Fundamentals exam 1

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thrombophlebitis:

clot accompanied by inflammation of the vein

communicable disease

infectious process transmitted from one person to another

hypostatic pneumonia

inflammation of lungs from stasis/pooling of secretions

gingivitis

inflammation of the gums

Stomatitis

inflammation of the mouth

duration

time during which med is present in concentration great enough to produce a response

onset

time it takes after med is administered for it to produce a response

peak

time it takes for a med to reach its highest effective concentration

avoid cold formula

to avoid abdominal cramping and nausea during enteral tube feedings what should you do?

Fracture

to break (a bone)

plantar flexion

toes pointed

dorsiflexion

toes towards head

evisceration

total separation of wound layers with protrusion of visceral organs through the wound opening

delegation

transferring responisbility of a task while retaining accountability for the outcome

dysphasia

trouble speaking

adverse effects

unintended undesireable effects

allergic reaction

unpredictable response to a med

log rolling

used for patients with cervical/spine injuries

residual volume

volume of enteral formula remaining in stomach

oxygen, oral airway, suction equipment, and padding

waht equipment should you have on hand for seizures?

contact

what precautions for MDROs and c.diff?

intensive care units, surgery, patients with catheters

when should you use CHG wipes?

skin, saliva, oral mucosa, intestinal tract, respiratory tract, genitourinary tract

where is normal flora located?

left upper quadrant

where is stomach located?

reservoir

where pathogens survive and multiply

breasts

where should you not apply an estrogen patch?

near nurses desk

where should you place patients at risk for falls in the hospital?

joint

where two bones attach

toddlers

which age group is at a high choking risk?

alcoholism

which client having emergency surgery should nurse anticipate to be at highes risk for post op mortality?

yellow bell peppers, cantaloupe, oranges, kiwi

which foods are collagen heavy?

potatoes and papayas

which foods are good sources of vitamin c?

all eggs

which foods should be included in a low residue diet?

focusing

which interview skill is being used when the nurse says "you mentioned before you are having a problem with your colostomy?"

clear liquids

which is most common diet nurse can anticipate after client who had abdominal surgery exhibits a return of intestinal peristalsis?

stability of vital signs

which is next most important assessment made by nurse after ensuring a post op client has a patent airway?

providing assistance with the intake of meals

which is the most common independent nursing intervention to help a debilitated older adult maintain body weight while in the hospital?

determing the content and feeling of the clients message

which is the nurse doing when using the interviewing technique attentive listening?

low serum albumin

which lab result indicates inadequate protein intake?

dental caries

which physical characteristic supports conclusion of fluoride deficiency?

burns, pneumonia

which problems increased clients caloric requirements?

inadequate intake of carbs

which rationale explains the presence of ketosis in an otherwise healthy adult?

towards the wound

which way should you remove tape?

respiratory depression

while taking opioids/narcotics what could patients develop?

podiatrist

who can cut a diabetic patients toenails?

immunocompromised patients

who is protective isolation for?

RN

who is the leader of the healthcare team?

RN

who is the nursing leader?

c. diff

with what disease should you use soap and water instead of hand sanitizer?

droplet

with what precautions must the patient wear a regular mask when leaving the room?

secondary intention

wound edges not approximated, loss of tissue, pressure ulcers, left open until filled with scar tissue, wounds heal by granulation tissue formation

dehinscence

wound edges pull apart, partial or total separation of wound layers, increased risk with abdominal surgeries

primary intention

wound that is closed, low risk of infection, little tissue loss, skin edges approximated, surgical incision, healing occurs by epithelization

tertiary intention

wound that is open for several days then approximated: for monitoring infection or awaiting pathology results

slough

soft, stringy, yellow, white, tan, grey, green or brown dead tissue (remove for wound healing)

pharmokinetics

study of how a med enters the body, moves through the body, leaves the body

Ophthalmology

study of the eye and eye diseases

seizure

sudden surge of electrical activity in brain, disorderly discharge of neurons in brain

