Exam 3 Review Flashcards
A nurse notices smoke coming from a patient’s room. What is the nurse’s immediate action according to the RACE protocol?
A) Rescue any patients in immediate danger.
B) Activate the fire alarm.
C) Confine the fire by closing doors.
D) Extinguish the fire if safe to do so.
A
What is a complication of immobility?
Muscle atrophy
A patient with a history of seizures is being admitted to the hospital. Which of the following safety measures should be included in the care plan?
A) Placing a padded tongue blade at the bedside.
B) Keeping the bed in a high position.
C) Ensuring the availability of suction equipment at the bedside.
D) Applying wrist restraints to prevent injury.
C
Which of the following is a priority action for a nurse when using a mechanical lift to transfer a patient from a bed to a chair?
A) Ensure the sling is the correct size for the patient.
B) Operate the lift independently to save time.
C) Position the chair at a 45-degree angle to the bed.
D) Leave the lift’s wheels unlocked for easier maneuverability.
A
If a patient has soft restraints (wrist restraint, vest, etc), how often must the order be put in?
every 24 hours
A nurse is assessing pain in an infant. Which pain scale should the nurse use?
FLACC
A nurse is assessing an infant. Which of the following are manifestations of pain in an infant? (Select all)
A. pursed lips
B. Loud cry
C. Lowered eyebrows
D. Rigid body
E. Pushes away stimulus
B, C, D
Who defines health as a state of complete physical, mental, and social well-being; not just absence of disease?
WHO - World Health Organization
Jean Watson proposed that health consists of what three elements?
1) a high level of overall physical, mental, and social functioning
2) a general adaptive-maintenance level of daily functioning
3) the absence of illness (or the presence of efforts that lead to its absence)
What are factors that interrupt health?
Physical disease
Injury
Mental illness
Pain
Loss
Impending death
A healthy person attends an event about prevention of the flu. What level of health prevention is this?
Primary
Pain that has a duration of less than 6 months?
Acute pain
Organisms such as animals and insects that transmit pathogenic bacteria, viruses, protozoa would contribute to which style of transmission?
Vector transmission
What would you do if you suspect a child has ingested large amounts of medication that was not intended for them?
Call poison control
What poisoning can happen if you run a gas powered car in a closed garage?
Carbon monoxide poisoning
Why would a nurse need to know about home safety?
To know the environment a patient is being discharged to
What does RACE stand for in fire safety?
Rescue, activate, contain, extinguish
What does PASS stand for in fire safety?
Pull pin, aim at base, squeeze, swipe
What is a ‘never’ event in healthcare?
Serious, preventable events that could result in death or disability
Give examples of a ‘never’ event…
pressure injuries, falls, catheter infections, poorly controlled blood sugar, air embolism, wrong blood administered
Pressure injuries, contractures and loss of strength are physical effects that can result from _____
Restraints
What are emotional effects of restraints?
Anger, fear, humiliation, low self-esteem
What are a few types of restraints?
all four bed rails up, sedatives, physical force by another, equipment such as arm restraints
What must you have to use restraints?
Dr. orders
Why is body weight a consideration for skin integrity?
Skin folds are more prevalent and can harbor moisture which leads to skin breakdown
Encourages optimal function and healthy behaviors?
Health Promotion
Initiatives for improving overall health and well-being.
A. Wellness assessments
B. Health Promotion
C. Immunization clinics
D. Wellness programs
D. wellness programs
Evaluation to determine health status and needs.
A. Relieving factors
B. Secondary prevention
C. Wellness assessments
D. Wellness programs
C. wellness assessments
Health consists of physical, mental, and social functioning.
A. Immunization clinics
B. Self-report of pain
C. Wellness assessments
D. Jean Watson’s Theory
D. Jean Watson’s Theory
Early detection and treatment of illnesses.
A. Primary Prevention
B. Secondary prevention
C. Tertiary prevention
B. Secondary prevention
Complete physical, mental and social well-being is ____
health
What is used for predicting pressure sore risk?
Braden Scale
This encourages optimal function and healthy behaviors?
Health promotion
Initiatives for improving overall health and well-being?
Wellness programs
Evaluations to determine health status and needs?
Wellness assessment
When should a Braden Scale evaluation be performed?
Upon admission and again 48-72 hours later
If a patient is _____ or below on the Braden Scale they are considered at risk for pressure sores.
18
High risk is considered ___ or below on the Braden Scale.
12
Activities to prevent disease onset are _____ prevention.
primary
Pain that lasts less than 6 months?
Acute pain
Pain lasting longer than 6 months?
Chronic pain
Which type of cutaneous pain control would best benefit a client who is afraid of needles?
A. TENS
B. PENS
C. spinal cord stimulator
D. acupuncture
A. TENS
The nurse is educating a group of clients in a community center about the use of over-the-counter pain medications such as nonsteroidal anti-inflammatory drugs (NSAIDs). What information would be most important to include? Select all that apply.
