1020 Final Flashcards
What assessments or trends indicate infection?
Inflammation Fever Elevated WBC Count Redness Swelling
Nursing Interventions to prevent pressure ulcers.
Turning q2 hours
Use Lift sheets when available
Bed is Dry and wrinkle free
What does granulation tissue / a healing wound look like?
Pink and vascular, sometimes red
Nursing Interventions for a patient with a swollen ankle?
RICE and Pain / Antibiotic meds
Patients that are at greater risk for wound healing?
Pt’s w/ comorbidities
Elevated WBC
Elderly person
What has occurred if an antibiotic is not working for a patient that has been prescribed it 3 times within a year?
Drug Resistance
Penicillin G will elevate what electrolyte?
K / Potassium
What antibiotic causes flushing of the chest and neck?
Vancomycin
What is the name of the flushing syndrome cause by vancomycin?
Red Man Syndrome
What GI infection is a side effect of cephalosporin?
Clostridium difficile / C-Diff
When does peak drug level occur for IV infusion?
30 - 60 minutes after IV infusion
What is Lupus Triad?
fever, joint pain, and rash in a woman of childbearing age
IgE is triggered in what hypersensitivity?
Type1 allergic reaction to insect, food, environmental
All apply to Lupus except?
Curable with medication
Broad spectrum antibiotics are the least toxic, but causes the following? Choose all that apply?
Decrease in Normal Flora
Superinfections
What antibiotic has a high cross contamination occurrence with a history of anaphylaxis with Penicillin?
Cephalosporins
The nurse put a plan in place and set patient goals, she then put the plans into action. The next step for the nurse is?
Evaluation
What cells are destroyed in HIV?
The body’s CD4 T cells become infected with HIV
When does a patient need to return to have their TB test read after receiving their TB injection?
48-72 hours
Showing that you are accountable for your behavior is an example of?
Professionalism
A patient is observed by the student nurse performing ADL’s at breakfast, and is demonstrating she is able to feed herself; the nurse documents the following: pick correct response.
The patient feeding herself at breakfast, ate 100%
A patient is stung by a bee and suddenly begins wheezing and unable to breath is experiencing ?
Anaphylaxis
An intradermal TB test is positive if?
15mm at site (anything greater than 10 and swelling)
Redman syndrome is caused by?
Rapid release of histamines
Vancomycin
Infusing the IV to quickly
The ELISA test only requires a one time test for HIV?
false
Wound healing can be delayed by many factors, choose all that apply ?
Decreased albumin Corticosteroids Uneven wound edges Immobility Elderly
Your patient had a temp of 104 F at 12 am, at 4 am his temp is 101.5 F, and at 8 am his temp is 99.1 F. What do you conclude from this scenario?
Temperature trends indicates the patient is improving
The patients white count is 18,000/ml, he has a large gapping leg wound. You receive the following orders, what will you do first?
Collect a culture and sensitivity from the wound
Your patient is leaving to go home, you give verbal instructions as well as a sheet with written home-going instructions for discharge, and ask, “ are these instructions clear, do you have any questions”? The patient responds, “ I’ll read them later, you told me what i need to know”. What might be a concern for the nurse after that comment?
The patient may not be able to read
Teaching is most effective when it responds to?
The learner’s needs
I will be back in 10 minutes with your medication, is the definition of?
Fidelity
Efforts to ensure that all people have full and equal access to opportunities that enable them to lead healthy lives. All people must be treated equally to avoid health inequities and health disparities.. What is?
Equity
An integration of the best evidence from the most current research, nursing expertise, and the values and preferences of individuals, families, and communities applied to nursing practice, based on scientific rationale.. what is ?
Evidence based practice
A patient is is experiencing a painful swollen wrist with a small dirt, stone & grass-filled gash on the side of her wrist after falling on gravel in her drive way, you anticipate the treatments that will be ordered, but which treatment would you expect will not be included?
heat
The patient’s CD4 T cells are less than 200 cells/ml and is diagnosed with pneumocystis pneumonia, the nurse knows the patient?
Has Acquired Immunodeficiency Syndrome
A patient is diagnosed with HIV, which factor is most important to assess before the initiation of antiviral drug therapy (ART) for this patient?
The patients desire to adhere to the therapy
How do you know the antiviral therapy is effective (ART) according to what lab test result?
Viral Load
A patient is diagnosed with Acquired Immuno-Deficiency Syndrome (AIDS); what type of precautions will the patient be placed on?
Standard
Nurses are accountable for their actions, what clinical decision below is most important?
Take immediate action when there is a change in patient condition
A patient expresses to you, “ I am afraid to have surgery tomorrow, I feel I don’t fully understand why I need to have it and I am afraid to make my doctor mad if I question him”. According to the nursing code of ethics, which ensures that the nurse will promote the patient’s wishes?