Enucleation

surgical removal of the eyeball

Contracture

the permanent tightening of fascia, muscles, tendons, ligaments, or skin that occurs when normally elastic connective tissues are replaced with nonelastic fibrous tissues

Mastication

the process of chewing

motor and sensory function returns

there are discharge criteria for client in PACU regardless of anesthesia used. which is criterion specific for a patient who has received spinal anesthesia?

intensity of pressure, duration of pressure, tissue tolerance

what are the three elements of pressure ulcer development?

medical and surgical

what are the two types of asepsis?

nursing intervention that help prevent negative effect of immobility

what are these examples of: sequential compression devices, thrombo embolic devices, active/passive ROM, gait belts, calcium rich diet if kidney is functioning well, flexing feet while sitting, anticoagulants

dysphagia

what are these warning signs of: coughing/choking, facial paralysis, abnormal gag reflex, delayed swallowing, pocketing

assessment, diagnosis, solutions, implementation of advanced nursing skills, evaluating outcomes, patient teaching

what cannot be delegated?

location, depth of tissue involvement, type and amount, appearance, wound dimensions, character of drainage/exudate description, condition of surrounding skin

what do assessment of wounds include?

high protein

what do infants need nutrition wise?

ischemia and damage to the underlying tissue

what does a pressure ulcer result in?

effects of meds on body, symptoms meds relieve, meds desired effects

what does classification include?

impaired body alignment

what does damage to cns mean?

bruises, contusion, tears, sprains, fractures

what does direct trauma to muscoloskeletal system mean?

healthcare providers order

what does irrigation require before implementing?

advanced age, history of falls, incontinence/frequency/nocturia, meds within 24 hours, patient care equipment, cognitive impairment

what does the fall risk survey include?

Hypercoagulability, venous wall abnormalities, blood flow stasis

what does virchows triad consist of ?

hypercoagulability, vessel wall abnormalities, blood flow stasis

what does virchows triad include?

meat and spinach

what food is a good source of iron?

19

what gauge needle for debridement?

mosquitoes

what is an example of a vector?

not taken without primary healthcare provider, use different method of birth control if taking oral, stop taking 2 weeks before surgery, apply sunscreen to skin exposed to sun

what is important to know about taking st johns wort?

pain management

what is primary goal for hospice care?

protect public health/safety through applying disease control/prevention

what is the CDCs goal?

3.4-5.4

what is the albumin level?

breast milk

what is the best nutrition for infants?

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

what is the chain of infection in order?

oral

what is the easiest and most desirable route to administer medications?

prevents gastric mucosal damage

what is the major advantage of using a double lumen tube?

diarrhea

what is the most common side effect of a gastric tube?

albumin

what is the most common test if you suspect insufficient nutrition?

listen

what is the most important thing nurses can do to establish a positive culture of pain management?

5000-10000

what is the normal WBC count?

60-120

what is the normal blood glucose level?

15-36

what is the pre albumin level?

remove debris and dead tissue from wound

what is the primary reason for debridement

to avoid med errors

what is the purpose of medication reconciliation?

maintain a balanced perspective

what is the purpose of the use of humor by the nurse?

braden scale

what is the scale used for pressure ulcer risk assessment?

patients self report

what is the single most reliable indicator of pain?

170-370

what is the transferrin level?

6-8.3

what is total protein level?

leave the same way they enter

what is true about pathogens entering and leaving the body?

the lower the score the higher the risk

what is true of the braden scale?

mechanical soft

what kind of diet consists of these foods: all of above and cream soups, ground meat, flaked fish, cottage cheese, cheese, potatoes, pancakes, bread, cooked veggies, canned fruit, banana, soup, PB, eggs

clear liquid

what kind of diet consists of these foods: fat free both, coffee, tea, soda, clear fruit juice, gelatin, fruit ices, popsicles, ice chips

full liquid

what kind of diet consists of these foods: smooth dairy products, blended soups, custards, veggie juice, fruit juice, sherbert, pudding, frozen yogurt,

soft/low residue

what kind of diet consists of these types of foods: all of above and low fiber foods, pasta, casseroles, tender meats, fruit, cake, desserts, cookies

airborne

what kind of precautions for tb, measles, smallpox?

