Virginia Commonwealth University

Nursing 202
Mid-Term Exam Study Guide

Testing Procedures: ALL belongings, including water bottles, tissues, paper, backpacks, books,
electronic devices (smart watches, eyewear, cell phones, tablets, laptops) to be turned to OFF and stored
in the front of room. You will need to know/bring your eID for entering on the GradeIt answer
sheets.
Only these Materials allowed at your desk: two (2) #2 pencils, eraser.
Please use the restroom prior to beginning the test. You will not be allowed to leave the room without a
proctor at your side once the test begins.

60 questions, (no more than 8 will be either matching or select all that apply, no partial credit,
NCLEX style like Hesi case study or end of chp quizzes, application questions with patient
scenarios)

1. The Nursing Process (questions such as which of the nursing diagnosis would be most appropriate?)
Identify correct Nursing diagnostic statementsfor example, from a list of statements and patient
scenarios.
Diagnoses for Pt. at Risk for Injury
o Risk for Poisoning
o Risk for Suffocation
o Risk for Trauma
o Latex Allergy response
o Risk for aspiration
o Risk for Disuse Syndrome (related to immobility, atrophy)
o Deficient knowledge (Injury Prevention)
Fluid/Electrolyte/Acid-base imbalance
o Deficient Fluid Volume
o Excess Fluid Volume
o Risk for Imbalanced Fluid Volume
o Risk for Deficient Fluid volume
o Impaired Gas Exchange

Be able to identify assessment data to support a specific nursing diagnosis

Types of Nursing Diagnosis
Actual Nursing D (composed of label, definition, defining characteristics and related f)
Risk Nursing D (vulnerability of patient to something)
Possible Nursing D (problem suspected but more data collection needed: Possible
Chronic low self-esteem)
Wellness Diagnosis (Ex. Readiness for Enhanced Family Coping, Readiness for
Enhanced Health Maintenance, etc)
Writing a Nursing Diagnosis
Two-part statement (PE)
o Problem + etiology (what causes the problem or what contributes to the
manifestation of the identified problem)
o Ex. Bathing/Hygiene Self-Care Deficit related to fear of falling in the tub and obesity
Three-part statement (PED)
o Problem + etiology + defining characteristics
 o Ex. Bathing/Hygiene self-Care Deficit related to fear of falling in the tub and obesity
as characterized by strong body and urine odor, unclean hair: Im afraid Ill fall
in the tub
Distinguish among the different steps in the nursing process (different phases of the Nursing
Process)/ Define steps in the Nursing process in correct order
o Assessment
Collection, validation, and communication of patient data
Gather data, verify data, confirm observations, organize data, make inferences from data,
communicate data to patient, other nurses or providers
o Nursing Diagnosis
Analysis of patient data to identify patient strengths and health problems that independent
nursing intervention can prevent or resolve
Analyze data, identify related factors, identify potential nursing diagnosis and develop
one that is appropriate to the patient problem
o Planning (outcome identification)
Identify short and long term goals (patient outcomes)
Prioritize nursing diagnosis and develop a plan based on this (planning nursing
interventions)
Specify deadlines for completion, always have a specific and measurable end goal (ex. pt
will be able to walk vs patient will be able to ambulate half of hallway)
o Implementation (intervention)
Carry out plan based on goals, teach patient and family, encourage self-care
Continue assessment while documenting everything
o Evaluation
Determine effects of nursing interventions, reassess care plan, which factors had + or
effects, record patient responses
When youll find out if you will continue, modify or terminate nursing care
Identify appropriate outcomes from Nursing diagnostic statement (remember that you have to write
outcome very specifically and meausurable)
o Outcome statement must:
State what patient will do, be very specific, measurable and has a target time
Ex. Mr. M will drink 60 mL fluid every 2 hours while awake beginning 2/22/14.
o Interventions statements start with a verb: ex. check what medications are given, offer a
backrub, help patient ambulate, etc.
Recognize appropriate documentation
o Objective data: observable and measurable facts (signs)
o Subjective data: information that only the patients feels and describe (symptoms)
Guidelines:
Contents
o Must be complete, accurate, concise, current and factual manner
o Record patient findings (observations of behavior) rather than your interpretation of these
findings
o Avoid words such as good average normal or sufficient which may mean
different things to different readers
o Avoid generalizations such as seems comfortable today. Instead you can say vitals
signs returned to baseline.
Timing
o Never document interventions before carrying them out
 o Writing progress notes: upon admission, transfer, discharge, pre-op and post-op, any
change in patient status or when you talk to a physician about an abnormal result of a
patient
o Record sequentially
Confidentiality
o Let the patient know that everything documented will be kept confidential
Define (and note differences) in these terms the nurse uses during assessment phase of nursing
process:
o Verifying or validating: confirming observed or collected data by asking further questions to
patient or performing assessment before proceeding to another patient topic
o Observation: conscious and deliberate use of the five senses to gather data
o Observation of cues: observing both subjective and objective data that suggests patient
condition (this is what you record, not your interpretation of an observation)
o Inference: the judgement you reach about the cues, so this cannot be verified until you validate
with assessment, asking other healthcare team members, clarifying with patient

