Module 11, 12, 13 (test 4)
Why is acute pain protective?
because it warns people of injury or disease
What are vesicular breath sounds?
description - soft pitched, low intensity gentle sighing location - over peripheral lung, best heard at base characteristics - best heard on inspiration (5:2) ratio
What is an anthelmintic enema?
destroys intestinal parasites
What is tactile-kinesthetic distraction?
holding or stroking a loved one, pet, or toy; rocking; and slow rhythmic breathing
What is a purre diet?
Any food that is purred
What are simple sugars?
monosaccharides and disaccharides
What suctionig pressure should be done for trach suctioning
not past 150 mmHg
What type of tubing is used for blood
Y tube
What is a bristol stool chart?
a chart that characterizes different types of stool based on size shape and consistency
What is a reconstructive surgery?
a procedure that restores your body after an injury, after a disease, or it corrects defects you were born with.
What is a TENS unit and how does it work?
a small, battery-operated device that has leads connected to sticky pads called electrodes.
What is diabetic neuropathy?
nerve damage that occurs because of the metabolic derangements associated with diabetes mellitus
What is referred pain?
pain felt in a part of the body other than its actual source
What is phantom pain?
pain in a missing limb
What is cutaneous pain?
pain originating from skin surface or subcutaneous structures
What is an analgesic?
pain reliever
What is venipuncture?
the puncture of a vein as part of a medical procedure, typically to withdraw a blood sample or for an intravenous injection.
Define autologous blood transfusion
the reinfusion of blood or blood components to the same individual from whom they were taken.
What is the gate control theory?
the theory that the spinal cord contains a neurological "gate" that blocks pain signals or allows them to pass on to the brain. The "gate" is opened by the activity of pain signals traveling up small nerve fibers and is closed by activity in larger fibers or by information coming from the brain.
What is angina?
chest pain
What is SASH?
saline administer medication saline heparin (10-100 u/mL)
How to treat respiratory acidosis?
- reversal of sedative meds (if applicable) - intubation - BiPAP - hydration
What are the components of the lower airway
- trachea - primary brochi - bronchioles - alveoli
How deep do you insert a catheter when suctioning a trach?
- until bifurcation (length of catheter)
What causes stridor
- upper airway obstruction - Croup (sounds like a seal barking)
What are secondary tubing IV sets?
- volume-controlled set - piggyback set
What are the stages of shock?
-Compensated -Decompensated -Irreversible
What is a renal diet?
-Restricts protein, potassium, sodium, and phosphorus -Carbohydrates are encouraged to provide needed energy for healing -vitamin supplements -fluid intake limitations
What is a large bore catheter (18 gauge) used for?
- for rapid need of fluid - trauma
What are bronchial lung noises?
- high-pitched and longer -heard primarily over the trachea
What causes wheezes in the lungs?
- infection - allergic reaction - obstruction (like a horn/hum)
What saline solution is hypertonic?
3% saline
Which intravenous (IV) solution is expected for a patient with cerebral edema?
3% saline Hypertonic solutions such as 3% saline pull water from in the cell into the extracellular fluid. These are useful in cases of severe hyponatremia and severe edema, specifically cerebral edema.
What is a normal fluid intake for a day for an adult?
3,000 ml for men and of 2,200 ml for women
What is a good serum potassium range?
3.5-5 mEq/L
What is the respiratory rate of a newborn?
30-60 breaths per minute
What is Extracellular fluid (ECF)?
35%
A nurse is assessing a patient with COPD who is experiencing dyspnea. What action will the nurse take first? A. Place the patient in Fowler position. B. Encourage diaphragmatic breathing. C. Ask the patient to cough. D. Initiate oral suctioning of secretions.
A
What is a PCA pump and how does it work?
A patient-controlled analgesia (PCA) pump is a safe way for people in pain to give themselves intravenous (IV) pain medicine (analgesia) when they need it
A nurse is preparing medications for patients in the ICU. The nurse is aware that patient variables may affect the absorption of these medications. Which statements accurately describe these variables the nurse will use as a basis for practice? Select all that apply. A. Patients in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed. B. Some people experience the same response with a placebo as with the active drug used in studies. C. People with liver disease metabolize drugs more quickly than people with normal liver functioning. D. A patient who receives a pain medication in a noisy environment may not receive full benefit from the medication's effects. E. Oral medications should not be given with food as the food may delay the absorption of the medications. F. Circadian rhythms and cycles may influence drug action.