airborne

what kind of precautions for varicella zoster and disseminated varicella zoster?

weak leg

what leg should you use first when ambulating with a walker?

organ meats

what meats are high in cholesterol?

liquid

what medication form is best for infants?

gloves, goggles, gown, mask,hand hygien

what order is doffing?

hand hygiene, gown, mask, goggles, gloves

what order is donning?

obesity

what places client at highest risk for post op nausea and vomiting after receiving general anesthesia?

side lying

what position is most likely to cause pressure ulcers?

droplet

what precautions for diptheria, rubella, mumpls

contact

what precautions for ebola, major wound infections, RSV?

droplet

what precautions for scarlet fever and plague

contact

what precautions for varicella zoster, scabies, MRSA?

airborne

what precautions must you wear an n-95 mask?

droplet

what precautions of strep,pertussis, influenza?

contact

what precautions should the patient have a dedicated bp cuff, stethoscope, and thermometer?

airborne

what precautions should use a negative air pressure air flow room?

>12 exchanges per hour

what should positive airflow be set to for protective isolation?

keep walkways clear of obstacles

what should the nurse do to best prevent a client from falling?

perfume and hairspray

what should you avoid using near hearing aids?

time it starts and ends, sequence, type of movements

what should you note with seizures?

strong side

what side of the body should you hold a cane on?

within 60 minutes

what timeframe is a "now" order?

pure food and drug act

what was the first american law to regulate meds?

place at an angle

when adding sterile items to a sterile field what should you remember?

dominant

when applying sterile gloves what hand should go first?

when skin integrity is broken from trauma, surgical incision, burns

when are sterile dressing used?

listening to each quadrant for 5 minutes

when can you determine there are no bowel sounds?

choose device that allows for the most independence and maximum safety

when choosing an assitive device what should you do?

4-5 day post op

when does surgical wound infection appear?

medication interactions

when one med modifies the action of another

hyperemic changes

when pressure is relieved, blood vessels vasodialte to restore blood flow to tissues

when decision for surgery is made

when should nurse initiate planned interventions regarding clients perioperative managements?

when its cool or soapy

when should you change bath water?

as soon as it is given

when should you document medication admin?

Hermiplegia

paralysis of one side of the body

hospices

programs for end of life care

red, yellow, black

protect ___, cleanse ____, debride ____

transferrin

protein in blood that binds iron and transports it

nonmaleficance

the avoidance of harm or hurt

generic

the manufacturer who develops the drug assigns the name

hemovac

round drain with springs inside that must be compressed to create a suction

virulence

ability of organism to produce disease (numbers present, ability to enter and survive in host, susceptibility of host

Scoliosis

abnormal lateral curvature of the spine

asepsis

absence of pathogen or disease producing microbes

toxic effect

accumulation of med in bloodstream

as desired

ad lib

ABCS

age over 85, bone disorders, coagulation disorders, surgery

podromal

in this stage of infection from onset of nonspecific signs and symptoms to specific signs and symptoms

trade

"brand name" name under which manufacturer markets the medication

place in low fowlers

"my incision feels funny" which should nurse do first?

1

5 ml= ?tsp

before meals

AC

extended release

ER

Angi (o)

Vessel

Kyphosis

hunchback

Lordosis

swayback

3 seconds or less

How many seconds should capillary refill be?

myoclonic seizure

causes patients muscles to tense

lungs

client spikes a fever during post op day after abdominal surgery. nurse suspects fever indicates an infection. where at?

neutropenic

eliminates raw, unprocessed, and fresh fruits/ veggies, drinking tap water and emphasizes well cooked foods

acute

should acute or chronic wounds come first?

no

should you interrupt nasogastric tubing for care?

reverse trendelenburg

entire bed frame tilted with foot of bed down

no

should you restrain a patient during a seizure?

trendelenburgs

entire bed frame tilted with head of bed down

chemical

enzymes digest/ dissolve necrotic tissue, dakins solution for this debridement

ensure clients allergy band includes clients identified allergies

client admitted to ambulatory care for bilateral herniorrhaphy. what should nurse do first in regards to his allergies?

systemic infection

examples of this infection are influenza, mono, cold

>300

how many grams of cholesterol to be considered low cholesterol?

