Final Exam Flashcards
Most common treatments for peptic ulcers
proton pump inhibitor
2 antiboiotics
What do you need to make sure the patient is willing to do for treatment of H. Pylori
Finish the medication
If you have a renal patient which medicines should they not take
Maalox
What happens if you take to much Maalox
Diarrhea
What kind of med is carafat
Mucosal Barrier
Do you take carafat before or after you eat
Before
What comfort measures would you ask the AP to do for a patient that has a NG tube and is a GI bleeder with suctioning?
Provide oral hygiene
Is an out pouching of the intestine
Diverticulitis
What type of diet should you eat if you have divertiulitis
High Fiber
What should you avoid eating if you have divertiulitis
alcohol seeds nuts corn popcorn cucumbers tomatoes figs strawberries
cholecystecotomy
removal of the gall bladder
How are you going to care for a patient with gastroenteritis that has a excoriated perinium
wash with soap and water
put dry
baby wipes
What kinds of foods should a person with gall bladder pains avoid
Fatty Foods
After surgery a patient has shoulder pains what do you do for them?
have them ambulate
The difference between acute and chronic cystitis
Clay or light colored stools
Patient comes in the doctors office and has lost forty pounds since their last visit. what is the best thing for the nurse to do
ask if the weight lose was intentional
why did they lose the weight
are you having problems swallowing
If someone is having problems swallowing what is that a sign of
Cancer
What do you do after giving a NG tube feeding
Flush it
check for residual
listen to the lung sounds
When your watching what you eat what kind of things do you want to look at
portion control
calories
psychological reason why you are eating
are they stressed or depressed
When you are caring for a bariatric patient what is the most appropriate action when transferring them
make sure you have a enough staff on hand when you moving the paitent
What can you assign the AP to do with a bariatric patient who is in a normal hospital bed?
Check for pressure ulcers
how do you develop bacterial cystitis, UTI
E. Coli
not cleaning properly
estrogen levels low
not going to the bath room when you have to go
Postmenopausal patient has two UTI (cystitis) in a short amount of time. what do you tell this patient
Could be due to low estrogen
A patient with an indwelling catheter what are some reasons they my have the catheter
neurogenic bladder
incontinent
a patient comes from a nursing home that has had a lot of falls what is the first thing you a want to do
Get a urine sample and look for UTI
signs and symptoms for older patients with UTI’S
level of consciousness
confused
agitation
a female with urinary incontinents how would you help this patient and make her feel comfortable
ask about her lifestyle and find stratages that will work for her
a patient with a fungal urinary tract infection what should the nurse do
get a list of current meds
look at current medical HX
how would the nurse promote good nutrition when working with older adults
Dentures in
Glasses on
bed pan out of sight
what does the nurse tell the AP before going to feed the patient
make sure the urinal is removed make sure it is a nice quite environment to eat in warm food warm cold food cold sit pt up
risk factors for gastritis
NSAIDS Caffeine Alcohol Corticoid steroids H. Pylori
What do you tell the patient to do when on a toilet training program?
Hold it until next scheduled time to go
A calorie malnutrition in which fat and proteins are wasted
marasmus
lack of protein quality and quantity
kwashiorkor
combination of energy and protein malnutrition
Marasmus-kwashiorkor
Sodium range
135-145
Potassium range
3.5-5
Calcium rnage
9-10.5
Chloride range
98-106
Magnesium range
1.3-2.1
Phosphorus range
3-4.5
Positive Chvostek (face) and trousseau (hand) are signs of
Hypocalcemia
Which statements about the purpose of the immunity system are true? (select all that apply)
A. The immune system provides protection from and eliminates or destroys microorganisms
B. The immune system is able to identify non-self proteins and cells
C. The immune system removes foreign proteins and other substances
D. The immune system protects against allergic/anaphylactic reactions
E. The immune system is able to prevent healthy body cells from being destroyed.
A,B,C,E
Which factors may affect the function of the immune system? (select all that apply)
A. Nutritional Status B. Environmental conditions C. Drugs D. Family health history E. Age
A,B,C,E
The immune system is responsible for self tolerance. Which functions related to self tolerance are included the immune systems responsibilities? ( select all that apply)
A. Recognizing self versus non self
B. Be recognized by T-lymphocyte helper/inducer T cells
C. Recognize different proteins on cell membranes
D. Recognize self versus the inflammatory response
E. Identify non-self, which includes all invading cells and organisms
A,C,E
From where do most immune cells originate?