A,B,D,F
A nurse has been asked to witness a patient signature on an informed consent form for surgery. What communication from the surgeon does the nurse expect the patient to receive before signing the form? Select all that apply. A. Option of nontreatment B. Underlying disease process and its natural course C. Notice that once the form is signed, the patient cannot withdraw the consent D. Explanation of the guaranteed outcome of the procedure or treatment E. Name and qualifications of the provider of the procedure or treatment F. Explanation of the risks and benefits of the procedure or treatment
A,B,E,F
A nurse is caring for patients who are nonverbal. What are examples of behavioral responses to pain? Select all that apply. A. Cradling a wrist that was injured in a car accident B. Moaning and crying from abdominal pain C. Increasing pulse following a myocardial infarction D. Striking out at a nurse who attempts to provide a bath E. Acting depressed and withdrawn while experiencing chronic cancer pain F. Pulling away from a nurse trying to give an injection
A,B,F
While assessing a patient in the PACU following abdominal surgery, a nurse promptly contacts the surgeon for which of these findings? Select all that apply. Electronic Health Record Vital signs 1200: T 97.4, P-89, RR 12, BP/102/70 1215: T 97.4, P-92, RR 12, BP/100/68 1230: T 97.2, P-112, RR 12, BP/98/60 Intake Output/Hemovac 1200: 200 mL 0.9% saline infused 30 mL sanguineous material 1215: IV NSS 25 mL 45 mL serosanguineous material 1230: IV NSS 25 mL 250 mL bright red blood A. Tachycardia B. IV with normal saline solution C. Wound drainage D. Patient restless E. Patient reports incisional pain 8/10
A,C,D
During postconference, nursing students are exploring definitions of pain and its nature. Which statements should be included in this discussion? Select all that apply. A. "It is whatever the health care provider treating the pain says it is." B. "Pain exists whenever the person experiencing it says it is present." C. "It is an emotional and sensory reaction to tissue damage." D. "Pain is a simple, universal, and easy-to-describe phenomenon." E. "When a cause cannot be identified, pain is psychological in nature." F. "It is classified by duration, location, source, transmission, and etiology."
B,C,F
A nurse working in the pulmonary clinic is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. A. Avoid exercise. B. Take steps to manage or reduce anxiety. C. Eat meals 1 to 2 hours prior to breathing treatments. D. Eat a high-protein/high-calorie diet. E. Maintain a high-Fowler position when possible. F. Drink 2 to 3 pints of clear fluids daily.
B,D,E
What is occult blood?
Blood that is not visible (microscopic)
What are normal stools like for breastfed babies?
Breastfed newborns usually have seedy, loose stool that looks like light mustard. Yellow or tan.
A nurse administers a dose of an oral medication for hypertension to a patient who immediately vomits after swallowing the pill. What action will the nurse take first? A. Readminister the medication and notify the health care provider. B. Obtain the pill in a liquid form for administration. C. Assess the emesis, looking for the pill. D. Notify the primary care provider.
C
What are loop diuretics used for?
CHF renal or hepatic disease hypertensive crisis edema
What causes rhonchi
COPD fluid in the lungs (Sounds like snorkeling)
What is neurogenic shock?
Caused by spinal cord injury, usually as a result of a traumatic accident or injury. (Rationale:A patient in neurogenic shock is expected to be hypotensive and hypovolemic due to the unopposed parasympathetic nervous system. Their blood pressure would be low, as in a reading of 74/42 mm Hg, and their heart rate would also be low, as in a reading of 48 bpm.)
Why are clear liquid diets used?
Clear liquid diets may be used before certain tests or procedures, such as a colonoscopy, or before or after certain types of surgery. They may also be used to help treat gastrointestinal problems, such as nausea, vomiting, or diarrhea.
How do experiences with pain differ when it comes to older adults?
Longer periods of hyperalgesia following painful stimuli. Combined with slower healing after injury, this may lead to prolonged periods of discomfort and functional impairment.
What affects the metabolic rate and burns more calories when a person is in the ICU?
Loss of fat and protein can be dramatic and typically leave the patient in a net negative nitrogen balance.
What is metabolic acidosis?
Low pH and low bicarbonate
What are Trousseau and Chvostek signs.
