Final exam Flashcards
1
Q
Oliguria
A
Painful urination
2
Q
Dysuria
A
Difficulty urinating
3
Q
Nocturia
A
Urinating at night
4
Q
polyuria
A
Frequent urination
5
Q
Urinary frequency
A
How frequent you urinate
6
Q
Urinary hesitancy
A
Difficulty starting stream
7
Q
What is urge incontinence?
A
(Overactive bladder) sudden urge to urinate followed by involuntary urinary leakage
8
Q
What is reflex incontinence?
A
Urinary incontinence caused by trauma or damage to nervous system
9
Q
What is detrusor hyperreflexia?
A
Increased detrusor muscle contractility, occurs even when no sensation to void
10
Q
What is mixed incontinence?
A
Symptoms of more than one incontinence type is experienced
11
Q
Overflow incontinence
A
Inability to empty bladder, retention
12
Q
What are other indications of overflow incontinence?
A
Dribbling, urine and weak urine stream, chronic over distension
13
Q
Functional incontinence
A
Occurs in many older adults, mental/ADL impairment that effects voiding in time
14
Q
Transient incontinence
A
Results form temporary condition, caused by delirium, infection,etc.
15
Q
Gross total incontinence
A
Continuous leaking of urine day and night/periodic uncontrollable leaking of large volumes of urine
16
Q
Intake and output assessment
A
Monitor fluids PO and IV; measure output; is it more intake than output? Vice versa?
17
Q
I&O interventions
A
NPO, fluid restrictions, increase fluid intake, indwelling catheter to measure output, graduated cylinders
18
Q
What is a CAUTI?
A
Catheter associated UTI
19
Q
Do you use sterile gloves when dong Catheter care?
A
NO
20
Q
When do you use sterile gloves with catheters?
A
When inserting a new catheter
21
Q
What do you assess when using a condom catheter?
A
Penile circulation, discoloration, secure positioning, tip has 1-2 inches from border of bag
22
Q
How many types of enemas are there?
A
4
23
Q
What is an emollient enema?
A
Stool softener, increase intestinal secretion of water, short term benefit only
24
Q
What is an osmotic enema?
A
Pulls fluid into intestine and causes distension and increased peristalsis- can be used for chronic constipation
25
What is a bulk forming enema?
High fiber, powder mixes with water to form normal feces, least irritating-> caution for clients with fluid restriction
26
What is the stimulant enema?
Causes local irritation to increase intestinal motility and inhibit reabsorption of water in large intestine
27
Interventions for incontinence
Kegel/pelvic floor exercises, scheduled toileting times, indwelling catheter, monitoring output
28
How do you assess the ABD?
Inspect, auscultate, palpate, percussion
29
What are expected findings of an abdominal assessment?
Round/flat contour, no visible peristalsis or pulsations, no discoloration, normoactive BS X 4 quadrants, no pain,tenderness, masses, or guarding with light palpation, no organomegaly, pain, tenderness, guarding with deep palpation. No lesions.
30
Risk factors for bowel elimination issues
Decreased physical activity, dehydration, malnutrition, diet issues, increased age,pregnancy, surgery and anesthesia, opioids and antibiotics, holding it in, depression
31
Laxatives
Used to increase stool motility, bulk forming, or increase Bowel movement frequency
32
Digital disimpaction
Use if enemas fail to remove impaction, last resort for constipation, provider order is necessary to remove impaction. Watch out for heart rate to increase and BP to drop bc of vagus nerve stimulation
33
Intestinal obstruction assessment
Abdominal distension, hyperactive bowel sounds (early), or hypoactive bowel sounds (late). No gas or bowel movements
34
Anabolic rxn
Synthesis
35
Catabolic rxn
Breaking down
36
Essential nutrient recommendations
Protein, whole wheats and grains, fruits, dairy.
37
What religions do not consume pork?
Buddhism, Judaism, Islam
38
Nutrient therapy
used to treat conditions like diabetes, kidney disease, heart disease, etc.
39
Dysphagia assessment
Voice change after swallowing, drooling, coughing, feeing of food stuck in throat
40
Dysphagia interventions
High-fowler’s position, smaller bites, thickened/altered diets
41
How do you calculate a BMI?
(lb/in squared) times 703
42
How many kilocalories are in a gram of fat?
9
43
How many kilocalories are in a protein?
4
44
how many kilocalories are in a carbohydrate?
4
45
what is nutrient therapy used for?
To treat and prevent conditions such as diabetes, heart disease, kidney disease, arthritis, obesity, and depression
46
What is the number one cause of food borne illness?