>5

how many microns for droplet precautions?

<5

how many microns is airborne precautions for?

3

how many nurses needed for logrolling?

2

how many nurses on the side the patient is to be turned to in logrolling?

activities of daily living

6 routine activities that people tend to do every day without needing assistance

at least 3

how many times should you read labels?

8

1 cup= ? oz

1000

1 liter=? ml

every 1-2 hours

how often should a patient be turned?

2 lbs

1000 mL=? lbs

1

1000 ml= ? L

1

15 ml= ? tbsp

epilepsy

2 or more unprovoked seizures

1

240 ml= ? cups

every 2 hours

how often should nurses move patients at risk for pressure ulcers?

1

30 ml= ? oz

2

30 ml= ? tbsp

delayed gastric emptying

>250 ml in stomach on 2 assessments 1 hr apart or single 500 ml

Aura

A bright light smell or taste

Osteoporosis

A condition in which the body's bones become weak and break easily.

Cartilage

A connective tissue that is more flexible than bone and that protects the ends of bones and keeps them from rubbing together.

15 minutes

how often should patient be observed if theyre restrained?

Aero

Air

Arteri (o)

Artery

every 5 minutes

how often should you check on a patient in the tub or shower?

Cuticle

Band of epidermis at the base and sides of the nail plate

controlled delivery

CD

controlled release

CR

progress notes

client admitted to hospital with tentative medical diagnosis and multiple diagnostic tests are performed. where in the clients medical record can the nurse find documentation about current medical diagnosis after diagnostic test results are reviewed by PHCP?

suctioning mucus from respiratory passages

client admitted to post anesthesia unit which nursing action is most important during clients stay?

Ligaments

Connect bone to bone

Tendons

Connect muscle to bone

every 15 minutes

how often should you observe a patient in restraints?

auscultate for bowel sounds

client has abdominal surgery. what should nurse do to best assess for a sign of post op ileus in client after surgery?

Optometrist

Eye doctor

Footdrop

Foot is permanently fixed in plantar flex ion

Aden (o)

Gland

liver and shrimp

client has high serum cholesterol level. what should client avoid?

Acne

Inflamed or infected sebaceous glands in the skin

Strain

Injury to a muscle or to the band of tissue that attaches a muscle to a bone

Long acting

LA

Endentulous

Lack of teeth

Effleurage

Light, continuous stroking movement applied with the fingers (digital) or the palms (palmar) in a slow, rhythmic manner.

continue to observe functioning of device

client has negative pressure wound therapy. what should nurse do when film over wound collapses when negative pressure is exerted

Logroll

Maneuver used to turn a reclining patient from one side to the other or completely over without moving the spinal column out of alignment.

malnutrition

client is anorexic because of stomatitis related to chemo. which should the nurse be most concerned about when planning care for client?

Embolism

Obstruction of a blood vessel by a clot of blood or foreign substance

Epidermis

Outer layer of skin

after meals

PC

-algia

Pain

Alopecia

Partial or complete loss of hair

Dorsal recumbent

Patient lying on back with knees bent up

Ac

Pertaining to

Abdmin (o)

Pertaining to the abdomen

inadequate diets

client is diagnosed with iron deficiency anemia. which major cause of iron deficiency will influence a focused assessment by the nurse

rescue/remove, activate alarm, contain, extinguish/evacuate

RACE?

sustained release

SR

Dermis

Sensitive vascular layer of the skin directly below the epidermis

time release

TR

Lunula

The half-moon-shaped, whitish area at the base of a nail

Apocrine

This type of sweat gland is found mainly in the arm pits and groin area, display what type of secretion

pumpkin

client is diagnosed with vitamin a deficiency and loves pie. what pie can the client eat?

client will be sleepy but able to follow verbal commands

client received conscious sedation during colonoscopy. which should nurse expect regarding clients experience with this procedure?

