Review Test # 3, Questions with Answers

1) Outline the causes of constipation in adults. Discuss the reasons that the elderly are prone to
constipation.
Constipation is a symptom not a disease. It is a decrease of bowel movements, accompanied by prrlonged
or difficult passage of hard, dry stools. When intestinal motility slows, the fe cal mass becomes exposed
over time to the intestinal walls and most of the fecal water content is absorbed. Little water iis left to
soften and lubricate stool.
Common causes of constipation are:
a) Irregular bowel habits and ignoring the urge to defecate can cause constipation.
b) Clients who have a low fiber duet, high in animal fats, and refined sugars often have constipation
problems. Also, low fluid intake slows peristalsis.
c) Lengthy bed rest or lack of regular exercise causes constipation.
d) Heavy laxative use causes loss of normal defecation reflex. In addition the lower colon is completely
emptied, requiring time to refill with bulk.
e) Tranquilizers, opiates, anticholinergenics, iron, diuretics, antacids with calcium or aluminum, and
antiparkinsonianism drugs can cause it.
f) Older adults experienced slowed peristalsis, loss of abdominal elasticity, and reduced intestinal mucus
secretion. Older adults often eat low-fiber foods.
g) Constipation is also caused by GI abnormalities such as bowel obstruction, paralytic ileus, and
diverticulitis.
h) Neurological conditions that block nerves impulses to the colon (spinal cord injury, tumors) can cause
constipation.
i) Organic illnesses such as hypothyroidism, hypocalcemia, or hypokalemia can cause constipation.

2) Outline the steps for assessment of the abdomen.

The lighting should consist of a strong overhead light and a secondary stand light. Cover female breast
and genitalia. Person should have emptied their bladder, position person supine, knees bent and arms
across chest or at their sides (behind head causes tensing in abdomen).
First series of assessment is:
Inspection- look for:
Contour: describes the nutritional state and normally ranges from flat to rounded (e.g., flat, rounded,
scaphoid, protuberant).
Symmetry: it should be symmetric bilaterally. Note any localized bulging, visible mass, or asymmetric
shape.
Umbilicus: normally is midline and inverted, with no sign of discoloration, inflammation, or hernia. It can
become averted with ascites, or underlying mass. Deeply sunken with obesity. Enlarged and averted with
umbilical hernia. Bluish periumbilical color occurs with intra-abdominal bleeding (Cullen sign).
Skin: the surface is smooth and even with homogeneous color. May become red with localized
inflammation. Skin glistening and taut occurs with ascites. Striae also occurs with ascites. Striae look
purple-blue with Cushing's syndrome. Veins are not usually seen but a fine venous network veins occur with
portal hypertension, cirrhosis, ascites and vena cava obstruction. Veins are more visible with malnutrition
due to thinned adipose tissue.

Pulsation or movement: waves of peristalsis are visible in very thin persons. Respiratory movement also
shown in the abdomen, particularly in males. Normally, you may see the pulsations from the aorta.
Hair distribution: the pattern of pubic hair growth normally has a diamond shape in adult males, and an
inverted triangle in adult females
Deamenor.
Auscultation- Depart from the usual sequence and auscultate because palpation and percussion increase
peristalsis. Use the diaphragm because bowel sounds are relatively high pitch. Do not push hard because it
may stimulate bowel sounds. Begin in the RLQ at the ileocecal valve because bowel sounds are always
present here. Bowel sounds are gurgling, cascading high pitched sounds, occurring irregularly anywhere
from 5 to 30 times per minute. Two distinct patterns include Hyperactive- high pitched, rushing tinkling
sounds that signal increased motility), and Hypoactive or absent sounds follow abdominal surgery or with
inflammation of the peritoneum. Also listen for Vascular sounds or bruits over the aorta, renal arteries,
iliac, and femoral arteries, especially in people with hypertension.
Percussion- percuss general tympany (in all 4 quadrants to determine tympany and dullness; (tympany
should predominate). Dulness occurs over a distended bladder, adipose tissue, fluid, or mass.
Hyperresonance is present with gaseous distension. Liver span (to map out liver 6-12cm is normal), and
splenic dullness (the area of splenic dullness is not wider than 7cm). Percuss to assess the relative density
of abdominal contents, to locate organs, and to screen for abnormal fluid masses.
Costovertebral Angle Tenderness- used to assess the kidney, place one hand over the 12th rib at the
costovertebral angle on the back. Thump that hand with the ulnar edge of your other fist. The person
normally feels a thud but no pain.
Palpation- Palpate surface and deep areas. Perform palpation to judge the size, location, and consistency
of certain organs, and to screen for abnormal mass or tenderness. Begin with light palpation with the first
four fingers close together, depress the skin about 1 cm. Make gentle circular motions and lift the fingers
to another area do not drag them. Next perform deep palpation (depress 5-8 cm.) moving clockwise
explore the entire abdomen. Mild tenderness normally is present when palpating the sigmoid colon. Any
other tenderness should be investigated.

3) How does the nurse obtain a stool sample for occult blood?
Medical aseptic technique should be used during collection of stool specimens. Because 25% of the solid
portion of a stool is bacteria from the colon, the nurse should wear disposable gloves when handling
specimens.
Hand washing is necessary for anyone who might come in contact with specimen. Often the client can
obtain the specimen if properly instructed. The nurse explains that feces can not be mixed with urine or
water. For this reason the client must defecate into a clean, dry bedpan or special container placed under
the toilet seat. Test performed by the laboratory for occult (microscopic) blood require only a small
sample.
After obtaining the specimen, the nurse labels and tightly seals the container and completes laboratory
requisition forms. The nurse records specimen collection in the client's medical records. A common lab
test for occult blood is the Guaiac test done at home or bedside

4) Discuss abnormal coloring of the stool.

Color Cause
White or Clay / Absence of bile
Black or tarry (melena)/Iron ingestion or upper GI bleeding
Red / Lower GI bleeding, hemorrhoids
Pale with fat / Malabsorption of fat

5) Discuss the nursing diagnosis of Diarrhea. What are the related nursing diagnoses associated with
diarrhea?
Diarrhea is an increase in the number of stool and the passage of liquid, unformed feces. Many conditions
causes diarrhea. The aims of treatment are to remove precipitating conditions and to slow peristalsis.
Diarrhea can be related to infection, changes in diet or alteration in gastrointestinal functioning.
Assessment includes auscultation for bowel sounds (hyperactive).Asses frequency of stools (indication for
fluid and electrolyte imbalance). Assess skin turgor (for dehydration), and have clients describe pain
(colicky and spasmodic) Evaluate perianal area (for redness and breakdown). Related to includes infection,
changes in diet, or alteration in GI functioning
Related Nursing Diagnoses
Risk for fluid volume deficit R/T excessive loss of fluid through the GI tract.
Acute pain R/T abdominal cramping and irritation/excoriation of delicate skin.
Impaired skin integrity R/T effects of excretions on delicate tissue.

6) What is paralytic ileus and how is treated?

Paralytic ileus is a condition that temporally stops peristalsis due to surgery that involves direct
manipulation of the bowels. This condition usually lasts 24 to 48 hours. The patient is kept in bed in a low
Fowler's position, and nothing is given by mouth.
An intestinal tube may be inserted as a nasogastric tube into the duodenum and connected to intermittent
suction and the patient is positioned to facilitate the advancement of the tube.
Bowel sounds, BP, pulse, and respiration are checked every 2 to 4 hours, or as indicated.
Parenteral fluid with electrolytes and medication to promote peristalsis are administered as ordered.
Intake and output is measured. The patient is helped to turn and deep breathe every 2 to 4 hours. Active
or passive range of motion (ROM) exercises is performed every 4 hours. Walking is helpful as gravity is a
useful force. When intestinal output increases and bowel sounds return, the intestinal tube may be
clamped and small amounts of warm tea may be given. If pain, distension, or cramps do not recur, the
intestinal tube may be removed, but a rectal tube or an enema may be ordered to relieve distension.

7) Discuss laxative use.

Laxatives and cathartics soften stool to promote peristalsis. When used correctly, laxatives safely
maintain elimination patterns.
Laxative overuse can cause diarrhea that can lead to dehydration and electrolyte depletion. Mineral oil, a

common laxative, decreases fat-soluble vitamin absorption. Laxatives can influence the efficiency of other
medications by altering the transit time which is the time the medication remains in the GI tract. Heavy
laxative use causes loss of normal defecation reflex.

8) Define urinary frequency, urgency, dysuria, enuresis, retention, nocturia, oliguria, anuria, and
discuss all the different nursing diagnosis of incontinence.
Urinary frequency: frequent urination or urgency without an increase in the total daily volume of urine.
The condition may result from bladder or urethral infection, a diminished bladder capacity, or other
structural abnormalities.
Urgency: a feeling of the need to void urine immediately.
Dysuria: painful, burning urination usually caused by a bacterial infection or obstruction of the urinary
tract.
Enuresis: Incontinence of urine, especially nocturnal bed-wetting.
Retention: an abnormal, involuntary accumulation of urine in the bladder as result of a loss of muscle tone
in the bladder, Neurologic dysfunction or damage to the bladder, obstruction of the urethra, or
administration of a narcotic analgesic, especially morphine.
Nocturia: Excessive urination at night. It may be a symptom of renal or prostatic disease or bladder
outlet obstruction. The condition may also occur in people who drink excessive fluids, particularly alcohol
or coffee before bedtime, or in older patients who have excess body fluids that are mobilized by lying
down.
Oliguria: a diminished capacity to form and pass urine (less than 400 ml in every 24 hours) so that the end
products of metabolism cannot be excreted efficiently. It is usually cause by imbalances in body fluids and
electrolytes, renal lesions, or urinary tract obstruction. Also called oliguresis.
Anuria: the absence of urine production or a urinary output of less than 100ml per day. Anuria may be
caused by kidney failure or dysfunction, a decline in blood pressure below required to maintain filtration
pressure in the kidney, or an obstruction in the urinary passages.
Incontinence: the inability to control urination or defecation. Urinary incontinence may be caused by
anatomic, physiologic or pathologic factors. There are five types of urinary incontinence: functional,
overflow, reflex, stress or urge.
Nursing Diagnosis
Functional; urinary incontinence R/T weakened supporting pelvic structures.
Functional urinary incontinence R/T inability to locate bathroom.
Functional urinary incontinence R/T neuromuscular limitations.
Stress urinary incontinence R/T high intra-abdominal pressure (e.g., obesity, gravid uterus).
Stress urinary incontinence R/T incompetent bladder outlet.

Total urinary incontinence R/T neurological dysfunction.

Total urinary incontinence R/T neuropathy preventing transmission of reflex indicating bladder fullness.
Urge urinary incontinence R/T decreased bladder capacity.
Urge urinary incontinence R/T irritation of bladder stretch receptors causing spasm.
Risk for urge urinary incontinence R/T effects of medication caffeine, alcohol.
Risk for urinary incontinence R/T ineffective toileting habits.
Risk for urinary incontinence R/T small bladder capacity.

9) What is a normal urinary output?

