Nursing Refresher Study material from course quizzes and test
grasping reflex
when a finger is placed in each hand and it grasp
A client with obsessive-compulsive disorder has become immobilized by elaborate handwashing and walking rituals. The nurse recalls that the basis of obsessive-compulsive disorder is often what feelings?
. Anxiety and guilt
500 mg of lidocaine has been added to D5W. The final solution has a volume of 1000 ml. You realize that the IV solution contains how many mg of lidocaine per ml?
0.5 mg/ml
Creatinine
0.7-1.4 mg/100 mL
True or False: Clients who are not restrained are more likely to die during their hospital stay than restrained clients.
Fasle
Gauge used to regulate the amount of oxygen delivered to the client and is attached to the oxygen source.
Flowmeter
Which therapeutic communication technique is useful when the nurse and a client have a conversation and the client begins to repeat the conversation to himself or herself?
Focusing
the time between the beginning of one contraction and the beginning of the next
Frequency
Types of fetal presentation include all except:
Fundal
An age-related reduction in the number of laryngeal nerve endings contributes to diminished efficiency of this reflex.
Gag
A nurse is caring for a patient who has been admitted for alcohol withdrawal. The patient asks the nurse about the potential long-term complications of drinking alcohol. Which of the following would the nurse tell the patient? Select all that apply.
Gastric bleeding b. Cirrhosis c. Depression e. Arrhythmias
Within a few hours of alcohol withdrawal the nurse should assess the client for the presence of what symptoms?
Irritability and tremors
the study of the way in which certain body movements and gestures serve as a form of nonverbal communication.
Kinesics
The client rests on the knees and chest and turns the head, which is supported on a small pillow, to one side
Knee-chest position
Arrhythmias, chills, illusions, increased salivation, diaphoresis, dispersonalization, and distortions
LSD
procedure that involves examining body fluids or specimens and comparing the components of a collected specimen with normal findings
Laboratory test
Symmetrical decrease in fetal heart rate beginning at or after the peak of the contraction and returning to baseline only after the contraction has ended, indicating possible uteroplacental insufficiency and potential that the fetus is not receiving adequate oxygenation.
Late deceleration
Removing poisonous substances from the stomach or intestines with gastric or intestinal tubes is known as performing this.
Lavage
Reclining position with the feet in metal supports called stirrups
Lithotomy position
procedure for withdrawing spinal fluid
Lumbar puncture
Lithium is prescribed for a client with bipolar disorder experiencing a manic episode. When teaching the client about this medication, the nurse will emphasize which fact about lithium?
Maintaining adequate salt and water intake is important
During an interview a 32-year-old man describes symptoms of decreased appetite, insomnia, anhedonia, and feelings of worthlessness that have been present for the past few weeks. He reports having had a few episodes of feeling depressed in the past but says that the feelings subsided. Recently he has felt worse, and he is now concerned that his symptoms are negatively affecting his job performance and fears he may lose his job "if someone doesn't help me soon." The nurse suspects these symptoms are related to which disorder?
Major depressive disorder
What is the priority nursing intervention for a forgetful, disoriented client with the diagnosis of dementia of the Alzheimer type?
Managing the client's unsafe behaviors
lochia
Maternal discharge of blood, mucus, and tissue from the uterus; may last for several weeks after birth.
measuring the amount of glucose in capillary blood
Measurement of capillary blood glucose
The client stands with the upper half of the body leaning forward
Modified standing position
A nurse is caring for depressed older adults. What precipitating factor listed for depression is most common in the older adult without cognitive problems?
Multiple losses
What drug does a nurse anticipate that the primary healthcare provider will prescribe for a client demonstrating clinical manifestations associated with an opioid overdose?
Naloxone
The added length of these tubes permits them to be placed in the small bowel.
Nasointestinal
Fluvoxamine
Obsessive Compulsive Disorder
Cephalohematoma is caused by _____ and may persist up to _____
PRESSURE DURING DELIVERY---3MONTHS
Lorazepam and Sertraline
Panic Disorder
procedure for withdrawing fluid from the abdominal cavity
Paracentesis
Consists of vocal sounds that are not actually words, but which communicate a message.
Paralanguage
A nurse is assessing an adolescent client with the diagnosis of schizophrenia, undifferentiated type. Which signs and symptoms should the nurse expect the client to experience?
Paranoid delusions and hallucinations
abruptio placentae
Partial or total premature separation of a normally implanted placenta.
physical inspection of the vagina and cervix with palpation of the uterus and ovaries
Pelvic examination
A client is admitted with the diagnosis of borderline personality disorder and possible depression. The client has a history of abusive acting-out behavior. What is most important to assess when caring for this client?
