m To assist clients (sick or well) in the

performance of activities contributing to

health, it recovery or peaceful death that
the clients will perform unaided, if they had
the necessary will, strength or knowledge
m 2aregiver
m 2ommunicator
m Educator/Teacher
m 2ounselor
m Manager/2oordinator
m 2hange Agent
m Leader
m 2linician
m Advocate
m
© articipation of client in his own care
ensured
m À© rights of the client protected
m i© utonomy is safeguarded
m ש eeds of client communicated
m î© nformations related to condition is
provided
m ש urture therapeutic alliance
m © iven opinions and choices
m
©erson
m E© nvironment
m H©ealth
m N©ursing

Scope
a. Health promotion
b. Disease prevention
c. Health restoration
d. 2are of the death and suffering individuals
m îD© î want© pleasure principle
m Ego© reality, arbiter
m Superego© moral principle

î
 

À


Manic Schizo Bulimia
Antisocial O2
Narcisistic anorexia
m Joundation of Nursing
rofession
m ³DYNAMî2
m Systematic and rational
m ’

m 

  
m   
m 
     
 
m 2©ollection of data
m O© bservation of data
m V© alidation of data
m î© dentification of data

Types of data
a. Subjective
b. Objective
m T© rust
m R©apport
m U© nconditional regards
m S©et limits
m T©herapeutic communication
m 2©onfidentiality
m
©roximities
m A©ctive listening and observation
m T© ouch
m S©et limits
m
roximities
^u©
 inches (intimate)
^
© inches (personal)
^4©
 ft ( social)
^
©4u ft(public)
m Observation (senses)
m înterview© purposeful conversation
^ Jormal© highly structured, questionnaire,
limited time, yes or no
^ înformal© rapport building, free flowing,
open ended
m
hysical Assessment (î

A)
m Laand Dx result
m Records review
Total
atient 2are
© All aspect of one or more patient
care
© 2ontinuous care (endorsement)
© Shift based focus
© Does not necessitate care (same
nurse)
m Junctional nursing
^ Division of task
^ Task focused
^ Nurses are more competent for repeated
actions
^ Absence of hollistic care
m Team Nursing
^ RN¶s lead the team and other assistive
personnel
^ 2harge nurse
^ 2oordination of client¶s care plan
^ collaboration
m Limitations of Team Nursing
^ Role confusion
^ Lack of time of the team leader to
client
^ Non©continuity of care
m 2ase Management
^ 2oordinates and links health care service to
patient and family
^ Rn responsible for care from admission up to
following up of discharge
^ Group of clinicians© collaborative group who
oversees the management of case
^ 2ase©type©based care
m
rimary Nursing
^ Aim to place RN at bedside and
improves professional relationship
between staff
^ Assumes caseload of patients
^ Designed to maintain continuity of care
A nursing care that focuses on the relationship of
the nurse with her client with the same nurse
rendering care all throughout the client¶s
hospitalization.

a. Total patient care c. Team Nursing

b. Junctional Nursing d.
rimary Nursing
d.
rimary Nursing
6
 

Dorothea Orem Self care and self
care deficit
Jlorence Nightingale Environmental
Theory/Nurturing
Environment
Roy Adoptation Model
Hildegrad
eplau N
î
J


i

× 


 

 

 


 


îmogene King Goal Attainment Theory
Martha Roger Humanistic Science
Theory/Science of
Unitary Human Being
Leininger Transcultural Nursing
Watson Human 2aring Theory
î


 

×




À
  


  


  


 
 


 

× 



6


Rosemarie
arse Human Becoming
Theory
Dorothy Johnson Behavioral System
Model (7 subsystems)
Neuman Stress Adaptation Model
Myra Levine 2onservation Model





 


  


 



Lydia Hall 2ore©2are©2ure
Margareth Neuman Health as Expanding
2onsciousness Theory
Joyce Travelbee Humanistic Revolution
Theory
Ernestine Wiedenbach
rescriptive theory
(
hilosophy,
urpose,
practice, art)

 J 




 ×  

Abdella Watson
îmogene King Martha Roger
A. Temperature
a. 2ore temperature© deep tissue
b. Surface temperature© surface tissue

Jactors affecting heat loss

a. 2onduction© from one place to another
b. Evaporation© insensible heat loss
c. Radiation© with contact
d. 2onvection© air current
^ Sites
½ A. Rectal© most accurate
© © mins, 2î to quadriplegic client
½ B. Tympanic© quickest
½ 2. Oral© most accessible
½ D. Axillary© safest and non invasive
Types of fever

