exam 3 204

Nurse providing care on long term care unit who is at a high risk of developing pressure injuries?

-patient w/ spinal cord injury -patient who is comatose -Patient w/ urinary incontinence -immobile patient w/ excessive would drainage

PCP Schedules a bone scan for a client w/ osteoporosis. Which nursing action is beneficial for the client?

-placing client in supine for 1 hr for easy assessment -instructing the client to empty their bladder before the scan

While reviewing a patients lab results, nurse finds Blood urea nitrogen (BUN) level of 30 mg/dL. Which complication does the nurse antici[ate in the patient?

-severe dehydration -congestive heart failure -acute glomerulonephritis

Increase of billirubin in blood, decrease in urine. What is the problem?

-steatorrhea: fecal fat that occurs with obstructive jaundice

Why is contrast used in CT scans?

-to help highlight the areas of your body being examined. -better accuracy

decreased kidney perfusion

-would be increased by specific gravity of the urine -normal range is 1.005-1.040

What are nursing interventions proven to prevent pressure injuries?

-Frequent turning every 2 hours (Q2 hrs) -head of bed at 30 degrees -use of moisture barriers, creams, ointments -gel pads -inflatable mattresses/water beds -keeping skin dry & cool

Rickets

-Vitamin D deficiency in children -Softening of bones due to failure to calcify normally Symptoms include: -Bowed legs -Enlarged head -Joints -Rib cage -Deformed pelvis

Which term would be used by a nurse conducting a health awareness program on eating disorders?

-anorexia nervosa -bulimia nervosa -anorexia in teens

complication assessed in ultrasound of the heptaobillary system?

-calculi: stone in billary tract -cirrhosis: scarring of the liver

During assessment of older patient, nurse finds patient is susceptible to pressure injury. Which action would the nurse take to prevent a pressure injury for this patient?

-change patients position once every 2 hrs -prevent patients inner knees from pressing into each other ( you dont want skin on skin contact at any time) -avoid placing the patient in positions that increase stress on bony prominences

acid base imbalances

-changes in pH of urine can indicate this -average pH of urine is 6 or between 4.6-8.0

A patient w/ multiple bone fractures is experiencing difficulty w/ voluntary movement secondary to the casts. Nurse identifies red skin that blances with application of pressure over the spinal area. Which action would decrease patients risk of developing pressure injuries?

-check skin around casts regularly -take care to avoid friction injuries during repositioning, bathing, transferring patient -use good hygiene techniques to ensure the patients skin is clean and dry after bowl movements

Upon examination of the 56 y/o patient who is hemiplegic, nurse providing care at a long term care facility notices a pressure injury of the skin over the sacrum. which factor may influence the development of bed ulcers in this patient?

-chronic immobility can cause pressure injuries -dehydration of the body can cause pressure injuries -edema of the skin can cause pressure injuries

would healing by secondary intention

-chronic wound fails to progrress to healing in a timely manner; often remaining open for extended periods of time -new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue

Upon finding redness, foul odor, increased drainage at the site of a patients wound, which action, taken by a nurse indicates need for further teachings

-covers the wound w/ transparent film -uses a hydrocolloid dressing for wound

Which patient condition would cause the nurse to monitor for develop,emt of hypoklameia?

-diarrhea -vomiting -potassium-wasting diuretics usage

Which intervention would the nurse undertake before a scheduled intravenous pyelogram (IVP) for a client with a renal disorder?

-ensure that a consent form is signed (it is invasive) -assess the client for iodine sensitivity (contrast may cause hypersensitivity) -administer an enema or cathartic to the client (to empty colon of feces and gas) -client may be asked to turn certain ways

Which food does the nurse include when preparing a diet plan for a patient with hypokalemia (low potassium)?

-fish -cantaloupes -bananas -oranges (orange juice is a good source of potassium)

Which manifestation in a patient who is on tube feeding suggests intolerance to feedings?

-high gastric residual (lots of tube feeding that is not getting digested, going to cause nausea and vomiting) -nausea -vomiting -cramping

Phases of healing

-inflammatory: Increase in pain, redness (3 days) -proliferative: filling in the wound bed with new tissue (granulation tissue) and resurfacing the wound to the skin (several weeks) -maturation: remodeling phase (can last up to a year)

antidiuretic hormone (ADH)

-influences the absorption of water by kidney tubules -A hormone that helps blood vessels constrict and helps the kidneys control the amount of water and salt in the body. -anti- against diuretic-promote urine output

pernicious anemia

-lack of mature erythrocytes caused by inability to absorb vitamin B12 into the bloodstream -b12 deficiency

When a client with chronic dyspnea is scheduled for computed tomography (CT) using contrast, which assessment information would the nurse communicate to the HCP before the procedure?