Potential for suicide
The Oklahoma Board of Nursing governs the practice of:
Practical Nurses, Registered nurses, and Advanced Unlicensed Assistants
When a nurse is admitting an older client to the mental health unit, it is important to identify any signs of dementia. What signs and symptoms denote the presence of dementia of the Alzheimer's Disease? Select all that apply.
Problems finding the right word or name c. Forgetfulness e. Increased frequency of losing or missing familiar objects
A nurse uses therapeutic communication techniques in order to achieve desired client outcomes. Which communication technique is a part of therapeutic communication?
Providing relevant information to the client
This zone is best for giving speeches
Public
A client has been receiving oxycodone for moderate pain associated with multiple injuries sustained in a motor vehicle collision. The client has returned three times for refills of the prescription. Which assessment finding, in addition to the client's slurred speech, leads the nurse to suspect opioid intoxication?
Pupil constriction
Who is responsible for patient assessment and analysis of collected data?
RN
The Oklahoma Board of Nursing governs the practice of:
RN,LPN, and unlicensed nursing
procedures that use roentgen rays, or x-rays, to produce images of body structures
Radiography:
elements whose molecular structures are altered to produce radiation
Radionuclide imaging
sucking reflex
Reflex that causes a newborn to make sucking motions when a nipple if placed in the mouth
A client is experiencing a panic attack. In light of the information shown, select the appropriate nursing intervention.
Remaining with the client until crisis is over
What should be the nurse's first intervention in the care of a client with a generalized anxiety disorder?
Removing as many stimuli from the client's environment as possible
Acts that include those that do not require nursing judgment are not complex care situations and are common, repeated tasks that carry little risk.
Right Task
The stability of the patient, potential for harm, and the level of technology involved.
Right circumstance
This involves the licensed nurse being clear, concise, correct, and complete.
Right directions and communication
The education and competence of the person to whom you are delegating. Additionally, it requires the licensed nurse to be familiar with the job description of the person and the agency's policy.
Right person
Following up on tasks delegated not only at completion but also frequent inspection.
Right supervision and evaluation
spontaneous rupture of membranes
SROM
True or False: Residual urine that remains in the bladder after voiding can support the growth of microorganisms, leading to infection.
True
True or False: Restraints must be the last intervention used after trying all other measures for fall-prevention.
True
True or False: Surfactant is a lipoprotein produced by cells in the alveoli that promotes elasticity of the lungs and enhances gas diffusion.
True
True or False: The Rinne test is an assessment technique for comparing air versus bone conduction of sound.
True
True or False: The geographic location of the nursing school is one of the factors that influences a future nurse's choice of a nursing program.
True
True or False: The lub-dub sounds of the heart are called "S1and S2."
True
True or False: The nurse obtains database information beginning during the admission interview and physical examination.
True
True or False: The physical characteristics of urine include its volume, color, clarity, and odor.
True
True or False: Verbal communication is used to instruct, clarify, and exchange ideas
True
True or False: Weight and height is generally measured and noted during the first interaction with the client.
True
soft tissue examination using sound waves
Ultrasonography
What should the nurse do when talking with a client with a history of panic disorder who is displaying many of the emotional and physiologic symptoms of a panic attack?
Use short sentences and give the patient one direction at a time.
Is IV Therapy within the scope of practice of an Oklahoma LPN?
Yes- under certain conditions
rooting reflex
a baby's tendency, when touched on the cheek, to turn toward the touch, open the mouth, and search for the nipple
Startle
a loud noise elicites neonatal arm abduction and leg flexion, and hands stay clentched
visceral pain
a poorly localized, dull, or diffuse pain that arises from the abdominal organs, or viscera
Oxytocin causes the milk to be expressed from the alveioli into the lacteiferous ducts, which is called "let down." it is neurohormonal reflex; either neuro (the mind) or hormones (oxytocin) may stimulate let down.
let down reflex
The __________ position is used to facilitate gynecologic, urologic, and rectal examinations
lithotomy
the postpartum vaginal discharge that typically continues for 4-6 weeks after childbirth
lochia
vaginal discharge that is mostly mucus, is clear and colorless, lasts from the tenth day to the twenty first day after birth
lochia alba
This is bright red blood, bloody consistency, fleshy odor. May have small clots <quarter size. Lasts 1-3 days after delivery
lochia rubra
pinkish vaginal discharge that lasts from the third day to the tenth day after birth
lochia serosa
helps in diagnosis of polyps or tumors of the bowel, intestinal obstruction, and structural changes within the intestine
lower gastrointestinal x-ray
procedure involving insertion of a needle between lumbar vertebrae in the spinal canal but below the spinal cord itself
lumbar puncture or spinal tap
technique that uses magnetic fields to indirectly visualize brain structure
magnetic resonance imaging (MRI)
Wacky behavior, euphoria, elevated heart rate, distorted sense of time and self-perception
marijuana or cannabis
inflammation of a breast (or udder)
mastitis
intestinal discharges of the fetus that form the first stools in the newborn
meconium
detects spinal tumors, ruptured intervertebral disks, and bony changes in the vertebrae
myelography
1L=1000ml 1g=1000mg 10ml=0.01L 1kg=1000g 1cc=0.001L 1ml=1cc 100mg=0.1g 0.5g=50mg 750ml=0.75L 1mcg=0.001mg
none
5 ml =? 1T=3tsp 15ml=? 1lb=16oz 15gr=1g 1tsp=60gtts 1gr=60mg 1kg=2.2lbs
none
When assessing pain for adults, what is commonly used to grade the severity?
