Case Studies Flashcards by Sarah LaVally

Cannula prongs should be lubricated with…

water-based gel

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1 tsp is equal to how many mL?

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What class of medication reduces cough?

antitussive

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Vesicular lung sounds are a (blank) finding in peripheral lung fields.

normal

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How should the nurse perform lung auscultation?

Beginning at the top of the chest, comparing one side to the other, moving downward, and finishing at the lung base

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What are three ways the nurse can prevent venous thromboembolism?

dorsal flex and plantar flex feet
use sequential compression devices
administer enoxaparin (an anticoagulant)

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Unilateral calf edema is a possible sign of…

thrombophlebitis (report to HCP)

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How does the nurse assess for orthostatic hypotension?

Take BP and pulse in lying, sitting, and standing positions

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Deep breathing can help prevent…

atelectasis

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The Braden Scale assesses…

risk for pressure sores

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The 90-degree side lying position places pressure on the…

greater trochanter (high risk for skin breakdown)

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How can the nurse prevent pressure sores?

Reposition the patient every 2 hours while awake

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What class of medication increases the risk for bleeding during surgery and post-op and should be withheld prior to surgery?

anticoagulants

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Method for final verification (review scheduled procedure, site, and client)

“time out”

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How should the patient be positioned in the immediate post-anesthesia period?

On their side

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Hypoactive bowel sounds are (blank) after anesthesia.

expected

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Packed RBC are only compatible with…

normal saline

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Unintentional opening of a wound is called…

dehiscence

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pain or burning with urination

dysuria

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bladder training: start with every (blank) hours during the day and every (blank) hours at night

2, 4

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(Blank) can be used for internal organ irrigation such as bladder or stomach

Saline

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Monitor skin integrity and pulse volumed of restrained extremities every (blank) minutes.

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Restraints must be removed at least every (blank) hours.

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Resistance to antibiotic is a risk factor for…

sepsis

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Elevated creatinine indicates a problem with the...

kidneys

What position should the patient be in for an enema or suppository?

Sim's

After catheter removal, report if the patient has not voided after (blank) hours.

Do not open or crush (blank) medications.

extended release

What is the order for abdominal assessment?

inspection, auscultation, percussion, palpation

What position should the patient be in for abdominal auscultation?

supine

Where should the nurse begin to auscultate for bowel sounds?

right lower quadrant

Bowel sounds are normally heard (blank) times per minute.

5-35

The most common adverse effect of opioid analgesics is...

constipation

The average adult needs how much fluid daily to prevent constipation?

1400-2000 mL

barium liquid swallow followed by x-rays of esophagus, stomach, duodenum

upper GI series

Docusate sodium is a...

stool softener

What procedures are performed to assess for presence of fecal impaction?

digital rectal or radiographic exam

Vagal nerve stimulation causes (blank) of heart rate.

slowing

Verbal prescriptions should be...

read back and signed within 24 hours.

(Blank) heightens perception of pain and impairs coping skills.

Fatigue

All (blank) products should be avoided in children unless prescribed.

aspirin

(Blank) promotes muscle relaxation and relief of pain caused by stiffness or spasm.

Heat

(Blank) occurs following the initial vasoconstricting effects of cold.

Reflex vasodilation

(Blank) sends stimulating impulses through the skin, blocking pain signals from reaching the brain.

Transcutaneous electrical nerve stimulator

With an intramuscular injection, you can use the (blank) site for most people.

ventrogluteal

For intramuscular injections, the nurse should follow facility policy for (blank).

aspiration

method where the muscle is tensed fully and then relaxed completely

progressive relaxation

Teaching is best provided (blank) surgery.

before

Veracity means...

truthfulness

When administering eye drops, pull the conjunctival sac (blank) and apply light pressure over the (blank).

down; inner canthus

The severity of a burn is determined by...

depth of burn, extent of burn, location of burn, client risk factors

What is the initial treatment of a thermal, partial thickness burn?

dry dressing

Chronic middle ear infections are associated with...

hearing loss

entry of foreign substances into the lungs

aspiration

professionals that adapt fine motor movements for provision of self care

occupational therapists

What measures should be taken for a client with dysphagia?