2. Critical thinking/judgment: (generally about safety: ex. you walk into a patient room and sees this,
what would you do first?)
Distinguish between inductive and deductive reasoning
o Inductive: building from specific ideas or actions to get conclusions about general ideas
o Deductive: one examines a general idea then considers specific actions
Nursing actions indicative of critical thinking, good judgment, patient advocacy when given
common patient scenarios. For example, what should the nurse do first if IV not infusing, etc.
Given a patient incident scenario, recognize proper documentation of the event

3. Patient/Nurse Safety
Handwashing
When washing with soap and water with soiled hands, make sure to rub for at least 15 secs
4 ways to perform:
a) Hand washing
b) Antiseptic handwashing
c) Alcohol based hand rubbing
o Are more effective for standard hand washing than soap. They are more accessible than sinks,
reduce bacterial count on hands, improve skin condition, best for killing bacteria, least dyring
to your hands
d) Surgical hand hygiene/antisepsis
** Best hand hygiene for removing spores is Soap and water
When to perform hand hygiene
Before patient contact
Before donning gloves for a procedure
Before inserting any invasive devices that dont require surgery
After contact with the patient
After contact with wounds or body
Fluids/excretions
After the removal of gloves
Personal protective equipment (PPE)when to wear mask (special instances where you wear a
different type of mask, difference of you wearing the mask or the patient wearing the mask), gown,
gloves, goggles
When to wear PPE
 Standard precautions: hand hygiene + gloves when handling body fluids or soiled materials, face
mask for procedures that is likely to create splashes
Airborne Precautions (all PPE): tb, rubella aka measles, varicella (chicken pox), possibly SARS
Droplet Precautions (all PPE, keep visitors 3 ft away): mumps, rubella, diphtheria, adenovirus
infection
Contact Precaution for infected or colonized by multidrug-resistant organism (MDRO)
Safe body mechanics when moving a patient or moving objects
Keep back straight and squat instead of bending back down when performing tasks
Guard patients knees with your knees when transferring them from bed to chair
Gait belt on and do a rocking motion before transferring them and asking them to push up
Proper identification of patients when giving medications, treatments, etc
Name and date of birth, at least two patient identifier (so verbal and wrist band or computer
name)
Meaning of colonized organisms, how organisms are spread
A colonized patient means patient is carrier of the bacteria or virus without any pathogenic signs or
symptoms (so no manifestations yet). It becomes an infection when the patient start exhibiting signs
and symptoms
Means of Transmission
When organism finds a portal of exit from its reservoir (aka natural habitat)
Contact route: Direct (touching a carrier or infected person) or indirect (touching a contaminated
inanimate object: paper, blood, body fluids, etc), animal vectors too!
Airborne transmission (coughs, sneeze, talks or when organisms become attached to dust
particles)
Droplet transmission (like airborne except that droplet particles are bigger than airborne particles)
**Patient is most infectious during the prodromal stage**
Age and safety risk factors and assessment of these (two end of the spectrum)
Fetal
o Maternal smoking, alcohol consumption, addictive drugs, xray during 1st trimester, certain
pesticides
Infant
o Falling, suffocation, choking from aspirated milk or ingested object, burns, car accident, crib
or playpen injuries, electric shock poisoning
Toddler
o Physical trauma from falling, banging into objects, or getting cut by sharp objects, motor
vehicle crashes, burns, poisoning, drowning, electric shock
Adolescent
o Motor vehicle or bicycle crashes
o Recreational injuries, firearms (suicide and homicide), substance abuse
Older Adults
o Falling, burns, motor vehicle crashes and pedestrian injuries
Factors affecting ability to protect self from injury:
Age and development: the young and the old are the most risk for safety
Lifestyle:
o Young: very active, sports but in elderly = less active
o Smoker, alcoholic, recreational drugs (can interfere with normal state of consciousness)
o Socioeconomic, diet, diabetes and eating disorders
Mobility and health status
Sensory-perceptual alterations
Cognitive awareness
 Emotional State
Ability to Communicate
Safety awareness
Environmental factors
How to assess for Risk for injury
o Nursing history and physical examination
o Risk assessment tools: Braden scale (pressure ulcer), Fall-risk scale, Get up and go test, Snellen
Chart, Weber test
o Assessment of patients home environment

