2nd Semester Hesi
Enema: A regular enema needs to be placed approximately how far above the anus?
12 inches
Enema: A high enema needs to be placed approximately how far above the anus?
12 to 18 inches
What is the normal needle gauge range associated with intravenous therapies?
18-20 gauge
After the nurse has finished teaching a client about sickle cell anemia, which statement indicates that the client has a correct understanding of the condition? 1. I have abnormal platelets 2. I have abnormal hemoglobin 3. I have abnormal hematocrit 4. I have abnormal white blood cells
2
As a nasotracheal catheter is inserted to suction the airway, a patient begins to gag and says, "I feel like i'm going to throw up." What is the nurse's best response? 1. Complete the catheter insertion in 5 seconds or less 2. Remove the catheter 3. Encourage the patient to take several deep breaths to minimize the nausea 4. Stop advancing the catheter, and allow the patient to rest for several minutes
2
The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the primary health care provider? 1. Stoma is beefy red and shiny 2. Purple discoloration of the stoma 3. Skin excoriation around stoma 4. Semiformed stool noted in the ostomy pouch
2
When preparing to suction a patient's oral cavity, why would the nurse first suction a small amount of sterile water through the catheter? 1. To moisten the exterior of the plastic catheter 2. To ensure that the catheter's suction is functioning properly 3. To minimize friction as the catheter moves within the oral cavity 4. To avoid startling the patient with the sound created by the suction
2
Which action would the nurse perform when preparing to suction a patient's oropharynx? 1. Apply sterile gloves 2. Place the patient in a semi-fowler's or sitting position 3. Remove the nasal cannula 4. Flush the suction catheter with 200mL of warm tap water
2
Which technique would the nurse use to change a patient's tracheostomy ties? 1. Use a slipknot 2. Ensure that two fingers fit snugly under the tie 3. Knot the ends of the tie in the eyelets on the faceplate 4. Ask the patients to hold his or her breath while the ties are changed
2
When administering medication into the abdominal area, how far should your site be from the umbilicus?
2 inches
When administering a subcutaneous injection, you should not exceed how many mLs?
2 mL
After the initiation of a blood transfusion, how fast should you administer blood for the first 15 minutes?
2 mL/min
A colostomy should start functioning how many days after surgery?
2 to 3 days
Nutrition: What are the recommended servings for fat-free or low-fat dairy in a 2,000 calorie DASH diet?
2 to 3 servings a day
Nutrition: What are the recommended servings for fats and oils in a 2,000 calorie DASH diet?
2 to 3 servings a day
The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? 1. Redness around the pin sites 2. Pain on palpation at the pin site 3. Thick, yellow drainage from the pin sites 4. Clear, watery drainage from the pin sites
3
What would the nurse's priority in order to minimize a patient's risk for injury during oxygen therapy? 1. Advising the patient to call for assistance before getting out of bed 2. Instructing NAP to immediately correct the flow rate if the oxygen regulator is not set as prescribed 3. Observing the six rights of medication administration 4. Monitoring the patient for signs of hypoxia
3
While suctioning the nasotracheal airway, the nurse notes that a patient's pulse rate has fallen from 102 bpm to 80 bpm. What is the best course of action? 1. Encourage the patient to take several deep breaths 2. Interrupt suction to the catheter for at least 10 seconds 3. Discontinue suctioning by removing the suction catheter 4. Assess the patient's pulse oximetry reading to see if oxygenation is adequate
3
You are caring for a postoperative patient whose hematocrit and hemoglobin are low from an elevated surgical blood loss. What can you do to help determine the impact of the dropping H&H? 1. Assess capillary refill from lower extremities 2. Monitor urinary output 3. Assess postural blood pressure 4. Assess gait strength
3
Enema: A low enema needs to be placed approximately how far above the anus?
3 inches
How far should a needle be advanced beneath the skin during an intradermal injection?
3 mm
How far should the tip of the rectal tube be inserted into an adult patient?
3 to 4 inches
When assessing the Electrolyte levels of a patient, what would the normal range of potassium be?
3.5-5.0 mEq
A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? 1. Folate deficiency 2. Malabsorption of fat 3. Intestinal obstruction 4. Fluid and electrolyte imbalance
4
A client with a high cholesterol level says to the nurse, "Why can't I take a medication that will eliminate all the cholesterol in my body so it isn't a problem?" The nurse explains that some cholesterol is needed to perform which body function? 1. Blood clotting 2. Bone formation 3. Muscle contraction 4. Cellular membrane structure
4
The nurse is preparing to measure the oxygen saturation level of a patient with obesity. Which action would help ensure an adequate measurement? 1. Place the sensor on the ear 2. Place the sensor on the bridge of the nose 3. Place the sensor on a finger 4. USe a disposable tape-on sensor
4
If the SA node were to fail, the AV node can initiate and sustain a heart rate of how many beats per minute?
40-60
When should preoperative medications be given?
45-70 minutes before surgery
At what angle should a subcutaneous injection be administered/
45-90 degrees
At what angle should an Intradermal injection be administered?
5 - 15 degrees
How far should oxygen delivery systems be kept away from heat sources?
5 feet
Nutrition: What are the recommended servings for sweets in a 2,000 calorie DASH diet?
5 servings or fewer a week
Place the steps for an ileostomy pouch change in the correct order. 1. Close the end of the pouch 2. Measure the stoma 3. cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent 4. press the pouch in place over the stoma 5. remove the old pouch 6. trace the correct measurement onto the back of the wafer 7. assess the stoma and the skin around it 8. Cleanse and dry the peristomal skin
5, 8, 7, 2, 6, 3, 4, and 1
Bowel sounds will normally be hypoactive following surgery, what is the normal frequency to which you would hear bowel sounds on auscultation?
5-30 per minute
Nutrition: What are the recommended servings for Lean meat in a 2,000 calorie DASH diet?
6 1-ounce servings or less
When assessing laboratory results for a patient at risk fo CAD, what is the desired level for Plasma Low-Density Lipoproteins (LDLs)?
<130 mg/dL
A nursing intervention that is appropriate for the patient with a nursing diagnosis of anxiety related to lack of knowledge of etiology and treatment of headache is to? a. Help the patient examine lifestyle patterns and precipitating factors b. Administer medications as ordered to relieve pain and promote relaxation c. Provide a quiet, dimly lit environment to reduce stimuli that increase muscle tension and anxiety d. Support the patient's use of counseling of psychotherapy to enhance conflict resolution and stress reduction
A
The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube? a. Lubricate the first 2.5 to 3 inches of the tip of the tube b. Place the patient in a side-lying position with the right knee flexed c. Flush the tube with the solution d. Hold the tube in the rectum until all of the fluid has been instilled
A
Which intervention might the nurse delegate to nursing assistive personnel when inserting a nasogastric tube? a. Positioning the patient in a high-Fowler's position b. Assessing the patient's abdomen for bowel sounds c. Determining any history of unexplained nosebleeds d. Educating the patient about the need for the intervention
A
When setting the flow rate for oxygen, at what rate would you need to use a humidified source of oxygen when using a nasal cannula?
Above 4L/Min
Definition: A serious but uncommon limb-threatening condition in which increased pressure within one or more compartments reduces circulation to the lower leg or forearm
Acute Compartment Syndrome
Health Promotion: What are common health promotion techniques regarding the physical activity you would recommend for a patient experiencing PVD?
Aerobic physical activity three or four times a week, each session lasting 40 minutes on average
After how many minutes of transfusion can the rate of transfusion be adjusted to the prescribed rate?
After 15 minutes
Definition -The pressure or resistance that the ventricles must overcome to eject blood through the semilunar valves and into the peripheral blood vessels
After load
Intravenous Complications: Sudden onset of dyspnea, coughing, chest pain, hypotension, tachycardia, decreased level of consciousness, possible signs of stroke
Air Embolism
This is the corticosteroid hormone that causes resorption of sodium and water within the kidneys. This resorption leads to an increase in ECF volume and BP
Aldosterone
This is the corticosteroid hormone that causes resorption of sodium and water within the kidneys. This resorption leads to an increase in ECF volume and BP.
Aldosterone
This medication is used to lower plasma uric acid levels and helps facilitate the mobilization of tophi.
Allopurinol
What are the benefits of using skeletal traction over skin traction?
Allows for the use of heavier weights, and allows for longer traction times
Broad Medications: - Stimulate release of norepinephrine and dopamine - Block reuptake of norepinephrine and dopamine
Amphetamines
Definition: This is a progressive degenerative disease involving the motor system and as the disease progresses, muscle weakness and atrophy develop until flaccid tetraplegia develops
Amyotrophic Lateral Sclerosis
CBC: What are you looking for when you are assessing Hemoglobin/Hematocrit levels post surgery and what would the levels indicate?
An increase could indicate dehydration, while a decrease could mean excessive fluid or anemia
Definition: A severe, potentially life-threatening allergic reaction caused by exposure to an allergen. Can cause a drop in blood pressure, narrowing of the airway, and can present with rapid weak pulses, skin rash, nausea, and vomiting
Anaphylaxis
Definition: Permanent localized dilation of an artery, which enlarges the artery to at least two times its normal diameter
Aneurysm
Cardiovascular: This is chest pain resulting from myocardial ischemia caused by inadequate myocardial blood and oxygen supply.
Angina
Definition: Episodes of chest pain that is usually precipitated by activity or exercise and maybe relieved by rest and medications. This is chest pain that is caused by reduced blood flow.
Angina
This hormone is responsible for raising blood pressure by vasoconstriction, sympathetic nervous stimulation, and increased aldosterone biosynthesis
Angiotensin 2
This hormone is responsible for raising blood pressure by vasoconstriction, sympathetic nervous stimulation, and increased aldosterone biosynthesis
Angiotensin II
What are the clinical signs and symptoms of hypoxia?
Apprehension, restlessness, inability to concentrate, decreased level of consciousness, dizziness, and behavioral changes. Patients could also present with cyanosis of the skin and mucous membranes.
What is the normal amount of tidal volume?
Approximately 500 mL
Arterial or Venous Insufficiency: Elevational pallor and dependent rubor of lower extremities. Decreased or absent peripheral pulses.
Arterial
Arterial or Venous Insufficiency: Loss of hair and dry scaly skin on lower extremities, thickened toe nails, cold and gray-blue skin in lower extremities.
Arterial
You will only see a decreased or diminished pulse with venous or arterial insufficiency
Arterial
What are the differences in ulcer development between arterial and venous insufficiency?
Arterial - ulcers have symmetric margins and usually has a deep base and necrotic tissue, generally absent of bleeding Venous - Ulcers with uneven margins, typically bleed, and superficial
A patient experiencing Intermittent Claudication would most likely be suffering for arterial or venous insufficiency
Arterial Insufficiency
Upon assessment of this condition, you may find the presence of intermittent claudication and/or rest pain.
Arterial Insufficiency
This branch of the vascular system delivers oxygen and nutrient to various tissues in the body. From there, blood can either be directed toward the skin to promote heat loss or diverted away from it to conserve heat.
Arterial System
What are the two sub-systems of the vascular system?
Arterial and Venous systems
Definition: The most common chronic arterial disorder, characterized by loss of elasticity, thickening and calcification of arterial walls.
Arteriosclerosis
What are the causes of arterial insufficiency?
Arteriosclerosis, thrombosis, embolus, aneurysm, diabetes mellitus, and partial or complete arterial occlusions
When performing the skill of nasotracheal and nasopharyngeal suctioning, how long should you wait in between passes of the suction catheter?
At least 1 minute.
Definition: This condition is characterized by multiple rapid impulses from many foci depolarize in the atria in a totally disorganized manner at a rate of 350-600 times per minute
Atrial Fibrillation
This hormone is excreted by atrial cells when they become stretched and helps regulate ECV by influencing how much sodium and water are excreted in urine. This hormone opposes the effects of aldosterone.
