Nursing 295 Final Exam

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Heart Ranges (ages)

*decreases with age* -infant 120-180 -toddler 90-140 -preschooler 80-110 -school aged 75-100 -adolescent 60-90 -adult 60-100

Respiratory Ranges (ages)

*decreases with age* -newborn 30-60 -infants 30-50 -toddlers 25-32 -child 20-30 -adolescent 16-20 -adult 12-20

Blood Pressure Ranges (ages)

*increases with age* -newborn 40 mmHg -1 month 85-54 mmHg -1 year 95/65 mmHg -6 years 105/65 -10-13 110/65 mmHg -14-17 119/75 mmHg -18+ less than 120/80 mmHg

PNS

- 44 pairs of nerves 12 cranial nerves 32 spinal nerves - Somatic and autonomic NS

melanomas

- 90% are caused by UV exposure - Using tanning bed before the age of 30 increases one's risk of developing melanoma by 75%

lesions

- Exposed surface? - Intertriginous / skin folds? - Areas of allergens (jewelry, exposed skin, feet, hands

vestibulocochlear (acoustic, 8)

- Hearing - Whisper test - cranial nerves

Knee

- Hinge joint = limited ROM - Lifelong weight bearing - Cruciate (crossed) ligaments hold femur on top of tibia - Medial and lateral meniscus cushion on the joint

basal cell carcinoma

- Most common in caucasians, hispanics, chinese, japanese and other asian populations

immobilization complications

- Muscle atrophy - Contracture - Foot drop - Pain - Muscle spasm

orientation

- Person - Place - Time - mental state assessment

near reaction

- Pupils constrict - Eyes converge - Lens accommodates

Cultural/ethnic differences

- Skin color - Hair texture - Increased risk within groups - (skin differences)

Ankle

- Tibia - Fibula - Talus - Talar joint

muscles/motor activity

- innervated by nervous system, if innervation is interrupted, no movement

location

- lesion - Generalized - Localized

Fracture treatment

- realign - immobilize -

trigeminal (5)

- sensory/motor of face and mouth - Light touch 3 dermatomes, bite on tongue blade - cranial nerves

What is bronchitis and how can it be diagnosed?

-Inflamed mucus membranes -Percussion: resonant -Breath sounds: coarse crackles, wheeze, rhonchi -May clear with cough

What is pneumonia and how can you diagnose it?

-Inflammatory response to infection -Percussion: dull -Auscultation: late inspiratory crackles

Abdominal exam sequence

-Inspection -Auscultation -Palpation -Percussion

Contraindication of irrigating a colostomy

-Irritable bowel syndrome -Peristomal hernia -Post-radiation damage to the bowel -Diverticulitis -Crohn's disease

Client education with casts

-Keep dry -Do not put anything into cast -Move joints above and bellow casts -Elevate above the heart -Maintain weight bearing status -Inspect color, skin, temperature, and odor -Pain management

Cleaning enemas help

-Relieve constipation or fecal impaction -Prevent leakage of fecal material during surgery -Allow visualization of the intestinal tract -Aid in establishing regular bowel function

How is infants respiratory system unique?

-Round chest -Nose breathers -Belly breathers -Harsh sounding

Prevention of DVT

-Simulate action of the leg muscles -Compression boots -Anti embolic stockings -Foot pumps, early ambulation, ROM

External fixation

-Used to stabilize fracture during healing -Takes place of the casting or traction

Cervical spine

-Vertebrae -Sternomastoid and trapezius muscles

Hyperactive bowel sounds

-Very high pitched -More frequent

Pulling Insulin

-air in NPH (clear) -air in regular (cloudy) -pull cloudy -pull clear

Large intestine consists of

-cecum -colon >ascending >transverse >descending >sigmoid -rectum

Heat Stroke

-life threatening, core temp about 103-104 -rapid, strong pulse, throbbing headache, delirium. confusion, impaired judgement, hot/dry skin, seizures, coma

Auscultation of abdomen

-listen in all four quadrants, -Hyperactive, Hypoactive, normal, high pitched, 5-15/minute, or absent (listen for 3-5 mins in each quadrant before concluding

What injuries most commonly cause a fat embolus?

-long bones. tibia, rubs, pelvis -Liposuction, crush injuries, spinal fusion, total joint replacement

Droplet Precautions

-mumpes. flu, whooping cough, large particles that only travel three feet when someone is coughing or sneezing

Carinal nerve 3 name and function

-oculomotor -lid movement

Pulse oximetry

-on roomier above or equal to 95% -on oxygen, between 92%-97%

The nurse is reviewing doctor's orders on their pt. They notice that there is a doctor's order to call the physician if the pt BP is above 150/90. The most recent BP is 170/94. The nurse is preparing to call the physician. What standardized form of communication is recommended? A. SBAR B. SOAP C. PIE D. CMS

A. SBAR

Which assessment would the nurse make prior to using a pulse oximeter to measure oxygen saturation? A. capillary refill B. pulse farthest away from the monitoring site C. blood pressure D. respiratory rate

A. capillary refill

Rectal temperatures are taken: a. a person has a diarrhea b. a person has had rectal surgery c. the person has trauma to their face d. the person has a heart problem

The goal of the healthcare team is to: a. Carry out the MDs orders b. Develop plans of care for residents c. Provide quality care d. Complain about the workload

Your personal feelings about death a. affect the care you give b. are shared with the dying person c. do not matter while you are working d. are shared with the resident and their family

Your resident is wealthy. He offers you a "little gift" in the form of cash for providing expert care. You should: a. Accept and say nothing b. Accept like a tip and share it with your coworkers c. Refuse graciously d. Look to see if anyone is listening or watching

Which of the following changes in the skin growth should be reported immediately to the nurse. a. change in color b.bleeding c. change in size d. all of the above

Which of the following is an important function of the skin: a. prevents pressure on the subcutaneous tissue b. provides support to the internal organs c. first line defense against infection d. all of the above

Which of the following statements is false: a. OBRA requires activity programs for nursing home residents b. Activities are important for physical and emotional health c. personal choice is protected d. Each resident by law to participate in at least two activities daily

Which of the word below best describes of apetite: a. gavage b. regurgitation c. dysphagia d. anorexia

Which statement below is not a safety measure for tub baths and showers? a. clean the tub or shower before after use b. turn hot water on first, then cold c. place needed items within the person's reach d. fill the tub before the person gets in it

You go to check on Mrs. Jones, she is very agitated. Your task is to give her a bed bath, When you walk in the room, she tells you "Get out of here. I do not want a bed bath". What should you do? a. Speak loudly because maybe Mrs. Jones didn't hear or understand you. b. Run c. Tell the client they have no choice, shut up and lets get cleaned up d. Talk calmly, slowly, reassure the client. Do not force them. Report the refusal to the nurse.

Normal saline solution (isotonic) enema

Distends the intestine, increases peristalsis, and softens stool

Tap water (hypotonic) enema

Distends the intestine, increases peristalsis, and softens stool

Soap suds enema

Distends the intestine, irritates the intestinal mucosa which stimulates peristalsis and softens stool

True or False Multiple sclerosis is cured with diet and medications

False

True or False You can never refuse to perform a delegated task.

False

True or False Nursing Assistants are responsible for starting oxygen therapy

False

True or False Pain that is described as "chronic" means it is sudden onset

False

True or False Reporting and recording are done before you give the patient care

False

True or False Stroke is leading cause of disability in adults

False

True or False The blood pressure cuff works best if applied over clothing

False

True or False Urinary urgency is the loss of bladder control

False

True or False When residents are sick they are hungrier

False

What is the fasted route to give a medication?

before meals

Anatomy of GI tract

begins with the mouth --> esophagus --> stomach --> small intestines --> large intestine --> anus

Flat thorax percussion

bone

Intravascular fluid

plasma

four times a day

qid

Therapeutic range

range of therapeutic concentration

Annualr

ring shaped lesion

CVA tenderness

signal a kidney infection

Hypotonic enemas

tap water solution

Infiltration

the IV fluid is going into the tissues -the catheter. is dislodged and not in the vein -must be removed and call the IV nurse immediately -keep arm elevated, usually it resolves on its own

Primary effect

the drug works for the reason it was given

NG tubes are passed through

the nose into the stomach

Active range of motion

the process whereby a patient puts a joint through its full extent of movement

Venous star

varicosities

Carinal nerve 4 test

cardinal fields of gaze

Abnormal stomach

- Abdominal distention - Rebound tenderness - Protuberant and hard/firm - Tender, painful - Absence of bowel sounds

subjective data (skin)

- Any known problems - Change in pigment - Change in moles - Excessive dryness, moisture - Pruritus or itching - Excessive bruising - Rash or lesions - Medications - Hair loss - Change in nails - Environmental or occupational hazards - Self care behaviors

adolescents (skin)

- Apocrine glands = sweating - Sebaceous glands = acne - Terminal hair

traction

- Applies pulling force on fracture to re-align - Skin vs. skeletal - fracture healing

TMJ

- Articulation of the mandible and the temporal bone - Hinge joint - Limited movement

children (neuro exam)

- Assess behavior such as hyperactivity, history of seizures, headache, eye pain - May indicate ADHD, meningitis, concussion - Assess dietary intake (caffeine, sugar) - Assess for lead in home with infants and children - Assess for behavioral indicators, signs for child abuse - Unable to show emotion, or responds inappropriately to painful procedures

depressed lesion

- Atrophy - Erosion - Ulcer - Fissure - Crack in skin

LOC (level of consciousness)

- Awake, alert - Drowsy, lethargic, but easily awakened - Stuporous - Obtunded - comatose - mental state assessment

hip

- Ball and socket - Allows for wide range of motion - Femur articulates in acetabulum

shoulder joint

- Ball and socket joint - Humerus articulates in the shoulder socket, the upper outer end of the scapula - Supported by rotator cuff - 4 muscles - Together called the shoulder girdle - Allows for wide range of motion

DVT (deep vein thrombosis)

- Blood clot formation in veins secondary to immobility - Veins of pelvis, LE's highly susceptible - Highest incidence after hip fx - Prevention: simulate the action of the leg muscles - compression boots - Anti embolic stockings - Foot pumps, early ambulation, ROM - Treatment: Anticoagulate - Heparin SC, LMW heparin- Fragmin, Lovenox; - Coumadin- will need INR monitoring

abnormal bowels

- Bloody, red, maroon, black, white - Odor consistent with cdiff - No BM greater than 3 days - Diarrhea greater than 3x in 24 hours - Pencil thin stool

musculoskeletal system

- Bony skeletal has no inherent movement - Supplied by muscles, tendons, ligaments

nursing diagnoses

- Bowel incontinence - Constipation / at risk for impaction - Diarrhea - Nausea / vomiting - Toileting self care deficit - Disturbed body image related to bowel diversion - Impaired skin integrity related to skin irritation from diarrhea - Potential complication: electrolyte imbalance related to diarrhea

CNS

- Brain - Spinal cord

judgement

- Career plans - mental state assessment

elder vision

- Central and peripheral vision diminish - Lids lose elasticity - Lens opaque, cataracts - Slow pupillary response - Macular degeneration - Glaucoma

musculoskeletal exam

- Cephalocaudal: start at the head - Inspect : symmetry, deformities, erythema, edema, ecchymosis, muscle mass - Palpate : warmth, tenderness, crepitus with ROM. - Range of motion: each joint

glossopharyngeal (10) vagus (10)

- Check throat / visceral organs - Say Ah, uvula palate rise in midline - cranial nerves

wound infection

- Clients with ORIF - Monitor incision - osteomyelitis

position sense

- Close eyes, move end of finger, great toe up or down, grasp from sides, not from nail - sensory assessment

light touch

- Close eyes, use cotton wisp, have patient say "now" when they feel the light touch - sensory assessment

pain

- Close eyes, use sharp item, have patient say "now" when they feel the pain/sharp - sensory assessment

conjunctiva

- Conjunctival sac - Eye drops - Wraps up over sclera Inspection - Pull down on lower lid - Pull up upper lids - Have patient look up, down, right, left - Inspect for erythema, lesions, discharge Problems - Conjunctivitis (pink eye) - Very contagious

dermis

- Connective tissue, collagen, vascular - skin

consensual

- Continue looking straight ahead - Shine light - Look at other eye for pupil constriction

fat embolism

- Contributory factor in many fatalities associated with fxs (mortality rate 5-10%) - Fat globules enter systemic circulation, embolize to lungs, brain, heart, kidney - Most common with injuries involving long bones, tibia, ribs, pelvis - Liposuction, crush injuries, spinal fusion, total joint replacement - Usually occurs 12-72 hours after injury. - Produces signs/symptoms ARDS

higher intellect

- Count backwards - mental state assessment

pupil abnormalities

- Cranial nerve 3 - Unequal = increased ICP - Pinpoint = drugs, brain injury - Dilated = brain herniation, anoxia, drugs - Fixed and dilated = irreversible brain damage or brain death

cardiac & respiratory

- Cyanosis (circumoral) - skin function

DIP

- Distal interphalanges - hand

process of defecation

- Distention of the rectum - Contraction of the sigmoid colon and rectal muscles - Internal anal sphincter relaxes - Valsalva maneuver

skin function

- External structure for muscles, vessels, bones - Communicates with nervous system about external environment Sensory receptors in skin for - Touch - Temperature - Vibrations - Pain - Assists thermoregulation thru vasodilation and sweating - Largest organ of immune system - Intact, healthy skin is major barrier against pathogens - Reflects disease states

facial (7)

- Face motor/sensory - Check for symmetry of face, puff out cheeks, squeeze eyes - cranial nerves

subcutaneous tissue

- Fat cells, cushion, generate heat, store calories - skin

normal stomach

- Flat abdomen - Soft - Non tender - Normal bowel sounds

managing diarrhea

- Good hand washing - Monitor stools, fluid balance, electrolyte status and skin integrity Treatment - antidiarrheal meds - Use of probiotics to combat antibiotics - BRAT diet / clear liquids - Limit caffeine intake

accessory (11)

- Head, neck, shoulders - Shrug shoulder, turn head against resistance - cranial nerves

testing for occult blood

- Hemoccult slide - Any trace of blue color is a positive test (blue = blood) Restrictions - Red meat, chicken, fish - Vitamin ZC - Medications - Cannot be performed by a nursing assistant

pregnancy (neuro exam)

- Importance of folic acid supplementation - Deficiencies linked to neural tube defects - Carpal tunnel, H/As, lower extremity cramps, numbness or tingling in thighs - Hyperactive reflexes

managing constipation

- Increase intake of fluids / fiber - Increase physical activity - Provide privacy - Assist patient to a seated position - Assess for complications