. întermittent© fever with periods of normal and
subnormal temp
. Remittent© fluctuations for about  degrees 2elsius
but with no area where temp is normal
. Relapsing© fever for few days
© days normal
temperature
4. 2onstant© constantly high
B. Respiration© medulla oblongata

©ucpm© eupnea
>u© tachypnea
<
© bradypnea
u© apnea
Rhytym

. 2heyne©stoke© waxing and waning
© very deep©very shallow©apnea
© îrreversible shock
^. Kussmaul¶s© DKA, deep
labored breathing
^. Biot¶s respiration© very shallow
apnea

.
ulse© wave of contractions
produced by left ventricle
î. Guidelines
a.
sychological preparation
b.
hysical preparation (empty the
bladder)
c. Environment
d. equipment
e.
ositioning
Registered Nurse
a. Maintain proper body mechanics
b. Widen base of support
c. Bend knees
d. Do no bend your back
e. Avoid stretching/reaching
f. Maintain Good body alignment
m J. Abdomen (îA
e
a)
m G. if female (
y/o)+male md+female RN
(witness)
î. înspection ± use of Sight
îî.
alpation© touch
î. Light/superficial© press the area lightly (circles)
îî. Deep/bimanual© Direct hand©palpate, NDH©
support the organ or mass

oints: a. Light first before deep
b. Wilm¶s tumor, appendicitis, abdominal
aneurysm
îîî.
ercussion© striking or tapping of body parts
m Direct© frontal sinus, direct
m îndirect© pleximeter (middle finger of
NDH), plexor (middle finger of DH)
m Blunt© Use of percussion hammer, Deep
tendon reflex
m Listening to body sounds produced by the body

m Types
^ a. Direct© use of unaided ear
^ îndirect© use of stethoscope
m 2olor
^Yellow
^Bluish
^Redness
Note: Asses for burns
m Strawberry Tongue
m Red Beefy tongue
m Black hairy tongue

Ears
© Weber© equal laterization of sound
© Rhine
m A©ortic© nd intercostal space @ right sternal
boarder
m
© ulmonic© nd î2S left sternal boarder
m Erb¶s point© rd ics left sternal boarder
m T©ricuspid© 4th ics left sternal boarder
m M©itral© pmi, 4th©th ics midclavicular line left side
m G2S
m Reflexes
m Superficial© cremasteric reflex
© Babinski (+)
u months©
cerebral palsy
 One of the responsibilities of Mr. 2yrile,RN, an
industrial nurse, is to conduct physical head to
toe assessment, he took the vital signs. Which
of the four assessment techniques did he
utilize?
m Auscultation .
alpation
m
ercussion 4. înspection
^
,, c.
,
^ ,4 d.
,,4
d.
,,4
m 6i× iÀ

À
i6î× Ô

 




  

 
 

. Handwashing
. Gloves
. Goggles
4. Gowns
.
atient©care equipment
. Environmental control
7. Linen
. Occupational health and
bloodborne pathogens
9.
atient placement

u. Respiratory hygiene


. Safe injection practices
 î 

   
D©ash with soap and running
water
À©eport without delay
i©ssess the source

©ost Exposure
rophylaxis
(
E
) in
to  hours
m
. Lumbar puncture practices
i



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m Àî À

 î



m À
 
m ’ ’  

m  À 


m     !"
  À


î’#$’#’ oi

© hickenpox (Disseminated varicella)
i© nthrax
© easles

© ulmonary Tuberculosis
© ARS
À
 
 


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î’#$’#’ oÀi
© RSA
À© otavirus and RSV
© cabies
i© bscess or wounds with uncontained drainage
À
 
 



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 &  
&  '&
* *  
’
 ’ 

î’#$’#’ All respiratory infections except
RSV o À

6î
© iphtheria (pseudomembrane)
À© ubella (German measles)
© ral pharyngitis

© ertussis/
neumonia
© egionnaire¶s disease

© rythema infectiosum (Jifth disease)
6© onsillitis
î© nfluenza
© carlet fever
© eningitis
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 2rowds: flu and colds
 Jresh flowers, vegetables and fruits: molds and
fungi
 Live immunizations: (O
V, MMR, B2G, Varicella
vaccines)
 Stagnant water: Legionnaire¶s disease/

neumonia

ets with ticks: Scabies
 Bird droppings: Histoplasmosis
 Raw meat, potted plants, fish tanks, cat litter box
and gardening: Toxoplasmosis
m
atient¶s Bill of Rights
^ Reflects acknowledgement of a client¶s
right to participate in her of his health
with an emphasis in client autonomy
^ Morality© behavior (customs, traditions)
^ Values (beliefs and attitudes©decision
making)

 

 