-metformin taken today (supposed to be stopped 24 hrs before procedures tht require contrast) -serum creatinine 2.1 mg d/l (contrast is nephrotoxic & nurse would inform provider tht this is elevated) -shellfish allergy

right-shift differential WBC

-occurs in clients with liver disease and pernicious anemia -a shift to the left occurs in an infectious process and is related to immature neutrophils

bone scan assesses

-osteomyelitis (bone infection caused by fungi in bone), -osteoporosis (bone density & bone mass decreases), -primary malignant (tumor), -metastatic malignant lesions of a bone (break away from where they are orig formed (primary) & travel thru blood or lymph -certain fractures

Which finding would a nurse assess a presence after application of a patients bandage?

-pallor -paresthesia ("pins & needles") -pulselessness

main risk of myelogram is a

spinal headache that usually resolves w/in 2 days of a procedure myelogram-involves the introduction of a spinal needle into the spinal canal and the injection of contrast material in the space around the spinal cord and nerve roots (the subarachnoid space) using a real-time form of x-ray called fluoroscopy

Which diagnostic study is used to determine bone density?

standard x ray

calculi

stone in billiary tract

The nurse is caring for a patient who is sceduled for a colonoscopy in 10 days. Nurse determines that the patient is taking aspirin daily to relieve knee pain. Which nursing intervention is best in this situation?

stop taking aspirin 7 days before surgery because it is a blood thining medication

serum glucose readings reflect...

these reflect short term (hours) variations

CT scan is used for?

to indentify soft tissues, bony abnormalities, and various types of musculoskeletal trauma

transferrin

transports iron

clean catch urine specimen

urinate a small amt, stop glowm and then fill one half of the specimen cup -collect midstream urine to send as a test specimen

Urobilinogen

urine billirubin problem

Positron Emission Tomography (PET)

used to distinguish between benign and malignant pulmonary nodules

bronchoscopy

visual examination of the bronchi, aids with diagnosis of pulmonary diseases

diskogram

visualize abnormalities of intervertebral disc

which vitamin is essential for the synthesis of prothrombin by the liver

vitamin k -prothrombin is synthesized in the liver in the presence of vit K; vit k initiates the vital process of coagulation

What are the items allowed in a clear liquid diet?

water, black coffee, broth/clear soup, apple juice, tea, pedialyte, sports drinks, cola/ sprite

Abuses alcohol. urinalysis report reveals specific gravity level of 1.040

when ur dehydrated, Blood urea nitrogen (BUN) is elevated

wound healing by primary intention

wounds such as surgical incisions or traumatic wounds in which the edges of the wound can be approximated to heal

What is not well visualized by an MRI?

Bone

Which foods are high in iron for the vegetarian diet?

Broccoli, pumpkin seeds, figs, kale, avocados, bananas, almonds, tomatoes, brussel sprouts, spinach, potatoes, green peas, collared greens/Red meats for non vegetarian

Which condition would the nurse expect to find in a patient with a troponin level of 0.8 ng/mL?

Cardiac muscle injury

calcium sources

dairy products, leafy vegetables, legumes yogurt, cheese, spinach

eschar

dead tissue that sheds or falls off from the skin.

dsypnea

difficult or labored breathing

-osis

disease

What is important to know abould a wound drain collection device?

drainage needs to be measured, usually not sutured in place to allow fro easy removal, works off of negative pressure/suction, should drain gradually

pseudo

false, deceptive

Which other nutrient would the nurse include in the teaching while counseling the parents of an adolescent with anemia related to an inadequate diet after explaining that sev. different nutrients like iron, protein & vit b12 are involved?

folic acid

Which symptom supports the nurse's assessment that a child with malnutrition has a vit c deficiency?

gingivitis

increase amts of proteins in the urine indicate

glomerular disorders

What does a nurse do to help a patient who is overstimulated and a patient who is understimulated

Overstimulated patient- decrease stimulation by dimming the lights, turning the tv volume down, closing the door of the room, clustering the activities, so that the patient has time to rest Understimulated patient- turn on tv/put on music, open window shades, place the client near the nurses station, provide touch via massage and talk to the patient

