NR 224 Fundamentals Final Review
What is the term for a collection of hardened feces in the rectum that cannot be expelled due to unrelieved constipation?
Fecal Impaction
1 gram of fat = ____ kcal
9 kcal Most calorie dense
Saturated fats are found mostly in ______ sources
Animal Sources
When a patient complains that something has given way; what should the nurse associate this finding with?
Dehiscence
How does the nurse measure the length of the NG tube for insertion?
Tip of the nose --> earlobe --> xiphoid process
Which vitamins are considered fat-soluble vitamins that are stored in fatty compartments of the body?
Vitamin A, D, E, and K
Which wound bed tissue is characterized as soft white or yellow tissue; a stringy substance attached to the wound bed that needs to be removed before wound can heal?
Slough
Nutrients are absorbed in what portion of the digestive tract?
Small intestine [duodenum]
Which enema solution creates intestinal irritation to stimulate peristalsis by using castile soap?
Soapsuds
Which enema solution should used in caution in pregnant women and elderly because it may cause an electrolyte imbalance or damage to intestinal mucosa?
Soapsuds
1 gram of carbohydrates = ____ kcal
4 kcal
Which organ is responsible for drug excretion?
Kidney
Which minerals require a daily intake of 100 mg or less
Microminerals
What needles sizes are used for IM injection
Obese - 3 inch Thin - 1/2 to 1 inch
Proteins are necessary for _________ balance
Positive protein and nitrogen balance for healing, growth, and tissue repair
How should the nurse instill ear drops for children < 3 years of age?
Pull auricle DOWN and BACK
Which food induce a laxative effect?
fruits, vegetables, bran, chocolate, alcohol, and coffee
What are the six rights of medication administration?
1. Right Patient 2. Right Medication 3. Right Dose 4. Right Route 5. Right Time 6. Right Documentation
What is TOP PRIORITY when a medication error occur?
Assess the patient FIRST; patient's safety and well being is priority!
1 gram of protein = ___ kcal
4 kcal
Breast milk or formula provides sufficient nutrition for the first _____ to _____ months of life
4 to 6 months Breast milk benefits: fewer food allergies and intolerances; fewer infant infections; easier digestion; convenience, availability, and freshness; temperature always correct; economical because it is less expensive than formula; and increased time for mother and infant interaction. (Potter 1002) Infants should not have regular cow's milk during the first year of life. It is too concentrated for an infant's kidneys to manage, increases the risk of milk product allergies, and is a poor source of iron and vitamins C and E. Honey and corn syrup are potential sources of botulism toxin and should not be used in an infant's diet. This toxin is potentially fatal in children under 1 year of age (Potter 1002)
< ___ % of fat intake of daily nutrition is considered a nutritional deficiency
< 10%
Which program established guidelines for balancing calories?
ChooseMyPlate
Least formed stool is present in which portion of the digestive tract?
Ascending Colon
How should the nurse determine the needle length and angle of insertion for a subcutaneous injection?
Based on patient's weight and estimate about of subcutaneous tissue
Which measurement is determined by dividing the patients weight in kilograms by height in meters squared and is considered to be the most reliable indicator of nutritional status and health by HCP's?
Body Mass Index [BMI]
If the patient is in severe pain and is requesting pain medication but it is before the PRN medication is supposed to be administer, what should the nurse do?
Call the prescriber and request a STAT order
If the physicians order is written incorrectly, is unable to be read, or is incomplete what should the nurse do?
Call the prescriber and verify/justify the order
Which cathartic form is most effective because of its stimulant effect on the rectal mucosa (Example: Dulcolax)?
Cathartic Suppositories
Why is water critical?
Cell function depends on fluid environment Infants have greatest percentage of total body water; older adults have the least Water makes up 60-70% of total body weight
What are the therapeutic diets?