Autonomy Self determination
Nonmaleficence 2ause no harm
Beneficence Duty to maintain do
good to others
Justice Equitable distribution of
benefits and tasks
(according to care)
Veracity truth
Jidelity Duty to do what one has
promised
m According to the code of ethics, which of the
following is the primary responsibility of the
nurse?
a. Assist towards peaceful death
b.
reservation of health at all cost
c. Health is a fundamental right
d.
romotion of health prevention of illness, alleviation of
suffering and restoration of health
c. Health is a fundamental right
m R©escue© remove all
clients in the vicinity
m A©larm© Activate fire
alarm
m 2© onfine© close all doors
and windows
m E© xtinguish© fire
extinguisher
m
© pull the pin
m A© im at the base of fire
m S©queeze the handles
m S© weep the fire from side to
side
6

  
J

A Wood,cloth,
upholstery,paper,
rubbish,plastic
B Jlammable liquids or
gases, grease, tar,
oil©based paint
2 Electrical equipment
Nursing considerations

. No smoking
. Don not use wool blanket/metal objects

Treatment Modality
a. High O delivery
a. Venturi mask© 2O
D/2AL
b. încubator, o hood©pedia
b. Low o delivery

. Nasal cannula© 4u©u
. Simple Jace mask© u©u
.
artial rebreather mask© u©9u
4. Non rebreather mask©9u©9


 

înfants Jrench ©
2hildren Jrench ©
u
Adults Jrench
©

2onscious with gag reflex©semifowler¶s with head
on one side (oral),Neck hyperextended (nasal)

Dyspnea, drooling of saliva, low abg and BS

  


 
’  


 


 

 

 
mAmbuBAG (
uu
oxygen)
m
arts
^ înner 2annula
^ Outer 2annula
^ Obturator
m
osition (insertion) Jowler¶s
m Time: © minutes each
suction
^ ©
u seconds suction
m Tube destruction
^ DOB
^ Noisy
^ Dificulty in suctioning (insertion)
^ Thick,dry secretions
^ Mech vent (increased peak
pressure)
m Assist in coughing and deep breathing
m
rovide humidification and suctioning
m 2lean inner cannula regularly
m The physician repositions or replaces the tube
m Secure the tube in place
m înstructional policy
m Jirst 7 hours nurse manually ventilates while the
other call resuscitation team
m After 7 hours extend the neck and open the
tissue of the stoma
m Grasp retention sutures
m Use a dilator
m
repare to insert
m Ventilate
Note: do not deflate
m2ough
mOral Hygiene
mJeeding
m NEX
m High fowler¶s neck hyperextended
m STO
(2YANOTî2 and 2OUGH)
m
LA2EMENT
A©spirate gastric secretions
 

 
 ! """
m J!

m î


m Appendicitis: Any position if unruptured, and semi
fowler if ruptured.
m Asthma: Sitting position, leaning forward, to
promote patient breathing
m Autonomic dysreflexia: High fowler. ît will prevent
patient from hypertension stroke.
m Bronchoscopy: Semi Jowler, to prevent aspiration
after procedure.
m 2ast: elevate extremity to prevent edema.
m 2ataract surgery: Semi fowler to prevent edema at
the operative site.
m 2erebral aneurysm: Semi fowler to promote
venous drainage and decrease î2

m 2left lip: Supine after operation, prevent pressure

on the suture line.
m 2left palate:
rone/side lying position for drainage
of mucus and/or blood.
m încreased întracranial
ressure (î2
): Elevate
head of the bed.
m Mastectomy: Elevate the extremity of the affected
side (on pillow) to prevent lymphedema.
m Radium implant in the cervix: Jlat to prevent
dislodge of the implant.
m Shock: Modified trendelenburg to promote venous
return.
m Spinal cord injury: îmmobilize the patient
Which of the following is the correct guideline
when positioning patients?
a.
ut pillows above the joint to immobilize it
b.
osition of the joints should be slightly extended
c. Joints of the patients are to be supported with pillows
d.
atients position should be changed at least three or
four times a day
. /


  
 
'