numeric scale
infection or septicemia after childbirth, Any infection of genital canal within 28 days after abortion or birth (Streptococcal and anaerobic organisms, endometritis, wound infections, UTI, mastitis).
condition where blood is moving slowly through the veins and begins to pool within the vessels
This ostomy is also referred to as a Kock pouch.
continent
a substance such as barium sulfate or iodine, that adds density to a body organ or cavity
contrast media
collection of body fluid suspected of containing infectious microorganisms
culture
Continuous instillation of liquid nourishment for 8 to 12 hours is known as this type of feeding.
cyclic
visual examination of the urinary bladder
cystoscopy
Hallucinations
delirium
Inappropriate responses
delirium
Reversible
delirium
Language may be distorted and slurred
dementia
Long term memory loss
dementia
All of the following are methods of alternative measures for pain management EXCEPT:
denial
Separation of the longitudinal muscles of the abdomen (rectus abdominis) during pregnancy.
diastasis recti
dystocia
difficult birth
dystocia
difficult labor
pregnancy complication elevated bp, albuminuria, oliguria, convulsions and coma
eclampsia
Thinning and shortening of the cervix that occurs late in pregnancy or during labor
effacement
examination of the electrical activity in the heart
electrocardiography
examination of the energy emitted by the brain
electroencephalography
examination of the energy produced by stimulated muscles
electromyography
inflammation of the lining of the uterus (of the endometrium)
endometritis
______ is performed using optical scopes for a visual examination of internal structures.
endoscopy
visual examination of internal structure
endoscopy
the entrance of the fetal head or the presenting part into the pelvic inlet
engagement
breasts during lactation feel hard and warm and are enlarged, shiny, and painful, and is not an unusual condition during first 24 to 48 horus after breasts fill with milk
engorged
verbal communication
expressing ideas to others by using spoken words
0.5 g of Aldomet (methyldopa) has been prescribed po. The Aldomet is available in tablets labeled 250 mg. You should administer 1.5 tablets.
false
A boggy uterus is a complication of the first stage of labor.
false
A contrast medium makes dense body areas appear hollow when imaged on an x-ray film.
false
A hypotonic solution contains a greater amount of dissolved substances as normally found in plasma.
false
A low lying placenta that is implanted near the cervix is called an abruptio placenta.
false
A stock supply automatically keeps a record of dispensed medications.
false
Acupressure is a pain management technique in which long thin needles are inserted into the skin.
false
An otic application is a medication instilled in the inner ear.
false
Contraction duration is the time from the beginning of one contraction to the beginning of the next contraction.
false
During ultrasonography, a probe called a transducer is inserted into the body.
false
Hyperemesis gravidarum may cause dehydration and electrolyte imbalance in the pregnant woman but is not harmful to the fetus.
false
In ophthalmic medication application, gentle rubbing effectively distributes the medication over the surface of the eye.
false
Nonopioids are examples of controlled substances.
false
Patients who are diagnosed with a placenta previa must undergo a Caesarean section.
false
T or F 600 ml of D5W has been prescribed for IV infusion over 5 hours. You are using an IV administration set that delivers 10 gtts/ml. You should run the IV at 30 gtts/min.
false
The Sims' position is a reclining position with the knees bent, hips rotated outward, and feet flat.
false
The smaller the number, the smaller the diameter of a needle gauge.
false
The supply of medications should remain unlocked to ensure quick access during an emergency situation.
false
The two-inch area around the umbilicus is an ideal location for a subcutaneous injection.
false
Transcutaneous electrical nerve stimulation has been found to be effective in all clients.
false
Early decelerations are caused by the compression of the ----during contractions and are considered reassuring.
fetal head
form of radiography that displays an image in real time
fluroscopy
neuropathic pain
pain from damage to neurons of either the peripheral or central nervous system
Functional pain
pain sensitivity due to an abnormal processing or function of the central nervous system in response to normal stimuli
cervical insufficiency
painless dilation of cervix due to structural or functional defect or cervix
A ________________ is a procedure for withdrawing fluid from the abdominal cavity.
