Nur101 - PCHS - Exam 1
What's the concentration of oxygen in room air?
21 percent
A practitioner prescribes oxycodone oral solution 15mg every 6 hours. The drug is supplied in a 500-mL bottle that indicates 5mg/mL. How much oral solution should the nurse administer? Record your answer using a whole number. __________________mL
3ml
What is the normal radial pulse for adults?
60-100 bpm
Which are the most important nursing actions when speaking with an older adult whose hearing is impaired? Select all that apply A. Limit background noise B. Exaggerate lip movements C. Raise the pitch of your voice D. Stand directly in front of the patient when speaking E. Raise the volume of your voice while speaking directly toward the patient's good ear
A (Correct) - Limiting competing stimuli promotes reception of verbal messages. D (Correct) - This focuses the patient's attention on the nurse. A hearing-impaired receiver must be aware that a message is being sent before the message can be received and decoded. B (Incorrect) - This may be demeaning and ineffective because the patient may not be able to read lips. C (Incorrect) - This is not helpful. Hearing loss in the older adult typically involves a decreased perception of high-pitched sounds. E (Incorrect) - This is demeaning and may be viewed by the patient as aggressive behavior.
A patient verbally communicates with the nurse while exhibiting nonverbal behavior. How should the nurse confirm the meaning of the nonverbal behavior? A. Look for similarity in meaning between the patient's verbal and nonverbal behavior B. Ask family members to help interpret the patient's behavior C. Validate inferences by asking the patient direct questions D. Recognize that what a patient says is most important
A (Correct) - The patient is the primary source of information. When nonverbal communication reinforces the verbal message, the message reflects the true feelings of the patient because nonverbal behavior is under less conscious control than verbal statements. B (Incorrect) - This abdicates the nurse's responsibility to others and obtains a response that is influenced by emotion and subjectivity. C (Incorrect) - Direct questions are too specific. Open-ended questions or gently pointing out the congruence between actions and words are more effective techniques than direct questions in this situation. D (Incorrect) - Nonverbal behaviors, rather than verbal statements, better reflect true feelings. Actions speak louder than words!
Which interviewing skill is used when the nurse says, "you mentioned before that you are having a problem with your colostomy"? A. Focusing B. Clarifying C. Paraphrasing D. Acknowledging
A (Correct) - This example of focusing helps the patient explore a topic of importance. The nurse selects one topic for further discussion from among several topics presented by the patient. B (Incorrect) - This is not an example of clarifying, which lets the patient know that a message was unclear and seeks specific information to make the message clearer. C (Incorrect) - This is not an example of paraphrasing, which is restating the patient's message in similar words. D (Incorrect) - This is not an example of acknowledging, which is providing judgmental recognition for a contribution to the conversation, a change in behavior, or an effort by the patient.
What is a secondary infection?
A subsequent infection caused by a lowered immune response thanks to the primary infection.
What is PQRST?
A way to assess pain: Precipitating Factors, Quality, Radiating, Severity, Time.
Which question by the nurse best assesses a client's pain tolerance? A. "At what point on the scale of 1 to 10 do you feel that you must have pain medication?" B. "What activities help distract you so that you don't feel the need for pain medication?" C. "How intense on a scale of 1 to 10 is the pain that you feel right now?" D. "Do you take pain medication frequently?"
A. "At what point on the scale of 1 to 10 do you feel that you must have pain medication?"
A nurse needs to document a patients intake for the shift. Which of the following items would be included in the total? Select all that apply. A. 4 ounces of orange juice B. 6 ounces of broth C. 8 ounces of applesauce D. 8 ounces of ice cream
A. 4 ounces of orange juice B. 6 ounces of broth D. 8 ounces of ice cream
An elderly client, who is not oriented to time, place or person, had a total hip replacement. The client is attempting to get out of bed and pull out the IV line that is infusing antibiotics. The client has bilateral soft wrist restraints and a vest restraint. Which of the following interventions by the nurse are appropriate? Select all that apply. A. Ask the client if he needs to use the bathroom, and provide range-of-motion exercises every 2 hours. B. Document the type of restraint used and assess the need for continued use. C. Tie the restraints to the side rail of the bed. D. Obtain a new physician order for the restraint every 12 hours.
