New one from learningext.com

for the week of 05.23.05 A ten year-old client is recovering from a splenectomy following a traumatic injury. The child's laboratory results show a low hemoglobin and hematocrit. Which of these assigned actions would the nurse do first? 1. Maintain a high protein diet 2. Encourage bed activities and games 3. Plan nursing care around lengthy rest periods 4. Promote a diet rich in iron

Study Guide

Does anyone have a MedSurg study guide I can run through the copy machine?

N4-Test Successful IV Starts

This article has a lot of good advice and pictures for starting IV's and perfecting techniques.
http://www.nursingcenter.com/library/journalarticle.asp?article_id=582116
Answers are in the comments.

1.
To become truly proficient in venipuncture techniques, you must
a. attend instructional classes.
b. perform many procedures on real patients.
c. practice on anatomic training arms.
d. work with clinical preceptors.

2.
You should perform venipunctures initially on patients who
a. have chronic diseases.
b. are well hydrated.
c. have a history of many courses of infusion therapy.
d. are dehydrated.

3.
The maximum number of unsuccessful venipuncture attempts before calling a more skilled practitioner for help is
a. two.
b. three.
c. four.
d. five.

4.
Assess a patient for an MLC or PICC if I.V. therapy is likely to continue beyond
a. 3 days.
b. 4 days.
c. 5 days.
d. 6 days.

5.
Short peripheral catheters are indicated when
a. therapy lasts more than 7 days.
b. fluids have a pH between 5 and 9.
c. fluids have an osmolarity of more than 500 mOsm/liter.
d. medications have a pH of less than 5.

6.
For venipuncture in most adults, start with veins in the
a. wrist.
b. forearm.
c. hand.
d. upper arm.

7.
When initiating peripheral I.V. access,
a. start with the most proximal site available.
b. avoid rotating from one extremity to the other.
c. start with the dominant arm.
d. avoid routine use of veins in and above the antecubital fossa.

8.
The best option for emergent I.V. access in the lower extremity is the
a. calf.
b. thigh.
c. dorsum of the foot.
d. popliteal space.

9.
Which site should you avoid for venipuncture?
a. veins above a previous I.V. infiltration
b. an extremity with an arteriovenous fistula
c. veins in the forearm
d. veins above a phlebitic area

10.
A suitable vein for venipuncture feels soft, elastic, and
a. hard.
b. engorged.
c. bumpy.
d. flat.

11.
To avoid inadvertent arterial puncture, remember that
a. veins are located deeper than arteries.
b. arterial pulsation disappears after proper tourniquet application.
c. arteries and veins lie close together in the antecubital fossa.
d. arteries are frequently damaged during venipuncture.

12.
Which intervention helps to prevent nerve damage during venipuncture?
a. Use a plunging or jabbing technique to insert the catheter.
b. Avoid venipuncture on the dorsal aspect of the wrist.
c. Immediately remove the cannula if you suspect nerve damage.
d. Perform venipuncture 1 inch above the level of the wrist.

13.
If your patient complains of tingling or numbness during venipuncture, you may have damaged a
a. nerve.
b. tendon.
c. ligament.
d. artery.

14.
Which statement about over-the-needle catheters is correct?
a. They shouldn't be used to administer vesicants.
b. Use them only for one-time bolus injections.
c. They greatly increase the risk of vein injury.
d. They're an ideal choice for hand or forearm veins.

15.
Which statement about a PICC is correct?
a. It's indicated for therapies that will last 1 to 12 months.
b. Its tip resides in the proximal portion of the upper arm.
c. It's used only for therapies with osmolarities less than 500 mOsm/liter.
d. It's used only for therapies with a pH range of 5 to 9.

16.
Which catheter size is indicated for trauma patients and those requiring large, rapid fluid volumes?
a. 22-gauge
b. 20-gauge
c. 18-gauge
d. 16-gauge

17.
Placing the patient's arm across his chest and standing on the opposite side of the bed can help you cannulate the
a. basilic vein.
b. metacarpal vein.
c. cubital vein.
d. dorsal hand veins.

18.
Which is correct about the large upper cephalic vein?
a. It's easy to visualize.
b. It can accommodate only 24- to 20-gauge catheters.
c. It should be reserved for an MLC or PICC.
d. It's easy to stabilize.

19.
Which statement is correct about cannulating a vein in the upper extremity?
a. The veins in the fingers and thumbs can support a catheter for long periods.
b. Veins in the hands require a handboard.
c. After you apply a handboard, finger mobility should be restricted.
d. The veins in the fingers allow for increased blood flow around the catheter.

20.
If you see and feel the vessel pulsating after you apply the tourniquet, you're over
a. a vein.
b. a nerve.
c. an artery.
d. a venule.

21.
The most deadly hospital-acquired infection is
a. urinary tract infection.
b. pneumonia.
c. surgical site infection.
d. bloodstream infection associated with I.V. devices.

22.
To decrease infections associated with I.V. catheters,
a. use an over-the-catheter system without an extension set.
b. use a closed catheter system.
c. use alcohol to disinfect the patient's skin.
d. use multidose vials.

23.
If your patient's vein fills poorly after tourniquet application, try
a. positioning his arm above heart level.
b. gently rubbing his arm to warm the skin.
c. having him make a tight fist during venipuncture.
d. covering his entire arm with cool compresses for 5 to 10 minutes.

24.
Which statement about tourniquet application is correct?
a. Apply the tourniquet 1 to 2 inches above the intended venipuncture site.
b. Venous distension may take longer in elderly patients.
c. Reusable multiple-patient-use tourniquets are preferred.
d. Peripheral veins in a well-hydrated patient should distend in about 2 minutes.

25.
According to the CDC, the preferred agent for preparing the venipuncture site is
a. tincture of iodine 2%.
b. chlorhexidine gluconate solution.
c. 10% povidone-iodine.
d. 70% isopropyl alcohol.

26.
Always clean visibly dirty skin with
a. soap and water.
b. an aqueous benzalkonium-like compound.
c. hexachlorophene.
d. an alcohol-based hand rub.

27.
Which statement about venipuncture site preparation is correct?
a. Shave the site if it's excessively hairy.
b. Apply 70% isopropyl alcohol after a 10% povidone-iodine prep.
c. Apply chlorhexidine solution in a back-and-forth motion.
d. Blot excess antimicrobial solution at the insertion site.

28.
Which statement about upper extremity veins is correct?
a. Keeping the vein in a taut, distended, stable position will prevent rolling.
b. Arm veins are easier to immobilize than hand veins.
c. There's less risk of nerve injury in the hand and wrist areas.
d. Arm veins are easier to cannulate because they're surrounded with less fatty tissue.

29.
Which statement about using local anesthetics in venipuncture is correct?
a. The anesthetic of choice is 1% lidocaine with epinephrine.
b. Topical anesthetic creams must be applied 15 minutes before venipuncture.
c. The intradermal anesthetic should be administered beside or below the vein.
d. The intradermal anesthetic should be administered before tourniquet application.

30.
Which insertion technique is preferred if you've injected a local anesthetic?
a. tunneling
b. approaching the vein from the top
c. inserting the cannula distal to a valve
d. approaching the vein from the side

31.
When inserting the cannula,
a. use a 50-degree angle.
b. look for blood backflow in the cannula tubing or hub.
c. insert the cannula bevel down.
d. always expect to feel a popping or giving-way sensation.

32.
If the initial insertion isn't successful,
a. remove the cannula tip from the skin and reposition it.
b. remove the cannula and insert a new one in another site.
c. reinsert the stylet into the catheter and try again.
d. reuse the catheter for a second venipuncture.

33.
When approaching a vein that's visible for a short segment,
a. insert the cannula directly over the segment.
b. avoid tunneling to reduce trauma on insertion.
c. aim for bifurcations and valves.
d. insert 1 to 2 cm below the visible segment.

34.
To cannulate a deep vein that's palpable but hard to see,
a. palpate the site again after applying the skin antiseptic.
b. use a tentative "stop and start" technique.
c. ask the patient to clench her fist as tightly as possible.
d. use anatomic landmarks to mentally locate the vein.

35.
To properly secure the catheter,
a. use clean tape, preferably from your pocket.
b. place a 1-inch-wide tape strip across the hub, making sure it covers the puncture site.
c. place a 1-inch-wide tape strip over the tubing directly on top of the tape under the hub.
d. make sure a short segment of tubing extends beyond the hand.

36.
Which statement about a transparent dressing is correct?
a. It lets you observe the insertion site.
b. It needs to be replaced routinely because it's not waterproof.
c. You apply it directly to the site while stretching it.
d. It should cover the catheter and the entire hub.

37.
When preparing to remove the I.V. cannula, first
a. turn off the I.V. infusion.
b. remove all tape.
c. put on gloves.
d. moisten the transparent dressing with alcohol.

38.
To decrease excessive blood spillage,
a. leave the tourniquet on when removing the stylet.
b. release the tourniquet before removing the stylet.
c. remove the stylet before cannulating the vein.
d. use a 50-degree approach when cannulating the vein.

N5 log in

Look soon in case anything changes or gets deleted!

http://www.deltacollege.edu/emp/kippolito/password.html

User ID-mental
Password- health

There are study guide questions for the exams here. Get them now and answer them ahead of time. Look at the class projects, drugs to know, lectures, power points, and other stuff. Get an idea of how the class grades look to compare with our class's final grades.

N5 Karen Ippolito's Test Taking Helps

This was posted for the Spring 2005 class, and so could be subject to change. It should give us some idea of what to expect.