- elevate to high Fowler's when eating - keep elevated at least 1 hour after eating - all fluids at room temperature

Pallor of any mucous membranes may indicate...

anemia

Regular measurement of weight is a good indicator of...

nutritional status

How many calories does the average adult need per day?

20-35 calories/kg

protein lab values

6.4 - 8.3 mEq/L

What is needed when a client asks not to be resuscitated?

identifying bracelet

Feed client with feeding tube once...

bowel sounds are present (usually 24 hours after insertion)

Before teaching, the nurse should assess...

readiness to learn

Fluid volume deficit often causes what changes in vital signs?

orthostatic hypotension and tachycardia

How are orthostatic vital signs measured?

lying, sitting, standing (both VP and pulse are typically measured in each position)

What measure provides the most important data about fluid volume status?

daily weights

Where should skin turgor be assess in the elderly?

over sternum

1 kg is equal to how many lbs?

2.2

A decrease in serum protein leads to and increase in...

free drug molecules

What should the nurse do when there is a medication error?

complete incident report and primary nurse notify HCP

Obstruction in IV tubing is often caused by...

patient movement

What actions should be taken when there is an IV site complication (ex. phlebitis)?

- discontinue IV - take action for complication - start IV at a different site

Fluid volume excess leads to abnormal...

breath sounds

The nurse does not need a prescription to record...

I&O

Fluid volume excess leads to what changes in the pulse?

tachycardia (increase in rate) and bounding pulse (increase in volume)

When should diuretics be taken?

in the morning (to reduce nocturia)

What should NOT be used as a patient identifier?

room number

What are signs of fluid volume deficit?

changes in mental status, change in urine output, tachycardia, longitudinal furrows on tongue

What should the nurse do when the patient is unable to swallow?

suction oral secretions

How should oral secretions be suctioned?

gently with tonsil tip or Yankauer suction device

When the patient is dying, where do cyanosis and mottling first occur?

in the hands and feet and then progress centrally

irregular or patchy discoloration of skin

mottling

redness that occurs when an area is lower than the heart (most common in legs)

dependent rubor

occurs when tissue is relieved of pressure; abnormal when redness lasts longer than 1 hour and surround tissue does not blanch

reactive hyperemia

Pressure ulcers usually occur over...

bony prominences

Spongy skin indicates that (blank) has occurred.

pressure damage

What position should the patient sleep in for pressure relief?

30 degree lateral inclined

dressing for stage I pressure ulcer

transparent film

dressing for stage III or IV pressure ulcer

hydrogel covered with foam dressing

purulent drainage

pus

serous drainage

thin, watery

sanguineous drainage

bright red

What measures should the nurse take to reduce the effect of diarrhea on skin?

- clean and dry skin | - apply moisture-repellent ointment

precaution used for all patients

standard

extension of wound under skin

sinus tract

How should the nurse assess a sinus tract?

sterile cotton-tipped applicator

Safe, effective pressure for irrigation is between...

4 and 15 PSI

Incorrectly labeled medications are the responsibility of the...

pharmacist

Assess for drug toxicity with a...

peak and trough test

How many sleep cycles does an adult have?

4-6

Meals should be avoided how many hours before bedtime?

3-4

Lying in bed awake for more than (blank) may increase anxiety and inhibit sleep.

30 minutes

effleurage massage

"to touch lightly"

petrissage massage

"knead or rub with force"; used to break down tension in large muscles

lack of airflow through the nose and/or mouth for periods of 10 seconds or longer during sleep

obstructive sleep apnea

Where should patients with increased monitoring be placed?

near the nurse's station

A decrease of up to (blank) BPM during NREM sleep is considered normal.

Can vital signs be delegated to the UAP?

Yes