Stage 2 pressure injury

Partial-thickness skin loss w/ exposed dermis ---------- partial-thickness wound involves epidermis and/or dermis but does not extend through the level of the dermis

which test is considered the most accurate in the evaluation of the effectiveness of diet and insulin therapy over time?

glycostated hemoglobin (GHb)

How does the RN plan on caring for a patient who is hearing impaired? visually impaired?

hearing impairment- make sure patient has hearing aids, RN faces the patient & speaks in a reg. speed, make sure surrounding area is not too loud w/ distractions, avoid yelling, and avoid over pronunciation visually impaired- make sure glasses are worn as needed, walkways are clear, food is described to a patient relating to a clock.

color of urine dark, smoky urine suggests

hematuria -blood in urine

Hemoglobin synthesis

hemo; BLOOD -globin: small heme-proteins that reversibly bind oxygen synthesis: combo of parts to form a whole

Vitamin B-12 is needed for

hemoglobin synthesis

glomerular

Small balls of capillaries in the kidney

While performing a needle aspiration biopsy, the hcp inserts the needle into the pleural cavity. Which complication is being assessed in the patient ?

hemothorax

occult blood

hidden blood

what are factors that affect wound healing?

immobility, comorbidities, poor nutrition, poor perfusion, infection, decreased sensation, aging

C-reactive protein

increased during an infectious process

color of urine yellow-brown

indicates excessive urine

The urinalysis report of a client reveals pH to be 6, turbidity-cloudy, specific gravity of 1.02, and 0.6 mg/dL of proteins. What does the primary healthcare provider infer from the findings?

infection -cloudy urine indicates infection, sedmentation, or high levels of protein in the urine

What are complications found in wound healing?

infection, dehiscence, evisceration, hematoma, bleeding, hemorrhage, pain, fistula, eschar

What does it mean when a patient has impaired equilibrium?

inner ear may have issues causing dizziness, spinning of the room, and loss of balance = fall risk

Which supplement does the nurse expect to be prescribed when caring for a burn patient with elevated transferrin levels?

iron- where the iron is the transferrin goes the opposite directionq

athro-

joint

What are important facts about an NG tube and parenteral nutrition?

aspiration as possible so be careful! check for placement with an x/ray and whn in question- if during feeding the patient shows signs of aspiration, stop feed and verify placement (signs are gagging, coughing, anxiety, setting up etc)

What would be indicative of a high blood pH?

ketoacidosis

nephro

kidney

a primary care health care provider prescribes three stool specimens of occult blood for a client who reports blood-streaked stools & a 10 lb wt loss in 1 mos. To ensure valid results, which instruction would the nurse give to the client?

avoid eating red meat before testing -red meat can react with reagents used in the test and cause false-positive results

coagulation

blood clotting

Vitamin D is involved in

calcium absorption and metabolism

renal

kidney

nephrotoxic

capable of causing kidney damage

athroscopic procedure and prescribes a sedative. what is something you should do prior?

check that patient has signed a consent form, always have to before giving a sedative

Which action would the nurse take when collecting a 24 hr urine specimen?

check to verify whether a preservative is needed -this prevents breakdown of specimen

What info abt a client who is scheduled for MRI of the chest would be the most important for nurse to report to HCP before procedure?

client has surgical clips in place after craniotomy -clips are metal and may move slightly w/ MRI, causing bleeding into brain tissue

Which urine characteristic is consistent with a UTI?

cloudy urine -cellular debris, WBC, bacteria, pus make urine become cloudy

adrenal insufficiency

leads to high potassium (hyperkalemia) by decreasing excretion of potassium

MRI is used to diagnose

lesions/distinguish vascular from nonvascular structures

What symptoms are assoicated with hyperglycemia?

lethargy(slow/sluggish), confusion, thirst, nausea, flushed face, abdominal pain a\

A client has a low hemoglobin level that is attributed to a nutritional deficiency. Which foods should the nurse teach the client to increase in the diet? (Select all that apply.)

liver & spinach -they are high in iron

heptaobillary

liver, gallbladder,bile ducts

What does the nurse note when a patient is showing signs of infection on the road?

local symptoms include- erythema, warm to touch, possible drainage systemic- chills, fever, general malaise

hemorrhage

loss of blood from damaged blood vessels. A hemorrhage may be internal or external, and usually involves a lot of bleeding in a short time.