A. Take NSAIDS with food or meals
B. Use of aspirin can prolong bleeding time
C. Use of two NSAIDS simultaneously can control pain
D. Use of ibuprofen is safer than perscription NSAIDS
E. Use of acetaminophen is an effective anti-inflammatory medicine
A, B, D
At what times during the shift should the nurse assess the fifth vital sign? Select all that apply.
A. Upon admission
B. Before and after each potentially painful procedure
C. With each check of vital signs, if pain is a potential problem
D. With a change in the patient’s condition
E. Immediately after the delivery of pain meds
A, B, C, D
Which information should the nurse include when documenting the characteristics of a pressure wound located on the hip of a client? Select all that apply.
A. Location of the wound
B. Length, width, depth
C. Nutrition status of the client
D. Presence of undermining or tunneling
E. Number and type of dressings used
F. Drainage amount, color, consistency, odor
A, B, D, F
Which lifestyle choices can lead to alterations in skin integrity? (select all that apply)
A. Smoking
B. Tanning
C. Exercise
D. Daily bathing
E. Adequate nutrition
A, B
The nurse is providing tuberculin testing at a community-health program. Which factors should the nurse assess during the prevaccination screening? Select all that apply.
A. History of diabetes mellitus
B. Current and past tabacco use
C. Prior exposure to Tuberculosis
D. Country of birth and recent travel
E. Employment in healthcare setting
C, D, E
An individual begins gasping for air and makes an unusual high-pitched, harsh, crowing sound. What could be occurring?
A. Airway obstruction
B. asthma attack
C. Pneumonia
D. Croup
A
In which position should the nurse place the client to perform percussion and postural drainage for the middle lung lobes?
A. Supine
B. High Fowlers
C. Trendelenburg
C
What should the nurse educator include when giving a presentation to a group of nurses about ways to prevent nurse back injuries while transferring a patient? Select all that apply.
A. Use electric or mechanical lift when available
B. Obtain assistance from co-workers
C. Lock wheels on furniture and equipment before moving
D. Move clients around equipment and furniture
E. Transfer client first, then cords
A, B, C
The nurse is transferring a client to bed upon admission. Which position should the nurse place the client in before beginning a physical assessment?
A. Fowlers
B. Semi-fowlers
C. Prone
B
What priority concern should the nurse have for a client who has had a stroke and has left-sided hemiparesis?
A. Disuse syndrom
B. Sedentary lifestyle
C. Risk for injury
D. Impaired physical mobility
A
A woman performing a monthly breast self-exam is an example of which level of prevention?
Secondary
What can the nurse do to act as a role model and promote health and wellness to clients? Select all that apply
A. Maintaining a healthy BMI
B. Not smoking
C. Maintain a healthy work/life balance
D. Engage in preventative medicine
E. Practice sensory stimulation for stress relief
A, B, C, D
Which level of health prevention is represented by a client receiving physical therapy following a hip fracture?
Tertiary
True or False: A pressure injury is a specific type of tissue injury from unrelieved pressure, usually over bony prominences
True
Age, loss of skin turgor, skin fragility, decrease in collagen, decrease in peripheral circulation and oxygen are all factors that affect ____ ______.
Would healing
This type of drainage is thick and appears reddish; brighter drainage indicates active bleeding.
Sanguineous drainage
This type of drainage is watery, clear or slightly yellow in appearance. (Same fluid found in a blister)
Serous drainage
This type of drainage has serum and blood. It is watery and looks pale pink due to mixture of red and clear fluids.
Serosanguineous drainage
This type of drainage is a result of infection. It is thick and can have a foul odor. Its color can be yellow, green, tan, brown)
Purulent drainage
A mixed drainage of pus and blood is what type of drainage?
Purosanguineous
A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first?
A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask
B. A client who has emphysema and is receiving oxygen at 3L/min via transtracheal oxygen cannula
C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar
D. A client who has COPD and is receiving oxygen at 2 L/min via nasal cannula
A.
A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations?
A. increased intestinal motility
B. respiratory alkalosis
C. decreased cardiac output
D. hypocalcemia
C
A nurse is caring for a toddler at a well-child visit when the mother calls, “Help! Why baby is chocking on food.” Which of the following findings indicate the toddler has an airway obstruction?
A. Flushing of the skin
B. Inability to speak or cry
C. Presence of nausea and mild emesis
D. Capillary refill time of 1.5 sec
B
WNL
within normal limits
How long between puffs on an inhaler?
20-30 second gaps
To prevent thrush when using an inhaler what should the patient do?
Rinse mouth after use, especially steroids
True or False: When inhaled, albuterol is short-acting and when taken orally it is long-acting.
True
Which drug when Inhaled is a short-acting treatment for bronchospasm and asthma
albuterol
A nurse is providing instructions to a client who has a new prescription for oral albuterol. Which of the following instructions should the nurse include?