N5 – Test-Taking Skills Review Nursing 5,
Exam #1 will consist of 50 questions worth 2 points each = 100 total possible points.
The material covered in Units I and II is over 19 chapters, therefore there will be an average of 2-3 questions from each chapter.

Here are some sample questions that will familiarize you with the way that Nursing 5 test questions will look. Answer the sample questions, then scroll down to check your answers and to receive some test-taking tips:

1. A mental health system concern that was shared during both the Period of Enlightenment and the Community Mental Health Period is:
A. Moving patients out of asylums.
B. Studying brain structure and function.
C. Meeting basic human needs humanely.
D. Providing medication to control symptoms.

2. The development responsible for the greatest change in care of the mentally ill in the last half-century is:
A. Self-help groups.
B. Outpatient therapy.
C. Psychotropic drugs.
D. Patients’ rights awareness.

3. Which of the following scenarios can be assessed as demonstrating that the nurse is functioning outside the scope of psychotherapeutic management? The nurse:
A. Assesses a patient for medication side effects.
B. Administers electroconvulsive therapy.
C. Structures meaningful unit activities.
D. Encourages a patient to express feelings.

4. When a nurse administers a drug with anticholinergic properties, it is important to assess for symptoms associated with inhibition of:
A. Spinal nerve function.
B. The central nervous system.
C. The sympathetic nervous system.
D. The parasympathetic nervous system.

5. A 19-year old is admitted to the psychiatric unit following a suicide attempt. The patient receives Prozac 40 mg. qd, attends a variety of group therapies and activities during the day, and in the evening watches TV or talks to visitors. The psychotherapeutic management activity that is lacking is:
A. Adequate drug therapy.
B. Therapeutic milieu therapy.
C. Maintaining contact with significant others.
D. Significant communication with nursing staff

6. A patient who has lung cancer continues to smoke, saying, “I think my cancer is more the result of a bad gene than of smoking.” The nurse can make the assessment that the patient is using:
A. Denial.
B. Compensation.
C. Intellectualization.
D. Reaction formation.

7. A patient begins shouting at the nurse, “Stay away from me.” He is waving his arms in the air and backing into the corner of the room. The initial nursing intervention in this situation should be to:
A. Obtain an order for seclusion.
B. Administer a prn injection of haloperidol.
C. Call for assistance to physically restrain the patient.
D. Talk to the patient in a calm, nonthreatening manner.

8. The nurse who is asked to interpret the goal of psychiatric treatment within a managed care framework to a patient would state, “The goal is to:
A. Promote individual and group health.”
B. Decrease disability and prevent relapse.”
C. Identify individuals with predisposition for mental disorders.”
D. Help the individual achieve an optimal level of functioning in the least amount of time.”

9. When explaining risk assessment, the nurse would indicate that the highest priority for admission to hospital-based care is:
A. Safety of self and others.
B. Confusion and disorientation.
C. Withdrawal from harmful substances.
D. Medical illness complicating psychiatric disorder.

10 The nurse has assessed a patient as having moderately advanced Alzheimer’s
disease. The patient is too confused to be left alone and the family works during the day. A community-based referral the nurse could make would be:
A. Subacute care.
B. A group home.
C. Adult day care.
D. A clubhouse program..

11. During a one-to-one interaction with the nurse, a patient frequently looks nervously at the door. The nurse’s best response to this nonverbal cue would be:
A. “This is our time together. No one is going to interrupt us.”
B. “It looks as if you are eager to end our discussion for today.”
C. “I notice you keep looking toward the door. Is something wrong?”
D. “If you are uncomfortable in this room, we can move to someplace else.”

12. Nursing interventions for a patient exhibiting stage 3 or stage 4 anxiety will be based upon:
A. Meeting dependency needs.
B. Availability of family support.
C. The relief behaviors the patient uses.
D. The issues underlying the anxiety.

13 A patient is shouting loudly and is verbally aggressive. What judgment can the nurse make about this behavior? The behavior:
A Is acceptable if directed toward the nurse, but not another patient.
B Is not harmful and may prevent the patient from physically acting out.
C Is a major warning sign that the patient may become physically aggressive.
D Allows the patient to vent frustration and alleviate stress without hurting anyone.

14. The best outcome the nurse can expect when a psychiatric patient is placed on a psychotropic medication is that the patient will:
A. Be free of side effects.
B. Develop dependence on the drug.
C. Recover and never need the drug again.
D. Improve enough to warrant drug continuation.

15. The environmental element of milieu management with the highest priority is:
A. Clearly establishing norms and designating limits.
B. Scheduling purposeful activities throughout the day.
C. Creating an environment of psychological and physical safety.
D. Promoting a balance between patient dependence and independence.

Answers to Unit I & II sample exam questions:
1. C
2. C
3. B
4. D
5. D
6. A
7. D
8. D
9. A
10. C
11. C
12. D
13. C
14. C
15. C
Remember that the rules of test taking are:

1. Read the question at least 2 times before marking an answer. Check for words such as “but”, “except,” and “not” as these words will change the meaning of the question and guide you to the answer you are looking for.

2. Know that the qualifiers or descriptors that are in the stem of the exam question are there to lead you to the right answer. As a matter of fact, some are like blinking neon arrows that point to the right answer choice. Look at question #10. You are told that the client has “moderate” Alzheimer’s and the family works during the day. the “Moderate” word eliminates the subacute option, and the “works during the day” is the flashing neon arrow that points to the right answer – Adult Day Care.

3. Play the Sesame Street game and sing to yourself the song from that program, “Which one of these things is not like the others...” Look at your possible 4 answers and if there is one that is different and 3 that are similar in concept – then choose the different one. Look at question #6. The first three choices all restrain a patient in some way (medications are “chemical restraint”) and the fourth choice D offers us a choice to use communication. While the patient is acting irrational, he is not posing a threat so we will choose the “different” answer. Also, we know that one of our objectives is to choose the least restrictive intervention while still maintaining safety.

4. Ask your self the following questions:
a. Is there an answer that provides safety for the patient or staff? (question #9)
b. If you have four correct answers, is there one answer that covers the entire situation posed by the question? (look at question #1 and question #8 for an example of this)
c. Only deal with the information that is provided in the exam question – don’t “tell yourself a story” or in other words fill in information that is not provided by the question. See question #5 for an example of this. A student might assume that the patient has nurse contact because the question says he attends group activities – but the question does not state this. Don’t assume. The answer is D.

5. Most of the time, to do really well on an exam, you need to know your material.
Sometimes there are ways to “figure out” the right answer even if you haven’t studied, but many exam questions demand that you have a certain knowledge base about the subject. For example, questions #2, #3 (know the nurses’ scope of practice, #4 (know your drugs), #6 (know your defense mechanisms) require that you have certain factual knowledge before you can answer – so spend the time studying concepts – not just memorizing facts. Memorization may have gotten you through anatomy – but it will not serve you well in nursing where critical thinking and making the right connections lead to the right answers.

6. As you study, define every word that you don’t know. Study with a Webster’s (regular) dictionary and a Taber’s or medical dictionary at your side so that when you come upon a word that you cannot define, you can look it up. Write the definition in your text close to the new word. This is an essential practice because when you come to the test, you will not have the opportunity to look up words that are new to you. So, just look up all new words and you will have a more successful testing experience.

N5 - Calculations Exam - Heads Up

I don't want to make anyone nervous or anything, but the math shy might want to take note. This is in Karen Ippolito's N5 course description found in docushare.
Calculations Exam

A mandatory math exam will be given in this course. The exam will consist of a minimum of ten questions. The testing content will cover calculations and medications utilized in this course. The student must pass this exam with a score of 90% to pass clinical and the course. The initial exam will be given the first or second week of the course. If a student does not score 90%, it will be the responsibility of the student to remediate and schedule a repeat test, which must be completed with a score of 100%, NO LATER THAN WEEK 7 of the course. Failure of the student to schedule re-testing within the time frames or failure to score 90% on the exam will result in a clinical failure.

Nurses Are Tops

Nurses are tops .
In a recent Gallup survey ranking various professions, 79% of the participants rated nurses “high” or “very high” for honesty and ethics. In fact, nurses have ranked at or near the top of the list since being added in 1999. Who's bringing up the rear? Lawyers (18%), members of Congress (10%), advertising practitioners (10%), and car salespeople (9%).
http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=577508

Challenges of military nursing: Come on board hospital ship COMFORT

This is one of the articles that I had bookmarked to read later. It is about nursing on a navy hospital ship at the beginning of the Iraq war.
http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=541691

Book Buybacks?

There is a new nursing student who is interested in buying any books from our class. If anyone wants to sell their books, let me know.

I Watched a Movie

Last night I actually sat down and watched a movie. It was weird just sitting there, killing time and not studying.

SJDeltaRNstudents12/06

I just wanted to let everyone know that our ATI test scores are up on the ATI testing site: www.atitesting.com, just log in by using your SSN# and password is last 4 digits of SSN# to get your results, remember, we had to get above a 40.0 on the Pharmacology exam! Have a great summer!

RECOMMENDATIONS FOR STUDY THIS SUMMER FOR BEGINNING MEDICAL SURGICAL NURSING

This is from Mrs. Flanders

I recommend that you do the exercises in the STUDY GUIDE for MEDICAL SURGICAL NURSING Assessment and Management of Clinical Problems, Lewis, Heitkemper and Dirksen. If you like to read the chapters first, I recommend that you have the study guide with you as you read and complete the exercises as you go. I know sometimes you never get to the study guide because you haven’t finished reading. Use good time management as you study. The exercises help you to focus on the key points in the chapters and give you a well organized review of the subject when you are preparing for the exams. Know your pathophysiology and diagnostic studies.