Atrial Natriuretic Peptide.
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? a. Call a code b. Check the client's status c. Call the health care provider d. Document the lack of complexes
B
A client with myocardial infarction is developing cardiogenic shock. What condition should the nurse carefully assess the client for? a. Pulsus Paradoxus b. Ventricular dysrhythmias c. Rising diastolic blood pressure d. Falling central venous pressure
B
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? a. Stridor b. Crackles c. Scattered rhonchi d. Diminished breath sounds
B
The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client's peripheral response to pain? a. sternal rub b. nailbed pressure c. pressure on the orbital rim d. squeezing the sternocleidomastoid muscle
B
The nurse is preparing equipment to administer a unit of blood to a patient. Which type of fluid would the nurse piggyback with the blood transfusion? a. 0.45% normal saline b. 0.9% normal saline c. Dextrose 5% and 0.45% normal saline d. Dextrose 5% and 0.9% normal saline
B
What would the nurse do if he or she encountered resistance when inserting a nasogastric tube? a. Ask the patient to cough b. Withdraw the tube to the nasopharynx c. Encourage the patient to swallow d. Instruct the patient to hyperextend the neck
B
Which action would the nurse take to ensure the safety of an older adult patient who has received an enema? a. Assess for the presence of external hemorrhoids b. Provide assistance to the bathroom for the expulsion of fluid and stool c. Document the patient's physical response to the enema d. Instruct the patient to attempt to retain the fluid for 2 to 5 minutes
B
This is an abnormal finding that could indicate the presence of CNS disease and is characterized by the dorsiflexion of the great toe and fanning of the other toes.
Babinski Sign
What is one test that can be used in order to diagnose a hiatal hernia?
Barium swallow with fluoroscopy
Definition - Sensory receptors in the arch of the aorta and at the origin of the internal carotid arteries that are stimulated when the arterial walls are stretched by an increased blood pressure
Baroreceptors
Why should laxatives and enemas be avoided during a flare up of diverticulitis?
Because they increase intestinal motility
Rebound tenderness upon deep palpation is a positive _______ sign.
Blumberg
Normal Lung Sounds: This sound is described as a harsh hollow sound heard over the trachea and mainstem bronchi
Bronchial/Tubular
Normal Lung Sounds: This sound is heard over the branching bronchi
Bronchovesicular
Definition - Swishing sound that may occur from turbulent blood flow in narrowed or atherosclerotic arteries
Bruit
Definition: A turbulent, swishing sound, which can be soft or loud in pitch. This sound is heard as a result of blood trying to pass through a narrowed artery
Bruit
Definition: This condition is an occlusive disease of the median and small arteries and veins. It causes diminished pulses of distal extremities. Extremities will be cool and red in the dependent position and have pain that increases in severity at night
Buerger's Disease
How can the nurse ensure that a patient's IV tubing will not tug on the infusion catheter after a transparent dressing is applied to an infusion site on the arm? a. Encircle the arm with tape b. Secure the tubing and catheter hub with tape c. Secure the tubing in two different locations on the arm d. Label the dressing with the date and time of application
C
The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? a. Muffled heart sounds b. Client reports dyspnea c. A rise in blood pressure d. Jugular venous distention
C
Which action would the nurse take to reduce the risk of infection among patients and staff when administering an enema to an older adult patient with dementia? a. Lubricate the tip of the rectal tube b. Pad the patient's bed thoroughly c. Perform hand hygiene before donning gloves d. Help the patient onto a bedpan to expel the enema fluid and stool
C
Which finding tells the nurse that a patient may have had a positive reaction to a tuberculin test? a. a raised wheal the size of a mosquito bite b. a bruised area 10 mm or greater in diameter c. A hard, raised area 15mm or greater in diameter d. A flat, reddened area 5 mm or greater in diameter
C
Which needle gauge and length would be most appropriate for the nurse to use when giving a subcutaneous injection to a patient of average height and weight? a. 20 gauge, 1/2 inch b. 22 gauge, 1 inch c. 25 gauge, 3/8 inch d. 27 gauge, 1 inch
C
Cardiovascular: Elevated values of this indicate myocardial damage. Elevation occurs within hours and peaks at 18 hours following an acute ischemic attack
CK-MB
Definition: This cardiac enzyme shows that damage has occured to the heart. Elevation of this enzyme occurs 24-48 hours after incident and decreases to normal levels after 72 hours. This level can be increased with other skeletal muscle damage as well.
CPK-MB
This is the largest portion of the brain and controls intelligence, creativity, and memory.
Cerebrum
When the patient has to be monitored continuously for oxygen saturation, how frequently should you assess skin integrity and how frequently should the sensor be moved.
Checked every 2 hours and moved every 4 hours
What are common manifestations associated with the presence of Coronary Artery Disease?
Chest pain, palpitations, dyspnea, syncope, cough, hemoptysis, or excessive fatigue
Headaches: Oxygen can often be used to help treat this type of headache
Cluster
Headaches: This type of headache commonly recurs several times a day for several weeks, and can also occur after falling asleep
Cluster
What is the most common surgical procedure for the treatment of diverticulitis?
Colon resection, with or without a colostomy
Types of Care: Incorporates the model of primary care delivery with a population based approach
Community Health Care
Definition: A grating sound caused by loosened bone and cartilage in a synovial joint
Crepitus
Definition: The condition caused by air trapped in and under the skin and can be felt as a crackling sensation beneath the fingertips
Crepitus
Definition: A chronic inflammatory disease of the small intestine, the colon, or both; the terminal ileum is most often affected
Crohn's Disease
Ulcerative Colitis or Crohn's Disease: Severe malabsorption by small intestine
Crohn's disease
A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? a. Have you eaten more high-fiber foods lately b. Have you taken antibiotics recently c. Do you have gluten intolerance d. Have you experienced frequent , small liquid stools recently?
D
The nurse is assessing the adaptation of a client to changes in functional status after a stroke. Which observation indicates to the nurse that the client is adapting most successfully? a. Gets angry with family if they interrupt a task b. Experiences bouts of depression and irritability c. Has difficulty with using modified feeding utensils d. Consistently uses adaptive equipment in dressing self
D
The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? a. I can sit down to put on my pants and shoes b. I try to exercise every day and rest when I'm tired c. My son removed all loose rugs from my bedroom d. I'll try to eat my food either very warm or very cold
D
What is the nursing action to set up suction for Hemovac drainage system? a. Set the suction to lowest level possible b. Hemovacs are always set to medium suction c. Connect to the wall on intermediate suction d. Compress the hemovac, creating suction
D
What is the proper method for cleansing the evacuation port of a wound drainage system? a. Cleanse it with normal saline b. Wash it with soap and warm water c. Rinse it with sterile water d. Wipe it with an alcohol sponge
D
When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel report immediately to the nurse as a potential abnormality? a. The drainage is odorless b. The drainage is straw colored c. The patient doesn't like looking at the drainage tubing d. The amount of drainage was greater today than yesterday
D
When providing teaching to a group of parents regarding ADHD, which information should the nurse include? 1. Children with ADHD have low intelligence 2. Children with ADHD have an infection in their spinal fluid 3. EEG results are typically normal in children with ADHD 4. Learning disabilities are often present in the child who has ADHD
D
A patient suffering from irritable bowel syndrome, they often report that abdominal pain is relieved by what?
Defecation
Definition: The partial or total separation of wound layers that occurs when an incision fails to heal properly
Dehiscence
Definition - Excessive, abnormal sweating in relation to you environment and activity level
Diaphoresis
Definition - The phase of the cardiac cycle that consists of relaxation and filling of the atria and ventricles; normally about two-thirds of the cardiac cycle
Diastole
What nutritional education should be provided to a patient with diverticulosis?
Diet high in fiber, cellulose, hemicellulose. Should eat 25-35 g of fiber. Fresh fruits and vegetables with high fiber are recommended
Definition: This is the removal of a nucleus pulposus of an intervertebral disk. This may be performed alone or with a laminectomy
Diskectomy
Other than Dopaminergic Medications, what are other medications that are used to treat Parkinson's disease
Dopamine Agonists and Anticholinergics
These are the drugs of choice in treating Parkinson's Disease and can take 4-6 weeks to reach a base therapeutic levels.
Dopaminergic Medications (Levodopa and Sinemet)
When assessing the patient's cast, what should you assess for?
Drainage, alignment, and fit
Patients with this type of ischemic stroke usually have rapid improvements
Embolic Stroke
This type of ischemic stroke happens more in younger adults and occurs with exertion, activity, and while the individual is awake
Embolic Stroke
This type of ischemic stroke has the maximum neurologic deficits at the onset with those deficits including: paralysis and expressive aphasia
Embolic Stroke
This type of ischemic stroke is caused by a dislodged clot and can often have a sudden onset of symptoms
Embolic Stroke
Definition: This is the condition characterized by the collection of pus within the pleural cavity. Treatment for this focuses on treating the infection, emptying the cavity, re-expanding the lung, and controlling the infection
Empyema
Definition: This is the instillation of a solution into the rectum and sigmoid colon. The primary purpose of this is to promote defication.
Enema
What are the three types of aphasia?
Expressive, receptive, and mixed
With patients suffering from gout, what foods would you encourage them to avoid?
Foods high in purines such as: Seafood, yeast, beans, peans ,spinach, asparagus, and organ meat
In what situation would it be appropriate to delegate the care of a tracheostomy to the NAP?
For a patient with a well established tracheostomy tube.
Definition: A fracture caused by osteoporosis or other disease that weakens bone
Fragility Fracture
Definition: The Vibration felt by palpation on the surface of the chest when the patient speaks
Fremitus
What is the classic manifestation of ulcerative colitis?
Frequent blood mucosal stools
Lobes of the Brain: Primary motor are, controls voluntary eye movement, behavioral regulation, cognition, and access to current sensory data
Frontal Lobe
Definition: The backflow of gastric and duodenal contents into the esophagus. The reflux is caused by an incompetent lower esophageal sphincter, pyloric stenosis, or motility disorder
GERD
Definition: The degree to which a person has the ability to obtain, communicate, process, and understand basic health information to make appropriate health decisions
Health Literacy
What are key features associated with the presence of a sliding hiatal hernia?
Heartburn, regurgitation, chest pain, dysphagia, belching
What are the four phases of wound healing?
Hemostasis, inflammation, proliferation, maturation
Definition: A frequent consequence of traumatic thoracic injuries and is characterized by the collection of blood in the pleural space.
Hemothorax
These two drainage systems are classified as closed-drain systems
Hemovac and Jackson-Pratt
Definition: A weakness in the abdominal muscle wall through which a segment of the bowel or other abdominal structure protrudes
Hernia
Definition: This involves the protrusion of the stomach though the esophageal hiatus of the diaphragm into the chest.
Hiatal Hernia
Although a high fiber diet is indicated for a patient with diverticulosis, why is it contraindicated for a patient with symptoms of diverticulitis?
High-fiber foods can be irritating.
This is the portion of the brain plays a major role in autonomic nervous system control, which helps control temperature and cognition.
Hypothalamus
This is the portion of the brain that is responsible for the production of hormones secreted by the pituitary gland and the hypothalamus
Hypothalamus
Definition: Low levels of oxygen in the blood
Hypoxemia
Definition - Inadequate tissue oxygenation at the cellular level.
Hypoxia
Definition: An effective system of communication used in many agencies for hand-off purposes.
ISBARR
Definition: A hernia that cannot be reduced or placed back into the abdominal cavity. This type of hernia requires immediate surgical evaluation
Incarcerated hernia
Definition - A tool that encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume
Incentive Spirometer
CBC: What are you looking for when you are assessing WBC count post surgery and what would the levels indicate?
Increase level could mean infection. Decreased level could indicate an immune deficiency
The nurse is caring for the client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising?
