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28 Cards in this Set
- Front
- Back
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what are the 5 steps of the nursing process?
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assessment
analysis diagnosis planning evaluation |
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what procedures can a RN delegate to unlicensed assistive personnel?
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they do not perform invaisive or sterile procedures.
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what questions should a nurse ask herself when deciding what patient should be assessed first?
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Which client is the most critically ill? Which client is most likely to experience a significant change in condition?Which client requires assessment by an RN?
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S/S of Acute Hemolytic reaction:
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chills, fever, low back pain, flushing, tachycardia, hypotension progressing to acute renal failure, chock, cardiac arrest.
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what do you do FIRST if a client is suspected to have an acute hemolytic reaction?
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STOP the infussion!
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S/S of a Febrile nonhemolytic reaction(most common):
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sudden chills and fever, headaches, flushing, anxiety, and muscle pain
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What do you do if your patient is having a Febrile nonhemolytic reaction?
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Give antipyretics as prescribed
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S/S of anaphylactic reaction and severe allergic reaction:
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anxiety, uticaria, wheezing, progressive cyanosis leading leading to shock and possible cardiac arrest.
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what do you do if your patient is having an anaphylactic or severe allergic reaction during a blood transfussion?
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initiate CPR
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S/S of circulatory overload during a blood trasfussion:
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cough, dyspnea, pulmonary congestion, headache, hypertension.
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what nursing intervention is appropriate when you suspect a circulatory overload during a blood transfusion?
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place client in upright position with feet in dependent position and administer diuretics, oxygen, morphine
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S/S of sepsis during a blood transfussion:
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rapid onset of chills, high fever, vomiting, marked hypotension, or shock
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what do you do if patient shows signs of sepsis during a blood transfussion?
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ensure a patent airway, obtain blood for culture, administer prescribed antibiotics, take vital signs every 5 minutes until stable.
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what is aldosterone?
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Aldosterone is secreated by the adrenal glands, it causes retention of sodium, which causes water retention and potassium excretion.
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What is ADH?
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Antidiuretic Hormone is secreted by the pituitary gland, which causes the body to retain water
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What is BUN?
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it measures the amount of urea nitrogen in the blood. Urea is formed in the liver as the end product of protein metabolism. The BUN is directly related to the matabolic function of the liver and the excretory function of the kidneys.
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What is Creatinine?
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as with BUN, is excreated entirely by the kidneys and is therefore directly proportional to renal excretory function. it's a better test for renal function than BUN.
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four common causes of fluid deficit:
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GI causes: diarrhea, vomiting,GI suctioning; decrease in fluid intake, increase in fluid output such as sweating; massive edema, ascites.
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four common causes of fluid overload:
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Heart failure; cirrhosis; excess ingestion of table salt or overhydration with sodium containing fluids.
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two samples of isotonic IV fluids:
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ringer lactate; normal saline
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what is Site Marking?
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marking the operative site is required for procedures involving right/left distinctions, multiple structures, and levels. site marking should be done with the involvement of the client.
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role of the nurse during the operative phase:
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assessment of the operative suite.
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role of the nurse during the preparation phase:
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education, discharge plan, NPO, Meds
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role of the nurse during the posanesthesia phase:
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pain management, postanesthesia precautions
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what is wound dehiscence?
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separation of the wound edges; it is more likely to occur with vertical incisions.
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what factors increase surgical risk?
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age,obesity, malnutrition, preoperative dehydration/hypovolemia, infection, use of anticoagulants(aspirin).
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why liver disease increases risk of complication for surgery?
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because it imapaires the liver ability to detoxify medications used during surgery to produce prothrombin or to metabolize nutrients for wound healing
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how should the patient be potitioned immediately after surgery?
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on the side or head to side in order to prevent aspiration of any emesis.
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