Nursing 211 Final Exam
never delegate - ANS assessment
teaching
evaluation
orthopnea - ANS air hungry
obstructive disorders - ANS COPD, pneumonia, TB, asthma
restrictive - ANS obesity, scoliosis, neuromuscular disorder, casts and braces
preventing atelectasis - ANS ambulation, incentive spirometer, pursed-lip breathing;
diaphragmatic breathing, turn cough and deep breath
nasal cannula - ANS 24-40%, 1-6 L
simple face mask - ANS 40-60%, 6-12 L
partial rebreather mask - ANS 70-90%, 6-15 L; reservoir bag should NOT collapse
non-rebreather mask - ANS 90-100%, 15 L
venturi mask - ANS specific, most accurate oxygen delivery
ejection fraction - ANS the amount of blood pumped out of the left ventricle with each
contraction; indication of the effectiveness of the heart; normal = 55-70%; CHF = <40%
arterial insufficiency - ANS pain intermittent and related to activity; pulses decreased or absent;
delayed cap refill; skin is pale, shiny with hair loss and cool; impaired sensorimotor; pale ulcer
base with even edge; delayed healing
venous insufficiency - ANS constant aching pain; red, warm skin with patchy brown
discoloration; edema; red ulcer base with uneven edge; delayed healing
cardiogenic shock - ANS shock; result of heart failure
hypovolemic shock - ANS shock; result of large quantity of blood or plasma
distributive shock - ANS shock; massive peripheral vasodilation traps blood in peripheral
microcirculation; severe allergic reaction
, stage I pressure ulcer treatment - ANS hydrocolloids, skin sealants, lubricating sprays,
moisturizing lotions; removal of risk factor
stage II pressure ulcer treatment - ANS transparent film (Tegaderm), hydrocolloids, hydrogel
wafers,, specialty absorptivity, alginate dressings; removal of risk factors
stage III pressure ulcer treatment - ANS collagen, wound fillers, debriding agents (autolytic,
enzymatic); removal of risk factors
stage IV pressure ulcer treatment - ANS collagen, wound fibers, alginates, debriding agents;
removal of risk factors
marasmus - ANS condition of starvation that results from deficient calorie intake
kwashiorkor - ANS condition of starvation caused by decreased protein intake
female rule of 5 - ANS 100 lbs/5 feet; 5lbs/in
male rule of 5 - ANS 106 lbs/5 feet; 6lbs/in
RBC - ANS adult male 4.7-6.1
adult female 4.2-5.4
HGB - ANS adult male 14-18
adult female 12-16
HCT - ANS adult male 42-52%
adult female 37-47%
WBC - ANS 5,000 - 10,000
albumin - ANS 3.5-5.0
prealbumin - ANS 15-36
nociceptive - ANS includes somatic and visceral pain; surgery, broken bone, cuts, headache;
aching, gnawing, pounding, dull
neuropathic - ANS direct injury to nerves; amputated limb, compression injuries; burning,
shooting, electrical, abnormal sensation
COLDERR - ANS C - Character
O - Onset
L - Location
never delegate - ANS assessment
teaching
evaluation
orthopnea - ANS air hungry
obstructive disorders - ANS COPD, pneumonia, TB, asthma
restrictive - ANS obesity, scoliosis, neuromuscular disorder, casts and braces
preventing atelectasis - ANS ambulation, incentive spirometer, pursed-lip breathing;
diaphragmatic breathing, turn cough and deep breath
nasal cannula - ANS 24-40%, 1-6 L
simple face mask - ANS 40-60%, 6-12 L
partial rebreather mask - ANS 70-90%, 6-15 L; reservoir bag should NOT collapse
non-rebreather mask - ANS 90-100%, 15 L
venturi mask - ANS specific, most accurate oxygen delivery
ejection fraction - ANS the amount of blood pumped out of the left ventricle with each
contraction; indication of the effectiveness of the heart; normal = 55-70%; CHF = <40%
arterial insufficiency - ANS pain intermittent and related to activity; pulses decreased or absent;
delayed cap refill; skin is pale, shiny with hair loss and cool; impaired sensorimotor; pale ulcer
base with even edge; delayed healing
venous insufficiency - ANS constant aching pain; red, warm skin with patchy brown
discoloration; edema; red ulcer base with uneven edge; delayed healing
cardiogenic shock - ANS shock; result of heart failure
hypovolemic shock - ANS shock; result of large quantity of blood or plasma
distributive shock - ANS shock; massive peripheral vasodilation traps blood in peripheral
microcirculation; severe allergic reaction
, stage I pressure ulcer treatment - ANS hydrocolloids, skin sealants, lubricating sprays,
moisturizing lotions; removal of risk factor
stage II pressure ulcer treatment - ANS transparent film (Tegaderm), hydrocolloids, hydrogel
wafers,, specialty absorptivity, alginate dressings; removal of risk factors
stage III pressure ulcer treatment - ANS collagen, wound fillers, debriding agents (autolytic,
enzymatic); removal of risk factors
stage IV pressure ulcer treatment - ANS collagen, wound fibers, alginates, debriding agents;
removal of risk factors
marasmus - ANS condition of starvation that results from deficient calorie intake
kwashiorkor - ANS condition of starvation caused by decreased protein intake
female rule of 5 - ANS 100 lbs/5 feet; 5lbs/in
male rule of 5 - ANS 106 lbs/5 feet; 6lbs/in
RBC - ANS adult male 4.7-6.1
adult female 4.2-5.4
HGB - ANS adult male 14-18
adult female 12-16
HCT - ANS adult male 42-52%
adult female 37-47%
WBC - ANS 5,000 - 10,000
albumin - ANS 3.5-5.0
prealbumin - ANS 15-36
nociceptive - ANS includes somatic and visceral pain; surgery, broken bone, cuts, headache;
aching, gnawing, pounding, dull
neuropathic - ANS direct injury to nerves; amputated limb, compression injuries; burning,
shooting, electrical, abnormal sensation
COLDERR - ANS C - Character
O - Onset
L - Location