Increasing temperature, decreasing pulse, decreasing respirations, and increasing blood pressure
Definition: Classic leg pain that occurs after a certain distance of walking. Often feels like a burning muscular pain
Intermittent Claudication
Definition: A surgical procedure in which metal pins, screw, rods, plates, or prostheses are inserted inside the body to immobilize a fracture during healing
Internal Fixation
Definition: Functional disorder characterized by chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating
Irritable Bowel Syndrome
This refers to reversible cellular injury that occurs when the demand for oxygen exceeds the supply because of a reduction or cessation of blood flow.
Ischemia
When assessing laboratory results for a patient at risk for CAD, what is the desired level of cholesterol?
Less than 200mg/dL
What are a few examples of modifiable risk factors associated with Coronary Artery Disease?
Lifestyle habits, smoking, management of chronic health conditions, and stress
Intravenous Complications: Redness, heat, swelling at catheter-skin entry point, possibly purulent drainage.
Local Infection
Types of Care: Highly individualized and well-coordinated to help provide partial or total care for a period of time, sometimes indefinitely
Long-Term Care
Headaches: This type of headache often has a prodromal phase followed by the headache phase
Migraine
Types of Headaches: Characterized by recurring vascular headache
Migraine
Medication Description: - Increases wakefulness in patients with sleep disorders - Stimulates CNS and augments serotonin action - Used to help treat narcolepsy
Modafinil
When on a stimulant to help treat ADHD, it is important to monitor what in regards to nutrition and development?
Monitor growth, encourage eating before medication and after it wears off
Definition: This is a chronis, progressive, noncontagious, degenerative disease of the CNS characterized by demyelinization of the neurones
Multiple Sclerosis
This is the bacteria that causes tuberculosis?
Mycobacterium Tuberculosis
What are common manifestations associated with Right-Sided Heart Failure?
Neck vein distension, edema, weight gain, coolness of extremities, abdominal pain, ascites, nausea, and vomiting.
After each unit of blood has been transfused, what needs to happen with the tubing?
Needs to be flushed with 0.9% normal saline
Definition: A sensitive tumor consisting of damaged nerve cells that forms most often in patients with amputations of the upper extremities
Neuroma
Nociception: Poorly localized, shooting, burning, fiery, shock-like, tingling, painful numbness
Neuropathic
Can the skill of nasotracheal and nasopharyngeal suctioning be delegated to nursing assistive personnel?
No
When performing the skill of nasotracheal and nasopharyngeal suctioning, how long should suctioning be performed?
No longer than 15 seconds
When performing the skill of nasotracheal and nasopharyngeal suctioning, how many times can you perform the procedure?
No more than 2 passes
Definition: The term that is used to describe how pain becomes a conscious experience
Nociception
What is one of the last signs to appear with the presence of a fath embolism?
Nonpalpable, red-brown petechiae. This appears on the neck, upper arms, and/or chest
Enemas: An enema that is the safest solution to use because it exerts the same osmotic pressure as fluids in the interstitial space.
Normal Saline Enema
What are some of the sensory disturbances associated with the presence of a TIA?
Numbness of the face, hand, arm, or leg, and vertigo
Outflow or Inflow Disease: Obstructions in the femoral, popliteal, and tibial arteries and below superficial femoral artery that cause burning or cramping in the calves, ankles, feet and toes
Outflow Disease
What are the five areas in which you should assess for a post-operative patient?
Pain/Vital Signs, Hemorrhage/Bleeding, LOC, Airway/Respiratory assessment, Gag reflex
What are some of the clinical manifestations associated with the presence of RA?
Painful stiff hands and feet, fatigue, low-grade fever, and ulnar drift/deviation
What are some of the manifestations associated with arterial insufficiency?
Pallor, dependent rubor, cool to touch, changes in hair growth, thickened nails, sensory loss, slow capillary refill, muscle atrophy, and intermittent claudication
Definition - An exaggerated decrease in systolic pressure by more than 10 mmHg during the inspiratory phase of the respiratory cycle
Paradoxical Blood Pressure
The presence of stridor would indicate which abnormality within the lungs?
Partial or complete obstruction of the upper airway
This drainage system is classified as an open-drain system
Penrose
Cardiovascular: Intermittent claudication, rest pain, loss of hair, formation of dry scaly skin, thickened toenails, and cold gray-blue color of skin are signs and symptoms associated with what?
Peripheral Artery Disease
Definition: An impairment of blood supply to the peripheral tissues, particularly in the lower extremities
Peripheral Vascular Disease
Definition: Inflammation of the pharynx, resulting in sore throat. This is usually caused by viral and/or bacterial infections
Pharyngitis
Postoperative Phases: Focuses on preparing the patient for care in an extended-care environment such as a medical surgical unit, step-down unit, skilled nursing agency, or home. May last 15 to 30 minutes, although 1 to 2 hours is more typical
Phase 2
Postoperative Phases: Known as extended-care environment, most often occurs on a hospital unit or in the home
Phase 3
Medication Description: - Anticonvulsant - Narrow therapeutic range 10-20 mcg/ml - Can cause severe local tissue damage (Purple glove syndrome)
Phenytoin (Dilantin)
Definition: A collapse of the lung that occurs when air leaks into the space between your lung and chest wall
Pneumothorax
Definition - The degree of myocardial fiber stretch at the end of diastole and just before contraction
Preload
What are some risk factors associated with the development of GERD?
Presence of an NG tube, sleep apnea, increased intra-abdominal pressure, increased intra-gastric pressure, pregnancy
Types of Care: Ranges from prevention to management of chronic health conditions and involves three main areas or empowering people and communities, multisectoral policy and action, and primary care/essential public health functions
Primary Care
What are the signs and symptoms associated with Tuberculosis?
Productive cough, fever, night sweats, weight loss, hemoptysis, and loss of appetite
Wound Healing: This phase lasts 3 to 24 days and the main activities during this phase are the filling of the wound with granulation tissue, wound contraction, and wound resurfacing by epithelialization
Proliferation Phase
Cardiovascular: Angiotensin II stimulates the release of aldosterone, what is the purpose of aldosterone?
Promotes water and sodium retention by the kidneys.
Definition: Awareness of body position
Proprioception
Definition - The difference between the systolic and diastolic pressure
Pulse Pressure
Definition: The accumulation of septic purulent exudate within the pleural space
Pyothorax
Definition: This condition is characterized by vasospasms of the arterioles and arteries of the upper and lower extremities. These spasms cause constrictions of the cutaneous vessels which can lead to numbness, tingling, swelling, and blanching/cyanosis
Raynaud's Disease
When assessing the color and integrity of a healthy stoma, how should it appear?
Reddish/pink and moist, protruding about 1-3 cm from the abdominal wall
Definition: The amount of air left in the lungs after forced exhalation
Residual Volume
Areas of the Heart: Receives deoxygenated blood from the body through the superior and inferior vena cava.
Right Atrium
Normally patients with diverticula show no symptoms unless pain or bleeding develops. How are diverticula normally diagnosed?
Routine Colonoscopy
What are the three categories of angina?
Stable, unstable, and variant
Definition: A fatty protein that lines alveoli and reduces alveolar surface tension
Surfactant
Definition - The phase of the cardiac cycle that consists of the contraction and emptying of the atria and ventricles
Systole
Definition: The palpable vibration of the chest wall that results from the transmission of sound vibrations through the lung tissue to the chest wall.
Tactile Fremitus
Enemas: An enema that consists of a hypotonic solution that exerts an osmotic pressure lower than fluid in interstitial space. Should use caution with repeat enemas of this type due to potential of toxicity and circulatory overload.
Tap Water Enema
Lobes of the Brain: Auditory center for sound interpretation, complicated memory patterns, Wernicke area for language comprehension
Temporal Lobe
The color, quality, and texture/consistency of the stool with the ostomy can depend on what?
The location in which the ostomy was placed along the intestinal tract.
Crackles and rales would indicate which abnormality within the lungs?
The presence of fluid
Describe the proper fitting for crutches.
There should be a 2" gap between axillary fold and arm piece, bear most weight on hands, should be 15-30 degree flexion in elbow. Crutches should be just longer than the length of axillary to floor
What are common manifestations of a stroke?
Unilateral numbness, loss of vision, speech difficulties, and imbalance
This method of medication injection prevents leakage of medication into subcutaneous tissues, seals medication in the muscle, and minimizes irritation by pulling the skin during an injection.
Z-Track method
When providing education to a patient with an ostomy, you should inform them to empty their pouch when?
- 1/3 to 1/2 full - Entire pouch system every 3-7 days - Times of inactivity, before bed, 2-4 hours after eating
What is always the initial intervention when it comes to ADHD and at what age will they begin administering stimulants?
- Behavioral interventions - At ae 6
What are nursing interventions associated in the treatment of Pneumonia?
- Chest physiotherapy - Postural Drainage
Pain associated with a myocardial infarction can often be described how?
- Crushing substernal pain that radiates to jaw, back, and left arm. - Pain lasting longer than 30 minutes
What are the common causes of hypoxia?
- Decreased hemoglobin level -Diminished concentration of inspired oxygen - inability of the tissue to extract oxygen from blood - decreased diffusion of oxygen from the alveoli -Poor tissue perfusion -Impaired ventilation
What are some of the purposed of administering preoperative medications
- Increase sedation - Decrease anxiety and increase comfort - Decrease gastric acid, volume, decreased nausea and vomiting. - Dry up oral and respiratory secretions
For infants receiving a subcutaneous injection, you should not exceed what volume of solution?
0.5 mL
A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast? 1. I need to avoid getting the cast wet 2. I need to cover the casted leg with warm blankets 3. I need to use my fingertips to lift and move my leg 4. I need to use something padded to scratch under the cast if it itches
1
How frequently should the Yankauer suction device and connecting tubing be replaced?
every 24 hours or when visibly soiled with blood or vomitus.
number 2
number 2
How often should you monitor vital signs and for signs and symptoms of an adverse reaction during a blood transfusion?
- At 5 minutes - At 15 minutes - every 30 minutes until an hour after completion of transfusion - Depending on hospital policy
What are some interactions that Methylphenidate (Ritalin) has one other medications or substances?
- Caffeine increases effects - Decreases effects of antihypertensives - Alters insulin effects - Increases effects of anticoagulants, barbiturates, anticonvulsants
What would put a patient at a higher risk for diverticulosis?
- Diet high in refined sugar or lacking in fiber. - Sedentary lifestyle, decreased level of activity, or constipation - Incidence increases with age
You patient is suffering from an acute attack of diverticulitis, what orders do you think your patient would be put on after the flare up?
- NPO, bedrest with bathroom privileges - Broad-spectrum antibiotics and a steroid to treat inflammation
What are the specific types of action associated with antiseizure medications?
- Suppress sodium influx - Suppress calcium influx - Enhance action of GABA
What are the causes of seizure disorders?
