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PCC2: Parker > Final Exam > Flashcards

Final Exam Flashcards

1
Q

What is essential to note for IV potassium?

A

NEVER push potassium

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2
Q

What is atelectasis?

A

collapse of the alveoli

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3
Q

How can we prevent atelectasis?

A

encourage coughing/deep breathing, incentive spirometer

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4
Q

What does poor skin turgor and dry mucous membranes indicate?

A

fluid volume deficit

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5
Q

what may happen to the blood pressure during fluid volume deficit? What about the HR?

A

decreased BP
tachycardia

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6
Q

How can we prepare a patient for an MRI?

A

remove jewelry or metal, remove transdermal medication patches and insulin pumps/implants

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7
Q

Case study:
Exhibit 1
Patient is irritable, agitated, restless.
Exhibit 2
Nurse assesses client room and hears alarm beeping, overhead light is on, and TV is turned to full volume.

Which sensory condition are they likely
experiencing?

A

sensory overload

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8
Q

what interventions should be implemented for fluid volume overload?

A

daily weights (same time, same clothes), for bed weight-1 gown, sheet, pillow, assess for weight gain, I & O s

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9
Q

Which assessments are needed for suspected fluid volume overload?

A

breath sounds, check pulse, edema, JVD

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10
Q

When is the STOP BANG assessment required?

A

to assess a pt for a need of sleep study r/t sleep apnea

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11
Q

After assessing a post-op patient, a nurse auscultates all 4 quadrants of the pts abdomen and hears no bowel sounds after listening to each for 5 mins, what does the nurse suspect?

A

paralytic ileus

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12
Q

Give 3 examples of individuals who are at high risk for CAUTI?

A

older adults, prolonged catheter use, and immune compromised

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13
Q

What interventions can the nurse implement to prevent CAUTI?

A

-sterile technique
-routine perineal care
-bag below bladder
-empty bag regularly

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14
Q

What should the nurse do if a patient requiring a blood transfusion states, “I’m Jehovah’s Witness and can’t take that?”

A

accept their refusal and document

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15
Q

What condition may a patient develop if atelectasis is not treated?

A

fluid builds up making a place for bacteria to cause pneumonia

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16
Q

What are the main indications of late stage hypoxia?

A

blue on lips and fingertips

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17
Q

What type of medication causes extravasation?

A

vesicant

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18
Q

Name the IV complication:
cold, pale, puffy

A

infiltration

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19
Q

Name the IV complication:
redness, warmth, pain, burning, streaking

A

phlebitis

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20
Q

what are the rights of medication administration?

A

med, dose, route, client, time, documentation

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21
Q

What type of order is needed right away, where you must stop what you are doing and perform the task?

A

STAT

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22
Q

What are some required components of a medication order?

A

patient name
medication name
dose
strength
route
specific instructions (frequency, take w/food, etc.)
reason for admin
provider signature

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23
Q

The nursing student asks the RN what PPE they need to put on for contact precautions, how should the nurse respond?

A

gloves and gown

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24
Q

What type of precaution requires face mask?

A

face mask (surgical)

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25
Q

What type of solution can be used with blood products?

A

0.9 % normal saline (this is isotonic)

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26
Q

How often does TPN tubing need to be changed to prevent infection?

A

every 24hrs

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27
Q

what symptoms may a septic pt present with?

A

fever >100.4 F
elevated HR
BP trending downward

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28
Q

What are s/s of sleep apnea?

A

daytime sleepiness, snoring, O2 drop while asleep, abrupt cessation to breathing

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29
Q

What instruction should be provided for a midstream urine collection?

A
  1. clean urinary meatus
  2. start peeing
  3. catch in cup from middle of stream, not the first drips
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30
Q

A patient with a healing wound is due for a dressing change. The nurse assesses clear-light yellow drainage, free of blood.
How can the nurse best document this finding?

A

serous drainage

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31
Q

what consideration must be made while wasting a narcotic (controlled substance)?

A

another licensed nurse (RN) must be witness

32
Q

In addition to being incontinent, what else must a patient have to require a catheter?

A

perineal wound (not just incontinence alone)

33
Q

What does the presence of a bleb/wheal indicate for an intradermal injection?

A

effective administration

34
Q

what angle is indicated for an intramuscular injection?

A

90 degrees

35
Q

Mrs. Parker hears the RN tell the nursing student, “give this injection at a 45-90 degree angle.”
What type of injection can Mrs. Parker suspect they are giving?

A

subcutaneous

36
Q

This method is used for intramuscular injections to prevent the medication from leaking out of the muscle tissue.

A

z-track method

37
Q

What type of injection is an insulin injection?

A

subcutaneous (45-90 degrees)

38
Q

This type of drainage appears light pink and is watery.

A

serosanguineous

39
Q

How should green, yellow wound drainage be documented?

