Final
State and describe the 4 levels of consciousness
1. Awake and alert 2. Lethargic - appears drowsy, or asleep. Can be aroused with gentle shaking 3. Stuporous - unconscious mostly and must be shaken or shouted at to be roused 4. Comatose - cannot be roused, even with painful stimuli
What are the 3 key categories of behavior assessed in the Glasgow Coma Scale?
1. Eye opening 2. Verbal response 3. Motor response Each category is given a numerical value: Max score: 15 = fully awake, alert, oriented Lowest score: 3 = deep coma
Morse Fall Risk Assessment
1. History of falling 2. Secondary diagnosis 3. Ambulatory aid 4. IV/saline lock 5. Gait 6. Mental status 0-24 no risk 25-50 low risk 51+ high risk
The 5 kinds of Nurse Notes styles discussed
1. Narrative - detailed, chronological 2. PIE (problem, intervention, evaluation) - care plan is incorporated into the progress notes 3. Focus (DAR) - brings the focus of care back to the patient and the patient's concerns 4. SOAPIE - Subj, Obj, Analysis, Plan of care, Intervention, Evaluation 5. CHARTING BY EXCEPTION - short, saves time, only abnormal findings
Tanner's 4 Clinical Judgment Model Phases?
1. Noticing 2. Interpreting 3. Responding 4. Reflecting: - in action - on action
What are the BMI ranges?
1. Underweight: Under 18.5 2. Healthy Weight: 18.5-24.9 3. Overweight: 25-29.9 4. Obese: 30 or greater
The average amt of voided urine per day is __ mL per day
1500 mL
Glasgow Coma Scale
3 - coma 15 - alert
We worry about urine output when it is less than __ mL per hour
30 mL
Braden Scale Range
9 - very high risk 10-12 - high risk 13-14 - moderate risk 15-18 - mild risk 19-23 - no risk
A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? A. Check to see whether the catheter is patent. B. Reassure the client that it is not possible for her to urinate. C. Re-catheterize the bladder with a larger-gauge catheter. D. Collect a urine specimen for analysis.
A
A nurse exits the room of a confused patient without raising the side rails on the bed. The failure to raise the side rails would be which of the following elements of liability related to malpractice? A. Breach of duty B. Causation C. Duty D. Damages
A
A nurse is caring for a client who has a prescription for a 24-hr urine collection. Which of the following actions should the nurse take? A. Discard the first voiding. B. Keep the urine in a single container at room temperature. C. Ask the client to urinate and pour the urine into a specimen container. D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.
A
For which of the following situations should the nurse initiate a Rapid Response Team? Select all that apply. A.Urine output of 40 mL over 4 hours B.Systolic blood pressure of 92/60 C.Heart rate of 144 BPM D.Respiratory rate of 30/min
A (URINE LESS THAN 50 mL over 4 hrs) C (HR OVER 140) D (resp rate over 28/min)
A nurse is caring for a patient with an NGT connected to low intermittent suction. Which of the following nursing interventions are appropriate for the nurse to take to prevent leakage of gastric contents from the pigtail vent (BLUE Part) of a Salem Sump tube? Select all that apply. A.Keep the pigtail positioned above the level of the stomach B.Use an anti-reflux valve on the pigtail C.Flush the pigtail vent with saline every hour D.Plug the pigtail with a cover at all times
A,B
A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.) A. Older adults are more prone to dehydration than younger adults are. B. Older adults need the same amount of most vitamins and minerals as younger adults do. C. Many older men and women need calcium supplementation D. Older adults need more calories than they did when they were younger. E. Older adults should consume a diet low in carbohydrates.
A,B,C
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (Select all that apply.) A. Warm the enema solution prior to instillation. B. Position the client on the left side with the right leg flexed forward. C. Lubricate the rectal tube or nozzle. D. Slowly insert the rectal tube about 5 cm (2 in). E. Hang the enema container 61 cm (24 in) above the client's anus.