Respiratory System:

Chapters 25-28 pp 152-185

Hematology:

Chapters 29-30 pp 186-201

Immunology:

Chapters 12-14 pp 59-81

Neurological System:

Chapters 54-57 pp 412-445

Genitourinary System:

Chapters 43-45 pp 323-350 (Emphasis your understanding of the normal anatomy and physiology of the renal system, e.g. glomerular filtration. Know the pertinent lab tests and how they indicate problems).

Endocrine system:

Chapters 46-48 pp 351-375 (Pay particular attention to these glands: pituitary, thyroid, parathyroid, pancreas, adrenal. Know diabetes mellitus)

Musculoskeletal System:

Chapters 60-63 pp 459-488

A Note From Mrs. Flanders

A NOTE OF THANKS


When I heard the news that I was not selected for the position, it was a very difficult time for me. Your response of support and strength made helped me through that time. I cannot thank you enough for all of your efforts in my behalf. You presented yourselves to the Board and the Administration as professionals. You stood up with dignity and pride.

I don’t know what the future holds for me. I do know that I am not giving up and I hope to be able to continue teaching. It will take some time to see what unfolds. As I so often say, it depends.

At the end of each semester I have found that I experience emotions of sadness that I am ending a close relationship with a wonderful group of people and feelings of pride and happiness as I look back over the semester and see the growth the students have made in 18 short weeks.

Each one of you has a special place in my heart. It is such a privilege to be able to assist you in your pursuit of the profession of nursing. I have the pleasure of seeing each of you achieve the “desired outcome” of moving up another level in your pursuit. I see so much talent, intelligence, and caring for the clients you serve and for one another. That first day when you are full of doubts, I am full of hope and confidence. Then gradually I see you begin to become confident. I see you bringing your unique gifts to our profession. Now you are moving on to another step and you will be challenged to grow in even bigger steps. Know that you have it in you to achieve this and give it all you have!

I will be following your progress. I want to see each one of you receive your pin and your degree.



Sonia Flanders

Well...We did it!

We made it through the first semester, 3 to go! Finals are always my least favorite day because when you finish that test... that's it. Just when you are getting comfortable with all of your classmates, it's time to say goodbye. At least we are going through this together and don't have to say goodbye, just see you later.
I also want to say thank you to everyone that posted helps and comments this semester. It was awesome and sure reduced the workload and stress. I hope that everyone keeps on contributing.
Keep watching through the summer. I will post the upcoming chapters for those who want to get ahead and the stuff we already have been through for those who want to learn it better.
It has been suggested to me that I take a nap. What a novel idea! I am thinking seriously about it.
Thanks!

Thanks for the blog info.!

Just wanted to take a minute (before my brain explodes from studying) to say THANK YOU to everyone who posted finals info. on the blog...it's been a great study tool. Special thanks to Bonnie and Debbie who I know have put a lot of time into making this blog successful. GOOD LUCK TO EVERYONE....HAVE A GREAT SUMMER!

SNA needs help for reception!

Kristine Cavanagh said...
Kristine May 26, 2:30 am I really hope that these websites can continue to be utilized for the rest of our program. I think it has been a great source of information. I know many students from N4 who are willing to give up there notes, and we can put them on here. And another thing is that I need about 4 more people to volunteer to help with the SNA tables at the reception, for selling patches, memberships, clipboards, and just guiding people in the right direction, preferabbly towards Life Uniform, since we will get 10% of there profits that day.Call me if your interested 239-2331 or 815-8603 or email kriscavan...@comcast.net, you can also contact me at those numbers if you are in need of T-shirts or sweat-shirts. Good luck to all on the FINAL

Computer Crisis !

My laptop is no longer available to me because my AC adapter is not hooking up somehow. The battery just ran out with hardly any notice, so I was not able to email tonight's lecture notes to myself to continues to post. Sorry.

Not only that , all of my lecture notes and everything else are only on that computer. BIG BUMMER!

I am now chained to a desk computer, so I will not be going to the school too early since all the of study materials (the ones that I am interested in) are on the laptop.
It figures!

So I will be studying on the blog tomorrow until 1115 am.

Kim's study question answers

What is angina?
Chest pain, exertion- exercise, emotion, eating

Pt w/ essential hypertension, what is the cause and/or symptoms?
Unknown, asymptomatic

What is a serious complication of HTN?
Cardiomyopathy, kidney failure – watch creatinine level 0.5-1.5mg/dl

**What is digoxin? Causes?
Negative chronotrop, positive inotrop

What part of the ECG makes the ventricles work?
QRS interval

What part of the ECG makes the atria work?
P wave

How does cardizem help you?
Blocks ca channels in the heart and blood vessels. It will lower BP through arteriol dilation.
* Used for Angina, HTN, and dysrhthmias

Pt. has activity intolerance r/t reduced cardiac reserve and enforced bedrest. Before you let them get up what are you going to do?
check blood work for Sed rate (erythrocyte sedimentation rate) and make sure normal.T
heir pulse should be less than 150

Sed is useful for?
Monitoring the course of inflammatory activity in rheumatic diseases

When doing pt. teaching first you want to:
assess their level of understanding

Pt. has had a splenectomy (spleen removed), what will be impaired?
Their immune system, and they will need a pneumonia and flu vaccine.

The most common adverse effect to chemo?
Nausea & vomiting

To combat the most adverse effect to chemo?
give antiemetics

ABCDE in assessing skin cancer, what do they stand for?
Assemetry, border, color, diameter, elevation

A pt. has ACS, what did they come in with?
chest pain, acute coronary syndrome, any chest pain is referred to as this

Beta-blockers- how can you tell if they are being effective?
By reducing the heart rate
Decrease the effects of norepineferine
Inhibit the sympathetic nervous system
End in ol / lol

Ace-Inhibitors
Block angiotension from being converted to renin; thus decreasing afterload, used for cardiomyopathy

If you have PVC, what electrolytes are off?
Potassium, decreased cardiac output & using more O2 due to decreased filling pressures

Why do TENS unit work?
Delivery of electric current thru electrodes connected by lead wires to a small battery operated simulator

Which would predispose your pt. to correctal cancer?
Having polyp formation

Pt. has GI bleed, what kind of diet should they have?
NPO

Pt. is having a peritoneal lavage what is contraindicated?
Having a full bladder, they need to empty their bladder

Your 70 yr. old pt. wants to get up and use bathroom. He has pain, is anemic, and weak. How are you going help him?
Get a bedpan for him to use

Real estate agent smokes a pack a day and drinks several cocktails in the evening, what is the most powerful contributor to their Coronary Artery Disease?
smoking

When assessing a HTN pt. what do they most commonly experience?
NOTHING, they are many times asymptomatic

Dietary control of HTN in addition to a sodium restriction is?
Grains 8 serve
Vegie 4.5 serve
Fruit 5 serve
Low fat / fat free foods 3 serve
Meat, poultry, fish 2 serve
Nuts, seeds, dry beans 4-5 serve/week
Fats & oils 2-3 serve
Sweets 5 serve/week
* IF IT TASTES GOOD SPIT IT OUT!! DASH DIET!

What are target organs secondary to HTN?
kidneys, KIDNEY FAILURE! Water retention - need to look at BUN and creatinine

Petechia are related to?
Aspirin products

What do you measure when client is taking heparin?
PTT or aPTT (same type of test)

What do you measure when pt. taking coumadin?
INR, PT, PTT

What do you tell a pt. eating green leafy veggies with anticoagulants?
eat same amount everyday

Vegan pt. has anemia what are some things they can eat to increase their iron?
Legumes, whole grains, wheat products – this have higher iron content

Pernicious anemia pt. that is a vegan will need?
B12 shots for the rest of their life

**Calculate MAP


A shift in the location of the PMI indicates?
enlarged heart, left sided heart failure

When talking with a pt. regarding pt. efforts to control cardiac disease you speak of?
preventative measure


Troponin why monitor?
heart failure. Additional tests include ck, ckmb, myglobin

What would you advise the client that would have the maximum amount of impact on that pts. Health of HTN?
Having a sedentary lifestyle.
Alcohol use is the 2nd best answer

What are challenges faced by 65 year old?
Some wrong answers are: managing home, developing licensure activities, and selecting a vocation

Acute Coronary Syndrome tx:
MONA, not in that order
Oxygen, Aspirin, Nitrates, Morphine

PMI location
5th intercostal, 2” left of the midline

Clubbed fingers indicates?
Inadequate oxygen to digits, prolonged O2 deficiency

CHF is
#1 admitting dx. For pts. 65 & older, readmission is mainly due to noncompliance

** Cardiomyopathy


Myocardial infarction
Death to an area of the heart, TISSUE IS TIME!!!

Distended neck veins / jugular vein distention indicates
Elevated right arterial pressure

Myocardial Infarction blood studies include
CK-creatine kinase, LDH-lactic dehydrogenase, AST-serum asparte aminotransferase (formerly SGOT)

Preload
The volume of blood in the ventricles @ end of diastole

Afterload
The peripheral resistance against which the ventricle must pump

Medication the a pt. will take to combat breast cancer
Tamoxifin
Hep A
Interferon ( page 1110), antiviral

CHF: serious complications; risk factors, causes, symptoms
Risk factors: Hypertension, CAD, MI, obesity, diabetes, hyperlipidemia

INR lab test is used for
Coumadin

Included in pain assessment tool
Pattern of pain, area of pain, intensity of pain, nature of pain

Transdermal pain relief
For a pt. that can’t tolerate PO meds
Absorbtion is slow for some of the meds

A 42 yr. old male that drinks & smokes is prone to?
Coronary Artery Disease, teach no smoking!

