Fundamentals of Nursing

FUNDAMENTALS OF NURSING
Dervid Santos Jungco
What Is Nursing?
What is Nursing?
Nursing is caring Nursing is an art Nursing is a science Nursing is client centered Nursing is holistic Nursing is concerned with health promotion Nursing is a Helping profession
HISTORICAL PERSPECTIVE IN NURSING
Nursing in the Philippines

1. Where does diseases came from? 2. Can these diseases be expelled away from the body? 3. Early Filipinos believed in :

The first hospital established in the Philippines is: San Lazaro [1578] De Indio [1586] Aguas Santas [1590] De Dios [1596] The first nursing school established in the Philippines is: Saint Paul [1907] PGH [1907] St. Lukes [1907] Mary Johnston [1907]

The first college of Nursing in the Philippines is: MCU [1947], UP [1948] Anastacia Giron Tupas Socorro Diaz Conchita Ruiz Francisca Delgado
Nursing History : I. Intuitive Period

1. When does Intuitive period begun and ended? 2. Intuitive means: 3. Man is considered as: 4. Nursing is mainly performed by: 5. Illness is caused: 6. The person that uses white magic:
Nursing in the near east

1. From Nomads to: 2. Beginning of communication and science
3. Nursing remained the duty of:

4. Nursing it still tied with: 5. The birth of 3 great religions:

BABYLONIA

EGYPT
ISRAEL
Nursing in the far east

CHINA
INDIA
Nursing in Ancient Greece

AESCULAPIUS
HIPPOCRATES
CADUCEUS
The Caduceus
Transition From Pagan to Christianity

ROME
II. Period of apprentice nursing

1. When does the period of apprentice nursing began and ended? 2. During this period, who performs the nursing care? on-the-job training performed without any formal education; attributed to the religious orders of the Christian church. Built hospitals were staffed by religious orders who dedicated their lives to the care of patients.
Notable personages and events during the apprentice period

1. The Crusades
2. St. Clare
3. St. Elizabeth Of Hungary
4. St. Catherine of Sienna
5. St. Vincent De Paul
III. The Dark Period Of Nursing
Notable people and events during the dark period

1. The Establishment of the Deaconess school of Nursing at Kaiserwerth Germany 2. Jean Mance
3. Clara Barton
IV. Period Of Educated Nursing

1. When does this period began and ended? o FLORENCE NIGHTINGALE - Born in Florence, Italy on - The mother of modern Nursing - The Lady with the Lamp, Nurses the soldiers during the - Born in , educated in and worked in - Did not accept the new scientific discoveries, ignored the Germ Theory and bacteriologic researches - Thought that all diseased are eliminated by cleanliness - Died in 1910, at 90 years old Works - Notes on matter about the health of the British army, - Notes on Nursing, - Notes on Hospitals
Notable people and events during the period of Educated Nursing

1. Linda Richards
2.
3. 4.
Dr. William Halstead

Caroline Hampton Halstead Isabel Hampton Robb
Associated Alumnae became American Nurses Association (1911) The American Society of Superintendents of Training Schools for Nurses became the National League for Nursing Education (1912)
Clara Louise Maas The Age of Specialization
5. 6.
V. Period of Contemporary Nursing

1. When does this period began and ended?
UN, WHO Scientific & technical research Atomic energy Computers Diagnostic & therapeutic agents Space medicine and Nuclear Medicine
MODULE REVIEW
1. 1. 2. A. 2. When asked about the PNA, Ms. Guzman responded by saying that PNA was established: 1922 1926 1,4 3. With Mrs. Delgado as first president 4. With Mrs. Tupas as first president B. 2,3 C. 1,3 D. 2,3
She dies of yellow fever in her search for truth to prove that yellow fever is carried by a mosquitoes. A. Clara Louise Maas B. Pearl Tucker C. Isabel Hampton Robb D. Caroline Hampton
MODULE REVIEW
3. Early beliefs of the Filipinos with regards to diseases are superstitious. If a birth is said to be difficult, nonos were said to be the cause of these pamaos. To disperse these nonos, The mabuting hilot will: A. A hole will be dig on the Clients head to remove these bad spirits B. A bamboo will be slap on the Clients head for several times C. A long leaf that is believed to be capable of dispersing the spirits will be slap on the clients head and body for several times D. Insert a Gunpowder in a bamboo cane that will be exploded close to the clients head to disperse the spirits
MODULE REVIEW
4. The first college of nursing that was established in the Philippines is: A. Manila Central University B. University Of The Philippines C. University Of Santo Tomas D. Iloilo Mission Hospital School Of Nursing 5. As a national nurses association, it is characterized as follows except: A. Both a professional body and a labor union B. Affiliated with the International Council Of Nurses C. Advocating for improved work and life condition of Nurses D. Accrediting body for continuing education program
MODULE REVIEW
6. Established in 1906 by the Baptist foreign mission society of America. Miss rose nicolet, was its first superintendent. A. St. Paul Hospital School of nursing B. Iloilo Mission Hospital School of nursing C. Philippine General Hospital School of nursing D. St. Lukes Hospital School of nursing 7. She was the daughter of Hungarian kings, who feed 300-900 people everyday in their gate, builds hospitals, and care of the poor and sick herself. A. Elizabeth B. Catherine C. Nightingale D. Vincent De Paul
MODULE REVIEW
8. He was called the father of sanitation. A. Abraham B. Hippocrates C. Moses D. Willam Halstead 9. Period of nursing where religious Christian orders emerged to take care of the sick A. Apprentice period B. Dark period C. Contemporary period D. Educative period
MODULE REVIEW
10. Florence nightingale is born in : A. Germany B. Britain C. France D. Italy 11. Which is unlikely of Florence Nightingale? A. Born May 12, 1840 B. Built St. Thomas school of nursing when she was 40 years old C. Notes in nursing D. Notes in hospital 12. What country did Florence Nightingale train in nursing? A. Belgium B. US C. Germany D. England
THEORIES IN NURSING
Nursing Theorist
1. Florence Nightingale 2. Virginia Henderson 3. Faye Abdellah 4. Dorothy Johnson 5. Imogene King 6. Madeline Leininger 7. Myra Levine 8. Betty Neuman 9. Dorothea Orem 10. Hildegard Peplau
Nursing Theorist
11. Callista Roy 12. Martha Rogers 13. Lydia Hall 14. Ida Jean Orlando 15. Jean Watson 16. Abraham Maslow
MODULE REVIEW
1. The four major concepts in nursing theory are the A. Person, Environment, Nursing, Health B. Person, Environment, Nurse, Health C. Nurse, Person, Environment, Cure D. Promotive, Preventive, Curative, Rehabilitative 2. According to her, Nursing is a helping or assistive profession to persons who are wholly or partly dependent or when those who are supposedly caring for them are no longer able to give care. A. Henderson B. Leininger C. Orem D. Neuman
3. The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health that he would perform unaided if he has the necessary strength, will and knowledge, and do this in such a way as to help him gain independence as rapidly as possible. A. Henderson B. Levin C. Abdellah D. Peplau
MODULE REVIEW
4. Which of the following nursing theorist conceptualizes that all persons strive to achieve self care? A. B. Sister Callista Roy Dorothy Johnson C. Dorothea Orem D. Jean Watson
5. To view the person holistically means to think of him or her conceptually as a: A. B. C. D. Physical being, who experiences pathology and physiologic changes Social being, who needs the dynamic of group interaction Psychological being whose mind influences his or her health status Biopsychosocial being who is in constant interaction with the environment
6. Carlo, a 16 year old client comes to the ER with acute asthmatic attack. RR is 46/min and he appears to be in acute respiratory distress. Using Maslows theory, which of the following action is to be initiated first? A. B. Promote emotional support Administer oxygen at 6/L per minute C. Suction the client every 30 minutes D. Administer bronchodilator
NURSING AS A PROFESSION
Nursing As A Profession
1. Education
2. Theory
3. Service 4. Autonomy 5. Code Of Ethics 6. Caring
Characteristic of a Nurse 1. 2. 3. 4. 5. 6. 7. PRUDENCE RESOURCEFULLNESS RELIABILITY HONESTY LOYALTY ACCOUNTABILITY SOCIALIZING AGENT
Roles of a Nurse
1. CARE PROVIDER/PARENT SURROGATE 2. TEACHER 3. COUNSELOR 4. CLIENT ADVOCATE 5. CHANGE AGENT 6. MANAGER 7. RESEARCHER 8. COLLABORATOR
MODULE REVIEW
1. Monica shared with the interviewer her most recent experiences about a restless pediatric patient whom she puts up the side rails of the bed to prevent accidental falls. Which of the following attributes is shown by Monica?
A. resourcefulness B. prudence C. honesty D. reliability
2. The priority of a nurse in a caregiver role is to: A. Recognize the needs of the client B. Provide direct nursing care C. Implement nursing care measures D. Provide nursing interventions
3. What role do you play when you hold all clients information entrusted to you in strictest confidence? A. Patients Advocate B. Teacher/Educator C. Patients Liaison D. Patients Arbiter
MODULE REVIEW
4. You made a mistake in giving the medicine to the wrong client. You notify the clients doctor and write an incident report. You are demonstrating:
A. B. Responsibility Accountability C. Authority D. Autocracy
5. The mentally ill person responds positively to the nurse who is warm and caring. This demonstrates the nurse role of: A. B. Counselor Mother surrogate C. Socializing Agent D. Change Agent
6. All of the following are functions of a Nurse Manager except: A. B. C. D. Performing bedside nursing Coordination and delegation of patients care Setting standards of performance Designating staff schedule
MODULE REVIEW
8. The most important quality being demonstrated by a Nurse in a role of a counselor and a teacher is:
A. B. Assertiveness Firmness C. Intelligence D. Active Listening
9. Which of the following is not true with regards to the Code of ethics of Filipino Nurses? A. B. C. D. The PNA for being the accredited professional organization was given the privilege to formulate the code of ethics with the consultation of the BON The code of ethics was first formulated in 1982 published in the proceedings of the third annual convention of the PNA house of delegates The present code utilized the Code of Good governance for the profession in the Philippines Certificate of registration of registered nurses maybe revoked or suspended for any violation of any provision of the code of ethics.
HEALTH AND ILLNESS
Health and Illness

Health
WHO Health is the ability to maintain homeostasis or dynamic equilibrium Walter Cannon Health is the ability to maintain internal milieu Claude Bernard
Health is a state of complete physical, mental and social wellbeing and not merely an absence of disease or infirmity
Illness Is a subjective perception of not being healthy Illness is not synonymous with DISEASE
What is the most important activity a nurse can perform to prevent illness and diseases?
Models of health
1. Dunns health and illness continuum A. Protected poor health B. HLW In favorable environment C. Poor health in unfavorable environment D. Emergent HLW in unfavorable environment 2. Smiths 4 models of health A. Clinical model B. Role performance model C. Adaptive model D. Eudemonistic model 3. Leavell and Clarks Ecologic model A. Agent B. Host C. Environment 4. Beckers health belief model
Leavell and Clarks Levels of prevention