-Disruption in electrical brain functioning - Secondary to brain trauma or anoxia, infection, stroke - Fever, electrolyte, or acid-base imbalance, alcohol, or drugs
A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1. This is a normal, expected event 2. The client is experiencing early signs of ischemic bowel 3. The client should not have the nasogastric tube removed 4. This indicates inadequate preoperative bowel preparation
1
A client is scheduled for a cholecystectomy and asks the primary nurse about the function of the gallbladder. Which explanation would the nurse give? 1. Stores and concentrates bile 2. Releases bile into the pancreatic duct 3. Connects the common bile duct and the pancreas 4. Controls the flow of fat through the sphincter of Oddi
1
A client with a hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? 1. Lying recumbent following meals 2. Consuming small, frequent, bland meals 3. Taking H2 receptor antagonist medications 4. Raising the head of the bed 6-inches
1
A client, readmitted for exacerbation of ulcerative colitis, is weak, thin, and irritable. The client states, "I am now ready for surgery to create an ileostomy." Which nursing intervention best meets the client's needs at this time? 1. Parenterally replace the client's fluids and electrolytes 2. Adjust client's diet to promote weight gain 3. Provide anticipatory teaching on the use of ileostomy appliances 4. Encourage client interactions with other clients who have an ileostomy
1
A nursing report is an important component of care. During the report, what is the primary purpose of an effective exchange of information? 1. The patient receives continuity of care 2. The accepting nurse receives notification of new practitioner orders 3. New trends in care are identified 4. The patient's risk status is stabilized
1
How can the nurse best minimize a patient's risk for infection during tracheostomy care? 1. Adhere to sterile technique when appropriate 2. Frequently assess for signs of local or systemic infection 3. Monitor for indications that tracheostomy care is needed 4. Instruct nursing assistive personnel to report any changes in color or odor of tracheal drainage
1
The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? 1. Clean mentation 2. Minimal Dyspnea 3. Oxygen saturation of 85% 4. Arterial oxygen level of 78 mmHg
1
The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? 1. I should increase the fiber in my diet 2. I will need to avoid caffeinated beverages 3. I'm going to learn some stress reduction techniques 4. I can have exacerbations and remissions with Crohn's disease
1
The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome. Which statement by the client indicates a need for further teaching? 1. I need to limit my intake of dietary fiber 2. I need to drink plenty, at least 8-10 cups daily 3. I need to eat regular meals and chew my food well 4. I will take the prescribed medications because they will regulate my bowel patterns
1
What would indicate to the nurse that the child taking methylphenidate requires additional teaching? 1. The child is seen drinking a cola product 2. The child checks his weight twice a week 3. The child takes the drug 45 minutes before a meal 4. The child takes the drug before breakfast and lunch
1
When a client is admitted with chest pain, a family member asks about the purpose of the prescribed 12-lead electrocardiogram. Which response would the nurse give? 1. Indicates whether a heart attack is occurring 2. Detects changes in the structures in the heart 3. Shows whether the heart muscle is pumping 4. Evaluates for prognosis after heart attack
1
When a client with a venous thrombosis is receiving warfarin, which test result would the nurse use to determine whether the daily does of warfarin is therapeutic? 1. INR 2. aPTT 3. Bleeding time 4. Sedimentation rate
1
Which Physiological process causes temperature elevation after a client has had a myocardial infarction? 1. Tissue necrosis and inflammation 2. Thrombosis following by thombolysis 3. Sympathetic nervous system stimulation 4. Infection process of myocardial muscle cells
1
Which action is most useful in evaluating the effectiveness of oropharyngeal suctioning? 1. Comparing presuctioning and postsucitoning respiratory assessment data 2. Confirming that the patient's pulse oximetry is >90% 3. Asking the patient to report any symptoms of dyspnea 4. Assessing the patients skin for signs of cyanosis
1
Which action may be delegated to nursing assistive personnel regarding the care of a patient with a tracheostomy? 1. Performing tracheostomy care for a patient whose tracheostomy was placed 1 week ago 2. Removing the outer cannula and placing the obturator 3. Holding the tracheostomy tube while the nurse changes the neck ties 4. Monitoring oxygen saturation levels and placing oxygen if needed.
1
Which dietary restriction will the nurse expect to be included in the plain for a client with left ventricular failure? 1. Sodium 2. Calcium 3. Potassium 4. Magnesium
1
Which of the following is a risk factor for decreased oxygen saturation level in a patient? 1. Chest wall injury 2. Restlessness 3. Hypotension 4. Prescribed bronchodilators
1
Which rationale explains why the nurse also monitors a client with a history of GERD for clinical manifestations of heart disease? 1. Esophageal pain may imitate the symptoms of a heart attack 2. GERD may predispose the client to the development of heart disease 3. Strenuous exercise may exacerbate reflux problems 4. Similar lab study changes may occur in both problems
1
Why is it important for the nurse to set the correct flow rate for a patient to whom oxygen is prescribed? 1. To provide the correct amount of oxygen to the patient 2. To ensure the therapeutic effects of oxygen therapy 3. To prevent any adverse reaction to the prescribed oxygen therapy 4. To minimize the risk of combustion during oxygen therapy
1
The nurse is planning to teach a client with GERD about substances to avoid. Which items should the nursei nclude on this list? (select all that apply) 1. Coffee 2. Chocolate 3. Peppermint 4. Nonfat milk 5. Fried Chicken 6. Scrambled eggs
1, 2, 3, and 5
Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply 1. Keep the cast clean and dry 2. allow the cast 24-72 hours to dry 3. keep the cast and extremity elevated 4. expect tingling and numbness in the extremity 5. Use a hair dryer set on a warm to hot setting to dry cast 6. Use soft, padded object that will fit under the cast to scratch the skin under the cast
1, 2, and 3
How far should the skin barrier for an ostomy be separated from the stoma?
1/8th of an inch
How far should oxygen be kept away from anything that can generate a spark?
10 feet
What is the appropriate pressure range using a suction device during tracheostomy care?
100 to 150 mmHg
What is the usual amount of residual volume left in the lungs after forced exhalation
1000 mL
Onset of ADHD usually occurs before what age?
12 years old
A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement? 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired range of motion while the client ambulates
2
A client is being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement? 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired range of motion while the client ambulates
2
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? 1. Stridor 2. Crackels 3. Scattered rhonchi 4. Diminished breath sounds
2
A health care provider informs a client that a T-tube will be in place after an abdominal cholecystectomy. Which would the nurse include in the preoperative teaching for this client regarding the primary reason why a T-tube is necessary? 1. Drain bile from the cystic duct 2. Keep the common bile duct patent 3. Prevent abscess formation at the surgical site 4. Provide a port for contrast dye in a cholangiogram
2
A patient has been ordered a transdermal patch of methylphenidate. The nurse teaches the family to leave the patch on for how long? 1. 2 hours 2. 9 hours 3. 20 hours 4. 24 hours
2
After oropharyngeal suctioning, what does the nurse do with the supplies? 1. Place the Yankauer catheter in a clean, dry area 2. Place all disposable equipment into the wrapper of the suction catheter before discarding it in a trash receptacle 3. Fold the paper drape with the outer surface inward, and dispose of it in a biohazard receptacle 4. Place dirty gloves in the biohazard receptacle in the patient's room
2
On the third postoperative day after a subtotal gastrectomy, a client reports severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. Which action would the nurse perform first? 1. Assist the client to ambulate 2. Obtain the client's vital signs 3. Administer the prescribed analgesic 4. Encourage use of the incentive spirometer
2
The nurse provides education to a client about colostomy care. To be effective when providing the teaching, the nurse would start with which step? 1. Wait until a family member is present 2. Assess barriers to learning colostomy care 3. Provide simply written instructions concerning the care 4. Wait until the client has accepted the change in body image
2
What is the benefit of completing a bedside report during hand-off? 1. The patient's roommate may overhear the patient's diagnosis 2. The patient and family can participate 3. The nurse gets to share all information with the patient 4. Patients are seen in the conference room
2
What is the priority intervention when performing oropharyngeal suctioning for a patient who is receiving oxygen by face mask? 1. Complete suctioning process in 20 seconds or less 2. Keep the oxygen mask near the patient's face during the suctioning procedure 3. Encourage the patient to take several deep breaths before suctioning begins 4. Increase the oxygen flow rate by 1 L/min for 3 minutes before suctioning
2
What should the nurse teach the NAP about selecting the appropriate site for measuring a patient's oxygen saturation level? 1. "Do not use the fingers if her nails are polished" 2. "I've checked her capillary refill, and it's acceptable in both her hands and feet" 3. "Please review the patient's previously documented pulse oximetry readings for the site used." 4. " Ask the patient to keep her finger motionless while you are monitoring her oxygen saturation."
2
What would the nurse do first when preparing to begin oxygen therapy for a patient? 1. Educate the NAP about the oxygen orders 2. Review the medical prescription for delivery method and flow rate 3. Place a "No Smoking" sign outside the hospital room 4. Ensure that suction equipment is present in the room.
2
What would the nurse monitor frequently to ensure that the prescribed amount of oxygen is being delivered to a patient? 1. Arterial blood gas level 2. Oxygen flow meter setting 3. Respiratory rate 4. Temperature
2
When preparing a nursing report, which of the following steps should the reporting nurse take? 1. Identify only changes that have occurred during the shift 2. Prioritize information on the basis of the patient's needs and problems 3. Review the complete health record 4. Identify only events that have occurred in the past 24 hours
2
Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy? 1. Cleaning the stoma with hydrogen peroxide and drying thoroughly 2. Cleaning and assessing the skin around the stoma 3. Assessing temperature and reporting skin breakdown immediately 4. Allowing the patient to re-oxygenate after each tracheal suctioning
2
You are caring for a postoperative patient following abdominal surgery. You know that the surgeon has handled the intestine during surgery, and as a result you anticipate the possibility of what possible side effect? 1. Increased surgical drainage 2. N&V 3. Increased peristalsis 4. UTI
2
You are caring for a postoperative patient who has just returned from the PACU after a hemicolectomy and is now requesting fluids to drink. What is your best response? 1. We need to start you slowly. Try a few sips and see if you can tolerate it 2. You won't be able to drink anything until your bowel sounds return 3. We need to keep the head of your bed flat for 6 hours, and then you'll be able to eat and drink 4. You won't be able to drink until you have passed flatus
2
A colostomy should start functioning how soon after surgery?
2-3 days
For a patient with an above the knee amputation, it is recommended that you lay them prone how many times a day?
2-3 times
When performing tracheostomy care, how long should you wait in between passes of the suction catheter?
20 to 30 seconds
What percentage of the population is affected by IBS?
20%
The Purkinje Fibers of the heart can act as a tertiary pacemaker if the higher levels fail and can initiate and sustain a heart rate of how many beats per minute?
20-40
What is the normal needle gauge range associated with intramuscular injections?
21-22 gauge
Changes in electrolyte, hematocrit, and hemoglobin levels often occur during the first _______ hours after surgery because of blood and fluid loss and the body's reaction to the surgical process.
24-48
What are the normal needle gauges for intradermal and subcutaneous injections?
25-30 gauge
A client has been diagnosed with cholelithiasis. Which fact about the condition would the nurse recall when assessing the client for risk factors? 1. Men are more likely to be affected than woman 2. Young people are affected more frequently than older adults 3. Individuals who are obese are more prone to this condition than those who are thin 4. People who are physically active are more apt to develop this condition than those who are sedentary
3
A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. which problem may be causing this pain? 1. Infection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. The recent occurrence of the fracture
3
A client has sustained a closed fracture and has just had a cast applied to the affected arm. the client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? 1. Infection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. The recent occurrence of the fracture
3
A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor? 1. Bed rest 2. Ibuprofen 3. Bending or lifting 4. Application of heat
3
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of gree-brown drainage since the surgery. Which nursing intervention is most appropriate? 1. Clamp the T-tube 2. Irrigate the T-tube 3. Document the findings 4. Notify the primary health care provider
3
The nurse is assessing the casted extremity of a client. Which sign is indicative of infection? 1. Dependent edema 2. Diminished distal pulses 3. Presence of a hot spot on the cast 4. Coolness and pallor of the extremity
3
The nurse is caring for a client who had an AKA 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take? 1. Apply ice to the site 2. Call the PHCP 3. Rewrap the residual limb with an elastic compression bandage 4. Apply a dry, sterile dressing and elevate the residual limb on 1 pillow
3
When a client with peripheral arterial disease tells the nurse about having leg pain and weakness after walking a short distance, how will the nurse document this information? 1. Rest pain 2. Raynaud phenomenon 3. Intermittent claudication 4. Phantom limb sensation
3
When a patient is receiving oxygen at home, which instruction to the family would help them understand how to use the oxygen safely? 1. Increase oxygen level as needed for the patient's comfort 2. Store extra oxygen cylinders horizontally 3. Place a "No Smoking" sign at the entrance of the home 4. Keep oxygen 5 feet away from anything that can generate a spark
3
When preparing the patient's environment for safe oxygen therapy, which intervention is a priority to minimize the patient's risk for injury? 1. Place appropriate signage to alert staff and visitors to the presence of oxygen in the patient's room 2. Instruct the NAP to immediately correct or report safety hazards 3. Inspect all electrical equipment in the patient's room for the presence of safety-check tags 4. Ensure that the patient receives the prescribed amount of oxygen via appropriate method
3
Which response would the nurse report immediately if it occurred in association with nasotracheal suctioning? 1. Patient complains of discomfort during the procedure 2. Patient has a severe bout of nonproductive coughing and complains of sore throat 3. After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88% 4. Patient's pulse rate increases by 10bpm
3
What is the typical age of onset for patients with rheumatoid arthritis?
