nurse exam 3

inflammatory:

lasts about 2-3 days WBCs (leukocytes and macrophages) move to wound enter wound and remain ingest debris and release growth factors that attract fibroblasts to fill wound

proliferation:

lasts for several weeks new tissue is built via fibroblasts capillaries grow across wound think layer of epithelial cells form across wound granulation tissue forms (scar tissue)

In the older adult client, wrinkling is related to:

loss of elasticity

factors that contribute to falls:

lower body weakness poor vision gait and/or balance issues problems with feet/shoes psychoactive meds postural dizziness environmental hazards

prone position:

lying face down

lithotomy position:

lying on back with legs raised and feet in stirrups

supine position:

lying on back, facing upward

Sims position

lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back

primary source of heat in body is:

metabolism

frequently used complementary health approaches:

nonvitamin, nonmineral, natural products deep breathing yoga chiropractic/osteopathic manipulation meditation massage

factors affecting an organism's potential to produce disease:

number of organisms virulence competence of person's immune system length/intimacy of contact between person/microbe

prodromal stage:

person is most infectious, vague and nonspecific signs of disease

apnea:

temporary cessation of breathing

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?

"It allows removal of blood and drainage from the surgical wound."

The licensed practical nurse (LPN) is observed by the registered nurse (RN) engaging in the re-enforcement of teaching related to therapeutic deep breathing and coughing with a client who is recovering from abdominal surgery. Which statement by the RN best supports the LPN's role in the implementation of this intervention?

"You served as a good role model while showing the client the proper technique for this intervention."

Which action by the nurse is most appropriate when attempting to remove surgical staples that have dried blood or drainage on them?

Apply moist saline compresses to loosen crusts before attempting to remove the staples.

types of health assessments:

Comprehensive, Problem-based/focused, Episodic/follow-up, Screening. ongoing partial: conducted at regular intervals focused: conducted to assess specific problem emergency: conducted to determine life-threatening or unstable conditions

The nurse performs an assessment observing for clues about the client's self-concept and coping ability. The client is scheduled for surgery today and while twisting and shredding a tissue states, "I have no concerns about this procedure...a piece of cake!" Which is the best nursing action?

Discuss the noted discrepancy between action and words with the client.

A young woman has been in an automobile crash and sustained a laceration across the left side of her face, resulting in a large scar. Which nursing diagnosis would be appropriate for this disfigurement?

Disturbed Body Image

A nursing student is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure?

Gather new sterile supplies and start over.

The nurse is caring for a client on the unit. During change of shift, another nurse is observed blowing on a patients wound in order to dry it. What is the most important reason this technique does not adhere to the standards of care for dressing changes?

Increases the risk of infection by contaminating the wound

What is the primary goal of the observable action associated with the removal of contaminated gloves?

Prevent contamination of ungloved hand

An older adult client has been admitted to the hospital with acute delirium and is temporarily unable to take care of her own dentures. How should the nurse care for the client's dentures?

Store the client's dentures in water when the client is not wearing them.

neonate safety:

avoid harmful fetal behavior never leave infant unattended use crib rails monitor settings for choking objects use care seats securely handle infants head on back during sleep

most significant and commonly observed infection causing agent:

bacteria

exchange of O2 and CO2 between alveoli of lungs and blood:

diffusion

means of transmission:

direct contact, indirect contact, airborne route

safety education for adults:

effects of stress on lifestyle and health defensive driving unsafe health habits safe workplace domestic violence

Which type of wound drainage should alert the nurse to the possibility of infection?

foul-smelling drainage that is grayish in color

A nurse is examining an adult client with inflammation of the gums. The nurse observes bleeding gums. How should the nurse record the findings in the client's medical record?

gingivitis

What intervention should be included in a plan of care to prevent pressure injury development in health care settings?

