fundamentals final practice questions

client says he has papers that names someone to make health decisions for him if he cant, waht is that

durable power of attorney (living will- inform medical ppl about care to provide if individual cant.

decreased circulation in legs- do what

elevate

when getting a capillary finger stick blood sample what is wrong

elevate finger above heart (right: wipe w antiseptic and dry puncture side of finger wrap in warm cloth

what pt is eligible for hospice -MS and uses wheelchair -end stage cirrhosis -hemiplegia bc stroke -cancer w weekly radiation

end stage cirrhosis (life expectacy of <6 mo)

fats provide

energy (protein- tissue repair, fluid bal, prevent edema)

middle age F: which diagnostic test should be routine

eye exam q2 yr

IM injection to obese pt

side hip between iliac crest and anterior iliac spine

potassium reflects

nerves heart conduction skeletal smooth muscle

braden scale to predict presure ulcer risk- what do u evaluate

nutrition sense perception moisture activity mobility friction shear (norton scale- incontinence, mental state, physical condition)

seizure pt, have what ready at bedside

o2 equipemtn

pt chokes and is coughing

observe close (assist to floor if losing conscious and might fall, abdominal thrust if choking and cant breathe or cough, open airway and look if foreign object)

with ice pack

-check cap refill before applying to affected area -fill 2/3 full of ice -avoid area w edema bc itll dec circulation -30 min intervals

when going to give feeding via gastrostomy tube, which should u do to initiate

-elevate bed flush w water check ph below 4

how to evaluate -heart -lungs -throid -skin

-inspect palpate ausculate -PERCUSS aussulate palpate -inspect palpate -inspect palpate

nurse caring for pt w tracheostomy, and gastromy tube for enteral feeding. which is important to communicate

-new perscriptions -ABG results -tracheal secretion characteristics

teaching abt body mechanics - which instructions to include

-sit w back supported -keep knees at hip level -use ergonomaclly disigned computer keyboard (not elbows away from body, and adjust monitor to tilt head)

protein require

0.8 g/kg

communication: clarifying- focusing- relevant ?- empathy-

"sounds like ur pain is intermittent" "now that we talked about meds, lets talk about pain" "do u have other symptoms" "it seems like u have had a rough time lately"

too much acetaminophen causes

(3-4 g /day) liver damage

Healing with Secondary Intention

- tender when touch, pink shiny tissue, serosanguineous drain (report if halo, redness, infection,purulent drainage, swelling, warm, strong odor)

Erikson's stages of psychosocial development

1. trust vs. mistrust- infant-18 mo 2. autonomy vs. shame and doubt- 18 mo- 3 yr 3. initiative vs. guilt- 3-5 yr 4. industry vs. inferiority- 5-13 5. identity vs. role confusion- 13-21 yr 6. intimacy vs. isolation- 21-39 7. generativity vs. stagnation-40-65 (middle adult) 8. integrity vs. despair- 65+

The nurse is assessing the nutritional status. the pt consumes 500 cals more pre day than his energy level requires. if his habits dont change, how long will it take for him to gain 4.5 kg (10 lbs)

10 weeks (1 lb is 3500 cals. consuming 500 extra cals each day for 7 days would be 3500 cals and 1 lb gain per week. )

_ ml = 1 tbsp

15

pedal edema 1+

2 mm (2+ is 4 mm 3+ is 6 mm 4+ is 8 mm)

1 oz = _ ml

30

1 oz = _ml

30

1 pint = _ ml

480

_ ml = 1 tsp

5

client has fluid restriction and can have 1 oz water w ech med. they have 3 meds a day. how many ml do u doccument