Urinary output is the total volume or urine excreted daily, normally between 700 and 2000ml. The smaller
number represents the minimum volume needed to excrete waste products. Various metabolic and renal
diseases may increase or decrease urinary output.
Normal adult should put out 1500-1600 ml/q. An output of < than 30ml/h is abnormal.

10) Discuss how to discontinue a Foley catheter.

When removing an indwelling catheter, the nurse promotes normal bladder function and prevents trauma
to the urethra.
To remove the catheter you'll need the following; a clean, disposable towel:; a trash receptacle, a sterile
syringe the same size as the volume within the catheter's inflated balloon., and disposable gloves. The end
of each catheter contains a label that will tell you the volume of solution (5 to 30ml) within the balloon.
Patient must be positioned in the same position used for catherization. Put a towel over the patient's
tights. Insert the syringe into the injection port. Slowly withdraw all the solution to deflate the balloon
completely; otherwise a partially deflated balloon will traumatize the urethral canal, as the catheter is
removed. The patients must be informed that he/her may feel a burning sensation as the catheter is
removed,. Pull the catheter slowly and smoothly. The patient may experience some dysuria, particularly if
the catheter has been placed for days or weeks. Until the bladder regains full tone, the client may also
experience polyuria or retention. The nurse assesses the patient urinary function by noting the first
voiding after catheter removal and document the time and amount of voiding for the next 24 hours.
If over 8 hours elapse, without voiding it may become necessary to reinsert the catheter. Also, the client
may need bladder retraining or habit training.

11) Discuss characteristics of urine.

Color: pale, straw color to amber.
Clarity: transparent at voiding.
Odor: should be aromatic. Urine has a characteristic odor which is stronger the more concentrated it is.
Stagnant urine has an ammonia odor.

12) Discuss Primary/Secondary/ Tertiary Care (Prevention).

Primary Care: is the provision of integrated, accessible health care services by clinicians who are
accountable for addressing a large majority of personal health services developing a sustained
partnersihip with clients, and practicing in the context of family and community.
The emphasis is on personal health services. Health promotion services are a key to quality health care,
and can lower the overall costs of health care by reducing the incidence of disease, minimizing
complications, and reducing the need to use more expensive health care resources. Primary care isn't
cheap, and its purpose is to maintain, improve health, and meets the basic needs preventing future
illnesses. Example: doctor's offices, clinics, outpatient services, prenatal care, immunization, mental
health counseling, and crisis prevention.
Secondary care: patient already has a diagnosis, and the nurse must teach them how to prevent
complications. It is necessary to avoid worsening of the condition. Example: hospitals, sub-acute care,
psychiatric facilities and rural hospitals. Example: Diabetic patient is taught how to properly to maintain
blood sugar level, testing, foot care, and how to inject.
Tertiary care: Highly specialized care. Focus on prevention of short and long term disabilities. Its goal is
to assist the patient to prevent complications from disability, and to live with their disability. Patients
have major physical limitations. Example: ICUs, rehabilitation centers.

13) Discus Local Adaptation Syndrome, and General Adaptation Syndrome.

Local Adaptation Syndrome: is a response of a body tissue, organ, or part to stress of trauma, illness, or
other physiological change. It involves only a part of the body. Usually is short term. E.g., blisters, sore
throat. LAS assist is restoring homeostasis to the body region or part.
Two localized responses:
I) Reflex Pain Response: rapid automatic response that serves as a protective mechanism. It is a local
response of the central nervous system to pain. Is an adaptive response and protects the tissue from
further damage. An example would be the unconscious removal of the hand from a hot surface.
II) Inflammatory Response: is stimulated by a local response to infection or trauma. It occurs in 3 phases:

Phase 1: bleeding is controlled by vasoconstriction at injury site. After bleeding is controlled the
capillaries open allowing RBCs, WBCs to fight and control infection.
Phase 2: is characterized by release of exudates from the wound. The exudates are a combination of
plasma, cells and byproducts that are released by the injured area depending on its size, location and
severity.
Phase 3: is repair of tissue by regeneration or scar formation. Regeneration replaces damaged cells with
identical or similar cells. The inflammatory response alerts the nurse that the body is adapting to a local
injury, while protecting the body from infection, and promoting healing.
General Adaptation Syndrome: is a biochemical model of stress developed by Hans Selye, which described
physiological events during stress response. It involves several body systems, primarily the autonomic
nervous system, and the endocrine system. It consists of 3 stages: alarm reaction, resistance stage, and
the exhaustion stage.
Stage I (Alarm Reaction): it involves the mobilization of the defense mechanisms of the body and mind to
cope with the stressor. Hormone levels rise to increase blood volume and thereby prepare the person to

act. This extensive hormonal activity prepares the person for the fight-or-flight response. Cardiac
output, oxygen intake, and respiratory rate are increased; the pupils of the eyes are dilated to produce a
greater visual field; and the heart rate is increased for more energy. At this point the person is ready to
fight or flee the stressor. It may last from a minute to many hours. If the stressor is extreme or remains
for a long time, there may be a threat to life.
Stage II (Resistance): is this stage the body stabilizes, and hormone levels, heart rate, BP, and cardiac
output return to normal. If the stress can be resolved, the body repairs damage that may have occurred.
LAS takes from here, each system recuperates locally. Otherwise if the stress remains present the
person enter the 3rd stage, exhaustion.
Stage III (Exhaustion): this occurs when the body can no longer resist stress and when the energy
necessary to maintain adaptation is depleted. The body is unable to defend itself against impact of the
stressor, physiological regulation diminishes, and if the stress continues death may result.

14) What kind of patients are in rehabilitation centers and long term care facilities?
Rehabilitation: is the restoration of a person to the fullest physical, mental, social, vocational, and
economic usefulness possible. Clients require rehabilitation after a physical or mental illness, injury or
chemical addiction. Rehabilitation services include physical, occupational, and speech therapy. Ideally,
rehabilitation begins the moment a client enters a health care setting for treatment. Initially,
rehabilitation may focus on the prevention of complications related to the illness or injury. As the
condition stabilizes rehabilitation is directed at maximizing the clients functioning.
Long Term Care: offer services over a prolonged period of time to people who have lost or never acquired
functional capacity. Long term care may be provide by institutional settings (nursing facilities, assisted
living facilities, hospices) communities (adult day care) or the home (respite care, home health). It
provides intermediate medical, nursing, or custodial care for clients recovering from acute or chronic
illnesses or disabilities.

15) Discuss different types of stress.

Situational stress: a state of apprehension, discomfort and anxiety precipitated by the experience of new
or changed situations or events. It usually disappears as the person adjusts to the new experience.
Example: starting nursing school, giving birth, major role changes, death of a family member, or
unexpected unemployment.
Developmental stress: Is the stress presented by a developmental stage (Erick Erickson), and by the
tasks and behaviors expected from the person. Repeated stress on that specific stage can lead the person
to developmental stage maturational crisis. Example: stress caused when moving from adolescence to
adulthood due to all what is expected from a responsible adult.
Anticipatory stress: the act of stressing or reacting to a potentially distressing situation before actually
confronting the problem. Example: the feeling of doom we get before getting the results from our
Fundamentals test.

16) Discuss the physical systems involved in GAS.

The systems involved are: parasympathetic nervous system, sympathetic nervous systems, the pituitary

gland (adrenal medulla and cortex).

17) What are the normal responses to stress?

The normal response to stress is a moderate response which narrows the perceptual field so that focus in
on immediate concerns with inattention toward other communications or details. Stress response is
natural, protective, and adaptive. Example: an unresolved disagreement with a friend, a sick parent, or an
upcoming final test. Normal responses to stress include: Increase BP and heart rate.

18) What is aphasia? What is sensory overload and sensory deprivation?

Aphasia: is an abnormal Neurologic condition in which language function is disordered or absent because of
an injury to certain areas of the cerebral cortex. There are three types of aphasia:
Expressive aphasia: a motor type of aphasia is the inability to name common objects to express simple
ideas in words or writing.
Sensory or Receptive Aphasia: is the inability to understand written or spoken language.
Global Aphasia: is the inability to understand language or communicate orally.
Sensory Overload: is when a person receives multiple sensory stimuli and cannot perceptually disregard or
selectively ignore some stimuli. This prevents the brain from responding appropriately to some stimuli and
the person no longer perceives the environment in a way that makes sense. This is common on acutely ill
clients, like those on ICUs.
Sensory Deprivation: this happens when a person experiences an inadequate quality or quantity of
stimulation, such as monotonous or meaningless stimuli. There are 3 types of sensory deprivation that
produces monotony and boredom:
1) Reduce Sensory Input: produced by sensory deficit from visual or hearing loss.
2) Elimination of order or meaning from input: exposure to strange environments.
3) Restriction of the environment: forced bed rest or reduced environmental variation.
Sensory deprivation tends to occur in people who are living in confined environments like nursing homes.

19) Discuss morphine, and how to reverse its effects.

Morphine is a white crystalline alkaloid derived from the opium poppy, Papaver somniferum. It acts on the
central nervous system to produce both depression and euphoria stimulation. It has a marked analgesic
effect and its principal therapeutic value is pain relief. It is readily absorbed by mouth and is stored is
skeletal muscle. Repeated use leads to physical dependence.
In case of adverse effects of injection or ingestion, emergency treatment includes gastric lavage,
charcoal, and respiratory support. Naxolone hydrochloride (Norcan) is administered intravenously to
arouse the patient and IV fluid is given to support circulation.

20) Discuss noninvasive ways to combat pain such as distraction and guided imagery.
Distraction: is a procedure that prevents or lessens the perception of pain by focusing attention on
sensations unrelated to pain.
Guided imagery: a therapeutic technique for relieving pain and anxiety, and for promoting relaxation in

which the client is encouraged to concentrate on an image that helps relieve discomfort.
Acupressure: a therapeutic technique of applying digital pressure in a specified way or designated points
on the body to relieve pain, produce relaxation, and prevents or reduce nausea.
Biofeedback: a process providing a person with visual or auditory information about autonomic physiologic
functions of his/her body, such as BP, muscle tension, and brain wave activity, usually through the use of
instruments. It may be used clinically to treat pain, anxiety, migraine headaches, and hypertension.
Self-hypnosis: can help alter pain perception through the influence of positive suggestion. Is like day
dreaming while concentrating on only one thought.

21) Discuss culture and pain.

Experiencing pain may be influenced by cultural factors. Individuals learn what is expected and accepted
by their culture; this includes how to react to pain. For example, for the Mexican-Americans, pain is
associated with suffering and a sense of loss. One's obligation as a person is to bear the burden of pain.
This attitude reflects an acceptance of pain as a measure of the human condition. Mexican-American
tends to be stoic in their response to pain. Men do not show their pain. Withdrawing, going to bed, or
trying to hide might indicate pain.
Cultural beliefs and values affect how individuals deal with pain. There are different meanings and
attitudes associated across various cultural groups. Some cultures believe it is natural to be
demonstrative about pain while others tend to be more introvertive. Some cultures believe that allowing
yourself to feel pain will only make you stronger.

22) Discuss pain perception in the elderly.