35-45 years old
A child has been diagnosed with ADHD. Which drug does the nurse anticipate the health care provider will prescribe? 1. Zolmitriptan 2. Doxapram 3. Benzphetamine 4. Methylphenidate
4
A client with diabetes mellitus has had a right below-knee amputation. given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery? 1. Hemorrhage 2. Edema of the residual limb 3. Slight redness of the incision 4. Separation of the wound edges
4
A woman who was discharged recently from the hospital after undergoing a hysterectomy calls the clinic and states that she has tenderness, redness, and swelling in her right calf. Which priority action would the nurse instruct the client to take? 1. Stay in bed for at least 3 days 2. Keep the leg elevated 3. Apply a warm compress 4. Go to the ER
4
Methylphenidate should not be taken by patients with a history of which condition? 1. Renal failure 2. Glaucoma 3. Hypothyroidism 4. Mental depression
4
The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg? 1. Elevated for 3 hours, then flat for 1 hour 2. Flat for 3 hours, then elevated for 1 hour 3. Flat for 12 hours, then elevated for 12 hours 4. Elevated on pillows continuously for 24-48 hours
4
The nurse is caring for a client admitted with peritonitis. Which finding in the medical record is most likely the cause? 1. Gastritis 2. Hiatal hernia 3. Diverticulosis 4. Bowel Obstruction
4
The nurse is conducting health screening for osteoporosis. Which client is at greatest risk for developing this problem? 1. a 25 year old woman who runs 2. a 36 year old man who has asthma 3. A 70 year old man who consumes excessive alcohol 4. A sedentary 65 year old woman who smokes cigarettes
4
The nurse measures a patient's oxygen saturation level as being 83%. What would the nurse do first? 1. Reassess the oxygen saturation in a different location 2. Promptly report the assessment data to the charge nurse 3. Encourage the patient to rest quietly in bed for 30 minutes 4. Ask the patient whether he or she is having trouble breathing
4
The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A let appears fractured. Which intervention should the nurse take? 1. Try to reduce fracture manually 2. Assist the victim to get up and walk to the sidewalk 3. Leave the victim for a few moments to call an ambulance 4. Stay with the victim and encourage him or her to remain still
4
What would the nurse do first when preparing to educate the patient about safe administration of oxygen therapy at home? 1. Evaluate the patient's understanding of the combustible nature of oxygen 2. Arrange for a capable family member to be present during the initial discussion 3. Collect written information to present to the patient as supplemental instructional materials 4. Assess the patient's emotional readiness and physical ability to provide autonomous care
4
Which action is part of the preparation for nasotracheal suctioning? 1. Place the patient in a supine position 2. Preoxygenate the patient with 100% oxygen 3. Suction 100mL of warm tap water to flush the suction catheter 4. Place water-soluble lubricant onto the open sterile catheter
4
Which action would the nurse include in the postprocedure plan of care for a client with peripheral arterial disease who is scheduled for a femoral angiogram? 1. Elevate the foot of the bed 2. Place in high-fowlers position 3. Perform urinary catheter care every 12 hours 4. Check pedal pulses every 15 minutes post procedure
4
Which action would the nurse take to prevent venous thrombus formation after abdominal surgery? 1. Keep the client in a gatch bed to elevate the knees 2. Have the client dangle the legs off the side of the bed 3. help the client use an incentive spirometer every hour 4. Encourage the client to ambulate multiple times a day
4
Which information would the nurse provide a client with a new colostomy about managing the appliance? 1. Use stoma powder for fungal rashes 2. Wash the peristomal area with soap first 3. Measure stoma once a month for size 4. Cut opening 1/8 to 1/16 inch larger than stoma
4
Which of the following strategies is safest when providing a recorded nursing report? 1. Ask the charge nurse to cover the patient's care so that the reporting nurse can leave 2. Call the accepting nurse to see if he or she can come in early 3. Leave after recording the report, with instructions for the accepting nurse to call with questions 4. Stay until after the accepting nurse listens to the report
4
After how many hours should a single unit of blood be swapped to avoid the buildup of bacteria?
4 hours
Nutrition: What are the recommended servings for nuts, seeds, and legumes in a 2,000 calorie DASH diet?
4 ot 5 servings a week
Nutrition: What are the recommended servings for fruits in a 2,000 calorie DASH diet?
4 to 5 servings a day
Nutrition: What are the recommended servings for vegetables in a 2,000 calorie DASH diet?
4 to 5 servings a day
You should expect the patient's stoma to for the first how many weeks after surgery?
4 to 6 weeks
Nutrition: What are the recommended servings for grains in a 2,000 calorie DASH diet?
6 to 8 servings a day
The SA node is the main pacemaker that initiates heartbeat and can generate electrical impulses how many times per minute?
60-100
At what angle should an Intramuscular injection be administered?
90 degrees
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? a. It can develop into ventricular fibrillation at any time b. It is almost impossible to convert to a normal rhythm c. It is uncomfortable for the client, giving a sense of impending doom d. It produces a high cardiac output with cerebral and myocardial ischemia
A
A patient experiencing a blood transfusion reaction is prescribed to receive epinephrine. What is the purpose of this medication when given for this indication? a. To relieve respiratory distress b. To block histamine receptors c. To reduce circulatory overload d. To combat bacterial infection
A
During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first? a. stop the instillation b. Ask the patient to take deep breaths to decrease the pain c. Tell the patient to bear down as he would when having a bowel movement d. Continue the instillation; then administer a pain medication
A
It is determined that a patient who received a blood transfusion received an infection from the blood. Whom should the nurse notify of this infection? a. Blood bank and infection control department b. State health department c. U.S. Centers for Disease control and prevention d. Centers for medicare and medicaid or the patient's private insurer
A
What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube? a. Examine each naris for patency and skin breakdown b. Place the patient in the high-Fowler's position c. Anesthetize the throat d. Have the patient take a few sips of water
A
Which action might the nurse perform to ensure that the wound drainage tubing does not pull on the insertion site? a. Attach the tubing to the patient's gown with a safety pin b. Tape the tubing to the patient's bed c. Attach the tubing to the nearest side rail d. Loop the tubing through the bed frame
A
Which action will best minimize the patient's risk for vein injury when removing an IV access device from a patient's arm? a. Keep the hub parallel to the skin b. Cleanse the site with an antibacterial swab c. Cut the dressing to facilitate its removal d. Turn the IV tubing roller clamp to the "off" position
A
Which patient does not have a medical condition that contraindicates placement of a nasogastric tube? a. a 28 year old patient who fractured a femur after heavy drinking b. a 73 year old patient who is on anticoagulation therapy c. a 54 year old patient who broke a cheekbone in a fall d. A 67 year old patient with a history of unexplained nosebleeds
A
What diet would you expect to be prescribed for a patient with diagnosed diverticulosis?
A diet high in fiber, with fruits/vegetables that are not heavy in seeds or peels
What is the most important method of diagnosing functional headaches?
A thorough history of the headache
Broad Medications: - Cause stimulant effect on hypothalamic and limbic areas to suppress appetite - Should not be given to children under 12 - Side effects: restlessness, euphoria, insomnia, tachycardia, palpitations, hypertension, seizures, erectile dysfunction
Anorexiants
This hormone regulates osmolarity of the body fluids by influencing how much water is excreted in urine. It is synthesized by neurons and released by the pituitary gland where it then circulates to the kidneys causing resorption of water by the collecting ducts.
Antidiuretic Hormone
What are some of the speech disturbances associated with a TIA?
Aphasia and slurred speech
Definition - The pulse located at the left fifth intercostal space in the midclavicular line; also called the point of maximal pulse
Apical Impulse
Definition: This is the acute inflammation of the veriform appendix that occurs most often in young adults
Appendicitis
Definition: An acute inflammation of the vermiform appendix that occurs most often among young adults
Appendicitis
Definition - A condition in which the airways and air sacs in the lungs collapse or do not expand properly
Atelectasis
Definition: This is condition is characterized by the collapse of the alveoli
Atelectasis
Definition: A form or arteriosclerosis in which deposits of fat and fibrin obstruct and harden the arteries
Atherosclerosis
What are some of the risk factors associated with Strokes?
Atherosclerosis, hypertension, anticoagulation therapy, diabetes mellitus, stress, obesity, and oral contraceptives
Cardiovascular: This is the portion of the heart that receives electrical impulses from the SA node and is located in the lower aspect of the atrial septum. If the SA node fails, this portion initiate and sustain a heart rate of 40-60 BPM
Atrioventricular (AV) Node
Definition: The death of bone tissue
Avascular necrosis
A patient is to receive one unit of packed red blood cells over 2 hours. Which rate is the usual flow rate for the first 15 minutes of blood transfusion? a. 1ml/min b. 2ml/min c. 10ml/min d. 25 ml/min
B
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presences of a pneumothorax in this client? a. A low respiratory rate b. Diminished breath sounds c. The presence of a barrel chest d. A sucking sound at the site of injury
B
What would the nurse use to irrigate a patient's nasogastric tube after providing medications? a. Coffee b. Purified water c. Tea d. Apple juice
B
What would then urse do if he or she were not able to insert a nasogastric tube in either of a patient's nares? a. Ask another nurse to attempt the insertion b. Document the attempts in the patient's medical record c. Notify the physician that the attempts were unsuccessful d. Allow the patient to rest for 30 minutes before resuming the process
B
When administering an intradermal injection, which outcome would require the nurse to withdraw the needle and begin again? a. aspiration of blood prior to injecting the medication b. Inability to feel resistance when injecting the medication c. Formation of a 6 mm bleb at the injection site d. Appearance of a lesion resembling a mosquito bite at the injection site
B
Which action by the nurse ensures patient safety when administering an intramuscular injection? a. Putting on clean gloves before administration b. Rotating injection sites c. Aspirating for blood return when administering a vaccine d. Injecting the medications quickly
B
Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied? a. Pinning the tubing to the patient's hospital gown b. Compressing the bulb while replacing the port cap c. Emptying the drainage container only when its 90% full d. Placing the drainage container below the wound site
B
Which action would the nurse take to diminish tissue irritation when administering a subcutaneous injection to a patient of average size? a. Massage the site after administration b. Make sure the volume of medication is less than 2 mL c. Administer the injection at an angle 45-90 degrees d. Wear clean gloves while administering the injection
B
What would the nurse do to assess a patient's risk for embolus when removing a venous access device? a. Inspect the site for redness b. Visualize the tip of the IV device c. Palpate the site for possible edema d. Ask the patient to rate any pain at the site
B Rationale: damage to the tip of the device, resulting in a portion of the device remaining in the vessel, may cause an embolus to form
Cardiovascular: These are specialized nerve endings affected by changes in arterial BP and are located in the walls of the aortic arch and carotid sinuses.
Baroreceptors
What level of oxygen saturation is deemed to be unacceptable?
Below 93%, below 90% being a clinical emergency
This is the process of splitting the cast down both sides to alleviate pressure on the injured extremity.
