Foundations Kaplan Prep Flashcards
You are taking a stool sample. Your samples should be the size of a _______ and taken from ___ different places in the stool.
walnut sized from 2 different places
Does immobility cause hypocalcemia or hypercalcemia?
hypercalcemia
Why does immobility increase cardiac workload?
Blood pools due to gravity, and there is no muscular activity helping to move blood.
How often and what should a patient with very limited mobility eat?
small, frequent meals of high protein and adequate carbs
What are the nursing interventions for pneumonia?
turn, cough, deep breathe and use incentive spirometer
What are the 2 permissible uses for confidential medical records?
diagnosis and treatment
What is the patient position for thoracentesis?
sitting up and leaning over a table
Define “pressure ulcer.”
Localized area of necrotic tissue that occurs when soft tissue is compromised, usually over bony prominences.
What are 4 causes of pressure ulcers?
Altered level of mobility, shear, friction, moisture
What do we look for when assessing for pressure ulcers?
non-blanching skin
List the signs of hypoxia.
Apprehension, restlessness, dizzy, confusion, fatigue, tachycardia, hyperpnea, dyspnea
What is the nursing intervention for orthopnea?
Put pillows under their head or elevate the head of the bed.
What are wet to dry dressings used for?
debridement
List 4 purposes of bronchoscopy.
take a sample, get rid of mucus plug, instill meds, collect secretions
What are 7 nursing considerations for bronchoscopy?
Explain procedure, pt. NPO for 6-12 hours, look for infection, remove dentures, pt. may have sore throat afterwards, Post test—remain sitting and lying on side—make sure gag reflex is present before feeding, assess for respiratory difficulty
Where should you clamp a Foley catheter when collection a urine sample?
below the port
For a soap suds enema, insert tube __ inches.
4
What position should patient be in for suctioning?
semi-Fowler’s
What should the nurse do before suctioning?
explain the procedure and hyperoxygenate the patient
Which is correct: suctioning while pushing catheter in, or suctioning while pulling catheter out?
while pulling catheter out
What condition makes it most important to have patient repeat back what he/she is told?
Presbycusis (age related hearing impairment) and other hearing impairment
Before MRI, what are 3 nursing tasks?
Assess for claustrophobia, remove jewelry, assess for implanted metal.
What are the benefits of proper positioning?
Proper body alignment, prevent injuries, facilitate breathing and cardiovascular function, ADLs
What tool helps prevent friction and pressure when repositioning?
draw sheets
What are 2 common places for a bone marrow biopsy?
Iliac crest and sternum
Where do you place the stethoscope to listen to apical pulse?
L 5th intercostal at midclavicular line
How do you assess for a pulse presure deficit?
With another person, one counting the apical pulse and one counting the peripheral pulse: the difference between the numbers is the pulse pressure deficit.
How do you calculate the insertion depth for an NG tube?
Nose to ear to xiphoid process
What assessment do you make before putting Ted Hose on the patient?
circulation
Is a doctor’s order needed for a nurse to put compression stockings on a patient?
yes
What question must you ask a patient before an angiogram?
Are you allergic to shellfish, iodine or dyes?
What are the 5 skin breakdown stages?
1, 2, 3, 4, and unstageable
What is the first step in the nursing process?
identify the nursing issues
What instructions does the nurse give for using an incentive spirometer?
seal lips over the end, inhale slowly while trying to get the marker to the point the doctor recommended while the ball (or disc) stays in the middle, hold your breath for 3 seconds, exhale slowly, repeat. Following the session, have the patient cough to clear the lungs.
What is the angle for Fowler’s position?
45-60 degrees
What is the angle for low Fowler’s position?
15-30 degrees
What is the angle for semi-Fowler’s position?
30-45 degrees
What is the angle for High Fowler’s position?
60-90 degrees
What is the most basic need, according to Maslow? What is the second most basic need, which can be addressed once the basic level need is filled?
Physiological is the most basic, followed by safety and security which can only be address once physiological needs are met.