Clear Liquid Clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices, popsicles Full Liquid smooth-textured dairy products (e.g., ice cream), strained or blended cream soups, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings, frozen yogurt Pureed clear and full liquid, with addition of scrambled eggs; pureed meats, vegetables, and fruits; mashed potatoes and gravy Mechanical Soft As for clear and full liquid and pureed, with addition of all cream soups, ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter, eggs (not fried) Soft/Low Residue Addition of low-fiber, easily digested foods such as pastas, casseroles, moist tender meats, and canned cooked fruits and vegetables; desserts, cakes, and cookies without nuts or coconut High Fiber Addition of fresh uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruits Low Sodium 4-g (no added salt), 2-g, 1-g, or 500-mg sodium diets; vary from no added salt to severe sodium restriction (500-mg sodium diet) Low Cholesterol 300 mg/day cholesterol Diabetic balanced intake of carbohydrates, fats, and proteins; varied caloric recommendations to accommodate patient's metabolic demands Regular No restrictions, unless specified (Potter 1017)
What is the term for a partial or total separation of wound layer during an event that increases itraabdominal pressure indicating the needed for splinting the area to support the healing tissue during these events?
Dehiscence
What are the three landmarks for IM injection?
Deltoid - less than 2mL (small medication volumes) - Three fingers below acromion process - common immunization sites for adults Vastus Lateralis - > 2mL - Anterior lateral aspect of thigh hand breadth above knee and hand breath below greater trochanter - Middle third used for injection - administer medications here for infants Ventrogluteal - > 2mL - Hand over greater trochanter of hip, thumb towards groin and index finger towards anterior superior iliac spine, middle finger extended along iliac crest toward butt, injection is the center of the triangle
Most formed stool is present in which portion of the digestive tract?
Descending Colon
Which amino acids ARE manufactured by the body?
Dispensable amino acids
When should the nurse document medication administration?
Document medications IMMEDIATELY after administration; DO NOT delay.
If the patient is unable to excrete or metabolize the drug [kidney or renal insufficiency] what happens?
Drug toxicity b/c the drug accumulates in the blood
What is the purpose of aspirating during IM administration?
Ensure proper placement of the needle Ensure no blood return to ensure syringe is NOT in vascular space
Which wound bed tissue is characterized as black or brown, hard, and necrotic; needs to be removed before wound can heal?
Eschar
What is the term for a total separation of wound layers; protrusion of visceral organs through wound opening indicating EMERGENCY surgical repair?
Evisceration
If the patient refuses medications, what should the nurse do?
Explore reasons why patient does not want medication. Educate if misunderstandings of medication therapy are apparent. Educate the patient on the importance of the medication Do NOT force patient to take medication; patients have the right to refuse treatment. If patient continues to refuse medication despite educational attempts, document and explain reason for not administering the medication and notify the prescriber
Why do subcutaneous injections take longer to absorb than intramuscular injections?
Fewer blood vessels are found under SQ tissue SQ tissue is NOT as richly supplied with blood as muscle
When kcal intake in food is GREATER THAN energy requirements what occurs?
Gain weight
Which wound bed tissue is characterized asked and moist; composed of new blood vessels indicating healing progression (full thickness repair)?
Granulation Tissue
Which laboratory test is used to measure microscopic amounts of blood in the feces (blood that cannot be seen)
Guaiac Fecal Occult Blood Test Repeat the test at least three times while the patient refrains from ingesting foods (e.g., some raw vegetables, red meat, poultry, fish) and medications (e.g., vitamin C, aspirin, non steroidal anti-inflammatory drugs) that cause false-positive results (Potter 1100)
What is the most effective method to prevent the transfer of clostridium difficile (C. Difficile) ?
HAND HYGIENE with soap and water is effective to physically remove C. difficile spores from the hands. (Potter 1092)
What is important to remember during ear instillation?
Have the patient assume a side lying position of 2-3 minutes Apply pressure to the tragus Place cotton ball in canal if needed for 15 minutes
If a wound is healing and healthy tissue is observed, how should the nurse stage the pressure ulcer?
Healing stage ____ pressure ulcer CANNOT document backwards
Which enema solution is contraindicated in patients who are dehydrated or young infants because of risk for fluid imbalance?
Hypertonic Solution
What is the degree of insertion for ID, IM, and SQ injections?
ID- 5 to 15 degrees IM- 90 degrees SQ- 45 degrees [1 inch of tissue or thin] or 90 degrees [2 inch of tissue or obese]
Which factors would contribute to stopping enema administration?
If bleeding occurs, abdomen becomes rigid and distended, pain occurs, or resistance is felt
Which amino acids are NOT manufactured by the body and MUST be obtained through diet or external source are known as?