Trousseau sign is seen as a spasm of the hand when the brachial artery is manually occluded; Chvostek sign is elicited when tapping of the facial nerve causes twitching of the nose or lips.
What two electrolytes have an inverse relationship?
calcium and phosphorus
What does remission mean?
cancer is responding to treatment and under control
What nutrients provide energy?
carbohydrates fats protein
What is psychogenic pain?
cause of pain cannot be identified
What foods cause constipation?
cheese, lean meat, eggs, pasta
When should the nurse assess acute pain in the hospital setting?
every hour
What is ablative surgery?
excision or removal of diseased body part
Define hypervolemia
fluid volume excess
What is phlebitis?
inflammation of a vein
What causes friction rub in the lungs?
inflammation roughens the surfaces the visceral and parietal pleura (Sounds like creaking floorboards)
Where can central venous catheters be put in the body?
internal jugular, common femoral, and subclavian veins.
What is hypoxia?
lack of oxygen
What is a bowel training program?
program that manipulates factors within a person's control (timing of defecation, exercise, diet) to produce a regular pattern of comfortable defecation without medication or enemas
What is coprolalia?
repetition of obscene words
Why are NG tubes inserted?
to decompress or drain the stomach of fluid or unwanted stomach contents
What is a diagnostic surgery?
to make or confirm a diagnosis
Why do loop diuretics need to be pushed slowly when administered via intravenous (IV) push?
to prevent ototoxicity
What is a water seat chest tube drainage?
used to restore proper air pressure to the lungs, re-inflate a collapsed lung as well as remove blood and other fluids.
What age can you do an IV on the scalp?
younger than 8 months
Symptoms of respiratory acidosis?
Rapid, shallow breathing, dyspnea, disorientation, muscle weakness
Define diffusion
movement of molecules from high concentration of solutes to low concentration
How to treat metaboli
- monitor potassium - evaluate for dialysis
What are the components of the upper airway?
- nose - pharynx - Larynx - epiglottis
How to veins change with age?
- Decreased density - Decreased collagen - Insufficient adipose tissue
How do you obtain a nursing health history?
- Determine why the patient needs care - determine the kind of care - Identify current or potential health deviations - Identify actions performed by the patient for meeting respiratory needs - Make use of aids to improve intake of air
What variables can influence bowel elimination?
- Developmental considerations - Daily patterns - Food and fluid - Activity and muscle tone - Lifestyle - Psychological - Pathologic conditions - Medications - Diagnostic studies - Surgery and anesthesia
What is respiratory alkalosis?
- High PH - low CO2 (caused by hyperventilation, treated by rebreathing exercises)
What neurologic symptoms occur from out-of-range serum sodium levels?
- Lethargy - confusion - weakness - dizziness - seizures
What is respiratory acidosis?
- low pH - high CO2
What are bronchovesicular lung noises?
- medium pitch sound during expiration - heard over the upper anterior chest and intercostal area
What are primary tubing IV sets?
- microdrip - macrodrip
What saline solution is hypotonic?
0.45% saline
What saline solution is isotonic?
0.9% saline solution
What is the flow rate range for nasal cannula?
1-6 L/min
What is a good magnesium range?
1.8-2.6 mg/dL
What is the flow rate for a face tent?
10-15 L/min
What is the flow rate for a non-rebreather mask?
10-15 L/min
What is a good serum sodium range?
135-145 mEq/L
What is the biggest size of an IV cath?
14 gauge
What size is a large bore IV?
18 gauge
What is a good phosphorus range?
2.7-4.5 mg/dL
What is the standard size IV for adults?
20 gauge
What is the good bicarbonate range?
22-26 mEq/L
What is the smallest size of a IV cath?
24 gauge
What is the maximum amount of time to infuse a blood transfusion?
4 hours
What is the flow rate range for a simple O2 mask?
5-10 L/min
What is the flow rate for a high-flow nasal cannula?
6-15 L/min
Water accounts for how much of a persons' total body weight?
60-75%
What percentage of fluid is Intracellular fluid (ICF)?
65%
What is the normal PH range?
7.35-7.45
What is a good serum calcium range?