Identify which procedures require sterilitye.g., those requiring sterile gloves

o Sterile technique: sterile equipment is free of all microorganism (dont cross a sterile field)
Indwelling Urinary Catheterization
Wound dressing
IV insertion and injectable meds are clean procedures

If restraints are used indication, appropriate type for patient condition, and know how often
nurse should check patient
o Try other interventions first. Use restraints as last resort.
o Reason can be behavioral (will hurt other people) or medical (hurt patient by pulling out
oxygen or IVs).
o Nurse may apply restraints but physician must see patient within 1 hour for evaluation.
Orders renewed every 24 hrs, PRN order prohibited.
o Must be continual visual and audio monitoring if patient is restrained and secluded.
o Monitor every: 15 min for behavioral restraints, every 2 hr for medical restraints

Know which patients/ patient conditions predispose to infection CHP 23 p 537 (read this chp
well! What is the prodromal stage? This is the most contagious stage, before symptoms
manifestations)
Factors affecting risk for Infection
o Integrity of skin and mucous membranes (they protect us as our first line of defense)
o pH levels of GI and genitourinary tracts (acidic= kills bacteria)
o integrity and number of WBC to resist certain pathogens
o age, sex, race and heredity which influence susceptibility (neonates and older adults are more
vulnerable to infection)
o immunizations, natural or acquired which resist infections
o level of fatigue, nutritional and general health status, presence of illness, medications,
previous or current treatment (makes host more susceptible)
o increased stress level= detrimental effects to the bodys defense mechanism
o use of invasive or indwelling medical devices (provides entry and exit portals for microbes)

General patient hygienic practicesteaching of

4. Vital Signs
Identify factors affecting pulse rate, respiratory rate, temperature, and B/P e.g., dehydration, fluid
overload, blood loss
Cardiac Output= HRxSV
Normal HR: 70
Normal SV: 70
Normal cardiac output: 70x70= 5L
 *Whenever one of HR or SV changes, the body compensates by changing HR or SV too. So the
initial response if your SV goes down is for your HR to go up.
Dehydration: SV goes down meaning HR goes up
o B/P: decreased because you have less fluid to pump
o HR rate: increased pulse rate, weak pulses (heart must pump faster to maintain normal BP
since BP tends to drop when dehydrated)
o Respiratory rate: increased: rapid and shallow breathing to deliver more O2 to faster
pumping heart
o Temperature: increased (patient cant sweat)
Fluid Overload: SV goes up meaning HR goes down?
o Pulse rate: heart contractility increases so pulse will be bounding
o Respiratory rate: SOB, increased RR bc of diluted blood (decreased rbc), dyspnea due to
increased fluid among pleural spaces, crackles can be heard too
o Temperature: drop because of decreased perfusion?
o B/P: increase
Blood loss: SV goes down meaning HR goes up
o Pulse rate: increase
o HR: Increase
o Respiratory rate: increase
o Temperature:
o B/P: decrease

Other Factors
Temperature
o Normal range: 97 to 98.6 (or around 36.5-37 centigrade)
o Aging causes baseline temperature to be a little lower due to decreased metabolism
o Gender: men usually have higher temp because they have higher metabolic rate
o Time of the day: lowest temp in the morning and highest is around afternoon
Pulse
o Normal range: 60-100 beats/min
o In some extremely fit adults, pulse can be as low as 40 because their cardiac muscle is very efficient
and can pump a lot of blood
Respirations
Normal range: 12-20 breaths/min
o Exercise
o Respiratory and cardiovascular disease
o A patient with pneumonia has higher RR because he/she cant move air in the infected part of
the lung.
o A patient with pleural cavity infection: compensatory mechanism is to increase the fluid in the
pleural cavity to kill infection or move a metastic cell. Thus, RR goes up because lungs cant
expand as much.
o Anemic patients tend to have higher RR, HR and BP because this is how they compensate for
fewer RBC
o Alterations in fluid, electrolyte and acid balances
o Medications
o Depressants such as alcohol and aderol can lower RR
o biopethamines?
o Trauma
o Infection (higher RR)
o Pain (Acute pain: rapid respiration)
o Emotions
Blood Pressure
Normal Range: 120/80
o Age, Gender, race
o Circadian rhythm
o Food intake
o Exercise
o Weight
o Emotional state
o Body position
o Drugs/medications

o Increase HR and RR in a patient who cant breathe well?