A. Ask the client if he needs to use the bathroom, and provide range-of-motion exercises every 2 hours. B. Document the type of restraint used and assess the need for continued use.
Which of the following procedure techniques has the most effect on the accuracy of an apical pulse count? A. Counting the rate for one full minute B. Exposing only the left side of the chest C. Determining why assessment of apical pulse is indicated D. Using your ring finger to palpate the intercostal spaces
A. Counting the rate for one full minute
A wound has a total separation of a wound exposing visceral organs through an opening occurs. What is this wound complication called? A. Evisceration B. Hemorrhage C. Dehiscence D. Laceration
A. Evisceration
Which is the best source of fiber that the nurse should include in a teaching plan for a patient who is at risk for constipation? A. Green beans B. White bread C. Peanut butter D. Grape jelly
A. Green beans
What is the final stage of healing that begins about 3 weeks to 6 months after injury? During this stage, the collagen is remodeled, new collagen tissue is deposited, and the scar becomes a flat, thin, white line. A. Maturation phase B. Microbial C. Granulation tissue D. Regeneration
A. Maturation phase
A nurse assesses the vital signs of a 50 year old female client and documents the results. Which of the following are considered within normal range for this client? Select all that apply. A. Oral temperature 98.2 degree F B. Apical pulse 88 beats/minute and regular C. Respiratory rate of 30 breaths/minute D. Blood pressure 114/78 mm Hg while in a sitting position E. Oxygen saturation of 90%
A. Oral temperature 98.2 degree F B. Apical pulse 88 beats/minute and regular D. Blood pressure 114/78 mm Hg while in a sitting position
Which of the following nursing interventions are appropriate for clients with swallowing difficulties? Select all that apply A. Sitting the patient upright B. Encouraging talking while eating C. Small portions D. Watch for pocketing in the mouth
A. Sitting the patient upright C. Small portions D. Watch for pocketing in the mouth
Where would the nurse place the oral thermometer for obtaining an oral temperature? A. The posterior pocket on either side of the frenulum B. Under the tip of the tongue C. On the upper side of the tongue D. At the level of the frenulum
A. The posterior pocket on either side of the frenulum
Name the three important dimensions to consistently measure to determine wound healing. A. Width, length, depth B. Length, depth, height C. Width, height, weight D. Width, length, temperature
A. Width, length, depth
Must be followed when a patient is known to be or suspected to be infected with pathogens transmitted by large-particle droplets (meningitis, pneumonia, diphtheria, mumps)? A. droplet precautions B. contact precautions C. airborne precautions D. disinfection
A. droplet
Which precautions should be used for patients who have or are suspected of having pathogens that are transmitted through the air by small particles.
Airborne precautions
What are the sites used to check pulse?
Apical, radial, brachial, carotid, popliteal, femoral, pedalis dorsalis
What should you ask a patient before taking his or her temperature?
Ask whether the patient has eaten, smoked or had something to drink within the last 30 minutes.
What is the nurse doing when using the interviewing technique of active listening? A. Identifying the patient's concerns and exploring them with why questions B. Determining the content and feeling of the patient's message C. Employing silence to encourage the patient to talk D. Using nonverbal skills to display interest
B (Correct) - Active listening is the use of all the senses to comprehend and appreciate the patient's verbal and nonverbal thoughts and feelings. A (Incorrect) - "Why" statements are direct questions that tend to put the patient on the defensive and cut off communication. C (Incorrect) - Silence is passive, not active. Silence allows the patient time for quiet contemplation of what has been discussed. D (Incorrect) - When talking with patients, verbal and nonverbal cues are used to indicate care and concern, which promote communication.
What is being communicated when the nurse leans forward during a patient interview? A. Privacy B. Interest C. Anxiety D. Aggression
B (Correct) - Leaning forward is a nonverbal behavior that conveys involvement. It is a form of physical attending, which is being present to another. A (Incorrect) - Privacy is not reflected by leaning forward during an interview. Privacy is facilitated by pulling a patient's curtain or finding a separate room or quiet space to talk. C (incorrect) - A closed posture, avoidance of eye contact, increased muscle tension, and increased motor activity convey anxiety. D (Incorrect) - Piercing eye contact, increased voice volume, challenging or confrontational conversation, invasion of personal space, and inappropriate touching convey aggression, which is a hostile, injurious, or destructive action or outlook.
A patient appears tearful and is quiet and withdrawn. The nurse says, "you seem very sad today." What interviewing approach did the nurse use? A. Examining B. Reflecting C. Clarifying D. Orienting
B (Correct) - Reflective technique refers to feelings implied in the content of verbal communication or inexhibited nonverbal behaviors. Patients who are crying, quiet, and withdrawn often are sad. A (Incorrect) - Examining is not an interviewing technique. C (Incorrect) - This is not an example of clarifying, which is the use of a statement to better understand a message when communication is unclear, rambling, or garbled. D (Incorrect) - This is not an example of orienting. Reality orientation is a nurse technique used to assist patients in restoring an awareness of what is actual, authentic, or real.
A patient with a colostomy wants to learn how to irrigate a newly created colostomy. The nurse provides this teaching by developing a therapeutic nurse-patient relationship and implementing teaching strategies. Identify the statements that are included in the working phase of this therapeutic relationship. Select all those that apply. A. "How do you feel about doing this procedure?" B. "Would you like to try to insert the cone yourself today?" C. "You did a great job managing the instillation of fluid today." D. "I am here to help you learn how to irrigate your colostomy." E. "I'll arrange for a home care nurse to visit you in your home when you are discharge."
B (Correct) - This statement reflects the working phase of a therapeutic relationship. It involves completing interventions that address expected outcomes, such as learning how to perform a colostomy irrigation. C (Correct) - This statement reflects the working phase of a therapeutic relationship. It includes providing feedback and encouragement. A (Incorrect) - This statement reflects the orientation phase of a therapeutic relationship. Although exploration of feelings is done throughout the phases, the primary goal of the orientation phase is the establishment of trust. Trust is promoted when the nurse focuses on the patient's emotional needs, is respectful, and individualizes care. D (Incorrect) - This statement reflects the orientation phase of a therapeutic relationship. The nurse and patient make a verbal agreement to work together to assist the patient to achieve a goal. E (Incorrect) - This statement reflects the termination phase of a therapeutic relationship. It focuses on summarizing what has transpired and been accomplished and looks to the future.
The nurse obtains the blood pressure of several adults. What blood pressure result causes the most concern? A. 102/70 B. 140/90 C. 125/85 D. 118/75
B. 140/90
What is the removal of nonviable, necrotic tissue? A. Wound infection B. Debridement C. Wound irrigation D. Surgery
B. Debridement
The client who has a fever experienced significant diaphoresis during the night. The client stated, "I am tired and I just want to sleep." What is the most appropriate action for the nurse to do regarding bathing the client? A. Consult with the physician before providing care B. Give a complete bed bath C. Postpone bathing until the afternoon D. Wait until the client feels better
B. Give a complete bed bath
What areas are common for pressure ulcers? Select all that apply A. Buttock B. Heels C. Scapula D. Elbows
B. Heels C. Scapula D. Elbows
A way for the causative agent to escape from the reservoir in which it has been growing (ex. human body: urine, feces, saliva, etc.) A. contaminated B. portal of exit C. portal of entry D. pathogen
B. Portal of exit
A patient is experiencing lack of sleep because of pain. Which is the most appropriate goal for this patient? "The patient will: A. Be provided with a back massage every evening before bedtime." B. Report feeling rested after awakening in the morning." C. Request less pain medication during the night." D. Experience four hours of uninterrupted sleep."
B. Report feeling rested after awakening in the morning."
You notice an area on your patient that has intact skin w/ non-blanchable redness. What stage would the nurse write in her documentation? A. Deep tissue injury B. Stage I C. Stage III D. Stage II
B. Stage I
The nurse must take a patient's rectal temperature. What should the nurse do? A. Take the temperature for 5 minutes B. Wear gloves throughout the procedure C. Place the patient in the right lateral position D. Insert the thermometer 2 inches into the rectum
B. Wear gloves throughout the procedure
Which of these steps in taking a blood pressure are correct? Select all that apply. A. Use a bladder that encircles 25% of the arm B. Wrap the cuff snugly around the client's arm C. As the client to hold their arm at heart level D. Have the client sit with feet flat on the floor
B. Wrap the cuff snugly around the client's arm D. Have the client sit with feet flat on the floor
5 hazards in home?
