Flashcard Set Preview
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| 1 |
How often do you bath somene?
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- Critical care- every day and freshen at night
- Long Term Care (LTC) - 1X/week
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| 2 |
What do you do if someone refuses a bath?
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- Negotiate a different time
- Different staff
- Partial bath
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| 3 |
Why do you dry thoroughly?
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To prevent excessive moisture which can increase skin break down and growth of bacteria.
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| 4 |
Do you rub the legs vigorously?
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No.
- Clots may be dislodged
- Damage to legs
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| 5 |
Things to consider when bathing someone:
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- Avoid drafts
- Use warm water
- Prevent chilling
- Soap - sproam (hypoallergenic)
- Tub/...
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| 6 |
Skin assessment:
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- Color - pallor, flush, cyanosis
- Temperature
- Texture - moisture
- Lesions - distribution...
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| 7 |
Purpose for bathing:
Client
Nurse
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Client:
- Cleanliness
- Self-esteem, wellbeing
- Circulation
- ROM
Nurse:
- Assessments...
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| 8 |
Types of baths
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1) Bed Bath:
- Complete - head to toe
- Partial - face, hands, pits, perineal (Evenings)
-...
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| 9 |
Moisturizing
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Daily
-Sween24 - For mild to moderate dry, itchy, flaky, red skin; use once a day...
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| 10 |
Products to prevent skin breakdown from moisture
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- Non-rinse cleanser
- Skin sealant
- Barrier- zinc, petrolatum and wafer barriers
- Disposable...
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| 11 |
Braden Risk Assessment Scale
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1) Sensory perception
2) Moisture
3) Activity
4) Mobility
5) Nutrition
6) Friction and...
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| 12 |
If red skin observed?
Things to consider to prevent a pressure ulcer.
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1) Prevent skin breakdown- avoid massaging it, moisturize, avoid hot water or drying out, protect...
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| 13 |
Upper urinary tract consists of:
Lower urinary tract consists of:
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1) Kidneys, ureters
2) Bladder, urethra
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| 14 |
Function of the kidneys
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1) Filtration - filters 20-25% of cardiac output per miute
2) Excretion
3) Fluid and electrolyte...
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| 15 |
Functional units of the kidneys
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Nephron
Glomerulus- inside the nephron, filtrs blood and begins urine formation
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| 16 |
Expected urine output
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ADULT:
1500-1600 ml/day (24 hours)
300-500 ml/4hours
80-120 ml/hour
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| 17 |
Act of voiding:
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- Voluntary muscle control (external sphincter), involuntary mucles of urethra, voluntary muscles...
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| 18 |
Regulation of BP
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- Renal ischemia = releases renin
- Renin = Angiotensi II
- Angiotensin II (vasoconstrictor)...
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| 19 |
Anti-Diuretic hormone (ADH)
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- Osmoreceptors in the hypothalamus- electrolytes in the blood
- Posterior pituitary triggers...
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| 20 |
Factors affecting urination:
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1) Fluid balace
2) Medications
3) Pelvic floor muscle tone
4) Diagnostic
5) Psychological...
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| 21 |
Disease conditions influencing urination:
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- Neurological impairment (paralysis)
- Benign prostatic hypertrophy
- Cognitive impairment...
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| 22 |
Disease conditions affecting renal function:
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- Prerenal - decreased blood flow to kidneys (diarrhea, vomiting, hemorrhaging, dehydration,...
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| 23 |
End stage renal disease (ESRD)
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- Severe metabolic disturbances
- Fatal if not treated
- Uremic syndrome- N wastes in bld,...
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| 24 |
Urinary tract infection (UTI)
-Causes
- Signs and symptoms
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Cause- ecoli, poor hygiene
Contributing- antibiotic use decreases normal flora, diabetes r/t...
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| 25 |
Urinary Retention
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Cause- stones, medications, anaesthetics, BPH (males)
S/S- Bloating, distended bladder,...
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| 26 |
Urinary Incontinence
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1) Functional - impaired ability to get to the BR
2) Overflow - small voids r/t retention
3)...
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| 27 |
Problems in urinary elimination (3)
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1) Urinary tract infectino (UTI)
2) Urinary retention
3) Urinary incontinence
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| 28 |
Nursing health history
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1) Nursing health history
- Pattern of Urination
- Symptoms of urinary alteration
- Factors...
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| 29 |
Physical Assessment
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2) Physical Assessment
- Skin
- Kidneys
- Bladder
- Female or Male perineum
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| 30 |
Assessment of urine
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3) Assessment of urine
- Intake and output
- Characteristics: color, clarity, odor
- Urine...
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| 31 |
Urine Testing
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4) Urine Testing
- Common urine tests- Urinalysis, Specific gravity, culture
- Blood Tests
-...
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| 32 |
Nursing Assessment of Urinary Elimination steps
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1) Health history
2) Physical Assessment
3) Assessment of urine
4) Urine testing
5) Diagnostic...
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| 33 |
Diagnostic examination
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5) Diagnostic examination
- Ultrasound
- Biopsy
- Intravenous pyelogram, Retrograde...
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| 34 |
Female position for cathetarization
Male postion for cathetarization
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Dorsal recumbant postion
Supine position
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| 35 |
Normal urinalysis values:
pH
Protein
Glucose
Ketones
Blood
Specific gravity
WBC's
Bacteria
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pH - 4.6-8.0, avg 6.0
Protein - none or up to 8mg/100ml
Glucose - None
Ketones- None
Blood-...