The ability of older clients to interpret pain can be complicated by the presence of multiple diseases with
vague symptoms that may affect similar parts of the body. Pain is not an inevitable part of aging, but once
an elder patient client suffers pain, there can be serious impairment of the functional status. Mobility,
activities of daily living, social activities outside the home and the activity tolerance can all be reduced.
It is important to recognize that there are misconceptions about pain management that need to be
addressed before the nurse can adequately intervene in a client pain management. Elderly clients often
believe it is unacceptable to show pain and have learned to use a variety of ways to cope with it instead
(occupied, sleeping, or distraction); client's behavior cannot be used to make assumptions about
presence/absence of pain. Also studies have shown that elderly clients underreport pain because many of
them grew up valuing the ability to "grin and bear it", and unfortunately the "Just say no to drugs" have
influenced them heavily. They underreport pain since they are expected to have pain, don't want to alarm
loved ones, fearful of losing independence, don't want to anger caregivers. Therefore, absence of a report
of pain does not mean absence of pain.

23) Discuss the qualities of pain.

Quality is a subjective characteristic of pain. Often a client might describe pain as crushing, throbbing,
sharp, dull, pricking, burning and aching. Pain associated with myocardial infraction is described as
crushing or viselike. Surgical incision pain is sharp or stabbing while neuropathic pain is described as a
burning pain.
Characteristics of pain: A patients self report is the most reliable indicator of pain. The

Nurse determines onset and duration and location of pain as well as intensity using a scale.
Classification of pain by location:
Superficial or Cutaneous- (pain is short/localized).
Deep visceral (sharp, dull, diffuse and may radiate).
Referred (felt in other region separate from source of pain).
Radiating (pain feels though it travels).
Classification of pain by duration:
Acute: follows acute injury disease, or surgical intervention has a rapid onset, varying in intensity (mild to
severe), and lasting for a brief period of time usually less than 6 months. It eventually resolves with or
without treatment after damage area heals.
Chronic: this type of pain is due to non-life-threatening cause, and frequently the cause is unknown.
Example: arthritis, low back pain, myofascial pain, headache and peripheral neuropathy.
Cancer: it may be due to a tumor progression and its related pathology, invasive procedures, toxicities of
treatment, infection, and physical limitation. Cancer pain can be chronic and/or acute, nociceptive and/or
neuropathic. It can be at the actual site of the tumor or distant to the site, which is called referred.
Classification of pain by its origin:
Somatic: arises from bone or joint, muscle, skin or connective tissue (usually aching or throbbing) in
quality and is well localized (nociceptive pain).
Visceral-Arises from visceral organs, such as GI tract, pancreas and is subdivided in two categories:
1) Tumor involvement of the organ capsule that causes aching and well localized pain.
2) Obstruction of hollow viscus which causes intermittent cramping and poorly localized pain.

Review Test # 1, Questions with Answers

Fundamentals Test One Review
1. What does the nurse do in the event of a fire?
Institutional fires typically result from an electrical or anesthetic-related fire. The
nurse protects the client from immediate injury, reports the exact location of the fire,
and contains the fire and extinguishes it if possible. All personnel are mobilized to

evacuate clients. If client is receiving oxygen but not on life support, the nurse
discontinues the oxygen. If on life support, the nurse may need to maintain the client's
respiratory system manually with an Ambu-bag until the client is moved away from the
fire. The best intervention is to prevent fire. Remember RACE-rescue, assist, confine,
and extinguish.

2. Discuss safety using electrical equipment in the hospital.

Electrical equipment must be maintained in good working order and should be grounded.
The third (longer) prong in an electrical plug is the ground. If a client receives an
electrical shock, the nurse should immediately determine whether the client has a pulse.
Use electrical equipment as instructed by the manufacturer. If the nurse does not know
how a piece of equipment works, ask for help. Never use pins on an electrical heating
pad. Cords and wires should not be exposed as a hazard for tripping or being pulled from
the equipment. Do not use electrical appliances near water.

3. Outline the steps for making an unoccupied bed.

a. Provide all equipment necessary at your fingertips.
b. Determine if client has been incontinent or if excess drainage is on linen. Gloves will
be necessary.
c. Assess activity orders or restrictions in mobility in planning if client can get out of
bed for procedure. Assist to bedside chair or recliner.
d. Lower side rails on both sides of bed and raise bed to comfortable working position.
e. Remove soiled linen and place in laundry bad. Avoid shaking or fanning linen.
f. Reposition mattress and wipe off any moisture using a washcloth moistened in
antiseptic solution. Dry thoroughly.
g. Apply all bottom linen on one side of bed before moving to opposite side.
h. Be sure fitted sheet is placed smoothly over mattress. To apply a flat unfitted sheet,
allow at 10in to hang over mattress edge. Lower hem of sheet should lie seam down, even
with bottom edge of mattress. Pull remaining top portion of sheet over top edge of
mattress.
i. While standing at head of bed, miter top corner of bottom sheet.
j. Tuck remaining portion of unfitted sheet under mattress.
k. Optional: Apply draw sheet, laying center fold along middle of bed lengthwise. Smooth
draw sheet over mattress and tuck excess edge under mattress, keeping palms down.
l. Move to opposite side of bed and spread bottom sheet smoothly over edge of
mattress from head to foot of bed.
m. Apply fitted sheet smoothly over each mattress corner. For an unfitted sheet, miter
top corner of bottom sheet making sure corner is taut.
n. Grasp remaining edge of unfitted bottom sheet and tuck tightly under mattress while
moving from head to foot of bed. Smooth folded draw sheet over bottom sheet and tuck
under mattress, first at middle, then at op, and then at bottom.
o. If needed, apply waterproof pad over bottom sheet or draw sheet.
p. Place top sheet over bed with vertical center fold lengthwise down middle of bed.
Open sheet out from head to foot, being sure top edge of sheet is even with top edge of
mattress.
q. Make horizontal toe pleat.
r. Tuck remaining portion of sheet under foot of mattress. Then place blanket over bed
with top edge parallel to top edge of sheet and 6-8 inches down from edge of sheet.

Optional: Apply additional spread over bed.

s. Make cuff by turning edge of top sheet down over top edge of blanket and spread.
t. Standing on one side at foot of bed, lift mattress corner slightly with one hand, with
other hand tuck top sheet, blanket, and spread under mattress. Be sure toe pleats are
not pulled out.
u. Make modified mitered corner with top sheet, blanket, and spread. After triangular
fold is made, do not tuck tip of triangle.
v. Go to the other side of bed. Spread sheet, blanket, and spread out evenly. Make cuff
with top sheet and blanket. Make modified corner at foot of bed.
w. Apply clean pillowcase.
x. Place call light within client's reach on bed rail or pillow and return bed to height
allowing for client transfer. Assist client to bed.
y. Arrange client's room. Remove and discard supplies. Wash hands.

4. Discuss the reasons for using good mechanics when practicing nursing.
To reduce the risk of injury to the client or to the nurse, the nurse must know and
practice proper body mechanics. These movements include: body alignment (maintains
adequate muscle tone), body balance (center of gravity), coordinated body movement,
the principle of friction, and exercise and activity.

5. Outline all the links in the chain of infection and give examples of each.
The presence of a pathogen does not mean that an infection will begin. Development of
an infection occurs in a cycle that depends on the presence of all of the following
elements:
1. An infectious agent or pathogen - microorganisms include bacteria, viruses, fungi, and
protozoa. The potential for microorganisms or parasites to cause disease depends on the
following factors: Sufficient number of organisms; Virulence, or ability to produce
disease; ability to enter and survive in the host; susceptibility of the host.
2. A reservoir or source for pathogen growth - A reservoir is a place where pathogens
can survive but may or may not multiply. The most common reservoir is the human body.
To thrive, organisms require a proper environment including food, oxygen
(aerobic/anaerobic), water, appropriate temperature (ideal temperature for most human
pathogens 35C), pH (5 to 8 preferred), and light.
Example: bacterium Legionella pneumophila causes Legionnaires' disease, lives in
contaminated water and water systems.
3. A portal of exit from the reservoir - After microorganisms find a site to grow and
multiply, they must find a portal of exit if they are to enter another host and cause
disease. Microorganisms can exit through a variety of sites, such as the skin and mucous
membranes, respiratory tract, urinary tract, gastrointestinal tract, reproductive tract,
and blood. Purulent drainage is a potential portal of exit.
4. A mode of transmission - The major mode of transmission of microorganism is the
hands of the health care worker. Three types of contact are direct, indirect, and
droplet. Vehicles are contaminated items such as water, drug solutions, blood, and food.
Vectors are flies, mosquitoes, louse, and fleas.
5. A portal of entry to a host - Organisms can enter in the same routes as exiting. (ie.
Organisms travel up the urethra in a urinary catheter.
6. A susceptible host - Depends on the individual degree of resistance to a pathogen.

6. What are hospital acquired infections, give examples.

Hospital acquired infections are called nosocomial infections. A hospital is one of the
most likely places for acquired infection because it harbors a high population of virulent
strains of microorganisms that may be resistant to antibiotics. Iatrogenic infections are
a type of nosocomial infection resulting from a diagnostic or therapeutic procedure (ie.
urinary infection develops after catheter insertion). Nosocomial infections are reduced
when practicing aseptic techniques. Exogenous infection arises from microorganisms
external to the individual that do not exist as normal flora (ie. Salmonella and
Clostridium tetani). Endogenous infections can occur when part of the client's flora
becomes altered and an overgrowth results (ie. Enterococci, yeasts, and streptococci.)
When sufficient numbers of microorganisms normally found in one body cavity or lining
are transferred to another body site, an endogenous infection develops.

7. Discuss the stages of infections.

A. Incubation Period - interval between entrance of pathogen into body and appearance
of first symptoms. (ie. chicken pox 2-3 weeks)
B. Prodromal Stage - Interval from onset of nonspecific signs and symptoms (malaise,
low-grade fever, fatigue) to more specific symptoms (During this time, microorganisms
grow and multiply, and client is more capable of spreading disease to others.)
C. Illness Stage - Interval when client manifests signs and symptoms specific to type of
infection (ie. Common cold manifested by sore throat, sinus congestion etc.)
D. Convalescence - Interval when acute symptoms of infection disappear.
8. What is an antigen and an antibody?
An antigen is a substance, usually a protein, that the body recognizes as foreign and
that can evoke an immune response.
An antibody is an immunoglobulin produced by lymphocytes in response to bacteria,
viruses , or other antigenic substances. An antibody is specific to an antigen. Each class
of antibody is named for its action. Antibodies include agglutinins, bacteriolysins,
opsonins, and precipitin.

9. Discuss patient risk for the hazards of immobility.

Clients in acute care settings may demonstrate some problems associated with
prolonged immobility, such as impaired respiratory status, orthostatic hypotension,
increase cardiac workload, thrombus formation, muscle atrophy and joint contractures,
and impaired skin integrity.

10. Discuss the types of equipment that can be used on the patient's bed to
promote good body alignment and for the prevention of decubiti.
Pillows-appropriate size for body part
Foot boots-maintain the foot in dorsiflexion.
Trochanter rolls-prevent external rotation of legs when client are in the supine position.