Burns, poison, falls, suffocation, fires
A young adult who had a leg amputated because of trauma says, "no one will ever choose to love a person with one leg." What is the best response by the nurse? A. "You are a good-looking person, and you will have no trouble meeting someone who cares." B. "You may feel that way now, but you will feel differently as time passes." C. "Do you feel that no one will marry you because you have one leg?" D. "How do you see your situation at this point?"
C (Correct) - This is an example of paraphrasing, which restates the patient's message in similar words. It promotes communication. A (Incorrect) - This negates the person's concerns. The patient needs to focus on the "negative" before focusing on the "positive". In addition, only the future will tell if the patient meets someone who cares. B (Incorrect) - This is false reassurance. There is no way the nurse can ensure that this belief will change. D (Incorrect) - This statement is unnecessary. The patient has already stated a point of view.
Which statement by the patient to a nurse indicates a precipitating factor associated with pain? A. "I usually feel a little dizzy and think I'm going to vomit when I have pain." B. "My pain usually comes and goes throughout the night." C. "I usually have pain after I get dressed in the morning." D. "My pain feels like a knife cutting right through me."
C. "I usually have pain after I get dressed in the morning."
The nurse is working with a middle-aged female after knee surgery. Ambulation is still difficult for the client, and the physical therapist has suggested the client use a cane. The nurse states which of the following with respect to using a cane rather than a walker for this injury? A. "The cane is just a reminder to use good posture." B. "The cane can be more dangerous than helpful, and another type of assistive device should be considered for this client." C. "The cane will help with fatigue while assisting the client with balance and support. D. "A cane does not offer any relief on weight-bearing joints."
C. "The cane will help with fatigue while assisting the client with balance and support.
Which assessment requires the nurse to assess the patient further? A. 18 year-old woman with a pulse rate of 140 after riding 2 miles on an exercise bike B. 50 year-old man with a BP of 112/60 on awakening in the morning C. 65 year-old man with a respiratory rate of 10 D. 40 year-old woman with a pulse of 88
C. 65 year-old man with a respiratory rate of 10
Which assessment result would require the nurse to assess the client further? A. A 21 year old male with a pulse rate of 140 after riding 2 miles on an exercise bike. B. A 50 year old man with a blood pressure of 118/64 upon awakening in the morning C. A 65 year old man with a respiratory rate of 10 D. A 40 year old man with a pulse of 88
C. A 65 year old man with a respiratory rate of 10
What is the body's natural cover? A. Slough B. Serous C. Eschar D. Exudate
C. Eschar
A patient states, "The pain moves from my chest down to my left arm." Which characteristic of pain is associated with this statement? A. Pattern B. Duration C. Location D. Constancy
C. Location
The nurse obtains the following vital signs on an adult patient: T: 100.6 F, BP: 100/60, HR 110, respirations:36. What is the first action by the nurse? A. Offer oral fluids B. Begin an IV infusion C. Obtain a pulse oximetry D. Administer oxygen
C. Obtain a pulse oximetry
The nurse witnesses another nurse, wearing a gown and gloves, enter a client room labeled "Airborne Precautions". Which of the following actions by the witnessing nurse is MOST appropriate? A. Notify the nurse manager to discuss policies with the other nurse. B. Ask a physician to give a presentation on which precautions require which types of personal protective equipment (PPE). C. Remind the other nurse that she needs a mask in addition to a gown and gloves for airborne-type precautions. D. Ask the other nurse to look up the policy about precautions.
