midterms Flashcards
Nurse practice act
The law in each state that governs nurses’ actions addresses each level of nursing.
HOSA
(Health occupations students of America) National organization specifically for student nurses.
ISBAR
(communication) Introduce yourself Situation Background Assessment Recommendation
The professional organization for LPN is the
National federation of LPN
The purpose of critical thinking connection is
Identify actions to take and inform to consider when caring for patients.
Concerns when providing care for an elderly patient
These patients often have chronic illness, sensory deficits, and multiple medications.
When you care for younger patients in a health-care provide’s office, you must keep in mind that…
Have difficulty understanding what is happening and expressing themselves during a procedure.
A unique aspect of home health is that
fewer supplies and less equipment are available than in a hospital setting.
the nurse is alone in the home with no other health-care staff to help make decisions about care.
When working in long-term care…
The setting is more homelike
You will need to use an easy, calming approach to residents.
Change in behavior can indicate health problems in the elderly.
Responsibilities as a nursing student regarding lab and diagnostic test result.
Check the test results often and note any abnormal findings.
Notify the health-care provider of significant abnormal results.
Post conference connection
To help evaluate the clinical experience off caring for patient in the clinical connection.
Responsibilities of a nurse
caring for more than on patient at a time
Helping families understand the care of the patient after discharge
notice any changes in the patients condition and notify the appropriate health-care professional.
student organization that is connected with the American nurses ass.
NSNA
QSEN ties into providing individuallized care for patients, including their
Preference, values, and needs in their plan care..
Quality improvement
Patient-centered care
Nursing care plan
A documented strategy that includes the health- care provider’s orders, nursing dx, and nursing orders
Rapport
creating trust between the nurse and the patient.
Nursing diagnosis
the consice statement of a problem that the patient is experiencing as a result of the patients diagnosis
Nursing goal
the overall direction that will indicate improvement in a problem.
Defining characters
the signs and symptoms experience by the patient that directly influence the nursing diagnosis.
Validate
overlapping, five-step method decision making.
Expected outcome
are statements of measurable action for patient within specific time frame in response to nursing interventions.
Independent intervention
actions the nurse performs that do not require a written order
Dependent intervention
actions the burse performs that requires a written order
Collaborative intervention
nursing actions that involve working with other disciplines such as physical therapy or social services.
Direct patient care
when an individuall nurse performs hands-on or one-on-one nursing interventions
Indirect patient care
activities that a nurse performs that do not involve hands on patient care.
How would you obtain information about your patient so that you can begin to develop a plan of care?
a. read the nursing admission assessment and recent nurses’s notes
b. read the health-care provider’s admission note and recent progress notes.
c. listen to the end-of-shift report at the nurse’s station
d. review the medication administration record and any treatment plans or notes.
Which step of the nursing process is concerned with identifying physical findings?
Assessment
Which step of the nursing process would you look at outcomes?
Evaluation
which step of the nursing process are priorities set?
Planning
Which step of the nursing process do you label problems
Diagnosis
Which step of the nursing process is most associated with action?
Implimentation
You are performing the daily assessment of your patient’s status. You notice some purplish marks on her arm where thebandage for her IV had been and the patients skin is torn. What type of assessment techniques did you use to obtain these data?
Inspection
To asses bowel sounds, which assessment technique will you use?
Auscultation
Your patient has severe peripheral vascular disease (poor circulation) in both lower extremities. You document that the patien’ts pedal pulses are absent. Which assessment teqnues did you use?
Palpation
You are assessing the NP with her assessment of an elderly, confused woman. You watch as the NP placesher hand on the woma’s back and then taps her own middle finger with her other hand. This assessment is called
Percussion
How is Maslow’s hierarchy of human needs used by nurses in a clinical setting?
It helps in prioritizing nursing diagnosis and care.
According to The Joint commision, all patients have the right to
Recieve medical care considerate of their culture, religion, and spiritual beings.
Cultural diversity in a hospital
Having employees from variety of countries and cultures
Employeing people of variety races
Employing people who may speak a variety of language as well as english
When an LPN is providing home care for patients of different cultures or religions the nurse should…
Show respect for the patient’s believs
Adapt their services even more than in the hospital setting.
When a patient is in a spiritual distress you should…
Use therapudic communiction techniques to encourage expression of feelings.
Allow the patient plenty of opportunities to explain his or her feelings.
Offer precense
Spend adequate time with the patient and pay attention to his or her actions.
CPR
Actions to restart the heart or breathing in an unresponsive patient
Leg monitor
Attaches to the patient and generates alarm when the leg is in a dependent position
Rescue breathing
Breathing for a person in respiratory arrest who still has a pulse
Heimlich maneuver
An action to relieve chocking by thrusting just below the xiphoid process.
Body mechanic
refeers to the movement of the muscles of the body for balance and leverage.
Base of support
feet and lower legs
Even if you delegate checks and releases what are your responsibilities when a patient must be restrained?
Follow up every 2 hours to be sure the patient is released from restraints and has been checked on every 30 minutes.
When a patient in a home setting uses supplemental O2, what teaching should you provide?
No one can smoke in the same room as the O2
No candles can be burned in the same room as the O2 source.
Patient using O2 should not use wool blankets or wear wool swaters.
Before applying restraints to any patient, you must first take…
Try using restraint alternatives without success.
Identify the need for restraints to prevent harm to the patient.
Obtain a health-care provider’s order for the type of restraint and the length of time it is to remain in place.
Hospitalized patients often have impaired mobility causing risk for injury because of…
They maybe weak as a result of surgery or bedrest.
How are fall assessment used?
To predict the patient’s risk for falls while in the hospital.