 &

&

2lient¶s approval to have his/her body touched by
specific individual
m Admission Agreement
m Blood transfusion
m Surgical 2onsent
m Research 2onsent
m Special 2onsents (restraints, photographing the
patient, disposal of body parts, donating
organs,autopsy)
m
hysical©restrict client movement through the
application of a device
m 2hemical© medications given to inhibit a specific
behavior or movement
m Behavioral management, medical standard care
standard (
 hours with procedure)
m jacket© confused and sedated in bed
m Belt© transporting
m Mittens or hand© scratch and injure oneself
m Limb© immobilize the limb for one hour
m Elbow infants and small children
m Mummy© blanket around the body, blood
extraction
^ 4 hours, pad bony prominences
m
hysician¶s order
m Specific time frame
m Not
RN
m Give reason
m Safe knot (quick release)
m Neurovascular,circulatory (qumins)
m Remove (qhours)
m The following can be alternative to restraints,
except;
a. The nurses places large plants or furniture as barriers
or division on patient¶s room
b. Two nurses in pairs act as buddies to watch out
agitated patients
c. Nurse offers warm beverages, soft lights, and back
rub
d.
lace television set to distract attention
m d.
lace television set to distract attention
m 2leansing enema
m 2arminative Enema© flatus
m Retension/Emollient enema© oil or
antibiotic
m Medicated Enema
 

înfant
 catheter
2hildren
4 to
 catheter
Adult  to  catheter

i 
înfant u©
uml
2hildren u©u ml
Adolescent uu©uu ml
Adult 7u©
uuuml
m Solution
 inches in height
m însertion ©4 inches in adult, ©,

m Encourgae to hold the solution (©
u mins for
cleansing, u mins for retention)
m
osition: left lateral sims with right knee flexed
m NEVER (A

ENDî2îTîS,ABDOMîNAL
AîN<
NAUSEA AND VOMîTTîNG)
i  6 "

Autonomic dysreflexia catheter
2hest Tube Drainage Extra
bottle/clamp/forcep/vase
linized gauze
2VA Suctioning equipment
2holinergic crisis Tracheostomy/et
DVT Tape measure

  6 


6
Hydrocephalus Tape measure
LTB Tracheostmoy
Myasthenic 2risis Et

arkinson¶s Suction apparatus

disease

îH
added mouth
gage
À 
  

  
#


Sengstaken© Scissors
blakemore tube
Spinal cord injury Tracheostomy
Thyroidectomy Tracheostomy
Tonsillectomy Jlashlight
Tracheostomy tube Obturator, hemostat
Wired jaw Wire cutter
m Oral
m SL
m SQ©tubercullin©heparin, rotate site
m îM
^ Vastus lateralis© 7 months and below
^ Ventrogluteal
^ Dorsogluteal© yo below
^ Deltoid©hep b for adult
^ Z track©seal off
a. Right patient
b. Right medication© label twice, generic name always,
check handbook
Anticoagulant
!
  D  

TT (4u©7u seconds)
T
u©
4 seconds

rotamine SO4 Vitamin K

SE: Bleeding (
R)
Aspirin (2î), green leafy
c. Right frequency
d.Right rate (don¶t eat don¶t chew don¶t
swallow© SL,Buccal)
e. Right dose
f. Right approach
g. Right to refuse
h. Right for education
i. Right documentation
À6
î
i






îD /© / ©7


SQ /©  © 4 

îM
/©
/ 2© 4© 9u ©


A© ©
4
The nurse prepares an îîM injection for an adult
client using Z©track. 4 ml of the medication is to
be administered to the client. Which of the
following site will you choose?
a. Deltoid
b. Rectus Jemoris
c. Ventrogluteal
d. Vastus Lateralis
. 0
 
în infants
year old and below, which of the
following is the site of choice for intramuscular
injection.

a. Deltoid
b. Rectus Jemoris
c. Ventrogluteal
d. Vastus Lateralis
. 0

* 

The rationale in giving medication via Z track is
a. ît decreases leakage of discolouring and irritating
medication into the subcutaneous tissue
b. ît allows a faster absorption of the medication
c. The Z track technique prevent irritation of the muscle
d. ît is more convenient
a. îT decreases leakage of discolouring and
irritating medication into the subcutaneous
tissue
m Allen¶s Test
m
h© 7.©7.4
m
2O© ©4 mmHg
m H2O© © meq/L
m în a client in the health care clinic, arterial blood
gas analysis gives the following esluts:
H 7.4,

2O mmhg H2O 4 meq/L. the nurse
interprets that the client has:
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
'. À

  



m Urination© micturition,voiding
^
oyluria
^ Anuria, oliguria

^ Medications that can cause retention

½ Anticcholinergic,antispamodic (papaverine,atrophine)
½ Antidepressant, antipsychotic (MAO)
½ Antihypertensive (hydralazine, methyldopa)
½ Beta blockers
½ Opiods hydrocodone (vicodine)
m 4 hours urine collection (composition)