Computed Tomagraphy (CT) & dye

may or may not required administration of an oral or intravenous contrast dye. when the dye is used, adequate fluid intake helps dilute and excrete the dye

What assessed in the braden scale?

mobility, activity, moisture, sensory perception, nutrition, friction and shear. Lower the #, Higher the risk!

Unstageable pressure injury

obscured full-thickness skin and tissue loss ---------- full thickness wound in which the amount of necrotic tissue (eschar), in wound bed makes it impossible to assess depth of wound or involvement with underlying structure

Testing the specimen of stool when it is still warm may apply for

ova and parasites

Coagulation results, INR (international normalized ratio) is 3.5 & documents as normal. Why?

patient has an artificial heart valve

the nurse is withdrawing the blood of 4 patients in a drug collection tube.

patient with prealbumin levels- 4 mg/dL albumin levels- 2.0 mg/dL

-scopic

pertaining to visual examination

Which lab result is important to communicate quickly to HCP?

potassium 3.0 mEq/L -indicative of hypokalema, needs to be quickly communicative so that potassium supplement can be started

stage 3

prescence of a lip around the wound

stage 4 pi

presence of a tunnel in the wound

While assessing patient for sacral pressure injury, what finding indicates stage 2 pressure injury?

presence of pink wound bed

what is evaluated using an IVP (intravenous pyleogram)

presence, position, shape and size of kidneys, ureters, and bladder

importance of gag reflex

prevent aspiration

If a patient is paralyzed and has decreased sensation, when moving the patient what does the RN utilize to safely move the patient?

proper body mechanics, blankets & sheets to lift & raise the patient to avoid friction & sheer

glycosylated hemoglobin test

provides accurate long-term index of childs avg blood glucose level for the 10- to 12 day period before the test; more glucose the RBC were exposed to, the greater the GHb %

thiamine is a

coenzyme in carbohydrate metabolism

Vitamin C plays a role in...

collagen formation

Tropnin

complex of 3 proteins found in cardiac and skeletal muscle. troponin I and T are exclusively present in cardiac. Proteins are released during myocardial damage and can be detected within 3 hours after a cardiac muscle injury

color of urine orange-amber color suggests

concentrated urine cause by phenazopyridine or foods like beets

Riboflavin

control agent for energy production and tissue formation

What are common areas for pressure injuries to occur?

sacrum, heels, hips, elbows, occipital bone, ears

When a patient is at risk for impaired skin integrity due to a continuous exposure to body fluids, which body fluid is a the lowest risk for skin break down?

saliva- poses a min risk with skin exposure

cirrhosis

scarring of the liver

undermining

area of tissue loss present under intact skin, usually along the edges of the wound, forming a "lip" around the wound

Which statement indicates the nurse has a correct understanding of kidney ultrasonography?

"kidney ultrasonography makes use of sound waves and has min. risk" -client has full bladder -produce images of kidneys, bladder, & associated structures

which statement would the nurse use to instruct the female client about obtaining a urine specimen?

"with the enclosed towelettes, wipe labia from front to back before collecting specimen"

Somogyi effect

(rebound hyperglycemia ) occurs when there is an increase in blood glucose @ bedtime & drop @ 2AM followed by rebound increase in the AM. periodic blood glucose monitoring, including at night, must be performed to document this effect

fistula

An abnormal opening or passage between two organs or between an organ and the surface of the body.

How many mLs are in 200 tsp?

1000 mLs

LDL levels should be lower than?

130

Triglycerides should be lower than?

150

Total cholesterol level should be under what?

200

HDL levels should be higher than?

45

Nurse is administering 1g of drug to a patient. half life of the drug id 4 hrs (will half itself in tht many hrs), how many hours will it take to reach 250 mg of the original dosage?

8

embolus

A clot that breaks lose and travels through the bloodstream. MOVING CLOT

ultrasonography

A noninvasive technique involving the formation of a two-dimensional image used for the examination and measurement of internal body structures and the detection of bodily abnormalities

Comorbities

A person who has more than one disease or chronic illness.

Hematoma

A pool of mostly clotted blood that forms in an organ, tissue, or body space. A hematoma is usually caused by a broken blood vessel that was damaged by surgery or an injury.

What is the only way that a patient can be told that they have cancer?