Wrist exam

- Inspect fo erythema, swelling deformity - Palpate carpal joints for warmth, tenderness, swelling ROM - Flexion - Extension - Radial deviation - Ulnar deviation

hand/finger exam

- Inspect for erythema, swelling, deformity - Palpate metacarpals, MCP, PIP, DIP - Test for CSM - Cap refill - Sensation - Movement ROM - Flexion/Extension - Abduction/Adduction

muscle bulk/tone/strength

- Inspect movements - Smooth? Tremors? - Start at shoulders, push, pull major muscle groups - Start at thighs, push, pull major muscle groups - Grading muscle strength 0 = worst, no movement 5 = best, normal movement - motor/coordination assessment

cerebellar gait/balance

- Inspect walk & turns - Heel toe walk - Feet together, eyes closed, stand 20 seconds w/o swaying - motor/coordination assessment

abdominal assessment

- Inspection - Palpation - Auscultation - Normal bowel sounds - 5-15 per minute - Hyperactive bowel sounds - very high pitched, more frequent - Hypoactive bowel sounds - low pitched, infrequent, quiet - Absent bowel sounds - listen 3-5 min in each quadrant before declaring

iris & pupil

- Inspection - Shape - Size - Color - Response to light

buccal mucosa

- Inspection Moist Pink Lesions Cancer, karposi's sarcoma Thrush

mouth

- Inspection Moist, well hydrated Lesions Lip color - pink, purple, blue

hard & soft palate

- Inspection Pale, pink, moist Lesions

tongue

- Inspection Protrudes in midline Steady Moist / dry Color Coating Sides Underside

direct pupil response

- Instruct patient to look straight ahead - Shine light - Look for pupil constriction

Client education (casts)

- Keep dry - Do not insert anything into cast - Move joints above, below cast - Elevate about the level of the heart - Maintain weight bearing status - Inspect skin, color, temperature, odor - Pain management

ethnicity (neuro exam)

- Language barriers - Irish = higher incidence of neural tube defects - African americans = higher incidence of HTN and stroke

elders (skin)

- Less sebaceous gland activity, less sweating - Subcutaneous tissue loss, epidermis thins, skin flattens & sags - Dermis less elastic - Hair migrates - Skin cancers

flat lesion

- Macule 1.0 cm or less - freckles - Patch > 1.0 cm

MCP

- Metacarpal phalanges - hand

squamous cell carcinoma

- Most common in african americans and asian indians

musculoskeletal diseases

- Muscular dystrophy - ALS, MS - Myasthenia gravis

Older adults (neuro exam)

- Neural impulses slower, decrease neurons - Slower response time - Change in memory, cognitive function, intelligence, processing requires work up - Rule out reversible causes first, then consider alzheimer's and other dementias - Diminished reflexes - Alterations in hearing, vision, pupillary size and reactivity - Skeletal muscles - decreased bulk - Muscular atrophy - Caution for asymmetrical changes or neurological symptoms

Nursing responsibilities (immobilization)

- Neuro/vascular assessment- - Compare both extremities - Know weight bearing status and reinforce with patient - Check for skin breakdown - Support and position extremity for comfort - Elevate above the level of the heart unless compartment syndrome is suspected then keep at heart level - Keep cast dry - Pain meds

infants (skin)

- Newborns = less fat = hypothermia - Smooth skin - Desquamation at birth - Sweat glands developed at one month - Diaper rash - Eczema

teeth & gums

- Number and conditions of teeth - Poor repair, edentulous - Conditions of gums - Moist, pink - Swollen, bleeding - Receding

open/surgical (fracture treatment)

- ORIF/ open reduction, internal fixation - Screws, plated, then a cast / immobilizer to protect - fracture healing

lesion shape

- One sided - Ring shaped - Clustered - Linear (lines)

raised solid lesion

- Papule up to 1.0 cm - pimples - Plaque > 1.0 cm - Crusts, dried, scab like - Nodule, elevated, extends deeper than papule Cyst - tumor

lacrimal apparatus

- Prevents dryness, smooths cornea, inhibits microbes Inspection - Swelling - Inflammation - Exudate - Palpation / masses, pain

promoting normal defecation

- Privacy - Assist with positioning - Consider the timing of the defecation - Good intake of flood / fluids - Encourage exercise

PIP

- Proximal interphalanges - hand

administering enemas

- Retention enemas - Return flow enemas - Managing flatulence - Managing incontinence - Managing impaction

realign (fracture)

- Return bones to their proper position - Closed/Non surgical - Use a cast/splint to maintain re-alignment - Open/ Surgical - Screws, plated, then a cast /immobilizer to protect - Traction

head

- Should be normocephalic - Hydrocephalic - fluid buildup Defects - Fetal alcohol syndrome (FES)

pregnant women (skin)

- Skin darkening 90% on - Face, nipples, areola, axillae, vulva, umbilicus - Increased sweating, sebaceous gland activity - Vascular spiders, hemangiomas already present can enlarge - Skin thickens, fat deposits

normal skin (write up)

- Skin is dry, moisturized, pink. Good turgor, dry and warm to touch. Scattered papules across bridge of nose and cheeks, uniform color. No other lesions noted

GI system

- Skin synthesizes vitamin D from GI tract - Reflects GI dysfunction - Jaundice - Neurofibromatosis - skin function

pedunculated lesion

- Skin tags - Horns

olfactory (1)

- Smell - alcohol wipe - cranial nerves

vascular lesions

- Spider angioma - Liver disease, B6 - Purpura - 0.5 cm, non blanching, infection, intravascular defect - Venous star - Varicosities - Petechias - < 0.5 cm - Telangectasia - Dilated capillaries - Ecchymosis - Trauma, vasculitis - Cherry angioma - Dilated demal, capillaries

muscles of neck

- Sternocleidomastoid and trapezius

health maintenance (skin)

- Sunblock - Smoking - Hydration - Routine skin care / moisturizing

cardinal fields of gaze

- Test that eyes and lids move together - Follow light or finger without moving head - Lazy eye?

sclera

- Tough white covering of the outer ⅔ of globe - Inspect - Pigmentation - Jaundice - Lesions

tympanic membrane

- Translucent, pearly gray, taut membrane - Concave

cornea

- Transparent, convex, avascular - Covers the iris and pupil Inspection - Abrasions, recent trauma, painful - Keratitis: lackluster cornea - Cataracts - lens opacity

color of lesion

- Uniform - Irregular - Brown - Beige - Red - Black - Skin cancer - Asymmetry - Borders - Color - Diameter

vibratory sense

- Use 128mmHz tuning fork, apply to most distance bones on finger - sensory assessment

Knee problems

- Valgus - Genu varum "bowed legs" - Genu valgum "knock knees" - Genu recurvatum "back knee"

normal bowels

- Varied shades of brown - odor/consistency/ shape and quantity is different for every person

cervical spine

- Vertebrae in neck - 7 cervical vertebrae - Inspect for deformities - Palpate for tenderness, muscle spasm. ROM: - Flexion - Extension - Lateral bending - Lateral rotation

eye

- Visual acuity Inspection of eye structures - Symmetry - lids/lashes - Conjunctiva - Sclera - Cornea - Iris - CN 3,4,6 - Pupil response - Cardinal fields of gaze: do the eyes move together

scoliosis

- abnormal lateral curvature of the spine - s shape

Older adults (deficits)

- changes in memory, cognitive function, etc. can be caused by: - Meds - Dehydration - Infection - Illness - Nutrition - Diabetes - Thyroid issues - Alcohol - Environmental changes - Depression - Psychiatric disorders

skin assessment

- color - lesions - shape, size, characteristics

skin inspection/palpation

- color - uniform, normal to ethnicity, widespread/local changes - lesions - characteristics, distribution - palpate skin - texture - smooth - temp - warm - moisture - dry, diaphoretic - turgor - hydration

whisper test

- cranial nerve 8 - Block one ear - Stand 1-2 ft away from uncovered ear - Whistler 2-3 words/numbers - If patient cant hear at 1-2 ft move in by 6 inch increments - Record distance from ear at which patient hears the whisper

factors affecting bowel elimination

- developmental stage - nutrition/hydration - personal/sociocultural factors - meds - surgery/procedures - food intolerance/diet - diverticulosis - fluid intake

oculomotor (3) trochlear (4) abducens (6)

- eyeball movement, lid movement, pupil response - Cardinal field of gaze, pupillary response with light - cranial nerves

optic (2)

- eyes - Hand held snellen eye chart - cranial nerves

raised lesion

- filled with fluid - Vesicle - Elevated capsule, straw colored - Pustule - Bulla

kyphosis

- hunchback - Exaggerated thoracic curve

distribution

- lesions - Psoriasis - Atopic / eczema - Contact dermatitis - Vitiligo - Skin folds / intertrigo

closed/non surgical (fracture treatment)

- manual re-alignment - Use a cast/splint to maintain re-alignment - fracture healing

Data collection

- mental state - LOC, orientation, memory, higher intellect, judgement - cranial nerves - motor/coordination - muscle bulk/tone/strength, coordination, cerebellar gait/balance - sensory - light touch, pain, position sense, vibratory sense - reflexes - triceps, brachial, brachioradialis, patellar, ankle, plantar

Hip Exam

-Inspect: gait for symmetry, gluteal muscle mass -Palpate: greater trochanters for tenderness -ROM: flexion with knee straight, flexion with knee flex, extension, internal rotation, external rotation, abduction, adduction

TMJ exam

-Inspect: jaw symmetry -Palpation: Fingertips in front of triages, ask patient to open mouth, should feel the joint space -ROM: open and close, move jaw side to side, thrust jaw forward

Foot Exam:

-Inspect: swelling, erythema, deformities, flat feet, corns, bunions, calluses -Palpate: tenderness -ROM: inversion, eversion, flexion, extension, abduction, adduction (toes)

Sequence of lung exam

-Inspection -Palpation -Percussion -Auscultation

Knee Exam

-Inspection: swelling, erythema, deformity -Palpation: patella, tendon, lateral joint spaces, posterior space -ROM: flexion, extension

Spine Exam

-Inspection: symmetry of muscle mass, contour of vertebral column -Palpation: spine tenderness, paravetrebral muscles, tenderness, spasm -ROM: flexion, extension, lateral bending, rotation

Elders skin

-Less sweating -Subcutaneous tissue loss, epidermis thins, skin flattens, sags -Dermis less elastic -Hair migrates -Skin cancers

Hypoactive bowel sounds

-Low pitched -Less frequent

Past health history for a lung exam

-Lung Disease or breathing problems -Anything similar in the past -Last PPD and/or chest x-ray -Immunizations -Allergies -Medications

What are adolescents most at risk for?

-MVAs -Binge drinking -Recreational drugs -Opiod addiction

Closed/ non-surgical fracture treatment

-Manual re-alignment -Use of cast/splint to maintain re-aligment

Uvula inspection

-Midline -Rises with phonation

Tongue inspection

-Midline -Steady -Moist -Color -Coating -Sides and underside

Lip inspection

-Moist, well hydrated -Lesions -Lip color

Squamous cell carcinoma

-Most common in African Americans and Asian Indians

Basal cell carcinoma

-Most common in Caucasians, hispanics, Chinese, Japanese, and other asian populations

Complications from immobilizing a limb/joint

-Muscle atrophy -Contracture -Foot drop -Pain -Muscle spasm

Examples of musculoskeletal diseases

-Muscular dystrophy -ALS,MS -Myasthenia gravis

Nursing responsibilities with immobilizers

-Nero/vascular assessment -Compare both extremities -Know weight bearing status -Check for skin breakdown -Support comfort -Elevate -Keep cast dry -Pain meds

Infants skin

-Newborns: less fat, hypothermia -Smooth -Desquamation at birth -Dont develop sweat glands until 1 month

OLDCART

-Onset -Location -Duration -Characteristics -Aggravating factors -Relieving factors -Treatment

What are adults and older adults most at risk for?

-Opiod addiction -Medication over dose -Falls

Signs of compartment syndrome

-Pain that is unresponsive to usual medication -Parathesia (numbness and tingling) -Pressure -Pallor -Paralysis/loss of function -Pulselessness

What does harsh/ grating breath sounds signal?

-Pleurisy -Inflamed visceral and parietal pleura -Caused by infection or tumor

What does distant breaht sounds and scatted wheezes throughout signal?

-Pneumothorax -COPD -Emphysema -Chronic bronchitis

What are examples of mechanical stress?

-Poor posture -Obesity -Lax abdominal muscles -Poorly designed work station

Lacrimal apparatis

-Prevents dryness, inhibits microbes -Inspect for: swelling, inflammation, exudate

Inspection of conjunctiva

-Pull down on lower lid -Pull down on lower lid -Have patient look up, down, right, and left -Inspect for erythema, lesions, or discharge

Use at least two methods to confirm NG tube placement

-Radiography (X-ray) is considered the most reliable method for identifying position of the NG tube -Check pH of gastric contents (less than 5.5 is acidic) -Visual assessment of aspirate -Monitoring of carbon dioxide

Treatment of compartment syndrome

-Reduce pressure -Removal or loosening of the bandage or cast -Surgical decompression

Rights of medication

-Right medication -Right dose -Right time / frequency -Right route -Right patient -Right documentation -Right reason

What is atelectasis?

-Secretions close small airways -Aleveoli colapse -Cleared by a cough -Possible set up for pneumonia

Iris inspection

-Size, shape, color

Inspecting precordium

-Skin color -Rate and rhythm of respiration -Heaves and lifts

Pregnant women skin

-Skin darkening -Increased sweating -Vascular spiders -Skin thickens -Fat deposits

Carinal nerve 11 name and function

-Spinal accessory -Shoulder muscles

Carinal nerve 12 test

-Stick out tongue

Health maintenance of skin

-Sunblock -Smoking -Hydration -Routine skin care/ moisturizing

What are you inspecting for in a musculoskeletal exam?

-Symmetry -Deformaties -Erythema -Edema -Ecchymosis -Muscle mass

Inspection of the nose

-Symmetry -Nares -Nasal mucosa

Inspection of palpebral fissure

-Symmetry -Width between lids -Upper lid covers part of the iris -Lower lid to lower margin of iris

Skin palpation

-Texture -Temperature -Moisture -Turgor

Epidermis

-Thin, tough outer layer -Avasular

What causes musculoskeletal problems?

