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Fundamentals of Nursing

Theories:
a. Martha Rogers Human Being Unitary theory
b. Myra Levine Human Becoming
c. Madeleine Leinenger transcultural nursing
d. Hildegard peplau interpersonal relationship
e. Imogene King goal attainment theory
f. Nightingale environmental
g. Dorothea orem General Care nursing self care, self care deficit, and nursing care
h. Margaret newman health care delivery system
i. Betty neuman health unconscious
j. Ida Jean Orlando dynamic nurse patient relationship
k. Dorothy Johnson behavioural model
l. Sis Callista Roy adaptation theory
m. Jean Watson human caring
n. Virginia Henderson - 14 basic/fundamental needs, define nursing
o. Faye Abdellah 21 basic needs
p. Lydia Hall care, cure, core


Drills

Situation 3 - Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk
for infection because of retained secretions. Part of Nurse Mario's nursing care plan is to loosen and remove excessive
secretions in the airway,
1. Mario prepares Richard for postural drainage and percussion. Which of the flowing is a special consideration
when doing the procedure?
a. Respiratory rate of 16 to 20 per minute
b. Client can tolerate sitting and lying position
c. Client has no signs of infection
d. Time of last food and fluid intake of the client

CORRECT ANSWER:D
RATIONALE: Postural drainage treatments are scheduled two or three times daily, depending on the degree of
lung congestion. The best times include before breakfast, before lunch, in the late afternoon and before bedtime.
It is best to avoid hours shortly after meals because postural drainage at these times can be tiring and can induce
vomiting.
OPTION A has no special consideration since it is normal
OPTIONS B & C dont have any special considerations
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7
th
Edition.pp. 1305

2. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the
procedure is;
a. Percussion uses only one hand white vibration uses both hands
b. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion
loose on the exhalation cycle
c. In both percussion and vibration the hands are on top of each other and hand action is in tune with client's
breath rhythm
d. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation
of air

CORRECT ANSWER: A
RATIONALE: Percussion sometimes called clapping is forceful striking of the skin with cupped hands. Vibration is
a series of vigorous quiverings (strong tremble or shake with a slight rapid motion) produced by hands that are
placed flat against the clients chest wall. Option A is true to both percussion and vibration.
OPTION B is not the correct way
OPTION C: percussion can be done with one hand
OPTION D: percussion is not slapping


ABG and ABB ANALYSIS

Metabolic Acidosis

of acids or less production of HCO3



low if compensation is occurring


administered cautiously because the carbon dioxide produced crosses rapidly into the cells and may cause paradoxical
worsening of intracellular hypercarbia and acidosis.

Nursing Responsibilities

of
extremities
invasive lines properly



Metabolic Alkalosis



dosterone










m ECF to ICF due to hydrogen ions moving out of the cell to ECF






pH; more HCO3; normal PaCo2 or elevated if compensation occurs

Nursing Responsibilities

invasive lines properly
ttern, lung sounds, skin color, and mental status






Respiratory Acidosis


d in body fluids



mechanical ventilation















Nursing Responsibilities


-Fowlers or another comfortable position to ease the work of breathing
postural drainage; antibiotic thx; regular coughing, turning, and deep
breathing & mechanical ventilation as appropriate



PR and rhythm, capillary refill, warmth and color of extremities



Respiratory Alkalosis


y elimination of CO2; pneumonia; shock; severe
anemia







exchange of
chloride




Nursing Responsibilities


ute and maintain seizure precautions as necessary

reverse hyperventilation
sist the patient with activities as necessary

Arterial Blood Gases

-base balance


is transported from the alveoli into the plasma

Arterial Blood Gases


- 100 mm Hg at sea level



- 100 % is a normal saturation


Arterial Blood Gas Interpretation


- 7.45


cause death


- 45 mm Hg



alkalosis
- 26 mEq/L)


