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PCC2: Parker > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

What is important for the nurse to avoid in suture removal?

A

allowing the external portion of a suture to go into the wound bed

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2
Q

Regarding foam, what consideration should be taken in negative pressure wound therapy (wound vac)?

A

foam should not touch in-tact skin

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3
Q

Describe serous fluid.

A

pale yellowy-clear.
Normal part of the wound healing process.

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4
Q

Describe sanguineous drainage.

A

bright red bloody fluid from wound

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5
Q

Describe serosanguineous wound drainage.

A

mixture of light yellowy and light red/pink fluid

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6
Q

Describe purulent drainage.

A

thick, foul odor, sticky, milky, green/yellow, brown - indicates infection of the wound

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7
Q

What type of drainage would likely be caused by wound trauma?

A

sanguineous

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8
Q

What does REM stand for?

A

rapid eye movement

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9
Q

What happens to gastric secretions during REM sleep?

A

increased gastric secretions

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10
Q

Vivid dreams are an indication of what type of sleep?

A

REM

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11
Q

In a medical facility, how can a nurse promote sleep?

A

provide healthy sleep environment (low lights, avoid sounds), try to do tasks all at once so you aren’t going in and out, and assess for any problems

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12
Q

What are some things that may effect/disrupt sleep?

A

waking pts up for unnecessary treatment, exposure to computer/monitor light, poor environment, personnel frequently entering room

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13
Q

What is the last resort for insomnia?

A

medication therapy

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14
Q

What factors may promote insomnia?

A

poor sleep hygiene (video games/lights/stimulation before sleeping/lack of routine schedule), medical condition, shift work, and stress

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15
Q

How is sleep apnea diagnosed?

A

sleep study

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16
Q

What is a common symptom that occurs with sleep apnea?

A

excessive daytime sleepiness and snoring

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17
Q

What is the primary treatment option for sleep apnea?

A

CPAP (continuous positive airway pressure)

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18
Q

What is a primary concern for individuals who have narcolepsy?

A

safety

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19
Q

What factors may increase occurrence of narcoleptic episodes, including cataplexy (sudden loss of muscle tone)?

A

strong emotion ( stress, anger, and fear)

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20
Q

What may be the first sign of pneumonia, especially in older adults?

A

confusion

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21
Q

Usage of what medical device may lead to HCAP (health care acquired pneumonia)?

A

ventilator

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22
Q

What population is at increased risk for both CAP (community) and HCAP (healthcare)?

A

older adults

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23
Q

What are some early symptoms of hypoxia?

A

restlessness, agitation, and anxious

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24
Q

What are some late symptoms of hypoxia?

A

cyanosis, altered LOC

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25
Q

Absent skeletal muscle tone may indicate which stage of sleep?

A

REM

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26
Q

What can be utilized to evaluate sleep?

A

STOP BANG Assessement

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27
Q

What happens to breathing with individuals who have sleep apnea?

A

air flow is blocked and breathing stops

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28
Q

What doe STOP BANG stand for?

A

S-snore? B-BMI
T-tired? A- age
O- observed? N- Neck size
P- Pressure? G- gender

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29
Q

Give an example of individuals who are at an increased risk for insomnia.

A

those who do shift work

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30
Q

What type of dressing would likely be used to maintain/provide moisture to a wound?

A

hydrogel/hydrocolloid

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31
Q

What type of dressing would be effective to use on an excessively moist wound?

A

alginate or foam

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32
Q

Why is it important to ensure wound is not too dry?

A

if it is too dry, granulation (new tissue) will not thrive

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33
Q

What is primary concern after sharp debridement?

A

increased risk for infection, as tissue is now exposed

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34
Q

What may be effective to use on a wound to absorb drainage and reduce bacteria?

A

Aquacel Ag (silver)

35
Q

What term describes the output from a stoma?

A

effluent

36
Q

How should a stoma appear?

A

beefy red

37
Q

Following ostomy procedures, how long is expected for stools to be liquid, regardless of the type?

A

up to 6 weeks

38
Q

What refers to a surgical complication of ostomies in which effluent can leak into the abdominal cavity?

A

anastomotic leak

39
Q

When is stomal necrosis most likely?

A

following surgery (3-5 days)

40
Q

What may be required for patients who have had a resection of the terminal ileum?

A

B 12 replacement

41
Q

What specific foods should be avoided for new ileostomy (pt education)?

A

celery, coconuts, corn popcorn, seeds, foods with peels, raw cabbage, meats with casings, and mushrooms

42
Q

The nurse should emphasize the important of what mechanical action for a client who has a new ileostomy?