-Trauma -Inflammation -Degeneration -Overuse -Congenital -Age -Tumor metastasis -Mechanical stress

Carinal nerve 5 name and function

-Trigeminal -Movement of temporal and masseter muscles -Pain and light to face and gums

Carinal nerve 4 name and function

-Trochelar -Eyeball movement

NG tubes are used for

-Used to decompress or drain fluid and air -Monitor bleeding in the GI tract -Remove substances (lavage) -Help treat intestinal obstructions -Typically attached to suction (intermittent or continuous)

Eye physical exam

-Visual acuity -Inspection of eye structures -Cranial nerves 3,4,6

Where does bacteria like to grow?

-Warm, dark, moist -Bladder, mouth, skin folds, blood stream

What are we looking for when you palpate in a musculoskeletal exam?

-Warmth -Tenderness -Crepitus with ROM

Palpate Abdomen

-abdomen flat (no distention) -soft -no tenderness or masses -normal bowel sounds

Hyponatremia

-dangerously low sodium levels -body fluids are too dilute -causes brain swells, confusion, sudden weight gain, urine output decreases, seizures, coma

Small intestine consists of

-duodenum -jejunum -ileum

UTI

-dysuria, frequency, urgency -odorous urine -cloudy urine -back pain -fever, chills, -hematuria

Primary intention healing

-edges approximated -usually an incision -use of sutures, staples, cement

Secondary intention healing

-edges not approximated -would heals from inside out

Kidneys

-filter waste, toxins, and water and excrete as urine -also regulate blood volume, blood pressure, electrolyte levels, and acid base balance -produce erythropeoitin, secrete renin, activate vitamin D3

Carinal nerve 2 name and function

-optic -sight

Pallor

-paleness -associated with anemia

Subjective data

-patients report -family -other healthcare provider -information gathered from medical record

ADH

-regulates osmolality of bodily fluids -causes kidneys to ABSORB water -fluid moves from the kidney into the intravascular space (blood) -concentrates the urine -if hormone is inhibited. the person would urinate more

Rights of Medication (7)

-right med -right dose -right time -right route -right patient -right documentation -right reason

UTI risk factors

-sexually active women -women using spermocidal gel -older women -pregnant -men with BPH -kidney stones -diabetes -history of UTIs

-sound occurs in systole -tricuspid and mitral valves close to allow ventricles to empty

Blood Pressure

-systolic less than 140 mmHg -diastolic less that 90 mmHg -pulse pressure 30-50 mmHg

Intradermal

-very small gauge -forms a wheel -usually TB syringe

Catastrophic reactions involve a. false beliefs b. restless behavior c. seeing something that is not there d. extreme responses

HIV can be spread by a. sneezing coughing b. insects c. holding hands and hugging d. unprotected anal, vaginal or oral sex as well as blood exposure to unbroken skin

Oral hygiene: a. is only done once daily b. is not important for the unconscious person c. causes pyorrhea d. prevents mouth odor and infection

The surgical replacement of a joint is called: a. open reduction b. healing fracture c. osteoporosis d. arthroplasty

To prevent aspiration when providing oral care to the unconscious person, you should a. place a kidney basin under the persons chin b. clean the mouth using sponge swabs moistened with a cleaning agent c. explain the procedure to the persons and provide for privacy d. position the resident in a side-lying position with the head turned to the side.

What can happen is constipation is not relieved? a. Enema b. Diarrhea c. Incontinence d. Fecal Impaction

When removing soiled linens, you must wear: a. A gown b. Face Mask c. Eye Protection d. Gloves

Which temperature is considered MOST accurate? a. Oral b. Axillary (A) c. Temporal d. Rectal (R)

ear canal

- 2.5-3 cm - Lined with ceruminous glands, skin - Horizontal in infants, curved up in adults Inspection - Gently pull top of ear up and back Look for - cercumen : orange, gold, dark brown - Edema, erythema, discharge, lesions - Foreign bodies

Carinal nerve 5 test

-Bite on tongue blade, pull out -Light touch 3 dermatomes

Carinal nerve 7 test

-Inspect for symmetrical facial features -Puff out cheeks, squeeze eyes shut

Open/ surgical fracture treatment

-ORIF/open reduction, internal fixation -Screws, plates, than a cast/immobilizer to protect

Carinal nerve 9 and 10 test

-Say AH check uvula -Soft palate rise and fall -Gag test

Carinal nerve 11 test

-Shrug shoulders -Turn head against resistance

Crackles

-atelectasis -secretions block small airways -possible set up for pneumonia

Documentation of an enema

1. Amount, type of solution used 2. Amount, consistency and color of stool 3. Pain assessment 4. Assessment of the perineal area for irritation, tears or bleeding

Emptying and changing an ostomy appliance

1. Stoma - for fecal or urinary elimination - constructed from a section of the colon or small intestine 2. Effluent: stoma output (outflow of liquid)

The pt has the following fluids in an 8 hr shift. Calculate the intake 3 tbs broth 6 oz juice 4 oz milk 750 mL water 8 oz jello

1326 mL

1 kg = ? lbs

2.2

Normal potassium levels

3.5-5.0 mEq/L

How much does the bladder hold?

500 mL

Microdrip

60 gtt/min

The nurse is turning a pt when she notices an area with non-blanchable redness over the pt coccyx. The pt complains of pain at the site, and the site is cooler than the area immediately around the site. The nurse recognizes that this pt has developed: A. stage I pressure B. stage II pressure C. an unstageable pressure D. deep tissue injury

A. stage I pressure

The beginning sign of a pressure sore is: a. Coolness b. Discoloration c. Swelling d. Numbness

When will the ordered med be given? Lasix 40 mg PO TID A. 0900 & 1600 B. 0900, 1300, 1700 C. 0900 & 2100 D. 0900 only

B. 0900, 1300, 1700

red eye

Bleeding into sclera

Looking at things from another's point of view is called: a. Politeness b. Work ethic c. Empathy d. Courtesy

Men often times have difficulty urinating because: a. kidneys atrophy b. bladder increases in size c. prostate gland enlarges d. urethra loses tone

Muscle Atrophy is: a. the abnormal shortening of a muscle b. bending backward c. the decrease in size or wasting away of a muscle d. excessive straightening of a body part

Contact Precautions

C Diff, MRSA, VRE

F to C

C=F-32/1.8

ICP

CN 3 and 4 are sensitive to this early warning sign

When do you not elevate?

Compartment syndrome

Deep tendon reflexes

DTR

flexion

Decreases the angle of a joint

rubror

Deep redness, associated with inflammation

Kyphosis

Exaggerated thoracic curve

Pleural Effusion

Fluid accumulation in the pleural space

Carinal nerve 2 test

Hand held Snellen chart

Nose

Inspection - Symmetry - Nasal skeleton, straight, deviated - Nares patent - Ask patient to occlude one side, breath through open side - Nasal mucosa - Intact, lesions, polyps, foreign bodies Palpation - Nasal skeleton

Organs in LUQ

Left lobe of liver, Spleen, stomach, body of the pancreas splenic flexure of colon

Linear

Lesion in lines

Schedule IV drug

Low potential for abuse and low risk for dependence

Enteral medications

NGT or GT

What controls muscles and motor activity?

Nervous system

Peripheral IV

Short term IV

Cephalocaidal

Start at the head

Urgency

The need to go

Clean catch specimen

The specimen requires special cleaning of the external genitalia prior to collection. Front to back!

What is the slowest route to give a medication

Topical

Nodule

a small lump

PRN

as needed

Dermatomal

one sided lesion

Extracellular fluid

outside the cells

after meals

Pyuria

pus in the urine

Tachycardia

rapid HR >100 bpm

Erythema

redness of the skin

Fowler's position

sitting position

Pterygium

thickening caused by chronic inflammation

Schedule II drug

High potential for abuse, can lead to dependence

Frequency

How often you go

PICC line

IV used for long term therapy

Phlebtis

Inflammation of the vein where the catheter is placed

Nasal sinuses

Inspect Palpate - Apply firm pressure - frontal - Press up from under the bony brow - Maxillary - Press up along cheekbone

What happens when compartment syndrome is not treated right away?

It can cause irreversible nerve and muscle damage

ABCD of skin cancer

- Asymmetry - Borders - Color - Diameter

uvula

- Inspection Midline Rises with phonation

hypoglossal (12)

- Muscles of tongue - Stick out tongue, move side to side - cranial nerves

coordination

- Rapid alternating movements - Point to point - Heel to shin - Upper and lower extremities bilaterally - motor/coordination assessment

memory

- Recent - Remote - Recall 3 things in last 5 minutes - mental state assessment

immune system

- Repairs skin to maintain skin's defenses - Infections - Cancers - skin function

Nasal cannula

-1-6 L/min -24-44% O2

Melanomas

-90% are caused by UV exposure

Carinal nerve 9 and 10 name and function

-Glossopharyngeal -Moving uvula -Gag reflex

Finger Exam

-Inspect: erythema, swelling, deformity -Palpate: metacarpals -ROM: flexion, extension, abduction, adduction

Sclera inspection

-Pigmentation (jaundice) -Leasions

Pupil inspection

-Size -Response to light

Heat exhaustion

-core temp 98.6-103., weakness, nausea, vomiting, syncope, tachycardia, headache, diaphoresis

Carinal nerve 1 name and function

-olfactory -smells

How many nephrons are in each kidney?

1 million

Match the correct oxygen delivery system to the correct amount of oxygen flow the device can deliver

1-6 L/min: non-breather 5-8 L/min: simple facemask 10-15 L/min: venturl mask 4-10 L/min: low flow nasal cannula

Ostomy's can be placed due to

1. Ulcerative colitis 2. Crohn's Disease 3. Cancer 4. Diverticulitis 5. Stage 3 and 4 pressure ulcers

Order: 320mg acetaminophen PO x1 now. Available: acetaminophen 160mg/5mL How many mL will you administer?

10 mL

Macrodrip

10,15,20 get/min

1 inch = ? cm

2.5

Normal RR for infant

30-50

Heart Rate

60-100 bpm

Placque

>1.0 cm, wheal, crust, scale

Staples and sutures should be removed within A. 7-14 days B. 1-3 days C. 14-21 days D. 5 days

A. 7-14 days

The pt voices concern to the nurse regarding his pt controlled analgesia (PCA) pump. He states he is afraid of getting an overdose is he presses the button too many times. The nurse reassures the pt that: Select all that apply A. there is a time delay (lockout) between pt doses B. there is a maximum dose the pt can receive C. the pt has a right to be concerned and needs to be careful D. the pt should be put on a ATC infusion instead because its safer

A. there is a time delay (lockout) between pt doses B. there is a maximum dose the pt can receive C. the pt has a right to be concerned and needs to be careful

When performing perineal care, you should clean the: a. labia b. urethra to the anal area c. anal area to the urethra d. buttocks to the urethra

A document about personal choices regarding life support when death is likely is a. a durable healthcare power of attorney b. a Do Not Resuscitate Order c. a living will d. Hospice Care

Development is a. an involuntary movement b. a skill that must be completed c. changes in mental, emotional, and social function d. the physical changes that can be measured and that occur in steady, orderly manner

Difficulty swallowing may be associated with: a. Congestive Heart Failure b. Parkinson's Disease c. Stroke d. Multiple Sclerosis

During which step of the nursing process is care provided? a. Assessment b. Evaluation c. Implementation d. Planning

On the basis of the nurses assessment of kidney function for an adult pt, which of the following is a normal finding for urinary output per hour? A. 10 mL/hr B. 20 mL/hr C. 30 mL/hr D. 100 mL/hr

C. 30 mL/hr

Hyper resonant thorax percussion

Chronic or acute air trapping

Vescile

Filled with straw colored fluid

Droplet precautions

Gloves, mask

Schedule III drug

Moderate to low potential for dependence

nothing by mouth

NPO

erythema

Non specific redness, associated with inflammation

Anuria

absence of urine

Pneumothorax

absent breath sounds

Effluent from the stoma is

acidic and contains digestive enzymes, it will cause the skin to breakdown

as desired

ad lib

Hematuria

blood in the urine

Interstitial fluid

edema

ILE-ostomy is an ostomy over the

ileum

Ostomy's can be

temporary or permanent

Tertiary intention healing

wound may be left open; to be sutured/stapled at a later date

tonsils

- Inspection Color, lesions Tonsil size, exudate Abnormalities Strep throat (swollen, bacterial growth)

External fixation

- Used to stabilize fracture during healing - Takes the place of casting or traction - immobilize fracture healing

Hand Anatomy

-MCP (metacarpal phalanges) -PIP (proximal interphalanges) -DIP (distal interphalanges)

-sound occurs in diastole -aortic and pulmonic valves close to allow ventricles to fill

Face mask

-used for 6-12 L/min

Objective data

-what you actually observe or do for the patient

Special considerations for NG tube

1. Check placement before administering fluids, medications or feedings 2. Sterile water should be used for flushes in immunocompromised or critically ill patients 3. In infants and children, insertion of the tube via the mouth may be appropriate 4. Age-specific equations are available to predict insertion distance and are the best method to determine insertion distance based on age and height for infants and children, 8 years, 4 months of age or younger

Type of effluent (outflow of liquid) to expect depending on location

1. Colostomy: soft or formed 2. Ileostomy: liquid thick 3. Ileal conduit: urine (drainage tube made from the ileum) 4. Ureterostomy: urine

Changing an ostomy appliance

1. Empty appliance 2. Start at the top and keep abdominal skin taunt 3. Gently remove pouch faceplate from skin by pushing skin from the appliance (not pulling the appliance from the skin) 4. Apply a silicone-based adhesive remover 5. If reusable, set aside to wash 6. Clean the skin around the stoma, removing all old adhesive 7. Pat area to dry 8. Apply skin protectant to a 2-in radius around the stoma 9. Measure the stoma with guide 10. Remove paper backing from the appliance faceplate 11. Gently press onto the skin with even pressure 12. Close bottom of the appliance or pouch by folding the end upward and applying the clamp

Large-volume enemas are either

1. Hypotonic 2. Isotonic

Special considerations for fecal incontinence collection device

1. May be left in place for up to SEVEN days 2. If perianal area becomes excoriated (skin is scraped or abraded), remove the device, cleanse the skin, then apply a skin barrier 3. After the barrier dries completely, you may reapply the device

Factors that affect bowel elemination

1. Mobility -Exercise improves GI motility/muscle tone 2. Diet -Foods high in fiber -High fluid intake 3. Medications -Antibiotics and laxatives: loosen stool, more frequent -Diuretics: Dry, hard stool, less frequent -Opioids: Decreased GI motility, constipation

Irrigating a colostomy

1. Never use an enema set—use lubricated cone tip and an irrigation sleeve 2. Physician orders amount and type of solution 3. Client sits on commode or toilet during procedure 4. Instill fluid (usually 500-1000 mL) over 5-10 minutes 5. Remove cone tip and drain solution through irrigation sleeve (takes up to 30-45 min.)