Right patient, right drug, right dose, right time, right route, right documentation, right to refuse

What are the seven rights of medication administration?

Ordered dose and unit concentration

What are the two required pieces of info from the medication order and the label that must be entered in all medication dose calculations?

Total parenteral nutrition

What does TPN mean?

As desired

What does ad lib mean?

Elixirs and suspension 2 times daily

What does elix and susp bid mean?

PO

What is the abbreviation for by mouth?

Q2h

What is the abbreviation for every 2 hours?

Qh

What is the abbreviation for every hour?

Supp

What is the abbreviation for suppositories?

Š

What is the abbreviation for without?

stat orders, breathing medications, analgesics

What is the priority medication administration order?

30 minutes before

When should you give pain medication before a painful procedure?

A

Without or absence of

An (o)

Without or absence of

extended release (2)

XL

extended release (3)

XR

Cerumen

Yellowish or brownish waxy secretions produced by sweat glands in the external ear

altered oral mucosa

a client has had a nasogastric tube to decompress the stomach for 3 days and is scheduled for surgery. what is the client at highest risk for?

impaired skin integrity

a client is incontinence of urine and stool. what is the client most at risk for?

sitz bath

a client just had perineum surgery, what type of bath should be prescribed?

serous

clear plasma

pressure ulcer

a local injury to the skin

to increase heat loss

a nurse is bathing a client who has a fever, why should the nurse use tepid bath water?

please eat your meat

a nurse is caring for a confused client with dementia. what should nurse say when assisting client to eat?

ensure water is at least 110 degrees

a nurse is giving a client a bed bath. what temperature should the water be at?

brush the hair from scalp toward hair ends

a nurse is responsible for providing hair care for a client. what should the nurse do to distribute oil evenly along hair shaft?

immediate need of the client

a nurse must make the decision to give a client a full or partial bed bath. which criterion is most important for the basis of this decision?

Restraint

a physical or chemical way to restrict voluntary movement or behavior

risk factors for pressure ulcer development

age, alterations in level of consciousness, impaired mobility, impaired sensory perception, poor nutrition, moisture, chronic illness, spinal cord injury, sheering and or friction

autolytic

allows eschar to be self digested, transparent film dressing, hydrocoloid dressing for this debridement

patient controlled analgesia pump (PCA)

allows patient to control their medication, cannot overdose

Perineum

area between vagina and anus

strong leg up then weak leg then crutches

ascending stairs with crutches what leg should go first?

the clients head

at what end should you push the stretcher?

room

at what temperature should you instill ear drops?

Halitosis

bad breath

Sprain

bands of tissues that connect two bones together

listen ofr air, ph 1-4, uncoiled tube in back of throat

before an xray to determine placement of NG tube what can you do?

buccal

between cheek and gum

abnormal reactive hyperemia

blanching doesnt occur with pressure

hemorrhage

bleeding from wound site, internal or external, hemostasis occurs within minutes

plateua

blood serum concentration of a med reached and maintained after repeated fixed doses

sanguinous

blood with red blood cells drainage

no

can a nursing student take verbal medication orders?

no

can you delegate medication admin?

yes but must document

can you revoke delegation?

atonic seizure

causes patients muscles to go limp

you appear startled you didnt finish your tray of food, you seem surprised that you were unable to eat all your breakfast

client states " i am surprised that i couldnt even eat half my breakfast." which statement by nurse uses reflective technique?

paraphrasing

client states "i think that i am dying." nurse says "you believe that you are dying." what interviewing technique is the nurse using?