implementing an every-2-hours turning schedule

portal of exit:

point of escape for the organism

trough level:

point when the drug is at its lowest concentration, indicating the rate of elimination

full stage of illness:

presence of specific signs ans symptoms of disease

common portals of exit:

respiratory GI genitourinary tracts breaks in skin blood/tissue

vital signs:

temp pulse respiration BP pain (5th sign)

9 sites at detecting pulse:

temporal facial carotid brachial radial femoral popliteal posterior tibial dorsal pedis

The nurse is preparing to give a vaccination to an infant. At which site should the nurse plan to administer the injection?

vastus lateralis

normal oral temp:

37 C (98.6 F)

A nurse is providing nail care to clients admitted to a health care facility. The nurse should know that which clients are most susceptible to nail problems?

clients with diabetes

integrative health care:

combination of allopathic and complementary and alternative modalities

therapeutic range:

concentration of drug in the blood serum that produces the desired effect without causing toxicity

A chant is a form of which category of meditation?

concentrative

holism:

connection and interactions between parts of the whole

A pediatric nurse is preparing a child for cleft palate repair surgery. The nurse identifies that this procedure will be documented as:

constructive

A full-thickness or third-degree burn develops a leathery covering called a(an):

eschar.

dorsal recumbent:

lying on back with legs bent and feet flat

2 categories of aseptic technique:

medical asepsis: clean surgical asepsis: sterile

5 rights of medication administration

right patient, right drug, right dose, right route, right time (right reason)

A new graduate nurse has recently started a new job in a long-term care facility. In the interview, the student was told there will be two weeks of orientation prior to working independantly. After the first night of work, the student was informed the facility is short staffed and the nurse would be working independantly. What is this new graduate at risk for developing?

role ambiguity

safety education for adolescents:

safe driving skills tobacco/alcohol gun safety healthy lifestyle sex/STIs/birth control physical exam for sports risks of piercing/tattoos guns/violence dangers of interweb

The nurse has completed administering medications through an enteral tube used for decompression. What is the appropriate nursing action?

Clamp the tube for at least 30 minutes

The nurse is preparing to administer medications to a client. The client asks, "Why are you using this to give me my medication?" The client is referring to the bar code scanner; what is the best response by the nurse?

"I am using this machine to scan the code on your wrist to identify and verify the medications prescribed for you before you receive them."

Types of Medication Orders

-Standing order (routine order): carried out until cancelled by another order -PRN order: as needed -Single or one-time order -Stat order: carried out immediately

viruses can't be treated with __1__, they require __2__.

1. antibiotics 2. antiviral medication

Normal respiration rate

12-20 breaths per minute

normal BP:

120/80

normal pulse rate:

60-100 bpm

High Fowler's Position:

A semi-sitting position; the head of the bed is raised 60 to 90 degrees

Which type of drug preparation is a medication in a clear liquid containing water, alcohol, sweeteners, and flavor? A. Elixir B. Suspension C. Solution D. Syrup

A. Elixir

Which measure is appropriate when caring for a patient who is hearing impaired? A. Speak to the patient before making your presence known. B. Increase noises in the background to stimulate the senses. C. Position yourself so that light is on your face. D. Do not use pantomime to express messages to avoid embarrassment

A. Speak to the patient before making your presence known

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The incoming nurse receives in the handoff report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments?

Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

intraosseous injection:

An injection into the bone; a medication delivery route.

An appendectomy is considered which classification of surgery based on purpose? A. Diagnostic B. Ablative C. Palliative D. Reconstructive

B. Ablative

In which phase of the perioperative period would the patient be transferred to the OR bed? A. Preoperative phase B. Intraoperative phase C. Postoperative phase

B. Intraoperative

During which stage of infection is the patient most contagious? A. Incubation period B. Prodromal stage C. Full stage of illness D. Convalescent period

B. Prodromal stage

Which physical assessment technique is used to assess temperature, turgor, texture, moisture, vibrations, and shape? A. Inspection B. Percussion C. Palpation D. Auscultation

C. palpation

The most powerful respiratory stimulus for breathing in a healthy person is ________.