Bivalving
This laboratory reading is often elevated in heart disorders such as heart failure and cardiogenic shock that reduce the renal circulation
Blood urea nitrogen
What are the three factors that effect the peripheral vascular resistance?
Blood viscosity, length of vessel, and diameter of vessel
What are some of the visual disturbances associated with the presence of a TIA?
Blurred vision, diplopia, tunnel vision, or hemianopsia
Definition: The realignment of the bone ends for proper healing that is accomplished by a closed method or an open procedure
Bone Reduction
Definition: This is the high-pitched bowel sounds that are proximal to an obstruction
Borborygmi
This portion of the brain contains the medulla, pons, and midbrain and contains special cells that constitute the reticular activating system, which controls awareness and alertness
Brainstem
This condition is an occlusive disease of the median and small arteries and veins. The disease often extends into the tissue around the vessel, resulting in fibrosis and scarring that binds the artery, vein, and nerve firmly together.
Buerger's Disease
A client has experienced a pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? a. Hot, flushed feeling b. Sudden chills and fever c. Chest pain that occurs suddenly d. Dyspnea when deep breaths are taken
C
A client with a chest injury has suffered a flail chest. The nurse assesses the client for which most distinctive sign of flail chest? a. Cyanosis b. Hypotension c. Paradoxical chest movement d. Dyspnea, especially on exhalation
C
A patient is to receive 3 units of packed red blood cells over 8 hours. What will the nurse do to maintain the patency of the patient's IV access line after each of the first two units of blood has been transfused? a. Infuse 0.9% normal saline at 100ml/hour b. Infuse dextrose 5% and 0.9% normal saline at the KVO rate c. Infuse 0.9% normal saline at the KVO rate d. Cap the intravenous line
C
A patient received two 300 ml units of packed red blood cells, and the line was flushed with 25 ml of solution between the units. What is the total amount of fluid the nurse will document having provided to the patient? a. 675ml b. 650 ml c. 625ml d. 600 ml
C
A patient receiving a unit of blood complains of feeling cold and begins to have shaking chills. What is the nurse's first action? a. Measure the patient's temperature b. Measure the patient's blood pressure c. Stop the transfusion d. Place a warmed blanket over the patient
C
What can the nurse do to minimize the patient's risk for injury when delivering an intramuscular injection? a. Instruct the patient to relax b. Insert the needle at a 45 degree angle c. Pull back on the plunger after inserting the needle d. Pull the skin taut at the injection site when inserting the needle
C
What would the nurse do before providing the patient with a scheduled intermittent feeding through a nasogastric tube? a. Listen to bowel sounds b. Listen to lung sounds c. Check NG tube placement d. Turn the patient onto his or her left side
C
What would the nurse do if material aspirated from a patient's nasogastric tube resembled coffee grounds in color and texture? a. Check the tube placement b. Assess the pH of the contents c. Notify the health care provider d. Irrigate the tube with water
C
When checking gastric aspirate from an NG tube, the nurse assesses a pH of 7. What would the nurse do next? a. Nothing, since this is an expected pH value b. Advance the tube c. Anticipate a chest x-ray d. Pull back on the tube
C
Which action by the nurse helps toe ensure patient safety when administering IV fluids by gravity to very young children? a. using microdrip tubing for the infusion b. Using macrodrip tubing for the infusion c. Using a volume-control device for the infusion d. Not infusing more than 25 mL/hour for IV fluids
C
Which instruction might the nurse give to the NAP regarding the care of a patient with a nasogastric tube? a. Remember to aspirate 5 to 10 mL of stomach contents before flushing the tube b. Let me know if the patient complains of anything related to the NG tube placement c. Tell me if you see any vomit in the patient's mouth during oral care d. Please see if the NG tubing has advanced at all
C
Definition - The volume of blood ejected by the heart each minute
Cardiac Output
Definition: This condition is characterized by fluid filling the space between the parietal and visceral layers of the pericadium
Cardiac Tamponande
Enemas: This enema provides relief from gaseous distension.
Carminative Solution Enema
Definition: A rigid device that immobilizes the affected body part while allowing other body parts to move
Cast
This portion of the brain receives immediate and continuous information about the condition of the muscles, joints, tendons.
Cerebellum
This portion of the brain is involved with almost all of the higher functions of the brain. Helps process and communicate all information coming from the peripheral nervous system and translates impulses into understandable feelings and thoughts
Cerebral Cortex
What nutritional education should be provided to patients with an ostomy?
Chew food thoroughly. Be cautious with foods high in fiber or cellulose.
Definition: Inflammation of the gallbladder that may occur as an acute or chronic problem
Cholecystitis
Intravenous Complications: How would you treat a patient that is presenting with signs and symptoms of air embolism after receiving intravenous therapy?
Clamp the system, place patient on the left side with the head of the bed raised
Enemas: This is the broad classification of enema that is used to promote the complete evacuation of feces from the colon.
Cleansing Enema
Definition: The sudden, brief, jerking contraction of a muscle or muscle group often seen in seizures
Clonus
Definition: A fracture that does not extend through the skin
Closed Fracture
Headache: This type of headache is characterized by severe, steady, penetrating head pain that is often caused by agitation or restlessness
Cluster
Types of Headaches: Characterized by severe unilateral burning pain located behind or around the eyes
Cluster
The mucosal surface of the colon in Crohn's disease often resembles what?
Cobblestone
Definition: The complex integration of mental processes and intellectual function for the purposes of reasoning, learning, memory, and personality.
Cognition
These are the blood vessels that provide blood to an area with altered tissue perfusion through smaller vessels.
Collateral Circulation
When comparing areas of the body possibly affected by peripheral vascular disease, it is important to assess bilaterally for what?
Color, symmetry, temperature, capillary refill, and hair patterns
Fracture Type: With this fracture, there is a break across the entire width of the bone in such a way that the bone is divided into two distinct sections
Complete Fracture
Fracture type: This fracture is produced by a loading force applied to the long axis of cancellous bone. This commonly occurs in the vertebrae of older patients
Compression Fracture
Definition: When this occurs, the joint cannot achieve full ROM. This sometimes leave a joint or joints in a nonfunctional position.
Contracture
Definition: This condition is characterized by narrowing or obstruction of 1 or more coronary arteries as a result of atherosclerosis. This condition decreases myocardial oxygen supply.
Coronary Artery Disease
This is the type of anti-inflammatory medication that is given in acute episodes of Crohn's disease and has long term effects such as fat deposits
Corticosteroids
A client in sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure of 82/60 mmHg reports dizziness. Which intervention should the nurse anticipate will be prescribed? a. Administer digoxin b. Defibrillate the client c. Continue to monitor the client d. Prepare for transcutaneous pacing
D
A patient prescribed two units of packed red blood cells is to receive a dose of intravenous medication between the two units. How would the nurse administer the medication? a. In the IV line for the blood product during the transfusion b. In th IV line for the blood product when the line is flushed with normal saline c. In oral form d. Through another IV line.
D
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? a. Slow, deep respirations b. Rapid, deep respirations c. Paradoxical respirations d. Pain, especially with inspiration
D
What can the nurse do to ensure proper site selection for subcutaneous insulin injection? a. Insert the needle at a 30 degree angle b. Select a different anatomical region for each injection c. Ask the patient to relax before inserting the needle d. Systematically rotate sites within the same anatomical location or area
D
What will the nurse do to preventp ossible complications after removing an IV access device in a patient on anticoagulant therapy? a. Instruct the patient to report immediately any sign of bleeding on the site dressing b. Perform hand hygiene and wear clean gloves while removing the device c. Encourage the patient to keep a cold compress on the site for 15 minutes d. Apply firm pressure to the site with sterile gauze for 10 minutes
D
Which action by the nurse helps to ensure that the medication is delivered into the muscle when administering an intramuscular injection? a. Using a 1 inch needle b. Inserting the needle at a 45-60 degree angle c. Withdrawing the needle immediately after delivering the medication d. Aspirating for blood return before injecting the medication
D
In a patient suffering from coronary artery disease, what diet would you recommend?
DASH diet
During the assessment of this vascular disorder you may find calf or groin tenderness or pain with or without swelling, a positive homan's sign may be present, and the skin is tender to the touch
DVT
Definition: Abnormal movement with rigidity characterized by extension of the arms and legs, pronation of the arms, plantar flexion, and body spasms in which the body is bowed forward
Decerebration
Definition: Abnormal motor movement seen in the patient with lesions that interrupt the corticospinal pathways
Decortication
These are common signs and symptoms associated with an increased intracranial pressure
Decreased LOC, Behavioral changes, headache, N/V, aphasia, dysarthria, seizures, Cushing triad, and postural changes
What are some assessment findings you may note with the presence of Crohn's disease?
Decreased or absent bowel sounds. Areas of high-pitched or rushing sounds. Muscle guarding, masses, rigidity, or tenderness
What are the causes of venous insufficiency?
Deep vein thrombosis or a history of varicose veins
What are the neurodevelopmental problems that characterize ADHD in early childhood?
Distractibility, impulsivity, hyperactivity, and inattention
Definition: These are pouchlike herniations of the mucosa through the muscular wall of any part of the gut, but most commonly in the colon
Diverticula
Definition: The inflammation or infection of the diverticula
Diverticulitis
Definition: The presence of many abnormal pouchlike herniations in the wall of the intestine
Diverticulosis
Although oropharyngeal suctioning may be delegated to nursing assistive personnel, you should not routinely delegate the procedure when?
During the immediate postoperative period for a patient who has had oral or neck surgery.
Definition: An epigastric burning sensation, often referred to as "heartburn"
Dyspepsia
What are some of the key features associated with GERD?
Dyspepsia, painful swallowing, pharyngitis, epigastric pain, nausea, heartburn, regurgitation, belching.
Definition - The subjective sensation of difficult or uncomfortable breathing or observed labored breathing with shortness of breath
Dyspnea
What are common manifestations associated with Left-Sided Heart Failure?
Dyspnea, orthopnea, cardiac asthma, rales, productive cough, fatigue, restlessness, anxiety, weakness, pulsus alternans
This is a test that uses ultrasound waves to assess cardiac structure and mobility, particularly of the valves.
Echocardiography
Categories of Surgery: What are the three categories of surgical procedures?
Elective, Urgent, and Emergent
How would you initially treat a patient experiencing cardiovascular shock.
Elevate head 10 degrees and elevate legs 20 degrees
Stroke Manifestations: - Sudden, severe symptoms - Warning signs are less common - Client remains conscious and may have headache
Embolic Stroke
Definition: A destructive problem of lung elastic tissue that reduces the ability to recoil after stretching and leads to hyperinflation of the lungs
Emphysema
What would you do to prevent muscle atrophy when a patient is in a cast?
Encourage isometric exercises every 4 hours
This is the portion of the brain that helps regulate emotion and contribute to smooth voluntary motor function
Epithalamus
How frequently should you assess the vascular access site after completion of infusion for a patient that is critically ill, sedated, or cognitively impaired.
Every 1 to 2 hours
A patient receiving a unit of blood begins to show signs of a transfusion reaction. How frequently should the nurse monitor the patient's vital signs after stopping the transfusion?
Every 15 minutes
How frequently should the pouching system be changed for a patient with an ostomy?
Every 3 to 7 days
After the first 24 hours of traction, how frequently should you assess patient circulation?
Every 4 hours
How frequently should you assess the vascular access site after completion of infusion for an adult who is alert, oriented, and reports no problems at the site?
Every 4 hours
During the postoperative phase of care, how often should the cerebral functioning and level of consciousness be assessed?
Every 4 to 8 hours
How frequently should skin traction be released (if available to) in order to inspect skin?
Every 8 hours
How frequently should you assess the cast of the patient?
Every 8 to 12 hours
For the first 24 hours of traction, how often should you assess patient circulation?
Every hour
Definition: The total separation of wound layers with the protrusion of visceral organs through the wound opening
Evisceration
Definition: The total separation of all wound layers and protrusion of internal organs through the open wound.