atelectasis

collapse of alveoli

shear

combination of friction and gravity

semicritical items

come in contact with mucous membranes or non intact skin

jackson pratt drain

constant low pressure, empty when 1/2 full, squeeze before closing to resume suction

critical

critical, semicritical, or noncritical: surgical instruments, cardiac or intravascular catheters, urinary catheters, implants

semicritical

critical,semicritical, noncritical: respiratory and anasthesia equipment, endoscopes, endotracheal tubes, gi endoscopes, diaphragm fitting rings

vascular insufficiency

decreased hair growth on legs and feet, absent or decreased pulses, infection in the foot, poor wound healing, thickened nails, shiny appearance of skin, blanching of skin on elevation

both crutches then strong leg

descending stairs with crutches what leg should go first?

Neuropathy

disease of the nerves

purulent

drainage that contains white blood cells and pus

orthostatic hypertension

drop in systolic pressure by at least 10 within 3 minutes of sitting up

eschar

dry tan brown or black colored dead tissue (remove for wound healing)

sordes

during oral care nurse identifies food and debris on hard palate of client, what word should the nurse document?

disinfection

eliminates most microbes, except bacterial spores

dehydration

pale conjunctival sac, tenting of skin over sternum, dry crusted lips

therapeutic effect

expected or predicted physiological response

systemic infection

fever, chills, increased heart rate and respiration rate, decreased bp, increased wbc, body aches, enlarged lymph nodes, n/v, fatigue/weakness, anorexia, organ failure

contaminated IV and bad needle care

for bloodstream what could causes of HAI be?

increase

for immobility what happens to calcium levels?

increases

for immobility what happens to urine output?

30 min rest before eating, high fowlers, food in stronger side of mouth, slow small bites, avoid distractions, sit up 30-60 min after meal

for patients on aspiration precautions what are some of the tips?

contaminated equipment, lack of aseptic technique, improper disposal of secretions

for respiratory tract what could causes of HAI be?

bad skin prep, lack of aseptic technique, contaminated antiseptic

for surgical wounds what could causes of HAI be?

catheters and bad perineal hygiene

for urinary what could causes of HAI be?

c. diff

for what disease can you not use alcohol based hand sanitizer?

protective isolation

for what should you use positive airflow exchange?

shear

force exerted against skin while skin remains stationary and bony structures move

localized infection

foul odor, pus, heat, pain, swelling, redness

pathological fractures

fractures caused by weakened bone tissue

enteral nutrition

functional GI tract unable to ingest food through mouth but can through stomach

palliative care

goal is to learn how to live life fully with an incurable condition

semi fowlers

head of bed at 30 degrees

fowlers

head of bed raised to 45 degrees or more: semi sitting position

Gout

hereditary metabolic disease that is a form of acute arthritis, characterized by excessive uric acid in the blood and around the joints

obtain directions from primary health care provider

hospitalized client has been receiving meds through variety of routes for several days has surgery scheduled at 10 am. which should the nurse plan to do on day of surgery?

sterile cotton tipped applicator

how do we measure depth of a wound?

CHG wipes

how do you decrease the risk of HAI?

mix with small amount of food (NOT IN MILK OR FORMULA)

how do you give infants liquid medication?

12 inches

how far out should you move a walker?

4 inches; 2 inches

how far should a suppository go in for an adult?; a child?

surgically

how is a gastrostomy tube placed?

inches

how is nitro paste ordered?

10-15 minutes

how long can a patient remain in the tub?

10 seconds

how long do you hold your breath for metered dose inhalers?

2-5 minutes

how long should you wait between different medications for inhalers?

20-30 seconds

how long should you wait between inhalations of the same medication?

2000-3000

how many calories do men need daily?

