FINAL EXAM JEOPARDY REVIEW Flashcards
Equipment that the nurse will use to monitor a patient experiencing pyrexia.
thermometer
Best route to assess the temperature of a client who is diaphoretic and unresponsive.
tympanic
Pulse that the nurse will assess on an adult found to be unresponsive and not breathing.
carotid
Physiological response of smoking and caffeine consumption causing an increase in blood pressure.
vasoconstriction
Nurse’s best response when an order says not to give a medication if BP is less than 100 mm Hg systolic and
client’s systolic BP is less than 100.
hold the medication
The next step a nurse should take after finding signs of infection in the wound of a stable client.
notify HCP
Maximum number of side rails on a client’s hospital bed that can be raised legally, without a provider’s order.
3
The nurse’s concern upon observing cyanosis in the foot of a client with ankle restraints.
blood flow/ circulation
Risk for a client with indwelling urinary catheter if the drainage bag is allowed to touch the floor.
infection (urinary tract)
Hand-washing method that must be performed to prevent the spread of C. diff.
soap and water
Technique the nurse will implement to reduce effects of orthostatic hypotension before ambulating a client who has been in bed for several days.
dangling on the bedside
Tool the nurse can use to assess a client’s risk for impaired skin integrity.
braden scale
Technique used to keep a client’s spine stable while repositioning.
log rolling
Tool the nurse can use to assess a client’s risk for falling.
morse scale
Method for cleaning a contaminated body area to prevent spreading infection.
least to most contaminated
Condition for which impaired sensory perception, impaired mobility, shear, friction, and moisture are risk factors.
pressure ulcer development/impaired skin integrity
Abnormal elimination that places a client at risk for skin breakdown.
incontenence
Stage of a shallow open reddish, pink ulcer without slough on the right ear of a client.
stage II
Type of healing required for a Stage IV pressure ulcer.
secondary intention
Type of wound drainage that indicates infection.
purulent
Critical-thinking skill utilized when the nurse reviews the effectiveness of nursing actions.
evaluation
Step of the Nursing Process necessary to develop a plan of care
assessment
Question the nurse should ask when a client reports a medication allergy.
Ask the patient to describe the type of reaction
Type of Nursing Diagnosis that indicates a potential patient response or reaction.
“risk for”