Fundamentals: Moderate Flashcards
What are the five rights of delegation?
- Right task
- Right circumstance
- Right person
- Right direction
- Right supervision
Which of the following should the nurse not delegate to a UAP?
A) Bathing
B) CPR
C) Wound Care
D) Charting patient I/Os
C) Wound care
Should the nurse prioritize a patient with inspiratory stridor, or one with severe abdominal pain?
Inspiratory stridor
Which of the following should the nurse not delegate to an LPN?
A) Blood transfusion
B) Tracheostomy care
C) Wound dressing change
D) NG insertion
A) Blood transfusion
What is the first step in the quality improvement process?
A) Collect data using an audit
B) Identify benchmark or standard of care
C) Perform root cause analysis for a performance gap
B) Identify benchmark or standard of care
True or False: It is important to include an incident report in the patient’s medical record.
False - An incident report is an internal document and should not be included or referenced in the patient’s chart
Which conflict management strategy produces the best outcome?
A) Compromising
B) Collaborating
C) Smoothing
D) Accommodating
B) Collaborating
Which stage of conflict is characterized by the individuals involved being unaware conflict is present or impending?
Latent conflict
If there is a fire, should the nurse first close the doors to the unit and patient rooms, or use the fire extinguisher to put out the fire?
Close the doors
R: Rescue
A: Alarm
C: Contain
E: Extinguish
Touching a patient without consent and causing harm is considered which kind of tort?
Battery
If a patient is involuntarily admitted, do they have the right to refuse medication?
Yes
Which of the following is NOT part of the nurse’s role in informed consent:
A) Ensure the patient is competent to provide consent
B) Answer patient questions about the procedure
C) Sign the consent form as a witness
B) Answer patient questions about the procedure - provider performing the procedure should answer the questions
The nurse is attempting to obtain informed consent from a patient who has questions about the planned procedure. What should be the nurse’s next step?
Call the provider to come answer the patient’s questions
According to Erikson’s stages of psychosocial development, what is the psychosocial crisis for adolescents? (12-18 years)
Identity vs role confusion
According to Erikson’s stages of psychosocial development, what is the psychosocial crisis for older age adults? (>65 years)
Integrity vs despair
What are two bloodborne pathogens that can be contracted with a needlestick injury?
Hepatitis (B or C) and HIV
What two things does the nurse need to wear when caring for a patient with an internal radiation device (brachytherapy)?
Dosimeter badge and lead apron
In the chain of infection, what term is used to describe how the agent goes from the reservoir to the new host?
Mode of transmission
In the chain of infection, what term is used to describe where the infectious agent lives and multiplies?
Reservoir
Medicating a patient with a sedative medication for the convenience of a nurse is considered which kind of tort?
False imprisonment
Which kind of tort occurs when a nurse fails to provide the standard of care required fo a patient, resulting in patient harm?
Malpractice
Is the following question therapeutic or non-therapeutic? “Why won’t you take your medication?”
Non-therapeutic - “Why” questions are typically not therapeutic
The nurse asks, “Do I understand you correctly when you say your stomach pain occurs before you get nauseous?” Which therapeutic technique is this?
Clarification or validation
Patient teaching on how to use an incentive spirometer involves which domain of learning?
Psychomotor learning
Name three forms of nonverbal communication
Any three of the following:
- Posture
- Facial expression
- Eye contact
- Gestures
- Touch
-Silence
Which of the following are non-modifiable risk factors for getting an illness?
A) Stress
B) Age
C) Ethnicity
D) Obesity
E) Genetics
B) Age
C) Ethnicity
E) Genetics
Which of the following nursing actions is inappropriate for a patient who wants to leave AMA?
A) Notify the provider
B) Call security
C) Educate patient on the risks of leaving AMA
D) Have patient sign an AMA form
B) Call security
Name two types of food a Kosher-observant patient may not consume
Any two of the following:
- Pork products
- Shellfish
- Meat with dairy
True or False? An ethics committee collects data regarding an ethical dilemma from the treatment team and family, decides the best course of action, and enforces that decision.
False
Name the six components of the chain of infection
- Infectious agent
- Reservoir
- Portal of exit
- Mode of transmission
- Portal of entry
- Susceptible host
Which type of anxiety may enhance learning?
Mild anxiety
What is the nurse’s priority action if a patient’s chest tube becomes disconnected from the drainage system?
Place the end of the tube in sterile water to maintain the water seal
What time of day should a patient receive chest physiotherapy?
Before meals or 1-2 hours after meals
Name three important teaching points to give a female patient in order to prevent a UTI
Any three of the following:
- Wipe front to back
- Wear cotton underwear
- Avoid bubble baths
- Avoid sitting in a wet bathing suit
- Avoid tight clothing
- Urinate after intercourse
- Drink ~ 3L of fluid per day
What key symptom is common in older adults who present with a UTI?
Confusion
How does the nurse collect a sterile urine specimen from a patient with an indwelling catheter?
Collect urine sample from the designated sampling port on the catheter, not from the drainage bag.
What is the nurse’s priority action if a patient’s urine output is less than 30mL/hr?
Notify the provider
When changing a patient’s ostomy appliance, how big should the nurse cut the skin barrier or wafer?
No more than 1/2” wider than the measured stoma size
Does asthma affect a patient’s ventilation, diffusion, or perfusion?
Ventilation
What is the maximum length of time a nurse should spend on a suction pass?