90 ml

pt alert but immobile. waht should u do to prevent complications

leg exercises 1-2 hr to prevent thrombophlebitiscough deep breathe 1-2 hr for resp move side-side 1-2 hr

primary prevention

Efforts to prevent an injury or illness from ever occurring -immunizations

primary prevention

Efforts to prevent an injury or illness from ever occurring. (education, immunization)

incomplete proteins

lentils veggies grain nut seed complete: egg soybean yogurt

WBCs 3,600=

leukopenia (dec in wbcs)

if theres a fire what should the nurse do first

RACE rescue, activate, confine, extinguish (evacuate patients first)

nurse ending pt nurse relationship, what should they discuss in termination phase of relationship

loss (intro- trust, self disclosure- working phase risk taking- working)

tertiary prevention

actions taken to contain damage once a disease or disability has progressed beyond its early stages (recovery)

indication of conductive hearing loss

ait conduction is less than bone conduction in L ear

what indicates adequate protein uptake and synthesis

albumin

kid has tonsil removal, do waht

analgesics routinely ice pack no coughing milk avoided

fluid vol deficit s/s

sunk eyeballs hypotension poor skin turgor

A nurse is doing an abdominal assessment, what position should pt be in

supine -to promote relaxation of abdominal muscles

if wound has evicerated, waht should nurse do

supine position w hip and knees flexed cover w sterile moist dressing monitor for shock (dont try to put it back in, dont leave and call surgeon- tell someone else to)

pt has temp 102.6, hr 105, soft non tender abdomen, menses overdue 2 days. whats the priority

temp.

pt w dysphagia at mealtime

tuck chin downward upright position lean slightly forward tild head forward

nurse changing dressing for pt recieving negative pressure wound therapy, what sequence

turn off vacuum on npwt and administer analgesic -remove soiled dressing -apply sterile glove -skin protectant -prepare foam to wound bed and cover w dressing -connect tubing and turn on

antimemetic stockings

turn sock inside out up to heel remove 1-2 hrs dont leave sock half way on or off

insert supposatory

use index finger to insert clean glove non dom hand to retract labia ease it along posterior vag wall

IM injection to 5 mo old

vastus lateralis

MRSA

wear gown private room sanitize linens

a nurse is providing chest physiotherapy to pt w left lower lobe atelectasis, what action should they take

place pt in trandellenburg

nutrition educaion

protein breaks to amino acids and ammonia carbs provide 4 cal /g of energy fat provide 9 cal/g of energy protein is energy

a post op pt has poor nutrition. what should nurse include in plan of care promote wound healing -limit cals to 25 cal.kg -intake of 500 mg/day of vit E -limit fluids to 20 ml/kg per day -protein intake of 1.5 g/kg of body wt per day

protein intake of 1.5 g/kg of body wt per day

enema

pt lay on left side insert tube 7-10 cm clean (not sterile) gloves hold solution 30 cm for low, 45 for high

the nurse is performing tracheostomy suctioning, what should they do if pt coughs

pull back 1 cm

8-10 mo

pull to standing position (turn from abdomen to back- 5 mo sit up w/o support- 8 mo crawl- 8-10 mo)

oral care to unconscous

raise bed head 30 on side dont lower side rail dont ut fingers in mouth

restraints responsibilites

remove every 2 hr provide fluids and nutrients rom exercises evaluate well being

what statement indicates lack of readiness to learn

reports severe pain

ph 7.5 paco2 32 hco3 24

resp alk

muscle group for movement of knee while other musc relax

antagonistic (antigravity- stabilizing knee joint synergistic- sync to make same movement skeletal- posture, voluntary movement

pt has dysrhythmia- what technique to assess pulse deficit

apical and radial pulse simultaneously- compare

client w NG gets diarrhea- do what

ask for prescription for isotonic formula

when assessing for emphysema, the client still smokes and says its "too late to quit" what should u do

assist pt in finding a local smoking cessation assistance program

technique to assess carotid arteries

ausculate arteries for bruits with bell of stethoscope

bicep refex is 2+, whats that mean

average (diminished-1 brisk- 3 hyperactive- 4)

giving diet advice to middle age pt w sedentary job

basal metabolic rate decreases eating disorders commen in adolescence and young adult vitamins not necessary if regular diet consume fish 2x/wk

islamic

body washed and wrapped during ritual then buried asap

pulses 4+

bounding (full strength-3 weak 1)