Evisceration
A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in cranial pressure if the nurse observes the client doing which activity?
Exhaling during repositioning
Definition: A surgical procedure in which pins or wires are inserted through the skin and affected bone and then connected to a rigid external frame outside the body to immobilize the fracture during healing
External fixation
What are contraindications for performing nasotracheal and nasopharyngeal suctioning?
Facial/neck trauma/surgery or gastric surgery, bleeding disorders or nasal bleeding, epiglottitis or croup, occluded nasal passages, or laryngospasm or irritable airway.
Definition: A procedure for acute compartment syndrome in which the surgeon cuts through the fascia to relieve pressure and tension on vital blood vessels and nerves
Fasciotomy
Definition: This is another serious complication of fractures in which fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after injury
Fat Embolism
What are some of the signs and symptoms of Multiple Sclerosis?
Fatigue/weakness, tremors, paresthesias, blurred vision, diplopia, dysphasia, decreased perception of pain/touch/temperature, abnormal reflexes, and memory changes
What are key features associated with the presence of a rolling hiatal hernia?
Feeling of fullness, breathlessness, feeling of suffocation, chest pain mimicking angina, worsening of symptoms in recumbent position
When assessing laboratory results for a patient at risk for CAD, what is the desired level for Plasma High-Density Lipoproteins (HDLs)?
Females >55 mg/dL Males >45 mg/dL
When treating a patient with ulcerative colitis or crohn's disease it is important to assess _______ as the result of diarrhea?
Fluid and electrolyte balance
Definition: This is a very common health problem worldwide that causes diarrhea and/or vomiting related to inflammation of the mucous membranes of the stomach and intestinal tract
Gastroenteritis
What are a few examples of non-modifiable risk factors associated with Coronary Artery Disease?
Gender, race, genetic predisposition, and age
This is the tool used in many acute care settings to establish baseline data in each of these areas: eye opening, motor response, and verbal response. The patient is then assigned a numeric score for each area. The lower the score, the lower the patient's neurologic function
Glasgow Coma Scale
Definition: A systemic disease in which urate crystals deposit in joints causing severe joint inflammation
Gout
Grand Mal/Petit Mal - Most common - Generalized alternating muscle spasms and jerkiness
Grand Mal
What are some of the signs and symptoms associated with an increased intracranial pressure?
Headache, abnormal respirations, rise in BP, Slowing pulse, elevating temp, vomiting, pupil changes
Cardiovascular: This is the inability of the heart to maintain adequate cardiac output to meet the metabolic needs of the body. This may cause congestion of the lungs and/or periphery
Heart Failure
Definition: The syndrome resulting from a cardiac disorder that impairs the ventricles ability to fill and effectively pump blood
Heart Failure
Definition: A collection of blood in the tissues that can occur as a result of a subarachnoid hemorrhage or an intracerebral hemorrhage
Hematoma
Stroke Manifestations: - Sudden onset of symptoms - Symptoms progress over minutes to hours due to ongoing bleeding
Hemorrhagic
This is the second major classification of stroke and happens when vessel integrity is interrupted and when bleeding occurs into the brain tissue or into the subarachnoid space
Hemorrhagic Stroke
Wound Healing: This phase is a series of physiological events designed to control blood loss, establish bacterial control, and seal the defect. During this phase, blood vessels constrict and platelets gather to stop bleeding.
Hemostasis
What are some of the risk factors associated with osteoporosis?
Hx of fractures, low body weight, cigarette smoking, use of oral corticosteroids for more than 3 months, women that are postmenopausal
Definition: This condition is characterized by the noninflammatory collection of serous fluid within the pleural cavities.
Hydrothorax
Definition: Increased partial pressure of arterial carbon dioxide levels
Hypercarbia
Enemas: This enema exerts osmotic pressure that pulls fluids out of the interstitial space. When the colon fills with water, the resultant distention promotes defecation. This enema is best used in patients that are unable to tolerate large volumes of fluid
Hypertonic Solution Enema
This is the portion of the brain that regulates autonomic responses of the sympathetic and parasympathetic nervous system.
Hypothalamus
This is the portion of the brain that regulates stress response, sleep, appetite, body temperature, fluid balance, and emotions
Hypothalamus
Intravenous Complications: Skin around catheter site taut, blanched, cool to the touch, edematous; may be painful. Infusion rate may be slowed or stopped.
Infiltration
Wound Healing: This phase consists of mast cells secreting histamine resulting in surrounding capillaries and movement of serum and white blood cells to the damaged tissues.
Inflammatory Phase
Outflow or Inflow disease: Obstructions in the distal end of the aorta and common, internal, and external iliac arteries that results in pain or discomfort in the lower back, buttocks, or thighs
Inflow Disease
Types of Care: Involves overnight care of 24 hours or greater in a health care facility
Inpatient Care
When performing tracheostomy care, how far should you insert the suction catheter for a patient at high risk for suction-related complications?
Insert the catheter into the tracheostomy tube until it emerges out of the end of the airway.
Definition: The presence of excess joint fluid, especially common in the knee
Joint Effusion
Definition: This is the removal of a part of the vertebral lamina. The surgery is done to relieve pressure on the nerves. It is often combines with removal of the protruding nucleus pulposus
Laminectomy
This portion of the gastrointestinal tract is responsible for movement, absorption, and elimination.
Large Intestine
Areas of the Heart: Receives oxygenated blood from the pulmonary veins through the mitral valve. This pumps blood into the left ventricle
Left Atrium
Where is pain associated with diverticulitis most often located?
Left Lower Quadrant of the abdomen
Areas of the Heart: Generates enough pressure to close the mitral valve and open the aortic valve. From here, blood is propelled into the aorta and the systemic arterial circulation
Left Ventricle
What are the earliest signs and symptoms associated with the presence of a fat embolism?
Low PaO2, dyspnea, and tachypnea
What are systemic signs and symptoms associated with Rheumatoid arthritis?
Low-grade fever, fatigue, weakness, anorexia, and paresthesias
When assessing a patient with suspected Arterial Insufficiency, how would the blood pressure of the lower extremities compare to those of the upper extremities?
Lower extremity blood pressure will be lower than upper extremity blood pressure.
Cardiovascular: Where is Angiotensin I is converted to Angiotensin II?
Lungs
This is a noninvasive procedure that identifies tissues, tumors, and vascular abnormalities. It is similar to a CT scan but provides more detailed pictures
MRI
This type of test is used to detect abnormalities in the brain's biochemical processes, such as that which occurs with epilepsy, Alzheimer's disease, and brain attack.
Magnetic Resonance Imaging
This type of test is used to evaluate perfusion and blood vessel abnormalities such as an arterial blockage, intracranial aneurysms, and AV malformations.
Magnetic Resonance Spectroscopy
What are some of the health promotion and maintenance recommendations for patients suffering from OA?
Maintain proper nutrition, take adequate work breaks, avoid repetitive motion or joint stress, stay active and maintain a healthy lifestyle
What are some of the signs and symptoms associated with ulcerative colitis?
Malaise, anorexia, anemia, dehydration, fever, and weight loss Patients may report tenesmus and lower abdominal colicky pain relieved with defecation
What are the normal hemoglobin levels for an individual
Male = 13-17 g/dL Female = 12-16 g/dL
Types of Care: Provides members with health services where costs have been determined by the managed care company and health care providers
Managed Care
Wound Healing: The final stage of healing and can take place for more than a year depending on the depth and extent of the wound. Collagen scar continues to reorganize and gain strength for several months
Maturation Phase
As the inflammation and infection of appendicitis progress, the pain becomes more severe and shifts the RLQ between the anterior iliac crest and the umbilicus. This location is referred to as the what?
McBurney point
Definition - The arterial blood pressure necessary (between 60 and 60 mmHg) to maintain perfusion of major body organs.
Mean Arterial Pressure
What is the proper way to measure the length of the nasogastric tube before insertion in an adult patient?
Measure the distance from the tip of the nose to the earlobe to the xyphoid process or mid umbilicus
Definition: A shift of the central thoracic structure towards one side
Mediastinal shift
Types of Care: Developed to meet the needs of ill children whose health care required constant coordination. Consists of an interprofessional health care team who continually communicate with the family and patient to ensure the comprehensive care is delivered
Medical Home
Enemas: This broad type of enema helps patients experiencing high levels of potassium or it can be used to help reduce bacteria in the colon before surgery
Medicated Enema
Brainstem: This portion of the brainstem includes the cardiac-slowing center, and the respiratory center
Medulla
Definition: The ability of an individual to retain and recall information for learning or recall of past experiences
Memory
This is the protective covering of the brain and the spinal cord.
Meninges
Medication Description: ADHD medication - Short duration with fast onset - Should be taken before school and last at 6pm to prevent insomnia - May cause weight loss and growth depression - Should provide a drug holiday during summer
Methlyphenidate (Ritalin)
Brainstem: This portion of the brainstem contains the cerebral aqueduct and the periaqueductal gray, which may abolish pain when stimulated
Midbrain
Headache: Beta Blockers can often be used to help prevent this type of headache
Migraine
Headaches: Sumatriptan and Zomig are often used to treat this type of headache
Migraine
Cardiovascular: Patients suffering from this may report a heavy viselike pain that radiates to the shoulders and down the arms or to the neck, jaw, and back. Other common locations for this pain are in the substernal, retrosternal, or epigastric areas
Myocardial Infarction
Cardiovascular: This can occur when myocardial tissue is abruptly and severely deprived of oxygen. It can lead to necrosis of myocardial tissue if blood flow is not restored.
Myocardial Infarction
Definition: Chest pain with longer duration than normal angina and is unrelieved with nitroglycerin
Myocardial Infarction
Cardiovascular: This is an oxygen-binding protein found in cardiac and skeletal muscle. The level of this protein rises within 2 hours after cell death and has a rapid decline in level after 7 hours but is not cardiac-specific
Myoglobin
Definition: This condition is characterized by excessive daytime sleepiness, cataplexy, and vivid auditory or visual perceptions
Narcolepsy
The presence of a wheeze would indicate which abnormality within the lungs?
Narrowing of the upper bronchi
Lobes of the Brain: Primary visual center
Occipital Lobe
Enemas: This type of encourages the evacuation of the bowels by lubricating the feces in the rectum and colon. To enhance the action of this enema, patients should retain the enema for several hours if possible
Oil Retention Enema
What is the typical age of onset for patients with osteoarthritis?
Older than 60 years old
During the presurgical phase, it is important to understand what about the patients prescribed medications?
On the day of surgery, the patient's usual drug schedule may need to be altered.
When assessing a patient in respiratory distress, you would not be able to palpate fremitus in what situation?
On the side of a collapsed lung
Definition: A fracture that extends through the skin, causing visible wound
Open Fracture
Definition: Shortness of breath that occurs when lying down and is relieved by sitting up
Orthopnea
Definition - A decrease in blood pressure that occurs the first few seconds to minutes after changing from a sitting or lying position to a standing position
Orthostatic Hypotension
Definition: The progressive deterioration and loss of articular cartilage and bone in one or more joints
Osteoarthritis
What are the 6 P's associated with the presence of acute compartment syndrome?
Pain, pressure, paralysis, paresthesia, pallor, and pulselessness
Lobes of the Brain: Understanding sensory input, three-dimensional perception, perception of body parts and position awareness, and taste impulses for interpretation
Parietal Lobe
Definition: This is a degenerative disease caused by the depletion of dopamine, which interferes with the inhibition of excitatory impulses, resulting in a dysfunction of the extrapyramidal system
Parkinson's Disease
In what situations would a hypertonic solution enema be contraindicated
Patients that are dehydrated or with young infants
Definition: The way an individual feels and behaves, often based on how he or she thinks
Personality.