What are the 3 highest levels of Maslow’s hierarchy?
Level 3: Love and belonging needs
Level 4: Self-esteem needs
Level 5: (highest) Self-actualization needs
How do you know when you have irrigated a wound long enough?
solution runs clear or prescribed amount of solution is used up
What is the patient position for lumbar puncture?
lateral recumbent fetal position
What assessment is performed after a lumbar puncture, and how often?
neurological assessment, every 15-30 minutes, make sure the patient has fluid intake
How long following a lumbar puncture does the patient have to lie flat?
4-12 hours
What diseases make airborne precautions necessary?
varicella, rubeola, TB, SARS
What are the characteristics needed for a room to be used in airborne precautions?
private room
monitored negative air pressure
6-12 air changes per hour
Keep door closed and patient in room
What is the purpose of EKG/ECG?
watch heart rhythm: sinus tachy, brady, V fib
When you move a patient, should you push or pull?
push
A timer is a critical piece of equipment for what therapy?
hot/cold
Over what time period is I/O measured?
24 hours
Why do you monitor glucose during a ccentral line feeding?
to avoid glucose overload if feeding is done too fast
parenteral feeding goes through the central line of a ____ line
PICC (peripherally inserted central catheter)
What are the usual pulse sites?
Temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial, apical
What angle should patient be positioned for NG tube feeding?
30 degrees
What should gastric pH be?
4 or less
Why should you check pulse while doing fecal deimpaction?
vagal nerve stimulation could cause drop in pulse rate
What is ADPIE?
The way to remember the nursing process: assessing
diagnosing, planning, implementing, evaluating
What is QSEN?
Quality and Safety Education for Nurses
When you wear a gown in the patient’s room for infection control, where do you take it off?
In the patient’s room before leaving.
When you wear a respirator in the patient’s room for infection control, where do you take it off?
Outside the patient’s room
The difference between blood pressure in a person’s arms is normal if it is under ____ mm Hg.
10
What is the Valsalva maneuver? What does it do to pulse rate?
performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one’s mouth, pinching one’s nose shut while pressing out as if blowing up a balloon. It slows the pulse rate by stimulating the vagus nerve.
Fraction of inspired oxygen (FiO2) is ___ L/min for nasal cannula, ___ L/min for rebreather mask, ___ L/min for partial rebreather mask, ___ for Venturi mask.
1-6 for nasal cannula, 12 for nonrebreather mask, 8-11 for partial rebreather mask, 4-10 for Venturi mask
What is the rule of thumb method for determining approximate ideal body weight?
For adult females: 100 lb/45.3 kg (for height of 5 feet or 152 cm) + 5 lb / 2.2 kg for each additional inch (2.5 cm) over 5 feet. For adult males: 106 lb / 48 kg (for height of 5 feet) + 6 lb / 2.7 kg for each additional inch over 5 feet.
Which theorist supports the developmental framework of family assessment?
Duvall
Which medications will delay healing of a postoperative wound?
corticosteroids
What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing?
hydrocolloid dressings
What size catheter is used for and adult?
14F to 16F
Which meds change the color of urine?
Levodopa and injectable iron compounds can cause brown or black urine. Phenazopyridine can cause orange or orange-red urine. Amitriptyline can cause green or blue-green urine, and diuretics can lighten the color of urine to pale yellow.
An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of ____.
impending dehiscence
If dehiscence occurs, what should the nurse do?
cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician.
lateral movement of a body part toward the midline of the body
adduction
lateral movement of a body part away from the midline of the body.
abduction
Define pyuria.
pus in the urine
How do cholinergics cause frequent urination?
they stimulate the detrusor muscle
How often should the nurse irrigate a Foley catheter?
Irrigation should be avoided unless there is an obstruction
Common side effect of antibiotics
diarrhea
What is sedation level 1?
awake and alert
When would you draw blood to assess a medication’s trough level?
in the 30 minute interval before the next dose