Sandbags-provide support and shape to body contours, they immobilize extremities and
maintain specific body alignment.
Hand rolls-maintain the thumb slightly adducted and in opposition to the fingers.
Hand-wrist splints- individually molded for the client to maintain proper alignment of
the thumb in slight adduction and wrist in slight dorsiflexion.
Trapeze bar-descends from a securely fastened overhead bar attached to the bed
frame. Allows the clients to use upper extremities to raise trunk off the bed.
Side rails- positioned along the sides of the length of the bed. They provide assistance
in rolling side to side or sitting up in bed.
Bed Boards- are plywood boards placed under the entire surface area of the mattress.
Wedge Pillow-Triangular pillow made of foam, used to maintain less abduction following
total hip replacement surgery.

11. What does ROM do for the patient?

Range of Motion is the maximum amount of movement available at a joint in one of the
three planes of the body: sagittal, frontal, or transverse. There is an overall
improvement of physiological functioning as a result of exercise. All systems become
sronger and function more efficiently. ROM's are for restorative care, relates to
physical self care and are instrumental activities of daily living. Active ROM-patient
moves, Passive ROM-nurse assist with movement.

12. How does the nurse prevent pulmonary complications for the patient on
prolonged bed rest?
Change the client every 2 hours, this allows the dependant lung regions to re- expand
and this reduces stagnation of secretions. Encourage the client to deep breath and
cough every 1 to 2 hours. Encourage client to us a incentive spirometer. Binders should
be removed every 2 hours to allow the client to breath deeply. The client should take in
a minimum of 2000 ml of fluid per day. Percussion and positioning is an effective method
of preventing pulmonary secretion stasis.

13. Discuss the proper use of restraints on patients.

The use of restraints must be part of the client's medical treatment, all less restrictive
interventions must be tried first, other disciplines must be used, and supporting
documentation must be provided. The use of restraints involves a psychological
adjustment for the client and family. If restraints must be used, the nurse assists
family members and clients by explaining their purpose and precautions taken to avoid
injury. Nursing homes must obtain informed consent from family members before using
restraints. Institutions require a physician's order that states the type of restraints,
specific client behaviors for which restraints are used, and a limited time frame.
Restraints are not to be ordered PRN (as needed). Use of restraints must meet the
following objectives: reduce the risk of client injury form falls. Prevent interruption of
therapy such as traction. Prevent the confused or combative client from removing life
support equipment. Reduce the risk of injury to others by the client.

14. Why does the nurse perform the nursing process? What are the five steps of

the nursing process. Outline what happens in each step.

The five steps of the nursing process are:
Assessment, Diagnosis, Planning, Implementation, and Evaluation.
-Assessment is the systematical collection, verification and analyzation and
communication of data about a client.
-Diagnosis is the use of critical thinking skills to analyze the client's assessment data to
form the nursing diagnoses. Includes decision-making steps the nurse uses to develop a
diagnostic statements.
-Planning is prioritizing and answering what, when, how and who questions.
-Implementation-describes the category of nursing for achieving the goals and expected
outcomes for nursing care are initiated and completed.
-Evaluation-the final step of the nursing process measures the client's response to
nursing actions and the clients progress toward achieving goals.
The nurse to perform the nursing process because it enables the nurse to organize and
deliver nursing care. It promotes individualized nursing care ans assists the nurse in
responding to client needs in a timely and reasonable manner to improve or maintain the
client's level of health.

15. How does the nurse validate subjective data?

The nurse validate subjective data through the use of the physical examination
inspection, palpation. percussion, auscultation and olfaction), diagnostic and laboratory
data.

16. Outline the Diagnostic statement. What is part I and Part II. What is the
Linking word? Which part contributes to the goal, which part contributes to the
nursing actions?
The diagnostic label is Part I, think linking word is R/T (related to), and then follows the
statement of related factors which is Part II. The diagnostic label is a category
approved by NANDA. The related factor is a condition that causes or is associated with
a client's actual or potential response to the health problem. The related factor can be
altered or resolved by nursing interventions, thus resulting in a resolution of the
diagnosis. This two-part format is accepted by most nursing leaders. The related factor
individualizes a client's nursing diagnosis, providing direction for the selection of the
appropriate intervention. Part II is the etiology, or cause of the nursing diagnosis must
be within the domain of nursing practice and a condition that responds to nursing
interventions. Part I contributes to the goal and part II contributes to the nursing
actions.

17. What is the outcome criteria of a patient goal?

An expected outcome is the specific, step-by-step objective that leads to attainment of
the goal and the resolution of the etiology for the nursing diagnosis. Outcomes are the
desired responses of a client's condition in the physiological, social, emotional,
developmental or spiritual dimensions. They provide a direction for nursing activities,
they provide a projected time span for goal attainment and an opportunity to state any
additional resources, the nurse used expected outcomes as criteria to evaluate the

effectiveness of nursing activities. Several expected outcomes are usually developed

for each goal and nursing diagnosis. Seven guidelines for writing goals: client-centered,
singular, observable, measurable, time-limited, mutual, and realistic factors. Use
Maslow's hierarchy of needs to prioritize these goals.

18. What does the nurse do when patient goals are not met?
Modify the care plan...the nurse identifies the variables or factors that interfered with
goal achievement. Usually a change in client's condition, needs, or abilities, makes
alternation of the care plan necessary. For example, when teaching self-administration
of insulin, the nurse discovers that the client has a literacy problem or a visual
impairment that prevents the reading of insulin dosages on the syringe. As a result,
original outcomes cannot be met. Thus the nurse uses new interventions and revises
outcomes to meet the goal of care.

19. What are actual and potential health problems?

An actual health problem is one that is perceived or experience by the client, such as a
sleep pattern disturbance related to a noisy environment. An at risk health problem
alerts the nurse to the need for preventive interventions. These are the potential risks
that can happen.

20. How does the nurse decide which problems is the priority one?
Maslow's hierarchy of needs can be one useful method for designating priorities. The
hierarchy of human needs in five levels of priority.

21. Why is the interview an important piece of the assessment step?

The first step in establishing the data base is to interview is a pattern of communication
initiated for a specific purpose and focused on a specific content area. In nursing, the
major purposes of the interview are to obtain a nursing health history, identify health
needs and risk factors and determine specific changes in level of wellness and patterns
of living. Perhaps most important, the interview should help clients relate their own
interpretation and understanding of their condition. This means the nurse and client
must be partners during the interview rather than the nurse controlling the interview.
Unless an interview allows the interaction may be unsuccessful.

22. What are closed/open questions? Give examples.

Open questions are questions that ask for narrative information. The open- ended
question is unbiased; it leaves the person free to answer in any way. This question
encourages the person to respond in paragraphs and to give a spontaneous account in any
order chosen. It lets the person express himself or herself fully.
Closed questions or direct questions ask for specific information. They elicit a short,
one- or two-word answer, a yes or no, or a forced choice.

23. Describe the various types of wound drainage.

The nurse notes the amount, color, odor, and consistency of drainage. Types are:
Serous- clear, watery plasma
Purulent-thick, yellow, green, tan or brown
Serosanguineous-Pale, red, watery: mixture of serous and sanguineous.
Sanguineous-Bright red: indicates active bleeding

24. What are universal precautions?

Recommended barriers and procedures that limit an individual's exposure to infectious
blood borne agents such as the human immunodeficiency virus (HIV), which causes
AIDS, and the virus that causes hepatitis.
Standard precautions are designed to reduce the risk of transmission of blood borne
and other pathogens. They should become habit and be observed in every client
encounter. Standard precautions apply to blood, all body fluids, secretions, excretions
(except sweat), non-intact skin, and mucous membranes. Hands are washed between
client contact, gloves are worn when touching the above, Masks, eye protection, or face
shields if splashes are likely, gowns are worn if soiling is likely, client care equipment is
properly cleaned and reprocessed, all sharps are discarded in a puncture resistant
container. Private room is unnecessary unless there are hygiene problems.

25. Discuss hand washing.

The most important and the most basic technique in preventing and controlling
transmission of infections is hand washing. It is a vigorous, brief rubbing together of all
surfaces of the hands lathered with soap, followed by a rinsing under a stream of water.
The purpose is to remove soli and transient organisms from the hands and to reduce
total microbial counts over time. Contaminated hands are the prime cause of cross
infection. Wash hands when visibly soled, before and after client contact, after contact
with a source of microorganisms, before the performance of invasive procedures, and
after removing gloves. Use antimicrobial soap in certain high risk situations (ie. before
performing an invasive procedure). Wash hands 10-15 seconds. Instruct clients and
visitors about the proper technique.

26. Define surgical asepsis and medical asepsis.

Surgical asepsis procedures used to eliminate any microorganisms; sterile technique. An
example is sterilization of surgical instruments.
Medical asepsis procedures used to reduce the number of microorganisms and prevent
their spread. Examples include hand washing and "no touch" dressing technique.

27. What is therapeutic communication?

Specific responses that encourage the expression of feelings and ideas and convey the
nurse's acceptance and respect. Techniques are: active listening, sharing observations,
sharing empathy, sharing hope, sharing humor, sharing feelings, using touch, using

silence, asking relevant questions, providing information, paraphrasing, clarifying,

focusing, summarizing, self-disclosing, and confronting.
?2011 thestudentnurse.com

Review Test # 2, Questions with Answers

1) What are intentional and unintentional torts? Give examples. What would be a crime committed
by a nurse?
A tort is a civil wrong made against a person or property. Torts may be classified as unintentional or
intentional.
Unintentional tort is negligence or malpractice.
Negligence -conduct falls below standard of care i.e. taking a stop sign
Malpractice: is negligence committed by a professional such as a nurse or physician.
Intentional torts are willful acts that violate another's rights. Examples are assault, battery, invasion of
privacy and defamation of character.
* Assault -verbal or offensive contact i.e. threaten to give injection w/o consent.
* Battery -any intentional touching w/o consent i.e. actually give injection.
* Invasion of Privacy
* Intrusion on seclusion
* Appropriation of name
* Publication of private or embarrassing facts

* Publicly placing one in a false light

* Defamation of Character -publication of false statements that result on damage to a person's
reputation.
* Malice -person knows information is false and still publishes it.
* Slander -if statement is ORAL.
* Libel -if statement is WRITTEN
A crime committed by a nurse will be considered a malpractice. Example: A misuse of controlled
substances.