o Heart pumping against high resistance = high bp
Patient conditions that require specific nursing actions related to VS
o So if you go in a patients room and see then SOB, you assess first!, move them up to a non-
flat position then take the vital signs, then you can act by either calling emt team etc.
When to take rectal temp versus oral temp. radial versus carotid pulse, etc
o You dont want to do a carotid pulse sa older patient (apical instead)
How often to check VS after a procedure
o Before and after invasive produre, every 15 min for an hour after an invasive procedure
o -Before and after a surgical or invasive diagnostic procedures.
o -Before and after activity that may increase risk (such as getting a patient up after a
procedure, always get VS before this activity)
o Other times to assess VS:
o Upon admission to any healthcare agency (this might not reflect than normal baseline
because of anxiety upon admission so you must check multiple times within the next 48
hours to get an accurate baseline)
o Based on agency institutional policy and procedures
o Anytime there is a change in the patients condition
o Before administering medications that affect cardiovascular or respiratory functioning (bc
pain meds can decrease in respiration which is compensated by the increased in cardiac
pumping: lower respiration but higher pulse)

5. Bedrestproblems associated with

SCDs what are they, purpose
Sequential Compression Device
o Used to prevent DVT (deep vein thrombosis aka blood clot that breaks off in the venous
system) and PE (pulmonary embolism aka blood clot that breaks off and moves into the
lungs)
o Most effective when only off for one hour a day, needs an MD doctor to put on
Who is at greatest risk for complications due to BR/immobilization
o Surgical Patients (especially orthopedic, abdominal, neurologic and thoracic)
o Older patients
o Increased body mass index patients
o Patients with heart disease, cancer or stroke
 How to prevent complications
Always Assess!
o Skin integrity
o Pulses must be felt
o Sensations
o Capillary refill less than 2 sec
o Help patient perform exercises or ambulate if possible
Active versus passive exercises
Active Exercise
o Patient independently moves joints through their full range of motion (isotonic exercise)
o Only active exercise improves muscle mass, tone, strength and cardiac/respiratory functioning
Passive Exercise
o Patient is unable to move independently so nurse moves each join through its ROM
o Both Active and Passive improves circulation in the affected area and joint mobility

6. Fluid, Electrolytes, and Acid-Base

Know the meaning of isotonic; distinguish between hypotonic, hypertonic, and isotonic IV
solutions.
IV Fluids
o Isotonic (270-300 mmol/L)
No change in cell volume when cell exposed to this
Ex: Normal Saline (NS), 5% Dextrose in water (D5W), Lactated Ringer solution
(LR)
o Hypotonic (less than 270 mmol/L)
Causes the cell to swell
Ex: .45% NS, .2% NS, .33% NaCl, 2.5% Dextrose in Water
o Hypertonic (more than 300 mmol/L)
Causes cell to shrink
Ex: 3% NaCl, 5% NaCl, 10% dextrose in water (D10W)

Know the meaning of hyper and hypo- and hyper-osmolality

Osmolality: has to do with the weight of solute in relation to water
Hyper Osmolality (Increased Osmolality)
You have more solutes in relation to water.
Kidneys respond by stimulating the brain to release ADH, which increases permeability
of kidneys to water causing water to be retained thus decreasing urine output
Hypo Osmolality (decreased osmolality)
You have less solutes in relation to water (think of a diluted solution)
Kidneys respond by stimulating hypothalamus for ADH suppression so theres a
decreased permeability of distal tubule so water reabsorbed into the blood is less thus
urine output increases
Understand who is most at risk for dehydration/fluid overload
o Either end of the spectrum
o Risk Factors for dehydration:
Vomiting, diarrhea, suction, fistulas, hemorrhage
Excessive sweating
Skin trauma, burns, draining wounds
Third-space fluid shifts
Excessive laxative or diuretic use
 Polyuria from renal disease or diuretics
Hyperglycemia
Change in mental status (unable to gain access to fluids, depression, confusion)
o Risk Factors for Fluid Overload:
Compromised regulatory mechanisms: renal failure, CHF, cirrhosis of liver, Cushing
Syndrome
GI irritation with hypotonic fluid
Excess IV fluids with sodium
Corticosteroid therapy
Excessive ingestion of sodium-containing substances in diet or sodium-containing
medications
Identify normal and abnormal urine output range per hr
o Micturition of 30cc per hour is the minimum, be concerned if less than this (cc=mL)
o Normal Daily input is around 2100 mL of Fluids
o Normal Daily Output:
Urine: 1500 mL
Insensible Loss: 500 mL
Feces: 150-200 mL
Which IV solution can be given with blood: Normal Saline, isotonic
Identify terms and rationale for heparin lock, saline lock, and KVO (keep vein open:IV goes in no
faster than 30cc per hour) IVs
Heparin lock
o Intravenous needle or catheter with an injection pad attached at the end
o This medication is used to keep IV catheters open and flowing freely. Heparin is an
anticoagulant drug that makes the blood thin to prevent formation of blood clots
o Basically same as saline lock except you flush it with heparin
Saline Lock
o An intravenous catheter inserted into a vein and left in place for the intermittent
administration of medication through its port or as an open line for emergency situations and
intermittently flushed with normal saline solution to maintain patency
KVO (Keep Vein Open)
o It takes a certain amount of flow to keep the vein open so that the blood vessel doesnt clot
itself off
o You really need to keep something running through the line at a rate of at least 10 cc but no
faster than 30cc per hour
o This is why we always use flush lines for slow infusions and for any drug being delivered by
syringe pump
**In IV catheters the smaller the number, the bigger the needle (so a 22 gauge will be smaller
than a 14 gauge)
Know which body system most affected by hypo/hyperkalemia, hypo/hypernatremia
hypo/hypercalcemia, hypo/hyperphospatemia-identify normal values of each

