Fundamentals exam 1
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?