You walk into the patient’s room and you discover that he has fallen, what will you do first?
Check the patient for any obvious injuries, including hip fracture and paralysis.
How often do you check on patient’s who are restraints?
Every 2 hours.
When a patient is relseased from wrist restraints, what assessment should you take?
Assess the hands and wrist for edema.
Check capillary refill
Assess the patien’ts ability to move and feel sensations in the arm and hand.
Assess the skin of the wrists for any open areas.
Assess the skin under the restraints for redness.
What must you always do when you apply restraints?
Tie them tightly so the patient cannot struggle.
To practice good body mechanics,
Turn your whole body or pivot
Bend your knees, not your back
How can nurses avoid being harmed by radiation?
Wear lead apron
Limit the time you spend with patients who have internal or implanted radiation
What do you do when you discover a fire?
Rescue
Alarm
Confine
Extenguish
How to use fire extiguisher?
Pull
Aim
Squeez
Sweep
Health care assosiated infection
Acquired while a patient is being cared
Primary infection
infection by one pathogen only
Septicemia
Microorganisms present and multiplying in the blood
Disinfectant
Cleaning agent that removes most pathogens
Direct contact
Person to person
Vector
an insect, tick
THe sequesnce of events that must occur for infection to spread from one person to another is called
Chain of infection
An infection caused by a different pathogen that the primary pathogen is called
Secondary infection
When examining a wound drainage specimen under the microscope, you see sphere-shaped micro in chains
Streptococci
Gram positive bacteria
Appear in purple or blue
Whe would emptying the bedside commode be a nursing responsibility rather than a house keeping
Nurses are responsible for measuring urine output and creating a pleasant environment for patients.
Delagating Cdiff to UAP
Ensuring that the UAP knows the correct precautions to take to prevent transmission of bacteria.
Observe the UAP carefully to ascertain his or her abilities regarding transmission-based precautions.
Kindly pointing out any errors in technique to protect the UAP and other patients.
Types of pathogen
Bacteria Viruses Protozoa Fungi Helminths
Types of bacteria
Cocci, Bacili, spirilla
Rickettsia
Rickettsia
spread through vectors
Viruses
TIny parasites the live within cells of hosts and produce there
Protozoa
Single-celled animals that live in water and cause intestinal illness when ingested..
Fungai
May be made up of one or more cells: Enters through cuts and cracks of skin.
Bacteria
One celled micro classifies by shapes
Proper squence of donning full PPE
Hand hygine Gown Mask eye protection hair covering shoe covering Gloves
Removing PPE
gloves Gown eye protection mask hair covering show covering hand hygiene
You are removing a feeding pump from the room of a patient who is being discharge
Disinfect it according yo yhr facility policy
Sterilize it using steam under pressure
Lesion
open areas
Excoriation
scrapes
mottling
purple blotch
maceration
soften skin
vasodialation
widening of blood vessel
Seborrhea
thick, oily scalp.
Draw sheet
A narrow sheet with two narrow hems at each end. Use to position the patient
Miltered corner
Use to anchor linens more firmly
Baths
Perform the bath as assigned
Composed of dead keratin cells
Hair and Nails
Bathing and caring for the skin of older adults
Apply lotion frequently to prevent dryness
Keep room warm during bath to prevent chilling
sebaceous and sweat glands produce less oil and sweat.
Provacy for school-age children
Place a “bath in progress” sign outside the door to prevent interruptions
Always knock before enter the patient’s room
Functions of sebum
Protect the skin from cracking
Lubricates
If a resident in a long-term care facility has been incontinent but is not scheduled for a bath or shower until tomorrow…
Provide perineal care to prevent skin breakdown and odor.
AM care
Hair Bath Shaving Oral care back massage dressing straightening linens
It is important to stay with a patient during the first bath or shower after surgery because the patient may be…
Experience vasodialation and become dizzy or faint.
Providing oral care for unconcious patient
posistion the patient on the left or right side with bed flat
Assess the mouth for session and sores
Keep a suction device on and ready for use.
Stoke patient with partial paralysis of his throat, oral care, what will you do
Stay with the patient in case she chokes while performing oral care, and assist her as needed.
When cleaning dentures
Line sink with clean paper towel
Use cool water
Store them in denture cup with cool water and a cleaning tablet.
Patient with IV containing heparin, you are assisting him with personal care.
Shave him with an electric razor, moving in circular motions over the beard.
Providing personal care with diabetes
File her toe nails straight accrosss but do not clip.
Importance of 2% trilosan products on surgical patients
Prevent patients from MRSA
Omit giving back massage
When a patient has broken ribs or broken spine.
Plantar flexion
foot pointing downward
Fowler’s posistion
Semi-sitting knee slightly elevated and head eleveated
Semi-fowler
45 degrees (tube feeding)
Log roll
Turn patient with the body as one unit
Contractures
Shortening or tightening of muscle as a result of disuse
Trochanter roll
lateral aspect of the patient’s thigh to prevent leg from rotating outward.
Shearing
Occurs when the skin layer is pulled across the muscle and bone, while slides over the bed sheet
Posistion of function
A patient posistion where his extrimities are in alignment to maintain the potential for use and movement
Orthopneic position
When a patient is in sever respiratory distress
Left sims
Administrating ename
How can you be certain that the wheels of a strecher are locked
Physically attemp to move the strecher, even if you have locked the wheels.
Why is it important what you will be doing when you reposition the patient?
The patient may be sedated
The patient will be more cooperative
The patient will be less likely to resist during position change
the patient can more easily assist with the position change
Gastrointestinal complication intervention
Help the patient choose well-balanced meals
Assess bowel sounds
Encourage fresh fruits and veggies
Perineal care position
Dorsal recumbent
Lateral position where would the pillows go?
between the knees and ankles and back
Spinal surgery
Log rolll the patient
Have total of 3 health care staff to assist
Have one person at the patient’s head to direct the turn
Purpose of assisting a patient to dangle
To determine if the patient can tolerate changing positions.