Indispensable amino acids
Why and when is the Z-track method used during IM injection?
It minimizes local skin irritation by "sealing" medication into muscle (Prevents tracking, staining of tissue, and deposit of medication into sensitive tissue) Inject 10 mL/second DO NOT rub sit after injection to prevent bruising
Which position should the patient be in while administering an enema?
Left Side-Lying or Sim's Position
Which organ is responsible for drug metabolism?
Liver
When kcal intake in food is LESS THAN energy requirements what occurs?
Loose weight
Which minerals require a daily intake of 100 mg or more?
Macrominerals These balance the pH of the body and certain amounts are necessary for acid-base balance
_______ nitrogen balance occurs when the body loses more nitrogen than it gains from infection, trauma, burns, fever, starvation, etc.
Negative Nitrogen Balance MUST provide patient with protein and proper nutrients to put patient into positive nitrogen balance
What are the ranges for body mass index?
Normal = 19-24 Overweight = 25-29 Obese = 30-39 Extremely Obese = > 40
Which enema solution is the safest for administration because it does NOT create a danger for excess fluid absorption?
Normal Saline [Isotonic Solution]
Which order is prescribed when patient needs medication QUICKLY but NOT right away? The nurse has 90 minutes to administer meds
Now Order
Which enema solution lubricates the rectum and allows the feces to absorb the oil making them soft and easier to pass?
Oil Retention
Which order is given when patient requires it? Example: morphine sulfate 2 mg IV q2h prn for incisional pain
PRN Order
Which patients are at greatest risk for cardiac dysrhythmia and high blood pressure with the Valsalva manuever and MUST avoid straining to pass stool?
Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound (Potter 1089)
How should the nurse properly administer oral medication?
Place all the patients medications in the same cup, except for medications with pre administration assessments Place tablets into medicine cup WITHOUT removing wrapper ALWAYS hold bottle with label against palm of hand when pouring Crush pills if the patient has difficulty swallowing and liquid medication is not an option (consult with pharmacists) Administer liquid medication packaged in single-dose cup directly from the single-dose cup. Do not pour into medicine cup. Draw up volumes of less than 10 mL in syringe designed for oral medication use without needle
Which actions should the nurse take if the patient experiences an evisceration?
Place sterile towels soaked in sterile saline over extruding tissues to reduce bacterial invasion or tissue drying NPO contact surgical team immediately observe for signs and symptoms of shock prep for emergency surgery place patient in low fowlers position STAY WITH PATIENT
What should the nurse instruct the patient in doing during buccal drug administration?
Placing the solid medication in the mouth against the mucous membranes of the cheek until it dissolves. Teach patients to alternate cheeks with each subsequent dose to avoid mucosal irritation. Warn patients not to chew or swallow the medication or to take any liquids with it.
What are methods to prevent medication errors from occurring?
Prepare medications for one person at a time. Follow the six rights of medication administration. Be sure to read labels at least three times (comparing medication administration record [MAR] with label) before administering the medication. Use at least two patient identifiers and review the patient's allergies whenever administering a medication. Do not allow any other activity to interrupt administration of medication to a patient (e.g., phone call, pager, discussion with other staff). Double-check all calculations and other high-risk medication administration processes (e.g., patient-controlled analgesia) and verify with another nurse. Do not interpret illegible handwriting; clarify with prescriber. Question unusually large or small doses. Document all medications as soon as they are given. When you have made an error, reflect on what went wrong and ask how you could have prevented the error. Evaluate the context or situation in which a medication error occurred. This helps to determine if nurses have the necessary resources for safe medication administration. Attend in-service programs that focus on the medications commonly administered. Ensure that you are well rested when caring for patients. Nurses make more errors when they are fatigued. Involve and educate the patient when administering medications. Address patients' concerns about medications before administering them (e.g., concerns about their appearance or side effects). Follow established policies and procedures when using technology to administer medications (e.g., automated medication dispensing systems [AMDSs] and bar-code scanning). Medication errors occur when nurses "work around" the technology (e.g., override alerts without thinking about them). (Potter 583)
When the prescriber writes a Rx for medications taken outside hospital this is considered to be a _____
Prescription Order
When a wound is healed by surgical incision (wound edges are approximated or closed) this is referred to as healing by ______ intention?
Primary Intention
How should the nurse instill ear drops for children > 4 and adults?
Pull auricle UP and BACK
Which type of drainage is characterized as thick, yellow, green, tan, or brown indicating infection?
Purulent
Where does fecal impaction occur in the colon?
Rectum
What are the assessment findings of a normal stoma?
bright pink or brick red Notify HCP of stoma is blue, purple, brown, or black which indicates circulation problem to the stoma
What steps should the nurse follow when administering a transdermal patch?
Remove old patch before applying new. Document the location of the new patch. Ask about patches during the medication history. Apply a label to the patch if it is difficult to see. Document removal of the patch as well. Discard in biohazard bin
Which order consists of a single dose of medication given IMMEDIATELY or only once? Administered during emergencies when condition suddenly changes Typically administered intravenously (IV)
STAT Order
Which type of drainage is characterized as bright red indicating active bleeding?
Sanguineous
Scarring can be severe with primary or secondary intention?
Secondary Intention
When a wound is left open until filled by scar tissue this is referred to as healing by _______ intention? (burn, pressure ulcer, etc) This poses a greater risk for infection
Secondary Intention
Which type of drainage is characterized as pale, pink, watery; a combination of clear and red fluid?
Serosanguineous
Which type of drainage is characterized as clear or watery plasma?
Serous
Which order consists of giving medication once at a specified time then discontinue? It is used for preoperative meds or meds before diagnostic exams. Example: Ativan 1 mg IV on call to MRI
Single or One Time Order
Which stage of wound healing is characterized by non-blanachable erythema of intact skin? This wound does NOT require a dressing
Stage I
Which stage of wound healing is characterized by partial-thickness skin loss; a shallow opened ulcer that may be in intact blister?
Stage II
Which stage of wound healing is characterized by full-thickness tissue loss NOT involving underlying fascia (NO bone, tendon, or muscle exposure). SQ fat may visible (slough). Tunneling and undermining may be included?
Stage III
Which stage of wound healing is characterized by full-thickness tissue loss with extensive destruction. EXPOSED bone, tendon, and/or muscle?
Stage IV
Which order is carried out until prescriber cancels it by another order or prescribed number of days has elapsed? The order Indicates final date or number of treatments or doses. Example: Tetracyclline 500 mg PO q6h or Decadorn 10 mg daily x 5 days
Standing or Routine Order
The ChooseMyPlate program was developed by whom?
U.S. Department of Agriculture
Which enema solution is considered to be hypotonic and should NOT be repeated because of the risk of water toxicity or circulatory overload if and because the body absorbs excessive amounts of water?
Tap Water [Hypotonic Solution]
When analyzing a fecal specimens for ova and parasites, what is required of the stool?
The stool MUST be warm. If the stool specimen remains at room temperature, bacteriological changes can alter the test results
What is the term for the [abnormal] method used to assist in stool passage by exerting pressure to expel fecal matter through voluntary contraction of the abdominal muscles while maintaining a forced expiration against a closed airway?
Valsalva Manuever *Normal passage of bowels should be painless, passing soft formed stool*
Vegans are at risk for which nutritional deficiency?
Vitamin B12 deficiency b/c the vitamin is only found in animal sources and vegans ONLY consume plant products
Which vitamins are considered water-soluble vitamins and need to be provided in daily food intake because they are not stored in the body?
Vitamin C and B
When energy requirements are completely met or EQUALS kcal intake in food what occurs?
Weight does not change
If blood return appears in the syringe during aspiration of IM administration, what should the nurse do?
Withdraw the needle and prepare injection again
What is the most reliable method of verification for placement of the NG tube?
X-ray Other methods include: pH test (aspirate and inspect color)
Which foods induce a constipating effect?
cheese, lean meats, eggs, and pasta
What are the goals of ChooseMyPlate?
decreasing portion size, increasing healthy food intake, increase water consumption, maintain body weight in a healthy range, increase activity, decrease salt intake, increase fruit, vegetable, and whole grain intake
What are the sites for subcutaneous injections?
outer posterior aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thigh alternative areas: scapular area of upper back and upper gluteal areas ROTATE SITES
What is blanching hyperemia?
press finger over affected area --> skin turns lighter in color --> removal of finger --> redness present