8.8-10.4 mg/dL
A nurse in the PACU is performing oral suctioning for a patient with an oropharyngeal airway, when the patient begins to vomit. What is the nurse's priority nursing action at this time? A. Removing the suction catheter and elevating the head of the bed B. Notifying the primary health care provider C. Confirming the size of the oral airway is correct D. Placing the patient in the supine position
A
When the nurse assists a patient recovering from abdominal surgery to walk, the nurse observes that the patient grimaces, moves stiffly, and becomes pale. The nurse received in shift report that the patient has consistently refused pain medication. To help promote comfort, which additional data will the nurse gather? Select all that apply. A. Patient's understanding of or fear of taking prescribed analgesics B. Assessment of any current pain C. Presence of anxiety or additional stressors D. Assessment of the surgical incision for infection E. What the patient has eaten to this point F. Whether the patient is using the incentive spirometer
A,B,C,D
A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? A. Slowing or stopping the infusion; monitoring vital signs, notifying the health care provider, and placing the patient in an upright position with their feet dependent B. Stopping the transfusion immediately and keeping the vein open with normal saline, notifying the health care provider immediately, and administering antihistamine parenterally as needed C. Stopping the transfusion immediately and keeping the vein open with normal saline, notifying the health care provider, and treating symptoms with acetaminophen D. Stopping the infusion immediately, obtaining a culture of the patient's blood, monitoring vital signs, notifying the health care provider, and administering a
A
A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What action will the nurse take next? A. Removing the IV from the site and start at another location B. Immediately notifying the primary care provider C. Outlining the affected area in ink and monitoring for changes D. Aspirating the catheter and attempting to flush again
A
A nurse on the respiratory unit is interpreting ABGs for several patients. The patient with which problem will the nurse suspect may have developed respiratory alkalosis? A. Hypoxia B. Atelectasis C. Chronic respiratory illness D. Sedative overdose
A
When administering an IVPB medication using gravity, what action is appropriate for the nurse take? A. Placing the primary IV bag below the level of the piggyback bag B. Disconnecting the tubing closest to the patient and flushing the intravenous access C. Ensuring the piggyback bag is below the main IV bag D. Closing the roller clamp to the secondary infusion
A
A scrub nurse is assisting a surgeon with a kidney transplant. What are the patient responsibilities of the scrub nurse? Select all that apply. A. Maintaining sterile technique B. Draping and handling instruments and supplies C. Identifying and assessing the patient on admission D. Integrating case management E. Preparing the skin at the surgical site F. Providing exposure of the operative area
A,B
A nurse is caring for a patient experiencing a fluid volume deficit. What should be included in the recorded intake and output for the patient? Select all that apply. A. Urine B. Carbonated beverage C. Formed stool D. Vomitus E. Chicken noodle soup F. Pressure wound irrigant
A,B,D,E
Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. A. Closely assessing the patient before, during, and after the procedure B. Hyperoxygenating the patient before and after suctioning C. Limiting the application of suction to 20 to 30 seconds D. Monitoring the pulse to detect effects of hypoxia and stimulation of the vagus nerve E. Using an appropriate suction pressure (80 to 150 mm Hg) F. Inserting the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube
A,B,D,E,F
A nurse carefully assesses the acid-base balance of a patient whose bicarbonate (HCO3-) level is decreased on the ABG results. This typically occurs in patients with damage to which organ? A. Kidneys B. Lungs C. Adrenal glands D. Brain
B
A nurse in the PACU is preparing to receive a patient from surgery who sustained a ruptured spleen in a motor vehicle accident. Which of these system assessments will take priority? Electronic Health Record: Operative Note Splenectomy secondary to trauma Estimated blood loss 900 mL A. Neurologic system, ambulatory function B. Cardiovascular system, vital signs C. GI system, bowel function D. Integumentary, skin breakdown
B
A nurse is assessing a patient receiving a continuous opioid infusion. For which outcome of treatment would the nurse immediately notify the primary care provider? A. A respiratory rate of 11/min with normal depth B. A sedation level of 4 C. Mild forgetfulness D. Reported constipation
B
A nurse is caring for a patient admitted for an acute asthma exacerbation. The patient reports extreme dyspnea, stating, "Turn up the oxygen, I'm not getting enough air." Which actions would the nurse take first? A. Suction the airway. B. Assess the pulse oximetry reading. C. Obtain a peak flow meter reading. D. Assess for cyanosis of the lips.