paracentesis
procedure for withdrawing fluid from the abdominal cavity
paracetesis
Colloids
particles that are intermediate in size between those in solutions and suspensions a homogeneous noncrystalline substance consisting of large molecules or ultramicroscopic particles of one substance dispersed through a second substance
A____________examination is the physical inspection of the vagina and cervix with palpation of the uterus and ovaries.
pelvic
physical inspection of the vagina and cervix, with palpation of the uterus and ovaries
pelvic examination
The rhythmic contractions of intestinal smooth muscle that facilitate defecation.
peristalsis
This is a transient period of MILD depression that occurs early in the postpartum period (begins 3rd or 4th day). If symptoms last longer than 2 weeks, evaluate for Depression & Psychosis
postpartum blues
abnormal condition associated with pregnancy, marked by high blood pressure, proteinuria, edema, and headache
preeclampsia
cervical insufficiency
premature dilation of the cervix
hormone responsible for milk production
prolactin
any severe mental disorder in which contact with reality is lost or highly distorted
psychosis
Roentgenography, also known as _______________, produces images of body structures using x-rays that produce electromagnetic energy that passes through body structures leaving an image of dense tissue on special film.
radiography
This type of enema uses a solution held within the large intestine for a specified period, usually at least 30 minutes.
retention
retained placenta
retention of the placenta beyond 30 minutes after birth
The procedure to surgically section a nerve root located close to the spinal cord is called a:
rhizotomy
corticotrophin releasing factor (CRF)
stimulates the brainstem to activate the sympathetic nervous system
Is a slower-than-expected return of the uterus to its nonpregnant condition.
subinvolution
contrast medium
substance injected into the body, introduced via catheter, or swallowed to facilitate radiographic images of internal structures that otherwise are difficult to visualize on x-ray films
A common surgical intervention to treat an incompetent cervix is a cerclage
true
A laboratory test involves comparing the components of a collected specimen with normal findings.
true
Ampicillin is available in liquid form labeled 0.25 mg in 1 ml. 0.125 mg of ampicillin has been prescribed po. You should administer .5 ml.
true
An IV will be administered using an infusion pump that delivers ml/hr. D5W has been prescribed to run IV at a rate of 100 ml/30 min. The IV should infuse at 200 ml/hr.
true
An infant weighs 10 lbs 8 oz. This is equivalent to 4.8 kg
true
Asking a second nurse to listen to a telephone order on an extension is an acceptable way of ensuring the order is recorded accurately.
true
Chemical and percutaneous rhizotomy are non-invasive types of pain management.
true
Contraction frequency is the time from the beginning of one contraction to the beginning of the next contraction.
true
During the admission assessment of pain the nurse will want to know the names and dosages of pain medication a client takes.
true
Functional pain is also called neuropathic pain.
true
If a newborn does not pass the hearing screen test, it should be repeated at age 3 months.
true
Instillation of a medication through an enteral tube is considered a method of oral administration.
true
Large nerves and blood vessels are absent in vastus lateralis site.
true
Lipohypertrophy is buildup of subcutaneous fat at the site of repeated insulin injections.
true
Many topically applied medications are administered to achieve a direct effect on the tissue to which they are applied.
true
Nurses do not allow their biases to interfere with their decisions to give or not give pain medications.
true
Older adults are more susceptible to dehydration.
true
Over-the-counter decongestant nasal sprays may cause a rebound effect if used too frequently or administered more than the recommended amount.
true
Percutaneous electrical nerve stimulation is an example of a non medication/nonsurgical intervention to manage pain.
true
The dorsogluteal site should be avoided in elderly clients to avoid risk of damage to the sciatic nerve with diminished musculature.
true
The health agency sets a predetermined timetable for most medication administrations.
true
Visceral pain is discomfort arising from internal organs.
true
aids in diagnosis of ulcers, GI tumors, narrowing of the esophagus
upper gastrointestinal x-ray
A urinary diversion that discharges urine from an opening on the abdomen.
urostomy
True or False: Diabetes mellitus is a common disorder associated with dysuria.
False
True or False: Eating beans aids the expelling of intestinal gas.
False
True or False: Intestinally placed tubes may lead to dumping syndrome.
True
True or False: Medications to reduce fever are available in suppository form.
True
True or False: Nasal strips are used to reduce or eliminate snoring.
True
True or False: Nurses can insert nasogastric tube into clients.
True
True or False: Nurses with a baccalaureate degree are preferred in areas requiring substantial decision-making.
True
True or False: Patients have the right to be free from restraints in long term care facilities.