fluid vol excess s/s

bounding pulse

need assistance to breathe- damage to

brainstem

hyperextension

bring back of hand as far back towards wrist as u can

middle age client- evaluate progress toward which develpmental task

ceasing to compare personal identity to others (young adults- learning to manage home, establish self in world, forming new friendships)

pt having poor coordination from head injury. what was injured

cerebellum

pt having difficulty w expression (part of brain that affects learning memory language)

cerebral cortex

pt post op isnt having UO, what should u do first

check if catheter is kinked

clubbing nails on pt with emphysemia- whats the underlying cause of it

chronic hypoxemia (low oxygen= clubbing nails)

collecting specimen for culture, nurse should

clean w sodium chloride irrigation clean gloves dont allow swab to sit and absorb rotate swab over base of wound

talking abt pain management in 65+ adults, what is trie

clients 65 and older are reluctant to report pain

eye drops for glaucom

close eyes gently and avoid blinking look up to ceiling during out into conjuntival sacc pressure to puncta after

calcium reflects

clotting nerve impulses muscle contraact and relax bone teeth

initiaing NG tube, do what

coat w water lube swallow water while enters tilt head back when insertion begins

caring for pt w mastectomy and self suction drainage, what should u do

collapse device to remove air after emptying -keep diaphram compressed -cleanse w alc after opening -drainage below incision

a nurse is gonna give meds to unconscious pt, they should bring the mar to the bedside to do what

compare MAR and name on MAR w clients arm band (2 identifications are required)

nurse suspects strabismus, what test should u do

corneal light reflex (strabismus- eyes dont align when client focuses) -confrontation test- compare visula fields -palperbal fissure is space between eyes is unequal in ptosis (drooping) -accomodation test- pupils constrict ehen closer

neuro assessment, asking client to stick out tongue is assessing

cranial nerve xII (x- vocalize viii- hear a whisper V- clench teeth and feel for muscle contraction

calcium 12.7, expect

dec DTR (hypocal- muscle tremor, chvostek and trousseau, numb tingle

positive chvostek sign means

dec calcium

pt is immobile, theyre now at risk for -dec urine output -increased intestinal mobility -resp alkalosis -hypocalcemia

decreased urine output

most distal pulse

dorsalis pedis (popliteal on knee- best when knee flexed and foot resting on table posterior tibial- inner ankle- best when food relaxed and extended femoral- inguinal area- best lying down w area exposed)

sodium reflects

fluid bal nerve impulse acid base

respite care

for caregivers who need time to rest from responsibilities (pts son is her caregiver and hes exhausted from helping her)

single lumen ng tube include in plan of care

frequent oral hyg measure drain every shift secure to client gown

iatrogenic HIA

from diagnostic or theraputic procedures

clear liquid diet

gelatin

pt has dysphagia, what should u do at meal time

give sour food first -stimulates saliva

change bed linens for pt with aids, wear what ppe

gloves gown

bp cuff too small,

high reading

diuresis/ polyuria retention oliguria dysuria

high vol of urine accumulation of urine in bladder low output pain

when pouring liquid med

hold label aginst palm so not contaminated or if med spills the label wont fade. put cap with inside facing up, fill cup on table so its even w the surface (right dose), discard excess in sink and wipe lid

stage 2 pressure ulcer, what dressing -hydrocolloid -collagen -calcium alginate -proteolytic enzyme

hydrocolloid (absorbs and exudates, provides moist environ) collagen- moist wound to stop bleeding calcium to stage iv (significant exudate and covered w another dressing) proteolytic- unstagable- facilitate debridement and soften eschar

pt having difficulty sleeping from head injury, wahts injured

hypothalamus

siderails

if confused, raising all 4 couldd cause fall -4 rails is restraint -leaving 2 up improves ability to move arond -if sedated, put all 4 up

pt 48 hr post op from bowel obstruction. reports gas pains in periumbilical area, which could be contributing to this post op complication -blood loss -npo -ng tube suctioning -impaired peristalsis of intestines