2) Describe the values clarification. What is the Nursing Code of Ethics, and what is its purpose?
A value is a personal belief about the worth of a given idea, attitude, custom, or object that sets
standards that influence behaviors.
Value clarification is a process of self-discovery that helps a person gain insight into values. It is not a set
of rules designed to interfere with conscientious decision making, and it does not suggest that a specific
set of values should be accepted by all persons.
Value clarification is an approach to individual appraisal of value. A person clarifying values learns to make
choices when alternatives are presented and determines whether choices are carefully made. The result
of value clarification is greater self-awareness and personal; insight.
There are 3 steps for value clarification:
I) Choosing one's beliefs and behaviors.
Choosing from alternatives.
Choosing freely.
Considering all consequences.
II) Prizing one's beliefs and behaviors.
Prizing and cherishing the choice.
Publicly affirming the choice.
III) Acting on one's beliefs.
Making the choice part of one's behavior.
Acting with s pattern of consistency and repetition.
A code of ethics is a set of ethical principles that are accepted by all members of a profession. Codes
serve as guidelines to assist nurses when conflict arises about correct practice and behavior.
The nursing code of ethics sets forth ideals of conduct. The American Nurses Association (ANA) have
established widely accepted codes that nurses attempt to follow. Nurses agree to responsibility for
specific actions and accountability for the consequences. To practice responsibly, professional nurses also
agree to maintain competence in the application of judgment.

3) What is malpractice? What is the Nursing Practice Act, and what is its purpose? What does it
mean to be liable for an action?
Malpractice is negligence committed by a professional such a nurse or physician.
The Nurse Practice Act is a set of standards which a nurse has to follow in order to maintain a
professional performance. The Nurse Practice Act, describe and define the legal boundaries of nursing

practice within each state. It defines the legal actions a nurse can take. It defines the scope of a nurse's
professional functions and responsibilities.
To be liable is to be held responsible for an action. For example, if a nurse tells people erroneously that a
client has a venereal disease, and the disclosure affects the client's business, the nurse could be held
liable for slander.
Nurse is held accountable for all actions that are performed incorrectly. To avoid liability nurse must:
follow standards of care, give competent health care, communicate with other health care providers,
document assessments, interventions, and evaluations fully; and develop empathetic rapport with client.

4) What is the Good Samaritan Act?

Good Samaritan laws have been enacted in almost every state to encourage health care professionals to
assist in emergency situations. Those laws limit liability and offer legal immunity for nurses who help at
the scene of an accident.

5) What is informed consent? What does it means for the nurse to be a witness during the signing
of the informed consent?
Informed consent: is a person's agreement to allow something to happen, such as surgery, based on a full
disclosure of risks, benefits, alternatives, and consequences of refusal. Informed consent not only
requires that a person be given all relevant information required to reach a decision regarding treatment,
but also requires that the person be capable of understanding the relevant information and does in fact
give consent.
Four factors must be verified for a consent to be valid:
I) The person giving consent must be mentally and physically competent and be legally an adult (over 18 yrs
of age or emancipated).
II) The consent must be given voluntarily; no forceful measures may be used to obtain it.
III) The person giving the consent must thoroughly understand the procedure, its risks and benefits, and
alternative procedures.
IV) The person giving consent has the right to have all questions answered satisfactorily and confirm his
or her understanding of the treatment given.
The nurse's signature witnessing the consent means that the client voluntarily gave consent, that the
client's signature is authentic, and that the client appears to be competent to give consent.

6) Define and give patient examples for the ethical principles discussed in class.
I) Autonomy: refers to a person's independence. As a standard in ethics, autonomy represents an
agreement to respect another's right to determine a course of action. For example, the purpose of the
preoperative consent that clients must read and sign before surgery is the assurance that the health care
team respects the client's independence by obtaining permission to proceed.
II) Beneficence (advocacy): refers to taking positive actions to help other. The practice of beneficence
encourages the urge to do good for others. For example, a child's immunization may cause discomfort
during administration, but the benefits of protection from disease, both for the individual and for
society, outweigh the temporary discomfort.

III) Nonmaleficience: is the avoidance of harm or hurt, seek to do the least harm if benefits must result
in some harm. For example a new bone marrow transplant procedure may promise a chance at cure. The
procedure, however, may require long periods of pain and suffering. These discomforts should be
considered in light of the suffering that the disease itself might cause, and in light of the suffering that
other treatments might cause. The commitment to provide least harmful interventions illustrates the
term of nonmalefiencience.
IV) Justice: refers to fairness. Health care providers agree to strive for justice in health care. For
example, treating clients at greater risk firt.
V) Fidelity: refers to the agreement to keep promises. Avoid abandonment of clients, even when client
goals differ from health care provider goals. For example, if a nurse assesses a client for pain and then
offers a plan to manage the pain, the standard of fidelity encourages monitoring the client's response to
the plan.

7) What are the nurse's responsibilities and actions after finding a patient injured from a fall?
The nurse completes an incident report. The report is completed even though an injury does not occur or
is not apparent. In many cases a physician is notified and determines actions to be taken to determine if
any injury has been suffered. If a client is affected, the physician documents the examination and
findings in the client's medical record.
The nurse documents only and objective description of what was actually observed, and follow up care that
occurred, and does not specify in the medical record that an incident report was prepared. These are the
guidelines:
a) The nurse who witnessed the incident or who found the client at the time of the incident files the
report.
b) Describe specifically what happened in concise, objective terms.
c) Describe objectively the client's condition when the accident was discovered.
d) Report any measures taken by oneself, other nurses, or physicians at the time of the incident.
e) Do not interpret or attempt to explain the cause of the incident or blame anyone.
f) Submit the report as soon as possible to the appropriate administrator.
g) Keep a written account of the incident report for personal files.
h) Do not photocopy the report since the copy could be subpoenaed in court.

8) What are the stages of death and dying according to Kubler-Ross?

It includes five stages:
I) Denial: individuals act as though nothing has happened and may refuse to believe that a loss has
occurred. Example; "No, that can be so."
II) Anger: the individual resist the loss and may "act out" to everyone and everything in the environment.
Example: "Why is God doing this to me?"
III) Bargaining: The individual attempts to make deals in a subtle or overt manner to prevent the loss.
Example: A hospitalized client may show model behavior because of a belief that the staff will find a cure
is she or he is a "good client."
IV) Depression: the individual realizes the loss and the full impact of its significance is apparent. The
person feel overwhelmed and shows withdrawal. This stage provides the opportunity to work trough the

loss and to begin solving problems.

V) Acceptance: Physiological reactions cease, and social interactions resume. Is coming to terms with the
situation, rather than submitting to resignation or hopelessness. Example: client wants to see friend
hasn't seen in years.

9) Define Growth and Development. Discuss the principles of growth and development.
Persons growth and develop throughout their lifespan. Growth and development is not a linear process, as
most theories tent to be, but multidimensional.
Growth refers to the quantitative changes that can be measured and compare to norms. For example,
taking the height and weight of a pediatric client and comparing the measurements to the standardized
charts.
Development: implies a progressive and continuous process of change leading to a state of organized and
specialized functional capacity, for example, a child's progressions from rolling over to crawling to walking
and developmental changes (Haywood, 1993)
These changes can be measured quantitatively but are more distinctly measured in qualitative changes.
Read page 155 of the book.

10) What are Erickson's Stages of Development and how they compare to Freud's?
Erickson believed that development was an evolutionary process based on sequencing biological,
psychological, and social events. He believed that the maturation of bodily functions was linked with
expectations of society and culture in which the person live.
Erickson defined 8 stages of life, first five coinciding with Freud's stages.
* Trust vs. Mistrust (Birth to 1 yr)
* Autonomy vs. Shame and Doubt (1 to 3yrs)
* Initiative vs. Guilt (3 to 6yrs)
* Industry vs. Inferiority (6 to 11yrs)
* Identity vs. Role Confusion (Puberty)
* Intimacy vs. Isolation (Young Adult)
* Generativity vs. Self-Absorption and Stagnation (Middle Age)
* Integrity vs. Despair (Old Age)
Freud's:
Id- primitive part, basic instinctual impulses driven to achieve pleasure.
Ego-helps judge reality accurately, regulate impulses, and make good decisions. Superego- "conscience"
performs inhibiting, restraining, and prohibiting actions; derived from the standards of outside social
forces (parent, teacher).
* Oral (Birth to 1 yr.) -sucking is extremely pleasurable. Realize mom/parent is separate from self.
( Anal (1 yr to 3 yrs) -toilet-training, prone to child abuse.
* Development is very predictable.
* Phallic or Oedipal complex (3 to 6 yrs) -sexual organ gains prominence.
Penis-envy-girls realize no penis. Child fantasizes about parent as first love.
* Latency (6 to 12 yrs) -time of minimal sexual interest or activity. Gather in groups of same sex peers.
* Genital (Puberty through Adulthood) -want to be with peers. Sexual urges reemerge.

Look on pages 158-159 for the comparison.

11) What are the physiological signs and symptoms of death?

a) Stiffening of body (rigor mortis), developing 2 to 4 hours after death (involves contraction of skeletal
and smooth muscle from lack of adenosine triphosphate).
b) Reduction in body temperature with loss of skin elasticity (algor mortis).
c) Purple discoloration of skin (livor mortis) in dependent areas from breakdown of red blood cells.
d) Softening and liquefying of body tissues by bacterial fermentation.

12) What are the perceptions of death according to the stages of development?
Infant: cries for death of mother or significant other.
Toddler: think that death is reversible.
School age (9-10): Understand that death in permanent.
Adolescent: They do not believe that death can happen to them. They believe they are invincible.
Adult: are confronted with the death of family members and friends of the same age.

13) What does the coroner do?

Death is to be reported and investigated by the coroner when there are reasonable grounds to believe
that the person died as a result of violence, homicide, accident, or death occurring in any unusual or
suspicious manner. The coroner should be also contacted if a client's death is unforeseen and sudden and
the client has not been seen by a physician in over 36 hours. Also, the coroner can override the family
decision over an autopsy.

14) How does the nurse provide care to grieving families? What is hospice care?
Nursing care of the grieving family begins with establishing the significance of the loss. The nurse
observes the response to loss and then attempts to identify the family's strengths in dealing with it.
When supporting the grieving family, the nurse must acknowledge their grief, understand the value of the
client to the family, and assist them through the dying process. Giving information, sharing concerns, and
expressing empathy will show the family that the nurse has been involved in helping the client to die
peacefully. Assessment of the family structure will guide the nurse in identifying strengths and those who
need additional support. Involving the family in the care of the dying client may help the family feel a
sense of participation and decrease their sense of helplessness during the dying process.
Hospice Care: generally clients that are accepted into hospice have less than 6 months to live and are
considered terminal. The nurse's role in working with hospice agencies emphasizes meeting the primary
wishes of the dying client and being open to individual desires of each client. When options are
complicated by family needs, hospice will try to work with the client wishes.
A hospice program emphasizes palliative treatment to control symptoms rather than curative treatment,
which treat disease.

15) What are the legal responsibilities after death?

16) Outline Federal Drug Administration Legislation. What does the Food and Drug Administration
do?
The role of the U.S. government in regulation of the pharmaceutical industry is to protect the health of
the people by ensuring that medications are safe and effective. The first American law to regulate
medications was the Pure Food and Drug Act (1906). This law simply requires all medications to be free of
impure products.
Enforcement of medication laws rest with the Food and Drug Administration (FDA), which ensures that all
medications on the market undergo vigorous review before they are allowed to be dispensed to the public.
Federal medication law has extended and refined controls on medication sales and distribution: medication
testing, naming and labeling: and the regulation of controlled substances.