A. Thymus
B Spleen
C. Liver
D. Bone marrow
Bone Marrow
The patient’s wound has increased blood flow (hyperemia) and swelling. Which stage of inflammation does the nurse recognize?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Stage 1
The nurse is providing care for a patient whose wound is producing the substance commonly called “pus” as exudate. Which stage of inflammation does the nurse recognize?
Stage 2
Which cell interacts in the presence of an antigen to start antibody production? (select all that apply)
A. B-lymphocytes B. Macrophages C. Neutrophils D. T-helper/inducer cells E T suppressor cells
A. B-lymphocytes
B. Macrophages
D. T-helper/inducer cells
A patient who had an organ transplant 2 months ago is experiencing rejection of the organ. What type of rejection is this?
A. Acute
B. Hyperacute
C. Delayed
D. Chronic
Acute
Cancer cells that are abnormal, serve no useful function, migrate, large nucleus ot plasma ratio, anaplasia, loose adherence and are harmful to normal body tissue
Malignant Cancer Cells
Substances that change the activity of the cell’s genes so that the cell becomes a cancer cell are called?
Carcinogens
Is the most common cause of cancer spread?
Blood borne metasaisis
Is used to describe the anatomic extent of the cancer
TNM (tumor, Node, Metastasis)
Number one cancer causing death in both men and women?
Lung and bronchus
Which pathological description of a client’s tumor does the nurse interpret as being the “most malignant” or “high grade” cancer?
C. Undifferentiated: = 50% aneuploid
7 warning signs of cancer
Changes in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or lump in the breast or else where Indigestion or difficulty swallowing Obvious change in mole or wart Nagging cough or hoarsness
The nurse learns that the most important function of the inflammation is which purpose?
Provide protection against invading organisms
Which medication should the nurse plan primary teaching?
Tylenol (Acetaminophen)
What recommendation is BEST to help prevent osteoarthritis?
Lose weight if needed
The white blood cell count with differential of a client undergoing preadmission testing before surgery indicates total count of 10,000 cells per cubic millimeter (mm^3) of blood. Which differential counts of percentages does the nurse report to the physician?
A. Eosinophils 220/mm^3
B. Monocytes 2000/mm^3
C. Segmented neutrophils 5700/mm^3
D. Lymphocytes 2100/mm^3
B. Monocytes 2000/mm^3
Also known as Humoral Immunity, involves antigen-antibody interactions to neutralize, eliminate or destroy foreign proteins?
(AMI) antibody-mediated immunity
A disease causing bacteria, protoza, fungus or virus is called?
Pathogen
Arthritis that is chronic, progressive,systemic inflammatory autoimmune disease process that affects primarily the synovial joints?
(RA) Rheumatoid Arthritis
The nurse is assessing an older patient and has a below normal fever 97. What is the BEST response?
A. Conclude the infection is not present
B. Monitor and continue to document any findings
C. Assess the client for more specific signs
D. Request blood cultures
Assess the client for more specific signs
Someone is diagnosed with osteoarthritis. What would be the first drug the nurse would tell them to use?
Tylenol
What is the absolute reason someone would NOT get a limb transplant?
If they have osteoporosis
After patient is released and goes to a long term care facility for rehab for a joint replacement. What action is important for the nurse to know?
A. Administer pain meds for transport
B. Answer last minute question by the family
C. Insure the family has directions to the facility
D. Provide a verbal hand off report to the facility
Provide a verbal hand off report to the facility
In a Rheumatoid arthritis facility which patient do you see first?
A. Jaw pain
B. Hot and swollen right wrist
C. Puffy area behind the knee
D. Joint deformities
Hot and swollen in the wrist
A patient with osteoarthritis’s is running a low grade fever. What is the best action by the Nurse?
A. Reassure patient problem will fade when the weather changes
B. Prepare to teach them about taking Tylenol
C. Inspect their hands and feet and toes
D. Assess the patient for subcutaneous nodules or bakers cyst.
Assess the patient for subcutaneous nodules or bakers cyst
A patient with rheumatoid arthritis is experiencing worsening physical status and are finding it difficult to maintain their role in the community. Stress is adding to their condition. As a visiting nurse what is the best thing for you to do?