Improper/lack of handwashing
47
What type of urinary incontinence may require the nurse to insert an indwelling catheter?
Overflow (caused by retention which is one of few reasons we insert catheter)
48
Kegels are performed by contracting the pelvic floor muscles, how many quick flicks and how many sustained contractions are performed?
5 quick flicks and 10 sustained contractions
49
what VS changes need to be monitored when performing digital disimpaction?
HR and BP; heart rate increases (arrhythmias) and BP decreases
50
What does a positive fluid wave and shifting dullness mean?
Abdominal ascites
51
What 4 things are being assessed for during deep palpation?
Organomegaly, tenderness, masses, guarding
52
What should the nurse perform last for a client with ABD pain?
Deep palpation
53
The nurse is calculating urinary output. What mL/hr should be reported to the physician ?
30 mL/hr
54
The nurse applies a condom catheter to a client. What finding means immediate removal?
Discoloration and pain
55
what head/neck position should a client with dysphagia use?
Head tilt forward chin down
56
what will the nurse teach the client with stress incontinence?
Kegel exercises
57
does unpasteurized juice cause food borne illness?
Yes
58
What food is a full and nectar based liquid?
Cream based soup
59
Which laxative stimulates peristalsis by irrigating bowels. Can become dependent upon for voiding.
Stimulant
60
Which vitamin is found in high citrus and fruits?
C
61
What does a protuberant abd indicate (when not a pregnant person)?
Swelling, organomegaly, abdominal distension
62
A client on a heart healthy diet should avoid this type of specific nutrient?
Sodium, saturated trans fats
63
Which food should not be increased for a client on blood thinners?
Vitamin K
64
Which type of incontinence is caused by a UTI?
Transient (may have urge)
65
What will a client not do if they have a bowel obstruction?
No gas or bowel movement at all
66
What diet requires carbohydrate monitoring?
ADA/Diabetic diet
67
What are three nursing interventions to reduce risk of CAUTI?
Peri care, bag below the waist, maintain closed system
68
What common type of medication is given after surgery that causes constipation?
Opioids
69
What type of enema solution is contraindicated for a client in fluid overload?
Tap water, hypotonic solutions
70
Name a complete protein
Soy or chicken
71
How many kilo calories are in a fat?
9
72
a client is on bed rest with a catheter, how often should you empty the bag?
Bag gets half full
73
what is it called when a client has difficulty urinating?
Hesitancy
74
Which assessment skill is used to hear tympany?
Percussion
75
What specific type of food should a vegetarian eat to maintain anabolism?
Soy (protein)
76
What is the term used to describe the symptom of urinary incontinence?
Dribbling or leaking
77
What is QSEN?
Quality and safety education for nurses
78
What are the five steps of the nursing process?
ADPIE- assessment, nursing diagnoses, planning, implementing, evaluating
79
What part of the nursing process entails recognizing and analyzing cues, prioritizing hypotheses, generating solutions, and evaluating the outcomes?
clinical judgement
80
what requires self-reflection of bias and stereotypes, is self motivated, evolving, and bridges cultural gaps?
Cultural competence
81
what are the 8 critical factors of history of present illness?
Location, character/quality, quantity/severity, timing, setting, aggravating/relieving factors, associated factors, client’s perception
82
What are the modes of transmission?
Contact, droplet, airborne, vector borne
83
What is the contact mode of transmission?
indirect(object to person) and direct(person to person), fecal-oral (handling food after using the restroom and failing to wash hands)
84
What is the droplet mode of transmission?
When microorganisms 5 mcg or larger can spread <6 feet, sneezing, coughing, talking
85
What is the airborne mode of transmission?
Organisms smaller than 5 mcg can travel greater than 6 feet, sneezing and coughing, wear an N95!
86
What is the vector borne mode of transmission?
Animals and insects carry the disease/illness
87
What causative agents infect the respiratory system frequently?
Myobacterium tuberculosis, streptococcus pneumonia
88
What causative agents infect the GI tract frequently?
Shigella, salmonella enteritidis, salmonella typhi, hepatitis A
89
What causative agents infect the genitourinary system frequently?
Escherichia coli, hepatitis A, herpes simplex virus(type 1), HIV
90
What causative agents infect the skin/mucous membranes frequently?
Herpes simplex virus, varicella
91
What causative agents infect the blood/ body fluids frequently?
HIV, hepatitis B and C
92
What PPE is used for contact precautions?
Gown and gloves for contact with patient or environment of care
93
What PPE are used for droplet precautions?
Surgical masks within 3 feet of patient
94
What PPE are used for airborne infection isolation patients?