17) Outline the various types of drugs orders. What is a protocol order? What is a drug half-life?
What are side effects? What are peak and through level?
Four types of medications orders are based on frequency and/or urgency of medication administration,
a) Protocol/Standing orders or routine medication orders: a standing order is carried out until the
prescriber cancels it by another order or until a prescribed number of days elapse.
b) prn Orders: the prescriber may order a medication when a client requires it. The nurse uses objective
and subjective assessment and discretion in determining whether or not the client needs the medication.
c) Single (one time) orders: a prescriber will often order a medication to be given only once at specific
time. For example, an order for 0.5 mg of Lorazepam, to calm a claustrophobic client before having a MRI
done.
d) STAT order: signifies that a single dose of a medication is to be given immediately and only once. STAT
orders are often written for emergencies when the client's condition changes suddenly.
All medications have a serum half-life, which is the time it takes for excretion processes to lower the
serum medication concentration by half. It varies from drug to drug.
Side effects: are unintended, secondary effects a medication predictably will cause. Side effects may be
harmless or injurious. If the side effects are serious enough to negate the beneficial effects of a
medication therapeutic action, the prescriber may discontinue the medication.
Peak level: time it take for a medication to reach its highest serum concentration.
Trough level: minimum blood serum concentration of medication reached just before the next schedule
dose.

18) What are orphan drugs?

Any pharmaceutical product that may be available to physicians and patients in countries other than the
United States but that has not been "adopted" by a domestic pharmaceutical manufacturer or distributor.
The U.S. Orphan Drug Act of 1983 offers federal financial incentives to commercial and nonprofit
organizations to develop and market the drugs previously unavailable in the USA.

19) Outline the legal responsibilities for nurses when giving drugs.
* Must have a License
* Have knowledge and experience with medication
* Must demonstrate accountability and responsibility
Make sure it's the RIGHT medication, dose, client, route, and time
The administration of medications to clients requires knowledge and a set of skills that is unique to the
nurse. The nurse should be licensed, have knowledge, be experienced and good attitude. To administer
medication safely to clients certain cognitive skills are essential. When a nurse administers a medication
to a client, the nurse accepts the responsibility that the medication or the nursing actions in administering
it, will not harm the client in any way.
Demonstrating accountability, and acting responsibly in professional practice, means that the nurse
acknowledges when errors in professional practice occurs.
Standards are those actions that ensure safe nursing practice.
There are 5 rights:
1) The right medication.
2) The right dose.
3) The right client.
4) The right route.
5) The right time.

20) What are pharmacodynamics and pharmacokinetics?

Pharmacodynamics: the study of how long a drug acts on a living organism, including pharmacologic
response and the duration and magnitude of response observed, relative to the concentration of the drug
at the active site in the organism.
Pharmacokinetics: is the study of how medications enter the body, reach their site of action, are
metabolized, and exit the body.
The study of the action of drugs within the body, including mechanisms of absorption, metabolism, and
excretion; onset of action; duration of effect; biotransformation; and effects and routes of excretion of
the metabolites of the drug.

21) How does the nurse works with narcotics?

a) Store all narcotics in a locked, secure cabinet or container (Computerized, locked cabinets are now
available).
b) Nurses in charge carry a set of keys (or a special computer entry code) for narcotics cabinet.
c) During institutions change of shift the nurse going off duty counts all the narcotics with the nurse
coming on duty. Both nurses sign the narcotic record to indicate that the count is correct.
d) Discrepancies in narcotic counts are reported immediately.
e) A special inventory record is used each time a narcotic is dispensed.
f) The record is used to document the client's name, date, time of medication administration, name of
medication, dose, and signature of nurse dispensing the medication.
g) The form provides an accurate ongoing count of narcotics used and remaining.
h) If only one part of a pre-measured dose of a controlled substance is given, a second nurse witnesses'
disposal of the unused portion and documents such on the record.

22) What does the nurse do for drug omissions, erroneous drug order?
A medication error is any event that could cause or lead to a client receiving inappropriate medication
therapy or failing to receive appropriate medication therapy.
When a error occurs, it should be acknowledged immediately and reported to the appropriate hospital
personnel (e.g., nurse manage, physician). Measures to counteract the effects of the error may be
necessary. The nurse is also responsible for completing an incident. Incident reports assist administrative
personnel in identifying hospital problems that contribute to medication errors.
Omissions: X-Rays, vomiting, dialysis, diarrhea, pre/post surgery with order NPO
Erroneous: call Dr if illegible handwriting
Maintaining Client's Rights:
* Be informed of med's name, purpose, action, and potential undesired effects
* Refuse a medication regardless of consequences
* Have nurse or Dr. assess a medication history, including allergies
* Advised of experimental nature of med and give consent
* Receive labeled meds safely without discomfort in accordance with the five rights
* Receive appropriate supportive therapy in relation to med therapy
* Not receive unnecessary medications.
?2011 thestudentnurse.com

Review For Final NUR1025

1) Be able to define the defense mechanism and give example for each one. Introjection,
Displacement, Undoing, Sublimation, Projection, Denial, Regression, Repression, Reaction-formation,
Compensation and Suppression.
Introjection: when a person internalizes some part of the external world into their psyche.

Displacement: when you take on a type of behavior and substitute it with another. Can be positive or
negative.
Undoing: the performance of a specific action that is intended to negate in part a previous action or
communication. According to some psychologists, undoing is related to the magical thinking of childhood.
For example, a spouse bring home flowers after having a lunchtime affair with someone else. Also known as
an unconscious defense mechanism.
Sublimation: an unconscious defense mechanism by which an unacceptable instinctive drive is diverted and
expressed through a personally approved, socially accepted mean. Substitute one behavior for another.
For example: couples that cannot have children decide to have pets instead.
Projection: an unconscious defense mechanism by which an individual attributes his or her own
unacceptable behavior, traits ideas or impulses to another person. It is noted in some stages of
schizophrenia. For example: the spouse that drinks excessively and blames its spouse for it.
Denial: an unconscious defense mechanism in which emotional conflict and anxiety are avoided by refusal
to acknowledge those thoughts, feelings, desires, impulses, or facts that are consciously intolerable.
Person refuses to acknowledge the presence pf a condition that is disturbing. For example: a person
receives a diagnosis of a incurable disease, but tells everyone that nothing is going to happen to her/him.
Regression: the person returns to a more comfortable method of behaving, For example: an elderly client
becoming infantile on her/his behavior.
Recation-Formation: an unconscious defense mechanism in which a person expresses toward another
person or situation feelings, attitudes, or behaviors that are opposite of what would normally be expected.
It begins in early childhood and proceeds through life. When a person gives a reason for behavior that is
opposite for its true cause. What you feel inside is not what you are projecting. For example when a
student feels admiration for another student but instead of expressing those feelings decides to spread
negative gossip.
Compensation: a complex defense mechanism that allows one to avoid the unpleasant or painful emotional
stimuli that result from a feeling of inferiority or inadequacy. Person substitutes what is perceived as a
weakness for strength. For example making an extraordinary effort to overcome a disability (blind people
uses/develop their other senses), scorning a quality that one lacks ("sour grapes") and substituting hard
work and excellent performance in one field for a lack of ability in another.
Suppression: the conscious inhibition of or effort to conceal unacceptable or painful thoughts, desires,
impulses, feelings or acts. Consciously bury something, a felling, a fact. For example: avoiding thinking of
the upcoming critical thinking exam.
Repression: when a person excludes an anxiety-producing event from awareness. An unconscious defense
mechanism that also underlies all defense mechanisms whereby unacceptable thoughts, feeling, ideas,
impulses or memories, especially those concerning some traumatic past event, are pushed from the
consciousness because of their principal guilt association or disagreeable content and are submerged in
the unconscious, where they remain dormant but operant. Such repressed emotional conflicts are the
source of anxiety that may lead to any of the anxiety disorders. For example the victim of a violent crime
"doesn't remember" the detail pertaining to the event.

2)What is the treatment for dehydration? What associated nursing diagnoses can be made with fluid
and electrolyte imbalance?

Dehydration is the excessive loss of water from body tissues. Dehydration is accompanied by a
disturbance in balance of essential electrolytes, particularly sodium, potassium, and chloride. It may follow
prolonged fever, diarrhea, vomiting, acidosis, and any condition in which there is rapid depletion of body
fluids. Signs of dehydration include poor skin turgor (not reliable in the elderly), flushed dry skin, coated
tongue, dry mucous membranes, Oliguria, irritability and confusion. Normal fluid volume and balanced
electrolyte values are the primary goal.
Treatment: enteral and parenteral replacement of fluids and electrolytes. Increase intake of fluids to a
specified amount according to age and metabolic needs. Weigh daily in same type of clothing at same time.
Monitor input and output.
Associated Nursing Diagnoses
+Fluid volume deficit r/t to excessive urinary output.
+Fluid volume deficit r/t uncontrolled diabetes
+Fluid volume deficit r/t increased capillary permeability and evaporative loss from burn wound.
+Fluid volume deficit r/t extreme heat/sun, dryness
+Fluid volume deficit r/t excessive use of laxatives, enemas, diuretics or alcohol
+Risk for fluid volume deficit r/t insufficient fluids for exercise
+Altered peripheral tissue perfusion r/t blood loss

3) Outline the signs and symptoms of hypo/hypercalcemia and hypo/hypernatremia. What is the
treatment for these disorders? Known the serum lab values for calcium, potassium and sodium.
Which electrolyte imbalance causes cerebral and pulmonary edema? Where is potassium and sodium
most abundant in the human body?
Hypocalcemia:
Signs and symptoms: numbness nad tingling of finger tips and cirumoral region, hyperactive reflexes,
positive Trosseau's sign (carpopedal spasm with hypoxia), positive Chvostek's sign (contraction of facial
muscle when facial nerve tapped), tetany, muscle cramps, and pathological fractures (chronic
hypocalcemia). Serum calcium level < 4.0 mEq/L.
Treatment: replacement of calcium salts, supplement vitamin D, and I.V. of calcium gluconate.
Hypercalcemia:
Signs and symptoms: anorexia, nausea and vomiting, weakness, lethargy, low back pain (from kidney
stones), decreased level of consciousness, personality changes and cardiac arrest. Serum level >5 mEq/L or
10.5mg/100ml.
Treatment: promote the excretion of calcium in urine by increasing fluid intake to 3000 to 4000 ml of
fluid daily or administration of a loop diuretic as ordered.
Hypokalemia:
Signs and symptoms: weakness and fatigue, decreased muscle tone, intestinal distension, decreased bowel
sounds, ventricular dysrhythmias, paresthesias and weak irregular pulse, paralytic ileus, flatulence, speech
change, vomiting, polyuria, nocturia, apathy and mental confusion. Serum potassium level < 3.5 mEq/L.
Treatment: replace K (orally), IV of K (give diluted, no faster than 20 mEq/h), do not infiltrate IV, and if
the person is not voiding do not give it.
Hyperkalemia:
Signs and symptoms: anxiety, dysrhythmias, paresthesias, weakness, abdominal cramps, diarrhea,
bradycardia, muscle twitching, EKG changes and paralysis.
Treatment: Give PO fluids, dyalisis, give kayexalate by mount, glucose/insulin IV, assess vital signs, use

cardiac monitor, and assess cardiac enzymes.