Male testicular exams should start at
Should start at the start of puberty

P wave
Atrial depolarization / 0.06-0.12 sec / precedes QRS-T waves

QRS wave
Ventricular depolarization / 0.04-0.12 sec / follows each p wave

T wave
Ventricular repolarization / 0.16 sec / follows each QRS wave

PR interval
Timing 0.12-0.20 / should not vary from one complex to another

QT interval

Timing varies w/ pulse rate0.31-0.38 sec @ HR of 72 beats/min – should not vary from one complex to another. Should not be more than half the preceding RR interval

RR interval
Timing varies w/ pulse rate / should be equidistant w/ slight variations on respirations

No P wave
Atrial fibrillation

Ventricles work
QRS wave

Atrials work
P wave

Your pt. has pancreatitis, why are they NPO?
To decrease pancreatic secretions

Stable angina is
Predictable

Unstable angina is
Unpredictable – occurs @ rest

What are some early signs of pulmonary edema?
Coughing, crackes, F ailure- left ventricular, O rthopnea, W heezing, L ung congestion, E mergency, R estless, S kin- cyanotic

A weight concern for a pt. w/ heart failure is?
gain of 5# in 3 days

Pt taking clonadine & thiazide
must stop meds, can’t take together

Taking beta-carotene, what theory is this
Free-radical theory

Man that is non compliant w/ heart meds #1 reason
They cause impotence

Aging & constipation
Increase activity & strengthen abd.

PVC causes
Caffeine, stimulants

Edema in legs causes
Nocturia, nocturnal dyspnea, keep pt. semi-fowlers position to sleep

Complication of a fibrinolytic
The clot-busters, check for scaps or bleeding, we don’t want this, they will become a bleeder!

Hospice
Referred by doctor, pt must accept care, 6 months to live

Lab values for prostate cancer PSA
Prostate specific antigen < 4 mcg/L
If higher than value above it’s cancer

**Increase in stress for families w/ dementia family member causes are
Lack of support


**Time limit after exposure to Hep A & B




**What to do w/ GI bleed



What to do with stomatitis
Bland diet, rinse mouth frequently normal saline lidocaine wash

Responsibility for tube feeding
Check placement, flushing, change tubing every 24 hr or manufacture guidelines = pump tubing, keep head elevated during & 30 min. after feeding

**Know basics of CPR


**Malnutrition related to CHF
ensure


How to feed pt w/ bowel resection
Advanced as tolerated diet clear-full etc.

Ischemia drug given
Cardizem, calcium channel blocker

Misc. Study Comments from Final's Eve

Preload increases in left side CHF,
After load also increases because renin release and vasoconstriction (kidneys don’t care about the heart) result is a decrease in contractility.

No hair eventually on legs with CHF - perfusion problem - 02, no hair

Bronchodilation is not a mechanism of action, whereas
activation of the beta 2 receptors which cause bronchdilation is.

Erythrocyte sedimentation rate (ESR) is ordered. An elevation will indicate something is going on, like an infection.

ACE inhibitors in early pregnancy

This question came up in the study session tonight.
Bottom line:
ACE inhibs ok for first trimester but not after.

ACE Inhibitors in Early Pregnancy
Medsafe Editorial Team

Oligohydramnios, renal failure, bony malformations and prolonged hypotension have been associated with the use of ACE inhibitors in the second and third trimesters of pregnancy.

However, recent case series suggest that teratogenicity or toxicity may not be a problem if a woman becomes pregnant while taking an ACE inhibitor.

Among a total of 93 completed pregnancies (including one twin) exposed to an ACE inhibitor during the first trimester, only one case of congenital anomaly was identified (congestive cardiomyopathy), and no cases of neonatal renal dysfunction occurred. Preterm birth, low birthweight and intrauterine growth retardation were common; possible causes were medication, more serious maternal illness and twin pregnancy. Two babies died in the perinatal period.
ACE inhibitors need not be contraindicated in women of childbearing potential, but women intending to become pregnant should switch from an ACE inhibitor in anticipation. A contraindication applies after the first trimester.

Study Guide Question #16

Geriatrics
A. Which theory of aging states that the aging process is slowed by taking nutritional supplements?
Free Radical Theory-use of anti-oxidants (food, vitamins and minerals to reduce/slow signs of aging)


B. Be able to identify behavior that indicates patients have ineffective health maintenance
Pt states that nothing will help, won't or doesn't take meds because they "won't help"; doesn't eat because it takes too much effort; is generally non-compliant with medications and life-style changes "because they won't help".
"I am too old for it too make any difference."
"Why bother, it won't help."
ETC
Also look at Table 5-15, p. 76 for ideas about assessment.

C. What nursing diagnosis is appropriate for a person who has altered hearing or sight?
Sight
Risk for (falls, inactivity, immobility)
Nutrition less than body requirements r/t inability to make food
Poss: Body image disturbance or social isolation

Hearing
Impaired (verbal communication, balance)
Risk for social isolation
Risk for falls (if balance problems)

See Table 5-9, p. 71

D. Be able to identify changes in the client's physical assessment related to aging.
TABLE 5-4, PAGE 63
This table is 3+ pages long-read it over.

E. Identify successful vs. Unsuccessful coping mechanisms according to Erik Erikson's theory for persons in the geriatric age group.
Ego integrity vs despair

People: review past and rearrange "photo album of life". This should result in sense of wholeness, purpose and a life well lived. (ego integrity) then, can accept you life as unique and can accept death as a meaningful part of life.

However----

If the life review is laden with opportunities missed or wrong directions taken, then despair happens, death is faced with anxiety.
Each person must face adjustments and reach final conflict resolution that is a product of all the previous developmental conflict resolutions.

F. The geriatric population loves to treat their constipation. Why is this a universal problem, and what can they do about it (NOT take a pill or enema)
The #1 thing is EXERCISE!

G. What issues effect caregivers of persons who are experiencing dementia or are disabled?
Lack of support is very big, leads to STRESS, overwhelming feelings of inadequacy, powerlessness and depression. (Caregiver role strain)
Also:
1. Lack of understanding of the time and energy needed for caregiving
2. Lack of information about specific tasks (i.e. Bathing, med admin)
3. Lack of respite or relief from caregiving
4. An inability to meet personal self-care needs (socialization and rest)
5. Conflict in family about decisions related to caregiving
6. Financial depletion of resources as a result of a caregiver's inability to work and the high cost of health care.
BUT
it all boils down to LACK OF SUPPORT

Niacin (Vit B) vs. Vit.B12

Bonnie - I had to run home quickly to pick up something, so I looked this up while I was there. I was thinking Niacin was for b12 deficiency - pernicious anemia, but quickly realized I was trying to make a connection that is not there. :-& (oops!)

So...
Niacin is a B vitamin. It is part of two coenzymes that aid energy metabolism.
Foods containing niacin are meat (chicken, shrimp, liver, tuna, you name it - peanut butter has almost as much as the shrimp per serving, but the other legumes have very little...and of course there is some in any fortified product - like cereal.

B12 is also part of two coenzyme, but is used in new cell synthesis, helps maintain nerve cells, reforms folate coenzyme, and helps to break down some fatty acids and amino acids. It is almost exclusively found in meats. (of course, there are also fortified products.)

Thus, vegans need to take a supplement or fortified product, like fortified soy milk.

Q14 from Final N2 study guide

Cancer
a.
Which medications would breast cancer pts take to specifically combat their disease process?
P-1369
Estrogen receptor blockers - tamoxifen (Nolvaldex) and toremifene (Fareston)
Estrogen receptors destroyer - fulvestrant (Faslodex)
Prevents estrogen production by inhibiting aromatase - fulvestrant (Faslodex), anastrozole (Arimedex), letrozole (Femara), exemestane (Aromasin), vorozole (Rizivor), aminoglutethimide (Cytadren)
b.
What nursing interventions are appropriate to manage the side effects of antineoplastics?
Small frequent plain meals
eat protein early in day
low residue diet
metoclopramide (Reglan), ondansetron (Zofran), granisetron (Kytril), dexamethazone (Decadron), aprepitant (Emend)
gum, hard candy
tables on P306-307 nursing interventions
c.
What are risk factors and when is screening appropriate for cancer?
It's in your genes (BRCA I, II) breast cancer
Environmental
Smoking
Drinking
Lifestyle
etc
Lots in the power point and notes

What does the letter in ABCD method of assessment stand for?
A asymmetry
B border
C color
D diameter

d.
Who is hospice care for?
Not for those who are still seeking a cure, but to help them with comfort through the end of life process.
Palliative Care = Comfort Care

For Su Salud Volunteers

From Julie Lang

Please come to the nursing office and pick up your certificate for six hours of community service.
Thanks Julie
954-5454
This is really a test to see if you actually do check your students emails :-)

St Joseph's ASA commercial

This is the link to the heart song from St. Joseph's ASA. Click on the Pump Song link at the top.
http://www.stjosephaspirin.com/index.jhtml

Cholesterol Quiz and More

15 questions about cholesterol, HDL, LDL, triglycerides, exercise, plaque, and atherosclerosis.
http://www.heartcenteronline.com/myheartdr/heart_q/heart_q_begin.cfm?action=popquiz&qid=2

Here is an angina quiz. 8Qs
http://www.heartcenteronline.com/myheartdr/heart_q/heart_q_begin.cfm?action=popquiz&qid=65

Here is a quiz on angioplasty and stenting. 8Qs
http://www.heartcenteronline.com/myheartdr/heart_q/heart_q_begin.cfm?action=popquiz&qid=43

Here is a quiz on heart disease. 10Qs
http://www.heartcenteronline.com/myheartdr/heart_q/heart_q_begin.cfm?action=popquiz&qid=23

