Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Skills > Exam 7 > Flashcards

Exam 7 Flashcards

1
Q

What does nutrition do for the body?

A

Essential for growth and development, tissue maintenance and repair, and organ function.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Assessments for nutrition

A

Daily weights
Labs: (Liver) AST, ALT, ALP, Albumin, Total protein (Kidney) BUN, Creatinine, eGFR, Glucose
Assess diet and health history
Any conditions affecting food consumption and and absorption

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Assessment for dysphagia (G=GI)

A 
Signs:
Cough while eating
Change in voice after swallowing
Abnormal oral movements 
Uncoordinated, inconsistent, slow speech 
Abnormal gag and swallowing
Pocketing
Regurgitation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How to assess for dysphagia?

A

Have pt sit in high Fowler and take a sip of water. If difficulties persists notify physician and registered dietician.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Complications of dysphagia?

A

Aspiration pneumonia
Dehydration
Decreased nutrition
Weight loss

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Nurses role in nutrition?

A 
Review orders
Advance diet as tolerated
Promote appetite 
Assist with eating
Use weighted silverware
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Types of ordered diets?

A 
NPO,
Clear liquid,
Full liquid, 
[Dysphagia stages, Thickened liquids, puréed]
Mechanical Soft,
Low sodium,
Low cholesterol
Diabetic 
Cardiac
Gluten free
Regular
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

NPO

A

Nothing by mouth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Clear liquid

A

Liquids that are clear at room temperature.

Ex: Clear fat-free broth, bouillon, coffee, tea, soda, clear fruit juice, jello, popsicles, water

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Full Liquid

A

Same for clear with dairy, strained or blended soup, refined cooked cereal, vegetable juice, puréed vegetables, all fruit juice, sherbets, puddings, frozen yogurt

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Dysphagia stages

A

All foods for clear and full in addition to scrambled eggs, puréed meats, vegetables, fruit, mashed potatoes and gravy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Mechanical soft

A

Foods that are mashed up by a machine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Low sodium

A

4g, 2g, 500mg restriction. Can vary from no salt added to severe restriction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Low Cholesterol

A

300 mg a day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Diabetic Diet

A

A balanced intake of carbs, fats, proteins and varied caloric recommendation based off the American diabetes association

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Gluten free diet

A

Eliminates wheats, oats, rye, barley, and their derivatives from their diet.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Regular diet

A

No restrictions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

How to feed patients with dysphagia or no ability to swallow?

A

Enteral nutrition via gastric tube (nasogastric, jejunal, or gastric).
Needed if pt is an aspiration risk or not alert.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q 
Gastric tubes (naso/oro) are for permanent use.
True or False?
A

False, if it’s still needed a permanent option will be added.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are the sizes of NG tubes? What is it used for?

A

<12,12,14,16, and 18 French.

12 or greater French is for gastric decompression or removal of gastric contents

Use: feeding/med admin, decompression, lavage (stomach pumping)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Types of gastric tubes?

A

Nasogastric (NGT)
Nasojejunal (NJT)
Orogastric
Surgically placed
Percutaneous Endoscopic Gastrostomy (PEG)
Percutaneous Endoscopic jejunostomy (PEJ)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

True or false: Going past the stomach is okay when inserting a gastric tube?

A

True, it’s okay since the small intestine is most important.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What to document for NGT insertion?

A 
Size
Nare it was placed in
Where it was secured
Gastric content residuals
Did pt tolerate 
Current tube condition
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

How to manage a nasogastric tube?

A

Very tube hasn’t moved by checking measurement.
Keep tube secure.
Always flush 30ml water before and after use.
Use aspiration/safety precautions: HOB higher than 30, ensure tube stays about stomach.
Assess nares for skin breakdown, and lube nostrils PRN
Assess oral mucosa integrity and moisture, offer oral swabs and chapstick PRN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Complications of a PEG tube?

A

Pain at site
Leakage of stomach contents around site
Dislodged or malfunction of tube.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

How long can a PEG tube last?

A

Months or years.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What medications do you need to use for an NGT or PEG.

A

Liquid is perfected but can also use crushes tables, opened capsules. 60ml enteral tube syringe is used to deliver medications.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What’s important to do before insertion and before use of an NGT?

A

Assess your abdomen and bowel sounds.

Inspect, auscaltate, palpate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What do you have to do before you can use the NGT or PEG tube? (hint: 60ml)

A

Confirm placement using enteral tube syringe (60mL). Aspirate 30mL gastric contents and assess color/consistency and then flush 30mL of air and listen for “air swoosh” utilizing stethoscope (this can only be done after xray has confirmed placement).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

At what amount of residuals should you hold feeding and medications for 2 hours?