B
A nurse is caring for a patient who is obese and has had abdominal surgery. The nurse prioritizes a plan to prevent what postoperative complication? A. Anesthetic interactions B. Impaired wound healing C. Weight gain D. Flatulence
B
A nurse is planning to administer digoxin to a patient. After reviewing the medical record, what action will the nurse take? Electronic Health Record Prescriptions 11/22/2025 digoxin loading dose 0.25 mg IV twice today only 11/23/2025 begin digoxin 0.125 mg orally daily Laboratory StudiesDigoxin level: 2.7 ng/mL (reference range 0.5-2 ng/mL) A. Administer the medication, recording the level in the MAR. B. Hold the medication and confer with the prescriber. C. Give the patient one half the dose. D. Evaluate the patient's kidney function studies.
B
A nurse on a medical-surgical unit is planning to administer an antibiotic to a patient with a kidney infection who is 10 weeks' pregnant. The drug reference states that the medication is teratogenic. Which action will the nurse take? A. Administer the medication, because the risk of illness is greater than the benefit of the medication. B. Hold the medication and collaborate with the health care provider to find an alternative. C. Ask the patient if they consent to receive the medication and document the response in the electronic health record. D. Collaborate with the pharmacist on dose reduction.
B
A nurse on an adult surgical floor enters a patient room and observes a family member pressing the button to administer a dose of PCA via the infusion pump. What response by the nurse is most appropriate? A. "That dose will sure be helpful after their type of surgery." B. "Having only the patient use the pump prevents respiratory complications." C. "If the patient asked you to press the button, then it's OK." D. "Since the pump has built in safeguards, you can help with pain management."
B
A nurse prepares to administer insulin to a patient with diabetes. What is the correct procedure to carry out this prescription? MAR 7:30 AM: 40 units of NPH insulin and 10 units of regular insulin daily subcutaneously. A. Inject air into the regular insulin vial and withdraw 10 units; then, using the same syringe, inject air into the NPH vial and withdraw 40 units of NPH insulin. B. Inject air into the NPH insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the regular insulin vial and withdraw 10 units; followed by withdrawal of 40 units of NPH insulin. C. Inject air into the regular insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the NPH insulin vial and withdraw 40 units; then, withdraw 10 units of regular insulin. D. Inject air into the NPH insulin vial and withdraw 40 units; then, using the same syringe, inject air int
B
A patient reports diffuse abdominal pain that is difficult to localize. The nurse documents this as which type of pain? A. Cutaneous B. Visceral C. Superficial D. Somatic
B
The nurse applies the gate control theory of pain to provide pain relief to a patient with chronic lower back pain. What nursing intervention will help relieve pain by "closing the gate"? A. Encouraging regular use of analgesics B. Applying moist heat to the area at intervals C. Reviewing the pain experience with the patient D. Ambulating the patient after administering medication
B
When assessing pain in a child, the nurse needs to be aware of what considerations? A. Immature neurologic development results in reduced pain sensation B. Inadequate or inconsistent relief of pain is widespread C. Reliable assessment tools are currently unavailable D. Narcotic analgesic use should be avoided
B
A nurse is caring for a patient who has a pleural chest tube attached to a disposable chest drainage system. Which nursing actions are indicated for this patient? Select all that apply. A. Avoiding turning the patient to prevent disconnections in the tubing B. Maintaining an occlusive dressing on the site C. Assessing the patient for signs of respiratory distress D. Keeping the chest drainage device at the level of the patient's thorax E. Ensuring there are no dependent loops or kinks in the tubing F. Observing for bubbles indicating air leak in the water seal chamber
B,C,E,F
How does culture affect people in pain?
Culture shapes how individuals experience and respond to pain including their propensity to seek treatment and when to do so
A nurse discovers that a medication error occurred. What is the nurse's priority? A. Recording the error on the medication sheet B. Notifying the physician regarding course of action C. Assessing the patient for adverse effects of the error D. Completing an event report, explaining how the mistake was made
C
A nurse in a rehabilitation facility is preparing to administer a skeletal muscle relaxant to a patient recovering from a motor vehicle accident. When the patient states, "I don't want that pill," what action will the nurse take next? A. Encourage the patient to take the pill to help reduce muscle spasm. B. Explain that the health care provider prescribes only necessary medications. C. Ask the patient to explain their concern about the medication. D. Question the patient about allergies and previous medication reactions.