True
True or False: Enteral nutrition is nourishment provided via the stomach or large intestine.
False
True or False: Physician orders are necessary for physical and chemical restraints.
True
Cardiotoxicity, respiratory arrest, auditory, visual, and olfactory hallucinations, coma, and confusion
cocaine
milky fluid secreted for the first day or two after parturition
colostrum
form of x-ray that shows planes of tissue
computed tomography (CT)
True or False: If IV Therapy is a requirement for employment of the LPN, this should be included on the facility website.
False
True or False: In second-intention healing, the wound edges are widely separated and are later brought together with some type of closure material.
False
Initial Assessment
-Admission when client enters healthcare system -Purpose to evaluate health status and identify health needs that are unmet -Must be documented by registered nurse -Parts may be delegated to non-licensed personnel
True or False: Oliguria means greater than normal urinary volume.
False
True or False: Planning is the way by which nurses determine whether a client has reached a goal.
False
True or False: Prolonged "tenting" of the skin when assessing skin turgor indicates edema in the client
False
True or False: Pursed-lip breathing is a technique where the client consciously prolongs the inspiration phase of breathing.
False
True or False: Remodeling follows the inflammatory phase of wound healing and may last 6 months to 2 years.
False
True or False: Staples compress the tissue, in case the wound swells.
False
INR
1.0
Specific gravity (urine)
1.005-1.030
magnesium range
1.3-2.3 mEq/L
2 tsp of cough medicine has been prepared. A measuring device marked in ml is being used. How many ml should be administered?
10
blood urea nitrogen (BUN)
10-20 mg/100 mL
Platelet count
100,000-400,000/mm3
Baseline FHR refers to the range of the FHR between contractions observed for a____ period of time
10minute
Fetal bradycardia is defined as a rate less than _____ beats/min for a period of ______ minutes.
110- 10
The normal range of FHR is
110‑160 beats/min
The nurse observes that @ 0600 there are 400 cc of NS LTC. The IV is infusing @ 75 cc/hr. What time will the next bag of fluids be hung?
1120
The doctor has ordered an IV with 10,000 units of heparin to infuse over 20 hours. Calculate the units of heparin the client will receive in a 24 hour period.
12,000 units
Hemoglobin Females
12-16 g/dL
Hemoglobin Males
13-18 g/dL
sodium range
135-145 mEq/L
1/4 gr of phenobarbital must be prepared. Phenobarbital is available in mg. How many mg of Phenobarbital should be prepared?
15 mg
Fetal tachycardia is defined as a rate of more than _____ beats/min for a period of _____minutes.
160-10
An IV is ordered to infuse at 50 ml/hr. The drip rate on the IV tubing states 20 gtts/ml. How many drops/min will need to be delivered?
17 gtts/min
The doctor has ordered 750 mg of Tylenol. You have on hand 200 mg/5 ml. How many ml will you give?
18.75 ml
True or False: Supervision is an inactive process of directing, guiding, and influencing the outcome of an individual's performance of an activity or task.
False
60 mg of liquid ampicillin has been prescribed. 60 mg is contained in 10 ml. A measuring device marked in tsp is being used. How many tsp should be administered?
2tsp
INR, patients taking warfarin sodium
2-3.5
True or False: The elasticity of lung tissue allows the lungs to stretch and fill with air during expiration and return to a resting position after inspiration.
False
phosphate range
2.5-4.5mg/dl
Partial Thromboplastin Time (PTT)
20-45 seconds
At 0600 the nurse hung 1000 cc of NS infusing @ 100 cc/hr. How many cc were LTC @ 1400?
200 cc LTC
Ancef 1.5 gm is ordered. It is suggested the ancef infuse at 2 gm/30 min. How many minutes will it take to infuse the ancef?
22 minutes 30 seconds
HCO3- range
22-26 mEq/L
Osmolality
280-300 mOsm/L water
True or False: The head-to-toe approach involves a number of position changes required of the client.
False
True or False: The use of gestures is preferable to the use of translators when neither the nurse nor the client speaks a compatible language.
False
Type O blood is considered the universal recipient.
False
True or False: Nonmaleficence means "doing good" or acting for another's benefit.
False means non-harming or inflicting the least harm possible to reach a beneficial outcome.
200 ml of 1/4% Magnacal must be prepared for a tube feeding. You have available full strength Magnacal. To prepare hte feeding you dilute how many ml of the full strength Magnacal with how many ml of water?
50 ml of full strength Magnacal with 150 ml of water
0.5 g of ampicillin must be prepared. Ampicillin is available in mg. How many mg of ampicillin should be prepared?
500mg
Albumin
3.5-5 g/100 mL
Potassium range
3.8-5 mEq/L
The IV is infusing at 33 cc/hr. There are 1000 cc of NS in the bag. How many hours and minutes will it take for the infusion?