A. Suggest to give up the role as an elder
B. See if they can call a meeting
C. Discuss their role duties
D. Assess their culture more
Asses their culture more
A client with stiff hands in the morning wants to finish their baby quilt. What are you going to use?
Wax
Where would you look for Heberdens nodes?
Distal ends for digits
Where would you look for Bouchards nodes
Proximal joint in digit
The difference between normal cells and benign cells. The teacher gives the correct description of benign tumors?
A. Benign tumors grow through invasion of other tissue
B. Benign tumors lost their contact inhibitions
C. Growing in the wrong place and wrong time is normal of benign tumors
D. The loss of characteristic are symptoms of anaplasia
Growing in the wrong place at the wrong time
What statement about carcinogenics is accurate?
A. Initiated cell will ALWAYS become clinical cancer
B. Normal hormones or proteins do not promote cancer growth
C. Tumor cells need their own blood supply
D. Cancer becomes a health problem once it is one centimeter larger
Tumor cells need their own blood supply
How is Metastasis most spread in the body?
Blood borne
A patient has very dry skin. What is the nurses BEST action?
Have the patient take a cool shower and apply lotion before drying off
If your transferring your patient into a chair and you notice her pressure relieving mattress has deep imprints. What would be the best thing for the nurse to do?
Get a different pressure relieving mattress
Assess their skin
Turn them every two hours
A patient has a pressure ulcer on their right ankle. What should the nurse do first?
Assess the ankle
The nurse is visiting a client at home and notices the patient is at risk for a pressure ulcer. What is the appropriate response to the caregiver?
Do not message the area and turn the patient every two hours
A patient is at risk for a pressure ulcer. What statement by the patient indicates that the patient understands how to decrease the risk of pressure ulcers?
I need to eat more protein
The nurse is assessing patients with wounds. Which patient is at risk for infection?
Someone who has a WBC count of 23000
The nurse is assessing a patient with a Braden Scale of 9.
What should the nurse include in the assessment?
How are you providing his care
The nurse is assessing a patient with peripheral vascular disease of an older patient. What action by the student nurse would cause the faculty to intervene?
Checking the corotoid arteries at the same time
If the patient has peripheral artery disease and the patient tells you “ i walk 5 blocks without plan”. What would the nurses next question be?
Could you walk 5 blocks two months ago
The patient has peripheral vascular disease is explaining the daily foot care routine to the nurse. What statement by the patient indicates there may be a barrier to foot care?
My hands shake when I do things that require coordination
A nurse is caring for someone with (DVT) Deep vein thrombosis. what assessment indicates priority outcome has been made?
O2 SAT is at 98%
A obese patient is in for follow up with a DVT. The patient has lost 20 pounds. What is the BEST action by the nurse?
Check to see if the anti embolism stocking still fit
The nurse is treating a patient with a non healing arterial leg ulcer. What is the BEST action by they nurse?
Call the wound nurse
Which statement by the patient indicate need for further teaching of care for peripheral arterial disease?
I can use a heating pad
Arthritis that is bilateral, an autoimmune disease, systemic and is caused by antibodies
Rheumatoid Arthritis
Characteristics of normal cells
Non traveling
Differentiated
Specific morpholog
Cardinal Signs of inflammation
redness swelling (edema) warmth pain loss of function
Is a progressive deterioration and loss of cartilage and bone in one or more joints
Osteoarthritis
Osteoarthritis is caused by
Aging and genetic fatctors
The nurse is caring fora client with chronic stasis ulcers. Which statement by the client indicates a need for further health teaching?
A. I will wear compression stockings at night
B. I will keep my affected leg above my heart
C. I will eat protein and vitamin C food to help heal the ulcer
D. I will change my dressing every 3 to 5 days as needed.
I will wear compression stockings at night
A chronic metabolic disease in which the bones that cause decreased density and possible fractures. it is known as “ silent disease/thief”
Osteoporosis
Osteoporosis is cause by a combination of:
genetic
lifestyle
environmental factors
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly
pigmented skin may not have visible blanching; its color may differ from the surrounding area. Is what pressure ulcer stage?
Stage 1
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without
slough. May also present as an intact or open/ruptured serum-filled blister. Is what stage pressure ulcer?
Stage 2
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.
Slough may be present but does not obscure the depth of tissue loss. May include undermining and
tunneling. Is what stage pressure ulcer?