Hypo/Hyperkalemia (CARDIAC System also skeletal)

Hypo: less than 3.5 mEq/L
o Results in muscle weakness, leg cramps, fatigue, paresthesia, dysrhythmias
Hyper: more than 5.0 mEq/L
o Results in cardiac irregularities
Hypo/Hypernatremia (Neurological Function)
Hypo: below 135 mEq/L
o From Loss of sodium or gain of water, so cells swell
 o Results in confusion, hypotension, edema, muscle cramps and weakness
Hyper: greater than 145 mEq/L
o From excess sodium or loss of water, cells shrink
o Results in weakness, disorientation, delusions
Hypo/Hypercalcemia (Muscular)
Hypo: below 9 mg/dL
o Results in tingling of fingers, mouth or feed, cramps, tetany and seizures
Hyper: above 11 mg/dL
o Results in nausea, slurred speech, vomiting, confusion, lethargy
Hypo/Hyperphospatemia (
Hypo: below 3.0 mg/dL or 1.8 mEq/L
o Results in irritability, fatigue, weakness, paresthesias, confusion, seizures and coma
Hyper: above 4.5 mg/dL or 2.6 mEq/L
o Results in tetany, anorexia, nausea, muscle weakness, tachycardia
Mechanisms for regulation of body fluids and acid base
Fluid Intake
Fluid Output
Kidneys
o ADH Regulation
Kidney can trigger or suppress ADH production in the hypothalamus
If blood osmolality is high, ADH production is triggered, H2O is retained and urine
output is decreased
o Renin-Angiotensin-Aldosterone System (RAA)
Renin to Ang I to Ang II (by ACE) to aldosterone
Ang II causes Na+ and water retention
Aldosterone causes Na+ retentions
BP patients given ACE inhibitors so they wont retain fluid (bc high volume, high
resistance)
o Atrial Natriuretic Factor (ANF)
ANF released from cells in the atrium
ANF promotes sodium wasting= acts as a diuretic
Vascular volume is reduced when ANF is released
Methods for regulation of O2 and CO2 (Acid-base balance)
3 methods of Acid-base regulation
Buffers
Respiratory System
Renal System (take the longest but longer and more powerful effects)
o Helps in regulation by selectively excreting or conserving bicarbonate and hydrogen
ions)
Role of buffers in regulating acid-base balance
Buffer: a substance that prevents body fluids from becoming too acidic or alkaline
o Carbonic acid (H2CO3) and Sodium Bicarbonate (HCO3) system
20:1 ratio (much more bicarbonate in ECF than H2CO3)
o Phosphate Buffer system
Alkaline sodium Phosphate (Na2HPO4) > Acid Sodium Phosphate (NaH2PO4)
o Protein Buffer system
Plasma proteins and globin portion of hemoglobin
Chemical groups combine with or release H+ ions
Role of HCO3- and H2CO3 in regulating acid base
Acids releases H+
 Carbonic Acid (H2CO3) is the main acidic element in our system.

Base Traps H+
Bircarbonate (HCO3) is the main basic compound in our system.

Our body regulates these molecules to maintain the acid-base balance.