A

thoroughly chewing food, as this will prevent a clog within the lumen

43
Q

What is expected of the initial output for an ileostomy?

A

viscous, green, shiny. High output (1500-1800cc daily)

44
Q

After the adaptation phase, what is expected of the appearance of effluent from an ileostomy?

A

stool-colored brown, and toothpaste consistency

45
Q

Due to the high acidity of ileostomy effluent, what concern should the nurse consider?

A

skin irritation

46
Q

For the client who has a new ileostomy/existing ileostomy, what should the nurse educate them to never take?

A

laxative

47
Q

What are the indications for colostomy irrigations?

A

improves quality of life by eliminating need for pouches, as well as providing bowel control

48
Q

How long does colostomy irrigation take before it can be considered reliable?

A

approximately 6 weeks

49
Q

What may cause candidiasis (yeast infection) of a stoma?

A

moisture, immunocompromised, and meds (chemo, antibiotics,)

50
Q

What may cause retraction of a stoma?

A

surgical technique, weight gain, and thick abdominal wall

51
Q

What should a nurse NEVER use within an ostomy pouch to eliminate odor?

A

aspirin

52
Q

JP (Jackson-Pratt) drains are only effective when:

A

suction/negative pressure is activated

53
Q

What is known as a normal breathing pattern?

A

eupnea

54
Q

Kussmaul’s (rapid and deep) respirations are expected in:

A

DKA (diabetic ketoacidosis)

55
Q

What breathing pattern may occur in cardiac conditions (MI, heart failure)?

A

Cheyne-Stokes (cycles of apnea and hyperventilation)

56
Q

What ways can a nurse promote respiratory function?

A

fluid intake, positioning, airway patency, pursed lip breathing, nebulizers, humidifiers

57
Q

What type of clothing should those on O2 be encouraged to wear? Why?

A

cotton only, as it prevents fabric spark (O2 is very flammable)

58
Q

What is the expected O2 saturation in those with COPD?

A

88-92%

59
Q

What may oxygen greater than 24-32% (1-3L/min) do to COPD clients?

A

negate their stimulus to breathe, decreasing respiratory drive

60
Q

Describe wound irrigation.

A

allow solution to flow from the least to most contaminated area

61
Q

How should solutions be applied to the skin for wound cleaning?

A

using gentle friction

62
Q

In what direction should a wound be cleaned?

A

from least contaminated area (in wound/incision/@drain) to the surrounding skin

63
Q

Aquacel Ag is a great dressing type to prevent/reduce what?

A

infection

64
Q

What is dehiscence?

A

partial or total separation of wound layers

65
Q

What is an evisceration?

A

medical emergency by which the organs have protruded through a wound opening

66
Q

What should increase in the diet of those with a wound?

A

protein

67
Q

When should JP drains be emptied?

A

around half full

68
Q

What describes the substances that come from a wound?

A

exudate

69
Q

What type of surgically placed drain can hold up to 500 mL of drainage, compared to JP, which only holds 20-50 mL?

A

hemovac

70
Q

Those who have viral pneumonia are at a higher risk for developing what?

A

bacterial pneumonia

71
Q

What is important for clients who have pneumonia to increase? Why?

A

fluids, as it helps loosen secretions so phlegm can be excreted

72
Q

What can a nurse use for those who have pneumonia to encourage deep breathing and coughing?

A

incentive spirometry

73
Q

How can HAP be avoided by a facility?

A

placing conveniently located hand sanitizer dispensers and ensuring supplies for handwashing are maintained and available

74
Q

How does a CPAP work?

A

the continuous air prevents airway from occluding, which maintains airway patency

75
Q

What is the cure for narcolepsy?

A

there is no cure

76
Q

What PPE is used for droplet precautions?

A

face shield, mask, gloves

77
Q

What type of breathing is expected with hypoxia?

A

rapid, shallow breathing

78
Q

What is known as collapse of an ostomy lumen? What may pts with this condition need?

A

stomal stenosis; laxatives

79
Q

In regard to communication, what should be evaluated prior to the nurse giving ostomy education to a patient?

A

readiness to learn, as this can be a sensitive topic for some

80
Q

What should be avoided when placing a wound vac?

A

allowing the foam piece to touch the intact skin

81
Q

What type of wounds are Penrose drains common in?

A

animal bites

82
Q

What type of drain may be expected with a mastectomy?

A

JP drain

83
Q

Rapid breaths followed by period of apnea may be seen in what conditions, what is this pattern called?

A

brain insult (Stroke, MI, brain infection/encephalopathy), Biots Respirations

PCC2: Parker (6 decks)

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