Quiz on heart failure. 8Qs
http://www.heartcenteronline.com/myheartdr/heart_q/heart_q_begin.cfm?action=popquiz&qid=45

A heart-healthy diet quiz 10Qs
http://www.heartcenteronline.com/myheartdr/heart_q/heart_q_begin.cfm?action=popquiz&qid=41

Women's heart health quiz. 12Qs
http://www.heartcenteronline.com/myheartdr/heart_q/heart_q_begin.cfm?action=popquiz&qid=62

Heart disease prevention quiz. 10Qs
http://www.heartcenteronline.com/myheartdr/heart_q/heart_q_begin.cfm?action=popquiz&qid=1

Heart attack quiz. 8Qs
http://www.heartcenteronline.com/myheartdr/heart_q/heart_q_begin.cfm?action=popquiz&qid=61

Blood pressure quiz. 10Qs
http://www.heartcenteronline.com/myheartdr/heart_q/heart_q_begin.cfm?action=popquiz&qid=22

Arrhythmia Quiz. 10Qs
http://www.heartcenteronline.com/myheartdr/heart_q/heart_q_begin.cfm?action=popquiz&qid=21

More Quizes. If you learned alot from the above quizes, here is a link for more.
http://www.heartcenteronline.com/myheartdr/heart_q/index.cfm?curpage=quiz

Hypertension Study Aids

Assessment of hypertension: ELEVATED
E- xertional SOB
L- ack of activity
E- arly morning headache
V- ascular changes
A- nxiety increased
T- ired
E- pitaxis
D- iastolic pressure elevated

Complications: 4 Cs

CHF
CVA
CAD
CRF

DIET (LOW)(HIGH)
L-Na
L-Calories
L-Chloresterol
NO Caffeine

Arteriosclerosis
H- Vitamins B & C
L- Fat

Aneurisms
L-Cholesterol
L-Caloric Intake

Study Guide Question #13

Pain
a. What should be included in a pain assessment tool?

Pattern
onset and duration

Area
precise location, general area or not able to localize (hurts all over, diffuse), referred pain, radiation of pain
1) describe the site
2) point to pain
3) mark on pain map

Intensity
Pain scales: (Figure 9-7, page 140)
Numeric
Simple Descirptive
Visual

Nature
quality and characteristics

Effects on sleep, daily activities, relationships, physical activity, emotional well being
How does person express pain
Strategies used to control

See Table 9-6, p. 140

b. What is the rationale for each step in administering trandermal pain relief?
Why do you take off the old patch and wipe the area clean?
What would you check before administering pain meds via patch? (Hint: blood pressure would be one, resp another, poss pain levels)
Do you put the patch is the same place every time? Why or why not?
What would you do if your client developed itching at the site of the patch or told you they had an allergy to adhesive?
I am sure you can think of others that should be checked too.
Five rights of med admin come to mind too.

c. How do non-pharmacological therapies, including a TENS unit, work?

TENS: transcutaeous electrical nerve stimulation
delivery of an electric curent through electrodes applied to the skin surface over the painful region, a trigger points or over a peripheral nerve
Scrambles the nerve conduction so it can't conduct pain impulses

Massage:
superficial or deep
accupressure
trigger point massage

Vibration:
poss provides relief by activating mechanoreceptors in muscles

Percutaneous ENS:
stimulates deeper peripherial tissues through insertion of a needle, to which a stimulator is attached, near a large peripheral or spinal nerve. Can be surgically implanted for long term use.

Accupuncture:
insersion of needles at designated points

Heat:
moist or dry heat to skin
superficial or deep

Cold:
Moist or dry cold to skin
Icing with ice cubes
Believed to be more effective and longer lasting than heat

Exercise:
Enhances circulation and cardiovascular fitness, relieves pain through conditioning.
(Exercise is good for everything, sort of like oxygen.)

Cognitive:
Distraction
Hypnosis
Relaxation

Study Guide Question #11

Be able to identify preventable measures and positive health practices. Know what behaviors contribute to cardiac diseases.

The risk factors for Coronary Artery Disease:
Unmodifiable: age, gender, ethnicity and genetic inheritance

Modifiable: elevated serum lipids, hypertension, smoking, obesity, physical inactivity, stress in daily living, control of diabetes

Positive health practices:

Reduce cholesterol to under 200 mg/dl or triglyceride levels to less than 200 mg/dl by reducing intake of ETOH, losing weight (if obese or overweight), exercise and reduce fat in your diet.
Reduce hypertension to levels under 140/90 or lower.
QUIT SMOKING!!
EXERCISE at least 3omins/3xweek causing qerspiration and increasing your heart rate by 30-50bpm
Control diabetes.
Reduce life stressors/control anger and hostility (Type A behaviors)

In nursing ID high-risk persons by assessing:
personal/family health hx
eating habits
type of diet
level of exercise
smoking habits
ETOH ingestion
Type A behaviors
recent life-stressing events
sleeping habits
presence of anxiety/depression
place/type of work
exposure to pollutants, allergens or noxious chemicals
degree of emotional stress associated with employment

Encourage good diet, exercise, stress reduction, quitting smoking, and control of other risk factors (life-style modifications) in pts with behaviors that contribute to cardiac diseases.

Also see p. 805, Table 33-3

If anyone can think of more to add, a different or better answer please post it!! Thanks, Debbie

Q15 from the Study Guide

Ok, here is the information for Q15 - or what I could find. Some of the things I wasn't exactly sure where she was coming from with the question. Please correct me if you think I'm off track.
Again, I can send it to you in a Word Document if you prefer. Just let me know. :)

15. Gastrointestinal

a. Why is your pancreatitis client in NPO status?
To reduce pancreatic secretions (p. 1135)

b. Be able to identify the best nutritional intervention immediately post gastric surgery. When are you going to do your patient teaching for these clients? What will you do to intervene if post operative complications occur? What will you do to prevent complications?
Discharge planning and instruction should be started as soon as the immediate postoperative period is passed. Dietary instructions may be given by the dietitian and reinforced by the nursing staff. Because the stomach’s reservoir has been greatly diminished after gastric resection, the meal size must be reduced accordingly. The patient should be advised to eliminate drinking fluids with meals. Dry foods with a low-carbohydrate content and moderate protein and fat content are better tolerated initially. These dietary changes, with the incorporation of short rest periods after each meal, reduce the likelihood of dumping syndrome. Reassurance that following these dietary measures will result in cessation of these symptoms within a few months is essential to long-term compliance. (p.1141)

The most common postoperative complications from peptic ulcer surgery are (1) dumping syndrome, (2) postprandial hypoglycemia, and (3) bile reflux gastritis. (p.1040)

Postoperative care:
§ An NG tube is used to decompress the remaining portion of the stomach to decrease pressure on the suture line and to allow for resolution of edema and inflammation resulting from surgical trauma.
§ The gastric aspirate must me carefully observed for color, amount, and odor during the immediate postoperative period.
§ If the tube becomes clogged during this period, the health provider may order periodic irrigations with normal saline solution. It is essential that the NG suction is working and the tube remains patent so that accumulated gastric secretions do no put a strain on the anastomosis.
§ This can lead to distention of the remaining portion of the stomach and result in (1) rupture of the sutures, (2) leakage of gastric contents into the peritoneal cavity, (3) hemorrhage, and (4) possible abscess formation.
(p.1042-1043)

In case of dehiscence &/or evisceration: IMMEDIATELY grab a roll of gauze, lay it out over the wound, and pour normal saline over it. THEN, call for help. (per Shelba’s lecture)

c. How are you going to manage symptoms of Hepetitis in order to preserve function of the CNS, nutritional status, and skin integrity? When will the differing therapies for prevention or cure of these viral diseases work?
§ CNS is effected by elevated levels of ammonia. Administer lactulose to increase elimination of stool – the ammonia will pass with it.
§ Eat a large breakfast – increase protein intake.
§ Prevention: Vaccines – Hep A & B
§ There is no cure for Hepetitis - Medical care is supportive depending on symptoms experienced.
§ Gamma Globulin - Hep B
§ Interferon – Hep B & C
(Per Shelba’s lecure notes for GI)

d. What symptoms indicate clients experiencing cholelithiasis are developing complications?
Cholelithiasis may produce severe symptoms or none at all. The severity of symptoms depends on whether the stones are stationary or mobile and whether obstruction is present. The gall bladder spasms in response to the stone. This sometimes produces severe pain, which is termed biliary colic. The pain can be excruciating and accompanied by tachycardia, diaphoresis, and prostration. The severe pain may last up to an hour, and when it subsides there is residual tenderness in the RUQ. When total obstruction occurs, symptoms related to bile blockage are manifested – including: jaundice, foamy dark/amber urine, no urobilinogen in urine, clay-colored stools, pruritis, intolerance to fatty foods, bleeding tendencies, and steatorrhea.
Complications that occur include cholangitis, biliary cirrhosis, carcinoma, and peritonitis.
(p.1142 and box)

e. When the patient’s bladder is full, remember it is a bad idea to place a catheter in the abdominal cavity for any kind of tap!!

Registration for Fall 2005

SJDeltaRNstudents12/06

Hi All! I am looking for any volunteers to switch clinical locations with me. Unfortunately, I was the last person to register and the only spot left for me was at the location that I just completed. More specifically, I was split up from a group that I carpool with from Elk Grove. If anyone in the following group is willing to trade, I would be very grateful.