If we have too much base, the HCO3 will combine with H+ to produce Carbonic Acid (H2CO3).
If we have too much acid in our body, the carbonic acid will release H+ to produce bicarbonate.
Identify signs of respiratory and metabolic acidosis & alkalosisbe able to differentiate between
respiratory and metabolic acidosis & alkalosis based on lab values (Tables 40-7 and 40-8 in text)
Respiratory:
o Acidosis
Low pH, high PaCO2, normal HCO3
o Alkalosis
High pH, low PaCO2, normal HCO3
Metabolic:
o Acidosis
Low pH, low HCO3, normal PaCO2
o Alkalosis
High pH, high HCO3, normal PaCO2
Acid-Base Compensation
o Respiratory Acidosis
Low pH, high PaCO2, HCO3 increases
o Respiratory Alkalosis
High pH, low PaCO2, HCO3 decreases
o Metabolic Acidosis
low pH, low HCO3, PaCO2 decreases
o Metabolic Alkalosis
high pH, high HCO3, PaCO2 increases
Signs and symptoms for Acid-base disturbances
Respiratory Acidosis
Acute: mental cloudiness, dizziness, muscular twitching, unconsciousness
ABG: pH < 7.35, PaCO3 > 45mm Hg, HCO3 slightly elevated
Chronic: weakness, dull headache
ABG: pH < 7.35, PaCO2 > 45 mm Hg, HCO3 >26 mEq/L (compensatory)
Respiratory Alkalosis
Lightheadedness, inability to concentrate, hyperventilation syndrome (tinnitus, palpitations,
sweating, dry mouth, tremulousness, convulsions and loss of consciousness)
ABG: pH > 7.45, PaCO2 <35 mm Hg, HCO3 < 22 mEq/L (compensatory)
Metabolic Acidosis
Headache, confusion, drowsiness, increased respiratory rate and depth, nausea and vomiting,
peripheral vasodilation
ABG: pH <7.35, HCO3 <22 mEq/L, PaCO2 <35 mm Hg
Hyperkalemia frequently present
Metabolic Alkalosis
Dizziness, tingling of fingers and toes, hypertonic muscles, depressed respirations
(compensatory)
ABG: pH >7.45, HCO3> 26 mEq/L, PaCO2 > 45 mm Hg (compensatory)
Hypokalemia may be present
IVhow to locate veins for IV placement
 o Use veins on distal extremities to allow further use of proximal ones later
o Avoid ventral and lateral surface of wrist due to potential nerve damage
o Usually non-dominant had is selected
o Do not use antecubital veins
o If the site is pulsating do not use it (it is more likely to be an artery than a vein)
o Do not use lower extremity veins for an adult (you need an order for this if you are really that
desperate)
o Cephalic, median, basilica veins typicallyused (larger, easy to puncture, less likely to rupture)
IV: what actions to take if IV patency in question
Phlebitis
o Inflammation of a vein, mechanical trauma from needle or catheter
o Signs: tenderness, redness, warm, slight edema of vein above insertion site
o Discontinue infusion immediately, apply warm moist compress to the affected site, start IV
on another vein
Infiltration
o The escape of fluid into the subcutaneous tissue (dislodged needle of penetrated vessel wall)
o Signs: swelling, pallor, coldness, pain around infusion site, significant decrease in flow rate
o Discontinue infusion if symptoms occur, restart infusion at different site
Know normal value ranges for bodys major electrolytes (table 40-3 in text)
Major Electrolytes Normal Value
Sodium (Na+) 135-145 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Calcium (Ca2+) Total serum: 8.6-10.2 mg/dL
Ionized serum: 4.5-5.1 mg/dL
Magnesium (Mg2+) 1.3-2.3 mEq/L
Chloride (Cl-) 97-107 mEq/L
Bicarbonate (HCO3) 22-26 mEq/L
Phosphate (PO4-) 2.5-4.5 mg/dL

