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Final exam study guide

Final exam study guide
Prioritization and delegation
Nurses continuously set and reset priorities to meet patient needs and maintain safety.
 Which patients are seen first?
Which assessment completed first?
Which interventions are provided first?
Prioritization principles
Systemic before local – “life before limb”
Acute before chronic – acuter exacerbation or new injury (mental confusion or chest pain) over
long term chronic illness
Stable vs. unstable
Actual problem before potential problem (e.g., medicating for acuter pain over ambulation for
client risk of DVT)
Listen carefully to patient, don’t assume (post -op pain could be in another location rather than
expected surgical pain)
Recognize & respond to trends vs transient findings – recognize gradual deterioration
Recognize signs of medical emergencies vs expected patient findings
Apply clinical knowledge to procedural standards to determine priority action – recognize timing
of administering certain meds (antidiabetic, antibiotics, etc.) is more important than
administration of some other meds
Priority setting frameworks
Maslow’s hierarchy of needs
1. Physiological needs – breathing, food, water, sleep, homeostasis, excretion
2. Safety – security of body, employment, resources, morality, of family, health, property
3. Love & belonging – friendship, family, sexual intimacy
4. Esteem – self-esteem, confidence, achievement, respect of others and by others
5. Self-actualization – morality, creativity, spontaneity, problem solving, lack of prejudice,
acceptance of facts
ABCs = Airway, Breathing, Circulation, & Disability
Airway—establish airway, identify airway concern (obstruction, stridor)
Breathing– assess effectiveness of breathing (apnea, depressed RR)
Circulation– includes bleeding, hypotension, dysrhythmia, inadequate cardiac output,
compartment syndrome, etc.
Disability—prevention of disabilities (evolving CVA, etc.)
Safety/risk reduction – look for safety risk, compare to other posed risks, give priority response
to greatest or most imminent risk
Assessment/ data collection – nursing process. Determine if additional info is needed prior to
calling provider, etc.
Least restrictive/ least invasive – less is more first
Acute vs chronic/ Urgent vs non-urgent/ Stable vs unstable
Assigning, Delegating, & Supervising
Assigning – the process of transferring authority, accountability, & responsibility of patient care
to another member of health care team
Delegating – the proves of transferring the authority & responsibility to another team member to
complete the task, while retaining accountability
Supervising – the process of directing, monitoring, & evaluating the performance of task by
another member
Rights of delegation
Right task
Right circumstance
Right person
Right direction
Right supervision/evaluation
Task that can delegated to LPN
Monitor patient findings (as input to the RNs assessment)
Reinforce patient teaching from care plan
Tracheostomy care
Monitor nasogastric tube patency
Administer enteral feedings
Insert foley catheter
Medication administration(yes: peripheral IV; no: IVP or chemo)
Task that can be delegated to UAP/NA/CNA/TECH
Feeding (without swallow precautions)
Specimen collection
Intake and output
Vital signs (stable pt)
RN task
Recheck (assessment involved)
IV Push medication
Transfuse blood product
Develop care plan/discharge plan
Telephone orders
Nonverbal: wordless transmission of information
 Body language
Posture, stance, gait
Facial expression & eye movement
Touch, gestures & symbolic expression
Written communication – effective in providing details and legal documentation, lacks the
nuances that voice inflection and interactive conversation can provide. The meaning of
written communication is often enhanced through discussion.
Electronic communication - quickly contribute to a person’s knowledge, providing patients and
health care professionals with vital information. patients and nurses must take time to
validate and verify shared information because misunderstandings can occur if feedback is
inadequate. Special care must be taken to maintain confidentiality while communicating
Types of communication
Intrapersonal - focuses on personal needs and can influence a person’s well-being.
Positive self-talk
Negative self-talk
Interpersonal – formal or informal and conversational, and it may or may not have a stated goal
or purpose. In the context of an interview, it may vary from the strictly formal to very casual.