Nursing consideration
a. Early in the morning
a. All voided specimen must be saved except
first urine voided
b.
roper labeling date and time started
c. Send specimen immediately to the lab
(Refrigirate)
m 2lean catch/mid stream
^ îdentify causative agent of UTî
^ Jirst urine voided
^ Midstream urine saved
½
roper labeling
½ Send to lab (umins)
m Mr. Ai,  y/o, complains of a burning sensation
on urination and a sense of urgency. A urine
specimen is to be collected. Which of the
following is the most appropriate way of
collecting the specimen?
a. 2atheterization
b. Voiding into clean urinal from where sample urine is to
be collected
c. clean catch urine collection
d. 4 hour urine collection
.   1  


m Normal saline
m Gauge

m 2lose monitoring for Bt reaction
m încrease circulatory blood
volume
m încrease o capacity of blood
m
RB2, whole blood© blood volume (4 hours)
m JJ
expland blood volume (u mins)
m
latelets© bleeding
m 2lotting factor and cryo precipitate
m
roper refrigiration
m 2rossmatching
m
repare equipments aseptically
m KVO
m 2lose observation  mins, after
 mines, vs qu
m Acute hemolytic reaction© chills,fever,
^ H©emolytic reaction© lower back pain
^ A©llergic reaction© plasma protein
^
©yrogenic© fever
^ 2©irculatory overload©fast blood administration
^ H©yperkalemia© hemolysis,coagultae
^ A©ir embolism
^ S©eptic reaction© contaminated blood
m S©top
m
©ulse check V/S
m î©nfuse NSS
m N©otify
m During the blood transfusion, the patient
manifest tachycardia, istended neck vein and
increase 2V
reading, the nurse should;

a. Obtain VS
b. încrease the rate of infusion
c. Stop the infusion
d. Decrease the rate of infusion
. ’
  



J


Supine Dorsal
recumbment
©9 ©4
înject ©
u ml înject ©
uml
Lower Abdomen înner thigh
Urine bag (bed Bed frame
frame)
m After îV
a renal stone was confirmed, a left
nephrectomy was done. Her post operative order
includes ³daily urine specimen to be sent to the
laboratory . Mark has a foley catheter attached to a
urinary drainage system. How will you collect the urine
specimen?

a. Empty a sample of urine from the collecting bag into the

specimen container
b. Disconnect the drainage tube from the indwelling catheter
and allow the urine to flow from the catheter into the
specimen container
c. Remove urine from the drainage tube with sterile needle
and empty urine from the syringe into the specimen
container
d. Disconnect the drainage from the collecting bag then allow
the urine to flow from the catheter into the specimen
container
#
 
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m
osition
^ M©Left lateral position with legs
flexed
½
rostate© standing position,
bending on the table
J© Dorsal recumbment position and
hips externally rotates
m Dependent measure
m 2upping© (popping sound,
© mins, ©
minutes,tenaciuos secretion
m Vibration© flat against chest wall,exhalation
m
ostural drainage©
u©
 minutes, ©4x a day, ©
hours after meals
m încrease OJî
m Admnister adjunct therapy
^ mucolytic drug
^ Expectorant
^ Bronchodilators
½ S©ympathomimetic
½ A© minophylline
½ X© anthine

½ 2ontraindicated
½ R©ib fracture
½ A©ctive tb
½
© regnant
m
osturalDrainage
^
osition and location
½Apical© high fowler¶s, sitting
½
osterior© sidelying, pillow
under chest wall
½Lower trendelenberg
m
revents lung collapse
m împroves pulmonary vetilation
m Upright,sitting
m Hold breath for © seconds
2losed 2ontinuous irrigation
^ To maintain patent urinary catheter and
tubing
Open îrrigation© free blockage
©way foley catheter©

st drainage© bloody©pink©removed after 
days©voids 4© days
m 2lamp for 4 hours
m Release after u minutes
m Assess for pain and bladder
distension
m Skin
^ Jirst line of defense

© înflammatory response© nd line of defense

© îmmune response© rd line of defense

TY
ES of wound
a. According to purpose
b. According to depth
c. According to contamination
m A. înflammatory phase© immediately
after injury © days
m B.
roliferative phase© ©4 days up to