1600-2400

how many calories do women need daily?

third day

how many days after surgery should nurse anticipate that post op patient will exhibit signs and symptoms of a wound infection?

assess patients vital signs

if error occurs what do you do first?

no

if venous thrombosis is present should you massage the area?

retinol binding protein

important for body tissue growth

convalescence

in this stage of infection acute symptoms disappear

illness

in this stage of infection signs and symptoms specific to infection

stage 4

in this stage of pressure ulcer debridement may be needed

stage 4

in this stage of pressure ulcer there is undermining and tunneling

infection

invasion of susceptible host by pathogens or microbes

direct

is transmission through vectors direct or indirect?

imbalanced nutrition

less than body requirements or more than body requirements

hematoma

localized collection of blood under tissues, appear as swelling

Gait

manner of walking

nursing assistive personel

meaning of NAP

total protein

measures total of 2 classes of proteins in the blood

friction

mechanical force exerted when skin is dragged across a coarse surface

trough

minimum blood serum concentration of med reached just before the next scheduled dose

peripheral neuropathy

muscle wasting of lower extremities, absence of deep tendon reflexes, foot deformities, infections, abnormal gait, decreased or absent vibratory sensation

leg exercises 10 times per hour when awake

nurse caring for client who had abdominal hysterectomy. which intervention best prevents post op thrombophlebitis?

reposition patient back to semi fowlers position

nurse enters room of client in photograph, client has right sided weakness and is attempting to transfer out of bed without nurses knowledge. what should nurse do first?

decreases the absorption of of many important nutrients

nurse is assessing a client who is admitted to the hospital with withdrawal from alcohol, which effect of alcohol on the body will influence the clients plan of care?

headache

nurse is assessing client who had spinal anasthesia. for which common response should nurse assess client?

oliguria

nurse is assessing post op client. which client response identified by nurse indicates altered renal perfusion?

maintain close supervision

nurse is caring for a confused client. what shuld the nurse do to prevent client from falling?

serosanguineous

nurse is caring for client who had abdominal surgery. which type of drainage should nurse expect 4 hours post surgery?

orthopneic

nurse is caring for client with impaired mobility. which position contributes most to formation of hip flexion contractures?

difficulty swallowing

nurse is caring for client with variety of nutrition related problems. which problem should nurse anticipate eventually may require client to have feeding tube inserted?

size of collection container

nurse is caring for one patient with jackson pratt drain and another with a hemovac drain. what is the difference?

drinking fluids

nurse is caring for post op client. which action prevents UTI?

intimate

nurse is changing the clients dressing over an abdominal would. which level of space is entered during the dressing change?

increasing transferrin level

nurse is evaluating effectiveness of nutritional program for a client with anemia. For which clinical finding should the nurse monitor the client because it is a short term indicator of an improved nutritional status ?

clean the skin with normal saline before applying dressing

nurse is to apply a transparent wound barrier over clients incision. which nursing action is appropriate?

ensure clients feet are guarded

nurse is transferring a client from bed to wheelchari using mechanical lift. which is a basic nursing intervention associated with this procedure?

direct questions

nurse must conduct a focused interview to complete an admission history, which interviewing technique should the nurse use?

turkey,scallops, flounder

nurse teaches client about prescribed low fat diet. which food selected by client indicates teaching was understood?

feelings

nurse uses reflective technique when communicating with an anxious client. what does the nurse need to focus on?

shallow breathing

obese client had gallbladder removed. which should nurse be most concerned about if exhibited by client?

excessive caloric intake

occupational nurse is facilitating a group discussion on weight reduction. which should the nurse explain is most common contributing factor to obesity?

mechanical soft

older adult admitted to hospital for multiple health problems. assessment reveals client has no teeth and is having difficulty eating. which should should be prescribed?

fats

older adult tends to prove easily and nurse recommends vitamin k. which foods increase absorption of vitamin k?

wrap limb in elastic compression bandage

on second post op day after above knee amputation clients elastic wrap dressing comes off. which should nurse do first?

hemiplegia

one sided paralysis

hemiparesis

one sided weakness

idiosyncratic reaction

over reaction or undereaction of different reaction from normal

absorption

passage of drug from admin site into bloodstream

check for med orders to treat hyperglycemia

patients blood glucose is 330 mg/dL. what is the priority nursing intervention?

