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NUR 120 Final Exam
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NUR 120 Final Examtrans-cultural nursing - CORRECT ANSWER providing care to patients and families across cultural
variations. Acknowledge, respect, & adapt to patient.
Culture can strongly influence a patients thinking, doing, and being.
Five signs of inflammation - CORRECT ANSWER redness, warmth, swelling, pain, loss of function.
sequence of events of inflammation - CORRECT ANSWER vasodilation, increased vascular permeability
(increased plasma), & leukocyte cellular infiltration
*Repairative process*begins at same time as injury**
cultural nursing assessment - CORRECT ANSWER Systematic way to identify the beliefs, values,
meanings, and behaviors of people while considering their history, life experiences, and the social
and physical environments in which they live.
*"Know Thyself" know your own cultural attitudes, beliefs. Recognize that every one has cultural
"baggage" do not judge anyone for their beliefs*
Blood Transfusion - CORRECT ANSWER blood must be started within 15-20 minutes from obtaining
the blood.
18G needle prefered (20 or higher can be used)
Blood Transfusion Consent - CORRECT ANSWER A patient's written permission to receive blood or
blood products. *IF* the patient is unable to sign and it is an emergency situation two doctors can
sign the consent.
Jehovah's Witness - CORRECT ANSWER No blood products should be used
blood transfusion procedure - CORRECT ANSWER any allergies?- type & cross match blood, check
blood for bubbles, dark color, or cloudiness- change IV line (per policy usually one or two units of
blood per line)- ID check by two nurses- baseline vitals- start with normal saline- run blood slowly for
first 15 minutes- stay with client for 15-30 min- recheck vital signs after 15 of infusing blood- if no
adverse affects increase rate- take vital signs every hour until completed and then every 3 hours (or
per facility protocol)- inform pt to report any s/s of reactions
,reactions during blood transfusion - CORRECT ANSWER stop the blood first! restart saline, notify
health care provider, may use supportive care (benadryl, oxygen, corticosteriods)
Electrolyte values - CORRECT ANSWER Sodium: 135-145 (-natremia)
Chloride: 96-106 (-chloremia)
Calcium: 8.5-10.5 (-calcemia)
Potassium: 3.5-5.5 (-kalemia)
Magnesium: 1.5-2.5 (-magnesemia)
Phosphorus: 2.7-4.5 (-phosphatemia)
FVD (fluid volume deficit) - CORRECT ANSWER hypovolemia
FVE (fluid volume excess) - CORRECT ANSWER hypervolemia
ABG (Arterial Blood Gas) - CORRECT ANSWER essential part of diagnosing & managing oxygenation
status and acid-base balance of high-risk patients
ABG's values (normal) - CORRECT ANSWER pH:7.35-7.45
Pco2: 45-35 (lungs/respiratory)
Hco3: 22-26 (kidneys/metabolic)
buffer systems in the body - CORRECT ANSWER *LUNGS AS A BUFFER*- primary control of body's
carbonic acid supply.
*KIDNEY AS A BUFFER*-works by concentration of bicarb in body. Kidneys either excrete or hang on
to bicarb in the response to the pH of blood. Acidosis- kidney excretes h ion & conserves bicarb.
Alkalosis - kidneys retain H ions.
*ECF, ICF, HGB* are other buffer systems for maintain acid-base balance
when a patient codes - CORRECT ANSWER --most people become acidosis when they code—they will
be administered sodium bicarb
foley catheter care - CORRECT ANSWER • Empty foley bag q8hr at least, keep below level of bladder,
do not let bag lay on floor
, • DC catheter correctly!
• Peri care- do not go up tubing, always go away from where catheter exits body
• Sterile specimen can be taken from port on catheter using sterile syringe w/needle- check facility
policy
urinalysis (UA) - CORRECT ANSWER urine screening test that includes physical observation, chemical
tests, and microscopic evaluation
*specific gravity*
urinalysis: dehydration - CORRECT ANSWER Urinalysis can tell us a lot about dehydration. The color
and clarity of urine, the urine's specific gravity (the mass of urine is compared with that of equal
amounts of distilled water), and the presence of ketones (carbon compounds that signify
dehydration) in the urine may all help to indicate the degree of dehydration.
prostate-specific antigen (PSA) - CORRECT ANSWER sensitive test for prostate cancer.
values less than 4ng/mL are considered normal
*abnormal values does not always indicate cancer* prostatitis often has elevated PSA
impaired vision - CORRECT ANSWER • Refractive errors
Caused by shortened or elongated eyeball that prevents light rays from focusing on retina.
Can be corrected by lenses that focus light
o Emmetropia - normal vision
o Myopa: nearsighted; blurred distance visioin
o Hyperopia; farsighted
o Astigmatism
impaired vision - CORRECT ANSWER *Need specific verbal commands
*Often see better in bright light
glaucoma - CORRECT ANSWER increased intraocular pressure results in damage to the retina and optic
nerve with loss of vision
AKA "silent thief"
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