7. Laboratory Values
Hemoglobin & Hematocrit normal values-range
Hemoglobin
o 13-18 g/dl (m); 12-16 g/dl (f)
o Carries oxygen, globin part can also bind or release H+ for acid=base balance
Hematocrit
o 40-50% (m); 38-48% (f)
o Ratio of the volume of RBC to the total volume of blood (so low hematocrit= low
hemoglobin)
What constitutes a CBC
o Be able to know what conditions patient may be suffering from due to results of CBC
o If platelets are too high, this may cause blood clots in undesired places, if too low, this
might lead to intracranial bleed
o In anemic patients, RBC is low thus hemoglobin and hematocrit are also low. They are
frequently tired and have little energy since theres not enough hemoglobin to carry
oxygen to tissues.
o High hematocrit and hemoglobin can also be an indicator of dehydration
Complete Blood Count components
o RBC Count (4.2-5.2 million/ mm3)
o Hemoglobin (13-18 g/dl for males, 12-16 g/dl for females)
 o Hematocrit (40-50% for males, 38-48% for females)
o Platelets (100,000-400,000/ mm3)
o WBC (5,000-10,000/mm3)
WBC differential
o Granulocytes/PMN Cells: Neutrophils (50-60%), Eosiniphils (1-3%), Basophils (0-1%)
o Band Neutrophils: < 5%
o Lymphocytes: 22-35%
o Monocytes: 5-10%
What constitutes a BMP
Basic Metabolic Panel (BMP)
1. Sodium (135-145 mEq/L)
2. Chloride (101-111 mEq/L)
3. Potassium (3.7- 5.2 mEq/L)
4. Blood Urea Nitorgen/BUN (7-20 mg/dL)
5. Creatinine (0.8-1.2 mg/dL)
6. Glucose (70-100 mg/dL)
7. Bicarbonate, HCO3 (20-29 mmol/L)
o Be able to relate manifestations to patients ng lab values
CBC values indicative of infection
o High WBC indicates infection
o Band Neutrophils increases when patient is fighting bacterial infection (shift to the left
because premature neutrophils are being released to fight off infection)
o Lymphocytes can increase when fighting fungal, bacterial and viral infections
o Monocytes increase in bacterial infections, called macrophages inside cells

Purpose of Hg A1c, what it measures, NL value

Hg A1c
o Measurements of glucose levels overtime (main type of glucose in our body binds with
hemoglobin)
o Average survival of RBC is 100 days so this tells you level of glucose that are hanging on
to the RBC for a span of 3 months
o If youre not diabetic, your target Hg A1c is below 6 (blood glucose 125)
Accu-check useconsiderations in where/how to get blood sample
o Where: capillary blood sample. Side of finger, only small amt
o How: dispose the first drop because alcohol likely to mix with it from cleaning
Why monitor blood glucose levels?
o Reveals individual patterns of blood glucose changes, and helps with the planning of
meals, activities and at what time of day to take medications (also important in diabetics
to see when they need and not need insulin)

8. Patient positionsterminology e.g., supine, prone, sims, orthopneic, Trendelenburg

Also, terms to describe movement/positioning from midline of bodysuch as abduction, adduction,
dorsal, frontal/ ventral, medial vs lateral, proximal vs distal; etc (*in the foot dorsal is top, plantar is
bottom)
Patient Positions
o Fowlers Position (semi-sitting position)
o Supine: patient lies flat on the back with head and shoulders slightly elevated with a pillow
o Prone: patient lies on the abdomen with head turned to the side, contradicted for people who have
spinal problem bc this can cause lordosis and plantar flexion due to pull of gravity
o Sims: patient on the left side and chest, the right knee and thigh are drawn up and left arm along the
back
o Orthopneic Patient Position: enables patient to breathe comfortably. Usually it is one in which patient
is sitting up and bent forward with the arms supported
o Trendelenburg: patient is supine on a surface inclined 45 degrees, head at the lower end and legs
flexed over the upper end (used in some minimally invasive lower abdomen or pelvic surgery)

9. Pt/nurse/collegial communication/interactions
Open-ended versus closed-ended questioning
o Use open-ended questions over close-ended question when talking to patient (open-ended
qs are less accusatory and more therapeutic)
Actions if you make a mistake
o Immediately assessing patient for any effects and do the compensatory intervention
immediately, report and document mistake
Communicating with assistive personnel
Factors to consider when delegating tasks to UAPs
o Qualifications and capabilities of personnel
o Stability of patient
o Complexity of activity
o Potential for harm
o Predictability of the outcome
o Overall context of other patient needs

10. Urinary system

Reasons for Urinary Catheterization
o To relieve discomfort f/t bladder distention (e.g. after surgery or r/t a medical condition)
o To obtain a sterile urine specimen
o To measure residual urine amounts
o To provide continuous urinary bladder drainage (during surgery or post op drainage)
o Direct administration of antibitics
o To promote repair to urinary structures after surgery
o Hourly urine output measurement in critically ill patients
o Urinary retention or blockage
o For some patients with urinary incontinence and have pressure ulcers
o Immobile patients (ex. Pelvic trauma)
o Patient request for comfort-end of life situations
Urinary catheter sizes
o In French (F) scale according to lumen size
o 14F-16F catheter with a 5-10mL balloon for adults (#14 is average)
o 5F to 8F used for infants and young children
o The bigger the number, the bigger the catheter
o As you go down the anatomy, catheters get bigger (so catheter in the ureters will be
smaller than catheter in the urethra)
Urine sampling techniques
Routine urinalysis technique
o Collect urine by having the patient void into a clean bedpan, urinal or repetical
Clean catch or midstream technique
o Patient voids and discards a small amount of urine, continues to void, then discards the
last amount of urine in the bladder (so you collect the middle part of urine)
Sterile Urine Collection technique
 o May be obtained by catheterizing the patients bladder or by taking specimen form an
indwelling catheter already in place
24-hour urine collection
o Discard the first void then begin the clock