No longer than 15 seconds
What is the maximum number of suctioning passes a nurse should perform in one session?
No more than three passes per session
Which of the following is not appropriate patient education regarding diabetic foot care?
A) Wear professionally fitted shoes
B) Inspect feet daily
C) Cut nails in a rounded shape
D) Wear cotton socks
C) Cut nails in a rounded shape - nails should be cut straight across
When irrigating a wound, what irrigation force should be used?
~ 8-15 psi
True or false: If a patient is violent, the nurse can place restraints on a patient without an order.
True; an order must be obtained from the provider ASAP after application
Name all of the fat soluble vitamins
Vitamins A, D, E, K
Name two localized symptoms of a surgical site infection
Any two of the following:
- Pain
- Erythema
- Induration
- Purulent drainage
Following an operation, when should a patient be allowed to drink water?
After the patient’s gag reflex returns
What is a solution’s tonicity if it causes water to move into a cell?
Hypotonic
Name three symptoms of fluid volume excess
Any three of the following:
- Weight gain
- Edema
- Tachycardia
- Tachypnea
- Hypertension
- Bounding pulse
- Dyspnea
- Crackles in lungs
- Jugular vein distention
If the patient’s next TPN bag will not be available on time, what type of fluid should the nurse administer until it arrives?
Administer 10-20% dextrose in water until it arrives
How often and with how much water should a feeding tube be flushed with during continuous feeding?
Flush every four hours with 30 mL of water
What kind of transmission precautions are required for a patient with TB?
Airborne precautions
What PP is required for a patient on airborne precautions?
Gown, gloves, N95 mask or respirator
True or false: If a patient is having a seizure, the nurse should attempt to insert an artificial airway.
False - the nurse should not put anything in a patient’s mouth during a seizure
Name two actions that are contraindicated for patients with a DVT
Do not place a pillow/knee gatch under the leg and do not massage the limb
To ensure an indwelling catheter drains properly, name two things to assess while providing patient care
Any two of the following:
- Make sure the bag is hanging below the level of the bladder
- Check tubing for kinks
- Ensure there are no dependent loops
Which of the following is NOT a risk factor associated with stress incontinence?
A) Stroke
B) Menopause
C) Prior pregnancy
D)Obesity
A) Stroke
In which chamber of a chest tube should continuous bubbling be observed?
The suction control chamber
What is expected or normal to observe in the water seal chamber of a chest tube?
Tidaling - Slight movement of the water level corresponding to a patient’s breaths
What is the most concerning symptom of a potassium imbalance? (Hyer/hypokalemia)
Cardiac dysrythmias
Are tachycardia, hypertension, and increased DTRs a sign of hypo or hypermagnesemia?
Hypomagnesemia
If a patient reports abdominal cramping during an enema, what should the nurse do first?
Lower the solution container
Name two risk factors for constipation
Any two of the following:
- Insufficient fluid intake
- Insufficient fiber intake
- Physical inactivity
- Medication side effects
- Older age
List the appropriate order to doff (remove) PPE
- Gloves
- Eye protection
- Gown
- Mask
List the appropriate order to don (put on) PPE
- Gown
- Mask
- Eye protection
- Gloves
Name three late signs of hypoxia
Any three of the following:
- Decreased LOC
- Cyanosis
- Increased lactic acid
- Dysrhythmias
- Bradycardia
- Bradypnea
- Hypotension
Name three early sign of hypoxia
Any three of the following:
- Restlessness
- Irritability
- Use of accessory muscles
- Nasal flaring
- Adventitious lung sounds
- Tachycardia
- Tachypnea
- Hypertension
- Pallor
After an x-ray confirms the location of an NG tube, what is the best way to confirm NG tube placement at the bedside?
Aspiration of fluid and testing the pH
Name two reasons a patient may need an NG tube
Two of the following:
- Decompression for bowel obstruction
- Short-term nutrition support
- Administration of medications
When reviewing results of a urinalysis, what are four substances that should no be present?
Any four of the following:
- Glucose
- Ketones
- Blood
- Protein
- Bilirubin
- Nitrates
- Leukocytes
- Esterase
What does a urine specific gravity of 1.040 indicate?
Concentrated urine
Hypoventilation due to a respiratory disorder can cause which acid-base imbalance?
Respiratory acidosis
Diabetic ketoacidosis (DKA) causes which type of acid-base imbalance?
Metabolic acidosis
Which stage of pressure injury is characterized by a deep wound with an exposed tendon or bone?
Stage IV (4)
Which stage of pressure injury is characterized by red, non-blanchable, intact skin?
Stage I
Name the five stages of grief defined by Kubler-Ross
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
Which stage of general adaptation syndrome is characterized by a “fight or flight” response, increased cortisol levels, and increased BP/HR?
Alarm reaction stage
Name two situations in which it is important to use soap and water vs hand sanitizer?
Any two of the following:
- Hands are visibly dirty
- Before eating
- After using the bathroom
After caring for a patient with infectious diarrhea (C-Diff)
What PPE is required when caring for a patient with contact precautions?
Gown and gloves
Opioid analgesics are appropriate for what level of pain?
Moderate to severe
How full should the bag of a partial rebreather mask be maintained?
2/3 full
Name two breathing techniques a patient with COPD can use when they feel short of breath
- Pursed lip breathing
- Diaphragmatic breathing
How many calories does 1g of fat provide?
9 calories
What nutrient is most important to prevent pressure injuries?
Protein
