fundies. exam review 11/9 Flashcards
the nurse clarifies the first stage of wound healing is?
inflammation
what indicates the vessels are dilating and allows plasma to leak into the wound site?
swelling
what are cardinal signs or symptoms of internal hemorrhage?
heart rate goes up, blood pressure goes down and restlessness
when a pt has dehiscence they have an increase in…
seroussequinous drainage (blood)
when cleaning a jp drain you use one alcohol to
clean the spout and another wipe to clean the plug
what dressing would you need for a stage 1 pressure ulcer?
the dressing needed would be a thin film dressing
a pt has a pooling of blood under unbroken skin. What is this called?
a hematoma
the advantages of a hydrocolloid dressing
they can be left in place up to 7 days and they are air aclusive which helps with breakdown of necrotic tissue
the nurse is changing a dressing and its sticking to the wound
add normal saline to it
when you have a pt with staples that need to be removed and using a staple puller. How should they be removed.
squeeze the handles completely and pull out
wound vacs promote healing by…
draining the wound edges back together by a negative pressure
The nurse recognizes a pt meds can delay…
wound healing
three meds that would delay wound healing…
anti-neoplastic, heparin, and steroids
the nurse has a 85 year old pt their wound healing would be slower wound healing because of what three factors?
athrosclerosis, decreased lung function, and slower metabolism
nutritional documentation that is most informative is
when you document the percentage of the food the pt ate
is jell-o a clear liquid?
yes
a nurse caring for a pt with bulimia you need to assess for
for induced vomiting
a pt who abuses alcohol is at risk for
deficiency of vitamin b or thiamine
a low cholesterol meat is?
turkey
your pt has an elevated high-density lipoprotein a high hdl
The nurse explains that such a report indicates that a good cholesterol
70 to 120 is a healthy blood sugar. So a blood sugar of 75 ?
is fine
when a pt is having a ng tube inserted
The pt needs to sit upright and extend the pt’s head a little
the most accurate way to examine the position of a ng tube is..?
a chest x-ray
the nurse has a pt who is being given a feeding and checking for residual. You aspirate and get 250 cc’s. What should you do?
Delay the feeding, replace the aspirate back and notify the doctor
administration of bolus of 60 cc’s to a pt intermittent tube feeding so run it for…?
about 10 minutes
after a feeding the pt’s HOB needs to be up…?
30 to 60 minutes after the feed
the pt has total parenteral nutrition running (tpn) monitor the flow rate
every 4 hours for adults
vitamin d comes from
sunlight
feeding internal tube feed and the pt starts complaining of nausea and diarrhea. What should you do?
stop the feed and inform the rn
a nurse is caring for a pt with internal tube feeding assess for tolerance by?
observing for abdominal distension
when a pt is receiving tpn what is one thing to test for
glucose with a dip stick
you have a pt on a soft diet. There is four things to be included in the diet they are?
eggs, soup, juice, and milk
the nurse counsels a bulimic pt that her disorder that can lead to some serious conditions such as?
esophageal and peptic ulcers
pt is on a bolus feed so make sure bed is elevated to…
30 to 40 degrees
if you are feeding a pt with a tube feeding and you suspect the pt is aspirating. The highest priority is ?
stop the feeding
pt’s who are not given tube feedings slowly, experience
glycosuria
poor body position can cause
aspiration
tough black tissue around a wound is called?
eschar
an assessment of a wound that would indicate healing would be…
pink granulated tissue
an open wound is called a?
abrasion
factors that effect wound healing would be?
decrease age, meds, nutrition, and their lifestyle
an abnormal passage that is formed between two internal organs is called?
a fistula
5 mL is equal to
1 teaspoon
