Exam 1 study guide

you observe a pt experiencing respiratory difficulty in the hall. You suspect foreign body obstruction. What is the most appropriate question to ask the pt?

" are you choking"

while visiting your pregnant coworker she starts to choke. the co-worker is conscious but unable to breath. Where should you administer thrusts? a. below the navel b. the chest c. at the diploid process d. the upper back

B. the chest

What is maslows hierarchy of needs based on?

Basic need muat be met before next levels can be met

Type of extinguisher for C fire

Electrical fires

Your pt has been Dx with a deep partial-thickness burn. What is the observation most likely based upon? How will the burn appear upon assessment?

Erythema with blisters

Who was the nurse leader that developed a theory in the 19th century was related to improvement of patient environment as a method of health promotion

Florence nightingale

describe/define "semi-fowlers"

HOB @ 30 dregrees

What system of comprehensive patient care consider the physical, emotional, and social environment and spiritual needs of a person?

Holistic healthcare

What is the patients bill of rights and what association develop it? The title of the American _____ associations 1972 document outlined that the patients expectation to be treated with ______ and compassion

Hospital ; dignity

When a fall occurs, the nurse should document the incident and initiate a(n) ____________ report.

Incident

The nursing process/step in the nursing process that ensures that the plan of care is meeting the patients needs?

Individual care plan

a disaster situation occurs and involves an explosion in a hospital laundry, What would this be classified as? Internal or External?

Internal

During early civilization __________ performed witchcraft and ritual to induce the bad spirits to leave the body of the ailing person

Medicine Men

What should the nurse do to protect her back when lifting or moving a patient?

Must bend at knees and hips. widen the base of support in direction you are going

What does 'PASS" stand for?

Pull, Aim, Squeeze, Sweep

Define and describe "RICE'

R: rest affected area E: ice for 48 hours after - 15/20 mins 4-8 times a day. C: compress with bandage E: Elevate above heart level

What is the wellness/illness continuum

Range of a persons total health

The pt arrived at the emergency dept. in pain and bleeding profusely with the following vital signs: BP 80/40, P 102, RR 22. What does the nurse recognize that these symptoms indicate?

Shock - Circulatory

A pt is admitted to the hospital after receiving trauma to the head. the pt begins to show signs of shock. How should the pt be positioned and why?

Supine (flat on back) to keep body aligned. Do not move pt because could cause major damage.

TRUE OR FALSE? When a nursing program is certified by a state agency it is considered to be an approved program

TRUE

What must the nurse realize when assessing physical and social environmental factors affecting health and illness?

They affect one another

Patient care emphasis on wellness, rather than illness, begins as a result of increased education concerning causes of illness. True or false

True

S/S of Hypovalemic shock: a. B/P b. Pulse rate c. Resp d. skin color e. pulse will feel f. skin will feel

a. Hypotension b. Tachycardia c. Tachypnea d. Pallor e. Weak & Thready f. Cold & clammy

A nurse instructs a nursing assistant about the proper use of gait belt and is observing a return demonstration. What action by the nursing assistant should cause the nurse to intervene? Explain why a. walking on the pt strong side b. walking to the side of the pt c. securing gait belt securely around the pt waist d. grasping the handles of the gait belt while the pt ambulates

a. walk on weaker side so that you are able to give assistance if pt starts to fall

where should the nurse place the load when carrying heavy objects?

close to body midline

Type of extinguisher for B fire

flammable liquid fires, grease, and anesthetics

what is the site of the most common strain injury acquired by the nurse when working

lumbar muscle group

Type of extinguisher for A fire

paper, wood, and cloth fires

When assessing the adult victim for pulselessness, the CPR rescuer should palpate the most reliable and accessible pulse. Which pulse will be palpated?

Carotid Pulse

When the nurse ambulates with a pt who has left-sided weakness, what actions should the nurse take? Explain what side you should walk on a. walk on the pt right side b. keep the pt away from heart furniture c. hold the pt arm securely d. keep the leg nearest the pt behind the pt knee e. Use a gait belt

D & E Pt should wear a gait belt to ambulate. Nurse should always walk on the weak side

What is Melena?

Dark, tarry stool

Type of extinguisher for ABC fire

all fires

What is important for the nurse to determine in order to decrease the risk for injury to a patient? a. if pt can read english b. if pt is left-handed c. if pt is able to eat unassisted d. if pt can dress independently

b. if pt is left handed

The pt is admitted to the emergency dept., having suffered frostbite to the hands, which are grayish-with in color. What action should the nurse implement when attempting to warm the hands?

wrap in hot moist towels

You are educating an immobilized pt on how to prevent muscle atrophy and contractors. The pt states I need calcium, more protein, and some type of exercise. Which statement implies the pt understand the education?

"some type of exercise" - this prevents muscle atrophy

What is included in a neuromuscular assessment?

1. circulation 2. movement 3. sensation 4. pain 5. color 6. skin temperature

What 3 factors must be considered regarding mobility with older adults

1. fearful of hydrolic lifts 2. Skin is too fragile & susceptible to injury 3. Loss of flexibility & joint mobility

What is the number a times a nurse should move each joint when performing PROM?

5 times

How much circulating blood is an avg adult male is supposed to have

8-12 pints

A long-term care facility is committing to a restrain free environment. what will the health care workers implement to encourage this environment? a. frequent orientation to surroundings b. explain all procedures and treatments c. discourage visitors d. maintain toileting routines e. minimize exercise and ambulation

A, B, D

The nurse assesses a pt in a Posey safety reminder device (SRD) for which problem(s) that may increase because of the use of SRDs? a. immobility b. lethargy c. risk for impaired circulation d. risk for skin impairment e. incontience

A, C, D , E

A nurse is assessing victims in an emergency situation. What will the nurse be assessing first?

Abnormal breathing

The good samaritan law will protect all people who offer assistance. What is necessary for this protection?

Act prudently

The pt with a heat stroke has been undressed and treated with cold packs and a fan. The pt temp is now down to 101.4 F. The pt starts to shiver. What action should the emergency dept nurse take? A. Raise the HOB b. Offer warm liquids c. Remove cold packs and fan d. Continue with cooling interventions

C shivering increases pt temp and makes muscles move and create energy.

Initial nursing actions for victim who suffered burns in a house fire?

Cool burns with cool compress for 2nd degree burn (Partial thickness burn)

TRUE OR FALSE When moving an older adult you should always support under the soft tissues?

FALSE - always support joints, soft tissue may tear easily

Pt arrives to ER with deep laceration to forearm. What should be the nurses first action? a. split the thigh and apply tape to approximate the edges b. apply ice and a pressure dressing to the thigh c. give a tetanus booster injection d. wash the laceration with an antiseptic

D

The pt is brought to the emergency dept. after having fractured an arm 12 hrs ago. the arm is very edematous from the fingers to the elbow, and the pt cannot move it. What should be the initial action of the nurse? a. test ROM b. take vitals c. place ice packs on the arm d. check fingers for capillary refill

D

pt arrives in the emergency department with a sucking wound to the L chest. What is the first action the nurse should take and why? EXPLAIN a. position on the L side b. Place several layers of gauze over wound c. Place pt supine d. Cover wound with airtight dressing tapes on 3 sides

D. Air leaking into pleural space & lung is not inflated

What is the most effective initial treatment of excessive/profuse bleeding?

Direct pressure

Primitive medical interventions were based on a belief that illness was caused by the presence of

Evil spirits

If a spinal injury is suspected, before the rescuers start CPR, the trachea should be opened with a _____ - _____________ manuever

Jaw-Thrust

Where did Florence nightingales original nursing education take place?

Kaiserwerth program

Treatment for a stabbing victim who still has the knife in place

Leave knife in skin. Immobilize with tape and dressing

you see a nurse pulling a pt across the bed linens. Is this the proper way for the pt to be moved?

No, older skin is very fragile, weak and thin. Pulling could cause skin to peel

The relationship among nursing, patients, health, and the environment are the basis for

Nursing models

What score does the graduate practical nurse require to be issued a license upon completion of the computerized examination?

Passing score

What is the order of Maslows hierarchy of needs?

Physiological, Safety and security, love and belongingness, esteem, self-actualization

a 5 year old child ingested bleach. Who should the nurse call to receive the best assistance for dealing with the victim

Poison Control

a pt has been stung by a bee and is brought to the Emergency dept. The nurse observes the sting size and identifies that the stinger is till in skin. What action should the nurse take?

Scrape with blade of knife to prevent venom to enter skin

When administering first aid in emergency situations, the nurse must first survey victims for severity of injuries. What term correctly describes this process?

Triage

define passive ROM

performed by nurse

define active ROM

performed by patient

Place the nursing activities in order for the priority of a patient to ambulate. Put a comma and space between each answer choice: a. Dangle the patient at the side of the bed b. Apply a gait belt c. Assist the patient to stand d. Inform the patient of activity e. Roll up the HOB

d. inform the patient of activity e. Roll up the HOB a dangle the patient at the side of the bed b. apply the gait belt c. assist the patient to stand

What must the nurse do before applying a safety reminder device (SRD)?

doctors orders

What measures can take before moving a patient with pain or who may have pain?

give analgesics and give time for them to start working prior to moving

What is the danger/complication of pulling the patient across bed linens?

skin is fragile and can tear

you're teaching a new nurse the initial nursing intervention for a dislocated arm. What is the first action for the nurse to implement?

splint arm at area of dislocation

the nurse is performing PROM for the patient. To what point will the nurse move the joint through ROM

to point of pain

what implantation might the nurse use to improve safety during a transfer?

transfer belt