-26 mEq/L





normal



respiratory alkalosis state
beled as: Metabolic acidosis with a compensatory respiratory alkalosis




Interpreting ABGs:

(A Systematic Approach)

step 1 Evaluate the pH

acidosis = < 7.35 --------------- 7.35-7.45 = normal --------------- > 7.45 = alkalosis or compensated state


step 2 Evaluate the pCO2

resp. acidosis =if>45 ------------35-45=normal;-------------if<35= resp. alkalosis

go to HCO3


step 3 Evaluate HCO3

metab. acidosis =if<22-----------22-26=normal-----------if>26= metab. alkalosis





Question 5. The nurse arrives at the site of an airplane crash and finds the following clients. Which client
should be checked first? The client with:

1. Closed fracture of the humerus
2. Full thickness (3rd and 4th degree) burns over the torso
3. Partial-thickness (1st degree) on the face and neck
4. Laceration to the forehead, who is wandering among the wreckage asking for help

Looking for answers(s):3
Explanation: A is INCORRECT because this client is not in immediate danger of respiratory or cardiac
dysfunction.
B is INCORRECT because, although this client is severely injured and will need intensive care, the client with a
compromised airway should be checked first.
C is CORRECT because clients with burns on the head, neck, and face may have inhalation injury which
impairs respiratory function. Remember the ABCs of CPR: airway is first.
D is INCORRECT because, although the possibility of a head injury exists, this client is awake and ambulatory
at this time.











The client needs to understand that the type of diabetes that she has:
A. is associated with destruction of the beta cells
B. Usually causes fat metabolism
C. Often occurs in obese individual
D. Is rarely controlled

Rationale:
In type 1 diabetes, the disease process is more severe than with type 2 diabetes, and onset is usually in
childhood:
Beta cells in the pancreas that produce insulin are gradually destroyed. Eventually insulin deficiency is
absolute.
Without insulin to move glucose into cells, blood glucose levels become excessively high, a condition
known as hyperglycemia.
Because the body cannot utilize the sugar, it spills over into the urine and is lost.
Weakness, weight loss, and excessive hunger and thirst are among the consequences of this "starvation
in the midst of plenty."
Patients become dependent on administered insulin for survival
(http://www.umm.edu/patiented/articles/what_type_1_diabetes_000009_1.htm)
B- fracture on long bones
C- Type 2 diabetes
Type 2 diabetes is the most common form of diabetes, accounting for 90% of cases. About 20 million Americans
have type 2 diabetes and half are unaware they have it. The disease mechanisms in type 2 diabetes are not
wholly known, but some experts suggest that it may involve the following three stages in most patients:
The first stage in type 2 diabetes is the condition called insulin resistance. Although insulin can attach
normally to receptors on liver and muscle cells, certain mechanisms prevent insulin from moving glucose
(blood sugar) into these cells where it can be used. Most patients with type 2 diabetes produce variable,
even normal or high, amounts of insulin, and in the beginning this amount is usually sufficient to
overcome such resistance
Over time, the pancreas becomes unable to produce enough insulin to overcome resistance. In type 2
diabetes, the initial effect of this stage is usually an abnormal rise in blood sugar right after a meal (called
postprandial hyperglycemia). This effect is now believed to be particularly damaging to the body.
Eventually, the cycle of elevated glucose further impairs and possibly destroys beta cells, thereby
stopping insulin production completely and causing full-blown diabetes. This is made evident by fasting
hyperglycemia , in which elevated glucose levels are present most of the time.
D- both types can be controlled




The client was taking regular and NPH insulin. She asks the nurse why she must mix the two insulin. The nurse explains
that regular and NPH are mixed to ensure:
A. Immediate onset of regular insulin within 2 hours
B. A peak action of NPH insulin is at 2 hours
C. A total duration of action of 24 hours
D. Onset of regular insulin within 2 hours

