exam 2 socrative questions

Question 1

what are some indications for a binder to be placed around a surgical patient with a new abdominal wound?

Answer 1

Reduction of stress on the abdominal incision

Provision of support to abdominal tissues when coughing or walking

Question 2

at what stage wound would you expect to see granulation tissue?

Answer 2

in a wound that is healing, possible stage IV
- characterized by new blood vessels

Question 3

what position of the bed is best to prevent shear?

Answer 3

30 degrees
- bed in higher position causes patient to slide down, causing shear

Question 4

what interventions reduce the risk for MARSI?

Answer 4

montgomery ties to secure the dressing.
adhesive remover.
gently loosen the ends of the tape and gently pull the outer end parallel with the skin surface toward the wound.

Question 5

what predisposing factor tends to increase the risk for pressure ulcer development?

Answer 5

decreased level of consciousness
- Older adults
* Individuals who have experienced trauma
* Individuals with spinal cord injuries (SCIs)
* Individuals who have sustained a fractured hip
* Individuals in long-term homes or community care, the acutely ill, or those in a hospice setting
* Individuals with diabetes mellitus
* Patients in critical care settings

Question 6

what are the 5 steps of wound irrigation?

Answer 6

1. Organized steps ensure a safe, effective irrigation of the wound.
2. Form cuff on waterproof biohazard bag and place near bed.
3. Fill 35-mL syringe with irrigation solution.
4. Attach 19-gauge angiocatheter.
5. Using continuous pressure, flush wound.

Question 7

what is an independent nursing intervention?

Answer 7

something that a nurse initiates in response to a nursing diagnosis without supervision, direction, or orders from others.

Question 8

what is the chief concern?

Answer 8

a brief statement about why a patient (in his or her own words) is seeking health care
- offers a focus to explore pt concern and issues

Question 9

When thinking about setting priorities, in general which of the following statements is true?

Answer 9

problem-focused diagnoses and problems take priority over wellness, possible risk, and health promotion problems

Question 10

what takes priority short-term acute patient care needs and problems or long term chronic needs?

Answer 10

Short-term acute patient care needs and problems typically take priority over longer-term chronic needs

Question 11

what is a nursing diagnosis?

Answer 11

a clinical judgment made by a nurse to describe a patient’s response or vulnerability to health conditions or life events that a nurse is licensed and competent to treat

Question 12

what 6 interventions does a nurse need to consider?

Answer 12

(1) desired patient outcomes
(2) characteristics of the nursing diagnosis
(3) research base knowledge for the intervention
(4) feasibility for doing the intervention
(5) acceptability to the patient
(6) your own competency

Question 13

what are dependent nursing interventions?

Answer 13

require an order from a health care provider examples:
providing wound care
starting an IV or invasive procedure
preparing a patient for a diagnostic test

Question 14

what are interdependent nursing interventions (aka other provider interventions)?

Answer 14

therapies that require the combined knowledge, skill, and expertise of multiple health care providers (such as collaborating with the unit discharge coordinator)

Question 15

what does PQRST stand for?

Answer 15

provokes, quality, radiate, severity, time

Question 16

consultation occurs when the nurse does what?

Answer 16

identifies a problem that the nurse or the interprofessional team are unable to solve

Question 17

you are the nurse taking care of a patient with a surgical wound where you have identified two significant nursing diagnoses: Acute Pain and Risk for Infection. Which diagnosis is likely your first priority?

Answer 17

acute pain
because of Maslow’s hierarchy of needs

Question 18

what is a clinical practice guidelineor protocol?

Answer 18

a systematically developed set of statements about appropriate health care for specific health care problems or clinical situations (e.g., pressure injury prevention, DVT prevention, fall prevention)

Question 19

what is hypokalemia?

Answer 19

when blood potassium levels are low, the brain cannot relay signals as effectively
- digestive system slows
- constipation and bloating

Question 20

what are lab findings for hypokalemia?

Answer 20

Serum K+ levelbelow3.5 mEq/L (3.5 mmol/L); ECG abnormalities: U waves, flattened or inverted T waves; ST segment depression

Question 21

what is hyperkalemia?

Answer 21

excess of sodium
- increased water consumption helps to eliminate potassium
- educate pt on restricting sodium
- monitor daily weight and total fluid volume status

Question 22

what is the physical examination for hypokalemia?

Answer 22

Bilateral muscle weakness that begins in quadriceps and may ascend to respiratory muscles, abdominal distention, decreased bowel sounds, constipation, dysrhythmias

Question 23

when do you measure gastric residual volumes (GRVs)?

Answer 23

every 4-6 hours

Question 24

when is delayed gastric emptying a concern?

Answer 24

(lack of absorption) is a concern if 250 mL or more remains in a patient’s stomach on two consecutive assessments (1 hour apart) or if a single GRV measurement exceeds 500 mL

Question 25

what do high gastric residuals indicate?

Answer 25

can indicate that the feeding is not being properly absorbed, which can lead to the risk for aspiration

Question 26

Which symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines?

Answer 26

Change in bowel habits
Blood in the stool
Incomplete emptying of the colon
Unexplained abdominal or back pain

Question 27

As the nurse caring for a client with parenteral nutrition (PN), which actions take priority?

Answer 27

Careful management of the central venous catheter (CVC)
Consistent reevaluation for the continuation of PN
Clinical and laboratory monitoring of the client
Adherence to principles of asepsis and infusion management
Changing the CVC dressing per facility protocol and whenever visibly contaminated

Question 28

what is parenteral nutrition (PN)?

Answer 28

IV administration of a complex, highly concentrated solution containing nutrients and electrolytes that is formulated to meet a patient’s needs

Question 29

where are high osmolarity solutions administered?

Answer 29

through a central venous catheter (CVC)

Question 30

where are lower osmolarity solutions administered?

Answer 30

through peripheral intravenous IV line

Question 31

what is the traditional way to measure a pt for an NG tube?

Answer 31

Measure distance from tip of nose to earlobe to xyphoid process

Question 32

what instructions do you include when educating a pt with chronic constipation?

Answer 32

Schedule time to use the toilet at the same time every day.
Exercise for 30 minutes every day.
Increase fiber and fluids in the diet.

Question 33

when would a pt need an enteral feeding?

Answer 33

when the Patient is unable to ingest food but has a functioning GI tract

Question 34

what is enteral nutrition (EN)?

Answer 34

• provides nutrients into the GI tract
• preferred method of meeting nutritional needs if a patient is unable to swallow or take in nutrients orally yet has a functioning GI tract
• EN provides physiological, safe, and economical nutritional support
• receive formula via nasogastric, jejunal, or gastric tubes.

Question 35

what do you need to direct the AP to assist in feeding a client?

Answer 35

Verbal coaching
Chin-down technique
Thickened liquids
Appropriate positioning
Inspect mouth for food pockets
RD & SLP consult

Question 36

how do potassium imbalances manifest?

Answer 36

manifest as bilateral muscle weakness, cardiac dysrhythmias, and abnormal serum K+ levels

Question 37

how do calcium and magnesium imbalances manifest?

Answer 37

manifest as altered neuromuscular excitability and abnormal serum Ca++ or Mg++ levels.

Question 38

how do the osmolality imbalances hyponatremia and hypernatremia manifest?

Answer 38

as decreased level of consciousness and abnormal serum Na+ levels

Question 39

what does an arterial blood gases (ABG) test measure?

Answer 39

measuresthe acidity (pH) and the levels of oxygenand carbon dioxide in the blood from an artery
- used to measure how well lungs are able to move oxygen into blood and remove carbon dioxide

Question 40

what is a clinical marker of vascular volume?

Answer 40

fullness of neck veins (not a clinical marker of hyperkalemia)

Question 41

What assessments does a nurse make before hanging an intravenous (IV) fluid that contains potassium?

Answer 41

Urine output
Serum potassium level

Question 42

do you need to check a patient’s consciousness before hanging an IV?

Answer 42

no, they do not need to be awake and alert

Question 43

Which assessment does the nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) excess?

Answer 43

Sudden weight gain (overnight)
Fullness of neck veins when upright
crackles in lungs
eduma
if severe: confusion, pulmonary edema, oliguria (urine outputbelow30 mL/hr)

Question 44

What is an important function of potassium in the body?

Answer 44

Maintains resting membrane potential of skeletal, smooth, and cardiac muscle, allowing normal muscle function

Question 45

An older-adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects new onset of crackles in the lung bases. What is the priority action?

Answer 45

decrease the IV flow rate

Question 46

What factor is the most important when determining a patient’s total fluid volume status?

Answer 46

daily weights
- Each kilogram (2.2 lbs) of weight gained or lost overnight is equal to 1 L of fluid retained or lost.

Question 47

what happens when sodium and water intake is less than output?

Answer 47

isotonic loss
can be caused by vomiting, diarrhea, sweating
may cause hypovolemic shock

Question 48

when is hypokalemia indicated?

Answer 48

serum K+ level below 3.5 mEq/L (3.5 mmol/L)