N005 8/15 - 10/14: I am looking for someone in M 9:00-1:00 & ThF 6:30-3:00 with Barnett (registration #55350) to switch to:
N005 8/15 - 10/14: M 9:00-1:00 & ThF 6:30-2:45 (look it's 15 minutes shorter!) with Ippolito (registration #17579)


N004 10/17 - 12/16: I am looking for someone in the SJMC WTh 6:30-4:30 Group (registration group #83788) to switch to:
N004 10/17 - 12/16: Dameron Hosp. WTh 6:30-4:30 Group (registration #64600)

As you can see the times are identical (and even 15 minutes shorter for N005), but it would allow our carpool to stay together and I'd love to experience a different hospital (though I must say that Dameron was very good to me - no complaints there!)

Thank you for your consideration. Please call me or email me if you are willing to trade.
Leslie Reisig
reisigfamily@frontiernet.net
916-684-7247 (home)
916-799-7247 (cell)

Q6 from Study Guide

Here is the information I collected regarding Question #6. I also posted the same information to the Google Group, so if you got that, no need to duplicate. I also have it in a Word document, so if you would like me to send it to you as an email attachment, just email me at:
shelandlucy@hotmail.com
Also, if you have anything to add, feel free to post it! :)

Lab Values
(Taken from Mosby’s “Manual of Laboratory & Diagnostic Tests”)

BNP “Brain Natriuretic Peptide” = released when ventricular diastolic pressure rises
(p.124 in last paragraph)

Closely related to ANF “Atrial Natriuretic Factor” in function. The protein is stored primarily in the ventricular myocardium. BNP levels are elevated when ventricular hypertrophy, severe hypertension, and CHF.

ESR “Erythrocyte Sedimentation Rate” (aka SED Rate) = to detect illnesses associated with acute and chronic infection, inflammation, advanced neoplasm, and tissue necrosis or infarction.

ESR is a measurement of the rate at which the RBC’s settle in saline solution or plasma over a specific time period. It is nonspecific and therefore not a diagnostic for any particular organ disease or injury.
Values:
Male: up to 15mm/hr
Female: up to 20mm/hr

Hgb “Hemoglobin” = a measure of the total amount of Hgb in the blood
(p. 276)
This test is used as a rapid indirect measurement of the RBC count. Values are slightly decreased in the elderly
Values:
Male: 14-18 g/dl
Female: 12-16g/dl
Critical values: <5.0>20g/dl

Hct “Hematocrit” = a rapid measurement of RBC count
(p.272)
This test is an indirect measurement of RBC number and volume. Values are slightly decreased in the elderly.
Values:
Male: 42%-52%
Female: 37%-47%

PT “Pro-Time”(aka INR “International Normalized Ratio”) = evaluate extrinsic system and common pathways in the clotting mechanism
(p.395-397)
The homeostasis and coagulation system is a homeostatic balance between factors encouraging clotting and the factors encouraging clot dissolution. The first reaction of the body to active bleeding is blood vessel construction. In small vessel injury this may be enough to stop bleeding. In large vessel injury, hemostasis is required to form a clot that will durably plug the hole until healing can occur.
Values:
Normal = 11.0-12.5 seconds; 85%-100%
Full anticoagulant therapy; >1.5-2.0 times control value; 20%-30%
Critical Values = >20 seconds
Full anticoagulant therapy: three times control value
INR
DVT prophylaxis 1.5-2.0
DVT 2.0-3.0
Orthopedic surgery 2.0-3.0
A-Fib related prophylaxis 2.0-3.0
PE 3.0-4.0
Prosthetic valve propylaxis 2.5-3.5

PTT “Partial Thromboplastin Time” (aka aPTT, a = “Activated”) = like the PT, assesses the intrinsic system and common pathway of clot formation, but is primarily used when the pt is taking Heparin.
(p.350)
(see PT for explanation)
Values:
aPTT: >70 seconds
PTT: >100 seconds


Troponin = to determine if pts chest pain is due to cardiac ischemia
(p. 464)
Cardiac markers for eveidence of an ischemic attack and predicting the possibility of future cardiac events.
Values:
Cardiac Troponin T <0.2>

Electrolytes:
K+ 3.5-4.5 mEq/L
Na+ 135-145 mEq/L
Ca++ 4.5-5.5 mEq/L
Mg++ 1.5-2.5 mEq/L

Study Group to practice Questions?

Is anyone interested in getting together at the college to practice questions for the final at 1500? We might dig up some questions to ask, at Richard's (after calculations test), Wed.night study group. It helps me to listen to how other people think and we can discuss what stage of the nursing process we are in. Don't forget to bring your instructor evaluation forms.

Right side? Left Side? HF Quiz

Remember:
Right side=edema in body and organs
Left side=edema in lungs
Are these Left or Right manifestations?

A-acites
B-coughing
C-dependent edema
D-distended neck veins
E-dyspnea
F-hemoptysis(cough blood)
G-hepatomegaly
H-nocturia
I-orthopnea(difficult to breathe laying down)
J-pulmonary congestion
K-S3 heart sounds
L-tachycardia
M-visceral congestion
N-peripheral congestion

Answers in comments

Q9 from study guide for N2 final

Most serious complications of untreated cardiac problems.
CHF- Renal Failure, Arrythmias, Left Ventricular Thrombus, Hepatomegaly, Pleural Effusion
Increased O2 needs anywhere, metabolic needs anywhere and/or increased vascular resistance, causes heart to work harder, wear out and fail. (African Ams. have higher incidence of and less reponse to ACE inhibs)
Risk Factors- Hypertension, Heart disease (CAD, MI), Diabetes, Age, Obesity, Habits (sedentary lifestyle, smoking) High serum cholesterol, alterations in afterload, preload, HR,CO and contractility of heart.
Precipitating Factors- Stress, arrythmias, Infections, Anemia, Thyroid disorders, Myopathies, Pregnancy, Paget's disease (of bone and breast), Nutritional deficiencies, Pulmonary diseases, Hypervolemia, Sepsis
S/Sx- (objective)BP:decreasing systolic; narrowing pulse pressure, Pulse:alternating strong-weak, increased, Respirations: crackles, Edema: dependent pitting (1+ to 4+), Liver: enlarged, tender, Neck veins: distended, CXR: cardiac enlargement, dilated pulmonary vessels, diffuse interstitial lung edema,
(subjective)SOB, paroxysmal nocturnal dyspnea(sudden breathlessness at night), orthopnea(sleeps on multiple pillows), dyspnea on exertion (climbing stairs), Apprehension, Anxiety, Irritability, Fatigue, Weakness
Remember:
Right side=edema in body and organs
Left side=edema in lungs

Hypertension- increased peripheral resistance leading to thickened arteriole walls and left ventricualr hypertrophy
Risk Factors- African American, birth control pills, overweight, smoking, stress, excess sodium intake, lack of activity
S/Sx- (objective) Systolic >140, diastolic >90, narrowed pulse pressure(subjective)There are no subjective signs for Primary (essential)-SILENT KILLER !
Secondary there are problems related to other conditions (renal, endocrine, neurogenic, pregnancy, drug induced, caffeine, ETOH, misc. and/or cardiac)-early morning headache, light headedness, tinnitis, palpitations, fatigue, insomnia, forgetfulness, irritablity, altered vision (white spots, blurring, or loss), retinal narrowing or hemorrhages, abdominal bruits, inequal pulses, nosebleeds

Angina- pathophys-coronary occlusion- cyanotic myocardium (within 10 sec)-with total occlusion contractility ceases (within several min)-depriving myocard cells of glucose-lactic acid builds-irritates nerve endings- transmit pain message to cardiac nerves and upper thoracic roots-referred pain to left shoulder and upper arm etc.
Etiology Stable- usually MI r/t atherosclerosis
Etiology Unstable- Rupture of thickened plaque, exposing thrombogenic surface
Risk Factors- Same as MI and athlerosclerosis, high serum LDL, low HDL, high triglyc, heart disease, hypertension,etc
S/Sx-
Stable-predictable,can be controlled with meds-outpatient
(objective) ST depression or elevation and/or T wave inversion during pain on EKG, restlessness, cool clammy pale skin,arrythmias (esp. vent), up or down BP, pretty much same as MI
(subjective) substernal episodic pain 5-15 min, provoked by exertion, relieved by rest and/or nitro,pain mild-severe, SOB, pressure, ache,squeezing, constrictive, heavy, choking, suffocating, sharp, tingling, poss. radiating to neck, jaw, arms, back, causes anxiety

Unstable-unpredictable,hospitalization,
(objective) same as stable
(subjective) new onset, increasing frequency, duration or severity, occurs at rest or minimal exertion, pain refractory to nitro(comes back when nitro wears off) other sympts same as stable
Interventions- assess pain first, bed rest, MONA (O2 (2 liters), ASA, Nitro, Morphine),EKG,
At home-Nitro-5 min-Nitro-5 min-Nitro-5min-911
Tests- EKG ( normal at rest), stress test, cardiac enzymes and troponins (normal),cardiac cath

A-Fib- Irritable cells in atria with multiple sites initiating electrical impulses. Results- not a complete depol, quivering atria, loss of full atrial contraction and kick,an occasional pulse makes it through the AV node and then the ventricals contract, can cause ventricular dysrhythmias(bad)
Risk factors-mural thrombi,HF, COPD, pericarditis, MI, pulmonary embolus, thyrotoxicosis, rheumatic heart disease, hypertension, mitral stenosis, atrial irritation, complications of coronary bypass or valve replacement surgery
S/Sx-
(objective)R-R irreg, pulse irreg, no discernable P waves, QRS normal(<.12)looks same upside down or right side up
(subjective) depends on the ventrical response,
Interventions- O2, anticoags, card meds (to control vent rhythym and CO), prepare for cardioversion(if needed), Instruct in use of meds as prescribed to control dysrhythmia

Instructor Evaluations

Please remember to copy the forms and write out an evaluation for our instructors for N1, N2, N3 and skills lab. It is very important for our instructors to have feedback on what works and what doesn't.