A,B,C
A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has recurrent UTIs. Which of the following factors should the nurse include? (Select all that apply.) A. Frequent sexual intercourse B. Lowering of testosterone levels C. Wiping from front to back D. Location of the urethra in relation to the anus E. Frequent catheterization
A,D,E
Using Evidence Based resources such as the Institute of Safe Medication Practices (ISMP) website ensures that the nurse administers medications safely. What information can be found in the ISMP website? Select all that apply. A.High alert drugs B.DO NOT CRUSH DRUGS C.Look alike drugs D.Sound alike drugs
ABCD
An 80-year-old woman was admitted to the local community hospital following a motor vehicle crash. Her injuries included a left fractured hip and left compound fractured wrist, which were both surgically repaired 2 days ago. The client is alert and oriented x 3; she gets out of bed to a chair with assistance at least two times a day. The nurse's note from the previous shift includes these notes regarding the client's skin assessment.Nurses' Notes3/16/20 0600Client has 1 in (2.2 cm)in diameter reddened area on coccyx that does not blanch. Both heels have purplish coloration and feel soft and "mushy." Superficial lacerations on her upper arms and chest are beginning to heal. Which of the following nursing actions are indicated for the client at this time? Select all that apply. A. Teach the assistive personnel to avoid positioning the client in a supine position. b. Limit the client's time sitting in a chair to no more than 1 hour at a time. c. While the client is in bed, position her heels to be off of the bed at all times. d. Teach the client and family to increase her nutritional intake of carbohydrates. e. Consult with the registered dietitian nutritionist for possible oral nutritional supplement. f. Use pressure-reducing mattress for the client's bed.
ABCEF
An 80-year-old woman was admitted to the local community hospital following a motor vehicle crash. Her injuries included a left fractured hip and left compound fractured wrist, which were both surgically repaired 3 days ago. The client has been alert and oriented x 3; she gets out of bed to a chair with assistance at least two times a day. The nurse documents the listed findings as part of the shift assessment. Select all the assessment findings that require follow-up by the nurse. A. Temperature =100.0 degrees F B. Heart Rate = 82 beats/min and regular C. Respirations 18 breaths per minute D. BP- 96/52 mm/Hg E. Left hip wound dry and staples intact F. Redness and heat around proximal end of left wrist incision H. Increasing lethargy I. States her pain is currently a 2 ( on a 0-10 pain intensity scale)
ADFH
Elderly do not present with the typical signs and symptoms of UTI. The sign of __ could possibly be the only indication of UTI in an elderly patient.
Altered mental state
What is a bruit?
An audible vascular sound associated with turbulent blood flow
A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Give the client thin liquids. B. Instruct the client to tuck her chin when swallowing. C. Have the client use a straw. D. Encourage the client to lie down and rest after meals.
B
A nurse is performing range-of-motion exercises on a bedrest patient and moves the patient's arm laterally toward the patient's body. What range of motion exercise is the nurse performing? A. Flexion B. Adduction C. Extension D. Abduction
B
A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? A. Macaroni and cheese B. Fresh fruit and whole wheat toast C. Bread pudding and yogurt D. Roast chicken and white rice
B
A patient is receiving a continuous feeding of ensure via g-tube at 40 mL/hr. In assessing the client, the nurse notes a residual volume of 80 mL. What should the nurse do next? A.Replace the aspirate and continue the feeding B.Replace the aspirate and hold the feeding C.Discard the aspirate and hold the feeding D.Notify the physician
B
During a clinical rotation on a geriatric medical unit, a student nurse fed a stroke patient some beef broth despite the fact that the patient's diet was restricted to thickened fluids. As a result, the patient aspirated and developed pneumonia. Which of the following statements underlies the student's potential liability in this situation? A. The student and the nursing instructor share liability for this lapse in care. B. The same standards of care that apply to a registered nurse apply to the student. C. The student's potential liability is likely negated by the insurance carried by the school of nursing. D. The patient's primary nurse is liable for failing to ensure that delegated care was appropriate.