days
½ © collagen deposition
m 2. Maturation© day 
up to
© years
m Red© wound in early regeneration
^Gentle wound care
^Alcohol free barrier
^Jill dead space©
hyrodgel,tegaderm© liquify
necrotic tissue and hydration
m S© ensory© decrease sensation and mental status
m M©oisture© fecal and urinary incontinence
m A©ctivity© excessive heat
m M©obility© excessive heat
m N©utrition© decrease tissues,hyponatremia,edema,
low vitamin c and zinc
m J©riction
m î. Ampula©redness,
non blanchable
erythema
m îî. B©lister
m îîî. 2©rater© full
thickness
involvement
m îV. D©ischarges© foul
smelling
m
atient Kulas, 7u years old is bedridden, upon
bed bath reveals a cm pressure ulcer that is
characterized by a liquid to semi liquid slough
with purulent discharge. According to the RYB
color code, a guide for wound care. What color
classification is it
a. Red
b. Yellow
c. Black
d. Blue
'. 2
&
m Sublavian, intrajugular
m îndications:
^ Severe malnutrition
^ Severe burns
^ Bowel disease
^ ARJ
^ Hepatic failure
^ înfection control
m 2omplication
^însertion© pneumothorax,
hemothorax
^înfusion© air embolism©valsalva
maneuver,
infection,hyperglycemia
A nurse is caring for a group of adult clients on an
acute crae in the unit. As a nurse you
understand that which of the following clients
would be the least likely candidate for parenteral
nutrition?
a.  year©old client with extensive burns
b . A 4 year©old client who has had an open
cholecystectomy
c. A 7 year©old client with severe exacerbation of
chron¶s disease
d. A  year©old client with persistent nausea and
vomiting from chemotherapy
' . $ 34 ,
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m A client receiving T
N complains of headache. A
nurse notes that the client has an increased
blood pressure, bounding pulse, jugular vein
distension, and crackles bilaterally. The nurse
interprets that the client is experiencing which
complication of T
N?
a. Sepsis
b. Air embolism
c. Hypervolemia
d. Hyperglycemia
c. Hypervolemia
m A client with T
N infusing has disconnected the
tubing from the central line catheter. A nurse
assesses the client and suspects air embolism. The
nurse should immediately place the client

a. On the left side, with the head lower than the feet
b. On the left side, with the head higher than the feet
c. On the right side, with the head lower than the feet
d. On the right side, with the head higher than the feet
.   
 &  
&  

m Temporary
m
ermanent© non functioning rectum or anus, colon
2A, Bowel 2A
 
î


2olon îleum
Large bowel Small bowel
Semi solid fecal Wet fecal material
material Ostomy appliance
With irrigation Meticulous skin
care
m Red to pink
m
ale© decrease vascularization
m
urple© impede circulation
m Normal© red to pink
^ No burning sensation
^ moist
m A© fluid
m T© Mushy
m D© Mucoid
m S© Solid
m The nurse is teaching a client how to irrigate his
stoma, which indicates that the client needs
more teaching?
a. Washing hands with soap and water when finished
b. Stopping irrigation for cramps and clamping the tubing
until cramps pass
c. Jilling the irrigation bag with uu to
uuu ml of
lukewarm water
d. Hanging the irrigation bag 4 to  (u©9u cm)
above the stoma
.   
 ' 431 
%51 56,!6 
'
 


m The client ask the nurse, when is the best time
to perform irrigation, is during

a. Early morning, before meals

b. Early morning, before meals upon arising
c. Early morning, after meals
d. Early morning
m . # 
  

m i  

$


m  

  

m chambers
^2ollection
^Water sealed
½Jlactuation (upon expiration)
½Rise and Jall
½întermittent bubbling
(respiration)
m Suction2ontrolled
^ u cm water
^ 2ontinuous bubbling



  J 

Disconnected 2over with 2over
from patient any cleanest opening with
material sterile
possible gauze/vaselin
ized gauze
Disconnected însert tip in a 2lamp the
from 2TT glass of tube farthest
sterile NSS from the
patient
m Upon assessment of patient Julio, the nurse
noticed that he is breathing a little more effort
and at a faster rate. The client¶s pulse is also
increased. Which of the following actions should
the nurse implement?
a. 2heck the tubing to ensure that there is no kink and
patient is not lying on it
b. încrease the suction
c. Lower the drainage bottles © feet below the level of
the client¶s chest
d. Ensure that the tube has two clamps in it to prevent
air leaks
m .   ' 

   


   

 
 
m You are assigned to patient Julio who has a
water seal drainage system and you noted that
the fluid in the chest tube and water seal column
has stopped fluctuating. Which is the
explanation?
a. The lung has fully expanded
b. The lung has collapsed
c. The chest tube is in the pleural space
d. The mediastinal space has decreased
.   
 7
m N
O for  hours and until
gag reflex returns
m Expect sore throat
m Observe respiratory
difficulties
Jollowing a bronchoscopy, which of the following
complains by Ryan should be noted?