A

purulent

40
Q

what is known as the output of a stoma?

A

effluent

41
Q

Which stage of sleep is the most restful portion and is the period of time where vivid dreams occur?

A

REM

42
Q

what is a common sign of early hypoxia?

A

restlessness

43
Q

Upon removing staples, the nurse notices the incision site pulling apart, what should they do?

A

this is dehiscence, they must stop

44
Q

What are the benefits of colostomy irrigation?

A

increases quality of life
provides scheduled bowel movements

45
Q

What should the nurse promote in patients to help thin secretions for pts with pneumonia?

A

increase fluid intake

46
Q

Provide some examples of food that the nurse should encourage their pt to eat who is trying to promote wound healing?

A

beef, eggs, cottage cheese

47
Q

What should TPN be administered through?

A

central line (device that terminates in a great vessel)

48
Q

What electrolyte are bananas and potatoes good sources of?

A

K + (potassium)

49
Q

What foods should be avoided on a low sodium diet?

A

junk food, canned food, and fast food

50
Q

What foods should the nurse encourage for a client who has low calcium?

A

dairy, tofu, and broccoli

51
Q

Nuts, seeds, fatty fish, and dark chocolate are foods high in which electrolyte?

A

magnesium

52
Q

What condition may a client experience if TPN is discontinued abruptly?

A

hypoglycemia

53
Q

What components are in lipid solutions?

A

fatty acids and additional calories

54
Q

While preparing a lipid solution, the nurse notices a pepper like substance floating on the top, and the the contents look similar to a lava lamp. What should the nurse do?

A

The nurse should not use this solution. Do not try to mix it back together, get a new one.

55
Q

What interventions can be implemented for the treatment of RLS (restless leg syndrome)?

A

limit caffeine and alcohol
and implement exercising
potential need for medication

56
Q

What type of breathing may indicate hypoxia?

A

rapid, shallow w/dyspnea

57
Q

Why should pts remain upright for 1 hr following bolus tube feedings?

A

to prevent aspiration

58
Q

How can the nurse determine correct placement of the feeding tube?

A

aspirate gastric secretions (use pH indicator strip)

59
Q

Why is it important to check the expiration date on enteral feeding solutions?

A

expired formula may promote transmission of microorganisms

60
Q

What statement by the RN to the new grad nurse demonstrates the correct rationale for tube-feeding formula to be at room temperature before administration?

A

“cold formula causes gastric cramping and discomfort”

61
Q

How can we promote client comfort and autonomy for vaginal installation medication administration?

A

ask them if they are able to do it on their own

62
Q

What condition is excessive daytime sleepiness often associated with? What is the treatment for this?

A

sleep apnea
CPAP

63
Q

Stage this wound:
skin intact, nonblanchable erythema

A

stage 1

64
Q

Identify the wound stage:
full skin loss w/possible muscle, bone, or tendon or tunneling

A

Stage IV

65
Q

Which pressure injury stage is marked by full skin loss, damaged subcutaneous tissue, and potential for visible fat?

A

Stage III

66
Q

Which stage of pressure injuries may look similar to a blister, but no fat tissue is visible?

A

Stage II

67
Q

The patient has a very dry appearing wound, what type of dressing may the nurse prepare to administer?

A

hydrogel or hydrocolloid

68
Q

The patient has a foul smelling wound with stringy yellow exudate, what type of wound dressing would the nurse prepare to apply?

A

Aquacel Ag (silver)

69
Q

What is orthopnea?

A

SOB while lying down

70
Q

A patient is newly prescribed take home O2 via nasal cannula, what are some teaching points the nurse should make?

A

NO smoking with O2
cotton fabric only
heat sources >10ft away
caution not to dent canister

71
Q

While obtaining the pts BP, the nurse notices spasm/contraction of the hand.
Which electrolyte change can the nurse MOST likely prepare to treat?

A

hypocalcemia

72
Q

What is the nursing priority for central lines?

A

sterile technique

73
Q

Which statement by the new grad nurse BEST demonstrates understanding of how to prevent speed shock?

A

giving medications at their recommended push rate

74
Q

What s/s may indicate speed shock?

A

facial flushing, irregular pulse, headache, hypotension, LOC, cardiac arrest

75
Q

Immediately following administration of IV med administration the nurse assesses facial flushing and hypotension, what actions should the nurse take?

A

this is speed shock, the nurse should clamp IV, notify MD, apply O2 if indicated, and continually monitor vital signs

76
Q

Why should we prep the feeding tube with enteral feeding solution prior to administration the feeding solution?

A

prevents excess air from entering GI tract once the infusion begins (less discomfort)

77
Q

What is a priority nursing intervention for a client with impaired cognition receiving enteral tube feeding?

A

gastric residual checks, as this decreases the risk of aspiration

PCC2: Parker (6 decks)

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