B
The nurse enters a patient's room before breakfast to administer the patient scheduled medications. The patient tells the nurse that he will take the medication later because he has visitors at this time. Of the following scheduled medications ordered for a patient, which medication is critical for the nurse administer at the correct time ? A. Colace 100 mg 1 tab PO daily B. Regular Insulin 6 units SQ before meals C. Calamine topical cream apply to affected area three times a day prn itching D. Multivitamin 1 tab PO daily
B
A nurse in a provider's office is evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions should the nurse suggest for helping to control or eliminate the client's incontinence? (Select all that apply.) A. Limit total daily fluid intake. B. Decrease or avoid caffeine. C. Take calcium supplements. D. Avoid drinking alcohol. E. Use the Credé maneuver.
B, D
A nurse is caring for a client who has had diarrhea for 4 days. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.) A. Bradycardia B. Hypotension C. Elevated temperature D. Poor skin turgor E. Peripheral edema
B,C,D
A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply) A Establish a schedule of urinating prior to meal times. B. Have the client record urination times. C. Gradually increase the urination intervals. D. Remind the client to hold urine until the next scheduled urination time. E. Provide a sterile container for urine
B,C,D
A nurse is caring for a client who has had diarrhea for 4 days. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.) A. Bradycardia B. Tachycardia C. Hypotension D. Elevated temperature E. Poor skin turgor F. Peripheral edema G. Weakened peripheral pulses
B,C,D,E,G
A diabetic patient who has had uncontrolled blood glucose levels for a prolonged time can suffer from which of these chronic complications? Select all that apply: A.HHNS B.Diabetic retinopathy C.DKA D.Nephropathy
B,D
A 71-year-old male client with moderate to late-stage Parkinson disease is admitted from home to the hospital with new-onset orthostatic hypotension and occasional dysphagia. According to his wife, he needs assistance with ADLs on days when his rigidity is worse, and walks short distances in the house using a walker. Choose the most likely options for the information missing from the statement below by selecting from the list of options provided. Note that not all options will be used.Because of the client's orthostatic hypotension and dysphagia, he is currently most likely at risk for __________ and ___________. During his hospital stay, he is also most likely at risk for complications associated with impaired mobility, especially _______________ and ___________ . A. Stroke B. Pressure Injury C. Aspiration D. Falling E. Constipation F. Urinary Incontinence G. Bleeding H. Diabetes mellitus
BCDE
Why do we leave a wound open when healing by tertiary intention?
Because it is infected
What are the geriatric syndromes?
Benjaminbutton Slays Dragons, Demons Fearlessly Over Water 1. Bladder control 2. Sleep problems 3. Dementia 4. Delirium 5. Falls 6. Osteoporosis 7. Weight Loss
A fellow student nurse tells you not to even think about carrying your own malpractice insurance because "you'll be a magnet for attorneys trying to make a buck." When you seek the advice of the American Nurses Association, you are likely to read which of the following reasons for purchasing a personal professional liability insurance policy? 1. Protection of the nurse's best interests 2. Limitations of employer's coverage 3. Care or advice given outside of work 4. Protection of the institution's best interests A. Select answer 1 only B. Select answers 1 and 2 C. Select answers 1, 2, and 3 D. Select all of the above
C
A nurse discovers that she has administered a medication that is the wrong dose. What should the nurse do first? A. Record the error on the medication sheet B. Notify the physician regarding course of action C. Monitor the patient's condition and observe for any effects of the error D. Complete an incident report x documentation
C
A nurse notes on the patient's chart the abbreviation DAT. The nurse interprets this as which of the following meaning? A. do as told B. drug and alcohol testing C. diet as tolerated D. documentation and technique
C
A nurse reviewing a patient's chart notes the abbreviation W&D. The nurse interprets this as which of the following terms? A.Wound and drainage B.Weight and dosage C.Warm and dry D.Wipe and debride
C
Which of the following nursing actions are considered dependent nursing interventions? Select All that Apply: A.Repositioning a patient every two hours B.Providing a bed bath and linen change C.Administering a newly prescribed medication D.Applying restraints on a patient
C,D
In an SBAR communication with the physician, in which portion would the nurse state a concise statement of the problem? A.Situation B.Background C.Assessment D.Recommendation
C. Assessment
The nurse is planning to teach a newly diagnosed diabetic patient WHO is unaware of the many complications of diabetes. The nurse identifies that the patient understands the macrovascular complications when the patient identifies which findings? Select all that apply. A.Urinating frequently B.Blurred vision C.Chest pain D.Sudden loss of movement and feeling on left extremities
CD
What is the adventitious breath sound heard as a result of the opening of deflated small airways and alveoli (occurs with pneumonia and pulmonary edema)
Crackles
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client? A. Eating more protein is optimal prior to testing. B. One stool specimen is sufficient for testing. C. A red color change indicates a positive test. D. The specimen cannot be contaminated with urine.
D
If you harm a patient by administering a medication (wrong drug, wrong dose, etc.) ordered by a physician, which of the following is true? A. You are not responsible, since you were merely following the doctor's orders. B. Only you are responsible, since you actually administered the medication. C. Only the physician is responsible, since he or she actually ordered the drug. D. Both you and the physician are responsible for your respective actions.
D
In which part of a patient's chart or electronic health record can the nurse obtain the medications and treatments ordered by the physician for the patient? A. Nurse's orders B. Physician's progress notes C. Treatment administration record D. Physician's orders
D
Which of the following parties is responsible for obtaining informed consent from a patient? A. The patient's family or significant other B. The patient's nurse C. The nursing supervisor D. The person performing the procedure, study or treatment
D
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A. Have the client hold his breath briefly and bear down. B. Discontinue the fluid instillation. C. Remind the client that cramping is common at this time. D. Lower the enema fluid container.
D
A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that, which of the following nutrients is the source of most of the body's energy? A. Fat B. Protein C. Glycogen D. Carbohydrates
D. Carbohydrates are the body's greatest energy source; providing energy for cells is their primary function.
An elderly male client with moderate to late-stage Parkinson disease is admitted from home to the hospital with new-onset orthostatic hypotension and occasional dysphagia. On admission, the nurse notes the listed assessment findings. Select to highlight the assessment findings that require follow-up by the nurse. Select all that apply. A.Lives at home with his wife who cares for him B.Walks short distances in the house without assistive device C.Is alert and oriented x4 D.Increasing resting tremors in both arms and hands, but right hand is worse than the left (client is right handed) E.Chokes at times when he eats F.Has fallen twice in the past week because of dizziness when he stands from a sitting or lying position G.Temp= 98.0 degrees F H.Apical pulse= 76 beats per minute I.Blood pressure= 128/74 mm/Hg in supine position J.States he is not in pain
DEF
Differentiate between diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HSS)
DKA: DM1 patients usually. No insulin leads to extreme hyperglycemia (i. BG > 240 mg/dL)- will have classic symptoms (3 Ps). Body cannot utilize carbs, so it does ketogenesis for fuel, which creates excessive ketones, making the blood dangerously acidic. HHS: DM2 patients usually. Pancreas makes enough insulin to avoid ketosis, but creates higher tolerance for blood glucose and it gets very high (BS > 600 mg/dL). Classic symptoms of hyperglycemia (3 Ps), profound dehydration. But no ketosis, so no ketones in urine.
Both Dawn phenomenon and Somogyi effect result in elevated blood glucose levels in the morning. Differentiate between Dawn phenomenon and Somogyi effect.
Dawn Phenomenon: Hyperglycemia in the morning resulting from adrenal glands releasing hormones that increase blood glucose in preparation for waking. Somogyi Effect: Hyperglycemia in the morning resulting from action of glucagon. Due to not eating while sleeping, pancreas releases glucagon to prevent hypoglycemia, but this results in too much blood glucose since there's not enough insulin to counter glucagon.
Time medication effect lasts in the body
Duration
Explain each diagnostic test/procedure for DM
Fasting Blood Glucose aka Fasting Plasma Glucose: Caloric fast for 8-12 hours, then blood draw. Normal: 99 or less Prediabetic: 100-125 Diabetic: 126 and up Random Blood Glucose: Check blood anytime. Diabetic = signs of diabetes + BG 200 and up Oral Glucose Tolerance Test: Caloric fast for 8-12 hours, then drink 75 g glucose. Normal: 139 or less Prediabetic: 140-199 Diabetic: 200 and up
Explain how glycogen assist in maintaining blood glucose level?
Glycogen is the stored form of glucose. When low blood sugar is detected, the pancreas releases glucagon which causes the liver to break down glycogen into glucose.
4 stages of wound healing
Help I Pain Much 1. Hemostasis 2. Inflammatory 3. Proliferation 4. Maturation
What is the physiologic basis for increased urine manifested by clients with untreated diabetes Mellitus?
High level of glucose in the blood --> body produces more urine to try to rid the glucose --> results in increased urination
MD orders 40 mL/hr NGT feeding. Before next feeding, you check residual and it's 40 mL. What should you do?
Hold feeding for 30 minutes and then check the residual again. If the residual volume is 50% or less, then resume feeding. If greater than 50% notify MD that patient is not tolerating.
DKA and HHS are metabolic processes that affect patients with DM 1 and DM2. Ketosis occurs more frequently in Type 1 DM. Why is it rare in DM Type 2 patients?
Ketosis (body burns fat for fuel) occurs when the body does not have/cannot utilize carbohydrate sources for metabolism. DM2 patients have enough insulin for the body to utilize carbohydrates, and avoid ketosis, but DM1 patients have no insulin, so the body is completely unable to utilize carbohydrates.
What is wound healing by secondary intention.
Open wounds are left open to heal by granulation from inside to outside. E.g. burns and pressure ulcers
The 5 Rights of Medication
PDDRT - Please Do Da Right Thang 1. right Patient 2. right Drug 3. right Dose 4. right Route 5. right Time
Explain how glucagon assists in maintaining blood glucose level?
Pancreas releases glucagon which tells liver to do glycogenolysis (break down glycogen into glucose) in order to raise blood sugar and avoid hypoglycemia. Insulin counters glucagon and they work together to maintain homeostasis (blood glucose of 70-100 mg/dL).
A patient consumed 30 percent of his meal. This is: A. Good B. Fair C. Poor
Poor. 100% - All 75% - Good 50% - Fair 25% - Poor 0% - None
Granulation tissue fills in a wound during the __ stage of healing?
Proliferation
Categories of the Braden Scale
Save My Adored Mother, No Friction 1. Sensory Perception 2. Mobility 3. Activity 4. Moisture 5. Nutrition 6. Friction and Shear
What is wound healing by primary intention?
Simplest form of wound healing. Can be closed by sutures or staples. Edges of wound are well approximated.
Differentiate between Stage 1,2,3,4,unstageable, DPTI pressure ulcers.
Stage 1 - intact, skin is red and unblancheable. Stage 2 - exposed dermis, or can present as a ruptured/intact serum-filled blister (partial thickness) Stage 3 - exposed subcutaneous fat (full thickness) Stage 4 - exposed tissue - muscle, ligament, bone DPTI - Dark purple, boggy/spongey; intact or non-intact Unstageable - When you cannot see extent of tissue damage due to slough or eschar. Must first debride to be able to stage it.
T/F - For fecal occult blood testing, the nurse should instruct the client to obtain three specimens from three different bowel movements.
True
T/F - When performing a cleansing enema, the correct length of insertion for a child is 2 in and for an adult client, it is 3-4 in.
True
T/F - A patient with a spinal cord injury is paralyzed from the waist down and is unable to empty his bladder. There is an order to perform an intermittent catheter insertion every 8 hours. Based on CAUTI guidelines, this patient warrants the insertion of a catheter.
True. Because he is unable to empty his bladder.
Hipaa violation or not: A nurse allows a laboratory technician to review the patient's chart prior to a blood draw that was ordered by the physician
Yes, violation because the nurse should only allow the lab tech to see the minimum amount of the patient's chart necessary to complete the lab tech's job
A patient's urine pH is found to be 6. Is this normal?
Yes. Normal pH of urine = 4.6 to 8
A wound healing by secondary intention heals by __
granulation
Time it takes for a medication to produce a response
onset
Time at which a medication reaches its highest effective concentration in the blood
peak
Time at which drug is at its lowest amount in the serum (blood)
trough