A. Primary B. Secondary C. Tertiary Monthly BSE for premenopausal women Operation timbang Immunization Teaching adolescences how to use condoms Teaching how to irrigate the colostomy Sputum examination for a client with tuberculosis Provision of PPD in a workplace Exercise and a balanced diet Palliative sugery for a client with endstage cancer Teaching a diabetic client how to properly obtain a blood specimen
Stages of Illness
1. 2. 3. 4. 5. Symptom Experience Assumption of the sick role Medical care contact Dependent patient role Recovery and Rehabilitation
GIVE UP THE SICK ROLE
Risk Factors
1. 2. 3. 4. 5. Genetic and Physiologic Factors Age Environment Lifestyle Sex
The Modifiable Risk Factors The Non Modifiable Risk Factors
Risk Factors
1. Edna, living in payatas dump site with difficulty of breathing 2. Danny, 80 year old male client with osteoporosis 3. Mila, with UTI 4. Christian Bjorn, An alcoholic diagnosed with liver cirrhosis 5. Jacob age 6 months, who experienced severe bleeding after circumcision, diagnosed with hemophilia A
MODULE REVIEW
1. Health education plan for Meldy stresses prevention of NCD or Non-communicable diseases that are influenced by lifestyle. These include the following EXCEPT:
A. Cancer B. Osteoporosis C. Diabetes Milletus Type A D. Cardiovascular diseases
2. Wellness clinics and health education activities have been integrated in government hospitals to render appropriate services. Which of the following purposes LEAST helps clients in cases of these health promotion activities? A. maintain maximum functions B. reduce the costs of health care C. promote health habits D. identify disease symptoms
3. With regards to illness prevention activities as part of nursing care, which of the following will help clients MOST? A. maintain maximum function B. reduce risk factor C. promote habits related to health care D. manage stress
MODULE REVIEW
4. The Philippine Nursing Act delineates the scope of nursing. It specifies that independent practicing nurse is responsible for:
A. health promotion and prevention of illness B. administration of written prescription for treatment and therapies C. rehabilitative aspect of care D. Collaborating with other healthcare providers for health restoration and alleviation of suffering 5. Assessment areas for the nurse is working with the family on health promotion strategies would include: A. the television shows that they watch B. the perceived health status and illness patterns of the family C. the family and all the relatives statuses D. the mental status of family and friends
MODULE REVIEW
6. The primary preventive measures against HIV-AIDS is:
A. withdrawal B. virus killing drugs C. foams and gels use D. condom use
7. A nurse has scheduled a hypertensive screening clinic. This service would be an example of which of the following types of health care?
A. tertiary prevention B. secondary prevention C. primary prevention D. protection
8. The nurse who is planning a health promotion program with clients in the community will have the LEAST focus on: A. assisting the clients to make informed decisions B. organizing methods to achieve optimal mental health C. reducing genetic risk factors for illness D. providing information and skills to maintain lifestyle changes
MODULE REVIEW
9. Health as a condition in which a person maintains balance and equilibrium is postulated by:
A. B. WHO Claude Bernard C. Walter Cannon D. Florence Nightingale
10. In this stage of illness, the person accepts or rejects a professionals suggestion. The person also becomes passive and may regress to an earlier stage. A. Symptom Experience B. Medical care contact C. Assumption of sick role D. Dependent patient role
11. Leah is suffering from constipation from being on bed rest, What measures would you suggest in order to prevent this? A. Eat more frequent small meals instead of three large one daily B. Walk for at least half an hour daily to stimulate peristalsis C. Drink more milk, increased calcium intake prevents constipation D. Drink eight full glass of fluid such as water daily
MODULE REVIEW
12. Lifestyle related diseases in general share common risk factors. These are the following except:
A. Physical activity B. Smoking C. Genetics D. Nutrition
13. In your health education class for clients with diabetes you teach them the areas for control of diabetes which includes all except: A. Regular physical activity B. Thorough knowledge of foot care C. Prevention nutrition D. Proper nutrition 14. Control of diabetes is under which level of prevention? A. Primary B. Secondary C. Tertiary D. Quarternary
HOMEOSTASIS : STRESS AND ADAPTATION
Stress and Adaptation

Stress A non specific response of the body to any demand made upon it Produced by a situation perceived as challenging, threatening or damaging to the state of homeostasis Stressor Stimulus that evokes the change Can be internal or external Can be physiological, psychological or social Adaptation A continuous and lifetime adjustment a person makes to cope with stressors
Physiologic Response to Stress

A. General Adaptation Syndrome (GAS) > Three Phases 1. 2. 3.
B. Local Adaptation Syndrome (LAS) >
General Adaptation Syndrome

How does the body response to stress?
Stress Management: 1. Massage 2. Guided Imagery 3. Meditation 4. Progressive Muscle Relaxation 5. Thought Stopping 6. Abdominal Breathing 7. Pharmacotherapy [ Non behavioral, Pharmacologic ]
Local adaptation syndrome

The process of inflammation :
Nursing Intervention for clients with inflammation:
MODULE REVIEW
1. Lifestyle modification begins with:
A. minimizing eating in fast food restaurants B. having an exercise regimen to follow regularly C. recognizing the impact of unhealthy habits D. avoiding pollutants in the environment 2. All of these are the behavior intervention to stress management. EXCEPT: A. guided imagery B. pharmacotherapy 3. Basic to progressive muscle relaxation is: A. focusing on an image to relax B. relaxing muscles from tension C. use of industrial equipment D. stopping disturbing thoughts C. meditation D. progressive muscle relaxation
MODULE REVIEW
4. A type of massage that involves a smooth, long and circular stroke used in the abdomen of a client during labor is called:
A. Petrissage B. Touch Therapy C. Tapotement D. Effleurage
5. When assessing a client's incision 1 day after surgery, the nurse expects to see which of the following as signs of a local inflammatory response? A. Clear, yellow drainage B. Pallor around sutures C. Redness and warmth D. Brown exudates at incision edges
6. When preparing a client with a draining vertical incision for ambulation, where should the nurse apply the thickest portion of a dressing? A. At the top of the wound B. At the base of the wound C. At the middle of the wound D. Over the total wound
MODULE REVIEW
7. Which of the following statement best explains the reason for using stress management with the clients?
A. Everyone is stressed B. It has been an accepted practice C. All stresses are harmful to the body D. Prolonged stress may cause physical and mental disturbance 8. Corticosteroids are potent suppressor of the bodys inflammatory response. Which of the following condition do they suppress? A. Sympathetic nervous system B. Pain receptors C. Immune response D. Neural transmission
9. A client has twisted his ankle during a game. Which of the following nursing intervention is inappropriate during the first 24 hours after the incident? A. Rest B. Heat application C. Cold application D. Immobilization
VITAL SIGNS
Assessing Vital Signs

Vitals signs include: 1. T 2. P 3. R 4. BP 3 Techniques used in assessing vital signs
1. 2. 3.
Temperature
The balance between the heat produce by the body and the heat lost from the body Measure in terms of Fahrenheit or Celsius Convert 1. 32 C to F 2. 100 F to C 3. 43 C to F 4. 50 F to C
Temperature
2 kinds of body temperature 1. Core 2. Surface
Heat Production
1. BMR 2. Muscle Activity 3. Thyroxine output 4. Sympathetic Stimulation 5. Fever
VS
Heat Loss
1. Radiation 2. Conduction 3. Convection 4. Evaporation
Regulation of body temperature

1. Skin / Shell 2. Hypothalamus Factors affecting body temperature
1. Age 2. Diurnal Variation 3. Exercise 4. Hormones 5. Stress 6. Environment
Alteration in Body Temperature

1. Pyrexia 2. Hyperpyrexia 3. Hypothermia Types of Fever 1. Intermittent 2. Relapsing 3. Remittent 4. Constant
42 41 40 39 38 37 36 35 34 12:00 AM 4:00 AM 8:00 AM 12:00 PM ? ? ?
Clinical signs of Fever

1. Onset
2. Course
3. Defervescence
- Crisis - Lysis
Assessing Body Temperature

1. ORAL (36.5 C to 37.5) Most accessible and convenient Can break if bitten Inaccurate if the client breaths through the mouth or eat hot or cold foods Cannot be used after oral surgery Remember ! 1. Wait 2. Place 3. Wash 4. Take for

2. RECTAL (37 C to 38) Most reliable and accurate Inconvenience Different readings depending on which side of the rectum No suitable for febrile clients because it does not change as fast as oral temperature Contraindicated in post-rectal surgery clients, diarrhea, Autonomic dysreflexia t5 up Presence of stool can interfere with accuracy Remember ! 1. Position 2. Lubricate 1 inch 3. Depth .5-1.5 4. Instruct to 5. Take for

3. AXILLARY (36 C to 37) Safest and most non invasive Thermometer must be left in place for a long time to obtain an accurate measurement Remember ! 1. Pat 2. Position

4. TYMPANIC (37 C to 38) Readily accessible, Reflects the core temperature Equipment is expensive. Can be uncomfortable and involves risk of injuring the ear canal if probe is inserted too far
Pulse
Is a wave of blood created by the contraction of the Left ventricle regulated by the ANS.
Terms to remember
1. Pulse rate 2. Peripheral pulse 3. Apical pulse 4. Pulse pressure 5. Pulse deficit 6. Tachycardia 7. Bradycardia 8. Pulse rhythm 9. Amplitude 2 is normal 3 is bounding 10.Arrhythmia 11.Bilateral Equality
Factors affecting the Pulse

1. Age
2. Sex
F>M
3. Exercise
4. Medication
5. Hemorrhage
6. Stress
7. Position changes
Pulse Locations
1. 2. 3. 4. 5. 6. 7. 8. 9.
Tips in assessing the pulse 1. Use the middle three fingers 2. In apical pulse, steth 3. The pressure when moderate 4. Wait for 5. Warm
15
Respiration
Respiration is
2 Types of respiration
1. External 2. Internal 2 Types of breathing 1. Costal 2. Diaphragmatic Regulators of Respiration
1. Medulla 2. Pons A. Pneumotaxic - inhibit B. Apneustic encourage inspi 3. Baroreceptors 4. Proprioceptors
Definition of terms
1. Inhalation/Inspiration : 2. Exhalation/Expiration 3. Ventilation 4. Hyperventilation 5. Hypoventilation Factors affecting respiration
1. Exercise 2. Stress 3. Environment 4. Altitude 5. Medication
Assessing Respiration
1. Rate Defined as Normally takes between Breathing that is normal Abnormally slow respiration Abnormally fast respiration Absence of breathing 2. Depth Can be observed by watching the movement of the chest Describe as 1. 2. 3. When large amount of air is inhaled The exchange of small volume of air When the normal tidal volume is taken
3. Body position If asked : Best position for maximal chest expansion Worst breathing position : 4. Medications 5. Rhythm Refers to the regularity of respiration Cheyne-Stokes chf,stroke,tumor increasing-decreasing Biots Kussmaul
6. Respiratory Quality Is the effort and sound of breathing Normally, the breathing should be
3 Normal sounds heard during auscultation 1. Vesicular sighing, soft intensity, vava, air through alveoli 2. Tubular high pitch harsh trachea 3. Bronchovesicular moderate intensity, bronchus
Adventitious breath sounds 1. Wheezing whistling sound produce by narrow airway 2. Crackles popping like sound, rattle, produce by fluid filled alveoli 3. Stridor high pitch turbulent airway obstruction epiglo 4. Grunting 5. Pleural Friction Rub grating like sound when 2 inflamed pleure rub
Blood Pressure
Is the measure of the pressure of the blood as it flows through the arteries
2 Blood pressure measure 1. Systolic 2. Diastolic Alteration in blood pressure 1. Hypertension 2. Hypotenstion
Physiology of blood pressure
Factors affecting blood pressure

1. Age 2. Sex 3. Exercise 4. Stress 5. Race 6. Obesity 8. Medication 9. Diurnal variation 10. Disease process
Measuring the Blood Pressure

1. Prepare the client Timing Size Positioning
encircle atleast 2/3 of the clients arm
sitting position, arm flex at the heart level
2. Wrap the deflated cuff evenly around the arm Placing 1

inch above the antecubital
3. Palpatory determination of the systolic BP Wait

1 to 2 minutes
4. Position the stethoscope appropriately Place over the

brachial pulse , bell shape
Bladder 40% of circum
Measuring the Blood Pressure

5. Auscultate the BP Pump up above Release carefully If to reassess, 6. Remove the cuff from the clients arm 7. Repeat if necessary No difference The arm with 8. Report and record
more than 10 mmHg between 2 arms
the higher blood pressure is used for subsequent
Errors in measuring blood pressure

1. Bladder Cuff that is too small > 2. Tilted mercury column > 3. Error of parallax > > 4. Insufficient rest before assessment > 5. Deflating the cuff too slowly > 6. Arm above the level of the heart > 7. Cuff wrapped too tightly false low > 8. Arms unsupported >
MODULE REVIEW
1. In assessing a client with hypertension, which of the following posts a much higher danger to a client? A. Systolic BP of 180 B. Diastolic BP of 120 C. Pulse pressure of 40 D. Respiratory rate of 20
2.How long will a nurse obtain an accurate reading of temperature via oral route? A. 1 minute B. 3 minutes C. 5 minutes D. 8 minutes
3. A client with lymphedema in both arms and the nurse must measure blood pressure using a thigh cuff. In reference to the clients baseline arm blood pressure, the nurse should expect the thigh to have a: A. A higher systolic blood pressure reading B. A high diastolic blood pressure reading C. A lower systolic blood pressure reading D. A lower diastolic blood pressure reading
MODULE REVIEW
4. One of the responsibilities of Mr. Lata, RN, an industrial nurse, is to conduct physical head-to-toe assessment of a newly hired factory worker. As part of the assessment, he took the vital signs. Which of the four assessment techniques did he utilize? 1. auscultation 2. percussion A. 1,2 & 3 C. 1 & 2 3. palpation 4. inspection B. 3 &4 D. 1,3 & 4
5. When assessing a clients blood pressure, the nurse finds it necessary to
recheck the reading. How many seconds after deflating the cuff should the nurse wait before rechecking the pressure? a. 100 b. 30 c. 45 d. 60
MODULE REVIEW
6. If the cuff is said to be wrapper to tightly, it will give a blood pressure reading that is: A. False high B. False low C. Accurate D. Indeterminate
7. When taking the blood pressure, the cuff should be:

A. Deflated fully then immediately start second reading for the same client B. Deflated quickly after inflating up to 180 mmHg C. Large enough to wrap around the upper arms of the adult client 1cm above brachial artery D. Inflated 30 mmHg above the estimated systolic BP based on the palpation of the bronchial artery
MODULE REVIEW
8. In a client with Kussmauls respiration, you can expect that the acid-base disturbance associated with this type of breathing is: A. Metabolic acidosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic alkalosis
9. A student nurse is observed putting a standard size cuff on an obese client. The action would probably result in BP reading that is:
A. false high
B. false low
C. normal
D. undetectable
10. A febrile client has a temperature of 108 Degrees Fahrenheit. How many degrees is this in centigrade? A. 42.2 B. 42.7 C. 43.4 D. 41.5
NURSING PROCESS
PHYSICAL ASSESSMENT
Physical Assessment
Is a systematic collection of data using the techniques of
2 Types
1. Complete 2. Specific Client preparation is essential before conducting physical examination 4 Techniques used in Physical assessment 1. Inspection vision,hearing,smell,=color,rashes,scar,shape,emotion,bodysturcture 2. Palpation touch,fingerpads,texture,temperature,vibration,position,size,consistency,mobility,degofdistention,pulse,tenderness 3. Percussion direct,indirect,plexor,pleximeter,90degrees,sizeshapeorgans,consistency. 4. Auscultation
Abdominal assessment
Abdominal assessment
Positioning during physical assessment

1. Supine
backlying position,bse
2. Dorsal Recumbent backlying,kneeflex,abassess 3. Sitting back unsupported, legs hang freely chest ausc, listening to breath 4. Fowlers
semi 45 high 90 .. Maximal lung expansion
5. Lithotomy backlying with legs supp stirrup, vaginal del, exam, speculum 6. Lateral sidelying 7. Sims semi prone, enema, therm, dre,
8. Prone
9. Standing
MODULE REVIEW
1. During breast self-examination, the purpose of standing in front of the mirror it to observe the breast for:
A. thickening of the tissue B. axillary lymphnode C. lumps in the breast tissue D. change in size and contour
2. In palpating the breast, the best position of the client is: A. Sitting B. Supine C. Lithotomy D. Dorsal Recumbent
3. In Vaginal examinations, the position of the client is usually:

A. Sims position B. Supine C. Genopectoral D. Lithotomy
4. LM determines that the client with Chest tube has crepitus. What technique did she used to illicit crepitus? A. Inspection B. Palpation C. Auscultation D. Percussion
MODULE REVIEW
5. During assessment, the nurse percussed Ana Maries costovertebral angle by placing the left hand over this area and striking it with the right fist. This percussion technique would produce which sound? A. Flat C. Hyper resonance B. Dull D. Tympany
6. The degree of patients abdominal distension may be determined by:
A. Inspection B. Percussion
C. Palpation D. Auscultation
7. When performing an abdominal assessment, the nurse should follow which examination sequence? A. Inspection, auscultation, percussion, and palpation B. Inspection, percussion, palpation, and auscultation C. Inspection, auscultation, palpation, and percussion D. Inspection, palpation, percussion, and auscultation
RECORDS : DOCUMENTATION AND REPORTING
Records
Is always written, it is a formal and legal documentation of a clients progress. Process of making an entry into a record - charting Department of Health Records Management and Archive Office > Medical Records Section >
2 General Types of records 1. Source oriented 2. Problem oriented
Reporting
Either oral, taped or written exchanges of information between nurses or other members of the health care team. 4 Types of Report 1. Change of shift report oral or written given 2x3x continuity of care A. Oral face to face B. Audio tape at the end of the shift to be as current C. Nursing rounds report given in the clients bedside 2. Telephone orders and reports - date time name giving receiving report 3. Transfer reports 4. Incidence reports record about an accident , all facts , within 24 hours after accident, not part of the med record but should be
noted
Documentation
Printed or written records that provides proof for authorization Forms of documentation 1. Nursing health history and assessment worksheet 2. Graphic flow sheet 3. Medicine and treatment record 4. Nursing Kardex 5. Discharge summary 6. Nursing progress notes
Documentation
1. Nursing health history and assessment worksheet
This is a special form completed by the nurse when the patient is admitted to the unit. It contains the basic biographical d ata, his present illness, past health history, family health history, emotional profile, environmental history and physical assessment. Including the nursing diagnosis on admission.
Documentation
2. Graphic flow sheet allows recording of specific information on a repeated basis
80 70 60 50 40 30 20 10 0 12:00 AM 8:00 AM 4:00 PM 12:00 AM
Respiration Pulse
Documentation
3. Medicine and treatment record
Medication and treatment given on a repeated basis Date medication dose frequency hour signature
Documentation
4. Nursing Kardex
Documentation
5. Discharge summary
1. A special progress report that helps to ensure that the clients discharge result in a desirable outcome. Begin upon admissio n, Teaching and counseling before discharge, medication and treatment, ADL, support, mode of discharge- alone, with family, person who will accompany, destination
Simple complex Most nurses regard this conventional recording of the date, time, and mode by which the patient leaves a healthcare unit but this record includes importantly, directs of planning for discharge that starts soon after the person is admitted to a healthcare institution. It is accepted that collaboration or multidisciplinary involvement (of all members of the health team) in discharge results in comprehensive care. What do you call this?
Guidelines in Recording and Documenting

1. Timing 2. Confidentiality 3. Permanence 4. Signature 5. Accuracy The patient had a good day The patient has a large wound 1cm below the ankle The client appears to be depressed The skin turgor is normal 6. Sequence 7. Complete 8. Brief 9. Appropriateness 10. Use of universally accepted abbreviation
MODULE REVIEW
1. A main function of the patients records is to: A. prepare the nurse for the shift worked B. serve as a record of financial charges C. serve as a vehicle for communication D. ensure that the message is received 2. When the nurse writes in the chart and discovers an error has been made, which is the BEST approach? A. erase the erroneous material B. carefully ink out the erroneous material C. place as asterisk next to the statement, then footnote it D. draw a straight line through the error and initial it. 3. Which of the following persons cannot have the access to the patient record? A. physical therapist C. the patient B. lawyer of the family D. speech therapist
MODULE REVIEW
4. POMR charting is different from traditional method because of which of the following practices?
1. SOAP charting 2. use of flow sheet

A. 3 & 4 B. 1 & 2
3. narrative charting 4 . use of checklist

C. 1 & 3 D. 2 & 3
5. Which of the following qualities are relevant in documenting patients care?

1.Accuracy and consciousness 2. thoroughness and currentness 3. systematic and orderly 4. legibly, properly dated and signed 5. use of locally accepted abbreviation A. 1,3,4 & 5 C. 1,2,3 & 5 B. 2,3,4 & 5 D. 1,2,3 & 4
MODULE REVIEW
6. The patients medical record is the best evidence of the care that is given to the patient. It is the property of: a. the patient owns the record b. the physical property of the hospital c. the health team property d. the doctor owns the record 7. Disposal of medical records in government hospitals/institutions must be done in close coordination with what agency?
a. DOH b. Records Management and Archives Office (RMAO) c. DILG d. MMDA
MODULE REVIEW
8. A problem oriented recording system that utilizes the problem solving process as the basis of patient care management: A. NANDA Diagnosis B. Nursing Care Plan C. Gordons Functional Health Patterns D. Problem Oriented Medical Recording
9. To safeguard anonymity of data after the report is written, the nurse researcher should: A. throw the papers in a wastebasket B. keep the papers for 5 years and dispose of these after C. burnt or shred the papers D. have the papers recycle but not as writing scratch paper
MODULE REVIEW
10. When documenting information in a clients medical record, the nurse should: A. Erase any errors B. Leave one line blank before each new entry C. Use a #2 pencil D. End each entry with the nurses signature and title 11. JSJ, R.N Observed that her patient Linda is uncooperative. She is shouting and spitted her medication just after JSJ Administer it to her. She correctly Documents the following in the chart: A. Patient is Uncooperative when taking the medication B. Patient is Shouting and Spitted the Oral Medication C. Patient Do not like taking her medication D. Patient seems to be uncooperative, shouting and spitting the medications
NURSING SKILLS : OXYGENATION
Pulse Oximeter
1. If the client is allergic to adhesive, what type of Pulse Oximeter should the nurse use? Use a clip sensor instead of an adhesive sensor 2. What is the best site for Pulse Oximeter? Good circulation, capillary refill if not, nasal sensor or
forehead sensor.
non invasive device use to measure oxygen saturation by a sensor attached to finger, toe,
nose, earlobe, or forehead. Detects hypoxemia before clinical sign and symptom develops LED-Photoreceptor 95-100
3. How should the nurse prepare the site? Clean with alcohol, remove nail polish 4. What is the rationale why the nurse should immobilize the monitoring site?
Movement may be misinterpreted as an arterial pulsation
5. How frequent should the nurse change the monitoring site? 4 hours for adhesive,
2 hours for spring / clip tension sensor
6. If the nurse notices that the window is open and sunlight is coming in from the outside, what should he do? Cover sensor
with a sheet or towel to block large amount of lights alter sa02
Sputum Specimen Collection

secretion from the lungs, bronchi and trachea
is the mucous
Purpose for collecting sputum specimen: 1. For C/S specific organism and drug sensitivity 2. Cytology identify the structure and pathology of cells, cancer.. 3. AFB use to identify tb 4. Evaluation effectiveness of therapy CBQ in obtaining Sputum Specimen: 1. When is the best time to collect a specimen? 2. In rinsing the mouth, what should the nurse use? 3. Clean or Sterile specimen container? 4. How much sputum will the nurse collect? 1-2 tbsp / 15-30 ml 5. Clean or Sterile gloves? 6. What should I instruct the client? 3 breaths cough 7. Priority after collection? Oral hygiene
Thoracentesis
Thoracentesis
CBQ On Thoracentesis 1. What is the position of the client for Thoracentesis? 2. Who will secure the consent for Thoracentesis? 3. What kind of anesthesia is used in this procedure? Only pressure not pain is felt
local anesthesia
4. What should be the nurses instruction to the client when the physician is inserting the needle and also during the withdrawal of the needle? exhale 5. After Thoracentesis, what should be the position of the client? 6. If expectoration of blood is noted, what should the nurse do? Notify the
physician for chest x ray
7. To evaluate the effectiveness of the procedure and to rule out the development of pneumothorax, the nurse will expect what procedure that will be done to the patient?
Incentive Spirometer
CBQ On Incentive Spirometer 1. What should be the optimum position of the client? Upright , sitting HF 2. How should the client hold the device? upright 3. What should you tell the client before putting the mouthpiece around the mouth? Exhale normally 4. How should the client seal the mouthpiece with her mouth? Loosely or Tightly? 6. What kind of instruction will you give to elevate the spirometer ball? Slow deep breath hold for 6 seconds 7. After using the incentive spirometer, what is the best thing the client should do? cough 8. How frequent should the client use the device? Q 15 , 4 times hourly during waking time 9. If the client is using a disposable mouthpiece, how frequent will the nurse change it? q24
Chest Physiotherapy
improve the clients gas exhange by removing secretions
PVD dependent nursing action perform to
1. Is chest physiotherapy dependent or independent nursing action? 2. What is the correct sequence in performing chest physiotherapy? Positioning,
percussion, vibration
8. How should the nurse position his hands when percussing the chest? Percussion is forceful
striking of the skin with cupper hands
9. To help prevent skin reddening after percussion, what should the nurse do initially before starting the procedure? Cover with towel or gown to
reduce discomfort
3. The secretion from various lung segments are drained by postural drainage using what force? 4. If the client has a pooling of secretion in the lower lobe of both lungs at the posterior segments, what is the best position that the nurse should utilize?
Trendelenburg position lying flat on the abdomen
10. How long should the nurse percuss each lung segment? 1-2 minutes
11. How will you know that you are performing the procedure correctly?
12. What part of the nurses hand should produce the vibration? Vigorous quivering of the hand produced
by the hand placed flat against the clients skin HEEL
5. Positions in PD is usually assumed for how many minutes? 10-15 minutes 6. The entire procedure of Chest physiotherapy will normally take how many minutes? 30 minutes 7. When is the best time in performing PD?
13. When should the nurse start vibrating the hand? During inhalation or exhalation?
13. How long should the nurse perform vibration? 5 vibration per lung segment
14. After each session of PVD, what should the nurse instruct the client? cough 15. What is the MAIN reason why CPT is contraindicated to some patients? Clients tolerance of
positioning
Suctioning
CBQ in Suctioning
aspiration of secretion using a catheter connected to a suction machine or wall outlet sterile technique
should be used .. Oro/nasopharyngeal light endotracheal - deep
1. How frequent should the nurse suction a client? Depends on the assessment, breath sound rattling or
bubbling breath sound that signals accumlation of secretion. Unable to expectorate, unable to swallow.
2. What technique should the nurse use throughout the procedure? Sterile or Clean? Medical or Surgical asepsis? 3. What are the possible lubricants that the nurse could use?
lubricant for the naso NSS or sterile water for oro, Water soluble
4. How should the nurse position a client before suctioning? Conscious : semi fowlers oral: head turned to
one side, naso- neckhyperextend unconscious : lateral position facing you prevent aspiration, let the tongue fall to prevent obstruction
5. How should the nurse instruct the client during tube insertion? 6. How long is the depth of insertion? Nose to earlobe
95-110
7. When to apply suction? Insertion or withdrawal? How much is the pressure applied? 8. In suctioning using the mouth as the portal of entry, how will the nurse prevent gagging? 9. What should the nurse do in case of any obstruction or difficulty inserting the tube?
Never force an obstruction, try another orifice
10. How long should a suction last? 5-10 sec, allow 30 sec interval between suction
Suctioning
11. If suction is to be repeated, how long should the nurse wait? 12. If the left bronchus is to be suctioned using the endotracheal approach, what instruction should you tell the client to facilitate the entry of the catheter into the left bronchus? 13. In endotracheal suctioning, if a resistance is met at the recommended distance, what should the nurse do? Mouth to midsternum, nose earlobe side of the neck thyroid cartilage 14. After suctioning, what is the primordial instruction that the nurse should tell the client?
CTT: 3 WAY BOTTLE SYSTEM

3 draining expiration , suction and gravity.
intercostal
space through the pleural cavity after trauma or surgery to drain either air or fluid. Air 2nd , fluid 8th air is + lung is make sure it is sealed. The tube uses gravitational force to drain, lower it.
Clamp if an air leak developed
OXYGEN DELIVERY
Low flow 1. Cannula 20-40 / 2-6L 2. Simple face mask 40-60 5-8L 3. Partial rebreathing 60-90 6-10L 4. Non rebreathing 90-100 6-15L
High flow 1.
CBQ on Oxygen Delivery
1. What is the best oxygen delivery device to use in clients with COPD? 2. What should the nurse do first, put the device [ face mask, cannula ] first or turn on the oxygen first? 3. What is the most non threatening method of oxygen delivery for most clients? 4. What is the preferable position when giving oxygen therapy? 5. What is the best lubricant to use when inserting the cannula to the nares? 6. How many percent of oxygen is present in the normal air the we breathe?
MODULE REVIEW
1. Mr. E.O. age 52 had a laryngectomy due to cancer of the larynx. Discharge instructions are given to Mr.F.O. and his family. Which response by written communication from Mr. F.O. or verbal response from the family, will be a signal to the nurse that the instructions need to be reclarified? a. it is acceptable to take over-the-counter medications now that condition is stable b. the suctioning at home must be a clean procedure, not sterile. c. report swelling, pain or excessive drainage d. cleans skin around stoma BID, use hydrogen peroxide and rinse with water, pat dry. 2. LM has chest tube attached to a pleural drainage system. When caring for LM you should: A. change the dressing daily using aseptic technique B. empty the drainage system at the end of the shift C. palpate the surrounding areas for crepitus D. clamp the chest tube when suctioning
MODULE REVIEW
3. Mang Ruben has emphysema and was rushed to the hospital because of sever dyspnea. The doctor ordered oxygen and a venturi mask was not available. Which is the best alternative that the nurse could use for Mang Ruben? A. Face mask B. Non rebreather mask C. Nasal Cannula D. Venturi mask
4. Mario listens to Richard's bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segment of the lungs when Mario does percussion would be:
A. Client lying on his back then flat on his abdomen on Trendelenburg position B. Client seated upright in bed or on chair then leaning forward in sitting position then flat on his back and on his abdomen C. Client lying flat on his back and then flat on his abdomen D. Client lying on his right then left side on Trendelenburg position
MODULE REVIEW
5. Mario prepares Richard for postural drainage and percussion, Which of the following is a special consideration when doing the procedure? A. Respiratory rate of 16 to 20 per minute B. Client can tolerate sitting and lying positions C. Client has no signs of infection D. Time of last food and fluid intake of the client 6. What is the difference between percussion and vibration? A. Percussion uses only one hand while vibration uses two hands B. Percussion delivers cushioned blow 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 clients breath rhythm D. Percussion slaps the chest to loosen secretion while vibration shakes the secretion along with the inhalation cycle
MODULE REVIEW
7. How long should you insert the catheter used in nasopharyngeal suctioning? A. From the mouth to the midsternum B. From the tip of the nose, to the earlobe and to the xyphoid process C. From the tip of the nose to the earlobe D. From the tip of the nose, to the earlobe and to the side of the neck
8. A client is to undergo Thoracentesis, the nurse knows that a preprocedural timeout is performed to:
A. Ascertain that the client is ready to undergo the procedure B. Make sure that the client has signed the consent C. Make sure that the members of the healthcare team will verify the client, the procedure and other aspects of the procedure D. Provide rest and comfort to all hospital personnel
MODULE REVIEW
9. After Thoracentesis, the patient is put on what position? A. Supine position B. Side lying , affected side C. Side lying, unaffected side D. Semi fowlers position
10. In preparing the client before incentive spirometry, The nurse should position the client:
A. Semi-fowlers B. fowlers C. High fowlers D. Orthopneic
MODULE REVIEW
11. A pulse oximeter is attached to Ms. Dizon to: A. Determine if the clients hemoglobin level is low and if she needs blood transfusion B. Check the level of tissue perfusion C. Check the clients Arterial blood gas D. Detect oxygen saturation of the arterial blood before symptoms of hypoxemia Develops 12. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by: A. Apply suction for at least 20 to 30 seconds each time to ensure that all secretions are removed B. Using clean gloves to prevent introduction of pathogen to the respiratory system C. Applying no suction while inserting the catheter D. Rotating the catheter as it is inserted with gentle suction
NURSING SKILLS : NUTRITION
Assessing Nutritional Status

ABCD Approach 1. A anthropometric measurement 2. B biochemical data 3. C clinical signs of nutritional status 4. D dietary history Anthropometric Measurements assessing using the
measurement of the human body
nutrition is the
sum of all interaction between an organism and the food it consumes. What person eats and how his body is using it. CAL / KCAL fats protein carbo
1. Height 2. Weight 3. Skin fold measurements fat, main form of stored energy 4. Mid upper arm circumference 30 ang average, measure
from the acromion to olecranon
5. BMI [ 20 to 25 ]
QUESTION : Compute for the BMI of Gardo, weighing 248 lbs and with a vertical length of 6 feet and 11 inches.
Assessing Nutritional Status

Biochemical Data use to detect malnutrition before anthropometric changes occurs
1. Hemoglobin low = IDA , normal should be not below 12 mg/dl 2. Hematocrit percentage of RBC in found in a whole blood 40-50 , 35-45 3. Serum Albumin protein , produced by the liver .. Changes slowly, good indicator of long term protein deficiency 3.5 to 5.5 g/dl 4. Transferrin more sensitive indicator of protein malnutrition because it responds quickly to changes. Synth by liver. High when low iron,
low when high iron.
5. Lymphocyte decreases as protein decreases 15-40% of rbc 6. Nitrogen Balance BUN 10-20 mg/dl elevated : starvation or excessive fluid intake, decrease cause by low protein diet. 7. Creatinine depends on the skeletal muscle mass, decrease / sm atrophy body builders. Clinical Signs of Malnutrition 1. Hair Patchy, dull, dry, oily 2. Skin bruised, pale, rash, scaly, dry oily 3. Eyes dry reddened 4. Tongue reddened and swollen 5. Mucus membrane reddened dry and cracked 6. Cardiovascular rapid, slow, low or high bp, irregular 7. Muscles poor tone, soft underdeveloped 8. Vitality lacking energy, apathetic, sleeping poorly
Diets
A. Clear Liquid Diet B. Full Liquid Diet C. Soft Diet D. Diabetic Diet E. Low salt Diet F. Acid/Alkaline Ash Diet G. Bland Diet H. Regular Diet I. High Fiber Diet
6. 7. 8. 9. 10.
cellulose / pectins
Whole-grain foods (such as bran cereals) and breads (those made with whole wheat grains). Fresh fruits (including the skin and pulp). Dried or stewed fruits (such as prunes, raisins, or apricots). Root vegetables (such as carrots, turnips, or potatoes). Raw or fresh vegetables, such as cabbage. (Lettuce is actually low in fiber.)
Diets
1. Coffee, Tea, Gelatin and Yogurt full 2. Pudding, Custards, Margarine and Peanut Butter full 3. Hard candy, clear apple juice and Bouillon clear 4. Whole wheat bread, raisins and corn HF/hr 5. 1 teaspoon of salt with no patis and toyo normal salt intake 6. Mashed potatos, Tender meat and fish with Avocado Soft 7. Milk, Vegetable, Fruits except cranberries and plums Alkaline ash 8. 50% CHO, 30% FATS, 20% CHON diabetic 9. Eggnog with Ginger Ale full liquid 10. 1500 mg of salt Low sod 11. Meat, Eggs, Cheese, Whole grains, Cranberies and Plums acid ash 12. 250 grams of carbohydrates, 67 grams of fats and 100 grams of protein in a 2,000 calorie daily intake without adding simple sugars. diabetic
Nasogastric Tube Insertion
Nasogastric Tube
1. What are the purposes of having an NGT? To administer feedings to a client who cannot eat or have high risk
for aspiration, to suction stomach contents to prevent distention, remove stomach content for analysis, wash the stomach in case of poisoning and to administer medication.
2. What is the clients position during NGT insertion? hf 3. How should the nurse select the best nostril before NGT insertion? Use penlight to
observe for intactness of the nostril, ask the client to breath and then listen on which nares is more patent
4. How can the nurse stiffen a rubber tube? Rubber is soft, place on ice 5. How can the nurse make the plastic tube more flexible?
water. Plastic tube is harder, place on warm
6. How long will the nurse insert the NGT? Infant midway bet umblicus and the xyphoid process 7. What is the best lubricant that a nurse could use in inserting the NGT? 8. During the insertion of the NGT, What instructions are necessary to facilitate the entry of the NGT? Hyperextend the clients neck and advance the tube, when you observe gag reflex, tilt head forward and swallow. 9. If the nurse notices that the clients is teary, what should the nurse do? 10. If for the first time, the nurse meets a resistance, what should he do?
Nasogastric Tube
11. Once the client starts to gag, what is the special instruction you need to tell the client to ease the insertion of the NGT? 12. The nurse notices that the client continuously gag despite resting. The nurse inspects the tube and notices that it is coiling on the clients throat, What is the nurses next action?
13. What are the ways to determine the placement of the tube? What is the BEST way? 5-20 cc of air
14. Where is the NGT taped after insertion? 15. In order to assure tube patency, what should the nurse do regularly?
of NSS
30 cc irrigation
16. In removing the NGT, what is the most vital instruction of the nurse to the patient when she is about to pull the tube? Deep breath and hold it, this will close the glottis preventing aspiration of
gastric content
NGT Feeding
1. What are the possible positions in giving NGT Feedings? Sitting position, fowlers, right side lying position. 2. Before feeding the client, what is the most important thing a nurse should assess?
Placement of the tube aspirate check for ph should be 1 to 5. pleural ph is 7.4
3. If the nurse notices that there is 30 ml of undigested formula, what should she do? >50 cc or more ask the nurse in charge or the doctor.
4. What should the nurse do with aspirated undigested formula? Discard or return to the client?
5. If the client experience discomfort during feeding, what should the nurse do?
clamping or pinching the tubing.
Stop temporarily by
6. If the nurse raises the syringe, what will happen to the speed of flow?
point.
12 inches above the insertion
7. How high should the nurse hold the syringe or the prefilled formula when administering the tube feedings? 8. At the near end of the tube feeding, what should the nurse add to the feeding solution to ensure that the lumen of the tube remains patent? Instill 60 cc of water 9. Before all the water runs down to the tube, what should the nurse do to prevent unnecessary distention?CLAMP 10. How long should the client maintain the sitting/fowlers position after feeding?
30 minutes
MODULE REVIEW
1. The nurse knows that if a client has a Hematocrit level of 60%, the client is probably experiencing: A. Delusions B. Too much fluid C. Too little fluid D. This is a normal value
2. Angela, 56 and weighing 60 Kg is in the wellness center for nutritional assessment. Upon computing her BMI, you know that Angela is: A. Underweight B. Overweight C. Normal D. Data insufficient
3. After an operation, Gerard has been given a clear liquid diet. The nurse will eliminate which of the following on the clients tray?
A. Coffee B. Gelatin C. Butterball candy D. Sarsi
MODULE REVIEW
4. Mr. Bruno asks, what is the normal allowable salt intake? Your best response is: A. 1 tsp of salt a day with iodine and sprinkle of MSG B. 5 gms of salt a day or 1 tsp of table salt a day C. 1 tbsp of salt a day with some patis and toyo D. 1 tsp of salt a day with no patis and toyo 5. How could the nurse best assess the patency of the tube after NGT insertion? A. X ray B. Aspirate the gastric content and check for the PH C. Instill 30 cc of air and listen for gurgling sounds D. Observe the client for coughing and choking or ask the client to hum 6. Assuming a cup of rice provides 50 grams of carbohydrates. How many calories are there in that cup of rice? A. 150 calories B. 250 calories C. 200 calories D. 400 calories
MODULE REVIEW
7. Which of the following if done by the nurse, is correct during NGT Insertion?
A. Use an oil based lubricant B. Measure the amount of the tube to be inserted from the Tip of the nose, to the earlobe, to the xiphoid process C. Soak the NGT in a basin of ice water to facilitate easy insertion D. Check the placement of the tube by introducing 10 cc of sterile water and auscultation for bubbling sound
NURSING SKILLS : ELIMINATION

MODULE 10
Elimination : Urinary
Assessing the normal urine 1. Amount per hour 2. Color n-straw amber transparent , ab cloudy red darkbrown 3. Clarity clear not cloudy 4. Odor aromatic, offensive UTI, sweet Glycosuria 5. Sterility no microorganism present, sterile 6. P.H 4.5-8.0 normally acidic 7. SG 1.01-1.025 overhydration of low , dehydration if high 8. Glucose should not be present, large ingestion can + 9. Ketones dka, aspirin toxicity, malnutrition 10. Blood not present, or in low amt hematuria bleeding from the urinary tract and other diseases
Collecting Urine Specimen for C/S

I . Clean catch 1. In cleaning the urinary meatus of a female client, how should the nurse wipe the labia minora? Front to back, swab the labia then meatus
2. How should the nurse clean the urinary meatus of a male client? hold
the penis, retract the foreskin, circular from meatus outward moving down the shaft
3. How many cc of urine is to be collected in a midstream clean catch urine specimen collection? Ask the client to void initially, after, place the specimen container under near meatus,
collect 30-60cc
4. If a urinary specimen for C/S has been left for a number of minutes, how many minutes should pass before you can consider that the specimen is contaminated? Cap the specimen, touch only the outside.
5. What kind of asepsis is observed during this procedure? Sterile technique
Collecting Urine Specimen for C/S

II . Urinary Catheter 1. What is the only type of catheter that allows sterile specimen collection?
catheters, not plastic, silicone or silastic catheter Self sealing rubber
2. Before inserting the syringe into the drainage port, what should the nurse do to prevent contamination of the specimen? Don gloves, wipe the area with a disinfectant swab 3. If there is no urine aspirated from the catheter, what should the nurse do? Clamp the drainage tubing for 30 minutes 4. How many minutes should the clamp be maintained? 30 minutes
5. To facilitate the self sealing of the rubber catheter, the nurse should inject the syringe at how many degrees? 30-45 degrees to facilitate self sealing
6. How many cc of urine is to be aspirated from the patient for a routine Urinalysis? C/S? 3 cc for c/s and 30 cc for urinalysis 7. In case of clamping the catheter, where should the nurse inject the syringe? Below or above the clamp site? Above the clampsite
Catheterization
Catheterization
1. What should be the position of a female client during catheterization?
position Dorsal recumbent
2. What kind of lubricant is used in urinary catheterization? 3. How long should the nurse insert a catheter if the client is male?
inches for females 8 inches for male and 4
4. During the insertion of the urinary catheter, the nurse instructs the client to?
or strain as if voiding
Deep breath
5. To ease insertion of the catheter into a male client, the nurse should hold the penis how many Degrees against the body? Perpendicular or 90 6. As the urine begins to flow, how many inch should the nurse further insert the tube before Inflating the balloon? 1-2 inches 7. In male clients, where should the nurse tape the catheter?
penoscrotal pressure Leg or abdomen to prevent
8. Where should the nurse secure the urinary drainage bag? Bed frame 9. What type of catheter is preferred for clients with BPH? coude 10. In removing the indwelling catheter, the nurse should instruct the client to INHALE or EXHALE? exhale
Elimination : Fecal
Assessing the normal stool 1. Color brown, ab: clay,white,black,tarry,red,pale,orange,green 2. Odor pungent, malansa blood/infection 3. Amount 100-400g 4. Consistency formed,semiformed,moist,soft constipated, diarrhea 5. Shape cylindrical with thick diameter 6. Frequency 1 to 2 times a day
Enema
Types of Enema
CBQ on Enema Types

solutions introduced in the rectum
1. How long does a retention enema is retained to obtain the desired softening effect? 1-3 hours 2. A type of enema used to relieve excessive flatus is? Carminative and harris flush 3. The amount of fluid that is use in a high cleansing enema is?
A. Retention Enema
1. Carminative Enema expel flatus 2. Oil Enema 1-3 hours retention to soften and lubricate
B. Non Retention
4. Mang Roberto is scheduled for a diagnostic examination, fluoroscopy of the urinary tract. He will receive what 1. Cleansing Enema [HIGH/LOW] left-dr-right kind of enema the morning before the A. Hypertonic sodiumphosphate procedure?
B. Hypotonic tap water C. Isotonic nss D. Soap 20ml castile soap 1000cc of water
5. Cleansing enema are retained for how many minutes? 5-10 minutes held how many inches above the rectum? 12 inches
2. Return Flow / Harris Flush 500cc , 5-6 times, 20 minutes to complete to expel flatus 6. For most enemas, the enema can is
Enema : The procedure

1. What is the preferred position in giving an enema? Left sims , left lateral 2. In giving an enema, the nurse uses which technique? Medical or Surgical asepsis? 7. If the client experiences cramping and pain, what should the nurse do? Clamp for 30 seconds 8. How will the nurse know that sufficient fluid is already administered to the client? urge to defecate
3. How long will the nurse insert the tube?3-4 9. How long will the client retain the fluid if this is a cleansing enema? 5-10 minutes 4. In any case that the nurse encounter any resistance in inserting the tube, What should the nurse do? Take a deep breath,
persist? Report to the nurse in charge
10. After the retention time, The nurse will assist a client to defecate in the toilet. What should be the nurses important instruction in a client who will defecate in the toilet? 11. In administering an enema to an incontinent client, what should the nurse do to help the client retain the solution? Press the buttocks together
5. During tube insertion, to relax the anal sphincter, the nurse will ask the client to? Inhale or Exhale?
6. In a high cleansing enema, how high should the nurse hold the enema can?
Ostomies
Definition of Terms
opening in the abdominal wall for elimnation of feces or urine
1. Gastrostomy to the stomach 2. Jejunostomy to the jejunum 3. Ileostomy 4. Colostomy 5. Ureterostomy 6. Ileal Conduit 7. Stoma Classification by 1. Permanence 2. Anatomic location
Ostomies
Assessing the Stoma

1. Color 2. Stoma size and shape 3. Stomal Bleeding 4. Peristomal skin 5. Type of feces
Changing ostomy appliance

1. When are pouches emptied? 1/3 to 1/2 2. When is the best time to perform ostomy appliance change? Not be close to meal or visiting
hours, drainage is least likely to occur
8. In cleaning the stoma, the nurse should use what? 9. What paste is used as an adhesive to attach the face plate and the appliance properly? 10. What is the normal color of the stoma?
3. Where is the best place to change the clients appliance? bathroom
4. What is the preferable position in 11. How frequent should the nurse change the changing the clients stoma? Lying,sitting,standing pouch? [Disposable 1 week, reusable, twice a week]
facilitate smoother pouch application avoid wrinkles
5. What Aseptic technique is used in this procedure? 6. If the area around the site is hairy, the nurse should clip or shave the hair? shave 7. Before removing the appliance, what should the nurse do first to its content? Empty
the content with its bottom opening into the bedpan, prevent spillage into the skin. assess
Colostomy Irrigation
1. What is the main purpose of Colostomy irrigation? 2. How frequent should the patient irrigate? 4. When is the best time to perform colostomy irrigation?
3. How much and what type of fluid is used during colostomy irrigation?
4. Where is the irrigation performed? 5. If cramping is felt during irrigation, you would instruct the client to? 6. How long is an irrigation performed? 7. If the client experience difficulty in inserting the tube, what should you instruct the client?
MODULE REVIEW
1. The physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should:
A. take the specimen to the laboratory immediately. B. apply a solution to the stool specimen. C. collect the specimen in a sterile container. D. store the specimen on ice.
Rationale: The nurse should collect the stool specimen using sterile technique and a sterile stool container. The stool may be collected
for 3 consecutive days; no follow-up care is needed. Although a stool culture should be taken to the laboratory as soon as possible, it need not be delivered immediately (unlike stool being examined for ova and parasites). Applying a solution to a stool specimen would contaminate it; this procedure is done when testing stool for occul t blood, not organisms. The nurse shouldn't store a stool culture on ice because the abrupt temperature change could kill the organisms.
2. A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this client's stools to be: A. coffee-ground-like. B. clay-colored. C. black and tarry. D. Bright Red
MODULE REVIEW
3. A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of:
A. increasing fluid intake to prevent dehydration. B. wearing an appliance pouch only at bedtime. C. consuming a low-protein, high-fiber diet. D. taking only enteric-coated medications. 4. The nurse must administer an enema to an adult client. The appropriate depth for inserting an enema into an average-sized adult is: A. 1" to 2". B. 4" to 6". C. 3" to 4". D. 6" to 8".
MODULE REVIEW
5. The nurse is teaching a client how to irrigate his stoma. Which action indicates that the client needs more teaching?
A. Hanging the irrigation bag 24" to 36" (60 to 90 cm) above the stoma B. Filling the irrigation bag with 500 to 1,000 ml of lukewarm water C. Stopping irrigation for cramps and clamping the tubing until cramps pass D. Washing hands with soap and water when finished
6. The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:
A. destroys the odor-proof seal. B. won't affect the colostomy system. C. is appropriate for relieving the gas in a colostomy system. D. destroys the moisture-barrier seal.
MODULE REVIEW
7. A colostomy can BEST be defined as: a. cutting the colon and bringing the proximal end through the abdominal wall b. creating a stomal orifice from the ileum c. excising a section of the colon and doing an end-to-end anastomosis d. removing the rectum and suturing the colon to the anus. 8. When an abdominoperineal resection is done, the patient should be informed he/she will have a;
a. temporary colostomy b. permanent colostomy
c. transverse loop colostomy d. double-barreled
9. A colostomy patient who wishes to avoid flatulence should not eat the following EXCEPT: a. corn and peanuts b. cabbage and asparagus c. mangoes and pineapples d. chewing gum and carbonated beverages
MODULE REVIEW
10. Maria is administering a cleansing enema to a patient with fecal impaction. Before administering the enema, she should place the patient in which of the following positions? a. on the right side of the body with the head of the bed elevated 45 degrees b. left Sims position c. on the left side of the body with the head of the bed elevated 45 degree d. right Sims position 11. On the second day following abdominoperineal resection, you anticipate that the colostomy stoma will appear: a. moist, pink, with flushed skin and painful when touched b. moist, red and raised above the skin surface c. dry, pale pink and with flushed skin d. dry, purple and depressed below the skin surface
MOBILITY
11. Flexion
Mobility
Definition of terms 1. 2. 3.
ability to move
12. Extension 13. Hyperextension
Line of gravity imaginary

vertical line drawn through an obj center of gravity
14. Abduction 15. Adduction 16. Rotation movement of the bone around
its central axis
Center of gravity point

in which all of the mass of a person is centered ant upp prt of sacrum
Base of support the

foundation
4.
5. 6.
Body mechanics
efficient coordinated and safe use of the body to produce motion and maintain balance
17. Circumduction distal part

move in circle prox part remains fixed
Body Alignment
geometric arrngt
18. Eversion sole outward 19. Inversion 20. Pronation palm down 21. Supination 22. Retraction movement of the part of a
body forward
Balance state of equilibrium
7.
8. 9.
Friction
force that opposes the motion of an object as it slid across the surface
Force enrgy req to accmp movment Inertia tndency rmain rest and
motion
10.
Fulcrum fixed point where a lever

moves
23. Protraction
Principle of Body Mechanics

1. 2. 3. 4. 5. Before moving anything, how could the nurse prepare the muscle for action? An object fell to the floor. How should the nurse pick the object? What is the most efficient way of bringing a heavy object from one place to another? How can a nurse increase his lifting power? Use arms as levers How many inches is the minimum distance between the feet to provide a maximum base of support?
12
6.
7.
Which is more recommended, pulling or pushing an object?

What is Pivoting?
Complications of Immobility
I. 1. 2. 3. 4. Musculoskeletal system Disuse osteoporosis Disuse atrophy Contractures Stiffness and Joint pain
II. 1. 2. 3. 4. 5. 6. Cardiovascular System Decrease Cardiac Function Increased use of Valsalva Maneuver Orthostatic Hypotension Venous stasis Dependent Edema Thrombophlebitis
III. Respiratory System 1. 2. 3. 4. Decrease respiratory movement Pooling of secretion Atelectasis Hypostatic Pneumonia
IV. Metabolic 1. 2. 3. 4. Decreased metabolic rate Negative nitrogen balance Anorexia Negative Calcium Balance
V. 1. 2. 3. Urinary system Urinary Stasis and Retention Renal Calculi Urinary Tract Infection
VI. Gastrointestinal System 1. 2. 3. Constipation Indigestion Nausea, Vomiting and Regurgitation
VII. Integumentary System
Prevention and Treatment of Decubitus Ulcer
Air fluidized bed
Prevention and Treatment of Decubitus Ulcer
Air fluidized bed
Equipments that aids in Mobility
Protective boots
MODULE REVIEW
1. Which for the following would MOST likely cause injury to the nurse when moving the patient from bed to the wheelchair?
A. bending at the knees C. using body weight to assist with the movement B. standing with feet together D. standing with feet apart 2. Which of the following is the CORRECT guideline when positioning patients? A. put pillows above a joint to immobilize it B. position of the joint should be slightly extended C. joints of patient to be supported with pillow D. patients position should be changed at least three or four times a day
MODULE REVIEW
3. The importance of forcing fluids with an immobilized patient is to: A. prevent pneumonia B. prevent urinary stasis C. prevent skin breakdown D. maintain peristalsis
4. An electrolyte imbalance that you can see in a client who is immobile is:
A. B. Hypocalcemia Hypercalcemia C. Hypernatremia D. Hypermagnesemia
5. Which of the following can be used by clients with problem of immobility to enable them raise their body from bed to wheelchair or perform some bed exercises? A. sandbag B. trochanter roll B. side-rail D. trapeze bar
MODULE REVIEW
6. Which of the following are appropriate goals for client with positioning and mobility needs? A. developing of contractures B. proper body alignment C. sensory alterations D. decrease in activity tolerance
7. Which of the following described Inertia?
A. B. C. D.
The amount of power required to move an object The ability of an object to maintain at rest or in motion The movement of the body against a surface The coordinated and proper use of the body in performing tasks
MODULE REVIEW
8. In assessing a client with Thrombophlebitis, the nurse would record the following data as expected findings: A. The calf is swollen, red and numb to touch B. The calf is smaller than the other calf C. The calf reddened D. The calf is pale 9. One of the disadvantage of a whirlpool bath for clients with Decubitus ulcer is that: A. Patients hypothermia B. Cross contamination of the ulcer C. Patients discomfort D. Excessive manpower requirement
NURSING SKILLS : MEDICATION
Medication Orders
1. 2. 3. 4. STAT Single Order Standing Order PRN Order
Determine the types of order of the following: 1. 2. 3. 4. 5. 6. 7. 8. Acetaminophen, po q4h X 5 days Demerol, IM qid Valium, 50mg prn Brevital, 100mg hs 1 day before surgery Brevital, 50mg qhs at bedtime Morphine, 20mg IM STAT Oxytocin, 8 mU/min IV at 10:00 A.M Haloperidol, 25mg IV STAT
Medication Administration
7 Rights of drug administration Right Drug Right Dose Right Time Right Route Right Patient Right Documentation Right Approach
Correct or Incorrect Approach?
The nurse practiced strict surgical asepsis when administering a rectal suppository. The nurse validated a doctors order because it was unclear. The nurse administered an unfamiliar medication Narcotics are placed in a locked cabinet The nurse administered a drug endorsed by the previous shift
Medication Administration
Correct or Incorrect Approach? 6. 7. 8. 9. 10. The nurse, who administered potassium unincorporated prepared an incident report and then report the situation to the nurse in charge. The client is very uncooperative during medication administration. The nurse hid the drug on the clients meal observing the bioethical principle of paternalism. The nurse returned an intermediate NPH insulin because it is cloudy. The nurse Relabeled a drug because the label fell. The Nurse reads to label thrice, upon opening the cabinet, during administration and after administration of the drug.
Nursing Skills : Computation

Answer the following questions: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Convert 68 Degrees Celsius to Fahrenheit? Convert 128 Degrees Fahrenheit to Celsius? How much fluid is lost if a client has lost 1.8 Kilogram? How many cc are there in 500 ml? A client weighing 65 Kilograms weighs how much in pounds? A client weighing 100 lbs weighs how much in Kilograms? A client who is 5 foot 8 inches in height is how tall in centimeters? How many tablespoon are there in 30 teaspoons? How many cc are there in 23 teaspoons? 4 grams of nitroglycerine is an equivalent of how many grains?

11. Mr. Felipe, 36 years old is to be given 2700ml of D5LR to infuse for 18 hours starting at 8 am. At what rate should the IV fluid be flowing hourly? A. B. 100 ml per hour 210 ml per hour C. 150 ml per hour D. 190 ml per hour
12. Mr. Atienza is to receive 150 ml/hour of D5 W IV infusion for 12 hours for a total of 1800 ml. He is also losing fluid which must be replaced every 2 hours. Between 8 am and 10 am, Mr. Atienza has lost 250 ml of gastric fluid. How much fluid should he receive at 11 am? A. B. 350 ml/hour 275 ml/hour C. 400 ml/hour D. 225 ml/hour

13. Digoxin, 10mg p.o was ordered. Stock is 2.5mg/tab. How many tablets should be given? A. 5 B. 10 C. 15 D. 20
14. An Elixir of Vicks 44 was given. The desired dose is 500mg p.o. and the nurse administered 1 teaspoon of the drug. How much is the stockdose?
A. 50 mg/ml C. 200 mg/ml
B. 100 mg/ml D. 250 mg/ml
15. Order reads: Administer NSS 2L for 24 hours on an adult client. What is the drop factor? A. 20 gtt/min B. 21 gtt/min C. 22 gtt/min D. 23 gtt/min

16. The doctor ordered 1,550 cc of D5LR for a dehydrated pediatric client. The drop rate was 48 gtt/min. How long will this fluid be infused? A. 12 hours B. 16 hours C. 32 hours D. 48 hours
17. A client is scheduled for NGT Feeding. Checking the residual volume, you determined that he has 40 cc residual from the last feeding. You reinstill the 40 cc of residual volume and added the 250 cc of feeding ordered by the doctor. You then instill 60 cc of water to clear the lumen and the tube. How much will you put in the clients chart as input? A. 250 cc B. 290 cc C. 350 cc D. 310 cc
Nursing Skills : Administration of Medications

I. ORAL Most common and the route of choice. Contraindicated for clients who has vomiting, gastric and intestinal suction, unconscious client and clients with NPO orders Questions: 1. 2. 3. 4. 5. 6. 7. Is it necessary to maintain aseptic technique when administering oral medications? Can you crush oral medications? In pouring a liquid medication, how should you pour it? Away from the label or towards the label? In liquid medications, Where will you read the meniscus? Can you put all oral medication of a client into the same cup? How many times should you check the label? When giving an Elixir, how long should you instruct the client to wait before following it up with water?

7. 8. 9. 10. 11. 12. 13. 14. During administration of oral medication, the client is put in what position? What is the best way to identify the clients identity? In case that the medication has an objectionable taste, what can you do to make it more acceptable for the client? If the client states: This medication looks unfamiliar to me, it doesnt seem to look like the usual medication I am taking What should you do? If the client refuses the medication, What will you do? In young infants, how can you administer an oral liquid medication? In older infants, what is best to use in administering an oral liquid medication? Where should you direct the medication if it is liquid, to prevent the infant from gagging? Can you combine the crushed oral medication to a childs lugaw? How about the childs milk? To remove aftertaste from the medications, what should you do?
15.
16.

II. PARENTERAL The fastest route for absorption and action. Irreversible effects once injected.

II. PARENTERAL > Intradermal Questions :
1.
2. 3. 4. 5. 6. 7.
What are the common reasons why intradermal injection is used? What are the possible sites used in intradermal injections? What are the gauges used for Intradermal injections? What needle lengths are available for intradermal injections? How many degrees should you angle the syringe when giving intradermal medications? Can you massage the clients skin after injection? What do you want to see after injection?

II. PARENTERAL > Subcutaneous Questions :
1. 2. 3. 4. 5.
6. 7. 8.
What are the common reasons why SQ injection is used? What are the possible sites used in SQ injections? What are the gauges used for SQ injections? What needle lengths are available for SQ injections? How many degrees should you angle the syringe when giving SQ medications in an obese client? Can you massage the clients skin after injection? Why is it necessary to rotate injection site? In insulin administration, SQ, what is the angle of the needle?

II. PARENTERAL > Intramuscular Questions :
1. 2. 3. 4. 5. 6.
7.
What are the common reasons why IM injection is used? What are the possible sites used in IM injections? What are the gauges used for IM injections? What needle lengths are available for IM injections? How do you clean the site for IM injections? How long will you inject the solution for the muscle to accommodate it properly? If the solution is highly irritating to the subcutaneous tissues, what technique should we use?

II. PARENTERAL > Intramuscular Questions :
1. 2. 3. 4. 5.
6. 7.
What are the common reasons why IM injection is used? What are the gauges used for IM injections What needle lengths are available for IM injections? How do you clean the site for IM injections? How long will you inject the solution for the muscle to accommodate it properly? If the solution is highly irritating to the subcutaneous tissues, what technique should we use? What are the sites used in injecting intramuscularly?

II. 1. PARENTERAL > Intramuscular Sites Ventrogluteal Site

II. 2. PARENTERAL > Intramuscular Sites Dorsogluteal

II. 3. PARENTERAL > Intramuscular Sites Vastus Lateralis

II. 4. PARENTERAL > Intramuscular Sites Rectus Femoris

II. 5. PARENTERAL > Intramuscular Sites Deltoid

II. PARENTERAL > Intramuscular > Z Track
1. 2.
3. 4. 5. 6. 7. 8.
What is the rationale for a Z track technique IM injection? The nurse notices that there is a 0.2cc of air during the administration of Parenteral iron preparation by another nurse. What should she do? A 5 ml of medication is to be administered to an elderly client. Which site is best for the nurse to choose? How should the nurse inject the needle, slowly or quickly? During aspiration, what if there is a blood that appeared in a syringe? How should the nurse retract the clients skin? Traction should be maintained for how many seconds after injection? Should the nurse massage after the Z track technique?

II. PARENTERAL > Intravenous
Questions :
1. 2. 3. 4. 5. 6.
7. 8. 9.
10.
11. 12.
What are the common reasons why IV injection is used? What are the gauges used for IV injections What needle lengths are available for IV injections? What are the types of IV Fluids? What are the things to check in a solution container? To ensure that no air can enter the clients system, what should the nurse do? If the clients skin is hairy, what can the nurse do? How will you know that an IV infusion is still inside a vein? What will happen to the IV flow of a current infusion line during an IV push? If the integrity is questionable, how can the nurse maintain the patency of the IV line? How frequent should a nurse change the IV Line? What are the potential complications of IV Infusion?

II.
1. 2. 3.
PARENTERAL > Intravenous > Complications

Infiltration Fluid overload Drug overload
4.
5. 6.
Phlebitis
Air embolism Speed Shock

II.
1. 2. 3. 4. 5. 6. 7. 8.
PARENTERAL > Aspirating from a VIAL or AMPULE

What is your PRIORITY consideration when you are going to prepare a medication from an ampule or vial aside from checking the drugs name? How can you bring all the medication down to the body of the ampule? How does a nurse break an ampule? Bend it towards you or away from you? How should the nurse hold the ampule during withdrawal of the drug? How does a nurse mix a solution in a vial? What is the rationale for using a filter needle? What is the rationale for using a different needle for aspiration and injection? How much air are you going to inject in a vial when drawing a 2 cc medication from it? During injection of air into the vial, where should be the bevel? Above or below the medication? How should the nurse hold the vial during drug withdrawal?
9.
10.

QUESTION: You are to obtain 10 units of regular insulin and 10 units of NPH Insulin from a vial. How should you withdraw the medication?

II. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. PARENTERAL > Blood Transfusion What are the possible blood types that you can give to an O+ client? A unit of blood is how much in ml? What is the only fluid compatible during BT? What is the gauge of the needle use in BT? To decrease risk of bacterial growth, upon receiving the blood, it should be administered within? The maximum time of infusing a unit of blood is? How many nurse should check the compatibility of the blood? If the blood is too cold, to prevent chills, the nurse should? What is the best way to check the clients identify before transfusion? How should the nurse mix the bag?

II.
11. 12.
PARENTERAL > Blood Transfusion

To take note of adverse reactions, the nurse should run the blood slowly for how many minutes? If you noticed any adverse reaction such as itching, hives. Increase in temperature, chills, fever or flank pain, what should you do? What is the KVO rate of BT? During the first 20 minutes, you need to infuse the blood slowly are how many gtt/min? Is consent needed for blood transfusion?
13. 14. 15.

III. TOPICAL Includes irrigations, instillations, patch, powder, lotions, liniment, ointment and pastes.

III.
1. 2.
TOPICAL > Transdermal Patch

How should a nurse select the best site for applying transdermal patches? Is it necessary to wash your hand before application of a transdermal patch? Can you apply the patch on an irritated, broken skin? Can you apply the patch on the knee? Can you apply the patch to a distal part of the extremities like the forearm? In application of the transdermal patch, should a nurse wear a glove to prevent any medication on his or her hand? To prevent skin irritation due to recurrent patching, what can you suggest to the client? What are the advantages and disadvantages of a transdermal patch?
3. 4. 5.
6. 7. 8.

III. TOPICAL > Ophthalmic Instillation and Irrigation
1. 2. 3. 4. 5. Why are instillation and irrigation performed? A doctors order states : Maxitrol 2 gtts OU. The nurse will administer on what eye? If an irrigation is indicated for the clients left eye, you need to place the client on what side during irrigation? Should the nurse use MEDICAL or SURGICAL asepsis during ophthalmic medication administration? In cleaning the eye prior to instillation or irrigation, the nurse should use a cotton ball moistened with ________ and should wipe the eye from ________ to ________ canthus.

III. TOPICAL > Ophthalmic Instillation
1. 2. 3. 4. 5. What should the nurse do to the first bead of the medication of an ointment? What should you give the client before instillation? What instruction do you need to tell the client prior to giving the drops of the medication? In using a dropper, on what part of the lower conjunctival sac will you instill the medication? In using an ointment, you need to direct the the tube at the lower conjunctival sac and move from _____ to _____ canthus. After administration of the medication, the nurse would instruct the client to: How long should the client press the nasolacrimal duct?
6.
7.

III. TOPICAL > Ophthalmic Irrigation
1. 2. 3. 4. 5. 6. To limit the effects of blinking reflex during irrigation, the nurse would do what? During the irrigation of an eye, the nurse should put the client on what side? The nurse will hold the irrigator how many inch/es above the eye? How should the nurse direct the irrigation? When should the nurse stop the irrigation? After the procedure, the nurse will have to remove excess medication. How do you wipe the secretions using a cotton ball?

III. TOPICAL > Otic Instillation
1. 2. Why is otic instillation performed? Will the nurse use medical or surgical asepsis? The doctor ordered an otic instillation for the clients OD, how should you position the client? left or right side lying? The nurse should make sure that before instilling the medication, in order to prevent startling of the client, she should: How should the nurse straighten the auditory canal of an infant? Where should the nurse instill the drug? In order to assist in the flow of medication, the nurse should: How many minutes should the client remain in a sidelying position? In order to help retain the medication, the nurse would put what on the clients auditory canal meatus for 15 minutes?
3.
4. 5. 6. 7. 8.

III. TOPICAL > Otic Irrigation
1. 2. Why is otic irrigation performed? Will the nurse use medical or surgical asepsis? The doctor ordered an otic irrigation for the clients OS, how should you position the client? left or right side lying? The nurse should make sure that before irrigation, in order to prevent startling of the client, she should: How should the nurse straighten the auditory canal of a 4 year old child? Where should the nurse point the tip of the syringe? In order to help retain the medication, the nurse would put what on the clients auditory canal meatus for 15 minutes? After the procedure, the nurse should assist the client to turn on what side?
3.
4. 5. 6. 7.

III. TOPICAL > Other methods 1. 2. 3. 4. Nasal instillation Inhalation Vaginal Rectal
MODULE REVIEW
1. You are to apply a transdermal patch of nitroglycerine to your client. The following are important guidelines to observe except: Apply to hairless area of the skin not subject to too much wrinkling Patches can be applied to distal part of the extremities like the forearm Change application and site regularly to prevent irritation of the skin Wear gloves to avoid any medication on hand You will be applying eye drops to miss Romualdez. After checking all the necessary information and cleaning the affected eyelid and eyelashes, you administer the ophthalmic drops by instilling the eye drops: Directly onto the cornea Into the outer third of the lower conjunctival sac Pressing on the lacrimal duct From the inner canthus going towards the side of the eye A. B. C. D. 2.
A. B. C. D.
MODULE REVIEW
3. When applying eye ointment, the following guidelines apply except: A. B. C. D. Squeeze about 2 cm of ointment and gently close but not squeeze the eye Apply the ointment from the inner canthus going outward of the affected eye Discard the first bead of the eye ointment before application because the tube is likely to expel more than desire amount of ointment Hold the tube above the conjunctival sac, do not let tip touch the conjunctiva
4.
If you are to give 2 nasal inhalation for a client, one is a bronchodilator and the other one is a steroid, which guideline should you follow?
Administer the steroid first, this is to open the airway by lessening the edema Administer the bronchodilator first, this is to relax the bronchial muscle and dilate the airway Order is not necessary in administering nasal inhalation as long as that the nurse will wait 1 minute between administration of 2 drugs Order is not necessary in administering nasal inhalation as long as the nurse will wait 30 minutes between puffs.
A. B. C. D.
MODULE REVIEW
3. When applying eye ointment, the following guidelines apply except: A. B. C. D. Squeeze about 2 cm of ointment and gently close but not squeeze the eye Apply the ointment from the inner canthus going outward of the affected eye Discard the first bead of the eye ointment before application because the tube is likely to expel more than desire amount of ointment Hold the tube above the conjunctival sac, do not let tip touch the conjunctiva
4.
If you are to give 2 nasal inhalation for a client, one is a bronchodilator and the other one is a steroid, which guideline should you follow?
Administer the steroid first, this is to open the airway by lessening the edema Administer the bronchodilator first, this is to relax the bronchial muscle and dilate the airway Order is not necessary in administering nasal inhalation as long as that the nurse will wait 1 minute between administration of 2 drugs Order is not necessary in administering nasal inhalation as long as the nurse will wait 30 minutes between puffs.
A. B. C. D.
MODULE REVIEW
5. In giving an epinephrine injection to a client, The nurse knows that which of the following is a side effect of the drug?
A. B.
Diuresis Hypertension
C. Tachycardia D. Insomnia
6. The client is taking Methamphetamine HCl and you will look closely for which of the following side effect? A. B. Bradypnea Bradycardia C. Hypotension D. Hallucinations
7. The nurse should NOT leave medication at the bedside because: A. B. C. the bedside table is not sterile it is convenient for the nurse the nurse will not be able to accurately document that the patient actually took the medication the patient may forget to take it.
D.
MODULE REVIEW
8. Non-pharmacologic pain management includes all the following EXCEPT: A. relaxation techniques B. use of herbal medicines C. massage D. body movement 9. How many minutes should the client remain lying on his left side after an administration of rectal suppository? A. B. 1 minute 30 minutes C. 5 minutes D. 15 minutes
MODULE REVIEW
10. In teaching the mother the proper administration of tetracycline eye ointment, which of the following is MOST crucial? a. squirt a small amount on the inside of the infected eyes lower lid b. use clean, wet cloth to gently wipe away the pus c. wash hands before medication administration d. do not use other eye ointments or drops or put anything else in eyes. 11. In case WQ will experience an acute hemolytic reaction, what will be your PRIORITY intervention? A. immediately stop the blood transfusion, infuse Dextrose 5% in Water and call the physician B. stop the blood transfusion and monitor the patient closely C. immediately stop the BT, infuse NSS, call the physician, notify the blood bank D. immediately stop the BT, notify the blood bank and administer antihistamines

Fundamentals of Nursing

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Fundamentals of Nursing

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FUNDAMENTALS OF NURSING

Dervid Santos Jungco

HISTORICAL PERSPECTIVE IN NURSING

Nursing in the Philippines

Nursing in the Philippines

Nursing in the Philippines

Nursing History : I. Intuitive Period

Nursing in the near east

3. Nursing remained the duty of:

Nursing in the near east

Nursing in the near east

Nursing in the far east

Nursing in Ancient Greece

Transition From Pagan to Christianity

II. Period of apprentice nursing

Notable personages and events during the apprentice period

3. St. Elizabeth Of Hungary

4. St. Catherine of Sienna

5. St. Vincent De Paul

III. The Dark Period Of Nursing

Notable people and events during the dark period

IV. Period Of Educated Nursing

Notable people and events during the period of Educated Nursing

Dr. William Halstead

V. Period of Contemporary Nursing

HEALTH AND ILLNESS

Health and Illness

Leavell and Clarks Levels of prevention

GIVE UP THE SICK ROLE

The Modifiable Risk Factors The Non Modifiable Risk Factors

HOMEOSTASIS : STRESS AND ADAPTATION

Stress and Adaptation

Physiologic Response to Stress

B. Local Adaptation Syndrome (LAS) >

General Adaptation Syndrome

Local adaptation syndrome

Nursing Intervention for clients with inflammation:

Assessing Vital Signs

Regulation of body temperature

1. Age 2. Diurnal Variation 3. Exercise 4. Hormones 5. Stress 6. Environment

Alteration in Body Temperature

Clinical signs of Fever

Assessing Body Temperature

Assessing Body Temperature

Assessing Body Temperature

Assessing Body Temperature

Factors affecting the Pulse

1. Medulla 2. Pons A. Pneumotaxic - inhibit B. Apneustic encourage inspi 3. Baroreceptors 4. Proprioceptors

1. Exercise 2. Stress 3. Environment 4. Altitude 5. Medication

Physiology of blood pressure

Factors affecting blood pressure

Measuring the Blood Pressure

sitting position, arm flex at the heart level

2. Wrap the deflated cuff evenly around the arm Placing 1

3. Palpatory determination of the systolic BP Wait

4. Position the stethoscope appropriately Place over the

Bladder 40% of circum

Measuring the Blood Pressure

more than 10 mmHg between 2 arms

the higher blood pressure is used for subsequent

Errors in measuring blood pressure

5. When assessing a clients blood pressure, the nurse finds it necessary to

7. When taking the blood pressure, the cuff should be: