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72 Cards in this Set
- Front
- Back
How do you test for intraocular pressure?
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Tonipen testing-touch pen to eye.
For glaucome. |
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Normal signs of aging in the eye?
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Light yellow sclera, slow pupil recovery, gray ring around the iris
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What is an eye symptom NOT associated with normal signs of aging?
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Photophobia
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How do you assess for accomodation of the eyes?
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Watch pupils dilate and constrict as move object closer/distant
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What is a good patient teaching for the eyes regarding the eyes?
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Wear sunglasses that protect from UV light to prevent development of cataracts.
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What is the average time a person blinks their eyes per minute?
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15 per minute. If less, add eye drops or artificial tears.
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What is the term for loss of the central area of vision assoc. with aging?
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Macular degeneration
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What are two tests for visual acuity?
What do they test? |
Snellen-far
Rosenbaum/Yagar-near |
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If a patient has presbyopia, what vision test do you use?
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Rosenbaum
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When asking about sleeping habits and a patient says they sleep with the radio on,what do you ask about?
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Tinnitus-ringing of the ears
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What test is used for hearing? Describe it.
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Rinne test-tests air conduction vs. bone conduction hearing
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In a Rinne test, what are normal results?
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Air conduction is 2X longer than bone.
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In normal aging, what are the results of a Rinne test?
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Often presbycusis, bone is longer than air
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If a person wears bifocal glasses, what eye problems are they correcting?
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Myopia, Presbyopia-near and distant vision
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A patient is in an MVA and wears contacts. You must assess vision. What do you do first?
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Remove the contacts.
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How do you walk with a blind person?
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Walk 1 step and slightly to the side of the person with their hand on your elbow. Warn them of height changes.
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How do you prevent spread of eye diseases between eyes or other people?
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Wash hands often. Now swapping washcloths, avoid eye touching or dropper touching. No cosmetics.
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A patient is having cataract surgery. What do you do before surgery?
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Assess vision in other eye before surgery.
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After cataract removal surgery, what teaching do you address?
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For the patient, how to correctly add eyedrops to eye
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What are the s/s of retinal detachment?
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No pain
Loss of central and peripheral vision light flashes-go now to ER! |
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What are some everyday causes of IOP?
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lifting, coughing, sneezing, straining during bowel movements
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What are some workrelated preventable causes of hearing damage?
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loud workplace, loud music, guns
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What are some frequently used drugs that cause ototoxicity?
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Gentomycin, tobomycin, aspirin, lasix
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What is a nursing diagnosis appropriate for Meniere's disease?
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Risk for falls r/t ms
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With an older patient, how do you best communicate with them?
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Drop voice, slower speech, face them
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What is the best way to fit a hearing aid?
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Go to a quiet environment to experiment with the volume. Turn up volume until they can hear.
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What are cochlear implants used for?
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Sensinuero hearing loss
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A patient is in respiratory distress. What is the FIRST action?
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Focus on respiratory system. Do not try to complete a full assessment. Do that later.
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What is the proper position for a thoracentesis?
How much s/b removed? |
Sit up, lean on table.
Remove 1 L of fluid from pleural area |
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A patient is in metabolic acidosis and is diabetic. What would you expect to observe?
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Kussmaul's respirations-rapid, deep breathing to blow off excess CO2
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How does smoking affect the lung action?
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Kills the ciliary action and mucociliary action to clear the lungs
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What are the normal blood gas values?
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pH 7.35-7.45
pCO2 35-45 HCO3 22-26 |
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A person with COPD exhibits a barrel chest. Why?
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The alveoli are overinflating because of air trapping
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How do you perform tactile fremitus?
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Stand behind the patient. Place the hand on the top of the patients back, asking them to say 99,move down
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What do you check before a bronchoscopy is performed?
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gag reflex
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Assess high pitch blowing sound in the lung bases.
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Bronchial sounds s/b heard in bronchials not bases.
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pneumonia.
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Wheezes
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Norms of:
arterial pressure oxygen saturation of blood |
O2 80-100%
SaO2 95-100% |
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What is a CT uses to rule out regarding the lungs?
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Pulmonary embolis
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What should you ask a patient BEFORE performing a CT?
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allergies to iodine or shellfish
Used in contrast media. |
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What should you educate the postop rhinoplasty patient regarding positions?
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45 degrees head elevation for 48 hours sitting to decrease swelling
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How do you immediately stop a nosebleed?
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Lean forward, pinch soft end of nose and apply direct pressure
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How do you treat allergic rhinitis?
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Identify allergen and avoid it.
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Patient has an upper respiratory infection. How do you prevent a secondary infection?
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high intake of oral fluids, watch change of sputum color, give tylenol for discomfort, nasal spray 3 days only
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When assessing apnea, what do you ask?
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CPAP machine? Use how often?
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What action do you perform before patient suctioning?
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Hyperoxygenation then suction 10-15 seconds.
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Regarding sunctioning, which body areas are clean, which are sterile?
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clean-oral/mouth
sterile-trachea, lungs |
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What action do you do before deflating the trach tube?
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Suction first.
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What behavior increases the chance of laryngeal cancer?
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alcohol use
(smoking) |
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A patient had a radical neck dissection. What is the highest nursing priority?
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Airway-maintain patency
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Education of nasal inhaler use.
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Blow nose before beginning. Squirt to side on inside of nostril. Then breath out of mouth.
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A patient has a nonproductive cough with sputum. What is their nursing diagnosis?
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Ineffective airway clearance
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How do you promote airway clearance of a pneumonia patient?
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Encourage coughing with a pillow splint at lung level while coughing
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A patient has 89% OSat, pneumonia, weak, needs assistance out of bed. What is priority?
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Impaired gas exchange
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What are some nursing education topics for prevention of recurring pneumonia?
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Vaccination, deep breathing, coughing
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How do you prevent aspiration pneumonia?
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Turn pt on lateral side to prevent swallowing.
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What makes a person at risk for aspiration?
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Change in LOC, impaired swallowing, GERD
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When is a patient with TB considered non-contagious anymore?
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After 3 consecutive negative sputums
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How to prevent TB transmission?
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Frequent hand washing
Use tissues 1X Cover mouth when coughing |
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How is B6 beneficial regarding TB?
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Prevents peripheral nerve damage
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How do you encourage a homeless person to get the series of meds to treat TB?
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Offer food with meds.
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What education do you give a 40PPY smoker?
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Smoking cessation
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A patient has chronic bronchitis. What is an observable goal of treatment reached?
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Cough, productive
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What is the characteristic to confirm CHRONIC bronchitis?
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Bronchitis that happened 2+ times in consecutive years
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What is the purpose of pursed lips breathing?
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Helps blow off CO2 and prevent collapse of airway, prevent airtrapping
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What is cor pulmonale?
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Right sided heart failure. Symptoms observed are JVD, ascites, edema
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What is an observable symptom of an acute asthma attack?
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Wheezing
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How do you treat wheezing?
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Maintain airway--Give meds-bronchidilator
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A COPD patient states they can't do anything for self anymore. What would be a dx?
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Ineffective coping r/t loss of independence
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A Cystic Fibrosis patient experiences lung tightening and secretions. What is an intervention?
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Chest physiotherapy
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A patient has an acute asthma attack. What is intervention?
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Give albuteral ASAP
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What would be a dietary intervention for COPD patient?
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High calorie, small, frequent meals
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