Carbon Dioxide

A nurse is caring for a female client with diarrhea. What instruction should the nurse give the client with regard to perineal hygiene?

Clean the perineal area from the front to back.

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home?

Clear clutter in the walkways of the new home.

The older adult client has been reporting sleeplessness for the past 3 days. Which type of sensory problems can result from this?

Cognitive dysfunction

A nurse is planning hygiene for a client with dementia. The nurse understands the need to provide an environment that will aid her in the care of this client. Which action will she perform?

Create a calming environment with little stimuli.

Which of the following interventions would be appropriate to stimulate the sense of stereognosis in long-term care residents? A. Tape pictures of loved ones on the walls. B. Play soft music in the recreation room. C. Prepare a fragrant cup of tea. D. Provide a soft, textured blanket on the bed.

D. Provide a soft, textured blanket on the bed.

Which pulse site is located on the inside of the elbow? A. Temporal B. Radial C. Femoral D. Brachial

D. brachial

The nurse is performing a psychosocial assessment on an older adult client. For which issue of clients in their later adult years should the nurse assess as a priority?

Depression and substance use

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next?

Document the color, odor, amount, and type of wound drainage.

safety education for older adults:

ID environmental hazards defensive driving vision/hearing test hearing aids/glasses available and functioning smoke detectors report neglect/abuse

types of medication errors:

Inappropriate prescribing of the drug Extra, omitted, or wrong doses Administration of drug to wrong patient Administration of drug by wrong route or rate Failure to give medication within prescribed time Incorrect preparation of a drug Improper technique when administering drug Giving a drug that has deteriorated

A new nurse is caring for a client who has a prescription for a stool specimen analysis. As the nurse performs the procedure without gloves, the charge nurse walks in to the client's bathroom and observes the new nurse obtaining the specimen. What is next priority action by the charge nurse?

Inform the new nurse to wear gloves when obtaining specimens that contains bodily fluids

factors affecting host susceptibility:

Intact skin and mucous membranes Normal pH levels Body's white blood cells Age, sex, race, hereditary factors Immunization, natural or acquired Fatigue, climate, nutritional and general health status Stress Use of invasive or indwelling medical devices

The dressing change on a deep upper-arm wound is painful for the client. When preparing a care plan for the client, the nurse will incorporate which nursing measure?

Plan to administer a prescribed analgesic 30 to 45 minutes prior to the dressing change.

A nurse is providing oral care to an unconscious client. When planning this intervention, the nurse should prioritize which nursing diagnosis?

Risk for Aspiration

A nurse is explaining the use and handling of dentures to an older adult client. What measures should the nurse mention to the client?

Store the dentures in water in a covered cup.

Following a surgical procedure, who is generally responsible for moving the client to the recovery area?

The anesthesiologist, circulating nurse, and surgeonf

What is the most appropriate outcome for the client who has a nursing diagnosis of "Risk for Injury related to the use of assistive mobility devices in an unfamiliar environment?"

The client will demonstrate safety measures to prevent falls.

Which short term goal may be appropriate for a client experiencing sensory overload?

The client will remain safe at all times.

T/F Pressure injuries are caused by unrelieved compression of the skin that results in damage to underlying tissues.

True

A nurse is helping an older woman undress and notices the woman's knee-high hose have left deep indentations. The woman has diabetes. Does this pose a risk to the client?

Yes, these can obstruct lower extremity circulation.

The nurse has provided a client with oral medications in a small plastic cup. What is the appropriate nursing intervention?

Wait with the client until the medications are taken.

The nurse is preparing to administer a medication to a client when the client states, "Last time I took that medication, I broke out in hives." What is the priority action by the nurse?

Withhold the medication and notify the health care provider that ordered the medication

portal of entry:

point at which organism enters a new host

A nurse working in long-term care is assessing residents at risk for the development of a pressure injury. Which one would be most at risk?

a client 86 years of age who is bedfast

After a client falls out of bed, the nurse completes:

a safety event report (incident report).