Enemas for infants and children

1. Only use isotonic solutions -Hypotonic solution can cause rapid fluid shift/fluid overload 2. Appropriate fluid volume: -Infant: 120 to 240 mL -2 to 4 years: 240 to 360 mL -4 to 10 years: 360 to 480 mL -11 years: 480 to 720 mL 3. Position the infant or toddler on their abdomen with knees bent 4. Position a child or adolescent on L side with R leg flexed toward chest

Cautions when removing a fecal impaction

1. Prevention is key 2. NOT a procedure you can delegate to assistive personnel 3. MUST have Health Care Provider Order 4. It may cause stimulation to vagus nerve which decreases heart rate or increases it's rhythm 5. STOP the procedure if excessive bleeding or pain occurs 6. Allow the patient to rest at intervals of removal

Patient-centered care for an enema

1. Provide for culturally sensitive hygiene needs 2. Use an interpreter as needed 3. Provide gender-congruent care as needed 4. Determine the patient's normal pattern of bowel elimination and accommodate that pattern in health care setting

Emptying an ostomy appliance

1. Remove clamp and fold end of appliance or pouch upward like a cuff 2. Empty contents into bedpan, toilet or measuring device 3. Wipe off lower 2 inch of appliance or pouch 4. Uncuff the end & re-apply clip or clamp -Make sure curve of clamp follows curve of patient's body

Administering a small-volume enema

1. Remove the cap and lubricate the end of rectal tube (2-3 inches) 2. Insert the tube 3 to 4 inches for an adult 3. Administer the entire contents, then remove the tube, keeping the container compressed 4. Encourage the patient to hold the solution for 5 to 15 minutes 5. Document the results

Commonly used enemas solutions

1. Tap water 2. Normal saline solution 3. Soap suds enema 4. Hypertonic 5. Oil (mineral, olive or cottonseed oil)

Proper fit of an ostomy

1. stoma size 2. location 3. type and amount of effluent 4. pt characteristics like mental and visual acuity and manual dexerity 5. Opening around the appliance should not be more than 1/8 inch larger than the stoma

Normal specific gravity

1.002-1.028

Normal magnesium levels

1.6-2.6 mEq/L

Hypotonic IV

1/2 NS -for dehydration, GI fluid loss,

1 kg= ? g

1000

cranial nerves (write up)

2 : optic visual acuity 20/20 OU, OD, OS 346:PERRLA, cardinal fields of gaze intact, no nystagmus or strabismus 5: trigeminal: able to clench jaw, light touch intact in all dermatomes 7: Facial: able to smile, frown, puff cheeks 8: Acoustic: hearing intact to whispered voice at 2 feet bilaterally 9&10: glossopharyngeal: uvula and soft palate rise in midline 11: spinal accessory: able to turn head, shrug shoulders against resistance 12: hypoglossal: tongue protrudes in midline, no tremors

grades of reflexes

4+ = hyperactive 2 = normal 0 = no response

1 tsp = ? mL

5 mL = ? tsp

Normal WBC count

5,000-10,000/mm3

The pt weighs 175 lbs. What is their weight in kg?

79.5 kg

1 cup = ? oz

8 oz = ? cups

Patch

> 1.0 cm

You are unsure of a vital sign measurement taken by you. You must: a. promptly ask the nurse to take it again b. ask another nursing assistant to check it for you c. report what you think d. wait an hour and then try again

You must check the MSDS a. before using a hazardous substance b. after cleaning up a leak or spill c. at the beginning of the shift d. at the end of the shift

The nurse is using a pulse oximeter to monitor a client who is receiving oxygen therapy via nasal cannula. the nurse explains to the client that which factor might affect the results of the pulse oximetry? A. alterations in circulation B. thyroid disease C. cardiovascular disease D. pain medications

A. alterations in circulation

A health care provider prescrives oxygen for a client at 4 liters per min via nasal cannula after initial pulse oximeter reading of 88% on room air. Which is the priority client assessment that the nurse should make prior to administering the oxygen? A. respiratory rate and effor B. apical heart rate and rhythm C. skin alterations and edema D. blood pressure and pulse

A. respiratory rate and effor

Mr. Poole's blood pressure measure remains above 150/100 mmHg. This is called. a. tachycardia b. hypertension c. hypotension d. anxiety

Spreading rumors or talking about the private matters of others is: a. Harassment b. Gossip c. Loads of fun d. Confidentiality

When taking an oral temperature with a glass thermometer. The thermometer must be left in place: a. 15 seconds b. 3 minutes c. 45 seconds d. 8 minutes

Identify the task that cannot be delegated to the NAP A. Repositioning q2 hours B. Perform a pressure ulcer risk assessment C. Report any redness or break in the pt skin to the nurse D. Report any abrasion from assitive devices to the nurse

B. Perform pressure ulcer risk assessment

Which of the following is part of the chain of infection? A. Vestibule (a space or cavity at the entrance to a canal, channel, tube, or vessel. For instance, the front of the mouth is a vestibule.) B. Reservoir (Any person, animal, plant, soil or substance in which an infectious agent normally lives and multiplies) C. Channel D. White Blood Cell

B. Reservoir

Which medical client is most likely to be experiencing diffuse pain? A. a client who just returned from diagnostic testing for appendicitis B. a client who has had shingles for the past 3 weeks affecting their entire right side of their body C. a client who is presented to the ER with a stab wound D. a client who was recently diagnosed with strep throat and is taking antibiotics

B. a client who has had shingles for the past 3 weeks affecting their entire right side of their body

When the balloon on an indwelling urinary catheter is inflated and the pt expresses discomfort, it is essential for the nurse to take which action? A. leave the catheter in place and call the physician B. aspirate the fluid from the balloon and advance the catheter C. continue to blow up the balloon because discomfort is expected D. pull back on the catheter slightly to determine tension

B. aspirate the fluid from the balloon and advance the catheter

A nurse is caring for a female client with an indwelling urinary catheter. Which action should the nurse take into consideration to reduce the client's risk of developing a UTI? A. use clean, not sterile technique when inserting the catheter B. ensure that the catheter is removed as soon as possible C. irrigate the catheter with sterile water once per shift D. administer prophylactice antibiotics as ordered

B. ensure that the catheter is removed as soon as possible

When implementing appropriate technique for med administration, the nurse is: A. administering med prepared by other nurses B. using sterile technique for nonparenteral meds C. leaving meds at the bedside when the client is in the bathroom D. documenting the reason for med refusal in the nurse's notes

B. using sterile technique for nonparenteral meds

Name on major contraindication to shaving a male resident with a straight razor ___________________.

Blood Thinner

Diastole

Blood filling the ventricles

What does dilated pupils mean?

Brain herniation, anoxia, drugs

Coarse Breath Sounds

Bronchitis -inflamed mucus membranes -may clear with cough

A safety device used to transfer a dependent resident from the bed to chair is called: a. posey vest b. hand roll c. transfer/gait belt d. foot board

A tube inserted into the stomach through a surgically create opening is called: a. a gastrostomy tube b. a jejunostomy tube c. a PEG tube d. a nasogastric tube

Hemoptysis is: a. mucous from the respiratory tract b. a black tarry stoll c. bloody stool d. infection

The call bell or signal light should ALWAYS be: a. on the bedrail b. attached to the pillow c. within the patients reach d. on the arm of the chair

The process of becoming "unclean" is called: a. asepsis b. disinfection c. contamination d. immunity

The spread of cancer to other body parts is called: a. gangrene b. Benign tumor c. metastasis d. malignant tumor

The word ACUTE when used to define illness means: a. an illness for which there is no reasonable expectation of recovery b. an ongoing illness for which there is no cure c. a sudden onset to an illness d. an illness that is gradual

Those persons who provide basic nursing care under the supervision of a registered nurse or a licensed practical nurse are: a. Licensed practical nurse b. Case managers c. Assistive personnel d. The "health care team"

When you assist a person to ambulate/walk, what should would do first: a. Apply braces to the legs b. Get crutches, cane or walker c. Apply a gait belt d. Get the patients glasses

Where does digestion begin? a. stomach b. esophagus c. mouth d. intestines

Which of the following vital signs should you report to the nurse immediately. a. 37.1, 78, 16, 118/64 b. 36.9 (r), 90, 20, 138/70 c. 36.4 (a), 158, 22, 90/46 d. 36.6, 100, 16, 120/88

Which of the following would not be a cause of constipation? a. medications b. decreased fluid intake c. high fiber diet d. inactivity

You enter a patients room and the resident states they are in pain. What should you do? a. ignore the clients statements b. tell the clients to suck it up the pain will go away c. report it to the nurse d. tell the client they will feel better if they just get out the bed

You enter a residents room and the resident has a new onset bedsore. You feel you need to document this in the medical record but also have a discussion with the nurse. Where would you opt to have this discussion? a. In the patients room b. In the hallway with the family c. In private d. At the local bar

The nurse is preparing to teach a client how to perform incentive spirometry. Which concepts should the nurse include? A. Proper, frequent use of incentive spirometry can improve pulmonary circulation B. Incentive spirometry provides visual reinforcement for deep breathing C. The client should forcefully exhale into the incentive spirometer and continue to exhale until unable to continue D. Oxygen saturation expected to decrease during the first few minutes of incentive spirometry

C. The client should forcefully exhale into the incentive spirometer and continue to exhale until unable to continue

Equation for cardiac output

CO=SVXHR

CO = SV x HR -can be measured as the amt of blood pumped by the heart in one minute

Cardiac output = ? x ?

What would you wear airborne precautions for?

Chickenpox, TB, Measles

normal feces

Color Quantity Shape Consistency Odor

ligaments

Connect bone to bone

Which statement about foot care is not true? a. feet are easily injured b. follow standard precautions and Blood borne Pathogen Standard c. Dirty feet and socks harbor microbes d. Cleaning toenails is easier in the morning

You are asked to collect a sputum specimen from your resident by the nurse. it is easier: a. After an activity b. After a meal c. Before a meal d. Upon awakening in the morning

Hypertonic solution enemas

Draws fluid out of the interstitial space into the colon, leading to distention which stimulates peristalsis

Trough level

Drug is at its lowest concentration

What does pinpoint pupils mean?

Drugs, brain injury

Chemotherapeutic effects

Effects of drugs that destroy disease producing microorganisms or body cells. (e.g. antibiotics, antineoplastic drugs)

C to F

F=1.8(C)+32

Where do we look for ROM?

In each joint

What does fixed and dilated pupils mean?

Irreversible brain damage or brain death

abduction

Movement away from the midline of the body

adduction

Movement toward the midline of the body

What would you wear droplet precautions for?

Mumps, flu, whooping cough

motor (write up)

Muscle bulk and tone intact Muscle strength 5+ in upper and lower extremities bilaterally Gait smooth, able to tandem walk without difficulty Cerebellar: point to point intact upper and lower extremities bilaterally Romberg: no sway Pronator drift: none

What moves the skeleton?

Muscles, tendons, and ligaments

The nurse asks you to give Mrs. Jones a milk and molasses enema. Should you give the enema?

Rebound tenderness

Pain with letting go

Example of indirect transmission

Personal contact with someone who is immunocompromised, a needle stick injury

Scoliosis

S shaped curvature of the spine

Where are acidic medications absorbed?

Stomach

Match the dressing to its description

Transparent dressing: clear, adherent polyurethane Hydrocolloid, hydrogel, foam or absorption dressing: absorptive and hydrating, Dry and moist to dry dressing: autolytic, enzymatic gauze

True or False HIV medications can make you very sick

True

True or False Respirations are counted immediately after taking a pulse. The resident should not know you are counting respirations.

True

True or False Restraints can increase a person's confusion or agitation

True

True or False The goal of bladder training programs is control of urination

True

True or False The skin is the body's first line of defense against disease

True

True or False Use of narcotic pain medications can cause constipation

True

inversion

Turning the sole of the foot inward

Urostomy

Ureters to ostomy

rooting reflex

a baby's tendency, when touched on the cheek, to turn toward the touch, open the mouth, and search for the nipple - infant reflex

Trade name

a commercial, legal name under which a company does business

Positive test for blood in urine

any trace of blue on slide

twice a day

bid

Airborne Precautions

chickenpox, TB, measles

COL-ostomy is an ostomy over the

colon

Hypovolemia

decreased vascular and interstitial volume -blood loss, dehydration

Medical history (neuro exam)

do you now have: - Hypertension - High cholesterol - Diabetes - Substance abuse - Environmental or occupational exposure - meds - do you now take (or not take) as prescribed

Peak level

drug is at its highest concentration

Irrigation is a way of achieving

fecal continence and control

Auscultating BP

first sound is systolic, second sound is diastolic

kyphosis

forward curvature of the spine, usually worsens with age but can be seen earlier

Pleurisy

harsh, grating breath sounds

blepharitis

inflammation of the eyelid

Pneumonia

inflammatory response to infection, exudates cause consolidation

Intracellular fluid

inside the cells

Forced vital capacity

max amt of air that can be removed from the lungs during forced expiration

MTP

metatarsal phalangeal joints

Peripheral cyanosis

nail beds, hands, feet

every 4 hours

q4h

Cleaning ememas are given to

remove feces from the colon

Pinguecula

thickening, yellow color on inner and outer margins of the cornea

Example of direct transmission

touching infected feces with no gloves on

Sublingual medications

under the tongue

Ideosyncratic reactions

unpredictable event

Papule

up to 1.0 cm

Nasal Cannula

used for a flow rate of 1-6 liters per minute -for COPD patients

Jaundice

yellowing of the skin

1 tbsp = ? tsp

3 tsp

Ms. Schnieder has an order for NPO after midnight. This means: a. fluids are restricted b. accurate records are kept of oral intake c. she can eat whatever she wants or drink whatever she wants d. she is encouraged to drink a variety of fluids

Painful or difficult urination is called a. dysuria b. micturition c. urinary urgency d. oliguria

The absence of breathing is called? a. apnea b. hypoxia c. orthopnea d. dyspnea

The normal body temperature range for the rectal site is: a. 98.6 to 100.6 degrees F b. 96.6 to 98.6 degrees F c. 97.6 to 99.6 degrees F d. 99.6 to 101 degrees F

The period of heart muscle relaxation is called a. diastole b. systole c. blood pressure d. mean arterial pressure