Stage 3
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some
parts of the wound bed. Often include undermining and tunneling. Is what stage pressure ulcer?
Stage 4
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or
brown) and/or eschar (tan, brown or black) in the wound bed. Is what stage pressure ulcer?
Unstagable
An infection of the skin is called?
Cellulitis
Acute pyelonephritis
An upper UTI of the kidney
The spread of the infection from the urinary tract to the bloodstream is called
Urosepsis
Signs and symptoms of a UTI
Frequency with little urine output Dysuria Pain when urinating Urgency the feeling that urination will happen immediately Low back pain Incontinent Nocturia
Signs and symptoms of UTI in older adults
Confusion Incontinence Fever Tachycardia Loss of appetite
A client in the community health clinic is prescribed trimethoprim/sulfamethoxazole for cystis. The client reports developing hives to “something called Septra.” What is the nurse’s BEST action?
Notify the Provider
Which intervention will the nurse include in the plan of care for a patient with serve liver disease?
eat a Low protein, high carb diet
3 Types of drug therapy for GERDS and peptic ulcers
antacids
histamine blockers
proton pump inhibitors
Acute gastritis Signs and symptoms
Rapid on set or discomfort
Chronic gastritis in relieved by
eating food
results when mucosal defenses become impaired and no longer protect the epithelium from the effects of acid and pepsin
Peptic Ulcer Disease
Most gastric and duodenal ulcers are caused by
H. Pylori
When taking a history of a client diagnosed with a gastric ulcer, which assessment finding does the nurse expect? Select all that apply A Vomiting B weight loss C Epigastric pain at night D Relief of epigastric pain after eating E Melena
A,C,E
Increases pH of gastric contents be deactivating pepsin
Antacids/Magnesium hydroxide Aluminum Hydroxide (amphojel)
When do you give Antacids/Magnesium and/or Aluminum (amphojel)
1 hr and 3 hrs after meals and at bed time
3 common names of H2 Antagonist
Zantac
Pepcid
Axid
What time of day do you give H2 Antagonist
Single dose at bedtime
Can you take aspirin while using pepto-bismol
No, it will cause an aspirin over dose
5 Proton pump inhibitors
Prilosec Prevacid Acphex Protonix Nexium
What should the nurse assess for with a patient that has ulcer disease
nutrition medication HX patients coping style vitals bowel sounds and color hemoglobin and hematcrit
A life threatening acute inflammation and infection of the visceral/parietal peritoneum and endothelial lining of the abdominal cavity is called
peritonitis
Signs and symptoms of peritonitis
Rigid board like stomach Abdominal pain Distended abdomen Nausea, anorexia, vomiting diminishing bowel sounds inability to pass gas high fever tachycardia dehydration decreased urine output hiccups
A very common health problem worldwide that causes diarrhea and/or vomiting as a result of inflammation of the mucous membrane of the stomach and intestinal tract
Gastroenteritis
Risk factors for cholecystitis
Women age American indian, mexican, caucasian obesity rapid weight loss family HX Crohns disease gastric bypass sickle cell disease diabetes mellitus pregnancy genetic factors
the 4 F’s of gall stones
Female
Forty
Fat
Fertile
cholelithiasis
gall stones
Calculation for BMI
Weight in lbs/ height in inches x height in inches
X 703
8 Complications of malnutrition
Muscle wasting Decreased activity tolerance Lethargy Edema Intolerant to cold Dry flaky skin Poor wound healing Possible death
cachexia means
muscle wasting
Patient can meet nutritional intake orally is
Total enteral nutrition
Used for long-term enternal feedings
Enterostomal feeding tubes
How to maintain a patent feeding tube
flush tube with 20 to 30 mL of water every 4 hours, before and after meals, before and after drugs given and after check residual volume
When a patient requires intensive nutritional support for an extended period of time the physician prescribes
(TPN) Total parenteral nutrition
Is the integration of the best current evidence to make decisions about patient care
EBP
Evidence Based Practice
A vital role of the nurse is to empower the patient and thier family to have control over their health care
Patient advocate
Members of the RRT
Intensive care unit nurse
Respiratory therapist
Intensivist
Hospitality
A physician who specializes in critical care
Intensivist
Family practice physician or internist employed by the hospital
Hospitality
5 broad core competencies for the health care professionals to ensure patient safety and quality care
Patient centered care Collaboration with interdisciplinary team Implement EBP use quality improvement for patient care Informatics in patient care
Self determination or self management
The nurse is obligated to protect the patient if they can not
Self manage or determine is called
Autonomy
Positive action and encourages nurses to do good for the patient is called
Beneficence
Preventing harm and ensures patients well being is called
Nonmaleficence
Agreement that the nurse will keep their obligations or promise to patients to follow through with care
Fidelity
Nurse is obligated to tell the truth is called
Veracity
Equality and fairness that all patients are treated equally
Social justice
SBAR
Situation
Background
Assessment
Recommendations
Isbarr
The I stands for
The last R stands for
Identify
Response
Pick stands for
Population
Intervention
Comparison
Outcome
Risk factors that increase the risk for surgical complications
Age Medications Med HX Health HX Family HX
Patients with cardiac disease may require preoperative therapy with what type of drug
Beta blocking drugs
The preoperative admitting nurse notices that the client scheduled for total joint replacement surgery in two hours has a smell of alcohol on his breath even though he states he has fasted for 10 hours. What is the nurses best action?
