Exam (elaborations)
LVN EXIT RETAKE EXAM
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LVN EXIT RETAKE EXAM
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LVN EXIT RETAKE EXAMPhysiological Needs - ANSWER Oxygenation
Circulation
Nutrition
Elimination
Fluid balance
Activity and exercise
Rest and Sleep
Maslow's Hierarchy of Needs - ANSWER physiological
Safety and security
Love and Belonging
Self esteem
Self Actualization
safety and security needs - ANSWER Living in a safe environment
Adequate income
Shelter from environment elements
love and belonging needs - ANSWER Love
Affection
Relationships
Involvement with community and spiritual groups help to meet this need
Self Esteem Needs - ANSWER Self respect
personal worth
social recognition
Self actualization needs - ANSWER personal growth
fulfilling own potential
Maslow's belief: very few individual reach this level
LVN 4 steps nursing process - ANSWER Data collect FIRST
Planning
Implementation
Evaluation
Least restrictive interventions - ANSWER Close and constant supervision
Assessing medications
Bed and wheelchair alarms
Mattress on floor next to client's bed
Least invasive interventions
Incontinent clients on bladder routine
Incentive spirometers/inhalation tx
, Oral or rectal administration of medications
Circulation - ANSWER 3rd highest priority
heart rate and BP with expected reference range necessary for adequate cardiac,
cerebral, and peripheral perfusion
chemical and/or physical cardiac support
resuscitation
supplemental fluids (to reestablish intravascular fluid volume and BP)
Safety and Risk Reduction Framework: - ANSWER safety risk to client
Greatest risk to client
Significance of risk compared to other risks
Survival Potential Framework - ANSWER Emergent- class I/highest
priority/immediate tx: chance for survival
Urgent- Class II/ serious and extensive injuries/ do not pose immediate threat to life/
potential for survival even with delayed tx
Nonurgent-Class III/ less serious and less extensive/ no threat
Expectant- Class IV/ potential survival does not exist even with tx
Acute vs. Chronic - ANSWER Acute needs may be more of a threat
chronic needs usually develop over period of time
Attend to alteration in acute phase before they evolve into chronic alteration
Assess circulatory status - ANSWER BP
Urinary output
Skin turgor
Pulse
3 point crutch gait - ANSWER pt stand and bear weight on the unaffected leg
transfer body weight to the crutches
advance the unaffected leg between the crutches
shift weight from the crutches to the unaffected leg
go up stairs is to align crutches on the stair
Sodium levels - ANSWER 136-145 mEq/L
high:
-report to PCP
-give hypotonic fluids
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