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| 36 |
Other nursing care required:
(3)
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1) Consent
2) Allergies
3) Pre and post procedure interventions
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| 37 |
Health education regarding urination:
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- Regular micturition- stimulation of reflex, maintenance of elimination habits and oral intake
-...
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| 38 |
Acute care of urination problems:
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- Maintain healthy habits
- Medications
- Urethral catheterization
- Alternatives to urethral...
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| 39 |
Restorative care after elimination problems:
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- Lifestyle modification
- Strengthen pelvic floor muscles
- Bladder training
- Habit retraining...
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| 40 |
Feeling of pressure of fullness
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Retention
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| 41 |
Confusion and chills
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S/S of UTI
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| 42 |
Voiding frequenly but small amounts
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Obstruction and retention
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| 43 |
Involuntary void with coughing
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Stress incontinence
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| 44 |
Polyuria occurs with what illness
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Diabetes
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| 45 |
Hemataurea
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Cancer or pyleonephritis
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| 46 |
List something that is NOT a sign of a UTI
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Acidic urine
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| 47 |
Functional incontinence
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Unable to physically reach the bathroom
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| 48 |
Normal urine output
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300-500 ml/ 4 hours
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| 49 |
Na+ excretion or retention is regulated by ?
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Aldosterone
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| 50 |
Diabetic patient with ERD, what is a life threatening effect?
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Retention of K+, effects the heart
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| 51 |
Which hormone is released when there is a decreased renal bld flow
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Renin
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| 52 |
Male with BPH has an increase risk for..?
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UTI
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| 53 |
Spasmodic flank pain is related to...?
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Renal calculus
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| 54 |
Blood drawn to assess kidney function test
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Serum creatinine
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| 55 |
During a renal biopsy a nurse monitors..?
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Decreasing BP - hemorrhage
- may look for tachycardia first
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| 56 |
Urinanalysis results reveal glucose present, ketones present , WBC's 2/low powerfield,...
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Uncontrolled diabetes- due to glucose and ketones
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| 57 |
GI tract consists of:
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Mouth
Esophagus
Stomach
Small intestine- Duodenum, jejunum, ileum
Large intestine- Ascending,...
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| 58 |
Functions of the colon
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1) Storage - unabsorbed food, 70% excreted in 72 hrs, 30% remains for a week
2) Absorption-...
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| 59 |
Functions of the GI
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1) Ingestion- food
2) Digestion - stomach
3) Absorption
4) Excretion - K+
5) Fluid and...
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| 60 |
Process of defacation:
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- Gastrocolic reflex- mass peristalsis by ingestion of food (3-4x/day)
- Movement of feces...
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| 61 |
Valsalva manoever
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Applies extra pressure while defacating.
Increases risk of aneurysm or heart attack because...
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| 62 |
Frequency of bowel elimination:
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3x a day TO 3x per week.
Less than 3x per week = constipation
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| 63 |
Factors affecting bowel elimination:
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1) Age
2) Diet - fiber increases BM, bulk forming, H2O,
3) Fluid intake
4) Physical activity-...
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| 64 |
Common bowel elimination problems:
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- Constipation - hard feces, pain
- Impaction- liquid diarrhea around it
- Diarrhea-...
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| 65 |
Constipation:
Definition
Causes
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Difficulty passing stool accompanied by excessive straining, infrequent bowel movements, not...
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| 66 |
Functional causes of constipation:
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- Medications
- Poor diet
- No exercise
- Lifestyle and bowel habits
- Environment
- Pregnancy...
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| 67 |
Anatomical causes of constipation:
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- Rectocele - pouches into vagina, weakened pelvic muscels
- Disease- cancer
- Injuries-...
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| 68 |
Causes of bowel incontinence
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- Rectal prolapse
- Acute disc problems
- Treatable diarrhea
- Fecal loading
- Weakness/...
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| 69 |
Initial management of bowel problems:
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- Bowel habits
- Diet and fluids
- Medications
- Coping strategies
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| 70 |
Acute care for bowel elimination problems:
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- Medications
- Enemas
- Fecal disimpaction
- Nasogastric tube
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| 71 |
Why do we collect specimen?
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If client has an obvious site of infection, fever of unknown origin, to determine organism's...
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| 72 |
Important considerations in specimen collection:
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- before antibiotic therapy
- Explain purpose and procedure to client
- Cleaning agents/...
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| 73 |
Fecal specimen collection
-Amount
-Conditions
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- Walnut sized or 15-30mls for liquid
- Fresh warm stool required (Stool culture and Ova &...
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| 74 |
Sterile urine specimen
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Clean port of Foley catheter with alcohol swab, remove urine with a syringe.
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| 75 |
Sputum specimen collection
-Amount
-Conditions
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- Tsp size
- Early in the morning, rinsed mouth, cough deeply, no saliva, send promptly
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| 76 |
Throat and wound specimen
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- Cotton tipped
- Avoid touching any other part of mouth/skin
- Place in a preservative medium
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| 77 |
Blood specimen
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-Taken for unexplained fever, 30 mins apart
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| 78 |
Pink topped specimen container
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Urine (pregnancy tests), feces, sputum
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| 79 |
Signs and symptoms of hypoxemia
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- Cyanosis
- Tired
- Confused, decreased LOC
- Increased respirations (tachypneic)
- Restelessness,...
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| 80 |
Why would you give Oxygen?
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- To increase O2 level and saturation
- Edema, fluid, collapsed alveoli
- Pulmonary embolus
-...
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| 81 |
Factors affecting pulse oximetry
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- Light transmision interference- pt motion, jaundice, CO, gel nails, nail polish
- Reduced...
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