A

500mL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Why would a gastric tube be removed?

A
  • Temporary tube being removed because permanent tube is being placed (-Ostomy tube)
  • Bowel obstruction resolved/Bowel sounds changed from absent to active
  • Out of coma
  • Lavage completed
  • Dysphagia resolved
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

List the 4 steps of the digestion process.

A
  1. Digestion: Begins in the mouth and ends in the small and large intestines
  2. Absorption: Intestine is the primary area of absorption
  3. Metabolism and storage of nutrients
  4. Elimination: Chyme is moved through peristalsis and is changed into feces
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

What are the three parts of the small intestine (in order)?

A

Duodenum, jejunum, and ileum

34
Q

What is absorbed by the small intestine?

A

Carbohydrates, protein, minerals, and water-soluble vitamins

35
Q

What is peristalsis?

A

A series of involuntary wave like muscle contractions which move food along the digestive tract

36
Q

Where is an ileostomy located?

A

Ileum/small intestine

37
Q

Where is a colostomy located?

A

Colon/large intestine

38
Q

What is the stool consistency of an ileostomy?

A

Thin to thick liquid

39
Q

What is the stool consistency of a transverse colostomy?

A

Thick liquid to soft consistency

40
Q

What is the stool consistency of a sigmoid colostomy?

A

More formed stool

41
Q

What are some nutritional considerations for a patient with an ostomy?

A
  • Consume low fiber for the first weeks
  • Eat slowly and chew food completely
  • Drink 10 to 12 glasses of water daily
  • Patient may choose to avoid gassy foods
42
Q

What position should a patient be in for enema and rectal suppository administration?

A

Left lateral Sims position

43
Q

What is the difference between impaction and constipation?

A

A person is unable to relieve the impaction on their own

44
Q

What do you need to assess before performing the digital removal of stool?

A

Heart rate

45
Q

What do different wound colors indicate?

A

Beefy Red – indicates tissue and skin healing, appropriate blood supply
Pink – no active s/s of infection, blood supply isn’t ideal
Yellow – slough or infection (Slough is the consistency of snot, indicates body ridding itself of bad tissue)
Black – dead tissue, no blood supply

46
Q

What causes skin tears?

A
  • Skin bumping into a hard object
  • Wound dressing changes & adhesive removal
  • Aggressively washing and/or drying the skin
47
Q

How often should you change wound dressing?

A

Leave dressing on unless visibly soiled or orders indicate dressing needs changed. You may only need to change outer dressing. Some wounds may be left open to air and will require a cleaning only.

48
Q

What are the risks of adhesive use on skin?

A

Adhesives can cause further damage, especially on chronic wounds and thin, fragile skin

49
Q

Who is at risk for pressure injuries?

A

Patients with decreased mobility, decreased sensory perception, fecal or urinary incontinence, or poor nutrition

50
Q

Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.)

  1. Lift the patient’s hips off the bed and slide the bedpan under the patient.
  2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle.
  3. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient.
  4. Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed.
  5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.
A

2, 5

51
Q

During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first?

  1. Stop the instillation.
  2. Ask the patient to take deep breaths to decrease the pain.
  3. Tell the patient to bear down as he would when having a bowel movement.
  4. Continue the instillation; then administer a pain medication.
A

1

52
Q

Which instructions do you include when educating a person with chronic constipation? (Select all that apply.)

  1. Increase fiber and fluids in the diet. 2. Use a low-volume enema daily.
  2. Avoid gluten in the diet.
  3. Take laxatives twice a day.
  4. Exercise for 30 minutes every day.
  5. Schedule time to use the toilet at the same time every day.
  6. Take probiotics 5 times a week.
A

1, 5, 6

53
Q

Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.)

  1. How to change the pouch
  2. How to empty the pouch
  3. How to open and close the pouch
  4. How to irrigate the colostomy
  5. How to determine whether the ostomy is healing appropriately
A

1, 2, 3, 5

54
Q

What temperature do tube feeds need to be given at?

A

Room temperature

55
Q

What is the primary source of absorption?

A

The small intestine, lined with villi (increases surface area)

56
Q

What’s influences bowel elimination?

A

Age, diet, fluid intake, physical activity, psychological factors, personal habits, position, pain, surgery and anesthesia, medications.

57
Q

Common bowel elimination problems?

A 
Constipation
Diarrhea
Flatulence
Impaction
Incontinence
Hemorrhoids
58
Q

Types of bowel diversions?

A 
Stoma 
Small intestines:
Ileostomy (more liquid)
Large intestine:
Colostomy (more solid) R side
Transverse colostomy (thick liq to soft)
Descending colostomy (Left mid abd)
Sigmoid colostomy (more formed)
59
Q

Nutrition and ostomy considerations?

