fundies. exam review 11/9

Question 1

the nurse clarifies the first stage of wound healing is?

Answer 1

inflammation

Question 2

what indicates the vessels are dilating and allows plasma to leak into the wound site?

Answer 2

swelling

Question 3

what are cardinal signs or symptoms of internal hemorrhage?

Answer 3

heart rate goes up, blood pressure goes down and restlessness

Question 4

when a pt has dehiscence they have an increase in…

Answer 4

seroussequinous drainage (blood)

Question 5

when cleaning a jp drain you use one alcohol to

Answer 5

clean the spout and another wipe to clean the plug

Question 6

what dressing would you need for a stage 1 pressure ulcer?

Answer 6

the dressing needed would be a thin film dressing

Question 7

a pt has a pooling of blood under unbroken skin. What is this called?

Answer 7

a hematoma

Question 8

the advantages of a hydrocolloid dressing

Answer 8

they can be left in place up to 7 days and they are air aclusive which helps with breakdown of necrotic tissue

Question 9

the nurse is changing a dressing and its sticking to the wound

Answer 9

add normal saline to it

Question 10

when you have a pt with staples that need to be removed and using a staple puller. How should they be removed.

Answer 10

squeeze the handles completely and pull out

Question 11

wound vacs promote healing by…

Answer 11

draining the wound edges back together by a negative pressure

Question 12

The nurse recognizes a pt meds can delay…

Answer 12

wound healing

Question 13

three meds that would delay wound healing…

Answer 13

anti-neoplastic, heparin, and steroids

Question 14

the nurse has a 85 year old pt their wound healing would be slower wound healing because of what three factors?

Answer 14

athrosclerosis, decreased lung function, and slower metabolism

Question 15

nutritional documentation that is most informative is

Answer 15

when you document the percentage of the food the pt ate

Question 16

is jell-o a clear liquid?

Answer 16

yes

Question 17

a nurse caring for a pt with bulimia you need to assess for

Answer 17

for induced vomiting

Question 18

a pt who abuses alcohol is at risk for

Answer 18

deficiency of vitamin b or thiamine

Question 19

a low cholesterol meat is?

Answer 19

turkey

Question 20

your pt has an elevated high-density lipoprotein a high hdl

Answer 20

The nurse explains that such a report indicates that a good cholesterol

Question 21

70 to 120 is a healthy blood sugar. So a blood sugar of 75 ?

Answer 21

is fine

Question 22

when a pt is having a ng tube inserted

Answer 22

The pt needs to sit upright and extend the pt’s head a little

Question 23

the most accurate way to examine the position of a ng tube is..?

Answer 23

a chest x-ray

Question 24

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?

Answer 24

Delay the feeding, replace the aspirate back and notify the doctor

Question 25

administration of bolus of 60 cc’s to a pt intermittent tube feeding so run it for…?

Answer 25

about 10 minutes

Question 26

after a feeding the pt’s HOB needs to be up…?

Answer 26

30 to 60 minutes after the feed

Question 27

the pt has total parenteral nutrition running (tpn) monitor the flow rate

Answer 27

every 4 hours for adults

Question 28

vitamin d comes from

Answer 28

sunlight

Question 29

feeding internal tube feed and the pt starts complaining of nausea and diarrhea. What should you do?

Answer 29

stop the feed and inform the rn

Question 30

a nurse is caring for a pt with internal tube feeding assess for tolerance by?

Answer 30

observing for abdominal distension

Question 31

when a pt is receiving tpn what is one thing to test for

Answer 31

glucose with a dip stick

Question 32

you have a pt on a soft diet. There is four things to be included in the diet they are?

Answer 32

eggs, soup, juice, and milk

Question 33

the nurse counsels a bulimic pt that her disorder that can lead to some serious conditions such as?

Answer 33

esophageal and peptic ulcers

Question 34

pt is on a bolus feed so make sure bed is elevated to…

Answer 34

30 to 40 degrees

Question 35

if you are feeding a pt with a tube feeding and you suspect the pt is aspirating. The highest priority is ?

Answer 35

stop the feeding

Question 36

pt’s who are not given tube feedings slowly, experience

Answer 36

glycosuria

Question 37

poor body position can cause

Answer 37

aspiration

Question 38

tough black tissue around a wound is called?

Answer 38

eschar

Question 39

an assessment of a wound that would indicate healing would be…

Answer 39

pink granulated tissue

Question 40

an open wound is called a?

Answer 40

abrasion

Question 41

factors that effect wound healing would be?

Answer 41

decrease age, meds, nutrition, and their lifestyle

Question 42

an abnormal passage that is formed between two internal organs is called?

Answer 42

a fistula

Question 43

5 mL is equal to

Answer 43

1 teaspoon