Tell the client the observation and provide the opportunity for him to explain
The joint commission NPSGs states that the patient deserves the right to be informed and involved in the decisions that affect their…
Health care
To ensure the right site is selected before surgery the site is marked by…
Patient
Licensed independent practitioner
What do you use when clearing the area of hair before surgery?
Electric clippers
Depilatories
When instructed by the the surgeon give the patient the prophylactic to prevent surgical site infections how many minutes before surgery
60 min
Which assessment parameter is most important for the nurse to employ for the client admitted to the PACU for recovery after surgery under epidural anesthesia?
Assessing the response to pinprick stimulation from feet to mid chest level
Partial splitting of the wound
Dehiscence
Total separation with internal organs protruding through the wound site is called
Evisceration
A nurse is teaching a client about magnesium hydroxide with aluminum hydroxide (Maalox). What instruct is important?
Report diarrhea to your healthcare provider
A nurse cares for a teenage girl with ileostomy. The client states I can not go to the prom with an osteomyelitis. How should the nurse respond?
Let’s talk to the enteristomal therapist about the options for ostomy supplies and dress styles
A client is receiving a bolus feeding through a dobhoff tube. What action by the nurse is most important?
Check for placement before each feeding
A nurse is caring for 4 clients receiving enternal tube feedings. Which client should the nurse see first?
Client with potassium level of 2.6
A nurse caring for a morbidly obese patient. What should the nurse have the AP do?
Ensure the side rails are not causing excess pressure
The nurse assesses a client on the MedSurg unit. Which client is at greatest risk for bacterial cystitis?
58 year old not taking estrogen replacement
Which is not a part of a habit training to manage incontinence ?
Changing the clients incontinent brief when wet.
A nurse is teaching a client urinary bladder training. Which statement should the nurse include in this clients teaching?
Try to consciously hold urine until scheduled time
A nurse assesses a client that presents with renal calculus. Which question should the nurse ask
Do any of your family members have this problem
A client with small bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are best
Does med come in liquid form
Flush tube before and after admin meds
Try to flush the tube with 30mL of water and gentle pressure
A nurse cares for a client with urinary incontinence the client states I am so embarrassed my bladder leaks like a young child’s bladder. How should the nurse respond?
I can teach you strategies to help control your incontience
An emergency department nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth constipation and an inability to void. Which question should the nurse ask first?
What medications are you taking
A nurse teaches a client with functional urinary incontinence. Which statement should the nurse include in this clients teaching?
Buy slacks with an elastic waistband that are easy to pull down
A nurse teaches a young female patient who is prescribed Amoxil for a urinary tract infection. Which statement should the nurse include in the patients teaching?
Use a second form of birth control while on this medication
After teaching a client bacterial cystitis who is prescribed PYRIDIUM the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching?
An orange color in my urine should not alarm me
A nurse cares for a client admitted from a nursing home after several recent falls. What should the nurse complete first?
Obtain a urine samples
After teaching a client with a history of renal calculi. The nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching?
I should drink at least 3 L of fluid everyday
A confused client with pneumonia is admitted with an indwelling catheter in place. During the interdisciplinary rounds the following day which question should the. Urge ask the primary healthcare provider?