N95 respirator, negative pressure isolation room also required
95
What causes Pallor?
Lack of color in skin, vasoconstriction, decreases in RBCs (oxygenated hemoglobin)
96
What causes erythema (red skin change)
Hyperemia (increased blood flow), polycythemia (increase in RBCs)
97
what causes cyanosis (blue skin color change)
Decreased perfusion, increased deoxygenated hemoglobin
98
what causes jaundice (yellow skin color change)
Increase in serum bilirubin (liver inflammation or disease)
99
What is objective data?
Can be seen, heard, or felt and measured; i.e. skin palpation, texture, thickness, edema, turgor
100
what is the ABCDE tool used for?
Evaluating skin lesions for cancer
101
What does the ABCDE skin tool stand for?
A- asymmetrical (abnormal)
B- Borders (are they smoothe or irregular?)
C- color (does it change over time?)
D- diameter (is it greater than 6 mm?)
E- elevation (is it elevated?)
102
what do you wash first when giving a bath?
Client’s face
103
How do you determine the order in which you wash a patient?
Wash cleanest to dirtiest
104
How do you wash a client’s extremities?
Long firm strokes distal to proximal
105
how do you wash the lower extremities on a client with a history of DVT?
Light strokes avoiding massaging or hard pressure
106
What are the things you should educate your client in diabetic foot care?
Do not walk barefoot, keep feet clean and dry, wash them in lukewarm water, dry them thoroughly, clean dry socks at all times, wear footwear that fits, check the inside of the shoes for rough objects, inspect the entire foot surface, with mirror or caregiver daily for Signs of redness, lesions, dryness, and infection. Don’t soak your feet! Cut your toenails straight across (not without a physician order) and file short with emery board
107
A lactovegetarian will eat which food?
Chicken
Fish
Milk
Eggs
Milk
108
What does it mean to provide patient centered care?
Try to see a client’s worldview
109
What describes the client as the full partner in compassionate and coordinated care?
Patient centered care
110
Which describes the conclusion about a client’s needs that leads to taking action?
Critical thinking
Diagnostic reasoning
Clinical judgement
Evaluating outcomes
Clinical judgement
111
How do nurses make clinical decisions?
By thinking about EBP
112
What clinical judgement skill causes the nurse to collect, categorize, and clarify data?
Interpretation
113
Which of the following is a QSEN competency?
Population health
Evidence-based practice
Genomics
Self-health care
Evidence-based practice
114
What do nurses evaluate during ADPIE?
Client outcomes
115
The nurse provides a bed bath and then asks the client how they feel. Which ADPIE is this?
Evaluation
116
Which is the analysis of the assessment data to determine actual or potential problem?
Diagnoses
117
Which intellectual standard describes communicating what is factual?
Clear
Relevant
Complete
Accurate
Accurate
118
What is the nurse doing when they help improve a client’s quality of life?
Being a caregiver
119
Which attitude is the new nurse demonstrating when looking up hospital policy for infection prevention measures?
Responsibility
120
Which role is the nurse performing when assisting the client in getting an advance directive?
Autonomy
Advocacy
Manager
Educator
Advocacy
121
Which of the following is a standard of professional performance?
Informatics
Nursing knowledge
Health promotion
Education
Education
122
Which is the process of conducting self-examination of one’s own biases toward other cultures?
Cultural desire
Cultural knowledge
Cultural skill
Cultural awareness
Cultural awareness
123
What should the nurse do to be culturally competent?
Examine one’s own beliefs
124
What is the nurse achieving when providing a medical licensed interpreter for a client who does not speak English?
Linguistic competency
125
What means the capacity to obtain, process, and understand basic health information and make health decisions?
Health literacy
126
What type of health difference is closely linked to social, economic, and or environment disadvantage?
Health disparity
127
What should the nurse do to build a therapeutic relationship with the client?
Use open ended questions
128
“I am in so much pain that I can not sleep”. This describes
Perception
Quality
Aggrivating factor
Associated factor
Perception
129
What is the client describing when they state “my chest feels really tight.”
Quality of pain
130
Which type of PPE must be worn when organisms can be spread > 6feet via sneezing?
N95
131
Which mode of transmission is characterized by germs being carried less than 6 feet via sneezing?
Droplet
132
After nurse removes their googles they will remove their:
Gown
133
Which is a risk factor for impaired skin integrity?
Using sunscreen
Warm and dry skin
Impaired mobility
Presence of a wound
Impaired mobility
134
A client with hypoxia may have which of the following skin color change?
Cyanosis
135
A client’s skin turgor test reveals tenting for 4 seconds. What does this indicate?