A tissue biopsy has been performed and confirmed cancerous lesions

Which teaching does the nurse provide patient with sodium level of 12p mEq/L?

Its okay to eat cured meat and cheese

Niacin

B vitamin that's made and used by your body to turn food into energy. It helps keep your nervous system, digestive system and skin healthy. Niacin (vitamin B-3) is often part of a daily multivitamin, but most people get enough niacin from the food they ea

how does the healthcare team know that a patient has an infection with a particular bacteria?

Culture is performed and when a culture and sensitivity is performed, correct antibiotic can be prescribed

patient has the most severe risk of malnutrition?

D- lowest risk of prealbumin, albumin, transferrin

What caution does the RN take when a patient is having a CT scan and when a patient is having an MRI?

For the CT scan make sure the patient has no allergies specifically shellfish, and for the MRI make sure there are no magnetic items near MRI room

Stage 4 pressure injury

Full thickness skin loss and tissue loss ----------- deeper than stage 3, involves exposure of muscle, bone, or connective tissue (tendons or cartilages)

Stage 3 pressure injury

Full-thickness Skin loss ----------- full-thickness wound that extends into subcutaneous tissue but do not extend through the fascia to muscle, bone or connective tissue. -may be undermining or tunneling

Which result is most important to communicate to HCP when the nurse reviews lab results in client who has pos testing for occult blood in the stool?

Hemoglobin level of 8.5 g/dL (expected range is 12-16 gm/dL) intermittent or continuous loss of small amt of blood over extended periods will lead to decrease hemoglobin level

Which response indicates the need for further teaching when the nurse is teaching feeding techniques to the parents of a child who is unable to eat properly and is on complete bed rest?

I should feed my child 1 hr before going to bed

2 days after delivery a client has a temp of 101 degrees general malaise, anorexia, and chills. Which clinical finding would the nurse expect to identify on the clients lab report?

Increased WBC -increased WBC is indicative of an infectious process

Stage 1 pressure injury

Non Blanchable Erythema of Intact Skin -------- intact, nonblistered skin with nonblanchable erythema, persistent redness, in an area exposed to pressure

What are the components of a food label?

Nutritional facts including the calories, distribution of fats, cholesterol, sodium, carbohydrates, sugars, proteins, vitamins, etc. along with a serving size and the recommended daily allowances

Describe what an albumin level tells the healthcare team

Pre-albumin and albumin help alert the healthcare team of potential undernourishment

what to do if someone is hemorrhaging?

Pressure should be applied directly to any obviously bleeding body part, and the part should be elevated.

What will the plan of care be if a patient has sensory deficits in taste and smell?

Recognize that deficit in nutrition is common, provide foods that smell good and that are seasoned nicely. Ensure that the patient has good oral hygiene and frequent dental cleanings

Which factor increases the risk of wound infection?

Reduced local tissue defenses may prevent any counter activity against the microorganisms infecting the wound

When a patient states "I eat all fruits and vegetables except bananas, and I eat very littel meat and cheese" the nurse infers the patient adheres to which diet?

Renal Diet- all fresh fruits & vegetables, except bananas

Describe what a CBC provides the healthcare team

The CBC and essence tells you if theres infection, anemia, and risk for hemorrhage

What does the biochemical profile provide the healthcare team?

This lab helps to determine if the kidneys and the liver are functioning properly and if the patient is well nourished

pulmonary angiogram

Visualize pulmonary vasculature and locate obstruction or pathologic conditions like pulmonary embolus

Which action would the nurse expect the healthcare provider to perform for a patient with symptoms of pharyngitis and a neg. rapid antigen detection test (RADT)?

Wait for the report from the throat culture. Wait for result before treating

tunnel or sinus tract

While similar to an undermining, it is a narrower passageway extending outward from the edge of the wound.

hydronephrosis

abnormal condition of water in the kidney

lethargic

acting in an indifferent or slow, sluggish manner

folic acid

acts a nexessary coenzyme in the formation of heme, iron containing protein in hemoglobin

contrast study of upper GI tract

administer barium sulfate orally

Which action would the nurse confirm before approving a clients transfer to radiology for an MRI?

all metal objects like jewlery, hair ornaments, and clothing containing metal were removed

Items allowed in a full liquid diet?

all types of fruit juices, and vegetable juice, milk, sorbet/frozen yogurt, soups w/out chunks, pudding/custard, honey