A patient has a viral infection. Which information would the nurse share with the patient?
“The virus can only multiply inside the body.”
The nurse is providing care for a patient who is confused and constantly pulls at an indwelling catheter and nasogastric (NG) tube. The nurse has tried multiple alternatives to restraints, none of which have been effective. Which specific question will the nurse mentally ask before calling the health-care provider for a restraint order?
“Are restraints necessary to maintain tube placement?”
The nurse is caring for multiple patients who are experiencing altered bladder function. Which patient will be the nurse’s priority?
The patient with painful bladder contractions and distention
The health-care provider orders a urinalysis for a patient with an indwelling urinary catheter. Which steps will the nurse perform to obtain the specimen?
Clean the port located in the tubing with an alcohol swab.
Using a blunt needle, withdraw 5 to 8 mL of urine from the port.
Unclamp the catheter tubing to allow the urine to flow freely into the collection bag.
Clamp the tubing below the level of the port to collect fresh urine.
The nurse is collecting data on a patient’s capillary refill. The patient has yellowed, thickened nails. Which technique would the nurse use?
Press the tip of the patient’s finger
Slide sheets are made out of
webbed nylon
Assistive device would you use after the patient had fallen to help him or her return to bed
A battery-operative lift
When performing ROM exercises, which action will you take first
Check the patien’ts chart for any contraindications to full ROM
Dyspnea
Having difficulty breathing
pulse deficit
apical heart rate is higher than radial pulse rate
Hypoxemia
decreased blood level of O2
Stridor
A high pitched crowing respiratory sound
Hypoxia
High-pitched crowing respiratory sound
Cheyne-stoke
Repetitious pattern of respirations that begin shallow.
Pulse sites
Radial Carotid temporal Brancial femoral popliteal proximal tibia distal pedis
Thermogenesis
Body’s heat production
Characteristics of the pulse should you always assess?
Lenght of each beat Strength Rate Depth Rhythm of beats
Ptosis
Numbness or a decreased sensation
Excursion
Chest wall appears sunken in between the ribs or under the xiphoid process as the patient inhales.
Dysphasia
Patient knows what he wants but cannot say the words
Aphasia
Difficulty coordinating and organizing the words correctly.
What type of assessment is performed on admission
Comprehensive health assessment
A patient wa admitted yesterday with pneumonia. When auscultating his breath sounds you detect rales in the right lower lobe. How quickly should you reasses?
within 15 minutes
A 5 year old patient has a fever of 104.4 axillary. When should you reassess the child temperature?
within 60 minutes.
What asessment findings may provide you with neurological status data?
Lethargy
Where do you hear the apical pulse best?
Just to the right of the sternum in the 2nd intercoastal space.
Irregular pulse assessment
Auscultate the apical pulse for 60 minutes.
Pulse characteristics
rate, rhythm, and strenght
Initial shift assessment
Observation, palpation, percussion, auscultation oand olfaction (except for the stomach)
What causes body odor
Bacteria break down sweat
The nurse is caring for a patient who has a leg infection. Which action indicates the nurse is using sterile technique?
Inserts a Foley catheter
The nurse is caring for a patient who has the flu. Which action should the nurse take?
Wear a mask when taking vital signs
The nurse is observing an unlicensed assistive personnel (UAP) provide care to patients on transmission-based precautions. Which action by the UAP would cause the nurse to intervene?
The UAP dons only gloves to provide a bath to a patient on contact precautions.
The nurse is assisting the registered nurse (RN) in caring for infants in a nursery. The nurse notices an infant with microcephaly (small head from abnormal brain development). How should the nurse interpret this finding?
The mother was infected with the Zika virus.
The nurse is performing range-of-motion exercises with a patient. The nurse gently pushes the patient’s foot back causing the patient’s toes to move toward the patient’s head. Which technique did the nurse use?
Dorsiflex
The nurse asks for two other coworkers to assist in turning a patient as a unit. Which patient is the nurse turning?
One who has had the spine fused
The nurse serves the lunch tray to a patient. In which position should the nurse place the patient?
High Fowler’s
The nurse is reinforcing teaching about deep breathing with a post-operative patient. Which patient behavior indicates a correct understanding of the teaching?
After breathing in, holds breath for 3 sec
The patient has contractures. What would the nurse observe when collecting data from the patient?
Shortened and tightened muscles
The nurse is having an immobile patient breathe deeply. Which goal is the nurse trying to achieve?
To prevent atelectasis
The patient is withdrawn for being on prolonged bedrest from an overwhelming infection. Which response should the nurse make?
“This must be hard for you.”
Which patient who needs to ambulate would be appropriate to assign to an unlicensed assistive personnel (UAP)?
The patient who is steady on feet
Which piece of equipment should the nurse obtain to transfer a patient from a bed to a stretcher?
Slide board
The nurse is ambulating a patient. Which patient findings would cause the nurse to let the patient rest and return the patient to bed?
Respiratory rate increases from 16 breaths/min to 28 breaths/min
- The patient states, “I am so tired.”
- The patient states, “I feel like the room is spinning.”``
The nurse is contributing to the plan of care for a patient with a cast. Which interventions should the nurse recommend including in the patient’s plan of care? Select all that apply.
Observe for drainage.
- Check for a malodorous smell.
- “Petal” the edges of the cast if crumbling
The nurse is giving a bath to a patient who is recovering from upper body burns. The patient states, “I look like a monster.” How should the nurse respond?