From Mrs. Flanders

Bone Marrow Drive

Mary Neville and her entire staff need a big thank you as well for a wonderfully coordinated bone marrow/blood drive.They were able to secure a grant from the Tracy Knights of Columbus so that all people who wanted to be tested for bone marrow could be tested.
The Student Nurses' Association were out in force with balloons, signs, flyers and tables as early at 7:10 AM when I went to my first class. They stayed throughout the day enlisting and informing students about bone marrow and the donation process. Not only did they gather samples but they also informed students of some biology and some humanitarian work.The Delta Blood Bank volunteers worked tirelessly with all the people who came through.
Finally, thank you to all the wonderful donors on this campus. When we speak of "family" as in "Family Fun Day," we also need to include family that comes together when there is a need. Those of you who went up to the Locke donor center know what I mean. There was a one-hour wait at some times because so many people came up to participate.
It was Olumuyiwa's birthday. That the donor drive was scheduled on his birthday was coincidental. Nevertheless, he was standing outside the exit door for the entire day. He thanked each person who donated or tried to donate on his behalf. It was a tiring day for him but he stayed throughout the entire day. The wonderful SJDC nursing staff and Student Nurses' Association made a sign that wished him a happy 22 birthday. Thank you to all who made this possible.
One very cute young lady stayed awhile to chat and complained about the needle hurting her and how she didn't like needles. She exchanged comments and banter since she claimed her dislike of needles yet she sported a lip ring. Olumuyiwa's friend asked her about the "needle" used to do the piercing. In typical college student fashion, logic was exchanged. However, her parting words were, "I hate needles and would never get a needle stuck in me again, but I'd do it for you if we match!"

From Mary Neville

Dear Delta Family,

I just wanted to take this opportunity to thank all of the people who came out and supported our Bone Marrow and Blood Drive yesterday, May 19, 2005. It was a great success, and a marvelous way for our Delta College student, Anthony Owoyomi, to celebrate his birthday.
We were able to contribute 84 bone marrow samples and 67 units of blood to this very important cause. Your support and patience, in what turned out to be a very long process, is most appreciated. Please pass on our gratitude to your students who participated.
Thank you,

Mary Neville,
Interim Director of Health Sciences

Heart Meds

Chrono(time)tropic effect - change in the heart rate - change refractory length

Dromo(running)tropic effect - change in the electrical conduction speed across the myocardium

Ino(fiber)tropic - change in the strength or contractility of the heart - cardiac glycosides - Frank-Starling law - Digoxin - Heart beat harder, slower

tropic - to influence

Sodium channel blockers - Quinidine - stabilize dysrhythmias by slowing spread of impulse conduction across the myocardium
Watch GI upset, digoxin, ekg

Potassium channel blockers - Amiodarone - stabilize dysrhythmias by prolonging duration the action potential and extending the refractory period
Watch blurred vision, light sensitivity, lung probs, GI upset, rash, digoxin, ekg


Calcium channel blockers - Verapamil are similar to beta blockers. Reduced automaticity in the SA node, slowed impulse conduction through AV node and prolonged refractory period
Watch bradycardia, digoxin, hypotension, headaches, constipation

Beta-adrenergic blockers - 'lols -propranolol - stabilize dysrhythmias by slowing heart rate and decreasing conduction velocity through AV node.
Watch hypotension, bradycardia - take pulse, dim. sex and impotence


Digoxin, (Adenosine, Ibutilide - rapid short term) are used for specific dysrhythmias, but do not act by blocking channels
Watch potassium, visual halos, GI upset, ekg

ACE inhibs - 'prils - ousts sodium and water which reduces afterload and preload by lowering blood volume and peripheral resistance
Watch cough, potassium, taste, hypotension


Diuretics - 'ides and spironolactone - reduce blood volume, edema, congestion - lowers blood pressure and workload
Watch electrolytes, hypotension, dehydration

Please add missing info, I did this real fast to start off.

Mrs. Flander's Clinical Objectives

This is her post to her group, but it is something that we all can think about.

OBJECTIVES FOR CLINICAL
NURSING 2
Week 8


You are all meeting your clinical objectives for this experience.
Before you begin clinical on Friday, I want you to take a few minutes and remember your first day in clinical at Lodi Memorial West.

Who were you that day?

What were your hopes and fears?

What skills did you have?

What thoughts and expectations did you have?

Then I want you to think forward to who you are today.

You are strong, confident, skilled, caring student nurses.

I am proud to have worked with you this semester. I have seen so much growth in each one of you. I want you to be as proud of yourselves as I am of you.

That is your assignment for clinical this week.

Study Group For N2 Final

Richard said he will go over stuff for the N2 final on Wed. It will be after a quick calc. exam. Whether you are in Pharm or not, come on out if you need help or want one last instructor sponsored study group. Class starts at 1800, the study session will probably be after 1845.

Richards Briefcase

Has anyone been able to follow the link in Richard's briefcase posted on docushare on the 17th of May? I tried, and was told that the page was inactive or something like that.

Monday Study Group

Lock 228 (or thereabouts)
With Julie Kay
1500 - 1700 hours

Pharm ATI Test

Reminder!
The Pharmacology ATI Exam will be on Monday night, 730pm. This test is for ALL N2 students.
Richard

Lecture Questions

1.I recorded the lecture and this is what I could get.
2.What is angina? Chest Pain
3.Pt. is diagnosed w/ essential HTN what is the cause? Unknown
4.Serious complication of HTN? cardiomyopathy
5.Digoxin causes a neg. chronotrope and a pos. inotrope
6.What part of the ECG makes the ventricles work? QRS
7.What part of the ECG makes the atria work? P wave
8.How does cardizem help you? Blocks ca channels in the heart and blood vessels. Lower BP through arteriol dilation. Used for Angina, HTN, and dysrhthmias
9.Pt. has activity intolerance r/t reduced cardiac reserve and enforced bedrest. Before you let them get up what r u going to do? - check blood work for Sed(erythrocyte sedimentation rate) rate and make sure its normal also their pulse should be less than 150
- Sed is useful in monitoring the course of inflammatory activity in rheumatic diseases
10. When doing pt. teaching first you want to assess their level of understanding
11. Pt. has had a splenectomy, what will be impaired? Their immune system, and they will nedd a pneumo and flu vaccine.
12. The most common adverse effect to chemo? To combat the most adverse effect to chemo? give antiemetics
13. ABCD in assessing skin cancer, what is A? Assemetry
14. A pt. has ACS, what did they come in with? chest pain.
15. B- blockers- how can you tell their effective? reduce Hr
16. If you have PVC, what electrolytes are off? potassium
17. Why do TENS unit work?Which would predispose your pt. to corectal cancer? polyp formation
18.Pt. has GI bleed, what kind of diet should they have? NPO
19.Pt. is having a peritoneal lavage what is contraindicated? A full bladder, they need to empty their bladder
20. 70y.o. pt. wants to get up and use bethroom. he has pain, anemic, and weak. How are you gonna help him? Get a bedpan.
21.realestate agent smokes a pack a day and drinks several cocktails an evening, what is the most powerful contributor to their CAD? smoking
22.When assesing a HTN pt. what do they most commonly experience? NOTHING
23. Dietary control of HTN in add. to na restriction, what else might you do?
24. B- blockers- inhibit sympathetic nervous system
25. What are target organs secondary to HTN? kidneys, need to look at BUN and creatine
26. petechia are r/t ASA products
27. What do you measure when client is taking heparin? PTT
28. What do you measure when pt. taking cumadin?
29. what do you tell a pt. eating green leafy veggies with anticoagulants? eat same amount everyday
30. vegan pt. is anemic what are some things they can eat to increase their iron? Big juicy steak or legumes and whole grains?
31. Pernicious anemia pt. will need b12 shots for the rest of their life
32. calculate MAP
33. If you cant palpate PMI in 5th ICS what does that mean? enlarged heart
34. when you talk to a pt. in efforts to control cardiac disease it is a.... preventative measure
35. troponin why monitor? for heart failure. also you can monitor ck and myglobin
36. What would you advise the client has the maximum amount of impact on health of HTN?
Sedentary lifestyle. ETOH is sec. best awnser
37. What are challenges faced by 65 y.o.? these are the wrong awsers- managing home, developing liesure activities, and selecting a vocation
38. When is interferon effective for Hep A?
39. Males should be taught about testicular self exam at what age?




16.

Test Strategies

1.
If the question asks what you should do in a situation, use the nursing process to determine which step in the process would be next.
2.
If the question asks what the client needs, use Maslow's hierarchy to determine which need to address first.
3.
If the question indicates that the client doesn't have an urgent physiologic need, focus on his safety.
4.
If the question involves communicating with a patient, use the principles of therapeutic communication.
Source: Nursing Student Success Made Incredibly Easy!, Lippincott Williams & Wilkins, 2005.