A

Consume low fiber for first weeks
Eat slowly and chew food completely
Drink 10-12 glasses of water
Patient may choose to avoid gassy foods

60
Q

How to assess bowel elimination?

A 
History
Physical assessment: mouth and abdomen. Identify normal patterns
Lab tests
Fecal specimens 
Diagnostic exams
61
Q

Medications to help with bowel elimination?

A

Cathartics and laxatives
Antidiarrheal agents
Enemas

62
Q

How to administer a rectal suppository?

A 
Sterile technique not required
Explain procedure
Position patient in lateral sims
Hand hygiene and don gloves
Lube fingers and meds
Insert apx 1” or when past sphincter
*place on wall not in stool
Med will melt when at body temperature 
Common meds: acetaminophen and dulcolax
63
Q

How to digitally remove stool.

A

Assess HR
Reposition pt and perform hand hygiene and don gloves
Lube fingers and insert into rectum
Gently loosen fecal mass and assess as stool is removed

64
Q

Layers of the skin?

A

Epidermis
Dermal (epidermal junction)
Dermis

65
Q

Types of wounds?

A

Surgical wounds: incisions
Cut/laceration
Skin tears
Ulcers (pressure ulcers, arterial, venous, diabetic wounds)

66
Q

How to assess a wound?

A 
What kind and how it occurred?
Location,
Color,
Size, 
Drainage,
Odor ,
Pain,
Assess skin around wound,
Assess old dressing when removed,
Drainage/exudate amount of old dressing
67
Q

Factors influencing healing process?

A 
Nutrition 
Tissue perfusion 
Infection
Age
Strese
68
Q

How to care for a skin tear?

A

Control bleeding
Apply saline or warm water and gently clean skin. Put ripped skin back into place
Pat dry with clean gauze
Measure size of tear
Add steri strips carefully
Cover skin with no adhesive bandage
Use stockinette instead of tape/adhesive
Document skin tear size, location, cleansing and dressing, how pt tolerated

69
Q

How to clean a simple wound?

A

Review orders
Leave dressing unless visibly soiled or indicated by orders.
Assess old dressing if removed. Document amount, color, and odor.
Assess wound characteristics
Clean per orders
Apply topical ointments or special medicated dressing
Apply top dressing securely
Document

DO NOT CHANGE INITIAL SURGICAL WOUND DRESSING

70
Q

What causes pressure injuries?

A

Unrelieved prolonged pressure
Localized damage to the skin and underlying soft tissue
Can be intact, a blister, or open ulcer.

71
Q

Patients at risk for pressure injuries?

A

Decreased mobility
Decreased sensory perception (quad/paraplegic)
Incontinence
Poor nutrition

72
Q

Pathogenesis of pressure injury?

A

Pressure applied over period of time causes a capillary to occlude and causes tissue ischemia
If blood flow returns area is erythematic in color due to vasodilation.

73
Q

How to assess a pressure injury?

A

Press a finger to the area:
If it turns lighter in color and erythema returns this is blanchable
If it doesn’t change color this is called non-blanchable. If this occurs deep pressure injury is probable

74
Q

What decreases tissue tolerance?

A

Poor nutrition, aging, hydration status, and low BP can decrease tolerance of tissue to pressure.

75
Q

Risk factors for pressure ulcer development

A 
Impaired sensory perception 
Shear
Alterations on LOC ( coma, disoriented)
Impaired mobility
Shear (sliding movement)
Friction (two surfaces moving across another)
Moisture
76
Q

How to predict pressure ulcers?

A

Braden scale

Factor risk assessment

77
Q

How to prevent ulcers?

A 
Protect bony prominences
Skin barriers when incontinent 
Keep sheets tight under pt
Keep Chux to a minimum 
Change position often 
Support surfaces (pillows, seat cushions, special mattress.)
78
Q

What is the Braden scale?

A

Tool that is evidenced base and allows health care professionals to predict pt risk for hospital acquired pressure ulcer

79
Q

Scored for Braden scale?

A 
19-23 no risk
15-18 mild risk
13-14 moderate risk 
10-12 high risk 
<9 severe risk
80
Q

Stages of pressure ulcers?

A

Stage 1: intact skin with non-blanchable redness
Stage 2: partial thickness skin loss involving epidermis, dermis, or both
Stage 3: full thickness tissue loss with visible fat
Stage 4: full thickness tissue loss with exposed bone, muscle, or tendon

81
Q

Nurse role in wound management?

A

Identify risk factors for ulcer development
Through skin assessment
Identify if infection is present
Identify any change in skin
Keep wounds clean and dressed per orders
Communicate

Skills (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions