardiovascular and endocrine...

38 Questions - 100 points - 4 DA Questions - Conversion - Abbreviations - 1 Select All that Apply - 7 Short 2 Lab Values Calcium RANGE: 9-11 ​ Fxn: ​ The foundation for bones and teeth ​ Functions the neuromuscular, cardiovascular and endocrine system ​ Aids in blood clotting ​ Can be found in a BMP draw HYPO-calcemia 3 Cx ​ Chronic Diarrhea ​ Malabsorption (AKA Crohn's Disease) ​ Vitamin D Deficiency 3 Sx ​ Diarrhea/ Abdominal cramping ​ Hyperactive deep tendon reflex ​ Seizures 3 Tx ​ Administer supplements orally or IV in conjunction with Vitamin D ​ Encourage high calcium foods ​ Initiate seizure and risk protocols HYPER- calcemia ​ 3 Cx ​ Pagets Disease ​ Bone Cancer ​ Hyperparathyroidism 3 Sx ​ Decrease level of consciousness/ altered mental state ​ Bone pain ​ Nausea, vomiting and constipation 3 Tx ​ Administer Calcitonin IM or SUBQ  ​ Assess and monitor for fractures ​ Reduce/ restrict calcium intake B.U.N (Blood Urea Nitrogen) RANGE: 10-20 LOW BUN IS RARE Fxn: ​ Helps determine how well kidneys are functioning ​ 3 Cx: ​ Liver and kidney disease ​ Dehydration ​ High protein diet ​ 3 Sx: ​ Fatigue ​ Swelling ​ Frequent Urination 3 Tx: ​ Increase fluid intake ​ Decrease protein intake ​ Blood pressure management Safety and Immobility ➔​ Nurses attend the safety of - Self - Patients ➔​ PHYSIOLOGICAL NEEDS ALWAYS COME FIRST: Food, water sleep SAFETY THEN FOLLOWS Safety for healthcare workers: Radiation ​ Healthcare workers are exposed to small amounts of radiation through CT Scans and other medical diagnosing devices Precautions ​ Time: Organize care to limit time with the patient ​ Distance: Perform care that is only absolutely necessary ​ Shielding: PPE aka protective shielding such as lead apron. Be sure to wear a film badge to indicate radiation exposure Fall risk factors and how we can prevent them as nurses:  ​ ANY pt is at risk for falling, preventions include: 1.​ Fall risk assessment 2.​ Environmental safety 3.​ Clean and dry floors 4.​ Client education *Restraints are used ONLY when absolutely necessary. In emergent situations, a restraint order must be notified immediately. Using ALL 4 side rails is considered a restraint! Restraints increase fall risks as patients try to come out of them! Factors Affecting Mobility: ​ Altercations in muscles ​ Injury to musculoskeletal ​ Poor posture ​ Impaired nervous system ​ Health status and age Patient Positioning Supine ​ Pt is flat on back to maintain alignment Lateral ​ Left or right side ​ Used to prevent ulcers Fowlers ​ Like supine but at a 45-60 degree angle ​ Promotes chest expansion and ventilation ​ Commonly used for NG Tube insertion and suctioning SEMI- Fowlers ​ 15-45 degree angle ​ Promotes lung expansion ​ Prevents aspiration ​ Prevents regurgitation ​ HIGH- Fowlers ​ 60-90 degree angle  ​ Relieves dyspnea ​ Promotes lung expansion ​ Prevents meal aspiration Prone ​ Pt on their stomach w/ head to the side ​ Promotes mouth drainage ​ Prevents hip contracture after lower amputations Trendelenburg ​ Head lowered w/ legs up ​ Promotes venous return REVERSE Trendelenburg ​ Foot of bed lower than head ​ Promotes gastric emptying ​ Helps with GERD and reflux Sims ​ Upper leg is more flexed than lower ​ Limits pressure on trochanter and sacrum ​ Ideal position for any enema or perineal procedure PT’S SHOULD BE REPOSITIONED EVERY 2 HOURS TO PREVENT PRESSURE INJURIES How do we reposition a patient? Moving up in bed ​ If patient is light in weight, Nurse can reposition patient Turning in bed ​ To prevent pressure injuries Logrolling ​ Transfer roller sheet ​ Scoot sheets ​ Roller tray OTHER DEVICES TO MOVE OR REPOSITION PT (also prevents back injury to nurses): ​ Hoyer Lifts aka mechanical lifts ​ Gait belts ​ Transfer boards Assisting with transfer can require: ​ Conditioning exercises ​ Assistive devices (mechanical lift, gait belts and transfer boards) ​ Dangling patients before standing Dangling refers to the patient sitting up right with their legs dangling on the side of the bed before getting up to AVOID ORTHOSTATIC HYPOTENSION. This reduces the risks of falls. What is orthostatic hypotension? ​ Drop in blood pressure when standing up causing dizziness, lightheadedness and syncope DEALING WITH ORTHOSTATIC HYPOTENSION: Tx ​ Anti Embolism stockings with compression wraps to prevent thrombus from forming ​ Abdominal binders ​ Medications to control orthostatic hypotension Use of ambulatory devices. How do we educate a client? Assistive devices: Canes: How to use them? ​ Hold cane on stronger side ​ Distribute even weight ​ Advance cane, forward weaker leg, then stronger leg ​ Avoid leaning over or on the cane Walkers: How to use them? ​ Stand erect ​ Pick up walker and advance, do NOT slide the walker unless wheels are present Crutches: How to use them? ​ Patients axilla should not be resting on the crutch pad d/t nerve damage ​ Distance of axilla to crutch pad should be 1.5 in or 3 fingers in length ​ Arms should be bent at a 30 degree angle when placed on hand rests ​ Patients should start positioning w/ the tripod position Gaits w/ crutches: ​ 4 point gait: Partial weight bearing, pt must shift weight constantly  Ex: Move right crutch (injured side), then move left foot, then move the left crutch then the right leg. 4 POINTS ON THE GROUND ​ 3 point gait: Used when weight bearing must be avoided, FASTER than 4 point gait Ex: BOTH crutches and injured leg swing together and then non injured leg bears weight ​ 2 point gait: Partial weight bearing, uses both feet Ex: RIGHT SIDE IS INJURED: So move the right crutch and uninjured leg (left leg) TOGETHER, then the left crutch and right leg together. ​ Swing to gait: Weight bearing is permitted, uses both feet Ex: Move crutches forward and swing BOTH legs into gait. Legs should land in between crutches ​ Swing through gait: Weight bearing, requires the most coordination and balance Ex: Move both crutches forward, then move both legs forward, however making sure the legs are landing past the crutches Stairs and Crutches: Going up the stairs = Good leg ​ Good leg goes onto the step followed by crutches and then the bad leg steps up Going down the stairs = Bad leg ​ Move crutches down on the step w/ bad leg then move good leg down the step ​ Sitting Down w/ crutches ​ Backup non injured leg to chair. Move both crutches to the injured leg, bend non injured leg while keeping the INJURED LEG extended! ​ Standing up w/ crutches ​ Put both crutches on injured side, keep injured leg extended while using the NON INJURED LEG to push up w/ non injured leg Nutrition What is Nutrition? ​ The study of food Metabolism ​ The way the body converts food into energy. Anabolism: ​ Formation of larger molecules from smaller ones  ​ Ex: Combining molecules for tissue repair REQUIRES energy ​ Catabolism: ​ Breaks down large molecules into smaller ones. This RELEASES energy Nutrition Facts Labels contain: ​ Serving size ​ Number of servings ​ Total calories/ calories from fat per serving ​ List key nutrients ​ % of daily values Energy Nutrients: Macronutrients: ​ Supply the body with energy (kilocalories). ​ 3 MAIN NUTRIENT CLASSES 1.​ Carbohydrates (Sugar) ​ Breaks down into glucose ​ PRIMARY ENERGY SOURCE ​ Muscle/organ function ​ Insulin secretion ​ Brain Energy