Can we discontinue the indwelling catheter
presence of bacteria in the urine
bacteriuria
inflammation of the bladder
cystits
blood in the urine
hematuria
A nurse is attempting to assist a morbidly obese patient back to bed and had an immediate pain in the lower back. What action by the nurse is most appropriate?
Fill out and file a variance report
a nurse caring for a post menopausal patient who has had 2 episodes of bacterial ureritis in the last 6 months. The patient Says,” i have never had a UTI, Why is this happening now? How should the nurse respond?
Low estrogen levels can make the tissue more susceptible to infection
A patient tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits for what additional data should the nurse assess as the priority
psychosocial influences on weight
Means no urine
Anuria
Pain when urinating
Dysuria
Whit the LGBTQ what should
You never do
Do not make assumptions
Who is involved in office quality improvement
Everyone
If you are looking for a Dr or hospital make sure the are part of
The joint commission
When assessing an older patient that is post op. How should the nurse assess for an infection
Look for change in behavior
Patient right to make healthcare decisions is called
Autonomy
A patients BP drops from 140 to 80. Who do you call
RRT
What additional teaching should the nurse teach the patient about HUMARA?
To take it at breakfast
How can you tell if a client with a gall bladder diet understands the diet. What would they order?
Roast chicken
Baked potato
OJ
A client that has just developed cancer. What statement by the client needs further teaching about their diet?
I can eat steak
A morbidly obese patient is admitted to a community hospital that does not typically care for bariatric sized clients. What action by the nurse is most appropriate?
Ensure adequate staffing when moving the pateint
A patient is in the bariatric unit one month after having gastric bypass surgery. The patient is crying and says i didn’t know it would be this hard to live like this. What is the best response by the nurse?
Assess the patients coping and support systems
several nurses have just helped an obese patient get out of bed. One nurse accesses the chart because she wants to know how much the patient weighs. What action is most appropriate?
State,” that is a violation of client confidentiality
Nurse assesses the patient who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather then acute?
Light colored stools
nurse cares for a patient who is prescribed patient controlled PCA after cholecystectomy the patient states when i wake up i am in pain. which action should the nurse take?
Encourage the patient to use the PCA pump upon awakening
a patient is in the family practice clinic today, the patient weighs 186.4 lbs, 6 months ago the patient weighed 211.8 lbs. What action by the nurse is best?
ask the patient if the weight loss was intentional
a nursing student is studying nutritional problems and learns that kwashiorkor is distinguished from marasmus with which finding?
Specific lack of protein
after teaching a patient who is recovering from laparoscopic cholecystectomy surgery the nurse assesses the patients understanding. Which statement made by the client indicates a correct understanding of the teaching?
I will decrease the amount of fatty foods in my diet
a nurse cares for a client who is recovering from laparoscopic cholecystectomy surgery. the patient reports pain in the shoulder blades. How should the nurse respond?
ambulating in the hallway 2x a day will help
After teaching a patient who has a history of cholelithiasis the nurse assesses the patients understanding. Which menu selection made by the patient indicates the patients clear understanding of the dietary teaching?
Roasted chicken, baked potato with chives and OJ
A nurse assesses a patient with a fungal UTI. Which assessments should the nurse complete?
Medical HX and current medical problems
Obtain a current list of med
Nurse is caring for a patient with gastrointestinal disorders should understand that whic category best describes the mechanism of the action of CARAFAT?
mucosal barrier fortifier
Nurse answers a patients call light and finds client in bathroom vomiting large amounts of blood. What is the best action by the nurse?
Put on gloves
Patient had an upper GI hemorrhage and now has an NG tube. What comfort measure may the nurse delegate to the UAP?
Performing oral hygiene often
Nurse is delegating feeding to a client to UAP. What actions does the nurse include in the directions to the UAP?
Ensure warm and cold items stay @ appropriate temps
remove bed pan soiled linens and other unpleasant items
sit with patient making atmosphere more relaxed
When working with an older adult to promotes good nutrition, what actions by the nurse are most appropriate?
allow uninterrupted to for eating
assess dentures for appropriate fit
ensure the patient has glasses on when eating
serve high calorie, high protein snacks
nurse plans care for a patient with overflow incontinence. Which intervention should the nurse include in the patients plan of care to assist with elimination
Use the valsalva maneuver
a client is being taught about drug therapy for H pylori infection. Which assessment by the nurse is most important?
willingness to adhere to drug therapy
student nurse studying stomach disorders learns that the risk factors for acute gastritis include?