The role of the ombudsman is: a. Work with the nursing home to protect the clients rights b. Control the nursing home budget c. Prepare classes that nurses aides take to learn hygiene d. Run a group of nursing homes

The type of bone that bears weight of the body is called: a. long bone b. flat bone c. irregular bone d. short bone

What does not promote effective listening? a. sitting back in the chair with your arms crossed b. making eye contact c. facing the person d. asking appropriate questions

When making an occupied bed, the nursing assistant should: a. raise the side rail on the unattended side b. lower both side rails before changing the bed c. help the client to sit in a chair while the bed is made d. put the dirty sheets on the floor

When transferring a resident to a wheelchair: a. The brakes must be locked b. Hold the handgrips c. Put your foot on the back of the wheels to hold in place d. Stand on the footplates

Which nursing care pattern focuses on tasks and jobs? a. Functional nursing b. Team nursing c. Primary nursing d. Care management

Your resident has a history of a stroke with residual weakness, you are asked to ambulate them. You should: a. Assist on weak side b. Assist on strong side c. Put them in a wheelchair d. Stand in front of them like you are a walker

Your resident is "comatose" you should assume: a. They can hear b. They can see c. They can touch d. They can speak

Your task is to help Mrs. Morris to eat lunch. Which statement below is incorrect? a. use a spoon for safety b. serve solid foods first and then liquids c. serve the foods in order she prefers d. tell her what food and fluids are on the tray

Sigmoid colostomy

A colostomy in the descending or sigmoid colon generally results in a stool similar to that normally passed through the rectum

The nurse is suctioning a client on a ventilator using a closed system endotracheal tube. In the process of advancing the catheter, the nurse meets resistance. What should the nurse do? A. withdraw the catheter at leats 0.5 in (1.25cm) before applying suction B. remove the catheter and start the process over to prevent infection C. turn the catheter counterclockwise and then advance at least 0.5 in (1.25 cm) D. continue to apply suction as this means the catheter is in the carina

A. withdraw the catheter at leats 0.5 in (1.25cm) before applying suction

Your patient's roommate has just died, how can you BEST help the client with the loss? a. Discourage individual activity b. Encourage the client talk c. Convince the client its no big loss. The roommate was a complainer d. Leave the client alone

Your resident is in back lying position. This is called: a. prone b. supine c. High Fowlers d. dorsal recumbent position

A 72-year-old female is admitted with a new diagnosis of stroke. She is dependent on the staff for all of her ADL's and is unable to reposition herself. Which interventions would be appropriate for this pt? A. reposition every 6 hours B. apply pressure relieving devices to feet C. give oral care every 2 hours and prn D. reposition every 2 hours E. delegate repositioning to nursing assitive personnel ABC ACDF BCDE ABCE

B C D E

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at FIO2 of 100%. Which oxygen delivery system should the nurse use? A. Nasal cannula B. Non-breather mask C. Venturl mask D. Simple mask

B. Non-breather mask

Systole

Blood being pumped out of the ventricles

Direct Questions are used to: a. show the person you care about them b. make sure you understand what was said c. focus on specific information d. allow the person time to think

Exercises that move each muscle and joint care called? a. Rotation b. Adduction c. Range of Motion d. Abduction

It is 4:00pm. In a 24- hour clock, how do you record time? a. 2400 b.4000 c.1600 d.0004

What is the besy way to promote the resident independence in bathing a resident who has had a stroke? a. Limit the client to washing her hands b. Leave the client alone and assume the client will do as much as she can c. Encourage the client to do as much as possible and assist as needed d. Give the client a complete bed bath only if requested

You go to check on a resident and the gown is soiled. The next action should be: a. clean the patient and put the soiled gown back on b. leave the patient dirty and change the gown c. clean the patient and put on a clean gown d. walk out of the room

Your patient has left sided weakness, how do you put on their shirt? a. Clients choice b. Right sleeve c. Left sleeve d. Both sleeve together

Eye exam

CN 3, 4, 6, -inspect for: symmetry, lids/lashes, conjunctiva, sclera, cornea, iris, pupil response

Transcelular fluid

CSF, synovial fluid

Mrs Jansen is dying. She is very very sad, She cries a lot. She rings her call bell at 2 a.m. and asks for the priest. You should: a. Ask her why she wants to see the patient b. Tell her to go back to sleep c. Tell her you will ask the nurse to call the priest in the morning d. Report her request to the nurse

Padding side rails on a bed serves a purpose. The purpose is: a. Restrain the patient b. Have somewhere to put the call button c. Keep the client warm d. Protect your client from possible injury

Phantom pain is a. suddenly felt b. constant and severe c. felt at the site of tissue damage and in nearby areas d. is felt in the body part which is no longer there

Stiffness or rigidity of skeletal muscles that occurs after death is called: a. DNR b. peristalsis c. postmortem d. rigor mortis

The BEST time to prepare for a disaster is: a. During your lunch b. When everyone has gone to bed c. During a tornado or hurricane d. Before it happens

The apical pulse is located? Choose One. a. in the neck b. at the wrist c. in the second finger d. below the left nipple

The following are risk factors for coronary artery disease. Which risk factor can not be changed a. lack of exercise b. smoking c. being overweight d. your mother and father both had heart attacks at 40 and 48

The following statements are about restraint use. Which is false? a. the least restrictive method is used b. restraints require a doctors order c. restraints can cause serious harm d. restraints are used to discipline a person who is uncooperative with care

The largest art of the brain and the center of thought and intelligence is: a. midbrain b. brainstem c. cerebellum d. cerebellum

The most common cause of COPD/emphysema is: a. Pollution b. Family History c. Asthma d. Smoking

The most common mental health problem is a. delirium b. alcoholism c. depression d. anxiety

To prevent shampoo from getting into your residents eyes, you should: a. Use a hand held nozzle b. Use dry shampoo c. Rinse the hair throughly d. Use a washcloth to cover the eyes

To residents share a room. One family wants to take pictures of the two residents together. A persons picture taken without permission is called: a. Assault b. Malpractice c. Negligence d. Invasion of Privacy

To use reagent strips correctly, you should: a. ask the nurse b. check the plan of care c. check your assignment flow sheet d. read and follow manufactures

What Act did Congress pass in 1987, to protect the quality of life, health and safety of nursing home residents? a. MedicareAct of 1987 b. Patients Bill of Rights c. EMTALA d. Omnibus Budget Reconciliation Act

What are the most obvious indications of hearing impairment? a. resident speaks loudly b. resident leans forward to hear c. resident turns or cups their better ear toward the speaker

What is the term for a device used to take the place of a missing body part? a. Pronation b. External rotation c. Amputation d. Prosthesis

What type of specimen is collected for a basic routine urinalysis: a. random urine specimen b. 24 hour urine specimen c. a clean cath urine specimen d. a midstream specimen

When changing an unsterile dressing, the nurse aide should wash hands: a. before the procedure b. after the procedure c. before and after the procedure d. before, after the removal of the soiled dressing, and after the procedure

When logrolling a resident, you must: a. make sure the bed is in Fowlers position b. make sure the bed is in the lowest position c. make sure that both bed rails are up d. turn the person as a unit, in alignment, with one motion

Which is not a rule for collecting specimen? a. use a clean container for each specimen b. use the correct container c. label the container accurately d. collect the specimen as soon as you have it

Which of following medical problems frequently develop in residents with diabetes? a. kidney failure b. stroke c. decreased vision d. all of the above

Which of the following measures will not help prevent urinary tract infection? a. encouraging the resident to do pelvic muscle exercises b. having the resident wear cotton underwear c. keeping the perineal area clean and dry d. promoting fluid intake as directed

Which statement is false about coughing and deep breathing a. they are done during bedrest b. they help remove mucous c. they move air into most parts of the lungs d. they are done after surgery because the are too painful.

You promote quality of life by: a. Delegating tasks to your coworkers b. Making sure you bring your resident chocolate and Starbucks c. Doing everything for the patient, they don't need to lift a finger d. Speaking to individuals in a respectful manner

Your resident has an ileostomy. Which statement is fake? a. the ostomy pouch must fit well b. food skin care is needed c. the entire large intestine has been removed d. the stool is formed

Your resident wears dentures. What should you check the dentures for when providing oral care? a. bleeding gums b. irritation or watch patches in the mouth c. dryness and cracks in the oral mucousa d. rough, sharp or chipped areas

The nurse is caring for a pt who has an indwelling catheter attached to a drainage bag. To achieve the desired outcome of this procedure, which nursing action should be taken? A. make sure the collection bag is higher than the bladder B. make sure the tubing is kinked C. make sure the tubing has dependent loops to gather urine D. make sure the bag is below the level of the bladder and secured to the bed

D. make sure the bag is below the level of the bladder and secured to the bed

Which med administration strategy is not implemented to increase med administration safely? A. compromised provider order entry B. bar codin C. unit dosing D. use of multidose med containers

D. use of multidose med containers

Hypertonic IV

D5NS, D51/2NS, D10, D20, 3% NS

Nasogastric tubes

Either pliable single- or double-lumen tube that allows for removal of gastric secretions and administration of medications or feedings

Disinfecting

Eliminating germs from surfaces with the exception of bacterial spores (C.diff)

True of False Accidents or errors in giving care should be reported to the nurse at the end of the shift.

False

True or False A married couple is admitted to a nursing facility. They should be assigned to separate rooms.

False

True or False Always use medical terms when you talk to the patient or resident.

False

True or False An oral temperature is the best route for a patient on oxygen

False

True or False Axillary temperatures are more reliable than oral temperatures.

False

True or False Everyone likes to be touched

False

True or False Foley catheters treat the cause of urinary incontinence

False

True or False If your resident starts to fall, move out of the way so you don't get hurt

False

True or False It is best practice to cut toenails with scissors

False

True or False Medical diagnosis and the nursing diagnosis are always the same

False

True or False Nursing Assistants supervise other Nursing Assistants

False

True or False Residents do not feel safe if you tell them what you are doing

False

True or False Restraints are safe and are always used to prevent falls

False

True or False The bed should be placed in low with the call bell in reach when providing patient care.

False

True or False The healthy adult produces about 1500ml urine per day

False

True or False The plan of care for a resident tells you when to apply and remove heat/ice

False

True or False The towel bar is the best place for the resident to hold on for support when the resident gets in or out of tub.

False

True or False Traction is removed when you make the persons bed

False

True or False Unless otherwise ordered, take vital signs with the resident standing

False

True or False Urinals when full should be placed on the overbed table

False

True or False You shouldn't tell the nurse if you are unable to hear a blood oxygen

False

True or False A back massage is safe for everyone

False

True or False A malignant tumor grows slowly and does not invade healthy tissue

False

True or False Acute confusion is usually permanent

False

True or False All colostomies are permanent

False

True or False As a nursing assistant it is your responsibility to check IV flow rates

False

True or False Battery is threatening to touch a person's body without their consent

False

True or False Dementia is a normal part of aging

False

True or False Everyone has a bowel movement everyday

False

True or False Everyone who works at an agency as the right to read the patient.residents records

False

True or False Hematuria means blood in the stool

False

True or False If you call the resident by name and the respond. You know it is them.

False

True or False In healthy adults, respirations should be between 24-30

False

True or False Inappropriate sexual behaviors by the resident are always on purpose

False

True or False Most residents enjoy enemas

False

True or False Women in nursing homes are not interested in shaving their underarms and legs

False

True or False You should always make yourself at home and sit on the resident bed while feeding

False

True or False You should pick your residents daily activities and make them go

False

Contact precautions

Gloves, mask, gown

Extravasation

IV chemo dress going into the tissues

Infiltration

IV fluid is going into tissues

Midline

IV used if needs therapy for 1-4 weeks

Hip exam

Inspect - Gait for symmetry - Gluteal muscle mass - Palpate greater trochanters for tenderness ROM - Flexion with knee straight - Flexion with knee flexed - Extension - Internal rotation/External rotation - Abduction/Adduction

Elbow exam

Inspect - erythema, swelling, deformity. Palpate - olecranon, humeral epicondyles, bursa. ROM - Flexion - Extension - Supination - Pronation

foot exam

Inspect - swelling, erythema, deformities. - Flat feet - Corns, bunions, calluses. - Extremely important for diabetes to inspect their feet daily Palpate - tenderness ROM - Inversion/eversion of forefoot - Flexion, extension, abduction, adduction of toes

Carinal nerve 3 test

Inspect eye front, lids equal

shoulder joint exam

Inspect for - symmetry of scapulae - shoulder height - muscle atrophy. Palpate - Sternoclavicular joint - Acromioclavicular joint - Bicipital groove - Glenohumeral joint - Rotator cuff area ROM - Flexion/Extension - Abduction/Adduction External rotation/Internal rotation

Ankle exam

Inspect: - swelling, redness, bruising Palpate: - swelling, warmth, tenderness ROM: - plantar flexion, dorsiflexion, inversion, eversion

normal lids/lashes

Inspection - Erythema - Lesions - Lid margins - Direction of lashes - lid problems

ear

Inspection - External ear - Ear canal using otoscope - Tympanic membrane using otoscope Palpation - External ear - Made of cartilage - Helix - Tragus - Lobe - Mastoid bone - Opening to ear canal Palpate for tenderness Palpate for mastoid tenderness Inspect - Position - Shape, symmetry - Lesions

TMJ exam

Inspection - jaw symmetry Palpation - Fingertips in front of tragus, ask pt to open mouth, should feel the joint space ROM - Open & close (opening should allow 3 fingers positioned vertically) - move jaw side-to-side - Thrust jaw forward

Knee exam

Inspection - swelling, erythema, deformity. Palpation: - patella, tendon, - Lateral joint spaces - Posterior space ROM: Hinge joint - Flexion/Extension

spine exam

Inspection: - symmetry of muscle mass - contour of vertebral column Palpation: - Spine tenderness - Paravertebral muscles, tenderness, spasm ROM - Flexion, extension - Lateral bending - Rotation

sensory (write up)

Intact to pain, light touch throughout Intact to vibration and position upper and lower digits bilaterally

Nystagmis

Involuntary movement during cardinal fields of gaze. Can be circular, vertical, or horizontal

nystagmus

Involuntary rapid eye movements - Involuntary during cardinal fields of gaze - Can be circular, vertical, horizontal

Where are alkaline medications absorbed?