Tell me more about it
The nurse is giving a bath to a patient who is recovering from upper body burns. The patient states, “I look like a monster.” How should the nurse respond?
Places metal, partial dentures in water only.
A patient is incontinent of urine. The nurse is changing linens. Which action should the nurse take?
Spray the mattress with disinfectant spray
How would the nurse explain the difference between a blanket bath and bag bath to a coworker?
“One has blanket, washcloths, and towels and the other has just washcloths.”
The nurse is working as a summer camp nurse. While accompanying campers on a hike, a hiker falls and is injured. The nurse has no medical equipment available. Which assessment process is the nurse least likely to use?
Tactile skills to determine the presence of internal injuries.
he nurse is preparing to reassess a patient at the beginning of the shift. For which assessment will the nurse need to acquire equipment?
Inspection of the tympanic membrane
The nurse is reassessing a patient’s apical pulse prior to the administration of cardiac medication. Which action by the nurse is inappropriate?
Listening to the posterior aspect of the thoracic cavity
The nurse is assisting the health-care provider during a lumbar puncture. The nurse is standing across from the health-care provider and helping the patient maintain a curled, side-lying position. The nurse accidentally places a hand on the sterile drape when shifting a grip on the patient. Which action will the nurse take?
Stop the procedure until the sterile drape is replaced.
The nurse is caring for multiple patients who are experiencing altered bladder function. Which patient will be the nurse’s priority?
The patient with painful bladder contractions and distention
A patient with emphysema (a lung disease) wants to know how to do household chores without becoming short of breath. Which program does the licensed practical nurse/licensed vocational nurse (LPN/LVN) expect the registered nurse (RN) or health-care provider will suggest?
Pulmonary rehabilitation
Which patient finding would cause the nurse to suspect a decreased respiratory rate?
The patient is sleeping
The nurse is reviewing a patient’s vital sign report. The patient has an infected abdominal wound. Which findings does the nurse expect?
Elevated heart rate and elevated temperature
In which situation should the nurse consult the safety data sheet (SDS)?
Before wiping up a cleaning product has been spilled
The nurse calls a Code Blue on a patient who is unresponsive. The family is in the room, and the nurse asks the unlicensed assistive personnel (UAP) to take the family out of the room. Which action does the nurse expect from the UAP?
Find a private room where phone calls are possible and offer the family beverages.
Which phrase should the nurse use to describe the nursing process?
Decision-making framework
The nurse is caring for a resident in a long-term care facility. Which action should the nurse take when charting care about this resident?
Use a specific time for each entry
The nurse writes the following in a patient’s chart: Heart tones strong. However, the nurse meant to write weak rather than strong. What should the nurse do?
Make a single horizontal line through strong and initial it.
Which action by the nurse is the most important way to prevent health-care–associated infections (HAIs)?
Perform hand washing
Which intervention is essential in preventing integumentary complications when caring for a patient who has limited mobility?
Turning the patient every 2 hr
The nurse is contributing to the plan of care for a patient who is on bedrest. Which cardiovascular interventions should the nurse recommend including in the patient’s plan of care? Select all that apply.
Encourage range of motion.
- Apply sequential compression devices.
- Use anti embolism stockings.
The nurse is preparing to administer an enema. In which position would the nurse place the patient?
Left sims
The nurse is observing an unlicensed assistive personnel (UAP) transfer a patient who has a Foley catheter to a wheelchair. Which action by the UAP would require the nurse to intervene?
The UAP tells the patient, “Place your hands around my neck.”
Which goal is the focus of the “Handle With Care” campaign?
To prevent musculoskeletal injuries in nurses
How many nurses is required for a log roll?
3
The nurse is performing range-of-motion exercises with a paralyzed patient. Which action should the nurse take?
Repeat each exercise five to ten times.
As the nurse is ambulating a patient, the patient states, “I feel like I am going to pass out,” and the patient begins to slump. Which action should the nurse take?
Pull the patient toward the nurse.
The nurse is caring for a patient who has an Ilizarov frame. The nurse is most likely caring for which patient?
One whose left leg is shorter than the right after a vehicle accident
Which action by the LPN/LVN indicates a correct understanding of the LPN’s/LVN’s role in the nursing process?
Carries out interventions
The nurse is caring for a patient with heart problems. Which actions should the nurse take during the assessment step of the nursing process?
Performs a focused heart examination
- Reviews results of a complete blood count
Auscultates heart tones
Nursing Process
ADPIE
The nurse is providing personal care to several different patients. Which actions would the nurse take?
The nurse assigns a total bed bath to a comatose patient.
The nurse stays with the patient during the initial shower after surgery
The nurse uses gauze and gloved hands to remove dentures.
The nurse is working in a long-term care facility. The nurse is helping a new resident adjust to the new surroundings. The nurse discovers the resident always takes a bath at night. Which action by the nurse is best?
Allow the resident to bathe at night
Which olfaction assessment is most common among medical health-care providers?
The odor of acetone on the breath of a patient with diabetes mellitus.
The nurse is newly hired in an extended care facility. The nurse asks about orange stickers located on the patients’ medical record and the doors of some rooms, in addition to the presence of orange bands on some patients’ wrists. Which purpose are the color reminders most likely to serve?
Fall risk
The nurse is working at the hospital when a blizzard occurs in the area. The state issues a state of emergency requiring all traffic remain off the roads unless it is an emergency. Which crisis does the nurse anticipate?
A shortage of staff that can get to the hospital
The nurse is attending an education program about how to avoid back injury at work. Which factor is important for the nurse to apply?
A wide base of support is considered adequate when the feet are shoulder distance apart.