NSAIDS
alcohol
caffeine
corticosteriods
After teaching a patient with divertivulitis a nurse asesses the patients understanding. Which menu selection made by the client indicates the client understands the dietary teaching?
Baked fish
steamed carrots
Apple juice
a nurse cares for adult patients who experience urge incontinence. For which patient should the nurse plan a habit training program?
78 year old female who is confusedd
nurse obtains a patient health history at a community health clinic. Which statement alerts the nurse to provide health teaching to the patient
i take a lot of Tylenol for my arthritis pain
what is a new nurses first priority?
Patient saftey
Do you always look up new meds before you administer to a patient?
Yes
What do you report to the on call DR if your patients pain meds are not working?
Allergies,
What are you going to report to the surgical team about the client before surgery?
They use multiple herbs and supplements
Your are discharging 4 patients. Which patient is in greatest need of after care?
Older adult with memory loss
Patient with abdominal drain is being assessed what priority goals let the nurse know the needs are being met?
No redness
Patient needs to go to the bathroom after receiving antithesis. What should the nurse do?
Give them a bed pan or urinal
The nurse assesses the client before surgery and notices brittle nail, dry skin poor tugor, muscle wasting what is the nurse going to do?
request the surgeon to order a dietitian consultant
A patient is anxious about the surgery. What is the best thing for the nurse to do?
Describe your feelings
A patient needs an IV antibiotic and ask to have it started later what should the nurses response be
You need to have it now and this is why
A patient signs a minimal invasive surgery consent. What does the nurse need to tell the surgeon?
Remind them that the surgery is minimally invasive
if you go into a room with equipment that has frade wires or cords what should the nurse do?
get new equipment
the surgeon just put sterile gloves on and lowered them below his waist what should the nurse do?
tell him he broke sterile field
what is the first thing a PACU nurse should check for a patient that still has an IV Anesthesia?
Pulse O2
What is most important thing for a nurse to do for a older client who has hearing aids getting ready to go to the OR?
hearing aids in until anesthesia starts
What is the most important thing for an OR nurse to do to emotionally support the patient?
Remain with them
What is the post op priority by the nurse?
hand off report
who will the nurse look at first?
BP 150/80
P118
R6
Respiratory of 6
If patients O2 SAT drops from 98-95 what are you going to do?
Assess for other indication of oxygenation
A patient 10hrs post op wants to take of their anti embolism stockings because they are hot an itchy. What should the nurses response be?
you need to keep them on to prevent blood clotting
what should the nurse do with a patient that has spinal anesthesia when the nurse raises the head of the bed for the patient and the blood pressure decreases?
Lower the head of the bed back down
What is the priority assessment for a post op unit patient
Check the airway
pain post op but denies any pain and does not want meds. What is the best thing the nurse can do for the patient?
assist to a comfortable position
post op patient vomited. After comforting and cleaning the client what should the nurse do?
listen to lungs
When changing a large dressing with drainage which teaching should you teach the patient?
Wash thier hands
Family is concerned their older adult parent is not coming out of anesthesia fast enough. What should the nurse tell the family?
Sometime older people take longer to wake up
What action warrants intervention by the RN when the student is changing a drainage pump?
when the student secures it to the sheet
most important function of immunity and inflammation
provides protection against invading organisms
The nurse is assessing an older patient for signs of infection. Their temp is 97.6. what is the best response by the nurse
assess the client for more signs
nurse is assessing an older patient, what is the most important assessment to prevent infections?
assess vaccine records for booster shots
how can you help prevent osteoarthritis in patients?
Lose weight if needed
what meds should the patient be taking for osteoarthritis?
Use tylenol
What is a reason you will not receive a total joint replacment
osteoporosis
what is the most important for the nurse to do periop for a total joint replacement?
Give antibiotic as ordered
which RA patient should you see first
red hot swollen
how can the nurse identify that the client with poor body image is being met?
The client joins a book club
a patient with RA should put —– on the red hot swollen site?
ice
a client wants to finish her baby blanket but her hands hurt what should the patient use?
wax
what is true about cancer?
tumors need their own blood supply
TNM
is means
in situ/pre cancer
TNM
123
means size of cancer
