,Define Primary nursing
1 primary RN assumes responsibility for a caseload of patients, provides care for the
same pts during their stay in health care facility. RN assesses pt, develops plan of care
and delivers appropriate nursing intervention. Communication is lateral from nurse to
nurse and caregiver to caregiver.
Define major surgery
Involves extensive reconstruction or alteration in body parts, poses great risks to well
being.
Describe a stage II pressure ulcer
Partial thickness loss of dermis presenting a shallow ulcer red- pink wound bed without
slough. May present an intact or open. ruptured serum filled blister. Shiny dry shallow
ulcer without slough or bruising.
Define Presbyscusis
Hearing loss associated with aging. Usually involves both a loss of hearing sensitivity and
a reduction in the clarity of speech.
Define Ventilation
,movement of air in and out of the lungs. Afterload ejection of blood from left ventricle
define contact precaution
Safeguards designed to reduce the risk of transmission of epidemiologically important
microorganisms by direct or indirect contact.
what sound do rhonchi make
sonorous wheeze-coarse, low pitched: may clear with cough.
describe head lice
attach their eggs to hair, eggs look like oval particles of dandruff. Lice are difficult to see,
observe for bites or pustule eruptions in the follicles and area where skin surfaces meet
behind the ears in the ears and in the groin.
describe diffusion
movement of gases between air spaces and blood stream
what is the final step in a complete assessment?
documentation
, S/S of hypostatic pneumonia
decreased lung expansion, generalized respiratory muscle weakness and secretions occur
without immobility. (comes from inflammation of the lung from stasis or pooling of
secretions. )
s/s of respiratory acidosis
increased PaCo2 and increased hydrogen ion concentration below 7.35. This reflects the
excess carbonic acid in the blood (hypoventilation produces R. acidosis)
what is the primary advantage of hydrogel dressing ?
contains a high percentage of water for wounds that require moisture. Maintaining a
moist wound environment needed for healing. Hydrogel facilitates debridement by
softening dead tissue.
A pt complains of chills, dizziness and feeling hot during a blood transfusion. What are
the nurses most appropriate actions?
Stop transfusion immediately.
Remove blood component and tubing containing and tubing contacting blood products
replace with new primed tubing with 0.9% sodium chloride
Maintain patent IV line with normal saline
Stay with patient observe signs and symptoms and monitor every 5 min.
Notify health care ream or response team
1 primary RN assumes responsibility for a caseload of patients, provides care for the
same pts during their stay in health care facility. RN assesses pt, develops plan of care
and delivers appropriate nursing intervention. Communication is lateral from nurse to
nurse and caregiver to caregiver.
Define major surgery
Involves extensive reconstruction or alteration in body parts, poses great risks to well
being.
Describe a stage II pressure ulcer
Partial thickness loss of dermis presenting a shallow ulcer red- pink wound bed without
slough. May present an intact or open. ruptured serum filled blister. Shiny dry shallow
ulcer without slough or bruising.
Define Presbyscusis
Hearing loss associated with aging. Usually involves both a loss of hearing sensitivity and
a reduction in the clarity of speech.
Define Ventilation
,movement of air in and out of the lungs. Afterload ejection of blood from left ventricle
define contact precaution
Safeguards designed to reduce the risk of transmission of epidemiologically important
microorganisms by direct or indirect contact.
what sound do rhonchi make
sonorous wheeze-coarse, low pitched: may clear with cough.
describe head lice
attach their eggs to hair, eggs look like oval particles of dandruff. Lice are difficult to see,
observe for bites or pustule eruptions in the follicles and area where skin surfaces meet
behind the ears in the ears and in the groin.
describe diffusion
movement of gases between air spaces and blood stream
what is the final step in a complete assessment?
documentation
, S/S of hypostatic pneumonia
decreased lung expansion, generalized respiratory muscle weakness and secretions occur
without immobility. (comes from inflammation of the lung from stasis or pooling of
secretions. )
s/s of respiratory acidosis
increased PaCo2 and increased hydrogen ion concentration below 7.35. This reflects the
excess carbonic acid in the blood (hypoventilation produces R. acidosis)
what is the primary advantage of hydrogel dressing ?
contains a high percentage of water for wounds that require moisture. Maintaining a
moist wound environment needed for healing. Hydrogel facilitates debridement by
softening dead tissue.
A pt complains of chills, dizziness and feeling hot during a blood transfusion. What are
the nurses most appropriate actions?
Stop transfusion immediately.
Remove blood component and tubing containing and tubing contacting blood products
replace with new primed tubing with 0.9% sodium chloride
Maintain patent IV line with normal saline
Stay with patient observe signs and symptoms and monitor every 5 min.
Notify health care ream or response team