Interprofessional communication
 Ethical implications
Therapeutic communication -primary focus: the patient. Nurses engaged in therapeutic
conversations set their own opinions and judgments aside to listen more fully to their
Encourage the listener to sit facing the patient
Remind nurse to maintain open stance or posture while listening
Suggest listener lean towards speaker
Refers to maintain eye contact without staring
Non-therapeutic communication - can be hurtful and potentially damaging to interaction.
Changing the subject or sharing personal opinions limit conversation between the nurse and
the patient and discourages open conversation on sensitive topics.
Communication process – respect, assertiveness, collab, delegation, advocacy
o establish heling relationship – trust, empathy, est. boundaries, respect cultural influences,
dev comprehensive plan of care
factors that affect communication
impaired verbal communication – (verbal, nonverbal, intrapersonal, interpersonal)
o culture – language barrier, appearance, personal space
o language
o interpreter
o disease process
o comprehension
communication tools
SBAR – situation, background, assessment, recommendations
Confidentiality & privacy – all pt info must be kept confidential + private; info only released E
pt informed consent
 Standardized national language
Medication administration
Medication administration
o Pharmacological concepts
− Drug names
 Chemical name – exact desc. of the drug is chem composition + molecular
 Generic (nonproprietary) name assigned by OSAN council when manf. is ready to
market the drug
 Official name – generic name listed in USP +NF
 Brand/trade/proprietary name – what the drug is sold as in stores
Mechanisms of drug action
o Absorption – movement of drug from administration site to the bloodstream; passage of
med molecules
o Distribution – transportation of a drug in bodily fluids (i.e., bloodstream) to various
tissues & organs through the body
− Within the body to tissues, organs, & specific sites of action
o Metabolism – AKA. Biotransformation – chemical inactivation of a drug through its
conversion into a more water-soluble compound or into metabolites that can be excreted
− Under influence of enzyme that detoxes, breaks down & removes active chemical
o Excretion – removal of drug molecules from their sites of action & eliminated from the
− Via kidney, liver, bowel, lungs, exocrine glands
Factors affecting drug action
− Absorption: route, ability to dissolve, blood flow, body surface area, lipid solubility
− Distribution: physical & chemical properties of med, circulation, membrane
permeability, protein-binding
− Metabolism: active chemical; occurs in liver, kidneys, blood, intestines, & lungs
− Excretion: chemical makeup decides method of exit; delayed excretion by inactivity,
poor diet, +  peristalsis
 Drug excretion: kidneys, liver, GI tract, lung, exocrine glands
 classification systems for drugs: usage, body system, chem/pharm class
adverse effects of drugs
o allergy – damaging immune response by the body to a substance to which it has become
− clinical manifestations: urticaria (hives), pruritis (itching), edema of soft tissue &
mucosa, rhinitis (inflammation of nasal mucosa), nausea, vomiting
− make sure you verify with the patient if they have any allergies to food, latex, or
medications – if yes, ask what happened & notify doc; some patients may not know
what a drug allergy is or if they have one
− anaphylaxis: sudden constriction of bronchioles, edema of the larynx & pharynx,
severe shortness of breath, wheezing, & severe hypotension; unpredictable response
to med
 discontinue medication, get order/administer epinephrine, IV fluids, steroids, &
an antihistamine
 patients with severe allergic reactions (like anaphylaxis) should wear a medic
alert bracelet/necklace & carry epinephrine for emergency situation
o drug tolerance – decreased response to repeated doses of medication & requires increased
doses of med to reach the desired effect
o toxic effect – accumulation of med within the bloodstream i.e., resp distress from