A. You can take this medication to abort an acute asthma attack
B. Tremors are an adverse side effect of this med
C. Prolonged use of this med can cause hyperglycemia
D. This med can slow skeletal growth rate
B
Which stage is superficial damage to the epidermis where skin appears intact but often red or discolored (non-blanchable)?
Stage 1
Stage of pressure ulcer cannot be determined due to eschar or slough covering the visibility of the wound. Which stage is this?
Unstageable
Skin is not intact, extends into but not through the underlying fascia, deep crater with or without tunneling.
Stage 3
Localized discolored area of intact skin, indicating underlying tissue damage. Skin is unbroken. Which stage of pressure ulcer is this?
Deep Tissue Injury (DTI)
A lubricant made in the lungs that keeps the alveoli from collapsing?
surfactant
The flow of blood by the cardio-pulmonary system into the alveolar capillaries.
Perfusion
Intercostal retractions are a sign of severe respiratory distress or _____
hypoxia
With pneumonia you will find ___ and ____ in the alveoli.
Puss and fluid
With asthma the bronchioles become _____ with higher resistance and wheezing.
narrow
What is the most chronic respiratory disease in school age children?
Asthma
What type of focused assessment would a patient with symptoms of decreased oxygenation, shortness of breath, activity intolerance or history of cardiac or respiratory problems receive?
Cardiopulmonary assessment
If a respiratory distress is present in a new patient, what kind of questions should be asked?
Closed ended questions
Select all that apply - What would you assess in a patient with a cough?
A. Productive or dry cough
B. Edema in the extremities
C. Lung Sounds
D. PERRLA
E. Capillary refill
F. Skin color and texture
A, B, C, E, F
Edema is the swelling of tissues caused by expansion of interstitial fluid volume. What does this tell you about the heart?
The left side is working too hard or right side is not working hard enough
Short of breath and abnormal low level of circulating oxygen in the arterial blood is ______
hypoxemia
Inadequate tissue oxygenation at the cellular level is _______
hypoxia
_____ can lead to ______ (word bank: hypoxia, hypoxemia)
hypoxemia can lead to hypoxia
Which two assessments are used for hypoxia and hypoxemia?
Respiratory and cardiopulmonary
What are two long term signs of hypoxia?
clubbing of nails and barrel shaped chest
What is hemoptysis?
blood in the sputum
What are signs and symptoms of hypoxia?
Restlessness, agitation, tachycardia, shortness of breath, anxiety, confusion, decreased oxygen saturation, nasal flaring, use of accessory muscles
What are signs and symptoms of hypoxemia?
respiratory rate over 20, shortness of breath, coughing, sweating, wheezing
How would you treat hypoxia and hypoxemia symptoms?
Getting Dr’s orders to administer oxygen
Select all that apply: What interventions would you take with a patient that has hypoxia or hypoxemia?
A. Bed in high fowlers at all times
B. Bed in trandelenburg
C. Use of incentive spirometer
D. Aspiration precautions
E. Mobilizing secretions
A, C, D, E
How often should you teach a patient to use an incentive spirometer?
5-10 times per hour while awake
Why would a patient be on aspiration precautions with hypoxia?
Because if they try to take deep breaths between bites of food they are at a higher risk for choking
Which receptor is stimulated by an unpleasant-tasting medication?
A. Olfactory
B. Gustation
C. Auditory
D. Tactile
B. Gustation
A 74-year-old client is hospitalized with acute-onset delirium of unknown etiology. The nurse questions the family and asks what has changed recently. Which responses made by the family could have contributed to the delirium? Select all that apply.
A. Bipolar disorder
B. New medication
C. Electrolyte Imbalance
D. Urinary Tract Infection
E. Physical change in the brain
B, C, D
Which clients are at the greatest risk for sensory deprivation? Select all that apply.
A. Older adult who lives at home and can’t drive
B. Older adult living in assisted living and mobile
C. Middle aged adult who suffers from sleep deprivation from working 16-18 hours a day on a computer
D. A teen who is blind and uses a seeing eye dog
E. A school age child with cerebral palsy since birth
F. Young adult who recently moved from another country and can’t speak the language of those in the neighborhood
A, C, D, E, F
What should the nurse assess and monitor for in the older adult client experiencing sensory decline? Select all that apply.
A. depression
B. social isolation
C. fatigue
D. decline in physical activity
E. hallucinations
A, B, E
A client with peripheral arterial disease presents to the clinic with an open wound on the left shin. Which findings would the nurse expect to discover during the assessment? Select all that apply.
A. Pain
B. Edema
C. Loss of hair
D. Tissue necrosis
E. Jagged would edges
A, C, D
When checking on a postoperative client, the nurse notices evisceration. What action should the nurse take?
A. Cover the wound with sterile towels or dressings soaked in sterile saline solution
B. Notify the surgeon
C. Prepare client for surgery
A
What skin condition should the nurse monitor in a client who is taking blood pressure medication?
A. Xerosis
B. Hematoma
C. Ischemia
C