30 hours and 18 minutes
You need to verify that a prescribed dose of Proleukin (aldesleukin) for a patient currently weighting 50 kg is appropriate. The drug literature recommends 600,000 unit/kg/dose. You determine that an appropriate dose for this patient would be?
30,000,000 units/dose
Normal respiration rate for the newborn is:
30-60 beats/min
Your patient's current weight is 70 kg. Nitroprusside is to be infused at 0.5 mcg/kg/min. How many mcg of nitroprusside should you infuse per min?
35 mcg/min
PaCO2 normal range
35-45 mm Hg
To complete a physical assessment, the space utilized will be how far of distance
6 inches- 4 feet
Total protein
6-8 g/100 mL
The client is to receive 15 mg/kg/day of codeine. How many mg/day will the 40 kg client receive?
600 mg/day
An IV solution contains 6 mg of NItrostat (nitroglycerin). 6 mg of Nitrostat is equivalent to how many mcg?
6000 mcg
PH level
7.35-7.45
One minute after birth a nurse assesses a newborn and auscultates a heart rate of 90 beats/min. The newborn has a strong, loud cry, moves all extremities well, and has acrocyanosis but is otherwise pink. What is this neonate's Apgar score?
8
calcium range
8.6-10.2 mg/dL
The IV is infusing @ 75 cc/hr. There are 600 cc LTC. What is the infusion time for the 600 cc?
8hours
Prothrombin time (PT)
9.5-12 seconds
pH (urine)
4.6-8.2
Hematocrit Females
40-48%
Hematocrit Males
42-50%
chloride range
97-107 mEq/L
In an ectopic pregnancy, the fertilized ovum implants in:
?
Pseudodementia
A condition with clinical symptoms of dementia but not due to organic disease and without the permanent cognitive sequelae. false dementia
?
A graduate who acquired an associate degree in nursing would be referred to as a:
Nagele's Rule
A method of determining the estimated date of birth (EDB): after obtaining the first day of the last menstrual period, subtract 3 months and add 7 days.
skin turgor
A reflection of the skin's elasticity, measured by monitoring the time it takes for the skin on he back of the hand to return to position after it is lightly pinched between the examiner's thumb and forefinger. Normal turgor is a return to normal contour within a few seconds; if the skin remains elevated (tented) more than a few seconds, turgor is decreased.
focused assessment
A type of physical assessment that is typically performed on patients who have sustained nonsignificant mechanisms of injury or on responsive medical patients. This type of examination is based on the chief complaint and focuses on one body system or part.
True or False: Illness is a state of discomfort that results when disease, deterioration, or injury impairs a person's health.
True
True or False: Implementation means carrying out the plan of care.
True
True or False: During World War II, abbreviated programs in practical nursing were developed to address the acute shortage of trained nurses.
True
artificial rupture of membranes
AROM
True or False: Increased peristaltic activity is termed the gastrocolic reflex.
True
A depressed client says, "I'm no good. I'm better off dead." What is the priority nursing intervention?
Alerting the staff to schedule 24-hour observation of the client
Under which conditions can an LPN perform IV Therapy/IV medication administration in the state of Oklahoma?
All of the above When the LPN has received IV training in nursing school, course of study, or by employer. b. When the employer's documented policies and procedures support the action. c. When the LPN has documented training/competency in the area.
What should the RN consider when delegating IV Therapy to an LPN?
All of the above. Documented training of LPN in IV Therapy. b. Competency of the LPN. c. Patient condition and facility policies/procedures
A scoring system used to evaluate newborns at 1 minute and 5 minutes after birth. The total score is achieved by assessing five signs: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each of the signs is assigned a score of 0, 1, or 2. The highest possible score is 10.
Apgar score
A client who attempted suicide by slashing the wrists is transferred from the emergency department to a mental health unit. What important nursing interventions must be implemented when the client arrives on the unit?
Assessing for suicidal thoughts b. Initiating a therapeutic relationship c. Inspecting the bandages for bleeding d. Instituting continuous monitoring f. Obtaining vital signs
The distribution of work that each staff member is responsible for (and already authorized to do) during a given work period
Assignment
What is the nurse's primary outcome goal when managing the care of a client diagnosed with generalized anxiety disorder (GAD)?
Assisting the client with the development of healthy, adaptive coping mechanisms
True or False: Fecal impactions result from retained barium from an intestinal x-ray.
True
True or False: Influenza is an example of an acute illness.
True
A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what?
Become aware of their personal values
After a client on the mental health unit with a known history of opioid addiction has a visit from several friends, a nurse finds the client in a deep sleep and unresponsive to attempts at arousal. The nurse assesses the client's vital signs and determines that an overdose of an opioid has occurred. Which findings support this conclusion?
Blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths/min
This type of feeding is the least desirable enteral feeding schedule because it distends the stomach rapidly, causing gastric discomfort.
Bolus
intermittent painless uterine contractions that occur with increasing frequency as the pregnancy progresses
Braxton Hicks contractions
A bolus administration consists of diluted medication given quickly into a vein.
False
An implanted catheter is inserted through the skin into a peripheral vein.
False
If IV Therapy is a requirement for employment of the LPN, this should be included on the facility website.
False
Once a nurse delegates a task, the responsibility and accountability for the task are transferred.
False
Passive listening is demonstrating full attention to what is being said, hearing both the content and the unspoken message
False
True or False: . A physical examination is the systematic collection of facts of data.
False
True or False: . In the remission state of illness, the relief or the cured state is permanent.
False
True or False: A misdemeanor is a serious criminal offense, such as murder, falsifying medical records, insurance fraud, and stealing narcotics.
False
What must the nurse understand about breaks with reality such as those experienced by clients with schizophrenia?
Clients believe that what they feel that they are experiencing is real.
Non-verbal communication
Communicating without the use of words.
Afterpains
Cramplike pain after childbirth caused by alternating relaxation and contraction of uterine muscles.
True or False: A restraint is used to restrict a person's freedom of movement, physical activity, or normal access to his or her body with the goal of making the nurse's job easier.
False
True or False: An advantage of the nasointestinal tube is that it does not become obstructed easily.
False
periodic decrease in FHR
Deceleration
True or False: Chronic purging eventually weakens digestive tract.
False
True or False: Constitutional laws are enacted by federal, state, or local legislatures.
False
A client has a diagnosis of schizoid personality disorder. During the assessment what should the nurse expect of the client's behavior?
Detached and socially distant
procedure that involves physical inspection of body structures and evidence of their functions
Diagnostic examination
Mottling
Discoloration of the skin in irregular areas; may be seen with chilling, poor perfusion, or hypoxia.
The nurse assesses a client with the diagnosis of bipolar disorder, manic episode. Which clinical findings support the diagnosis? Select all that apply.
Distractibility c. Talkativeness d. Decreased sleep e. Grandiosity
Reclining position with the knees bent, hips rotated outward, and feet flat
Dorsal recumbent position
implantation of the fertilized egg in any site other than the normal uterine location
Ectopic pregnancy
recording electrical impulses from structures such as the heart, brain, and skeletal muscles
Electrical graphic recordings:
An intuitive awareness of what a client is experiencing.
Empathy
visual examination of internal structures
Endoscopy
Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss does this intervention prevent?
Evaporation
One reason that a patient should be involved in his pain medication regime is:
He will likely receive a positive outcome sooner than a patient who is not involved.
A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients?
Impulsive
Which therapeutic communication technique involves using a coping strategy to help the nurse and client adjust to stress?
Sharing humor
A nurse is caring for several extremely depressed clients. What type of setting does the nurse recognize these clients do best in?
Simple daily routines
Which position may be used as an alternative to the lithotomy position during a rectal examination?
Sims position
The client lies on the left side with the chest leaning forward, the right knee bent toward the head, the right arm forward, and the left arm extended behind the body
Sims' position
Paroxetine
Social Anxiety Disorder,
in this stage expulsion of the placenta to a time of 1 - 4 hours after expulsion
Stage Four is defined as:
Relationship of the presenting fetal part to an imaginary line drawn between the pelvic ischial spines.
Station
Which activities is normally found in the personal zone?
Teaching
True or False: Gastric sump tubes, which are double-lumen tubes, are used almost exclusively to remove fluid and gas from the stomach.
True
True or False: Ice collars are often applied after tonsil removal.
True
The nurse is assessing the newborn in the first hour after birth. Which findings does the nurse identify as normal for the newborn? Select all that apply.
The newborn weighs 6 lbs (2,700 g). The circumference of the head is 33 cm (13 in).
collecting infectious specimens or microorganisms from the throat and examining their characteristics with a microscope
Throat culture:
A patient who is having difficulty breathing may benefit from a assuming a seated position with his arms supported on pillows or on the arm rests of a chair. This position is know as:
Tripod
A baby is considered small for gestational age with a weight of less than 5lbs and 8oz.
True
A hypovolemic client can suddenly become hypervolemic with the administration of albumin by IV infusion.
True
A volume-control set is a chamber in IV tubing that holds a portion of the solution from a larger container.
True
An RN can delegate IV medication administration to an LPN who has been appropriately trained.
True
Employers who require LPNs to administer IV medication should have a list of medications the LPN is able to administer.
True
IV Therapy for LPNs must be documented.