excessive morphine; hypoglycemia from too much insulin
o idiosyncratic effect – an unexpected, abnormal, or peculiar response to a medication
− extreme sensitivity to a medication, lack of response, or a paradoxical (opposite of
expected) responses
o interactions
− antagonistic: happens when one drug interferes with the actions of another &
decreases the resultant drug effect
 antagonist blocks response: agonist produces response
− synergistic: addictive effect
 effect of both drugs together is greater than the individual effects of the single
− drug incompatibilities: occur when multiple drugs are mixed, causing a chemical
deterioration of one or both drugs
o teratogenic – drugs known to cause developmental defects in a fetus (i.e., alcohol,
o pharmacology: study of drug effects; enter body, absorbed, realistic, physiological
function, metabolized, exit
o pharmacokinetics: what happens to the drug in the body; absorption, distribution,
metabolized, & excretion of drug; time until onset & peak
o pharmacodynamics: how the drug effects the body how meds achieve their effects at
various sites
− opioid analgesic – provides moderate to severe pain relief
− non-opioid analgesic – provides mild t moderate pain relief
− non-steroidal anti-inflammatory drugs (NSAIDs) – control mild to moderate pain,
fever, & various inflammatory conditions
− herbal supplements – generally not regulated by the FDA & can have serious
reactions when mixed with drugs
principle of safe medication administration
o 3 checks
1. Before you pour – check the med against the MAR; make sure name, route, dose, &
time match the MAR entry
2. After you pour – before returning the container or discarding anything; verify the
label against MAR
3. At the bedside – check the medication label
6 rights of medication administration – patient, drug, dose, route, time, documentation
Dosage calculation – formula method most commonly used
𝑑𝑜𝑠𝑒 𝑑𝑒𝑠𝑖𝑟𝑒𝑑 (𝐷)
𝑥 𝑞𝑢𝑎𝑛𝑡𝑖𝑡𝑦 𝑜𝑛 ℎ𝑎𝑛𝑑 (𝑄) = 𝑑𝑒𝑠𝑖𝑟𝑒𝑑 𝑞𝑢𝑎𝑛𝑡𝑖𝑡𝑦
𝑑𝑜𝑠𝑒 𝑜𝑛 ℎ𝑎𝑛𝑑 (𝐻)
Sites for administering medication
o Oral – tablets, capsules, liquid, buccal, sublingual, enteral
− Have A LOT of special considerations – i.e., how does the patient take their meds?
 Oral: prep by picking desired liquid/food for admin (water, juice, pudding, etc),
disposable med cup, pill splitter//crusher, straw if allows/wanted, clean gloves;
may also need stethoscope id giving cardiac med
 Buccal: rapidly absorbed in mucous membranes between gum & cheek in mouth
 Sublingual: rapidly absorbed in mucous membranes under the tongue
 Enteral: nasogastric (NG tube) & gastrotomy meds – for those that cant swallow
or have feeding tubes
 NG tube bypasses throat in case of dysphagia when GI is intact or to attach
wall suction in case of bowel surgery or obstruction (OBX)
 Give liquid eds, crushed meds flush before & after, elevate HOB, disconnect
from suction for 30 min
o Topical – applied directly to body surface/cavity; lotions/creams/ointments, transdermal
patches, eye & ear, nasal, vaginal, rectal
− Always wear gloves when giving/changing topical medications
o Inhalation – respiratory (nebulizers – atomizers, aerosols, MDIs), dry powder inhaler
− Nebulization: production of a fine spray, fig, powder, or mist from a liquid drug,
inhales med mixture by breathing deeply through mouthpiece attached to neb;
airways & alveoli are increasingly vascularized & absorb inhaled meds quickly
− Atomizers disperse med as large droplets; aerosol suspends droplets of med in a gas;
MDIs delivered measured dose of nebulized drug
− Dry powder inhalers activated by a pump rather than by inhalation, no spacer needed
o Parenteral – injected/infused into body tissues or into blood stream; ID, IM, IV, SQ
− Intradermal (ID): given into the dermis (middle layer of skin); commonly used for
allergy or TB testing
* 15 needle length: 3/8 needle gauge: 28g, 27g, 26g max vol: 0.1mL
* sites: above boob, upper back, lower forearm
 Subcutaneous (subcut): given into subcut tissue (layer of fat below dermis & above
o Slower absorption than IM because subcut tissue doesn’t have a rich blood