C
A nurse in the pediatric unit of an acute care hospital is awaiting a prescription for antibiotics for a toddler with a severe infection. Which information about the child is essential to document immediately? A. Beverage preference B. Whether a parent/guardian is present at the bedside C. Weight in kilograms D. Intake and output
C
A nurse is administering medications to an older adult with dysphagia. After crushing the pills, which action is most appropriate? A. Mixing the crushed medications with 120 mL of water before administering B. Mixing the medications into the patient's bowl of pudding C. Crushing each pill separately and administering each in a teaspoon of applesauce D. Asking the patient to chew the pills and providing juice after swallowing
C
A nurse is caring for a patient in the intensive care unit. How will the nurse interpret the patient's arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3-, 14 mEq/L? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
C
A nurse is caring for a patient who has developed hypernatremia. For which intravenous solution would the nurse anticipate a prescription? A. 5% dextrose in 0.9% NaCl B. 0.9% NaCl (normal saline) C. 0.45% NaCl (½-strength normal saline) D. 5% dextrose in lactated Ringer's solution
C
A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? A. Instructing the assistant to notify the health care team B. Assessing the patient's vital signs C. Removing the tape, adjusting the depth to the ordered depth, and retaping securely D. Taking no action, as the depth will adjust automatically
C
A nurse on the IV team is making rounds to assess patients receiving IV therapy. Under which circumstance will the nurse recommend an intravenous catheter be discontinued? A. The area surrounding the catheter is bruised. B. The patient's extremity is cool to touch. C. The site is red, warm, and swollen. D. Part of the catheter (1 mm) is visible under the dressing.
C
A nurse plans to promote a patient's natural pain mediators by using a whirlpool following intensive physical therapy to the legs. What is a potent pain-blocking neuromodulator, released through relaxation techniques? A. Prostaglandins B. Substance P C. Endorphins D. Serotonin
C Endorphins are produced at neural synapses at various points along the CNS pathway. They are powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria. It is thought that endorphins are released through pain relief measures, such as relaxation techniques. Prostaglandins, substance P, and serotonin (a hormone that can act to stimulate smooth muscles, inhibit gastric secretion, and produce vasoconstriction) are neurotransmitters or substances that either excite or inhibit target nerve cells.
A nurse is administering a medication to a patient via an enteral feeding tube. Which are accurate guidelines related to this procedure? Select all that apply. A. Crushing the enteric-coated pill and mix it in a liquid B. Initially flushing the tube with 60 mL of very warm water C. Using the recommended policy to check tube placement in the stomach or intestine D. Giving each medication separately and flush with water between each drug E. Lowering the head of the bed to prevent reflux F. Adjusting the amount of water used if patient's fluid intake is restricted
C,D,F
What are the side effects of narcotics?
Constipation, hypotension, miosis, respiratory depression, sedation
What is the difference between crystalloids and colloids?
Crystalloids are clear fluids, and colloids are thicker and more viscous.
A nurse has begun administering an intravenous antibiotic via the patient's peripheral venous access. Immediately, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? A. Repositioning the extremity and raise the height of the IV pole B. Applying pressure to the dressing on the IV C. Pulling the catheter out slightly and reinserting it D. Putting on gloves; removing the catheter
D
A nurse is planning to suction a patient's tracheostomy tube the day after its placement. Which action by the nurse is absolutely essential? A. Assessing the need to premedicate with an analgesic B. Placing the patient in low Fowler position C. Inserting the obturator into the outer cannula D. Maintaining aseptic technique
D
A nurse is providing teaching for a patient scheduled to have same-day surgery. Which teaching method would be most effective in preoperative teaching for ambulatory surgery? A. Lecture B. Discussion C. Audiovisuals D. Written instructions
D
A nurse teaches a patient the rationale for performing leg exercises after surgery. How does the nurse best explain the purpose of the exercises to the patient? A. Improves respiratory function B. Maintains functional abilities C. Provides diversional activities D. Increases venous return
D
A nursing student attending clinical on a medical-surgical unit receives report from the off-going nurse stating the patient has adventitious breath sounds that clear after expectorating sputum. Which adventitious breath sound will the student expect to auscultate? A. Bronchial B. Bronchovesicular C. Vesicular D. Wheezing
D
During preoperative teaching about pain management, the patient asks the nurse to explain how a PCA pump works. What will the nurse teach the patient about PCA? A. "It allows the patient to be completely free of pain during the postoperative period." B. "It allows the patient to take unlimited amounts of medication as needed." C. "It allows the patient to choose the type of medication given postoperatively." D. "It permits the patient to self-administer limited doses of pain medication."