The nurse is assigned to accompany and assist with a confused patient scheduled for x-ray studies. The nurse states she is in the first trimester of pregnancy. Which decision will the charge nurse make?
Replace the nurse with another.
The nurse is preparing to clean up a chemical spill in the medication room. Which action will the nurse take first?
Close the door and access the SDS book.
Nurses are acutely aware of the biological hazards that risk the safety of health-care personnel. Which action is commonly performed to reduce the risk of biological hazards?
Proper hand hygiene before and after touching patients.
The unlicensed assistive personnel (UAP) is reporting SpO2 results to the nurse. Which finding would cause the nurse to check a patient?
88% on room air.
The nurse continues to keep fingers on a patient’s radial pulse while counting respirations. What is the rationale for this action?
The nurse knows breathing can be controlled by the patient.
The nurse is observing an unlicensed assistive personnel (UAP) move a patient in bed. Which action by the UAP would the nurse praise?
Lifts the patient across the bed
Drainage types and color
Sanguineous drainage looks like blood. Option 2: Pink drainage is called serosanguineous. Option 3: Drainage that is clearer to slightly yellow fluid is serous. Option 4: Purulent drainage is pus.
The nurse is assisting the registered nurse (RN) in caring for a recent postoperative patient who had an amputation of the left leg. Which finding would alert the nurse of possible hemorrhage and shock?
Decreasing blood pressure and increasing pulse rate
The nurse changes a dressing and observes a patient’s wound has decreased in size. Where in a problem-oriented medical record would the nurse chart this information?
Progress notes
The nurse manager in an extended care facility is concerned about an increase in patient falls. Which situation is most likely contributing to the increase?
Call lights are not being answered promptly.
The nurse becomes aware of a mass casualty event from a bioterrorism attack in the form of a highly contagious disease. Which clue is likely to be the first indicator of this kind of attack?
People begin presenting at various hospitals with similar symptoms.
The nurse continues to work after an older parent with dementia moved into the nurse’s home. The nurse manager notes that the nurse made three medication errors in the past week. The nurse manager expects which cause for the nurse’s behavior as most likely?
A lack of sleep because of the parent’s night wandering and confusion
The nurse is providing care for a patient receiving radiation treatment for cervical cancer with a temporary vaginal implant. Which safety factor is least effective in protecting the nurse from radiation exposure?
The nurse needs gloves when checking the implant.
The nurse is collecting data from a patient and wants to know which herbal supplements the patient is taking. Which question would be best for the nurse to ask the patient?
“What prescribed and over the counter herbal medicine do you take?”
Disinfecting
Cleaned with solutions to kill pathogens
Chemical disinfection
Used to kill pathogens on equipment and supplies that cannot be heated.
Sterilization
Use of steam under pressure, gas, or radiation to kill all pathogens and their spores.
Ionizing radiation
A method of killing pathogens on satures.
Gaseous disinfection
A method used to kill pathogens on supplies and equipment that are heat sensitive and must remain dry.
Autoclaving
Sterilation method using steam under pressure.
Primary puncion while doing a sterile procedure
Obtaining the needed equipment and supplies
Checking expiration date
Obtaining the correct size of sterile gloves for the physicians, yourself and anyone else who will be assisting.
Opening gauze and handing it to the health-care provider
Peel open the packaging with the opening toward the health-care provider
Keep your bare hands covered by the packaging
Allow the health-care provider to remove the gauze from the packaging
Cleaning up the instrument prior to sterilization
Wash them with soapy water and then rinse
Leave hinged instruments
Rinse the instruments well with cold or warm water.
YOu obtained a package of commercially prepared sterile gauze. To ensure it is sterile prior to opening it…
Check the expiration date
Examine the package for any open or unsealed areas.
You are assigned to observe in the cardiac catheterization lab. What will you do before leaving the unit to go to lunch?
Cover your scrub with a lab coat or cloth isolation gown.
It is important to use sterile technique when you insert tubes and needles because
You are entering body tissues not normally exposed to pathogens
You are bypassing usual body defences against infection
Setting up the sterile field
If the sterile drape extends below the table surface, the part below it are considered unsterile
You may touch the outer 1 inch of the sterile drape with your bare hand because it is considered unsterile
A sterile drape with a moisture-proof back is not considered sterile if it becomes wet.
Opening or adding sterile park steps:
open the flap away from you
Open the first side flap
Open the remaining side flap
Open the flap towards you
Anaphylaxis
A life-threatening allergic reaction
Bolus feeding
Internittent instillation of formula into the PEG tube
Enternal nutrition
Delivery of tube feedings
Parenteral nutrition
Nutrients administered into the blood streams
PEG tube
Feeding tube that goes through the skin
Gastric decompression
Process of reducing the pressure withhin the stomach
Clear liquid diet
A diet that does not include solid foods and consists entirely of liquids which you can see through
Food intolerance
An adverse reaction to a food
Hemoglobin A1C
test that measures the gloucose
Nasogastric tube
Inserted through the nose down the esophagus
Full liquid diet
Diet that includes all clear liqiud and those fluids are too opaque to see through
TPN
Central venous catheter
PPN
Small peripheral vein
Resudual
Remaining formula from the stomach
Food allergy
Immunse system reacts to a food protien or other large molecule that has been eaten
Comfortable patient during mealtime
Provide wet warm washcloth for face and hands
Remove urinal
use damp cloth to wipe off over the bed table
place over the bed and meal tray in front of the patient
Average adult fluid intake
1,500-2500 ML
The primary conponents of supplied by a clear liquid diet are
calories and fluid
Mechanical soft diet is not abundant in what?