Advocacy
A nurse fails to perform the insertion and care of an intravenous catheter according to hospital policy. Which of the following could the nurse be subject to if the patient is harmed?
Institutional Standards
Your patient has a history of a severe reaction to bee stings, which psychomotor skill has the highest priority?
The patient demonstrates how to self administer the Epi-Pen
Your patient is an older adult with a decreased immunity. According to Healthy People 2020 and 2023 you should ?
Encourage the patient to stay up to date on their vaccinations.
You just received report on your 3 patient’s, which patient will you see first?
A patient with shortness of breath
The correct way to measure a wound ?
Length X width X depth
Consuming Less than 50% on 3 consecutive meals need a?
Dietary Consult
Corticosteriods
Inhibits phagocytosis
Inhibits wound healing
A stage 2 pressure wound has progressed to a stage 3 pressure wound and then healed at a stage 3. what is the correct documentation?
Stage 3 wound healed at stage 3
You are to get a wound culture, what is the proper way to do so? Select all that apply.
Cleanse wound with sterile NS and sterile 2x2’s
Using a sterile culture swab, rotate the swab in a 1-cm 2 area near the deepest area of the wound, using sufficient pressure to extract wound fluid from deep tissue layers(collecting microorganisms)
What is the 5 criteria for delegation by the RN?
Task Person Circumstances Supervision/Evaluation Right direction and communication
Slough, subcutaneous tissue layer is present
stage 3
Partial thickness- open clear fluid blister
Stage 2
Full- thickness tissue loss - slough, muscle, tendon, and bone is present
Stage 4
non-blanchable pinkish skin intact injury
Stage 1
Patterns of behaviors and thinking that people living in social groups learn, develop, and share. What is?
Culture
The array of differences among individuals, groups, communities?
Diversity
Identity: based on the language, geographic area, racial characteristics, and values of the group’s heritage. Example: People may declare their ethnic identity to be Irish, Vietnamese, Brazilian.. What is?
Ethnicity
You, an expert clinical nurse, understand that the following means a wound may be infected… Choose all that apply
- Leukocytes
- Purulent exudate oozing from the wound
- Spike in temp from 99.0 F to 101.0 F
AIDS is diagnosed when an HIV- positive individual develops at least one of several criteria: All that apply
- CD4+ T-Cell count less than 200
- Pneumocystis pneumonia (PCP) fungal infection
- Candidiasis infection must be of the bronchi, trachea, lungs, or esophagus (not only the mouth/thrush)
The white cells called GRANULOCYTES contain neutrophils and monocytes, their function
Phagocytes
Your patient is reporting lower leg pain. You assess the lower extremity and see that it is red, swollen, and very painful! Using your excellent critical thinking and clinical skills , you know that your patient my have? Select all that apply?
Cellulitis
DVT
Your patient has a mild response to an antigen, what medication would be most appropriate?
Antihistamine
Lymphocytes produce antibodies that protect our body from INVADERS called? Select all that apply ?
- B lymphocytes (IgG, IgM, IgE)
- Killer T cells
A patient who is a paraplegic has a stage 2 pressure injury. What teaching instruction will you give the care-giver that is MOST IMPORTANT
Reposition the patient every two hours
How does penicillin work on bacteria ?
- It weakens bacteria cell wall
- It’s bactericidal
- It’s inactivated by the enzyme penicillinase
You are preparing a care plan for your patient with SLE, you are selecting several nursing diagnoses. Choose all that apply to your patient
- Risk for infection
- Risk for activity intolerance
- Risk for Disturbed body imaging
- Risk for Ineffective Tissue
- Chronic pain
Your patient is exposed to an antigen, the patient starts wheezing, sneezing then becomes severely SOB, what medication is most appropriate at this time?
Epinephrine
All inflammatory responses need an antibiotic ?
False
What would you consider most important when your patient’s wound healing is delayed? Choose all that apply?
- Low albumin level
- Pulse oximetry
- mobility
Your patient has a large black eschar wound on his heel. According to EBP.. choose all that apply?
- It is a collection of dry, dead tissue that dries and becomes adherent to the heel wound.
- It is caused by pressure
- Eschar should not be debrided,when intact and firm
A patient with systemic lupus erythematosus (SLE) asks the nurse what medications are used to cure autoimmune diseases. The nurse should respond with which of the following?
Autoimmune diseases are not curable
What is true of Penicillin G? all that apply?
- Is the least toxic of all antibiotics
- Most common cause of drug allergy
- Contains vitamin K
Which infections are an example of a superinfection? All that apply?
- Clostridium difficile
- Vaginal infection
- Thrush
A patient has a superinfection after taking a Cephalosporin, he is being treated with an antibiotic. What antibiotic would you expect this patient to receive
Metronidazole (Flagyl)