a. Nausea and vomiting

b. Shortness of breath and laryngeal stridor
c. Blood tinged sputum while coughing
d. Sore throat and hoarseness
d. Sore throat and hoarseness

iÀi
×6
î 6!Ài
×6

 î
Semi©fowlers Sitting over
bedside table
Empty bladder Local Anesthesia
2heck VS >
L at a time
(B
,RR,Temp) within u mins
Right after thoracentesis, which of the following
is the most appropriate nursing intervention?
a. înstruct the patient not to cough or deep breath for
two hours
b. Observe for symptoms of tightness of chest or
bleeding
c.
lace an ice pack on puncture site
d. Remove dressing to check for bleeding.
b. Observe for symptoms of tightness of chest or bleeding
Thoracentesis may be performed for cytologic
study of pleural fluid. As a nurse your most
important function during the procedure is:
a. Keep the sterile equipment from contamination
b. Assist the physician
c. Open and close the three way stop cock
d. Observe the patient¶s vital signs
. '
  8



À


 

 
Monitor Urine Lie flat on affected
output, puncture side (head
site elevated u deg u
minutes)
Measure 2heck leak of fluid
Abdominal girth
m 2rutches
A.înitial position
B. u degrees flexed
2. Weight© crutch paralysis
D. 2rutch tips
2anes
© 9
cm, standard, quad cane
© Rubber tip
©
ermit elbow to flex
© Hold cane on the stronger side of the body
© Side of the foot
cm and
 cm in front
m Walkers
^ Jour legs with rubber tips
^  point gait,  point gait© walker

cm ahead
m 2rutches
^
atient supine position and the nurse measures from the
anterior fold of the axilla and adds . cm
^ .© cm below the axilla or three finger folds
^ Elbow flexion u degrees
^ Gaits
½ Jour point
½ Three point
½ Two point
½ Swing to gait
½ Swing through
m A client being measured for crutches asks the
nurse why the crutches cannot rest underneath
the arm for extra support. The nurse¶s response
is based on the following understanding that this
will result it:

a. A fall and injury

b. înjury to the brachial plexus nerves
c. Skin breakdown in the area of the axilla
d. împaired range of motion while the client
ambulates
b. înjury to the brachial plexus nerves
m A nurse has given a client instructions about
crutch safety. The nurse determines that the
client needs reinforcement of information if the
client states:
a. That he or she will not use someone else¶s crutches
b. The crutch tips will not slip even when wet
c. The need to have spare crutches and tips will be
available
d. The crutch tips should be inspected periodically for
wear
b. The crutch tips will not slip even when
wet


   6

Allergy test

D, TB test
îD, no red ink Determine tb
exposure,dormant/active TB
©
u mm iduration
>
u mm
HîV© mm

Evaluate after u minutes Evaluate after 4© 7 hours

Antibiotic© 7 day treatment
m Hypoxemia
m 9©
uu

Sites:

. Jingers <ring,middle, index>
. Nose
. Earlobe
4. Jorehand
. Toes

arts
a.  leads
b.
hotodetector

Nursing 2onsideration

. 2over probe with towel from external sourse
. Remove nail polish
m i i
mOperative consent
WHO?? Obtains:surgeon
Witness: Nurse
Secure
Give: patient
a. conscious
b. legal age
c. sound mind
emergency: doctor
WHAT??© name/age/sex
© diagnosis
© procedure
© benefits and risks
© alternative
© signature
WHEN?? Major/minor
anesthesia
invasive procedure (body cavity)
radiologic procedure and dye
 zones
a. unrestricted© unsterile, street clothes
b. semirestricted© scrub shoes, OR suit, and cap
c. restricted© + mask
a. Gown
b. Gloves
c. Drapes
d. Accidental puncture
e. When in doubt throw it out
f.
repare sterile field closest in time
g. Movement©sterile to sterile,unsterile to unterile
i



© responsible for
decisions to make
©Respondeat superior© let
the master answer the
situation
© res ipsa liquitor© let the
damage speak for itself
© extension doctrine©
consent from s.o.
B. Assistant to the surgeon(intern/MD/surgeon)
2. Anesthesiologist (MD/Nurse Anes)© LO2,îO,Blood
loss, O Saturation, VS
D. 2irculatory Nurse© Setup or
© Skin prep
© Ensures sterility of the team
E. Scrub Nurse© sets up the field
© Assist in draping the patient
© Handles sterile equipments
© sponge count
© after care
m 2ounting
^ înitial© manufacturer
^ Baseline© set up
^ 2losing© first closing© peritoneum, final© skin
m înduced state of
partial/total loss of
sensation, with or
without loss of
consciousness
 
  i 
 




  