C. Remind the other nurse that she needs a mask in addition to a gown and gloves for airborne-type precautions.
The nurse considers that body heat production is increased by: A. Vasodilation B. Evaporation C. Shivering D. Radiation
C. Shivering
Which principle of body mechanics should the nurse implement when providing nursing care? A. Hold an object away from the body. B. Extend the arms when lifting objects C. Squat when lifting objects off the floor D. Keep feet together when moving an object
C. Squat when lifting objects off the floor
A wound has full-thickness loss & muscle-tendon-bone exposed, slough is present, and it has undermining & tunneling. What stage is the wound? A. Stage V B. Unstageable C. Stage IV D. Stage III
C. Stage IV
A nurse is measuring a client's vital signs and uses a pulse oximeter to obtain which of the following types of information? A. respiratory rate B. amount of oxygen in the blood C. percentage of hemoglobin-carrying oxygen D. amount of carbon dioxide in the blood
C. percentage of hemoglobin-carrying oxygen
The element of miscommunication in which a nurse distractingly uses the phrase "um" repetitively in her communication.
Clarity
What do you want to avoid when asking questions?
Closed-ended questions.
What type of heat transfer happens when you lay on a cool table?
Conduction
The element of miscommunication in which you write "client complains of" vs. "client reports."
Connotative meaning
What are organisms and pathogens are present?
Contaminated
What type of heat transfer happens when you take a warm bath?
Convection
The goals of therapeutic communication mainly should depend on the: A. Environment in which communication takes place B. Role of the nurse in the particular clinical setting C. Skill level of the nurse in the situation D. Patient's verbalized concerns
D (Correct) - The patient and significant others and their needs are always the focus of nursing interventions, including the goals of communication. A (Incorrect) - Although the environment may enhance or be a barrier to communication, it does not determine the goals of communication. B (Incorrect) - The role of a nurse in a particular setting does not dictate the goals of communication. C (Incorrect) - Although the interviewing skills of the nurse may determine the effectiveness of communication, it does not set the goals of communication.
A patient states, "Do you think I could have cancer?" The nurse responds, "What did the doctor tell you?" What interviewing approach did the nurse use? A. Paraphrasing B. Confrontation C. Reflective technique D. Open-ended question
D (Correct) - This open-ended statement invites the patient to elaborate on the expressed thoughts with more than a one- or two-word response. A (Incorrect) - The nurse's response is not an example of paraphrasing, which is restating the patient's basic message in similar words. B (Incorrect) - This is not an example of confrontation. A confronting or challenging statement fails to consider feelings, puts the patient on the defensive, and is a barrier to communication. C (Incorrect) - The nurse's response is not an example of reflective technique, which is referring back the basic feelings underlying the patient's statement.
A nurse is obtaining a client's radial pulse and identifies that the rhythm is irregular. What should the nurse do next? A. Notify the client's primary health care provider B. Obtain the client's blood pressure C. Take the pulse in the other arm D. Assess the client's apical pulse
D. Assess the client's apical pulse
A patient's vital signs are: oral temperature 99◦F, pulse 88 beats per minute with a regular rhythm, respirations 16 breaths per minute and deep, and blood pressure 180/110 mmHg. Which sign should cause the most concern? A. Pulse B. Respirations C. Temperature D. Blood Pressure
D. Blood Pressure
A patient has a history of chronic pain. Which is one of the most important guidelines associated with providing nursing care to this patient? A. Asking what is an acceptable level of pain B. Providing interventions that do not precipitate pain C. Determining the level of function that can be performed without pain D. Focusing on pain management intervention before pain becomes excessive
D. Focusing on pain management intervention before pain becomes excessive
A patient's perineum and buttocks are constantly moist due to urinary and fecal incontinence. What is the best prevention plan? A. Place her in diapers. B. Clean her skin vigorously with soap and water after each episode of incontinence. C. Place four blue pads under the patient's buttocks and upper thighs to absorb the urine. D. Gently cleanse her skin, protect it with a barrier cream and use absorbent under pads to wick the moisture from the skin.
D. Gently cleanse her skin, protect it with a barrier cream and use absorbent under pads to wick the moisture from the skin.
Which of the following actions by the nurse is the MOST appropriate means of preventing infection? A. Washing hands after client contact B. Washing hands after removing gloves C. Hand hygiene between clients D. Hand hygiene before entry to a client's room and upon exit of a client's room
D. Hand hygiene before entry to a client's room and upon exit of a client's room
A patient has tube feedings ordered every four hours. Her feedings frequently are held due to gastric residual greater than 100mL her nutritional status puts her at risk for pressure ulcers because of: A. Her serum albumin B. Her weight change C. Her Braden Scale nutrition sub score D. All of the Above E. A and C only.