Deficient fluid volume/ dehydration
136
Which is expected of lesions?
Evolving
2mm in size
Irregular shape
Asymmetrical color
2mm in size
137
Which assessment finding should the nurse expect for a client with a fever?
Bradycardia
Hypotension
Hypothermia
Tachypnea
Tachypnea
138
Which is true about bathing?
Stroke distal to proximal
Wash dirty to clean
Wash with cold water
Massage legs
Stroke distal to proximal
139
Which could the nurse do when giving a bath?
Wash dirty to clean
Put up 4 side rails and leave the room
Soak all client’s feet
Use light strokes for a client with DVTs
Use light strokes for a client with DVTs
140
Diabetic toenails should be cut
Straight across
141
What is the clinical decision making model for nurses?
Nursing process
142
An emic world view is intercultural from an insider perspective T/F?
True
143
An implicit bias is when we are aware of a bias that is present T/F?
True
144
Responsibility, discipline, creativity, and curiosity are key to components of the attitudes of critical thinking T/F?
True
145
T/F: the most critical source of knowledge a nurse applies to critical thinking is not only from the medical record
True
146
A culturally competent assessment includes the client’s view of their illness T/F
True
147
what is the correct order for donning full PPE?
Gown, mask, goggles, gloves
148
Which type of heat loss occurs from the transfer of heat from one object to another?
Radiation
Conduction
Evaporation
Diaphoresis
Conduction
149
A client’s skin turgor test reveals tenting for 1 second. What does this indicate?
Good turgor, good hydration
150
What tool will the nurse use to assess for pediculus capitus?
Comb
151
Which of the following is correct?
U is approved for unit
2.2lb=1Kg
BID means four times a day
1 in. Is = to 2.45 cm
2.2lb=1Kg
152
T/F your client’s verbal description of their health problem is collected as objective data
False
153
Which is the nurse performing when asking the client what they preferred to be called?
Courtesy
Comfort
Connection
Confirmation
courtesy
154
T/F an open ended question is used to seek specific information about a problem
False
155
which WBC count ins expected for a client with an acute infection?
2,ooomm3
6,000mm3
9,000mm3
15,000mm3
15,000mm3 ( normal is 5,000-10,000 mm3)
156
What physical assessment technique uses touch to gather information?
palpation
157
What is the assessment of appearance and behavior?
General survey
158
Which temp alteration occurs when pyrogens trigger the immune system causing the hypothalamus to raise the set point?
Hyperthermia
Heatstroke
Hypothermia
Pyrexia
Pyrexia
159
Which finding is expected for an older client?
Increased subcutaneous fat
Increased cap refill
Decreased skin turgor
Increased body hair
decreased skin turgor
160
a microorganism that is transmitted by small, evaporated particles suspended in the air during needing requires:
Airborne isolation
161
what does delegate mean?
Entrust a task to another person
162
T/F make sure the client has all 4 bed rails up to ensure safety
False
163
Which action should the nurse take to auscultate heart sounds?
Assess in a W shaped pattern
Identify S1 but not S2
Use the diaphragm first
Begin at the 2nd ICS and LSB
Use the diaphragm first
164
Oxygenated blood is pumped from the left ventricle to the
aorta
165
What is the extra heart sound heard right before S1?
S4
166
S1=closure of the aortic and pulmonic valves T/F
False
167
What is a blowing or swishing sound over the mitral valve?
Murmur
168
The nurse knows that S1 is the sound of:
The tricuspid and mitral valves closing
169
What is a swishing or blowing sound heard over an artery?
Bruit
170
The nurse auscultating over the 2nd ICS RSB will hear:
Aortic valve area
171
The nurse may suspect right sided heart failure on which assessment findings?
Pale extremities
+0 pitting edema
+1 pedal pulses
JVD
JVD
172
The nurse may suspect right sided heart failure based on which assessment findings?
Pale extremities
+4 pitting edema
+1 pedal pulses
Crackles in the lungs
+4 pitting edema
173
The nurse auscultating over the 5th ICS L midclavicular will hear:
Mitral valve
174
what is assessed when measuring a radial pulse?
Rate, rhythm, strength
175
The nurse knows that S2 is the sound of:
The closure of the semilunar valves
176
What is an extra heart sound at the beginning of diastole?
S3
177
Deoxygenated blood is pumped from the right ventricle to
The lungs
178
A Doppler is used to detect a peripheral pulse undetectable through palpation T/F
True
179
A client with atherosclerosis is at risk for tissue ischemia T/F
True
180
What helps to promote venous return?