Small intestine

Example of airborne transmission

Small particles that travel more than 3 feet or those carried on dust particles

Applying a fecal incontinence collection device

It is an external collection system used to protect the perianal and perineal skin from breakdown due to repeated exposure to liquid stool

CN 3, 4, 6,

Oculomotor, trochlear, abducens, -Control lid movement, eyeball movement, and pupil response -Direct: instruct patient to look straight ahead, shine light and watch for pupil constriction -Consensual: watch for pupil constriction of the opposite eye -Accomodation: ask patient to look into the distance, then hold an object 10 inches away, pupils should constrict and eyeballs should converge

Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens Facial Vestibulocochlear Glossopharyngeal Vagus Accessory Hypoglossal

Oh Oh Oh To Touch And Feel Virgin Girls Vagina Ah Heaven

jaundice

Orange / yellow, associated with liver disease

hand deformities

Osteoarthritis Rheumatoid arthritis

Carinal nerve 6 test

Pupillary response

cyanosis

Purple, associated with hypoxia

Substitutive effects

Replacing one thing for another (Tylenol instead of alcohol)

Vehicle

any medium through which an impulse is propagated -water, IV drug use, blood

GI tract is how long from the mouth to the anus

approximately 30 ft

CVA tenderness

assess with fingertips or fist percussion over posterior costovertebral angles

Nursing Process (5 steps)

assess, diagnose, plan, implement, evaluate

ABCDs of Skin Cancer

asymmetry, borders, color, diameter

musculoskeletal problems

causes: - Trauma - Inflammation/ Rheumatoid arthritis/ Gout - Degeneration / osteoarthritis - Congenital - Overuse . repetitive use - Age / osteoporosis - Tumor metastasis - Mechanical stress / ergonomics (obesity/poor posture) - musculoskeletal diseases

Wheeze

common in asthma -air passing through a narrowed airway -loud: high pitched, may clear with cough -musical whistling

Therapeutic level

concentration of a drug in the blood that produces the desired effect without toxicity

tendons

connect muscle to bone

Ligament

connects bone to bone

Tendon

connects muscle to bone

Retirement usually results in: a. Physical changes from aging b. Financial security c. Less Free Time d. Typically a lower income

Organs in LLQ

igmoid colon, left ovary and tube

Intake

includes all fluids (anything at room temperature), all IVs, enteral feedings

Output

includes anything coming out of the body (urine, vomit, diarrhea, drainage, suctions)

What does unequal pupils mean?

increased ICP, unilateral brain herniation

extension

increases the angle of a joint

Chain of infection

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

Phlebitis

inflammation of the vein where the catheter is placed -patient will complain of pain

Order of abdominal exam

inspect, auscultate, palpation, percuss

Order of cardiac / lung and thorax exam

inspect, palpate, percuss, auscultate

palpebral fissure

inspect: - Symmetry - Width between lids - Upper lid covers part of iris - Lower lid to lower margin of iris - Widened palpebral fissure - Graves disease - Thyroid condition

Stage 1 pressure ulcer

intact skin, non-blanchable redness

entropion

inward turning of the rim of the eyelid

Bulla

large blister

Example of droplet transmission

large particles that only travel 3 feet when someone is coughing or sneezing

Tympanic thorax percussion

large volume of air (pneumothorax)

Generic name

legal noncommercial name for a drug

Oilguria

less than 400 mL a day

Central cyanosis

lips, oral mucosa, tongue

Ileostomys are not irrigated and ileum content is

liquid and cannot be controlled

Prone position

lying face down

Supine position

lying on back, facing upward

Sims position

lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back

Passive range of motion

movement that is performed completely by the examiner

Colosomy

new opening of the colon to the outside of the body

ileostomy

new opening of the ileum to the outside of the body

Schedule I drug

no current medical use and high potential for abuse

Erythema

non-specific redness associated with inflammation

Isotonic enemas

normal saline solution

OLDCART

onset, location, duration, characteristics, aggravating factors, relieving factors, treatment

CN 7, 8

facial, acoustic -facial: observe face for symmetry, tell patient to smile, frown, puff out cheeks -acoustic: whispered voice with one ear covered, 2 syllable word, assess if patient can hear and at what distance

Ectropion

outward turning of the rim of the eyelid

ectropion

outward turning of the rim of the eyelid

Basic needs

oxygen, nutrition, and temperature

Dysuria

painful urination

pallor

pale , associated with anemia

Stage 2 pressure ulcer

partial thickness loss of dermis, shallow, no slough

Secondary defense against organisms

phagocytosis, inflammation, fever

Compartment Syndrome

pressure buildup in the limbs, compromises capillary perfusion -associated with fractures, crushing injuries, burns, and surgeries, -results in edema -treatment: reduce pressure, loosen bandages, surgical decompression

Proteinuria

protein in the urine

Verifying NG tube placement must be done

before administering medications or fluids to ensure the tube is in the stomach or intestine

Cyanosis

bluish discoloration of the skin

Large-volume of solution are used for

rapid colonic emptying -Adults: 500 - 1000 mL -Infant: 150 - 250 mL

RAAS (renin-angiotensin-aldosterone system)

regulates extracellular fluid volume by influencing how much sodium and water are excreted in the urine -restores extracellular volume

Palliative effects

relieve the signs and symptoms of a disease but have no effect on the disease itself

Restorative effects

return the body to or maintain the body at optimal levels of health

external rotation

rotation of the hip or shoulder away from the midline

internal rotation

rotation of the hip or shoulder toward the midline

lateral position

side lying position

Compartment syndrome

signs: Pain: - Unresponsive to usual medication, distal to the injury Paresthesia: - Numbness and tingling - Pressure - Pallor - Paralysis/loss of function - Pulselessness Treatment - reduce the pressure- removal or loosening of the bandage or cast, surgical decompression

Inspection of abdomen

skin pigmentation, scarring/marks, shape, look for symmetry, note anything abnormal

Primary defense against organisms

skin, eyes, GI tract, GU tract

Bradycardia

slow HR <60 bpm

Vector

something that carries the infective organism and can transmit it to a host

CN 11, 12,

spinal accessory, hypoglossall -spinal accessory: test trapezius and sternomastoid muscle strength, have patient turn head and shrug shoulders agains resistance -hypoglossal: tongue protrudes in midline, no unusual movement

Cephalocaudal

start at the head, common for musculoskeletal exams

hordeolum

sty; an acute infection of a sebaceous gland of the eyelid

Tactile Fremitus

technique to determine if lung tissue under your hand is air-filled, fluid filled, or solid, "say 99" -normal = air filled

Examples of vector transmission

tick, mosquito

three times a day

tid

Hypervolemia

too much ECF -excessive retention of sodium and water in ECF -high sodium diet -BP elevated, pulse is bounding, edema, RR increase

CN 5

trigeminal, clench jaw, feel temporal or master muscles, lightly touch the cheek

Entropian

turning inward of the eyelid

pronation

turning the palm downward

eversion

turning the sole of the foot outward

UR-ostomy is an ostomy over the

ureter

Nursing diagnosis

used to evaluate the response of the whole person to actual or potential health problems

Cystoscopy

visual examination of the bladder

Examples of vehicle transmission

water, IV drug use, blood

Enemas may be dangerous for patients with

weakened intestinal walls -bowel inflammation or bowel infection

ECF major cation and anions

-Cations: Na+ -Anions: Cl- and HCO3-

Hypertonic solutions

-D5NS, D10, D50, 3% NS -Increasing blood volume

Elder vision

-Centeral and peripheral vision diminish -Lids loose elasticity -Lense opaque -Slow pupillary response -Macular degeneration -Glaucoma

Spine landmarks

-Cervical -Thoracic -Lumbar

Skin inspection

-Color -Uniform -Appropriate for ethnicity -Lesions

Dermis

-Connective tissue, collagen -Vascular

What are school age children most at risk for?

-Contact sports -Concussion protocol

Healthcare provider order

-Date/time prescription written, -Name of medication -dosage -frequency -route of administration -signature or prescriber

Process of defication

-Distention of the rectum -Contraction of the sigmoid colon and rectal muscles -Internal anal sphincter relaxes -Valsalva maneuver

Catheter care

-Do not push catheter inside the patient -Wash the catheter just outside the meatus with soapy water or alcohol swab -Keep system closed as much as possible

Symptoms of a UTI

-Dysuria, frequency , urgency -Odorous urine -Cloudy urine -Hematuria -Back pain -Fever, chills

Inspection of ear

-External ear (shape, symmetry, lesions) -Ear canal using otoscope -Tympanic membrane using otoscope

Normal BP for infant

85/54

1 tsp = ? mL

Which of the following stages of dying is usually the final stage for the client? a. Anger b. Acceptance c. Bargaining d. Depression

Skin functions

-External structure -Communicates with nervous system about external environment -Sensory receptors -Thermoregulation -Reflects disease states

Carinal nerve 7 name and function

-Facial -Movement of facial muscles

Hypodermis (subcutaneous layer)

-Fat cells -Cushion -Generate heat -Store calories

Kidneys job

-Filter waste -Regulate BV, BP, electrolyte levels, and pH -Product EPO, secrete renin, activate vitamin D3

What is pleural effusion and how can it be diagnosed?

-Fluid accumulation in the pleural space -Percussion: dull or flat -Breath sounds: muted

What does crackles mean?

Atelectasis

What is compartment syndrome associated with?

-Fractures -Crushing injuries -Extensive soft tissue damage -Severe burns -Venomus snake bites -Knee/leg surgeries

2700 mL for women and 3700 mL for men

Fluid intake recommendations

Airborne precautions

Mask, negative pressure room

pinguecula

Thickening, yellow color on inner and outer margins of the cornea

epidermis

Thin, tough outer layer, avascular - skin

MVA risk group

ages 16-19 -because they're new drivers, DUI risk is higher, binge drinking, recreational drug use,

Normal bowel sounds

-High pitched -5-15 per minute

Knee

-Hinge joint (limited ROM) -Life long weight bearing -Cruciate (crossed) ligaments hold femur on top of tibia -Medial and lateral meniscus cushion the joints

Elbow

-Humerus - Medial and lateral epicondyles of humerus - Ulna - Olecranon process of ulna

Elbow anatomy

-Humerus -Medial and lateral epicondyles of humerus -Ulna -Olecranon process of ulna

Carinal nerve 12 name and function

-Hypoglossal -Tongue movement

Intestinal diversions

-Ileostomies: Liquid, foul-smelling stool -Sigmoid Colostomies: pasty, formed stool

What is compartment syndrome?

-Increased pressure in compartments compromising capillary perfusion -Results in edema

What are infants, toddlers, and preschool age children most at risk for?

-Injuries -Lead poisoning -Choking -Unrestrained passenger -Drowning

Shoulder Exam

-Inspect for: symmetry of scapulae, shoulder height, and muscle atrophy -Palpate: sternoclavicular joint, acromioc,avicular joint, bicipital grove, glenohumeral joint, rotator cuff -ROM: Flexion, extension, abduction, adduction, external rotation, internal rotation

Wrist Exam

-Inspect: Erythema, swelling, deformity -Palpate: carpal joints for warmth, tenderness, swelling -ROM: flexion, extension, radial deviation, ulnar deviation

Ankle Exam

-Inspect: Swelling, redness, bruising -Palpate: swelling, warmth, tenderness -ROM: plantar flexion, dorsiflexion, inversion, and eversion

Elbow Exam

-Inspect: erythema, swelling, deformity -Palpate: olecranon, humeral epicondyles, bursa -ROM: flexion, extension, supination, pronation

Cervical spine exam

-Inspect: for deformities -Palpate: for tenderness, muscle spasm -ROM: flexion, extension, lateral bending, lateral rotation

ICF major cations and anion

-Cations: K+ and MG+ -Anion: PO4-3 (phosphate)

Hypotonic solutions

-1/2 NS -Decreasing blood volume

Non rebreather mask

-10-15 L/min -60-90% O2

How is pregnant womens respiratory system unique?

-20% rise in O2 consumption -Diaphragm rises

IM gage, needle size, syringe, angle, and injection sites

-21-23 -1-1.5 inch -1-5 mL -90 degrees -deltoid, ventrogluteal, vastus lateralis

SQ gage, needle size, syringe, angle, and injection sites

-25-27 -3/8-5/8 -1 mL -45 degrees -Upper arm, abdomen, or anterior thigh

Intradermal gage, needle size, syringe, angle, and injection sites

-25-28 -1/4-5/8 -5-15 degrees -Forearm, upper back, or upper chest

Subcutaneous

-45 or 90 degree angle (dependent upon subQ tissue) -insulin, heparin, -smaller gauge needle (higher number)

Simple face mask

-6-12 L/min -35-50% O2

Intramuscular

-90 degree. angle -flu vaccine -deltoid, vastus lateralis (infants) -larger gauge needle

Normal abdominal assessment

-Abdomen flat -Soft -Non-tender -Normal bowel sounds

Carinal nerve 6 name and function

-Abducens -Pupil response

Cornea inspection

-Abrasions/trauma -Kerititis -Cataracts

Carinal nerve 8 name and function

-Acoustic -Hearing

What is a pneumothorax and how can it be diagnosed?

-Air in pleural cavity -Percussion: dullness -Breath sounds: diminished or absent

What causes a wheeze?

-Air passing through a narrowed airway -Loud and high pitched -Common in asthma

Hip joint

-Allows for wide range of motion -Femur articulates in acetabulum

How is elders respiratory system unique?