True
Implanted catheters have a self-sealing port pierced through the skin with a special needle for the administration of IV medications or solutions.
True
Needleless systems are used to reduce the potential for infection with bloodborne pathogens during the administration of blood products
True
PolyHeme and Hemosol may improve the treatment of disorders that previously required blood transfusions
True
The nurse should pour 70% alcohol over any antineoplastic medication spill to inactivate the drug.
True
True or False: A diagnosis results from analyzing the collected data and determining whether they suggest a specific condition.
True
True or False: A person can forcibly exhale additional air by contracting abdominal muscles.
True
True or False: A sign of urinary retention is a progressively distending bladder.
True
True or False: A stage III pressure ulcer may be accompanied by serous drainage or purulent drainage caused by a wound infection.
True
True or False: Abraham Maslow, a psychologist, identified five levels of human needs.
True
True or False: An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor
True
When utilized in the control of pain, antidepressants and anticonvulsants are classified as:
adjuvant
pains felt by a woman after her baby is born
afterpains
Employer policies and procedures addressing IV therapy should be written and available to the LPN. These policies should include at least the following:
all of the above a. Routes of administration the LPN may use to infuse solutions and medications. b. IV fluids and medications the LPN is granted authority to administer in the facility as well as medications LPNs may not administer. c. Whether or not the LPN can draw blood via peripheral devices, venipuncture, &/or central venous lines.
Sweating, psychotic behavior, exhaustion, hypertension, hyperthermia, tachycardia, and dilated pupils
amphetamine
Prolapsed cord
an umbilical cord that protrudes beside or ahead of the presenting part of the fetus. Knee to chest or Trendelenburg(get on all fours)
determines the location where and the extent to which blood vessels have narrowed
angiography
An abnormal urinary elimination pattern characterized by absence of urine or a volume of 100 ml or less in 24 hours.
anuria
Absence or lack of usual muscle tone.
atony
A seatlike container that is used to collect urine or stool.
bedpan
The first stage of labor is defined as:
beginning of labor to complete dilatation of the cervix
How can LPNs be trained in IV Therapy?
both a and b Nursing School b. Employer
inspection of the bronchi
bronchoscopy
Negligence
careless neglect, often resulting in injury
The act of applying or inserting a hollow tube inside the bladder.
catheterization
detects pneumonia, broken ribs, lung tumors, enlarged heart
chest x-ray
facilitates determining the presence of gallstones and obstruction in the flow of bile
cholecystography
upper portion of the uterus above the entry to the uterine tubes
fundus
an indicator of deep vein thrombosis. The sign is present where pain in the calf is produced by passive dorsiflexion of the foot
homan's sign
nosocomial infection
hospital acquired infection
Device that produces small water droplets and may be used during oxygen administration in order to keep mucous membranes moist.
humidifier
excessive vomiting during pregnancy
hyperemesis gravidarum
A condition in which there is insufficient oxygen within arterial blood.
hypoxemia
A condition in which there is inadequate oxygen at the cellular level.
hypoxia
This occurs when a large, hardened mass of stool interferes with defecation.
impaction
placenta previa
implantation of the placenta over the cervical opening or in the lower region of the uterus
Anhedonia
inability to experience pleasure
The inability to control either urinary or bowel elimination.
incontinence
rooting reflex
infants tendency in turning toward the source of touching that occurs anywhere around his or her mouth
the state of being unable to produce offspring
infertility
objective data
information that is seen, heard, felt, or smelled by an observer; signs
The dome-shaped diaphragm contracts and moves downward in the thorax during this phase of breathing.
inspiration
Pain which does not respond to other methods of pain management and can be relieved with surgery is known as:
intractable
helps identify urinary malformations, tumors, stones, cysts, and obstructions in the kidneys and ureters
intravenous pyelography
reduction in size of an organ or part (as in the return of the uterus to normal size after childbirth)
involution
the production and secretion of milk by the mammary glands
lactation
examination of the abdominal cavity
laparoscopyvisual
The phases of stage 1 labor include
latent, active, transition
cutaneous pain
superficial pain usually involving the skin or subcutaneous tissue
This is inserted into a body cavity such as the rectum.
suppository
cerclage
surgical in which a stich is placed in the cervix
Early Decelerations - Fetal Heart Rate
symmetrical decrease in FHR
Mutual agreement on improvement of the client's immediate health problems occur in this phase of the nurse-client relationship.
terminating
placenta previa
the abnormal implantation of the placenta in the lower portion of the uterus
If a newborn's temperature is elevated, the nurse must consider that the room is too warm, the child is wearing too much clothing, the child may be dehydrated and ________
the child may have an infection
subjective data
things a person tells you about that you cannot observe through your senses; symptoms