Hyponatremia:
Signs and symptoms: cells swells, cramps, nausea, vomiting, fainting, rapid weak pulse, lethargy, fatigue,
apprehension, personality change, postural hypotension, postural dizziness, fingerprints remaining on
sternum after palpation, tachycardia, convulsions and coma. Serum sodium level < 135 mEq/L.
Treatment: oral fluids, Gatorade with salt, hypertonic IV fluids, sodium bicarbobate.
Hypernatremia:
Sings and symptoms: cells shrink, thirst, dry and flushed skin, dry and sticky tongue and mucous
membranes, irritability, sunken eyes, dark circles, Oliguria (100-400 cc/day), no tears, lethargy, and coma.
Serum sodium level > 145 mEq/L.
Treatment: assess vital signs for low-grade fever and postural hypotension, inspect mouth for dry tongue
and mucous membranes, monitor urinary output for Oliguria or Anuria, give IV fluids (.45NS) without NA,
diet restriction of salt.
Known the serum lab values for calcium, potassium and sodium.
Sodium: 135 to 145 mEq/L
Potassium: 3.5 to 5 mEq/L
Calcium: 4 to 5 mEq/L (normal total calcium is 8.5 to 10.5 mg/100ml)
Which electrolyte imbalance causes cerebral and pulmonary edema?
Hyponatremia causes pulmonary and cerebral edema (hypotonic and hypertonoic ECF)
Where is potassium and sodium most abundant in the human body?
Potassium in the body constitutes the predominant intracellular cation, helping to regulate neuromuscular
excitability and muscle contraction. It is must abundant in the tissue of muscles and the liver.
Sodium is 90% in extracellular fluid (ECF). Sodium is part of the body secretions like saliva, gastric and
intestinal secretions, bile, and pancreatic fluid. Sodium is the chief electrolyte in interstitial fluid, and its
interaction with potassium as the main intracellular electrolyte is critical for survival.

4) What are Chvostek's and Trosseau's sign? What do they indicate?

Chvostek's sign: is an abnormal spasm of the facial muscles elicited by light taps on the facial nerve in
patient who are hypocalcemic. It is a sign of tetany.
Trosseau's sign: a test for latent tetany in which carpal spasm is induced by inflating a
sphygmomanometer cuff on the upper arm to a pressure exceeding systolic blood pressure for 3 minutes.
A positive test result may be see in hypocalcemia and hypomagnesemia.

5) What physical assessment findings will the nurse discover with fluid volume excess and deficit?
What does specific gravity tell us about fluid status?
Fluid Volume Excess: edema, confusion, anasarca, weight gain, shortness of breath, intake greater than
output, abnormal breath sounds, rales (crackles), decreased hemoglobin and hematocrit, increased central
venous pressure, jugular vein distension, and possible hepatojugular reflex; changes on mental status,
Oliguria, altered electrolytes, restlessness and anxiety.
Fluid Volume Deficit: decreased urinary output, increased urine concentration, sudden weight loss,

decreased venous filling, increased hematocrit, decreased skin/tongue turgor, decreased blood pressure,
thirst, increased pulse rate, decreased pulse volume/pressure, change in mental state, increased body
temperature and weakness.
What does specific gravity tell us about fluid status?
Specific gravity is the ratio of density of a substance to the density of another substance accepted as a
standard. The usual standard for liquids and solids is water. Thus a solid or liquid with specific gravity of 4
is four times as dense as water at the same temperature. For example, the urine specific gravity test
measures the urine's degree of concentration and evaluates the kidney ability to conserve or excrete
water. The specific gravity, measured at bedside using a urinometer, normally ranges between 1.010 and
1.025.
What does the nurse does to help keep track of the patient's fluid volume status?
+ Assess blood pressure and pulse.
+ Obtain daily weight measurements.
+ Observes volume of urine output related to intake and specific gravity (measures fluid intake & output).
+ Palpates skin turgor.
+ Asks if the patient is thirty or weak.
+ Inspect mucous membranes for degree of moisture.
+ Observes for abnormal losses of fluids.
+ Assesses client's tolerance to changing from lying to sitting position.

6) What relationship does phosphorous have on calcium?

Phosphorus is essential for the metabolism of calcium, glucose and protein.
Calcium and phosphorus-phosphate are inversely proportional, if one rises the other falls.

7) Give the IV fluid most like blood and how does it expand the volume of plasma?
Plasma Volume Extender: an IV solution of dextran, proteins, or other substances used to treat shock
cause by volume blood.
Plasma Expander: a substance usually a high molecular dextran, that is administered intravenously to
increase the oncotic pressure of a patient.

8) What are the treatments for respiratory acidosis/alkalosis and metabolic acidosis/alkalosis?
Respiratory acidosis: an abnormal condition characterized by a low plasma pH resulting from reduced
alveolar ventilation, Ineffective treatment of acute respiratory acidosis can lead to coma and death.
Treatment: Remove any airway obstruction. Promote deep or pursed-up breathing. Use mechanical
ventilation and oxygen therapy. Administer IV bronchodilators and sodium bicarbonate (to buffer) as
ordered by physician.
Respiratory alkalosis: abnormal condition characterized by high plasma pH resulting from increased
alveolar ventilation.
Treatment: try to minimize patient's anxiety, slow rate of breathing and breathe less deeply, have the
patient breath into a paper bag and inhale exhaled CO2 to compensate for the deficit created by
hyperventilation may treat severe cases. Sedatives may also be administered to decrease the ventilation
rate.

Metabolic Acidosis: acidosis in which excess acid is added to the body fluids or bicarbonate is lost from
them. Blood ph is <7.35.
Treatment: treat the underlying pathology. For example if the patient has diarrhea stop it. If he/her has
an infection treat it/stop it.
Metabolic alkalosis: an abnormal condition characterized by the significant loss of acid in the body or by
increased levels of base bicarbonate. Severe untreated alkalosis may lead to coma and death. Blood pH is
>7.45.
Treatment: correct/stop vomiting and GI suctioning.
Normal
Ph Acid < 7.35-7.45 >Alkaline
HCO3 Acid < 22-28 >Alkaline
CO2 Alkaline< 35-45 > Acid
Recipe to read ABG's (Arterial Blood Gas):
1)First look at pH to see if is acidosis or alkalosis.
2) Next, check the metabolic versus the respiratory value; the value further away is the answer.

9) What is urinary retention and how the nurse assess it?

Urinary retention is the marked accumulation of urine in the bladder as a result of the inability of the
bladder to empty. Urine continues to collect in the bladder, stretching its wall and causing a feeling of
pressure, discomfort, and tenderness over symphisis pubis, restlessness, and diaphoresis (sweating).
The nurse should be aware of the volume and frequency of voiding in order to assess urinary retention.
The nurse should assess the abdomen for evidence of bladder distension using light palpation. The client
may feel tenderness or even pain. Percussion of a full bladder yields a dull percussion note.
How does the nurse observe for stones in the urine?
Kidney stones or renal calculi are calcium stones that lodge in the renal pelvis and pass through the
ureters. Immobilized patients are at risk for calculi because of altered calcium metabolism and the
resulting hypercalcemia.
How does the nurse deal with a patient's incontinence?
Incontinence is a very common problem, especially among older adults. Regardless of the cause,
incontinence is a psychologically distressing and socially disruptive problem. Urinary incontinence occurs
because the pressure in the bladder is too great or because the sphincters are too weak. Incontinence
may involve a small leakage of urine when the person laughs, coughs, or lifts something heavy. The client
can be taught to strengthen the muscles around the external sphincters to help manage this type of
incontinence. Alert clients need an incontinence product that is discreet and promotes self-care.
Persistent urge, stress, or overflow incontinence may need referral for urological evaluation. When urinary
incontinence results from decreased perception of bladder fullness or impaired voluntary motor control,
bladder training can be helpful. Bladder training provides cooperative clients with the opportunity to void
at regular intervals (1 + to 2 hours) to achieve continence. When paralyzed clients have overflow
incontinence, Crede's method may be used. This involves manual pressure over the lower abdomen to
express urine from the bladder at regular intervals. Crede's method requires a measure of expertise to
prevent injury to the bladder. Incontinence characterized by urine or fecal flow at unpredictable times
requires the use of adult disposable undergarments or underpads as the primary means of management.
Urine and feces are very irritating to the skin. Cleansing the skin thoroughly after each episode of
incontinence with warm soapy water and drying it thoroughly help prevent skin breakdown.

10) How does the nurse apply hot and cold applications?
Local heat produces vasodilation, which decreases tissue congestion by improving blood flow. Improved
circulation leads to healing, exudates consolidation, and analgesia. Also, heat reduces tissue viscosity,
which increases blood flow. Risk after heat treatments are burns, bleeding, chilling, dehydration, and
maceration.
Local cold application results in vasoconstriction, thus reducing soft tissue bleeding and edema. Also,
cooling slows nerve conduction, relieving pain. Improperly applied cold treatments can result in ischemia
and even frostbite.
To apply heat or cold the nurse should first have a doctor's order, which should include the body site to
be treated and the type, frequency and duration of application. Heat and cold applications can be
administered in sterile or non-sterile, dry or moist forms.
Clients at greater risk for adverse reactions to local heat or cold therapies are those with circulation and
sensation problems. This would include clients with known sensitivity to heat or cold, peripheral vascular
disease, diabetes, and Raynaud.s phenomenon.
Before using these therapies the nurse must understand the normal body responses to local temperatures
variations, assess the integrity of the body part, determine the client's ability to sense temperature
variations, and ensure proper operation of equipment. Avoid placing the heat or cold source directly to the
skin, always use a barrier. Is imperative to verify safe temperatures of hot and cold treatments to
prevent tissue burn and ischemia. The nurse is legally responsible for the safe administration of heat and
cold.

11) What is osteoporosis and how does the nurse assist the patient to help this disorder?
Osteoporosis is a disorder characterized by abnormal loss of bone density and deterioration of bone
tissue with an increased fracture risk. It occurs most frequently in post-menopausal woman, sedentary or
immobilized individuals, and patients on long-term steroid therapy.
Patient teaching focuses in factors influencing the development of osteoporosis, interventions to arrest or
slow the process, and measures to relieve the symptoms. Adequate dietary or supplemental calcium,
regular weight-bearing exercise, and modification of lifestyle, if necessary (e.g., cessation of smoking and
reduced use of caffeine and alcohol), help to maintain bone mass. Diet, exercise, and physical activity are
the primary keys to developing high-density bones that are resistant to osteoporosis. It is emphasized
that elderly people continue to need sufficient calcium, vitamin D, sunshine, and exercise to minimize the
progression of osteoporosis. Because gastrointestinal symptoms and abdominal distension are frequent
side effects of calcium supplements, the nurse instructs the patient to take them with meals. Also, the
nurse should remind the patient the importance of drinking adequate fluids to avoid renal calculi. Relief of
back pain resulting from compression fracture may be accomplished by telling the patient to rest in bed in
a supine position or side-lying position several times a day. The mattress should be firm and nonsagging.
Knee flexion increases comfort by relaxing back muscles. Intermittent local heat and back rubs promote
muscle relaxation. The nurse instructs the patient to move the trunk as a unit and to avoid twisting. The
nurse encourages good posture and teaches body mechanics.