Increased fluid
Bed rest
Ambulating
Dangle feet
Ambulating
181
Which assessment finding indicates venous insufficiency
Red/brown color on legs
Cap refill time of 4 sec
Deep sharp calf pain with activity
+1 peripheral pulses
Red/brown color on legs
182
Which finding indicates arterial disease?
+3 pretibial edema
Red/brown discoloration
Weeping irregular wounds
+1 pedal pulses Bilaterally
+1 pedal pulses bilaterally
183
Which finding indicates arterial disease?
+3 pretibial edema
Shiny hairless legs
Weeping irregular wounds
+2 pedal pulses Bilaterally
Shiny hairless legs
184
Which assessment finding indicates venous insufficiency?
Leg aching relieved by elevation
Cap refill time of 4 sec
Deep sharp calf pain with activity
Shiny hairless skin on legs
Leg aching relieved by elevation
185
How is a 4mm moderate pitting edema grading?
+2
186
Which assessment findings indicate a DVT?
Redness, warmth, swelling, pain in 1 leg
187
Which should be done to get an accurate BP?
Place 3-4 inches above pulse
Arm above the heart
Pump 20-30 above stated systolic
Arm not supported
Pump 20-30 above states systolic
188
Which would cause a false low BP reading?
Legs crossed
Arm above the heart
Cuff too narrow
Arm not supported
Arm above the heart
189
Which technique will the nurse use to assess to resonance?
Auscultation
Palpation
Inspection
Percussion
Percussion
190
what are high-pitched popping lung sounds on inspiration called?
Fine crackles
191
What are medium pitched with equal duration lung sounds heard over the major bronchi called?
Bronchovesicular
192
A respiratory rate of 8 bpm that is regular is called?
bradypnea
193
The nurse hears high-pitched, musical squeaking on auscultation of the lungs and documents:
Crackles
Friction rub
Wheezing
Stridor
Wheezing
194
A client with an SPO2 of 80% may have which skin color changes?
Cyanosis
195
The nurse auscultates high pitched, loud, and tubular sounds over the trachea and documents:
Normal bronchial breath sounds
196
Which will the nurse note on a client with COPD?
Nail bed angle of 160 degrees
AP diameter=T diameter
Resonance in all lung fields
Cap refill of 2 sec
AP=T
197
Respiratory rate that is 8bpm and depth is shallow?
Hypoventilation
198
What nail bed angle will the nurse note with a client with COPD
190 degrees
199
The nurse hears barking or honking on inspiration on auscultation of the trachea and documents:
Crackles
Friction rub
Wheezing
Stridor
Stridor
200
What are normal bronchial sounds?
High pitched, loud, and tubular sounds over the trachea
201
What are low pitched bubbling lung sounds on inspiration called?
Course crackles
202
What assessment will the nurse perform when the nurse palpates the chest wall while the client states 99
Tactile fremitus
203
When beginning lung auscultation start at the 2nd ICS LSB T/F
False
204
What tool is used to test visual acuity?
Snellen chart
205
Artificial eyes should be cleaned how often?
As needed
206
What does PERRLA stand for?
Pupils equal, round, and reactive to light with accommodation
207
Denture care should be performed when:
After meals and at bedtime
208
The Rinne test compares air and bone conduction T/F
True
209
Which of the following will increase in elderly adult client
Hearing acuity
Sense of smell
Cerumen
Saliva production
Cerumen
210
What can you use to clean artificial eyes?
Sterile/normal saline and soap and water
211
20/20 sees better than 20/15 T/F
False
212
Webber test indicates that there is hearing loss T/F
True
213
what does 20/30 mean?
The 20/20 person sees the same at 30 feet
214
To straighten the canal of an adult you pull it up and back T/F
true
215
How should the nurse manage the effects of immobility on the respiratory system ?
Turn the client every 4 hours
Teach the client to use an IS (insentive spirometer)
Position the client supine
Always apply oxygen
Teach the client to use an IS (incentive spirometer)
216
why apply SCDs?
Promote venous return
217
What intervention should the nurse take with a client with orthostatic hypotension and dizziness?
Dangle the legs while sitting for 1-2 minutes
218
Which is true for restraints?
Consent is not required
An order must be re-newed every 48 hours
Assessment is required every 4 hours
Assess for discontinuation at least every 2 hours
Assess for discontinuation at least every 2 hours
219
Which client should be the most motivated to learn?
The client who reports pain at a 8/10 on the pain scale.
The client who stays, "I just don't think I can tell my family about this."
The client who believes treatment will make them feel better.
The client who has a HR of 115 and a SpO2 of 88%.
The client who believes treatment will make them feel better