General + + + (RR) +
Local X + Localized X
Regional
Epidural X + + X
Spinal X + + (output X
below l©l)
2onscious X + + +
sedation
î. Onset/înduction© time anest is induced, loss of
consciousness
îî. Delirium/Excitement© loss of consciousness,
muscles relaxation,breathing pattern
îîî. Operative/Surgical© generalized muscle
relaxation and dep vs
îV. Danger/Recovery© cardiac and respiratory
arrest, pupils fixed and dilated
© încreased loc© wearing out from patient¶s body
m Safety© side rails
m Airway patency© suctioning or intubation
m 2
R (danger)
m Recovery (Safety)
m SîGN îN BEJORE îNDU2TîON OJ ANESTHESîA

©aitent confirmed
A©irway/aspiration risk
A©llergy
A©nesthesia safety checklist
S©ite marked
m TîME OUT© before incision
S©terility observed
î©ntroduce OR team
î©maging displayed
A©ntibiotics given for the last u mins
m SîGN OUT© transfer
R©ecord name of the procedure
î© nstrument, sponge,sharp count complete
S©pecimen
E©ndorse equipment problem
m
A2U/RR
a. Name of surgeon/procedure
m B. Evalutae with anes,VS, îO,hemodynamic status
m 2. Evaluate contraption
m D. Supine with head on the side
m E. Once conscious orient
m î. VS©Q
©
hour
½ © qumin©  hours
½ ©q
hour© 4 hours
½ ©4 hours© shift
½ ©qmins© critical

îî. Respiratory system© airway patency

©rr, pattern and depth
rr©
©ucpm
<
cpm© drug induced respiratory depression
>
 cpm© pain,metabloic rate
m îîî. 2ardio© rate, rhythm, grade, pulse
½ Absent© o
½ Weak© +

½ Normal© +
½ Strong© +
½ Bounding© +4

½ SHO2K© pulse deficit, apical and radial pulse

½
. decrease circulating blood volume
½ . possible obstruction
½ 2omplcation©DVT/Thrombophlebitis
m Thrombolytics© destroy clots©KîNASE (T
A)
m Anticougulants heparin (
TT©u  secs© effective
4u©7 seconds), warfarin
T (9.©
.
seconds x

.©)

m îV. Neuro©LO2, order of return of sense

Touch

ain
Warmth
2old
Movement
m V. Renal© UO©u©ucc/hour, skin turgor
m Vî. Gî© N
O© clear liquid©soft©DAT
^
. positive gag reflex
^ . bowel sound© ©u seconds
^ . passage of flatus
½ (©,, abdominal distension, N/v© paralytic
ileus)©bowel resection
m Vîî. întegumentary© incision site
^ Drainage,redness,sweeling pain, purulent
discharge© infection
^ Separtion of suture line, drainage© dehiscence
^
rotrusion of Abdominal 2ontents©
evisceration© sterile water, low fowler¶s with
knees bend
m A©ctivity u©
©
m R©espiration© u©
©
m 2irculation u©
©
m 2©onsciousness u©
©
m O saturation
^ 9©
uu © capillary test
^ ABG© u©
uu
^ Allen¶s test© collateral circulation©impede ulnar artery
 

  i  

 



Hypercalcemia
hosphate
Hypermagnesemia 2alcium Gluconate

HyperK Kayexelate
Metabolic Acidosis Na Bicarbonate
Angina NTG
2hole,
ancreatitis Demerol
î  
  

2hron¶s Disease, U. Steroids
2ollitis
Diabetes însipidus Vasopressin
Heparin
rotamine Sulfate
Warfarin Vit K
Lead Toxicity EDTA
Digoxin Toxicity Digibind
î2
Mannitol
2holinergic 2risis Atrophine Sulfate
Hyperthyroidism Synthroid
6    
  

Syphilis
enicillin
Rheumatoid Arthritis Aspirin

arkinson Levodopa
Alcoholism Disulfiram
Withdrawal from Alcohol Librium
Withdrawal from Opiods Narcan/Naloxone
UTî
yridium
Megaloblastic Anemia Vit b
/2yanocobalamin
Anemia rt ESRD E
OGEN
× 


× 
Muscle Spasticity Baclofen
Acetaminophen Acetylcystein
Malaria Quinines
Jilariasis Hetrazan
Diptheria
enicillin
Scabies Benzyl Benzoate
Gonorrhea 2eftriaxone
Toxoplasmosis Sulfanamide
înduction of Labor Oxytocin




  6
 

Jetal Lung Maturity Steroids
BT reaxtion Epinephrine
Anaphylactic Shock Ephinephrine
Antipsychotic for Elderly Haldol
Manic Episodes Lithium
Thyroid Storm Lugol¶s Solution
h.
ylori Metronidazole
Status Asthmaticus Epinephrine
Mestinon Athropine Sulfate
 
6
 
2HJ Digoxin
2hicken
ox Zovirax/Acyclovir