-Alveoli fibrose -Muscle weekness -Barrel chest

Treatment of DVT

-Anticoagulate -Heprin SC

Adolescents skin

-Apocrine glands (sweating) -Sebaceous glands (acne) -Terminal hair

Traction fracture treatment

-Applies puling source on fracture to re-align

Palpating the sinuses

-Apply firm pressure -Frontal and maxillary sinuses

Temporomandibular Joint (TMJ)

-Articulation of the mandible and the temporal bone -Hinge joint -Limited moves

Nursing process

-Assessment -Diagnosis -Planning -Implementation -Evaluation

ABCDs of skin cancer

-Asymmetry -Borders -Color -Diameter

Shoulder joint

-Ball and socket -Humerus articulates in shoulder socket Supported by rotator cuff -Together called shoulder girdle -Allows for wide range of motion

Venous thrombosis/ DVT

-Blood clot formation in veins secondary to immobility

Abnormal stool

-Bloody, red, marron, black, white -Odor consistent with Cdiff -No BM greater than 3 days -Diarrhea greater than 3 times in 24 hrs -Pencil thin stool

Isotonic solutions

.9%NS, Lactated Ringer's, D5W

600 mL is how many L

0.6 L

Isotonic IV

0.9% NS, Lactated Ringer's, D5W

Assessment of the bowel

1. Ask patient when he/she had their last bowel movement 2. Assess the abdomen, including auscultating for bowel sounds and palpating for tenderness/firmness 3. Assess the rectal area for: -Fissures -Hemorrhoids -Sores -Rectal tears 4. Assess the patient's labwork: -Platelet count -White blood count 5. An enema is contraindicated for patients with low platelets or low WBC counts 6. Assess for dizziness, lightheadedness, diaphoresis and clammy skin -Administering an enema can stimulate a vagal response (A reflex of the involuntary nervous system that causes the heart to slow down (bradycardia) and that, at the same time, affects the nerves to the blood vessels in the legs permitting those vessels to dilate (widen))

Special considerations for an enema

1. If an order states "until clear", check with the PCP before administering >3 enemas 2. Results are clear when there are no more pieces of stool in the enema return 3. Solution can be colored and still considered clear

Documentation of NG tube

1. Document size and type of NG tube used 2. Measurement from tip of the nose to the end of exposed tube 3. Results of x-ray to confirm placement (if applicable) 4. Record description of gastric contents, including pH 5. Patient's response to procedure 6. Type of suction (if applicable) 7. Patient teaching

Special considerations for small-volume enemas

1. Infant and child: -Insert the tube 1-1.5 inches for an infant and 2-3 inches for children -Hold the child's buttocks together for 5 to 10 minutes after to encourage retention of the enema 2. Older adults: -Use caution when using enemas containing phosphates on frail older adults due to potential for dehydration, electrolyte imbalances, and sodium phosphate toxicity

Guidelines for ostomy care

1. Keep as free of odor as possible -Appliance that can be drained, empty when 1/3 full -Non-drainable pouches when they are ½ full 2. Inspect the stoma regularly -Dark pink to red and moist -Pale = anemia -Dark or purple blue = compromised circulation or ischemia 3. Size stabilizes in 6 - 8 weeks, will protrude 0.5 - 1 inch from surface 4. Keep site around stoma clean and dry 5. Educate patient on care and encourage self-care when appropriate 6. Pouches that can be drained are replaced every 3-7 days 7. Non-drainable pouches require changing when ½ full 8. Encourage patient to participate in care and look at stoma

Testing mental status

1. Level of consciousness 2. Orientation, person, place, time 3. Memory, recent, remote, recall 3 things in 5 minutes 4. Higher intellect Judgement, safety

How to remove fecal impaction digitally

1. Lubricate index finger of dominate hand 2. Gently insert index finger into the canal 3. Work index finger around the hardened mass to break it up and remove pieces 4. Remove the impaction in intervals if severe

Contraindications for administration of an enema

1. Severe abdominal pain 2. Bowel obstruction 3. Bowel inflammation or bowel infection 4. Following rectal, prostate or colon surgery

Implementation of an enema

1. Verify the order for the enema 2. Gather all the equipment 3. Explain the procedure to the patient 4. Close the curtains around the bed. -Have bedpan, commode or nearby bathroom ready 5. Warm the enema solution -Warm to room temperature or slightly higher and test on inner wrist -If tap water is used, adjust temp from the faucet 6. Add the enema solution to the bag. -Allow the fluid to fill the tube before clamping 7. Position the patient on their left side (Sims position) with the upper thigh pulled toward the abdomen, or knee to chest position 8. Keep the patient covered, exposing only the rectal area. 9. Elevate the solution bag to no higher than 18 inches above the level of the anus (use IV pole) 10. Administer the solution slowly (5 to 10 minutes) 11. Lubricate the end of the rectal tube (2 to 3 inches) 12. Separate the buttocks, have the patient take several deep breaths 13. Insert enema tube 3 to 4 inches for an adult, directing it at an angle pointing toward the umbilicus 14. DO NOT FORCE ENTRY OF THE TUBE !!! 15. Introduce the solution slowly (over 5 to 10 minutes) -Assess for dizziness, lightheadedness, nausea, diaphoresis, and clammy skin -If patient experiences any of these symptoms, stop immediately, monitor heart rate and BP, and notify the PCP 16. After the solution is given, clamp the tubing and remove the tube 17. Return the patient to a comfortable position 18. Encourage them to hold the solution until the urge is too strong (5 to 15 min) 19. When the patient has a strong urge to defecate: -Place them in sitting position on the bedpan -Assist them to the commode or bathroom -Stay with the patient or have call light within reach 20. Inspect the results for documentation 21. Assist the patient with hygiene

How to protect the skin for pt with an ostomy

1. proper fit 2. proper seal

1 lb = ? oz

1 tbsp = ? mL

Macule

1.0 cm or less

1 g= ? mg

1000

1 mg= ? mcg

1000

Normal RR for adults

12-20

Respirations

12-20 bpm, non labored and regular

When do fat embolus occur?

12-72 hrs after injury

Normal HR for infant

120-180

Normal sodium levels

135-145 mEq/L

1 cup = ? mL

240

1 oz = ? mL

30 mL = ? oz

Infestation of the body with lice is called: a. dandruff b. pediculosis corporis c. pediculosis pubis d. pediculosis capitis

An infection of the bladder is called: a. cystitis b. pyelonephritis c. renal calculi d. dialysis

An older persons ability to sense pain is: a. Decreased b. Increased c. The same as every other adult d. the same as a baby

True or False Trochanter rolls prevent the hips from turning inward

True

An uncircumcised male resident needs perineal care. Which of the following statements is true? a. the foreskin should be retracted. After cleaning, the foreskin is returned to its natural position. b. you should perform the procedures as if the resident were circumcised c. the labia are separated Downward strokes from front to back are used the area d. there is no difference

Inflammation of the mouth is called: a. aphasia b. metastasis c. benign d. stomatitis

Normal O2 sat

95-100%

Normal temperature

98.6 F

Temperature

98.6 degrees but can range from 97 to 99. degrees

Purpura

>0.5 cm, non blanching, infection, intravascular defect

A rule of conduct made by the government body is called: a. A law b. Libel c. Tort d. Informed Consent

After urinating, the resident is assisted to: a. Wash their hands b. Get back in bed c. GIven something to drink d. Put in a diaper

Bath water temperature should be at what temperature: a. 110- 115 degrees F b. 110- 120 degrees F c. 105 degrees F d. 105- 109 degrees F

Blood vessels that carry blow away from the heart are called: a. arteries b. veins c. venulee d. capillaries

How much urine do the kidneys produce per hour?

50-60 mL

Urine output

50-60 mL/hr, anything less than 30 mL/hr is abnormal

Normal HR for adults

60-100

Normal calcium levels

8.5-10.5 mg/dL

A pt was admitted to the hospital with a wound to his right thigh that is not healing. Identify the reasons that a wound would fail to heal: A. infection B. dehiscence (surgical complication where the edges of a wound no longer meet) C. evisceration (the acute, complete disruption of the musculofascial layers, which results in herniation of the abdominal contents, usually the small bowel and omentum) D. nutrition deficit AB ABC CA ABCD

A B C D

A nurse is performing and assessment on a stage III pressure ulcer. Identify the wound assessment parameters that would be included in this assessment: A. location B. type of wound C. wound size D. presence of oder E. pain ABC BCE ABCDE DEB

A B C D E

Pt who are at increased risk for adverse med effects include: A. pt who treat themselves with over the counter meds B. very young pt C. elderly pt D. healthy young adults E. pt taking more than four meds ABCD ABCE BCDE all of the pt listed

A B C E

The nurse is demonstrating a dressing change to a nursing student. What key safety features should she emphasize during the process? A. knowing the type of wound B. knowing the expected amount of drainage C. knowing the pt blood type D. knowing whether drainage tubes are present ABD AB DC CB

A B D

To prevent med errors, the nurse should: A. clarify illegible orders with the prescriber B. document the med before administration C. prepare all of the client's meds for the shift at the same time D. minimize distractions during med administration E. verify pt allergies AB AC ADE BC BD CD

A D E

Information that you can see, hear, feel or smell is called: a. Assessment b. Observation c. Objective data d. Subjective data

Laws that deal with relationships between people are called? a. Criminal lwas b. Torts c. Responsibilities d. Civil laws

Protective isolation precautions might be orders for which pt: A. A cancer pt with a WBC count less than 1 (very low) B. A pt with C-Diff who is receiving oral antibiotics C. A pt with an open infected wound D. A pt who has tested positive for TB

A. A cancer pt with a WBC count less than 1 (very low)

When writing medication orders, transcribing and charting about medications, which of the following is true? A. Always include a zero before a decimal point B. Always include trailing zeros C. For medication dosages never use abbreviations - always spell out the entire order D. Obscure orders do not need to be verified if you know the provider and can project what you think they were trying to order

A. Always include a zero before a decimal point

In lecture we discussed heat therapy. Heat causes which of the following? Select all that apply A. vasodilation B. relaxes muscles C. vasoconstriction D. helps provide pain relief

A. vasodilation B. relaxes muscles D. helps provide pain relief

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? Select all that apply A. Assure that the packing material is completely saturated when placed in the wound B. Reduce the time interval between dressing changes C. Continue application of saline-moistened packing and apply a hydrocolloid dressing instead D. Use less packing material

A. Assure that the packing material is completely saturated when placed in the wound B. Reduce the time interval between dressing changes C. Continue application of saline-moistened packing and apply a hydrocolloid dressing instead

The best way for the nurse to clean the wound site in a client with a Penrose drain? A. In a circular motion beginning at the pin site an moving outward toward the edge of the wound B. In a wedge pattern from pin site to outer edge of wound and repeat C. In an up-and-down pattern beginning on left side of pin and then to right side D. In circular motion beginning at the outer edge of the wound and moving in toward the pin site

A. In a circular motion beginning at the pin site an moving outward toward the edge of the wound

A nurse is caring for multiple clients on a busy medical unit. Which client would require the nurse to use surgical asepsis and don PPE during care? A. bronchitis who needs nasopharyngeal suctioning B. pneumonia who is receiving oxygen via face mask C. lung cancer who needs continuous pulse oximeter D. chronic obstructive pulmonary disease who is receiving oxygen via nasal cannula

A. bronchitis who needs nasopharyngeal suctioning

The nurse is reviewing the med order sheet and finds this ordere: "restoril 15mg po HS PRN sleep". What is the nurses next action? A. call the provider for a clarification of the order due to the use of non approved abreviation B. transcribe the order into the MAR C. administer 7.5mg of Restoril when the pt asks for it to help them sleep D. administer a dose of 15 mg of Restoril at bedtime when the pt asks for it for sleep

A. call the provider for a clarification of the order due to the use of non approved abreviation

A nurse is caring for an older adult male client who is incontinent, prompting the nurse to consider the use of a condom catheter. Which effects of aging might contribute to urinary alterations? Select all that apply A. diminished ability of kidneys to concentrate urine kmay result in nocturia B. decreased bladder muscle tone may reduce the capacity of the bladder to hold urine C. decreased bladder contractility may lead to urine retention and stasis D. neuromuscular problems may interfere with voluntary control of urine E. decreased pH of urine may irritate the epithelial lining of the bladder F. decreased fluid intake may result in stenosis of the urterers

A. diminished ability of kidneys to concentrate urine kmay result in nocturia B. decreased bladder muscle tone may reduce the capacity of the bladder to hold urine C. decreased bladder contractility may lead to urine retention and stasis D. neuromuscular problems may interfere with voluntary control of urine

The nurse removes an ice pack and notices that the area undrneath the ice pack is bluish purple in color, which is an unexpected outcome of cold therapy. What action should the nurse take? A. discontinue the use of ice packs B. reapply the ice pack C. refill the ice pack to the top D. reapply the ice pack without the wrapping

A. discontinue the use of ice packs

The nurse is caring for a client who has had PCA therapy following orthopedic surgery. What should the nurse perform each subsequent assessment? Select all that apply A. respiratory rate B. current pain level C. sedation level D. mobility

A. respiratory rate B. current pain level C. sedation level

The nurse administers the scheduled morning meds. The previous dose of antihyperetensive meds was held due to a BP that was too low according to the health care providers parameters. What dodes the nurse do with this scheduled unit dose packaged antihyprtensive med? A. set the antihypertensive dose aside pending assessment B. teach the client to use the call bell whenever getting out of bed C. ask the client to report any dizziness and lightheadedness D. place the dose in the med cup with other meds

A. set the antihypertensive dose aside pending assessment

Identify the task the NAP cannot perform: A. staple or suture removal B. report drainage, bleeding, swelling at site to nurse C. report pt complaints of pain to nurse D. report elevation in pt temp to nurse

A. staple or suture removal

Which of the following would be an expected outcome of a forced air warming device? Select all that apply A. the pt temp will remain between 97.7-99.5 degrees B. the pt skin will become warm C. the pt capillary refill will be less than 2-3 seconds D. the pt will not experience shivering

A. the pt temp will remain between 97.7-99.5 degrees B. the pt skin will become warm D. the pt will not experience shivering

mental status (write up)

Alert, oriented to person, place and time. Memory intact for recent, remote events, able to recall 4 items in 5 minutes. Able to count backwards by 3s. Judgment intact regarding future plans

You are giving your resident a back massage. Which statement is false. a. Warm the lotion before applying it b. the massage should last about 1 minute c. use firm strokes d. always keep your hands in contact with his skin

A federal insurance plan providing benefits for older persons and some younger persons with disabilities is called: a. Medicaid b. Medicare c. Blue Cross/ Blue Shield d. Coventry

A microbe that is harmful and causes infection is called: a. reservoir b.pathogen c. a non- pathogen d. host

A resident uses crutches to walk. Which does not promote safety? a. a physical therapist measures and fits the person with crutches b. comfortable bedroom slippers won c. clothes fit well d. crutch tips are attached to the end of crutches

You are measuring vital signs on a resident. What do you report to the nurse immediately? a. the apical pulse b. any vital sign that is changed from a prior reading c. when you took the measurement d. vital signs within the normal range

Aortic (S2>S1), Pulmonic(S2>S1), Tricuspid(S2=S1), and Mitral(S2<S1)

APTM

What is abnormal lung sounds called?

Adventitious lung sounds

When is a patient most likely to get a DVT?

After hip fx

Systolic

Amount of pressure in the left ventricle when ejecting blood

palmar grasp

An infant reflex that occurs when something is placed in the infant's palm; the infant grasps the object. - infant reflex

Ileostomy

An opening in the ileal porotion of the small intestine -liquid fecal content -fecal ostomies can be temporary or permanent

Frequent urination at night is: a. dysuria b. nocturia c. urinary urgency d. polyuria

Large rings are dangerous because: a. They can fall off and can be lost b. They can scratch the resident c. They can damage equipment d. patients can pull them off your finger

Mr. Edwards is on strict bedrest. Which of the following statements is correct? a. he has a contracture b. good body alignment is important c. he can get up to use the bathroom only d. he has orthostatic hypotension

Mr. Kline is bedbound. How often should reposition him? a. at least every hour b. at least every two hours c. at least every four hours d. at least every shift

Mrs. Cooper is on isolation precautions. Which is false? a. say hello from the doorway every 15 minutes b. spend as little time as you can in her room c. provide her with hobby materials d. treat her with respect, kindness and dignity

Standard Precautions apply to: a. the health care team b. everyone c. nursing center residents d. persons only with infections

The loss of urine in response to a sudden, urgent need to void is called: a. mixed incontinence b. functional incontience c. overflow incontinence d. urge incontinence

You come into a room and find a patient having a seizure. You should: a. leave and find help b. remove any object the patient may hit c. restrain the patient's movements d. raise the foot of the bed

The nurse tells you to perform a procedure. Which is not true? a. The nurse must be available to answer questions and supervise b. Do whatever the nurse tells you to do c. The procedure must be in your job description d. Your state must allow nursing assistants to perform the procedure

You walk into check on your resident. They are in the bed, sweaty, seem really "out of sorts", and clutching their chest. You suspect: a. Stroke b. Heart attack c. TIA d. COPD

Which is more correct measure of urinary output? a. 30 oz b. 300ml or cc c. 2 cups d. 1 gallon

You are caring for Mr. Gomez. He requested to be shaved. Which statement is false? a. report nicks or cuts to the nurse at once b. shave away from the direction of hair growth c. soften the skin before shaving d. hold the skin taut as necessary

Specific gravity

As urine becomes more concentrated specific gravity increases

Organs in RLQ

Ascending colon, cecum, appendix, right ovary and tube, lower pole right kidney, right ureter, right spermatic cord

Carinal nerve 1 test

Ask them to smell something

You are doing a dressing change on a resident. You notice that the dressing has a red/yellow body fluid on it. The dressing is called: a. Gross b. Biohazards waste c. Bloody pus d. use droplet precautions

compartment syndrome

Associated with - Fractures - Crushing injuries - Extensive soft tissue damage - Severe burns - Venomous snake bites - Knee / leg surgeries - Increased pressure in compartments compromises capillary perfusion - Results in Edema - Emergency- delay in diagnosis or treatment can cause irreversible nerve and muscle damage - Prompt accurate nursing assessment vital

A pt with a large abdominal incision is being discharged. What statement by the pt indicates that teaching by the nurse has been effective? A. "now that my incision is without staples, it is healed and strong" B. "I need to avoid lifting anything heavy for at least several weeks" C. "As long as I don't have pain, I can do just about anything I want" D. "I don't have to worry about further drainage, now that the staples are out"

B. "I need to avoid lifting anything heavy for at least several weeks"

A neonatal nurse is caring for 2-day old infant. What pain assessment scale should the nurse use to assess the clients pain? A. wong baker B. CRIES C. FLACC D. PAINAD

B. CRIES

During the admission process, tlhe pt states that he is supposed to be on daily aspirin but stopped taking it because is nauseated him. The nurse recognizes that the pt stopped taking his medication because: A. the pt is noncompliant B. of the medication toxic affects C. off the medication's side effects D. pt is allergic

B. of the medication toxic affects

The nurse is caring for a client who is receiving continuous oxygen at 3L/min via nasal cannula. The client's oxygen saturation has continuously been 94% to 96% but suddenly drops to 86% as the nurse palpates the clients abdomen. The client denies respiratory difficulty or other distress. Which is a likely reason for the client's decreasing oxygen saturation? A. The nurse has inadvertently stepped on the client's oxygen tubing occluding the flow of oxygen B. the client is holding his or her breath C. the client's appendix has ruptured D. the client has developed a pulmonary embolism and has a ventilation perfusion mismatch

B. the client is holding his or her breath

A nurse uses a portable bladder ultrasound devise to assess bladder volume for a client who is unable to void. What accurately states information needed to interpret the results? A. the scan is contraindicated for female clients who have had a hysterectomy B. the device must be programmed for the biological sex of the client by pushing the correct button on the device C. three separate readings should be obtained over 1 hr and the postvoid residual averaged D. a postvoid residual of 450mL is often recommended as the guidlines for catheterization

B. the device must be programmed for the biological sex of the client by pushing the correct button on the device

The nurse is caring for a client who has decreased mobility. Which intervention is a simple, cost effective method for reducing the risk of pulmonary complication? A. Antibiotics B. turn, cough, deep breathe (TCDB) C. Oxygen therapy D. chest physiotherapy

B. turn, cough, deep breathe (TCDB)

The appropriate way to identify the "right client" is to: A. ask the client his or her name B. use at least two pt identifiers C. ask the primary nurse to identify the client D. say the client's name and request client verification

B. use at least two pt identifiers

The nurse needs to evaluate the effectiveness of a peroperating teaching session with a client scheduled for abdominal surgery. Which client statement indicates the need for further teaching? A. "I will splint my incision while i cough" B. while my SCDs (compression device) is on, I don't need to do leg exerecises" C. every 2 hours while im awake, i will take deep breaths and cough" D. "i will sit up in bed before using my incentive spirometer"

B. while my SCDs (compression device) is on, I don't need to do leg exerecises"

The nurse is preparing to administer medication to her pt. He is alert and oriented. When the medications are reviewed with the pt, the pt says that he does not take metoprolol. What is the best response by the nurse? A. ignore the pt statement and give the mmed B. withhold the med and discontinue the order C. convince the pt that the doctor ordered it,, and the should take it D. assess the pt concerns, re-checking the order and resolve the pt concerns before continuing with medication administration

B. withhold the med and discontinue the order

Communication that uses written/spoken word is: a. nonverbal b. focusing c. body language d. verbal communication

A client is postoperative day 1 and the nurses assessment reveals signs of pain, such as grimacing and guarding. Which is the most reliable method for assessing the client's pain? A. assess and document the clients behaviors over a period of hours B. compare the clients presentation to expected outcomes at this point in recovery C. ask the client to describe and rate his or her pain D. correlate the clients vital signs with his or her symptoms

C. ask the client to describe and rate his or her pain

The nurse is preparing to suction the nasopharyngeal airway of a client admitted chronic obstructive pulmonary disease. What would the nurse do? A. apply suction when withdrawing the catheter B. cover the suction opening prior to inserting the catheter C. cover the suction opening while inserting the catheter D. suction intermittently only while in the pharyngeal area

C. cover the suction opening while inserting the catheter

The nurse opens the multidose container of oxycodone. The nurse needs 1.5 tabs to deliver the as needed dose. The tabs in the container are not scored. What action b the nurses is best? A. call the pharmacy to request a supply change B. document the med dose as not administer C. cut the second tab in half using a pill splitter D. administer on tab until the issue is resolved

C. cut the second tab in half using a pill splitter

A client who is living with chronic pain has recived a health care providers order for a TENS unit. When applying the device to the clients skin, the nurse should do what action? A. turn on the unit shortly before applying the electrodes to the clients skin B. start with the lowest intensity and gradually increase it to the appropriate level C. disinfect the areas where the electrodes will be applied with chlorhexidine D. administer analgesia 30 mins before beginning a TENS session

C. disinfect the areas where the electrodes will be applied with chlorhexidine

The nurse assesses the urine of a client who is using a bedpan and finds that it is dark brown color. What mediation might be causing this effect? A. phenazopyridine B. amitriptyline C. levodopa D. diuretics

C. levodopa

What would you wear contact precautions for?

C.Diff, MRSA,VRE

spine

Cervical Thoracic Lumbar Sacrum Coccyx

In your role as a nursing assistant, you are able to: a. You can take verbal orders over the phone from doctors b. Give medications c. Insert a foley in the patients vagina or penis d. Report changes in the residents condition to the nurse

Increased signs, symptoms and behaviors of Alzheimers Disease during the hours of darkness is called a. night time fatigue b. sleep deprivation c. delirium d. sundowning

Urostomy (ileal conduit)

Created from a portion of the intestine that is resected from the ileum -it is permanent

A resident continues to ask you the same question over and over again each time you come into the room. You should: a. Tell the person you are tired of answering the same question b. Yell at the resident c. Report the behavior d. Be patient

An assisted living facility provides all of the following except: a. Housing b. Personal care c. Social activities d. 24 hour skilled nursing care

An official record of persons who have completed a Nursing Assistant training and competency evaluation programs. a. OBRA b. Civil law c. Protected nursing assistants records d. Nursing Assistant Registry

Anxiety is a. false belief b. feelings and emotions c. a persistent thought or idea d. a vague, uneasy feeling in response to stress

Before leaving on for lunch, you need to: a. Use the bathroom and wash your hands b. Turn off the computer c. Call home and check on your children d. Tell the nurse

Before putting your patients feet on the floor for ambulation, you want to ensure: a. They wear whatever they want b. Slippers c. Cowboy boots d. Non skid footwear

You are giving mouth care to an unconscious resident. You must be especially careful to prevent the resident from: a. Talking during the procedure b. Biting down on the toothbrush c. Eating the toothpaste d. Aspirating fluid

What should the nurse do when performing suture or staple removal? A. Snip both sides of the suture before removing B. Apply tension to the suture to remove the sutures C. Pull up on the knot to apply as much tension as possible D. Snip the suture as close to the skin as possible

D. Snip the suture as close to the skin as possible

The nurse is caring for a pt who is experiencing inadequate bladder emptying. To determine postvoid residual, which technique is the least invasive for the nurse to implement? A. insert an foley catheter B. straight cath this pt C. have the pt sit on the toilet for one hour after each void D. bladder scanner

D. bladder scanner

Nephrostomy

Kidneys to ostomy

Neurofibromatosis

Little wart like bumps all over the body

Spider angioma

Liver disease, B6

Organs in RUQ

Liver, gallbladder, upper pole of right kidney, hepatic flexure of colon, head of the pancreas

Schedule V

Lower risk than schedule IV

Oil (mineral, olive or cottonseed oil)

Lubricates the stool and the intestinal mucosa. Often used as a retention enema

Diastolic

Pressure exerted against the atrial walls when the heart is at rest

Which of the following would be considered in the Rights of Medication administration? Select all that apply Right pt Right medication Right discharge instructions Right documentation Right to refuse Right effect

Right pt Right medication Right documentaton Right to refuse Right effect

Why are women more prone to UTIs?

Shorter urethra

Synergistic effect

The combined effect of two or more drugs is greater than the effect of each drug alone

GFR

The amount of filtrate formed by the kidneys each minute

Ostomy

Surgically created opening in the abdominal wall for draining intestinal content or urine (Effluent) that causes a change in the way urine or stool exits the body as a result of a surgical procedure. Bodily waste is rerouted from its usual path because of malfunctioning parts of the urinary or digestive system. An ostomy can be temporary or permanent.

pterygium

Thickening of sclera caused by chronic inflammation

Stoma

The opening created by ostomy surgery. It is located on the abdomen and is dark pink in color. For most ostomies, a pouch is worn over the stoma to collect stool or urine. For some people it is possible to have a continent diversion, an alternative to a conventional ostomy that eliminates the necessity for a pouch.

Tactile Fremitus

To determine if the lung tissues air filled, fluid filled, or solid

Supportive effects

To support the effects of the first drug

reflexes (write up)

Triceps 2+ Biceps 2+ Brachioradialis 2+ Patellar 2+ Achilles 2+ Plantar response = toes down going

True or False A flowsheet is only used by RNS and used to record frequent measurements or observations.

True

True or False A resident can have a diagnosis of constipation and still stool

True

True or False Conflict in the workplace can impact the quality of the care provided.

True

True or False Giving your opinion, positive or negative, promotes effective communication

True

True or False Pain subjective and different for each individual

True

True or False Persons with foley catheters are at high risk for urinary infection

True

True or False Proper positioning prevents pressure ulcers and contractures

True

True or False Rectal temperatures are not taken if your resident has heart disease. Why?

True

True or False The most serious risk of restraint use is death

True

True or False The nursing progress never ends

True

True or False To brush ones hair start at the scalp and brush toward the hair ends

True

True or False When transferring a patient, the weak side moves first

True

True or False When using a fracture pan, the larger end is placed under the buttocks

True

True or False You are giving male perineal care. To clean the tip of the penis, start at the meatus of the urethra and work outward.

True

True or False Before using your stethoscope on a resident you should wipe the earpieces and diaphragm with antiseptic wipes.

True

True or False Even with residents of nursing facilities, use of condoms will prevent STDs.

True

True or False Follow Standard Precautions and the Bloodborne Pathogen Standard when giving oral care

True

True or False I will document appropriately, date, time, event and not leave anything out!

True

True or False Listen and use silence when dealing with an angry person

True

True or False Sodium causes the body to retain water

True

True or False Taking an apical pulse requires a stethoscope and some sort of clock

True

True or False The enema tubing is usually inserted 6 inches into the adult rectum

True

Carinal nerve 8 test

Whisper test

stepping reflex

a neonatal reflex in which an infant lifts first one leg and then the other in a coordinated pattern like walking - infant reflex

Falls

among those 65 or older, major reason for fatal and non-fatal injuries -more serious if patient is on an anticoagulant

Tidal Volume

amount of air healed after a normal inspiration

Residual volume

amount of air left in the lungs after a full expiration

Rubror

deep redness, associated w/ inflammation

Rubror

deep redness, associated with inflammation

Sterilizing

destroying all microorganisms and viruses on an object including spores

Nephrotoxic

destructive to kidney tissue

Pustule

elevation of skin containing pus

Removing fecal inpactions digitally (with fingers) are performed when

enemas and suppositories are not successful -Impaction occurs in all age groups

Past medical history (neuro exam)

ever had: - Head injury - Seizures - Tremors - Weakness - Incoordination - numbness/tingling - Difficulty swallowing or speaking - Stroke - Cancer

Polyuria

excessive urination

Nocturia

excessive urination at night

Non rebreather

flow rate of 10-15 L/min -bag attached to the side

Dull thorax percussion

fluid or tissue filled space

Stage 3 pressure ulcer

full thickness, damage to SC tissue, may have undermining

Stage 4 pressure ulcer

full thickness, exposed bone/tendon, slough, undermining/sinus tracts common

CN 9, 10,

glossopharyngeal, vagus -have patient say ahh and look into mouth, uvula should rise, gag reflex

Clustered

grouped lesion

Drop

gtt

Respiratory excursion

hands flat, relaxed on the chest wall, -hand should move symmetrically upon inhale

colostomy

the surgical creation of an artificial excretory opening between the colon and the body surface

Nursing 295 Final Exam

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