Nursing Final 2

juniperk's version from 2016-12-11 21:58

Section 1

Question Answer
What is subjective data?Information perceived by and from the patient
What is objective data?Observable/ measurable data that can be seen
What is Electronic Medical Record (EMR)?An EMR is an electronic patient care record created by an agency or agencies having common ownership.
What is Electronic Health Record (EHR)?The EHR is the patient care record created when agencies under different ownership share their data.
What is a source-oriented record?documentation system in which each health care group records data on its own separate form
What is problem-oriented medical record (POMR)? documentation system organized according to the person’s specific health problems; includes database, problem list, plan of care, and progress notes
What is PIE charting?the plan of care is incorporated into the progress notes in which problems are identified by number: Problem, Intervention, and Evaluation
What is Focus charting?a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care. the narrative portion of focus charting uses the data (D), action (A), response (R) format
What is charting by exception (CBE)?shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes
Name 3 types of diagnostic tests associated with identifying infectionWBC count (normal 5-10k); Presence of pathogen in urine, blood, sputum or draining cultures; Elevated erythrocyte sedimentation rate
What do you wear with Airborne precautions? Name an example that would need airborne precautions gloves/gown/N95 mask TB, varicella/shingles, SARS
What do you wear with Droplet precautions? Name an example that would need droplet precautionsgloves/gown/reg mask, visitors stay 3 feet away from pt. Rubella, mumps, flu
What do you wear with Contact precautions? Name an example that would need contact precautionsgloves/gown; do no share equipment. MRSA, VRE, ESBL
Name examples vitamin ALiver, carrots, yolk, milk
Name examples vitamin DSun, milk, fish liver oil
Name examples vitamin EVegetable oil, wheat germ, whole grain
Name examples vitamin KDark, green leafy vegetables

Section 2

Question Answer
What food do you need to avoid if you have GERD?Fried, fatty, and chocolate
What food do you need to avoid if you have celiac disease?Gluten
What food do you to monitor if you have diabetes?Control carb intake
Name some pathological factors that can affect urinationUTI, urine calculi (stones), abdominal trauma, prostate enlargement, dehydration, fluid intake, fluid loss
What types of medications affect urination?Nephrotoxic (renal injury) and diuretics
Name some developmental factors that can affect urinationToilet training, normal aging
Name some dietary factors that affect urinationcaffeine, high Na foods
Name some lifestyle factors that can affect urinationsetting, time, ebarrassment
Name a psychological factor that can affects urinationstress
What is the specific gravity of urine?1.010- 1.030.
What is the pH of urine?5.5-7.0
What is the normal output amount of urine?30 mL/hr
How can you assess for a urinary disease?Ask about normal urination; changes in pattern like frequency, urgency, incontinence or pain. Inspect for signs of urinary retention (distension about pubis symphysis) Inspect urine: color, clarity, and odor
What are interventions for urinary disease?Monitor I&O. Encourage a PO intake of 8-10 glasses of water (daily intake of 2400ml). Foley care 2x a shift. Watch for signs of sepsis if pt has UTI or nephritis
How can you educate for urinary disease?Signs and symptoms of UTI: burning, pus in urine, frequent urination, flank pain if nephritis. Prevention of UTI: drinking 2400 mL water daily, wearing cotton underwear, urinating after sex
Name the 4 types of urine specimen tests and their key pointsRoutine: no aseptic technique. Clean catch: antimicrobial solution to clean genital area & midstream. Sterile: straight cath to retrieve urine/clamp foley & collect through port. 24h: discard first urine, start clock, collect all urine for 24h in jug on ice
What is a cystoscopy?direct visualization of the bladder, ureters, & urethral orifices using a camera
What is Intravenous Pyelogram (IVP)?xray of kidney and ureters using contrast material; check for iodine, chitin, or shellfish allergy
What is an ultrasonography?ultrasound to produce image or photo of organ
What is a CT scan?Xray beam scan different angles of organ to produce a cross-sectional image; may or may not use contrast
What is a bladder scan?ultrasound of the bladder; used to measure amount of urine in bladder & check for urinary retention/complete bladder emptying