fundamentals exam #1

how often should immobilized pt be re-positioned?

1-2 hours

sharps containers can only be how full?

2/3

what degree is low fowlers?

30 degrees

what are some illnesses that require contact precautions?

MRSA, VRE, lice/scabies, major draining wounds, c diff

can two people who have TB share a room?

NO

is there prn restraint orders?

NO, only continue or discontinue

what causes more infections, aerobic or anaerobic organisms?

aerobic

what must you have for a restraint?

an order

how soon should patient move from bed to chair?

as soon as they are stable

vitamin B is good for what?

assists in energy metabolism

halitosis

bad breath

what requires aiborne/contact precautions?

chickenpox(varicella), herpes/shingles, SARS, small pox

what are CUS words?

concerns, unsafe, safety

immobility increases ________ rate

heart

neutropenia

low WBCs

immobility can decrease ______ rate

metabolic

how should equipment be cleaned from c.diff patient?

with bleach solution, alcohol is ineffective

what are symptoms of TB?

fever, night sweats x 2 weeks

increase what when skin is dry?

fluid intake

what should diet be rich in?

fluids, fruits, vegetables, and fiber

should you wear gloves when giving a food tray to an HIV/AIDS patient?

no, you are not coming in contact with blood or bodily fluids

A nurse assists a client who had bariatric surgery to be more mobile. What complication is the nurse attempting to prevent?

PE Immobility contributes to venous stasis, which can cause deep vein thrombosis and pulmonary embolism. Insufficient mobility does not contribute to incisional pain; incisional pain contributes to immobility. Stressors commonly associated with wound dehiscence include obesity, infection, and poor wound healing, not immobility. Anastomosis leakage occurs when gastrointestinal contents leak into the abdominal cavity; it is caused by leakage around, or separation of, sutures or staples where the stomach is stapled or the loop of jejunum is anastomosed to a new outlet from the stomach, or where it is attached to the proximal jejunum.

The fire alarm is sounding in a skilled nursing facility and smoke is pouring from the kitchen. What should the nurse do to ensure the safety of the clients, staff, and family members? Select all that apply. a. move bed ridden clients via stretcher b. place ambulatory clients in wheelchair c. turn off all sources of O2 d. provide manual respirations to critically ill pts e. close all windows and doors and use an ABC extinguisher

a, c, d, e When responding to a fire in a facility the nurse should move bedridden clients out of the area via stretchers. All sources of supplemental oxygen should be discontinued and manual respiratory support should be provided to critically ill clients. All windows and doors should be closed and an ABC fire extinguisher should be used to help contain the fire. Ambulatory clients should be asked to walk and not placed in wheelchairs.

the patient diagnosed with DVT is placed on a medical unit. which nursing intervention should be implemented. select all that apply a. place SCDs on both legs b. instruct pt to stay in bed and not ambulate c. encourage fluids and diet high in roughage d. monitor IV site every 4 hours and prn e. assess homans sign every 24 hours

b,c,d a. SCDs are used to prevent DVT, not treat b. bedrest 5-7 days after diagnosis of DVT allows time for clot to adhere to vein wall, which will prevent emboli c. bed rest will lead to constipation, fluids and high fiber will help. fluids will also help provide adequate fluid volume in the vasculature d. the pt has a heparin drip, which should be monitored e. homans is used to determine if they have a DVT. they are already diagnosed with a DVT. doing this could dislodge clot and cause emboli

how often should restraint be removed?

q2 hours for assessment and needs

what kind of mask would a airborne/contact patient wear when leaving the room?

regular mask, NOT N95

you need an order within ___________ after application

1 hour

in what order would you put on PPE?

1. gown 2. mask/respirator 3. goggles/faceshield 4. gloves

in what order do you remove PPE?

1. gown and gloves 2. goggles/face shield 3. mask/respirator 4. wash hands

how often should patient with catheter be cleaned?

3 times and as needed

how many bed rails up is considered restraints?

4

what degrees is semi fowlers?

45-60 degress

what is normal WBC count?

5000-10,000

what degrees is high fowlers?

90 degrees

hypoxia can cause what?

a patient to become agitated/aggressive

Which intrinsic factors may contribute to falls in older adults? Select all that apply. a. deconditioning b. impaired vision c. inappropriate foot wear d. improper use of assistive devices e. unfamiliar environment of hospital room

a, b Falls in older clients may be due to intrinsic factors and extrinsic factors. Deconditioning and impaired vision are intrinsic factors that can lead to falls. Inappropriate foot wear, improper use of assistive devices like walkers, and a lack of familiarity with the hospital room are extrinsic factors.

The nurse is teaching a client self-management care in preventing and spreading methicillin-resistant Staphylococcus aureus (MRSA). Which statements made by the client indicate the need for further learning? Select all that apply. a. i can share athletic equipment b. i can participate in contact sports c. i should sit on upholstered furniture d. i should use antibacterial soaps for bathing e. i should wash all infected skin areas before covering those areas

a,b,c MRSA infection is most commonly seen in hospitalized clients but is also now prevalent outside the hospital setting. The client who has MRSA should not share any athletic equipment with other people, as there may be a chance of spreading the infection. The client with MRSA should not participate in contact sports, as the infection may spread from one person to another. The infected client should not sit on upholstered furniture, as the wound may drain into the fabric, which could spread the disease. The client should use antibacterial soaps for bathing to prevent MRSA infection. It is necessary to wash all infected areas before covering those areas.

what level should cane be at?

hip level

nosocomial infection

hospital acquired infection

The nurse is providing instructions about foot care for a client with diabetes mellitus. What should the nurse include in the instructions? Select all that apply. a. wear shoes when out of bed b. soak the feet in warm water daily c. dry bw the toes after bathing d. remove corns as soon as they appear e. use a heating pad when feet feel cold

a. wear shoes when out of bed c. dry between toes after bathing Wearing shoes protects the feet from trauma; they should fit well and should be worn over clean socks. Drying between the toes after bathing prevents maceration and skin breakdown, thus maintaining skin integrity. Soaking the feet is contraindicated because it can cause macerations and skin breakdown, which allow a portal of entry for pathogenic organisms. Clients should not self-treat corns, calluses, warts, or ingrown toenails because of the potential for trauma and skin breakdown; these conditions should be treated by a podiatrist. Use of a heating pad, hot water bottle, or hot water is contraindicated because of the potential for burns; diabetic neuropathy, if present, does not allow the client to accurately evaluate the extremes of temperature.

patients who are immobile are at high risk for developing __________ and ____________ in the lungs

atelectasis hypostatic pneumonia

the nurse is discharging a client diagnosed with DVT from the hospital. which discharge instructions should be provided to client?

avoid green leafy vegetables and notify HCP of red or brown urine rationale: green leafy vegetables contain vitamin K which is the antidote for warfarin (anticoagulant, blood thinner) these foods will interfere with medication. red or brown urine may indicate bleeding

The nurse is concerned that her immobile client may develop contractures of their joints. What is an appropriate nursing intervention to help prevent the development of contractures? a. Turn and reposition the patient every 2 hours b. Assist the patient with passive ROM exercises c. Apply ace bandages to lower extremities d. Apply TED hose to the client's extremities

b

A nurse is teaching the client's daughter how to care for her mother with decreased mobility. The nurse suggest that the client increase which of the following nutrients in the client's diet? (Select all that apply) a. Carbohydrates b. Calories c. Protein d. Vitamin D e. Vitamin C

b,c,e

what is a iatrogenic infection?

hospital acquired infection

A nurse confers with the nutritionist about the diet of a 4-year-old child with spina bifida who spends many hours in a wheelchair. What should the nurse encourage the mother to increase in her child's diet? Select all that apply. a. fat b. fiber c. protein d. calories e. carbs

b. fiber c. protein Extra fiber is needed to combat constipation resulting from immobility. Extra protein is needed for maintaining muscle mass and to help prevent pressure ulcers. Of this child's dietary intake, 25% should consist of fat; this is the lowest recommended daily intake for fat. It should not be increased because more fat calories may lead to obesity in an immobilized child. Calories should be limited because energy needs are less for immobile children than for children who are active. Carbohydrates, especially simple sugars, should be limited to help prevent obesity.

A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment should the nurse make it a priority to use? Select all that apply. a. goggles b. surgical mask c. shoe covers d. gown e. gloves f. n95 hepa mask

b. surgical mask d. gown e. gloves A gown, mask, and gloves when bathing the client prevent contact with feces, sputum, or other body fluids during intimate body care. Goggles would only be important if the client was on mechanical ventilation to avoid contact with sputum. An N95 hepa mask would be necessary if the client had tuberculosis, but not for Cryptococcal pneumonia alone. Shoe covers are designed for protecting a sterile environment such as a surgery suite and are not necessary for giving client care at the bedside.

Which nursing action helps reduce the development of healthcare-associated methicillin-resistant Staphylococcus aureus (HA-MRSA)?

bathing pts with chlorhexidine gluconate solution Current evidence shows that bathing hospitalized clients with pre-moistened cloths or warm water containing chlorhexidine gluconate (CHG) solution can significantly reduce HA-MRSA infection by 23% to 32%. Topical antibiotic ointment, every other day bathing, and washing hands with soap and water after removing gloves are not identified as reducing HA-MRSA.

patients on ________________ medications make them more prone to become sick

immunosuppressant

what PPE is required for droplet precautions?

in addition to standard precautions, don mask within 3 feet of patient

immobility causes the release of ____________ into the circulation

calcium

how to walk with cane

cane goes first, then patient

knee gatch can elevate knees, but might inhibit what?

circulation

A nurse provides discharge teaching to an older adult about care associated with activities of daily living. Which factor should the nurse mainly consider when counseling the client on how often to take a tub bath?

condition of the skin The condition of the skin is priority for the frequency of bathing. Aging causes reduction in skin lubrication, which results in dry skin. The ability of the client to provide self-care influences how much assistance is necessary, not the frequency of bathing. The degree of the client's orientation influences safety factors applicable during the bath, not the frequency of bathing. A history of allergic reactions experienced by the client influences what bath products may be used, not the frequency of bathing.

what PPE is to be worn for contact precautions?

in addition to standard precautions: gown, gloves

what should be checked when removing restraints?

skin integrity, ROM, circulation, sensation, movement

What are airborne precautions?

standard precautions N95 mask for TB/measles

what happens to gut from immobility?

decreased peristalsis feeling of being full no appetite

immobility ____________ the metabolic rate

decreases

how should we wash legs?

distal to proximal

what happens to musculoskeletal system from immobility?

disuse osteoporosis atrophy contractures stiffness and pain

The nurse educates a client on decreasing the risk of developing antibiotic-resistant infections. Which statement made by the nurse will be most significant?

do not skip any dose of your antibiotics Antibiotic-resistant infection develops when the hardiest bacteria survive and multiply. This may happen when a client stops taking an entire course of antibiotics, which leads to infections that are resistant to many antibiotics. Therefore a client should not skip any dose of an antibiotic. Hand washing is required to prevent infections; it is not related to antibiotic-resistant infections. Antibiotics should not be stopped even if the client has started feeling better; the full course of treatment should be taken. Non-compliance in taking the full course of prescribed antibiotics can lead to an antibiotic-resistant infection. It is dangerous to take the unfinished antibiotics at a later time; it may prove fatal if the antibiotics are outdated.

a _________________ infection occurs when a patients flora is altered

endogenous

how often must a restraint order be renewed?

every 24 hrs

how often should catheter bag be drained?

every 8 hours

a ______________ infection comes from outside the body

exogenous

why would one use trendelenburg's position?

facilitates venous return

what is one food immunosuppresent pts might avoid eating?

fresh fruit

what PPE should be worn when with c.diff patient?

gown and gloves

what is the most common form of transmissions of pathogens?

hands

what kind of diet should an immobilized patient have?

high protein high calorie vitamin b & c

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)?

inactivity A DVT, or thrombus, may form as a result of venous stasis. It may lodge in a vein and can cause venous occlusion. Inactivity is a major cause of venous stasis leading to DVT. Pregnancy and tight clothing are also risk factors for DVT secondary to inactivity. Aerobic exercise is not a risk factor for DVT.

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers?

incontinence and inability to move independently Constant exposure to moisture (urine) and prolonged pressure that compresses capillary beds place a client at high risk for pressure ulcers. Although periodic exposure to moisture and occasional friction are risk factors for pressure ulcers, they do not place a client at highest risk. Although immobility places a client at risk for pressure ulcers, tube feedings should meet the client's nutritional needs and promote tissue integrity. Although being chair-bound increases a client's risk for pressure ulcers, adequate nutritional intake supports tissue integrity. If the client has upper body strength, weight can be shifted periodically to relieve pressure.

Leukocytosis

increase in the number of white blood cells

stomatitis

inflammation of the mouth

glossitis

inflammation of the tongue

The nurse is transferring a client from the bed to the chair. Which action should the nurse take during the transfer?

instruct the client to dangle the legs The nurse should place the client in high-Fowler position, or 80 to 90 degrees, and then assist the client to the side of the bed. Next, the nurse helps the client sit on the edge of the bed and then instructs the client to dangle the legs. The nurse then faces the client and places the chair next to and facing the head of the bed. The semi-Fowler, or 30 to 45 degrees, position is not high enough to get the client in a sitting position.

A client who had a right total hip replacement is progressing from the use of a walker to the use of a cane. In which hand should the nurse teach the client to hold the cane?

left hand A cane should be used on the unaffected side. Weight-bearing can be shared by a cane and an affected leg when they are advanced forward together. Teaching the client to use the right hand promotes leaning toward the affected side and does not permit sharing of weight by the stronger left side of the body. Teaching the client to use the stronger hand is unsafe; the stronger hand may not be the left hand. Teaching the client to use the dominant hand is unsafe; the dominant hand may not be the left hand.

what are some illnesses that require droplet precautions?

meningitis pneumonia flu measles/rubella

immobility can cause a negative ____________ balance

nitrogen

when a patient is immobile, the body excretes more ___________ than it ingests proteins, resulting in negative nitrogen balance

nitrogen

should we disconnect IV tubing when bathing patient?

no, increases chance of infection

can a patient have both physical and chemical restraints at the same time?

no, only one at a time

how often should perineal care be performed?

once a shift

A nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange?

orthopenic The orthopneic position is a sitting position that permits maximum lung expansion for gaseous exchange; it also enables the client to press the lower chest or abdomen against the overbed table, which increases pressure on the diaphragm to help with exhalation, reducing residual volume. The supine position does not permit the diaphragm to descend by gravity, and pressure of the abdominal organs against the diaphragm limits its movement. Low-Fowler and semi-Fowler positions do not maximize lung expansion to the same degree as the orthopneic position.

what are the 5 P's?

pain pallor paresthesia paralysis pulseless

what is a common symptom of DVT?

pain behind calves

hemiplegia

paralysis of one side of the body

what is active ROM

patient moves all joints thru their rom, unassisted

__________________is a common respiratory problem that occurs due to immobility.

pneumonia

patients with altered bone marrow function or diminished RBC production tire easily why?

reduced hemoglobin

A healthcare team is delegated the task of assisting a client with bathing. Which member of the healthcare team is responsible and accountable for this aspect of client care?

registered nurse Bathing is often delegated to a patient care associate (PCA) on the healthcare team. The registered nurse (RN) is accountable for the client care, but is not delegated the task of basic hygiene care such as bathing. Though the nursing aide is responsible for client care, he or she is not accountable for the client care. Similarly, a PCA may be responsible but not accountable for client care. As bathing is not generally delegated to a licensed vocational nurse (LVN), the LVN is neither responsible nor accountable for client care.

A client with a spinal cord injury tends to assume the low Fowler position excessively. In which area of the body will the nurse most likely discover a pressure ulcer?

sacrum The sacrum bears the most pressure because it is the focal point of the weight of the body when in the low Fowler position; also, shearing forces may cause local tissue trauma. Although other areas of the body are vulnerable, they do not bear as much body weight as the sacrum when the client is in the low Fowler position.

what position is recommended for patients at risk for pressure ulcers?

semi-fowlers 30 degrees

if patient is supine and having trouble breathing, what should you do first?

sit them up, then apply pulse oximeter

dehydration and edema increases the rate of what?

skin breakdown

vitamin C is good for what?

skin integrity and wound healing

A healthcare provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker?

strong upper arm strength and non weight bearing on the affected extremity A walker with four rubber tips on the legs requires more upper body strength than a rolling walker. A client who is non-weight bearing on the affected extremity is able to use a standard walker. A rolling walker is more appropriate for a client with weak upper arm strength and impaired stamina who is less able to lift up and move a walker with four rubber tips. A client with unilateral paralysis is not a candidate for a standard walker; the client must be able to grip and lift the walker with both upper extremities and move the walker forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able to lift up and move a walker with four rubber tips.

Diaphoretic

sweating

To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices?

they help the venous blood return to the heart Deep vein thrombosis (DVT) is a potential complication of any surgery lasting longer than 30 minutes. The purpose of pneumatic compression devices is to increase venous return. Clients often complain about pneumatic compression devices being hot and itchy. In addition to the pneumatic compression devices, a mechanical form of DVT prophylaxis, pharmaceutical prophylaxis is often required. Pneumatic compression devices are continued until the client is up ambulating frequently throughout the day.

what is passive ROM?

unable to move unassisted

patients with hep b, hep c, and HIV require what kind of precautions?

universal precautions

why would a patient be supine?

used for patients who are hypotensive

immobility can cause what to happen to the venous system?

vasodilation

when applying stockings, tell pt to avoid activities that promote what?

venous stasis e.g. crossing legs

A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching?

wash hands with soap and water Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-based hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission of C. difficile.

how should you clean your hands after handling c.diff patient?

wash hands with soap and water, not alcohol based sanitizer

hemiparesis

weakness on one side of the body

should affected DVT leg be elevated?

yes, relieves edema swelling and pain from the DVT

are patients allowed to use electric razors to shave if they are on blood thinners?

yes, safer than using straight blade

should the door remain shut with a patient with airborne/contact precautions?

yes, to maintain negative pressure