impaired peristalsis of intestines

order of abdomen exam

inspection, auscultation, percussion, palpation

how to clean wound

least contaminated (inside wound) to most contaminated (surrounding skin)

tonic clonic seizure- what should u do -lower to floor -give o2 -privacy -place on side lying

lower to floor

buddhist

male members prepare body

PH: 7.25 paco2- 40 hco3 - 18

metabolic acidosis

TENS (tb electrical nerve stimulation) for main management

modulates the transmission of pain imulse

2 penrose drains. waht dressing

montgomery straps (minimize irritation )

nurse in long care place, at lunch a pt chokes and is strongly coughing, what should u do -assist pt to floor -perform abdominal thrust -open airway w head chin tilt -observe pt closely

observe closely

glaucoma

obstruction in flow of vitreous humor in eye (retinopathy- changes in blood vessels in retina cataracts- block rays of light macular degen- aging, changes in sharp and central vision)

a nurse caring for pt w dysrhythmia. what technique should u use to assess for pulse deficit

obtain apical and radial rates simultaneously calculate: subtract apical and radial rates

whats the first step in nursing process

obtain pt info

the nurse is preparing client for fecal impaction, before the removal of the mass which enema should u administer

oil retention -to soften stool

pt starts to decrease height why

osteoporosis (kyphosis is hunchback, lordosis is exaggerated lumbar curve)

tachycardia

over 100 (palpation is "skiping beat", bradycardia is under 60 dysrhythmia- irregular rhythm)

rom with wrist- whats adduction

palm facing down, move wrist sideways towards thumb

flexing

palm towards inner part of forearm

what can the nurse test to assess tissue perfusion

perform blanch test (checks cap refil)

how to doccument pulse

peripheral pulses bylaterally symmetric, equal, and strong in all 4 extremities

through systematic method while obtaining objective data about client- what method should nurse ccollect this info

physical exam

proliferative stage healing

pink shiny tissue

hormones for stress adaptation released by

pituitary gland

checking lower extremities bp, where should u do it

place bladder of cuff over posterior aspect of thigh

hindu

place head facing north - cremate

eye drops

place med in conjunttival sac gentle pressure to duct keep dropper 1-2 cm from eye close gently after

a nurse is performing a neurological assessment, to promote safety the nurse stands nearby as the client follows instrucitons for what test

romberg -it evaluates standing balance with eyes open then closed. the nurse should stand by incase of falling

tests

romberg- standing balance kinesthetic sensation- identify position holding finger or toe 2 point discrimination- holding 1 or 2 objects touching body weber test- tuning fork

secondary prevention

screening

a nurse is assessing pt with history of heart murmur r/t aortic valve stenosis, which area should nurse place stethoscope to auscultate the aortic valve

second intercostal space to right of sternum

albuterol

shake well before use rinse mouth after wait 20-30 sec between deep breath and hold 10 sec

correct use of crutches

slightly flexed elbows put cretches together in a hand and use other hand to grip chair move cretches to step then affected leg when stairs avoid putting wt on axillae

what lab indicates confusion

sodium 123

pt has fever and watery diarrhea=

sodium 150 (high)

judiasm

stay with body until burial

IM inject to adults

ventrogluteal (thick muscles and no nerves or blood vesssels)

verify NG placement

verify x ray measure exposed tube determine ph

which breath sound do u hear over periphery of major lung fields

vesicular (bronchial over trachea, rhonchi over trachea, bronchovesicular on sides of sternal border)

complicated grief

when death was sudden

vit D deficient. include what in diet

whole milk (has a k d)

sterile technique for catheter

wipe labia minora anteroposteriorly direction use seeparate cotton fo left and right non dom hand to spread labia

abducting

with palm facing down move wrist sideways towards little finger

importance of coughing turning and deep breathing

wont get pneumonia

capillary blood sample and cant get enough blood

wrap finger in warm cloth

NG tube exit mark is moved since last feeding, do what

x ray

can under age pt give consent for self for sti treatment

yes (and substance abuse)

if the light of the otoscope reflects off the tympanic membrane, is that normal

yes it should be seen in the L/R lower quadrant