Rationale: Insulin comes as a solution (liquid) and a suspension (liquid with particles that will settle on standing)
to be injected subcutaneously (under the skin). Clients with diabetes often receive a combination of different types
of insulin to control their blood glucose level an each type has its diferent onset, peak and duration. Thus, when
regular and NPH are mixed there would be continous control in blood glucose.
Insulin Onset Peak Duration
Rapid (Regular) -1 hr 2-3 hrs 5-7 hrs
Intermediate (NPH) 1-2 hrs 4-15 hrs 24 hrs
Long-acting 4-8 hrs 10-30 hrs 36 hrs



14. When the nurse enters the room to administer the morning dose of regular and NPH insulin, the client
complains of dizziness, diaphoresis and nausea. The nurse does a blood glucose which is 30. What is the next nursing
action?
A. Give the usual dosage of regular insulin and get the clients breakfast tray
B. Hold the NPH insulin but give the regular insulin
C. Hold the regular and NPH insulin and call the physician
D. Give the client a glass of orange juice, hold all insulin and call the doctor

Rationale: A normal fasting blood glucose level is less than 110 mg/dl. A diagnosis of diabetes is made if your blood
glucose reading is 126 mg/dl or higher. Theres a risk for hypoglycemia due to its therapeutic regimen. Management of
hypoglycemia depends on the severity of the reaction. To reverse mild hypoglycemia, 15 g of simple carbohydrate, like
orange juice, is given and works quickly to increase blood glucose level. If client is unconscious or semiconscious, never
force to drink liquids, because fluids may be aspirated into the lungs. Any changes in the client, the doctor should be
informed specific changes may be ordered. (Black, MSN p. 1275) Hypoglycemia could be mild, moderate and severe,
simple interventions are plotted in Table 47-6 in same page # of the book.





SITUATION: Blood transfusion was ordered for Florence after an episode of severe bleeding.

51. Before blood transfusion, The nurse priority is to assess Andre for which of the following?

A. Clotting time
B. Vital Signs
C. Sodium
D. Weight

52. Before administering the transfusion, The nurse must start an IV infusion of which of the following?

A. Sterile water
B. NSS
C. D5W
D. D5LR

53. Which of the following is an appropriate needle for Blood transfusion?

A. A butterfly needle
B. An 18 gauge angiocatheter
C. A 25 gauge angiocatheter
D. A 21 gauge angiocatheter

54. Which of the following is not expected to be done by the nurse in case of a whole blood transfusion?

A. Assess the venipuncture for any signs of bleeding or hematoma
B. Prepare the blood transfusion using a microdrip tubing
C. Assess the patient closely for any reaction
D. Make sure that the drip chamber of the IV fluid is partially filled with blood

55. Which of the following is the recommended flow rate for the first 20 minutes of blood transfusion?

A. 10
B. 20
C. 40
D. 60


BURNS

1. The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or
bleeding are present, and the client states that he or she has little pain. How should this injury be categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness
Answer: D
The characteristics of the wound meet the criteria for a full-thickness injury (color that is black, brown, yellow, white or
red; no blisters; pain minimal; outer layer firm and inelastic).

2. The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is
very painful. How should this injury be categorized?

A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness

Answer: B
The characteristics of the wound meet the criteria for a superficial partial thickness injury (color that is pink or red;
blisters; pain present and high).


Which client factors should alert the nurse to potential increased complications with a burn injury?

A. The client is a 26-year-old male.
B. The client has had a burn injury in the past.
C. The burned areas include the hands and perineum.
D. The burn took place in an open field and ignited the clients clothing.

Answer: C
Burns of the perineum increase the risk for sepsis. Burns of the hands require special attention to ensure the best
functional outcome.


12. The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurses best first
action?

A. Administer oxygen.
B. Loosen the dressing.
C. Notify the emergency team.
D. Document the observation as the only action.

Answer: B
Respiratory difficulty can arise from external pressure. The first action in this situation would be to loosen the dressing
and then reassess the clients respiratory status.