Grand Mal/Petit Mal - Brief loss of consciousness (10 seconds or less) - Usually occurs in children
Petit Mal
Definition: A persistent altered sensory perception in the amputated body part that is unpleasant or painful
Phantom Limb Pain
Postoperative Phases: Occurs immediately after surgery, and the length of time the patient remains in this phase depends on the health status, surgical procedure, anesthesia type, and rate of progression to regain alertness and hemodynamic stability. Can range from 1 hour to days
Phase 1
Definition: A condition that can be caused by intravenous therapy characterized by inflammation of the vein
Phlebitis
Definition: This is the traditional way of casting and can often take more than 24 hours to dry depending on size and location.
Plaster Cast
Definition The build-up of excess fluid between the layers of pleura outside the lugns
Pleural Effusion
The presence of pleural friction rub would indicate which abnormality within the lungs?
Pleural Inflammation
This condition is characterized by an infection of the pulmonary tissue, including the interstitial space, alveoli, and bronchioles. This condition is the seventh leading cause of death in the U.S. and leading cause of deaths from infectious disease.
Pneumonia
What are some examples of postoperative complications related the respiratory system?
Pneumonia and Atelectasis
Brainstem: This portion of the brainstem includes the cardiac acceleration and vasoconstriction centers, and the pneumotaxic center that helps control respiratory patterns] and rate
Pons
Respiratory: This test is used to evaluate lung mechanics, gas exchange, and acid-base disturbance through spirometric measurements, lung volumes, and arterial blood gas levels
Pulmonary Function Test
Cardiovascular: This is a network of conducting strands in the heart beneath the ventricular endocardium. This network spreads the wave of depolarization through the ventricles but can act as a pacemaker with a rate between 20 and 40 BPM
Purkinje Fibers
This breathing technique helps slow the respiratory rate and maintain open airways during exhalation by keeping positive pressure in the airways
Pursed-Lip Breathing
Wound Drainage: This drainage appears thick, yellow, green, tan, or even brown
Purulent
This condition is present with blanching of the extremity caused by vasospasm of the superficial arterioles and arteries. May present with a reddish color upon relief of vasospasm, and may be numb, tingling, swollen, and cold.
Raynaud's Disease
Definition: A high-level of thinking process that allows an individual to make decisions and judgments
Reasoning
Definition This is a system within the body that regulates the ECF volume by influencing how much sodium and water are excreted in the urine. The process begins when specialized cells within the kidneys excrete the enzyme renin
Renin-Angiotensin-Aldosterone System
Definition: This is a system within the body that regulates the ECF volume by influencing how much sodium and water are excreted in the urine. The process begins when specialized cells within the kidneys excrete the enzyme renin.
Renin-Angiotensin-Aldosterone System
A patient has a blood transfusion reaction, and the transfusion is stopped. What should the nurse do with the remaining blood and transfusion administration set?
Return both to the blood bank
Areas of the Heart: Most blood passively flows here from the RA through the opened tricuspid valve. From here blood is propelled into the pulmonary artery to the lungs
Right Ventricle
Hiatal Hernia Type: The gastroesophageal junction remains in its normal intra-abdominal location, but the fundus rolls through the esophageal hiatus and into the chest beside the esophagus.
Rolling
Heart Sounds: The first heart sound that is heard as the atrioventricular valve closes and is heard loudest at the apex of the heart
S1
Heart Sounds: This is the heart sound that is hear when the semilunar valves close and is heard loudest at the base of the heart
S2
Heart Sounds: These two heart sounds are abnormal and are only heard in conditions like heart failure, valvular regurgitation, or atrial systole
S3 and S4
Types of Drainage: Bloody, red drainage
Sanguineous
Wound Drainage: This drainage is bright red and indicates active bleeding
Sanguineous
Types of Drainage: Yellowish mixed with light red or pale pink
Serosanguineous
Wound Drainage: This drainage can be pale, pink, wattery, and is a mixture of clear and red fluid
Serosanguineous
Types of Drainage: Normal drainage during the first few days
Serous
Wound Drainage: Drainage that appears like clear, watery plasma
Serous
When assessing the patients abdomen you should ensure that you do what before you percuss or palpate the abdomen?
Should always auscultate before because percussion and palpation can alter bowel sounds
Although diverticula can occur in any part of the intestinal tract, where do they occur most frequently?
Sigmoid colon
Cardiovascular: This is the portion of the heart that is the main pacemaker and initiates each heartbeat. It is located at the junction of the superior vena cava and right atrium.
Sinoatrial (SA) Node
Hiatal Hernia Type: The esophagogastric junction and a portion of the fundus of the stomach slide upward through the esophageal hiatus into the chest
Sliding
What are the differences in clinical manifestations between a sliding and rolling hiatal hernia?
Sliding - heartburn, substernal discomfort, dysphagia Rolling - Feeling of fullness after eating, breathlessness, chest pain
When assessing a post-operative patient with new stoma, it is not uncommon to see what?
Slight edema and/or bleeding
This is the longest and most convoluted portion of the digestive tract and is composed of three different regions: duodenum, jejunum, and ileum. The three main functions of this portion are movement, digestion, and absorption
Small Intestine
Enemas: This enema stimulates peristalsis by irritation of the intestinal tract. This enema consists of tap water or saline combined with soap.
Soapsuds Enema
Nociception: Well localized, sharp, stabbing, or dull, aching, cramping pain
Somatic
Angina Type: - occurs with activities that involve exertion or emotional stress - Relieved with rest or nitroglycerin - Stable pattern of onset, duration, severity, and relieving factors
Stable
This is a condition categorized by a red/brownish discoloration of the skin (usually on the lower extremities) that appears dry, scaling, and thickened. This condition is caused by the blood and water pooling in the lower legs.
Stasis Dermatitis
Fracture type: This type of fracture results from excessive strain and stress on the bone
Stress Fracture
Cardiovascular: These are specialized receptors located in the vena cava and right atrium that respond to pressure changes that affect circulatory blood volume
Stretch Receptors
This condition often manifests as a sudden focal neurological deficit and is caused by a cerebrovascular disease
Stroke
Definition - The amount of blood ejected by the left ventricle during each contraction
Stroke Volume
What are some of the manifestations associated with venous insufficiency?
Swelling, thickened skin, cyanosis, stasis dermatitis, superficial ankle ulcers with uneven margins and bleeding.
What are some of the side effects/adverse reactions associated with the use of amphetamines?
Tachycardia, palpitations, hypertension, restlessness, insomnia, dysrhythmias, tremors, anorexia, dry mouth, weight loss
Headaches: This type of headache can often occur after prolonged computer usage or eye disorders
Tension
While Crohn's disease can affect any part of the digestive tract, it most often affects which area?
Terminal ileum and ascending colon
This is the portion of the brain responsible for relaying sensory impulses to the cortex, provides a pain gate, and is part of the reticular activating system
Thalamus
Medication Description: - Analeptic medication - Used for neonatal apnea
Theophylline
Patients with this type of ischemia stroke show improvements over weeks to months but there is the possibility of permanent deficits.
Thrombotic Stroke
Stroke Manifestations: - No decreased level of consciousness within the first 24 hours - Symptoms get progressively worse as the infarction and edema increase
Thrombotic Stroke
This type of ischemic stroke is caused by a clot and usually has a gradual onset of minutes to hours
Thrombotic Stroke
This type of ischemic stroke may have deficits during the first few weeks such as: slight headaches, speech deficits, visual problems, and confusion
Thrombotic Stroke
This type of ischemic stroke most commonly occurs in older adults at rest or during sleep due to circadian patterns. The progression of this stroke is gradual and worsens over 1-2 days
Thrombotic Stroke
Definition: The amount of air that you inhale and exhale with a normal quiet breath
Tidal volume
This refers to the blood that flows through arteries and capillaries to target tissues and allows for the delivery of oxygen, fluid, and nutrients to cells
Tissue Perfusion
What is the primary purpose of skin traction?
To decrease painful muscle spasms that are accompany hip and proximal femur fractures
Why would an NG tube be used following bowel surgery?
To help decompress stomach and allow bowel to heal
Definition: Hard, irregularly shaped nodules in the skin conntaining chalky deposits of sodium urate
Tophi
Definition: Massive dilation of the colon and subsequent colonic ileus that can lead to gangrene and peritonitis
Toxic Mega Colon
Definition: The application of a pulling force to a part of the body to provide bone alignment or relief of muscle spasm
Traction
What are the three elements of traction?
Traction, countertraction, and line of pull
Intravenous Complications: Dyspnea, cough, crackles, or rales in dependent lobes of lungs, distended neck veins when upright.
Transfusion-Associated Circulatory Overload
This is often a warning sign of an acute ischemic attack and is characterized by temporary neurologic dysfunction resulting from a brief interruption in cerebral blood flow.
Transient Ischemic Attack
Cardiovascular: This is protein has a high affinity for myocardial injury; it rises within 3 hours and persists for up to 7-10 days
Troponin
Definition: This myocardial muscle protein is released into the bloodstream after injury to myocardial muscle. A rise in values indicates cardiac necrosis or acute MI
Troponin
True or False: There is a higher prevalence of IBS among women?
True
True or False: With Crohn's disease, interdisciplinary care includes dietary measures and medications
True
True/False: Symptoms of OA are often relieved after rest or sleep and worsen after extended activity.
True
When assessing a patient's stoma, what should you be looking for?
Type, location, color, swelling, trauma, healing or irritation of the skin.
Definition: A disease that creates widespread chronic inflammation of the rectum and rectosigmoid colon but can extend to the entire colon when the disease is extensive
Ulcerative Colitis
Ulcerative Colitis or Crohn's Disease: Hemorrhage is more common in this condition
Ulcerative colitis
Angina Type: - Associated with worsening cardiac ischemia - Occurs with an unpredictable degree of exertion or emotion and increases in occurrence, duration, and severity - Lasts longer than 15 minutes - Pain not relieved with nitroglycerin
Unstable
When performing tracheostomy care, how far should you insert the suction catheter for a patient not at risk for suction-related complications?
Until resistance is met, then pull back 1 to 2 cm.
Definition: Raise, irregularly shaped skin eruptions with varying sizes and shapes; eruptions have reddened margins and pale centers
Urticaria
Angina Type: - Results from coronary artery spasm - may occur at rest - Associated with ST-segment elevation noted on ECG
Variant
Definition: This type of vein is categorized by a dialated, tortuous and thickened appearance which is more prominent in a dependent position
Varicose Vein
Arterial or Venous Insufficiency: Edema, venous stasis, stasis dermatitis or brown discoloration, ulcers with uneven edges
Venous
This branch of the vascular system completes the circulation of the blood by returning blood from capillaries to the right side of the heart.
Venous System.
Normal Lung Sounds: This sound is a soft rustling sounds heard in lung tissue over small bronchioles
Vesicular
Nociception: Organs and the lining of body cavities, poorly localized, diffuse, deep cramping, or pressure, sharp, stabbing
Visceral
What are some of the motor/mobility disturbances associated with the presence of a TIA?
Weakness, facial droop, arm or leg drift, hand grasp, and ataxia
At what point can an NG tube be removed after bowel surgery?
When the client can pass gas
After the application of a plaster cast, it is important to ensure that you handle the cast in what manner?
With the palms of the hand to prevent damage
Definition: A partial or complete separation of the outer wound layers, sometimes described as a splitting open of the wound. This occurs most often between the fifth and tenth day after surgery and occurs more often in patients with diabetes, obesity, immune deficiency, or malnutrition
Wound Dehiscence
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What is the location that a normal allergy or TB test would be administered?
pal side of the forearm about 5 to 10 cm below the elbow.
Types of Headache: Characterized by bilateral pain with sensation of a band of tightness or pressure around the head
tention
What is the difference between Urgent and Emergent surgical procedures?
urgent prompt interventions and can be life threatening if delayed for more than 24-48 hours. Emergent requires immediate intervention
