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58 Cards in this Set
- Front
- Back
A client with a history of poor nutrition & chronic illness is admitted to the unit. As the nurse is caring for this client, she recalls that normal body flora resists ________ by releasing antibacterial substances and _________ multiplication of pathogenic ___________.
|
infection
inhibiting microorganisms |
|
Methods to reduce disease-producing microorganisms are ______ ________
|
hand washing
|
|
The minimum urinary output for an adult is _________
|
30 ml/hr
|
|
The nurse suspects a client may be experiencing urinary retention. When assessing this client, the nurse's first suspicion is when the client has _____ amounts of urine voided ______ times per hour
|
small
2 to 3 |
|
What is the name of an infection which develops that was not present at the time of client admission?
|
nosocomial infection
|
|
A client is taking Coumadin, which is making his urine orange & he wants to know what normal urine should look like. The nurse informs the client that normal urine is _______ ______ to _______ in color
|
pale straw
amber |
|
Stools that are dry and hard to pass are best described as __________
|
constipation
|
|
To maintain normal elimination patterns in a hospitalized client, the nurse should encourage the client to take time to defecate 1 hour after meals because mass _______ ________ occurs at this time.
|
colonic peristalsis
|
|
Where is urine formed in the kidney?
|
the glomerulus
|
|
A client is immobilized after surgery. The nurse observes a continual oozing of stool from the client's rectum. The nurse recognizes that this condition most likely represents _______ _________
|
fecal impaction
|
|
The recommended daily fluid intake for dilution of urine, promotion of micturition, and flushing the urethra of microorganisms is __________
|
2000-2500 ml/day
|
|
A client on the medical unit is scheduled to have a 24-hour urine collection to diagnose a urinary disorder. The nurse should keep the ________ jar in _____
|
collection
ice |
|
In order to receive a correct result in a fecal occult blood test, the nurse instructs the client to refrain from ingesting _____ and __________ that can cause a false positive result.
|
foods
medications |
|
An appropriate technique for a clean-void urine specimen collection is to _______ the specimen after the _______ stream of urine had passed.
|
collect
initial |
|
After applying an extremity restraint the nurse needs to assess _____ and __________ status
|
skin
neurovascular |
|
The use of restraints requires a _________ _______.
|
physician's order
|
|
In the hospital setting, the linen that is generally changed every day includes the ______ _______
|
bottom sheet
|
|
In delegating the morning care for the client, the nurse expects the assistant to wash the client's legs with _____ strokes from the _______ to the ____
|
long
ankle knee |
|
Dentures should be ______ with a ____ toothbrush.
|
brushed
soft |
|
When bathing extremities, as a rule the procedure will progress from _______ to _______
|
distal
proximal |
|
When making a hospital bed, the top sheet should be made with a _______ ______ corner
|
modified mitered
|
|
The purpose for creating a mitt with the wash cloth is to _____ in ______
|
hold
heat |
|
A nurse is assisting a client with right-sided hemiplegia transfer from the bed to a chair. The most appropriate action for the nurse is to support the ________ side
|
affected (right)
|
|
On entering the room, the nurse finds the client sitting upright in bed with his upper torso resting on the overbed table. This type of positioning represents an _________ ________
|
orthopneic position
|
|
The nurse is caring for a client who has pneumonia. To facilitate respiration & lung drainage this client should be best placed in the ________ ________
|
prone position
|
|
A blood component that carries oxygen throughout the body is ________
|
hemoglobin
|
|
The normal percent of oxygen in the environment is _____
|
21%
|
|
A nurse instructs a client to inhale & perform a series of coughs during exhalation. This is known as _______
|
cascade
|
|
In the blood there is _____ normal saline
|
0.9
|
|
Surgical = _______ technique
Medical = _______ technique |
sterile
medical |
|
ENEMA:
- between _______ degrees F - Fill bucket/bag with ______ ml solution - Raise container ______ " from the lovel of the rectum - Always hold tubing ___ ______ |
105-110
750-1000 12-18 in place |
|
ENEMA:
- Position patient in left _____, ____ underneath - _____ tip and insert tubing ______ inches - Encourage patient to hold in _____ minutes |
Sims
chux lubricate 3-4 10-15 |
|
Foot care on a patient will be ________-_______ driven
|
hospital
policy |
|
Never ______ dirty linen and don't let it touch your _______.
|
shake
uniform |
|
Abduction = ______ body
Adduction = ______ body |
away from
towards |
|
Crutches: _______ finger breadths beneath the axilla and ______ inches from the lateral border of the foot
|
2 to 3
6-8 |
|
Cane movement:
_______, ______, ______ |
cane
affected unaffected |
|
With a C&S test, note any ________ the patient is on.
|
antibiotics
|
|
In a guaiac stool test and a gastric contents test, a positive test is ______
|
blue
|
|
_______ _______ Act of 1987 defines patient rights and choices regarding the use fo restraints
|
Omnibus Reconciliation
|
|
In a patient requiring restraints, the _____ _______ restraint should be ordered
|
least restrictive
|
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For both vest and limb restraints: secure a _____ ______ ____ to the bed frame
|
quick release tie
|
|
Orders for restraints need to be renewed every _____ hours
|
24
|
|
Documentation (recording and reporting) ensures ______ and ______ of care
|
continuity
quality |
|
5 good habits of charting:
- Use _______ abbreviations - Be ______ - Be _______ - Just the _____ - Organize _____ |
accepted
concise timely facts data |
|
Rebreathing mask (____ flow system) has ___ bag attached.
Nonrebreathing mask (_____ flow system) has ___ bag attached. |
low
no high a |
|
Symptoms of hypoxia include:
______, _______, tachycardia, _______ blood pressure, diaphoresis, anxiety, and _______ |
dyspnea
cyanosis elevated confusion |
|
Clean an accu-chel machine ____ time per week regardless.
|
one
|
|
Test strips for an accu-chek are good until expiration date only if _______. One opened, they are good for ___ months after
|
unopened
3 |
|
Units of heparin (do or do not) equal units of insulin.
|
do not
|
|
Name the five rights for medication
|
Patient
Medication Time Dose Route |
|
Never ______ a contaminated needle.
|
recap
|
|
SQ injections:
____ degree angle with ____ to ____ inch needle |
45
1/2 5/8 |
|
IM injections:
Always ____ degree angle with ___ to ___ inch needle. Always _______ |
90
1 1 1/2 aspirate |
|
Name the five rights for medication
|
Patient
Medication Time Dose Route |
|
Never ______ a contaminated needle.
|
recap
|
|
SQ injections:
____ degree angle with ____ to ____ inch needle |
45
1/2 5/8 |
|
IM injections:
Always ____ degree angle with ___ to ___ inch needle. Always _______ |
90
1 1 1/2 aspirate |