D
A nurse is teaching a patient how to use a metered-dose inhaler for asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. A. "I'll be careful not to shake the canister before using it." B. "It's important to hold the canister upside down when using it." C. "I have to remember to inhale the medication through my nose." D. "I will continue to inhale when the cold propellant is in my throat." E. "I won't inhale more than one spray with one breath." F. "I will activate the device while continuing to inhale."
D,E,F
What causes low bicarbonate?
Diarrhea and diuretics
What natural chemicals in the body help relieve pain?
Endorphins
Who uses consistent carb diets?
Pt with Diabetes
What is a fat restricted diet?
Intended to lower the patient's total intake of fat
what is peak expiratory flow rate?
It is the maximum flow rate that can be achieved during a forced vital capacity maneuver.
What does codeine do for people with coughs?
It suppresses the activity in the brain that controls coughing.
What is Parenteral nutrition (PN)?
Parenteral nutrition (PN) means having nutrients and fluid directly into the bloodstream. It is a type of tube feeding for nutritional support. PN is usually used for people who cannot take nutrients in through their digestive system.
How do you get your bowel to return to normal flora?
Probiotic-rich foods like yogurt, kefir, and kimchi contain beneficial bacteria that can help restore the balance of good and bad bacteria in your gut.
What is the prostaglandin pain theory?
Prostaglandins been linked to the sensory perception of pain, but their role in the emotional response to pain is unclear. A new study has demonstrated that the aversive effects of inflammatory pain are driven by prostaglandin signaling specifically on serotonin-producing neurons in the brainstem.
What is a palliative surgery?
Surgery to reduce symptoms but not to cure disease
What are Ways to encourage clients to eat?
The person you're caring for may have a low appetite or need some encouragement to eat regularly. Try to offer food more often, including snacks throughout the day. Ask what foods the person you're caring for likes best. Offer those foods when you can.
What is the large/small fiber pain theory?
The theory stated that small fiber afferent stimuli, particularly pain, entering the substantia gelatinosa can be modulated by large-fiber afferent stimuli and descending spinal pathways so that their transmission to ascending spinal pathways is blocked or gated.
The nociception process that involves the conversion of painful stimuli into electrical impulses that travel from the periphery to the spinal cord is referred to as which of the following?
Transduction
What are irregular breath sounds called?
adventitious
What is a full liquid diet?
any liquid (juices and ice cream included)
What is a clear liquid diet?
anything that is clear or see through. ex. Bouillon, fat-free broth, grape, apple, cranberry juice. fruit drinks, popsickles, gelatin, tea, coffee, ginger ale, lemon-lime soda, supplemental formulas. and HARD CANDY
What are lactose intolerance symptoms
bloating, abdominal discomfort, diarrhea
Which factors should be assessed prior to administering a loop diuretic?
blood pressure potassium levels
What does congenital mean?
born with it
What is atelectasis?
collapsed lung
Define osmosis
diffusion of water across a selectively permeable membrane from a region of high water potential to a region of low water potential
What causes crackles in the lungs?
fluid in the lungs, heart disease, cystic fibrosis, bronchitis - coarse (shoveling large rocks) - fine (pop rocks)
After a trained nurse inserts a PICC line, what do they need to do to make sure it's patent?
flushed once weekly with 10mls of 0.9% Sodium Chloride to maintain patency when not in use or after any infusion or bolus injection.
What is FiO2?
fraction of inspired oxygen (if you take the air that someone is breathing and find out how much of it is oxygen, you get the FiO2. )
What foods have a laxative effect?
fruits and vegetables, bran, chocolate, alcohol, coffee
What are the three loop diuretics?
furosemide, bumetanide, torsemide
What is a consistent carb diet?
have the same types/amount of carbs consistently
What is metabolic alkalosis?
high pH and bicarbonate
What does ischemia?
lack of blood flow/ dying tissue
What are hypoactive bowel sounds?
less than 5 per minute
What are gas-producing foods?
onions, cabbage, beans, cauliflower
What is visceral pain?
organ pain
What is somatic pain?
originating from muscle, bone, joints, tendons, or blood vessels
What is PaCO2? What is the normal range?
partial pressure of oxygen in arterial blood. 35-45
What are complex sugars?
polysaccharides
A patient is prescribed a loop diuretic. What will happen to the potassium level when this medication is administered?
potassium levels will drop
What does heparin do?
prevents blood clotting