E. A and C. only.
A patient is very high risk for developing a pressure ulcer. What preventative interventions are indicated to protect her from developing a pressure ulcer? A. Pad bony prominences when position. B. Reposition her at least q2h C. Use a lift sheet for repositioning her to avoid friction and shear injuries when moving her across the sheets. D. Use the 30 degree lateral side position to avoid positioning onto sacral and trochanteric bony prominences. E. All of the above
E. All of the above
What type of heat transfer happens when you breathe?
Evaporation
Chain of infection is a process that destroys or kills pathogenic organisms? (T/F)?
False
Exogenous is thick walled capsules that can form when conditions for growth are poor, extremely difficult to kill. (T/F)?
False
Non-blanchable reddened areas of skin over bony prominences should be massaged every 2 hours. (T/F)
False
What is gauze?
Highly absorbent; used for packing; simplest form.
What is hydrocolloid?
Include hydrophilic particles; provides protective layer.
What are the stages o infection?
Incubation, primordial, illness, Decline, convalescence
What are the phases of fever?
Initial - febrile episode or onset Second - reaches its max and stays there Third - (defervescence) - returns to normal
What are the 4 types of fever?
Intermittent - alternate between fever and normal once a day Remittent - fluctuating temps but always above normal. Constant - always remains high Relapsing - fever keeps coming back every other day.
What are the three levels of communication?
Interpersonal, interpersonal, group
How should the blood pressure cuff be positioned?
It should cover 2/3 length of the airm. Too big a cuff can lead to low reading. Too small a cuff can lead to a false high.
What is alginate dressing?
Large drainage; made from seaweed; use for deep, tunneling, undermining wounds.
What is the chain of infection?
Link 1 - Infectious Agent Link 2 - Reservoir Link 3 - Portal of Exit Link 4 - Mode of Transmission Link 5 - Portal of Entry Link 6 - Susceptible Host
What are top six ways to prevent falls in healthcare setting?
Lock wheels, meeting needs, bed alarms,
4 hazards in community?
MVAs, lightening strikes, pollution, pathogens
What's the process of communication?
Need an encoder, decoder and messege
What are the causes of pain?
Neuropathic - nerve endings Phantom - Pain from location not on pt. anymore Psychogenic - stemming from psche Visceral - deep inside (from organs) Somatic - from moving parts like joints and ligaments. Usually superficial. Sharp & localized Nociceptive - Arising out of receptors (trauma, surgery).
The element of miscommunication in which in which the client doesn't ask a question because the nurse is talking rapidly and seems very busy.
Pacing
What is a way for the causative agent to enter a new reservoir or host?
Portal of Entry
What are the phases of therapeutic communication?
Preinteraction, orientation, working and termination
What is collagen dressing?
Promotes collagen formation; for full thickness wounds; doesn't stick to the wound.
What are the methods used to protect certain patients from microorganisms present int he environment, mainly immunocompromised patients. or those whose body defenses are not capable of protecting them infections and diseases, like bone marrow transplants, chemotherapy.)
Protective or reverse isolation.
What happens to respiratory rate when the temperature increase?
RR increases up to 4 breaths per minute for every degree rise in temperature.
What type of heat transfer happens when you enter a room full of people?
Radiation
What info do we need for monitoring pulse rate?
Rate. Strength, quality, Rhythm. 0 - absent 1 - weak 2 - normal rhythm 3 - strong
What is antimicrobial dressing?
Reduces or prevents infection; covers partial or full thickness wounds;
What are the six areas of hygiene?
Skin, eyes, nose, hair, skin, feet
What are the different types of isolation?
Standard - for all patients, no matter what the diagnosis or suspected diagnosis Contact - used for patients who have confirmed or suspected infection or colony of infectious agents that are transmitted by direct touch Ex: MRSA, VRE Droplet - used for patients who have infections or suspected infections that are transmitted via short distances on large particles. Ex: Flu, pneumonia Airborne - Used for patients who have infections or suspected infections that can be spread via long distances, like through ventilation. Ex: TB, Measles
What do you call a person who is likely to get an infection or disease, usually because the body defenses are weak?