The Nursing2005 American Nursing Student eNews

This eNews email page is packed full of things that will help us. There are practice questions, Q's and A's, and info that is helpful to students. You can subscibe (free) by clicking on this link.
http://www.nursingcenter.com/login/static.asp?pageid=538737

We made an "Impact"

At least with the school newspaper, the Impact, we made the frontpage. Here is their online link.
http://www.theimpactonline.com/main.cfm?include=frontpage

Calc Qs

1.
A client admitted to the hospital with diabetic ketoacidosis is getting a continuous infusion of regular insulin. The health care provider orders an I.V. containing 1 liter of dextrose 5% in water at 150 ml/hour to be started when the client's blood glucose level reaches 250 mg/dl. The drip factor of the I.V. tubing is 15 gtt/ml. What's the drip rate for the I.V. infusion in drops per minute?__________________________________________________
2.
A health care provider prescribes heparin 25,000 units in 250 ml of normal saline solution to infuse at 600 units/hour for a client who suffered an acute myocardial infarction. After 6 hours of heparin therapy, the client's partial thromboplastin time is subtherapeutic. The provider orders an increase in the infusion to 800 units/hour. The nurse should set the infusion pump to deliver how many milliliters per hour?__________________________________________________
3.
A septic client with hypotension is being treated with dopamine hydrochloride (Inotropin). The nurse asks a colleague to double-check the dosage that the client's getting. The bag contains 400 mg of dopamine hydrochloride in 250 ml, the infusion pump is running at 23 ml/hour, and the client weighs 79.5 kg. How many micrograms per kilogram per minute is the client getting?__________________________________________________
4.
A 64-year-old client has a cerebral aneurysm. The health care provider orders hydralazine (Apresoline), 15 mg I.V., every 4 hours as needed to keep systolic blood pressure under 140 mm Hg. The label on the hydralazine vial reads "hydralazine 20 mg/ml." To administer the correct dose, how many milliliters of medication should the nurse draw up in the syringe?__________________________________________________
5.
After a retropubic prostatectomy, a client needs continuous bladder irrigation. The client has an I.V. of D5W infusing at 40 ml/hr, and a triple-lumen urinary catheter with normal saline solution infusing at 200 ml/hr. The nurse empties the urinary catheter drainage bag three times during an 8-hour period for a total of 2,780 ml. How many milliliters does the nurse calculate as urine?__________________________________________________
6.
A 3-year-old child is to get 500 ml of dextrose 5% in normal saline solution over 8 hours. At what rate (in ml/hr) should the nurse set the infusion pump?

Cholesystitis

I found this in a student nurse newsletter. I have not checked out the entire site yet.


Memory Jogger
Cholecystitis occurs most commonly in overweight women over age 40 who haven't gone through menopause. To remember risk factors associated with cholecystitis, think of the 4 Fs.
Female
Fertile
Forty
Fat
Source: NCLEX-RN Review Made Incredibly Easy! 3rd ed., Lippincott Williams & Wilkins, 2005.

Hypotension Vs Hypertension

Causes
Hypotension Hypertension
Angina Esential hypertension
MI Anemias
Pericarditis Arteriosclerosis
valve defects Polycythemia
Heart Failure
Assessment
Behavior
Anxiety Nervous
Apprehension Irritable
Dec mentality Memory
Confusion Depression
Confusion
Neurologic
No diff Dec. vib sensation
reflex change
Babinski reflex
coordination change
Head and Neck
Distend neck veins Bruits over carotid
Worried expression Distend neck veins

Study and Memory Aids

Angina: Pain pattern
Exertion = Pain;
Rest + Nitro = Relief

Angina Precipitating Factors - 3 E's
Eating
Emotion
Exertion (Exercise)

Unstable Angina
Occurs at rest

Myocardial Infarction: "INTENSE PAIN"
I schemia
N ecrotic cardiac tissue
T ightness in chest
E xtended duration
N ausea
S evere pain
E CG changes

P revent Valsalva manuever
A nxiety
I ntense
N ot relieved by rest

Heart Failure: "OVERLOAD"
O rthopnea
V entricular failure
E nlarged heart
R eported weight gain
L ungs congested
O utput decreased
A pprehension
D ependent edema

Pulmonary Edema: "FOWLERS"
F ailure- left ventricular
O rthopnea
W heezing
L ung congestion
E mergency
R estless
S kin- cyanotic

Diets- (Low) (High)

Angina Pectoris
L- Calories
L- Cholesterol
L- Fat
L- Gas-forming foods

Heart Failure
L- Sodium
Small frequent feedings

Pulmonary Edema
L- Sodium
L- Fluids

Tips on Increasing Protein

Suggestions for Increasing Protein Intake

Eggs
* Add chopped, hard-cooked eggs to salads, dressings, vegetables, casseroles, and creamed meats.
* Add extra eggs or egg whites to quiches and to pancake and French toast batter.
* Add extra egg whites to scrambled eggs and omelets.

Milk
* Use in beverages and in cooking when possible.
* Use in preparing hot cereal, soup, cocoa, and pudding.
* Add cream sauces to vegetables and other dishes.

Powdered Milk
* Add to regular milk and milk drinks such as milk shakes.
* Use in sauces, cream soups, casseroles, meat loaf, mashed potatoes, breads, muffins, puddings, and custards.

Ice Cream, Yogurt, Frozen Yogurt
* Add to cereals, fruits, gelatin desserts, and pies; blend or whip with soft or cooked fruit.
* Add to milk.

Hard or Semisoft Cheeses
* Melt on sandwiches, breads, muffins, tortillas, vegetables, eggs, or desserts such as stewed fruit or pie.
* Grate and add to soups, sauces, casseroles, meat loaf, rice, noodles, or mashed potatoes.Cottage Cheese or Ricotta
* Mix with or use to stuff fruits and vegetables.
* Add to casseroles.
* Stuff pasta such as manicotti or shells.

Meat and Fish
* Add chopped, cooked meat or fish to vegetables, salads, casseroles, and soups.
* Use in omelets, soufflés, quiches, sandwich fillings, and stuffings.

Beans or Legumes
* Cook and use dried peas, legumes, beans, and bean curd (tofu) in soups or ethnic and regional dishes. Add to casseroles, pastas, and grain dishes that also contain cheese or meat.

Peanut Butter
* Spread on sandwiches, toast, muffins, pancakes, waffles, or crackers.
* Use as dip for raw vegetables such as carrots, cauliflower, and celery.
* Spread on fresh fruits such as apples and bananas.

Nuts, Seeds, Wheat Germ, and Other Ideas
* Add to casseroles, breads, muffins, pancakes, waffles, and cookies.
* Sprinkle on fruit, cereal, ice cream, yogurt, vegetables, and salads.
* Blend herbs and cream with parsley, spinach, or basil for a pasta or vegetable sauce.

Geriatric nutrition handbook. New York: Chapman and Hall; 1998.

Test - Nutrition in Older Adults

http://www.nursingcenter.com/prodev/ce_article.asp?tid=573406

Sorry about these late posts, I didn't realize that I had them sitting in drafts.
I don't have time to post answers, but if you don't know , it shows you what you need to find out. Answers can be found in article by following link.

1.
The hypermetabolism associated with trauma and surgery typically causes which nutritional deficit?
a. protein-energy undernutrition
b. malabsorption
c. failure to thrive
d. carbohydrate deficiency

2.
Overweight in older adults
a. significantly reduces life span.
b. may help protect against injury.
c. also reduces fat-free mass.
d. reduces the need for dietary protein.

3.
An older adult's daily diet should provide approximately how many kilocalories per kilogram of body weight?
a. 20
b. 30
c. 40
d. 50

4.
No more than which percentage of the daily diet of older adults should consist of fat?
a. 20%
b. 25%
c. 30%
d. 35%

5.
Approximately how many grams per kilogram of body weight is the recommended average daily protein intake for older adults?
a. 1
b. 1.5
c. 2
d. 2.5

6.
Without any specific indications for increasing or decreasing fluid intake, older adults should drink a minimum of how much fluid per day?
a. 1,000 mL
b. 1,500 mL
c. 2,000 mL
d. 2,500 mL

7.
Many older adults who live alone--especially those in rural areas--are at risk for poor nutrition as a result of
a. more interest in eating junk food as interest in other activities declines.
b. a decreasing ability to understand nutritional requirements.
c. a preference for nonperishables such as cold cereal.
d. inadequate access to transportation for grocery shopping.

8.
The Cardiovascular Health Study Research Group has defined frailty in older adults as the presence of three of five symptoms, including
a. cognitive impairment.
b. frequent infection.
c. visual impairment.
d. slow walking speed.

9.
In Medicare-funded nursing homes, certified nursing assistants are required to
a. remain with residents who are able to feed themselves until they begin eating.
b. perform nutritional assessments of undernourished residents.
c. record the percentage of food consumed by each resident at each meal.
d. feed residents any food they leave uneaten on their meal trays.

10.
Which method can determine height in an older adult who has a significant spinal curvature?
a. balance beam scale
b. knee-height measure
c. patient self-report
d. tape-measure estimation

11.
Most experts on geriatric nutrition agree that body mass index in older adults should range from
a. 18.5 to 24.9.
b. 19.5 to 26.
c. 22 to 27.
d. 24 to 30.

12.
Which measurement of visceral protein levels can reflect a patient's nutritional status of the previous three weeks?
a. albumin
b. transferring
c. prealbumin
d. retinol-binding protein

13.
Which measure is recommended to help alleviate dry mouth in older adults?
a. offering chewing gum to patients who cannot swallow candy
b. increasing dietary intake of bulky foods
c. using spices instead of salt to flavor foods
d. lubricating lips and dentures with petroleum jelly

14.
To encourage patients to eat at mealtimes,
a. give pain medications after meals to avoid sedation.
b. serve large meals with a variety of choices.
c. encourage family members to visit at mealtimes.
d. serve meals with patients in bed to promote comfort.

15.
Which intervention is specifically recommended for optimal nutritional intake in patients who have mild dementia?
a. initiating tube feedings to supplement dietary intake
b. mimicking actions like chewing, using slightly exaggerated motions
c. preparing food in an area separate from where it is served
d. changing food from its original form as much as possible