12) What are the normal levels of carbon dioxide (CO2), bicarbonate (HCO3) and ph in arterial
blood?
Blood PH 7.35-7.45
HCO3 (bicarb) 22-28

CO2 35-45
What acid-blood imbalance develops when the patient has nausea and vomiting, and diarrhea?
Hypokalemia
What are the buffer systems that interact with acid-base imbalances?
The lungs, and the kidneys.
Which one takes a few days to work, which one works immediately?
The kidneys buffer within 3 days, they are in charge of the bicarbonate.
The lungs buffer immediately, they are in charge of the carbonic acid.

13) What is the carbonic acid-sodium bicarbonate buffer system?

The lungs, and the kidneys.

14) Discuss the physiological changes that occur in the elderly that influences medication
pharmacokinetics. Page 910, Fig. 34-14
a)Drug-receptor interaction: brain receptors become more sensitive, making psychoactive drugs very
potent.
b)Circulation: vascular nerve control is less stable. Hypertensives, for example, may overshoot, dropping
blood pressure to low. Digoxin, for example, may slow the heart rate too much.
c)Metabolism: liver mass shrinks. Hepatic blood flow and enzyme activity decline. Metabolism drops to + to
2/3 the rate of young adults. Enzymes lose ability to process some drugs thus prolonging drug half-life.
d)Absorption: gastric emptying rate and gastrointestinal motility slow. Absorption capacity of cell and
active transport mechanism decline.
e)Excretion: in kidneys, renal blood flow, glomerular filtration rate, renal tubular secretion and
reabsorption, and number of functional nephrons decline. Blood flow and waste removal slow. Age-related
changes lengthen half-life for renally excreted drugs. Antidiabetic drugs, among others, stay in the body
longer.
f)Distribution: lean body mass falls. Adipose stores increases. Total body water declines, raising the
concentration of water-soluble drugs, such as digoxin, which can cause heart dysfunction. Plasma protein
diminishes, reducing sites available for protein-bound drugs and raises blood levels of free drugs.

15) Know various routes for medication administration. Page. 893

16) What is the treatment for anaphylaxis? Page 892

Antihistamines, epinephrine, and bronchodilators may be used to treat anaphylactic reactions (severe
allergic reactions). The client may also become severely hypotensive, necessitating emergency
resuscitation measures.

17) When do the nurse questions the doctor medication order? Page 899, Table 34-9.
+Questions administration of multiple tablets or vials for single dose.
+Questions ineligible writing.

+Questions medications ordered by nickname or unofficial abbreviation.

+Questions dosages that exceed the recommended one for therapeutic effect.

18) Outline how to draw medication from an ampule.

+Tap the top of ampule lightly and quickly with finger until fluid moves from neck of ampule.
+Place a small gauze pad around neck of ampule.
+Snap neck of ampule quickly and firmly away from hands.
+Draw up medication quickly.
+Hold ampule upside down, or set it on a flat surface. Insert syringe or filter needle (see agency policy)
into center of ampule opening. Do not allow needle tip or shaft to touch rim.
+Aspirate medication into syringe by gently pulling back on plunger.
+Keep needle tip under surface of liquid. Tip ampule to bring all fluid within reach of the needle.
+If air bubbles are aspirated, do not expel air into ampule.
+To expel excess air bubbles, remove needle from ampule. Hold syringe vertically with needle tip pointing
up, tap side of syringe to cause bubbles to rise toward needle. Draw back slightly, and then push plunger
upward to eject air. Do not eject fluid.
+If syringe contains excess fluid, use sink for disposal and recheck fluid level by holding the syringe
vertically.
+Cover needle with cap, change needle on syringe or use filter needle if you suspect medication is on
needle shaft.

19) Be able to calculate dosage and IV's. Know abbreviations.

Please refer to Mr. James Bray handouts.

20) Outline the nurse responsibilities in medication administration.

?Must have a License
?Have knowledge and experience with medication
?Must demonstrate accountability and responsibility
Make sure it's the RIGHT medication, dose, client, route, and time
The administration of medications to clients requires knowledge and a set of skills that is unique to the
nurse. The nurse should be licensed, have knowledge, be experienced and good attitude. To administer
medication safely to clients certain cognitive skills are essential. When a nurse administers a medication
to a client, the nurse accepts the responsibility that the medication or the nursing actions in administering
it will not harm the client in any way.
Demonstrating accountability, and acting responsibly in professional practice, means that the nurse
acknowledges when errors in professional practice occurs.
Standards are those actions that ensure safe nursing practice.
There are 5 rights:
1) Right patient
2) Right drug
3) Right route
4) Right time
5) Right dose
Sixth right is right documentation.
Always admit an error, report it to your supervisor and call the doctor.

21) Discuss the administration of Digoxin.

It is a cardiac glycoside obtained from the leaves of Digitalis lanata.
Indications: it is prescribed for the treatment of congestive heart failure and certain cardiac
arrhythmias (tachyarrhythmias, tachycardias).
Action: Increases the force of myocardial contraction. Prolongs refractory period of AV node. Decreases
conduction through the SA and AV nodes.
Restrictions: ventricular fibrillation, ventricular tachycardia, or know hypersensitivity to this drug
prohibits its use. Use cautiously in electrolyte abnormalities (hypokalemia, hypercalcemia, and
hypomagnesemia).
Adverse effects: Most serious are cardiac arrhythmia and heart block, disorientation, and visual
disturbances.

22) Know what happens in each step of the nursing process.

The five steps of the nursing process are:
Assessment, Diagnosis, Planning, Implementation, and Evaluation.
-Assessment is the systematical collection, verification and analyzation and communication of data about a
client.
-Diagnosis is the use of critical thinking skills to analyze the client's assessment data to form the nursing
diagnoses. Includes decision-making steps the nurse uses to develop a diagnostic statements.
-Planning is prioritizing and answering what, when, how and who questions.
-Implementation-describes the category of nursing for achieving the goals and expected outcomes for
nursing care are initiated and completed.
-Evaluation-the final step of the nursing process measures the client's response to nursing actions and the
client's progress toward achieving goals.
The nurse is to perform the nursing process because it enables the nurse to organize and deliver nursing
care. It promotes individualized nursing care and assists the nurse in responding to client needs in a timely
and reasonable manner to improve or maintain the client's level of health.

23) Discuss postoperative complications. Discuss the different types of anesthesia. What is wound
dehiscence? What are the normal signs of post-operative inflammation? What are the signs of
hemorrhage post-operatively? If a patient is NPO post-op when does the nurse resume the diet?
Discuss postoperative complications. Page 1709, table 49-1
Respiratory System
Atelectasis, Pneumonia, Hypoxia, and Pulmonary embolism.
Circulatory System
Hemorrhage, hypovolemic shock, thrombophebitis, thrombus, and embolus.
Gastrointestinal System
Abdominal distension, constipation and nausea and vomiting.
Genitourinary System
Urinary retention
Integumentary System

Wound infection, wound dehiscence, wound evisceration, and surgical mumps (parotitis).
Nervous system
Intractable pain.
Discuss the different types of anesthesia.
General anesthesia: result in an immobile, quiet client who does not recall the surgical procedure. It has 3
stages: induction, maintenance, and emergence.
Regional anesthesia: its induction results in loss of sensation in an area of the body. There are 3 types of
induction methods:
+ Nerve block: local anesthetic injected in nerve.
+ Spinal anesthesia: lumbar puncture introduces local anesthesia into the cerebrospinal fluid.
+ Epidural anesthesia: no as risky as the spinal anesthesia, the anesthetic agent is injected into the
epidural space outside the dura mater.
+ Intravenous regional anesthesia: local anesthetic is injected via IV line into an extremity below the level
of a tourniquet after blood has been withdrawn.
Local anesthesia: involves loss of sensation at desired site.
Conscious sedation: used for procedures that do not require complete anesthesia but rather a depressed
level of consciousness.
What is wound dehiscence?
It is a separation of wound edges at suture line. Signs and symptoms include increased drainage and
appearance of underlying tissue. Usually occurs 6 to 8 days after surgery.
What are the normal signs of post-operative inflammation?
Localized redness, edema, warmth, and throbbing.
What are the signs of hemorrhage post-operatively?
Fall of blood pressure, elevated heart and respiratory rate, thready pulse, cool, clammy, pale skin, and
restlessness. If hemorrhage is external the nurse observes increased bloody drainage on dressing, or
through drain. If hemorrhage is internal, the operative site becomes swollen and tight. For example, if a
client bleeds within the abdomen, the abdomen becomes tight and distended.

If a patient is NPO post-op when does the nurse resume the diet?
Normally a client does not receive fluids to drink in the PACU because of bowel sluggishness, with the risk
of nausea and vomiting, and because of grogginess from general anesthesia. The client will likely begin
taking ice chips or sips opf fluids when arriving on the acute care unit, unless otherwise indicated by the
doctor's orders. If the chips are tolerated, a clear meal will usually be ordered. The acute care nurse
closely monitors the client's initial oral intake for potential of aspiration or the presence of nausea and
vomiting. The client's diet will be liberalized as tolerated beginning the day after surgery for many
operative procedures. In cases of abdominal surgery, the bowel may need to rest and oral intake will not
be started for several days. NPO client's won't resume the diet until the doctor orders it.

24) What are the nursing interventions in the PACU (post anesthesia care unit).
The PACU nurse will receive a report from the operating room nurse or anesthesia provider explaining
whether there were any complications during surgery. This report is given while the PACU staff is

admitting the patient. The PACU nurse will attach the client to monitoring equipment such as the
noninvasive blood pressure monitor, ECG monitor, and pulse oximeter. Clients often receive some form of
oxygen at this point. After reviewing events in the operating room, the PACU nurse makes a complete
assessment of the client's status. The assessment should be performed rapidly and thoroughly and be
targeted to the needs of the postsurgical client. When the time for discharge arrives, the nurse evaluates
readiness for discharge from PACU on the basis of vital sign stability in comparison with the preoperative
data. The nurse calls the nursing unit to report vital signs, the type of surgery and anesthesia performed,
blood loss, level of consciousness, general physical condition, and presence of IV lines or drainage tubes.
The PACU nurse's report helps the nurse on the acute patient care area to anticipate special client needs
and obtain necessary equipment. The PACU nurse, if helping to transport the client, show the acute care
area nurse the recovery room record and reviews the client's condition and course of care. The PACU
nurse also points out the physician orders that require attention. Is important to remember that nursing
care in the PACU focuses on monitoring and maintaining respiratory, circulatory, fluid and electrolyte, and
neurological status, as well as the management of pain. Other important factor to assess include
temperature control, skin and incision/wound status, and genitourinary and gastrointestinal function.