Fiber
If a patient has been on a clear liquid diet and is off of it, the dietician is more likely to recommend…
protient and calories
Decubitus diet
High calorie, high protein
H2 blockers are sometimes interfere with absorpion of
B12
Iron
Folate
water absorption occurs in
Large intestine
The purpose of the pigtail of a double-lumen NG tube is to
serve as an air vent
Prevent the tube from adhering the stomach wall during decompression
Most reliable for checking the tube replacement is
X ray
Intermittent tube feeding should…
be on semi-fowler 30-45 degreed
Verify tube placement
Assess residual gastric volume.
Most common food allergies
Peanuts
wheat
eggs
How often should continuous feeding shold be assess
Every 4 hours
Reasons why a health-care provider would order gastric decompression
Partial bowel obstruction
Persistent vomittin
complete bowel obstruction
Coffee grounds vomit
Bleeding from the esophagus or stomach has occurred and mixed with stomach acid
When preparing to assess bowel sound with NG tube you should..
Clamp the NG tube
Bloatting of the stomach when having an NG tube
The NG tube us clogged
NG tube assessment every 2-4 hours…
Determine the patency of the tube Observe the color, amount, and clarity of the aspirate Auscultate bowel sounds Observe shape of the abdomen Palpate whether it is firm or soft
Evaluating patients intake of meal
The percentage of food eaten The patient's ability to tolerate the diet Signs of difficulty swallowing the level of independence the amount of oral fliud intake
While caring for a patient recieving parenteral nutrition, you know to monitor lab results…
Electrolytes
Prealbumin
total protien
glucose level
Transmitting through a smaller peripheral vein
PPN
Only midly hypertonic oor isotonic fluids
PH balance should be in the stomach
1-4
Ischemia
reduced blood flow to tissue
Necrotic
Dead tissue
Debridement
Remove by cutting
Eschar
Hard, dry, dead tissue (leathery like)
Abrasion
Scrape
Granulation tissue
new tissue
Laceration
sliced tissue
Dehiscence
Abdominal wound starts to open
During the inflammatory process, the physiological response
Capillaries dialate
leukoctes move into the interstitial space and attack microorganism
RBC cells delivers more O2 and nutrients to promote healing
Edema causes pressure on nerve endings, resulting discomfort
An elderly patient who lives alone and has a vascular ulcer on his right leg is most at risk for infection because..
May not see well enough to notive changes in the wound that indicate infection .
You are caring for a patient with several risk factors for a pressure injury. WHich would you avoid?
Pulling the sheets from beneth the patient so she does not have to turn frequently.
The nurse is caring for a patient receiving intermittent tube feedings. Prior to administering the next feeding, the nurse checks for residual volume. Which action by the nurse is correct if the residual amount is 130 mL?
Return the residual and proceed with the next feeding as ordered.
The nurse manager is concerned about patient complaints related to the delay in response to call lights. Due to short staffing, which solution to the problem will the nurse implement?
Ask the desk clerk to notify staff if call lights come on.
Which actions would the nurse take to provide appropriate infection control strategies? Select all that apply.
Wear an N95 respirator for a patient who has H1N1 flu
- Use airborne precautions when caring for a patient with chickenpox
- Reinforce cough etiquette for a patient with Streptococcus group A
The nurse has a hypersensitivity to latex gloves. Which signs and symptoms would the nurse exhibit? Select all that apply.
Itching
- Hives
- Watery eyes
A patient develops Rocky Mountain spotted fever (a Rickettsia infection) from the bite of a tick during a camping trip. Using the chain of infection, how would the nurse describe the process?
The patient is the susceptible host.
The tick is the reservoir.
The school nurse is talking about nutrition to a class of adolescents. Which comment by one of the adolescents will cause the nurse greatest concern?
“I never eat anything but small salads so that I can control my weight.”
The nurse is monitoring the intake and output for a patient. Which substances will the nurse include as intake? Select all that apply.
Part of a can of cola.
- An infused IV solution.
- A bowl of clear broth.
The nurse is caring for a patient who has septicemia. Which culture result would the nurse review to determine the pathogen causing the septicemia?
Blood
When should the nurse perform hand hygiene?
After changing a wound dressing
- When returning to the nursing unit from lunch
- After emptying a Foley catheter of urine
- After changing the sheets of a patient with fecal incontinence
A patient with a weak left leg is using a walker. Which patient finding would the nurse praise?
The patient moves the left leg with the walker, then the right.
The nurse is preparing a nutrition review session for patients who seek health care at a clinic. The topic requested by patients is about dietary fats and cholesterol in particular. Which information will help the patients remember facts about dietary fats?
Triglycerides are stored in the body and ingested through food.
The nurse is providing care to a patient who is from a different culture than the nurse. Which patient parameters would the nurse address to provide culturally competent care?
Perceptions
- Expectations
- Behavior
- Decision-making process
The nurse is assisting with the delivery of meal trays. Which actions should the nurse perform to prepare a patient’s environment for eating?
Remove any articles that emit an odor which may decrease the patient’s appetite.
- Inquire if the patient needs to go to the bathroom or use a bedpan prior to eating.
The nurse is monitoring the intake and output for a patient. Which substances will the nurse include as intake?
A fruit-flavored gelatin.
- Part of a can of cola.
- An infused IV solution.
- A bowl of clear broth.
The nurse in a long-term care facility is monitoring a patient who is recovering from an intestinal virus. The nurse needs to consider if the patient is ready to be advanced from a liquid to a regular diet. Which findings will cause the nurse to keep the patient on liquids?
The patient has nausea and vomiting.
- The patient’s abdomen is distended.
- The patient has hypoactive bowel sounds.
- The patient is experiencing cramping.