deconditioning

physiological changes following a period of inactivity, bed rest, sedentary lifestyle

pulmonary embolus

post op client experiences tachycardia, sudden chest pain, low BP. which complication is most likely happening?

changing soiled dressing carefully

post op client transferred back to surgical unit with abdominal dressing and penrose drain. which is most important nursing action in regards to penrose drain?

side effect

predictable, unavoidable secondary effect

colonization

presence and growth of microbes within a host without tissue invasion or damage

trochanter roll

prevents external rotation of hips when patient is supine

metabolism

process by which drug is altered to a less active form to prep for excretion

pharmacodynamics

process in which a medication interacts with the bodys cells to produce a biologic response

medication reconciliation

process of comparing a patients med orders to all medications that the patient has been taking

distribution

process of delivering med to tissues, organs, and specific site of action

excretion

process removes the less active drug or its metabolites

chemical

provides exact description of medications composition

pain management

providing treatement for a patients pain to eliminate pain or reduce it

urticaria

raises, irregularly, shaped skin eruptions with varying sizes (reddened margins and pale centers)

granulation tissue

red, moist tissue made of new blood vessels

reactive hyperemia

reddened skin will blanch with pressure, then turn pink/red again when pressure is removed

debridement

removal of necrotic tissue so healthy tissue can regenerate

ischemia

restriction of blood supply resulting in damage to or dysfunction of tissue

mechanical

this debridement wet-to-dry saline gauze dressings, used to debride a wound so granulation tissue will begin to form

localized infection

this infection does not affect whole body

acute

this pain is protective in nature, sudden onset, short duration, limited tissue damage, emotional response, vital signs elevated

chronic

this pain lasts longer than 6 months, constant/recurring, doesnt respond well to treatment

incubation

this stage of infection is between entrance of pathogens and symptoms

stage 3

this stage of pressure ulcer is characterized by full thickness skin loss

stage 1

this stage of pressure ulcer is characterized by nonblanchabke erythema of intact skin

stage 2

this stage of pressure ulcer is characterized by partial thickness skin loss with exposed dermis

stage 4

this stage of pressure ulcer is charcterized by full thickness skin and tissue loss

sublingual

under the tongue

superinfection

use of antibiotics may eliminate or change flora reducing defenses and allowing microbes to multiply

sterilization

used to clean surgical instruments

chronic wounds

vascular compromise, inflammation, repetitive insults to tissues

Hemiparesis

weakness on one side of the body

confusion, agitation, incontinence, general fatigue

what are atypical symptoms of disease in older adults?

food, oxygen, moisture, warm temperature, ph 5-7, darkness

what are characteristics of a good resrvoir?

needles and Bp cuffs

what are examples of vehicles?

administering, assessing effectiveness, recognizing unfavorable rea ctions

what are nurses responsible for in regards to medications?

narcotics

what are opioids also called?

vision/hearing loss, slowed reaction time, decreased rom, impaired memory, nocturia/incontinence, increased fall risk

what are some physiological changes of aging?

incubation, podromal, illness, convalescence

what are the 4 stages of infection?

right task, right circumstance, right person, right direction, right supervision

what are the 5 rights of delegation?

right task, right situation, right worker, right direction, right teaching

what are the 5 rights of delegation?

nonhealing wounds, shiny skin, loss of hair growth, cool skin temperature for one limb but not the other, pale of bluish skin, reduced capillary refill times, pallor on elevation and rubor on dependency

what are the clinical signs of limb ischemia?

assess/plan, communicate, ensure supervision, evaluate and give feedback

what are the delegation steps?

right medication, right dose, right patient, right route, right time, right documentation, right indication, right to refuse, right teaching

what are the medication standards?

hygiene, inspect skin, pad skin, apply, attach restraint straps to bed, 2 fingers under restraint, hygiene

what are the steps for applying restraints?


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