Susceptible host
What pulse rate is tachycardia and bradycardia?
Tachy - above 100 bpm Brady - below 60 bpm
How does thermoregulation work?
The body will vasodilate if too hot, creating more room in the vessels, cooling down the body. The body will vasoconstrict, if too cold, creating less room in the blood vessels and lowering body temps.
What is a primary infection?
The first infection a patient gets -- the reason for medical problems the pt. is experiencing.
The element of miscommunication in which a nurse is attempting to teach a client about her medications while the client is waiting for a phone call from her granddaughter.
Timing
In verbal communication, what qualities do you need?
Timing, tone, clarity, pacing,
A patient develops non-blanchable erythema or her sacrum after lying on her back for several hours. This indicates a Stage 1 pressure ulcer. (T/F)
True
A patient's urinary and fecal incontinence are risk factors for pressure ulcer development. (T/F)
True
What is hydrogel dressing?
Uses for comfort of patient; keeps wound bed moist; for little to no drainage.
The element of miscommunication in which you use of medical jargon such as "decubitus ulcer."
Vocabulary
A post-op client has been placed on a clear liquid diet. Which of the items is the client to consume on this diet? Select all that apply a. Broth b. Gelatin c. Pureed vegetables d. Coffee
a. Broth b. Gelatin d. Coffee
Which nursing action protects the patient from infection at the portal of entry? a. Positioning an indwelling urine collection bag below the level of the patient's pelvis b. Enclosing a urinary specimen in a biohazardous transport bag c. Wearing clean gloves when handling a patient's excretions d. Handwashing after removal of soiled protective gloves
a. Positioning an indwelling urine collection bag below the level of the patient's pelvis
The nurse identifies the presence of a fire in the utility room. Place the nurse's actions in order of priority using the RACE model. a. Pull the fire alarm b. Close unit doors and windows c. Shut the door to the utility room d. Provide emotional support to agitate patients
a. Pull the fire alarm c. Shut the door to the utility room b. Close unit doors and windows d. Provide emotional support to agitate patients
Which primary defense protects the body from infection? a. Tears in the eyes b. Alkalinity of gastric secretions c. Bile in the gastrointestinal system d. Moist environment of the epidermis
a. Tears in the eyes
Which nursing action protects the patient as a susceptible host in the chain of infection? a. Wearing personal protective equipment b. Administering childhood immunizations c. Recapping a used needle before discarding d. Disposing of soiled gloves in a waste container
b. Administering childhood immunizations
A patient's stool specimen is positive for Clostridium difficile. Which isolation precautions should the nurse institute for this patient? a. Droplet b. Contact c. Reverse d. Airborne
b. Contact
The risk management coordinator is preparing a program on the factors that contribute to falls in a hospital setting. Which factor that most often contributes to falls should be included in the program? a. Wet floors b. Frequent seizures c. Advanced age of patients d. Misuse of equipment by nurses
c. Advanced age of patients
Which nutrition is the body's most preferred energy source? a. Protein b. Fat c. Carbohydrate d. Vitamins
c. Carbohydrate
A nurse must make an unoccupied bed. Which nursing action is most important? a. Position the call bell in reach b. Place a pull sheet on top of the draw sheet c. Ensure that the bottom sheet is free of wrinkles d. Complete one side of the bed before completing the other side
c. Ensure that the bottom sheet is free of wrinkles
When giving a patient a bed bath, the nurse washes the patient's extremities from distal to proximal. The nurse does this to: a. Decrease the chance of infection b. Facilitate the removal of dry skin c. Stimulate venous return d. Minimize skin tears
c. Stimulate venous return
The nurse is caring for a group of hospitalized clients. What should the nurse do first to prevent client infections? a. Provide small bedside bags to dispose of used tissues b. Encourage staff to avoid coughing near clients c. Administer antibiotics as ordered d. Identify clients at risk
d. Identify clients at risk
The nurse is caring for a confused patient. What should the nurse do to prevent this patient from falling? a. Encourage the patient to use the corridor handrails b. Place the patient in a room near the nurses' station c. Reinforce how to use the call bell d. Maintain close supervision
d. Maintain close supervision