Fowler's position:

a semi-sitting position; the head of the bed is raised between 45 and 60 degrees

orthopnea

ability to breathe only in an upright position

bradypnea

abnormally slow breathing

ADME:

absorption, distribution, metabolism, excretion

half-life:

amount of time it takes for 50% of blood concentration of a drug to be eliminated from body

The nurse is preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection?

applying a new dressing with the gloves that were used to remove the old dressing

infectious agents:

bacteria, viruses, parasites

A client suffering from infectious diarrhea, dehydration, and right-sided paralysis is confined to bed. What is the client most prone to?

decubitus ulcer

dyspnea:

difficult or labored breathing

t/f a safety event report is a part of the medical record and should be mentioned in documentation.

false

maturation:

final stage, 3 weeks in; for months or years collagen is remodeled new collagen is deposited scar becomes flat, thin, white line

phases of wound healing:

hemostasis inflammatory proliferation maturation

hazards associated with restraints:

increased falling possibility skin breakdown contractures incontinence depression delirium anxiety aspiration and respiratory difficulties death

stages of infection:

incubation period prodromal stage full stage of illness convonvalescent period

A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate?

infection

components of infection cycle:

infectious agent reservoir portal of exit means of transmission portal of entry susceptible host

Which infection or disease may be spread by touching a contaminated inanimate article? A. Rabies B. Giardia C. E. coli D. Influenza

influenza

techniques used during physical assessment:

inspections: assessing size, color, shape, position, and symmetry palpation: assessing temp, turgor, texture, moisture, vibrations, and shape percussion: assessing location, shape, size, and density of tissues auscultation: assessing four characteristics of sound, that is, pitch, loudness, quality, and duration

health teachings in school:

monitor child internet use involved in school activities volunteer for safety committees ensure schools emergency plan is current

susceptible host:

must overcome resistance mounted by host's defenses

infection reservoir

natural habitat of organism

The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding?

nonblanchable redness

eupnea:

normal breathing

areas of surgical asepsis:

operating room labor/deliver area some diagnostic testing areas insertion of catheters sterile dressings injecting meds

drug preparations:

oral topical (including suppository) injectable

incubation period:

organisms growing and multiplying

knee-chest position:

patient is lying face down with the hips bent so that the knees and chest rest on the table

parts of medication order:

patient's name date and time order is written name of drug to be administered dosage of drug route by which drug is to be administered frequency of administration of the drug signature of person writing the order

exchange of O2 and CO2 between circulating blood and tissue cells:

perfusion

Tachypnea

rapid breathing

convalescent period:

recovery from infection

5 cardinal signs of acute infection:

redness heat swelling pain loss of function

positions used in physical assessment:

standing (posture, balance, gait) sitting (upper body) supine (relaxed abdominal muscles) dorsal recumbent (difficulty maintaining supine) sims (rectum or vagina/enema) prone (hip or posterior thorax) lithotomy (female genitalia and rectum) knee-chest (anus/rectum)

A student nurse studying anatomy and physiology learns that the largest organ of the body is the:

skin

The first line of defense against microorganisms and infection entering the body is the person's:

skin

hemostasis:

stoppage of bleeding; clotting occurs immediately after injury blood vessels constrict exudate is formed; swelling and pain increased perfusion; heat and redness platelets stimulate other cells to migrate to injury

The nurse is preparing to administer nasal medication via a dropper to a client with severe congestion. Into which position will the nurse place the client?

supine

The staff at a day-surgery clinic are meeting because there have been two significant medication errors committed over the past few weeks. To prevent future medication errors, what is the priority action for the nurse's to take?

take measures to ensure that nurses are not disturbed when obtaining and administering medications

allopathic medicine:

traditional medical care

t/f at any point in the infection cycle, it can be broken.

true

A nurse caring for a client who has a surgical wound after a cesarean section notes dehiscence of the wound and contacts the surgeon. Which is a finding related to this condition?

unintentional separation of the wound

stroke volume:

volume of blood ejected with each heartbeat