A colonized wound is
A high number of microorganizsm are present without signs and symptoms of infection
Stage 3 pressure injury
An open area that extends through the epidermis, dermis and sub with possible undermining or tunneling
Stage 4 pressure injury
Reveals the tendone, bone
You felt a hard ridge beneath the incision scar extending about 1 cm
This is normal
A patient is at risk for wound dehiscence, what intervention?
Assist the patient to splint the incision with a pillow when coughing
Administer stool softeners and antinausea medicine promptly.
First intention
An appendectomy incisionsatured closed
Second intention
A pressure ulcer being packed with moist gauze
3rd intention
A traumatic wound first left open to drain and then satured closed
You are calling a health care provider to report a possible wound infection. What information will you include?
Most recent VS Amount and type of wound drainage Observed signs of infection Patient's rating of pain Lab results
The reasons limb might have to be amputated is
Severe tissuse damage
severity decressed blood flow to the limb
Death of tissue
When you are caring for a patient prior to surgery, one of your primary concern is..
Ensuring that all proops ordered are carried out correctly.
Major focus for partial or total joint replacement is
Managing pain and mobility
Preventing complications related to immobility
Pathological fracture, possibly from a bone tumor, which diagnostic test?
MRI
a common condition that requirs a joint replacement is
Osteoarthritis
The reasons limb might have to be amputated is
Severe tissuse damage
severity fo
A typical ambulation order by a health care provider would be
“ambulate three times per day, 20 ft each time”
You are caring for a young child with hip dysplasia who is in a spica cast. Important nursing concern would be
Moving the patient carefully without using the abductor bar.
A patient is admitted with an elevated temp and complaining of pain under his arm cast. A bad odor is noted coming from the elbow. area od the cast.. what concern do you have?
The patient may have damaged the skin. under the cast causing infection.
A patient has a quarter-size amount of drainage on her cast. the next day the amount of drainage has increased to 2 inches. The nurse would be concerned about…
Infection under the cast.
Which would you consider to be significant findings when caring for a patient with skeletal traction
Resness and swelling at the pin insertion sites
Purulent drainage at the pin insertion sites.
Care of pin insertion sites include
Cleaning the area with hydrogen peroxide
Inspecting the site for signs and symptoms of infection
What do a patient use to grab something from the floor if the patient has total hip replacement?
Use an extension gripper to pick up
What are the articular surface in a total knee replacement?
a metal tibial component that articulates with the plastic surface of the femoral component
The patella is replaced with plastic or similar substance has plastic affied to the back
YOu know a patient’s crutches fit correctly when
There is a three-fingerbreadth gas of space between the axillary pad and the patien’ts axilla.
A patient states he has fallen twice since using crutches for a foot injury
Would you show me how you hold your foot when you walk with the crutches.
What is the advantage of a multiprolonged cane over a single?
It decreases the chances of the cane slipping as the patient leans on it.
Which of the following would you include when you teach a patient about using a cane?
Move the unaffected leg and the cane together, and then move the affected leg.
WHen a walker is correctly fit a patient, which of the following is true?
The walker will come to the patien’ts hip.
The patient’s elbows will be bent to a 30 degree angle when his or her hands are on the handles.
You are working with a patient whose left leg is weak. you are instructing her on walker use.
Move the walker and your left leg forward at the same time, and then move your right leg forward.
Anuria
Absence of urine
Dysuria
Painful urine
Resudual urine
Urine that remains in the bladder
Nocturia
Walking up at night to urinate
Incontinence
Inability to control urine
urinary retention
Inability to empty the bladder at all
Stress incontinence
When urine leaks out of the bladder as a result of increased abdominal pressure.
Urge incontinence
overactive bladder
BUN
a blood test that measure waste products
Indwelling catheter
Tube that remains in the bladder, also known as foley catheter.
Straight catheter
single tube with holes at the end that is used to empty the bladder of residual urine.
Urinary diversion
used for urine to eliminate by an alternate route rather than traveling through the bladder.
UTI
caused by presence of pathogens.
Order path of urine
Kidney, Ureter, bladder, urethra, urinary meatus
Contraction of which muscle causes the bladder to empty?
Detrusor
Urinary sepsis is a potential compliction of any UTI
A continous membrane lines all the structures of the urinary system.
Bacteria from outside the urinary meatus can spread
The total volume of a person’s blood flow through the kidneys each day to be filtered.
Two tests are most important in assessing the kidney function
Creatine and eGFR
Your patient has a GFR of 45 ml/min over 3 months period she has…
Chronic kidney disease.
Under what circumstances is it appropriate to use an indwelling catheter in a long -term care setting?
If a patient has stage 3 or 4 pressure ulcer
if the patient has terminal illness
If the patient has severe impairement
One quick and common way to get a lot of data about urine
Testing the urine with multiple-pad reagent stick.
You notice that the drainage bad is filling quickly with 750 mL of urine almost immidietly, what should you do?
Take no action because the patient is tolerating.
The three most important waste products to be filtered
Urea, creatine, and uric acid.
How long does the urine specimen is to sit in the fridge
1 hour
Minimum acceptable hourlly urine output
30 ml
One important nursing intervention for patients with suspected renal calculi
Strain the urine
In addition to collecting all urine passed 24 hour period, one of the most important step obtaining a 24 hour urine sample is to
Have the patient void, discard this urine, note the time, and then begin collecting.
Your patient has stress incontinence
Suggest the patient weat incontinence pad
Kegel exercises.
Mrs White gained 3 pounds since her daily weigh the previous morning
Is retaining approx. 1.5 L of fluid since yesterday.
Indwelling cath
Balloon
Straigh cath
one time drainage
Three way cath
continous bladder
condom cath
external cath
Size for indwellign cath is between
5-30ml
The nurse is caring for a patient who has a secondary infection. The nurse is most likely caring for which patient?