11. Circulation
Factors/conditions affecting circulation
o Heredity- inheriting a gene that predisposes you to a CV disease
o Age- as one ages, heart muscles weakens, arteries become less elastic, build up is more
frequent (arteriosclerosis), and becomes more susceptible to diseases
o Gender
o Serum lipid levels- if you have high cholesterol levels, build up can happen making it
harder for heart to pump due to higher resistance in hardened arteries
o Hypertension: higher pressure is needed to pump blood from heart
o Smoking- hardens arteries (arteriosclerosis)
o DM- higher incidence of heart disease as a result of insulin resistance
o Obesity- causes inflammatory responses that releases cytokines that can eventually affect
vasculature (Cardiometabolic syndrome: triad of heart disease, DM and obesity that are
inflammatory related)
o Stress: can lead to cardiac deterioration by constant secretion of inflammatory factors
o Heat and cold
o Health status, diet and alcohol
Blood flow through heart

Venous stasis/thrombophlebitis/SCDs
Venous stasis: pooling of blood in the leg, risk factor for forming blood clots in the veins
Thrombophlebitis: inflammation of a vein due to formation of blood clot
To prevent these, SCDs are often used
Measures nurse can take to promote circulation
Vascular
o For patients who have edema, mobilize them, elevate feet, turning or properly positioning the
patient
o Pillows under knees or more than 15 degrees of knee flexion
Cardiac
 o Positioning patient, monitor intake and output, fluid restriction if needed
Medications
o Diuretics helps eliminate fluid but in the process you can have hypokalemia which can cause
erratic heart beat
Preventing venous stasis
o Positioning, leg exercises, TEDS, SCDs, Foot pumps
SCDs
o sequential compression device effective if you take it off only for 1 hour each day

12. Oxygenation/respiration
Factors/conditions affecting oxygenation
Understand terminology/meaning of: (pg 594)
Eupnea: normal breathing
Tachypnea: rapid rate of breathing
Bradypnea: slow rate of breathing
Apnea: cessation of breathing
Hyperventilation: breathing very rapidly and deeply (get rid of extra CO2)
Hypoventilation: decreased rate and depth, irregular
Kussmauls breathing: can be used to compensate for diabetic ketoacidosis, metabolic acidosis,
deep and labored breathing, regular, trying to get rid of acid build up
Cheyne-Stokes respirations: altered breathing pattern, mostly end of life respiration, theres
irregular breathing pattern with periods of apnea
Biots respirations: associated with head injury, very irregular, fast pattern of breathing, can be
shallow, different from hyperventilation because of irregularity and usually associated with
trauma in medulla
Orthopnea: associated with COPD, pneumonia, this is difficulty in breathing in a flat position
Dyspnea: difficulty in breathing, can be caused by mechanical (obstructed) or due to illnesses
such as pneumonia or surgery, or broken rib or pneumothorax (when pleural cavity is punctured
so air can get in there compressing the lung), or cancer cells in the pleural cavity causing fluid
build up there
Recognize signs of altered breathing (inadequate ventilation)
o Tachycardia: HR is fast because there might not be enough blood to oxygenate lungs or
get rid of CO2
o Tachypnea: fast breathing
o Anxiety- facial expression (associated with fast shallow breathing)
o Restlessness or confusion (not getting enough O2 to the brain)
o Use of accessory muscles (can be associated with pain after abdominal surgery making it
painful to breathe with diaphragm)
o Change in level of response
o Increased BP
What can nurse do to promote oxygenation
o High fowlers position
o Cough/deep breathing exercises
o Incentive spirometer
o Recommend to the physician the start of O2 therapy
Oxygen delivery systems
o Nasal Cannula (1-6 L/min): used for patients who are non-critical with minor breathing
problems or for those who cant wear masks
o Face tent (8-12 L): alternative to aerosol mask for claustrophobic patients
 o Face mask (8-12 L): has holes on sides for exhalation of air
o Non-rebreather (6-15 L): used to deliver high flow rates and high concentration of O2,
cannot use humidifier
Know how much each liter increase in O2 will yield what percentage of O2
o 1 liter increase = 4% increase in oxygen
o So 1L/min = 24%
o 2L/min= 28%