o Arms &ABD fastest absorption; high & upper buttocks slowest absorption;
most evenly absorbed by ABD – don’t aspirate for blood return
* 45 or 90 needle length: 5/16, ½, 5/8 max vol: insulin: 1.0mL 28-31g, other SQ:
1.0mL 25-27g
 Intramuscular (IM): given into muscle
o better than subcut because muscles can also handle more fluid
o vastus lateralus preferred for infants
o z track method recommended for IM injections because it's less painful &
helps prevent irritation of subcutaneous tissue
o deltoid, ventrogluteal, vastus lateralis sites
o meds are absorbed rapidly where blood flow to the tissue is greater
* 90 needle length: 1, 1½, 2 needle gauge: 23g, 22g, 21g max vol: deltoid: 1mL,
other: 3mL
 Intravenous (IV): meds given via catheter or cannula into a vein; begins to act
immediately (so you stop it if an adverse reaction)
* needle length: 1 needle gauge: 19g, 18g
1.) Discuss the risk factors, causes, and signs/ symptoms for hypertension.
Risk Factors
 Family history, obesity, smoking/ drinking, stress, chronic kidney disease, too much
salt, and certain medications and vitamins
signs/ symptoms
- hypertension damages vital organs
- Ex: Coronary artery disease, left ventricular hypertrophy, heart failure, peripheral
vascular disease, renal failure , and retinal damage.
- (Other symptoms of hypertension) headache, fatigue, vision problems, chest pain,
difficulty breathing, pounding in chest, neck or ears, blood in urine, and irregular
2.) Explain the classification & stages of hypertension.
 Hypertension- is the persistent elevation at systolic/ diastolic blood pressure based on
constant heart readings
 Hypertension Crisis- can be very severe, abrupt, and elevated blood pressure results
- often occurs in patients who have hypertension and are not compliant with medications or
are under medicated
- the brain can swell, heart failure, sweat, etc.
- Treatment : hospitalization, IV meds, cardiac monitor, and monitor renal function
Medication classification
 Ace Inhibitors –“prils” drugs
Generic name
Common brand names
Prinivel, Zestril
o Action: Angiotensin is a chemical that causes the arteries to become narrow, especially in
the kidneys but also throughout the body. ACE stands for Angiotensin-converting
enzyme. ACE inhibitors help the body produce less angiotensin, which helps the blood
vessels relax and open up, which, in turn, lowers blood pressure.
o Indication: for mild to severe hypertension
o SE: headache and skin rash, “ACE cough” – dry, hacking cough due to build up, Firstdose can cause syncope, severe hypotension and fainting within 1-4 hours after the initial
dose or after a significant increase in dose
o Nurse measures: monitor hourly, Instruct the client to lie down for 3-4 hours after the
first dose, Give 1 hour before meals, Instruct the client to avoid substances– coffee, tea,
cola, OTC, cold meds
 Calcium channel blockers
Generic name
Common brand names
Amlodipine besylate
Diltiazem hydrochloride
Verapamil hydrochloride
o Action: prevents calcium from entering the smooth muscle cells of the heart and arteries.
decreasing the calcium, the hearts' contraction is not as forceful. Calcium channel
blockers relax and open up narrowed blood vessels, reduce heart rate and lower blood
o SE: peripheral edema of legs and ankles; flushed skin, headache, dizziness, nausea,
constipation, fatigue, weakness, impotence; Serious side effects- MI, hepatotoxicity, heart
failure, confusion,
o AE: flushing, headache, dizziness, weakness, bradycardia, orthostatic hypotension, sexual
o Nurse measures: before meals, “dangle” for a few minutes before ambulating and to
change positions slowly, Avoid caffeine, Avoid grapefruit when taking nifedipine
(Procardia) and Amlodipine (Norvasc)
Beta blockers –“olol” drugs
Generic name
Common brand names
Lopressor, Toprol
o Action: This results in slower heart rate, reduced contractility of the heart muscle, and
vasodilation of the arterioles, with reduction of PVR and BP
o SE: : Bradycardia, fatigue, difficult physical exertion, insomnia, impotence, confusion.