.
The female who is taking an antibiotic for a bacterial infection but then develops a yeast infection.
The nurse is caring for a patient with methicillin-resistant Staphylococcus aureus (MRSA). Which medication would the nurse observe on the patient’s medication administration record?
Vancomycin
The patient develops an injury to the inside of the nasal nare from a nasogastric (NG) feeding tube. Which type of injury did the patient sustain?
Mucosal membrane pressure injury
The nurse is preparing to irrigate a patient’s wound. Which piece of equipment would the nurse obtain?
19-gauge Angiocath
The nurse is removing a patient’s abdominal incision sutures. Which action should the nurse take?
Cut the suture next to the skin, adjacent to the knot
The nurse is using normal saline (NS) to clean a wound. Which intervention would the nurse perform when using NS?
“Lips” the previously opened (12 hours ago) normal saline bottle before using
The nurse is applying a hydrocolloid dressing to a patient’s wound. Which action should the nurse take?
Holds hand over applied dressing for a few seconds
The nurse collects data about a patient’s wound that has a transparent dressing. The nurse observes excessive drainage under the dressing. Which action should the nurse take next?
Notify the health-care provider
Which patient would be most prone to impaired wound healing?
A patient who has lymphedema, takes steroids, and has several stasis ulcers
The nurse is caring for several patients who have wound care. Which actions should the nurse take for each patient? Select all that apply.
.
After irrigating a wound, avoids touching the interior of the wound when drying
- Reactivates a patient’s Hemovac after emptying the contents
- Medicates a patient 30 minutes before a wet-to-damp dressing change
A patient is having internal hemorrhage from gastrointestinal surgery. Which findings will the nurse observe?
Large amount of bright red blood
- Elevated, thready pulse
- Low blood pressure
- Pale, sweaty skin
- Distended, rigid abdomen
A patient is side-lying. Which areas should the nurse monitor closely for reddened areas?
Shoulder
Malleolus
Greater trochanter
The nurse checks on a postoperative patient who states, “Something just popped.” When the nurse monitors the wound, the nurse finds the following (shown in the image). Which actions should the nurse take?
- Cover with sterile dressing soaked in normal saline.
- Take vital signs at least every 15 minutes
wet to damp dressing
Fluff the 4 × 4s before placing in wound.
- Loosely pack the 4 × 4s into the wound
- Cover the filled wound with damp, unfluffed 4 × 4s.
The nurse has to obtain a wound culture from a patient’s draining wound. Which action should the nurse take?
Swab the pinkish, red area of the wound
The nurse is contributing to the plan of care for an emaciated, continent patient who is prone to pressure injuries. Which interventions should the nurse recommend including in the patient’s plan of care?
Turn patient every 2 hours.
- Offer protein supplements as ordered.
- Apply gel-filled pad to bed.
- Monitor pressure points every 1 to 2 hours.
The nurse is checking a postoperative patient’s vital sign sheet. Based upon the findings, which action should the nurse take?
low fowler posistion
The nurse is applying a hydrocolloid dressing to a patient’s wound. Which action should the nurse take?
Holds hand over applied dressing for a few seconds
An adult patient tells the nurse in a health-care provider’s office about difficulty with weight management. The patient states, “My mother always told us to eat a specific number of foods from each food group every day.” Which comment by the nurse is likely to be most helpful to this patient?
“Your nutritional needs change with age and caloric intake should decrease.”
The nurse is caring for several patients who have wound care. Which actions should the nurse take for each patient?
Uses a bottle of normal saline for a wet-to-damp dressing change that was opened 48 hours ago
- After irrigating a wound, avoids touching the interior of the wound when drying
- Reactivates a patient’s Hemovac after emptying the contents
- Medicates a patient 30 minutes before a wet-to-damp dressing change
The nurse is using the Braden Scale to determine pressure injury risk. Which parameters would the nurse assess?
Sensory perception
- Moisture
- Nutrition
Presence of chronic illnesses
The nurse is applying a hydrocolloid dressing to a patient’s wound. Which action should the nurse take?
Holds hand over applied dressing for a few seconds
The nurse is removing a patient’s abdominal incision sutures. Which action should the nurse take?
Cut the suture next to the skin, adjacent to the knot
The nurse is pouring a sterile solution into a small cup on the sterile field. Which action by the nurse is considered incorrect?
The label of the solution bottle is opposite the nurse’s palm.
The nurse is providing care for a patient receiving tube feedings. When the nurse brings in insulin to be administered to the patient, the patient asks, “Why do I need insulin?” Which answer by the nurse is correct?
“Tube feedings can cause temporary hyperglycemia.”
The nurse is providing care for a patient who is on intake and output. During an 8-hr shift, the patient drinks 360 mL of water, has 240 mL of broth, and received 150 mL of tube feeding. The patient also voided 400 mL of urine and vomited 300 mL of fluid. Which conclusion can the nurse draw about the patient’s intake and output?
The patient’s intake and output are balanced
The nurse in a long-term care facility is monitoring a patient who is recovering from an intestinal virus. The nurse needs to consider if the patient is ready to be advanced from a liquid to a regular diet. Which findings will cause the nurse to keep the patient on liquids?
The patient has nausea and vomiting.
- The patient’s abdomen is distended.
- The patient has hypoactive bowel sounds.
- The patient is experiencing cramping.
The nurse is caring for a patient receiving intermittent tube feedings. Prior to administering the next feeding, the nurse checks for residual volume. Which action by the nurse is correct if the residual amount is 130 mL?
Return the residual and proceed with the next feeding as ordered.