Result is decreased cardiac output. Serious side effect- MI with abrupt withdrawal
o Nurse measures: avoid substances that interfere with the BB’s such as caffeinecontaining beverages and OTC cold remedies, sudden cessation of BB’s because this can
cause rebound hypertension
 Alpha adrenergic antagonists (blockers)
Generic name
Common brand names
Doxazosin mesylate
o Action: relax muscle tone of the vascular walls, helping small blood vessels remain open.
This improves blood flow and lowers blood pressure.
o AE: first-dose syncope, orthostatic hypotension, reflex tachycardia & increased workload
of the heart (may cause myocardial ischemia or infarction)
o Nurse measures: monitor for orthostatic hypertension, weight gain w/ edema,
tachycardia. Instruct clients to change positions slowly
 Alpha adrenergic agonists
Generic name
Common brand names
o Action: reduce blood pressure by decreasing the activity of the sympathetic (adrenalineproducing) portion of the involuntary nervous system. Methyldopa is considered a first
line antihypertensive during pregnancy because adverse effects are infrequent for the
pregnant woman or the developing fetus. This results in a decrease in peripheral vascular
resistance to lower BP.
o AE: dry mouth, sedation, erectile dysfunction, sleep disturbances, nightmares
o Nurse measures: avoid hot baths and showers because this worsens hypotension, Avoid
excessive use of caffeinated beverages, Take the medication at bedtime to avoid daytime
sleepiness, Suggest chewing gum or hard candies to relieve mouth dryness
 Angiotensin II receptor blockers (ARBs) –“sartan” drugs
Generic name
Common brand names
Losartan potassium
o Action: This means blood vessels stay open and blood pressure is reduced, lowering
peripheral resistance and blood volume.
o SE: Headache, skin rash, diarrhea, orthostatic hypotension, Good alternative for those
with “Ace” cough, Not as effective in African Americans unless taken with another drug,
Avoid foods high in potassium
 Diuretics
Generic name: Thiazide diuretics
Common brand names
Hydro-diuril, HCTZ
Usually, drug of choice for pt w/ uncomplicated hypertension
o Action: : act on the renal tubules to inhibit reabsorption of sodium chloride, which
increases potassium loss; water follows sodium- so sodium is not absorbed and blood
volume is decreased
o AE: dehydration, electrolyte imbalance, orthostatic hypotension, digoxin toxicity, erectile
dysfunction, atigue, hypokalemia, affect glucose control
Generic name: Potassium-sparing diuretics Common brand names
o Action: act on distal tubules of kidneys to inhibit reabsorption of sodium reducing
excretion of potassium
o AE: hyperkalemia, hypotension
Generic name: Loop diuretic
Common brand names
o Action: inhibit sodium chloride reabsorption in the ascending loop of Henle, thereby
increasing the excretion of sodium and potassium. Bumex has a much stronger action
than Lasix, but is shorter acting
o AE: electrolyte imbalance, orthostatic hypotension, ototoxicity (usually reversible),
 Nurse measures
 Diuretics reduce blood volume, Increase urine output-diuresis
 Long-term use results in vasodilation, which decreases B/P
 Monitor electrolytes, especially potassium
 Monitor for S/S of dehydration (thirst, weakness, muscle cramping, hypotension &
 Monitor I&O and weight
 Instruct the client to change positions slowly to avoid dizziness and falls
 Instruct the client to take the last dose in the afternoon to avoid nocturia
 People with diabetes may find that diuretic drugs increase their blood sugar level. A
change in medication, diet, insulin or oral anti-diabetic dosage corrects this in most cases