Question Trainer 1 Remediation Flashcards
true or false
the type of stroke can be determined solely based on manifestations
FALSe
manifestations of different types of stroke are similar and therefore it is critical to determine the type of stroke occuring; the type cannot be determined solely based on manifestations and the correct and appropriate treatent for the stroke type must be initiated
the type of stroke needs to be determined within a certain time frame after arrival in order for timely treatment to begin
TRUE OR FALSE
TRUE; Time is of the essence when providing care to a client who experiences an ischemic stroke, as thrombolytic therapy is only effective for a certain time frame once symptoms begin (4.5 to 6 hours). This is the priority assessment question, as thrombolytic therapy can restore circulation for this client.
How is the type of stroke usually identified ?
Usually done using imaging such as a CT scan
Different between bone marrow aspiration and biopsy
The two procedures are often done together. They differ in the specific content of the bone marrow they remove
Bone marrow has a fluid portion and a more solid portion. In bone marrow biopsy, your doctor uses a needle to withdraw a sample of the solid portion. In bone marrow aspiration, a needle is used to withdraw a sample of the fluid portion.
Risks include infection, bleeding, penetration of the breastbone which can cause heart or lung problems, or long lasting discomfort at the biopsy site.
The sternum may be used for bone marrow aspiration. However, there is not enough marrow available in the sternum for a biopsy.
The procedure can be done at the bedside or in the operating room
Therapeutic Communication Do’s
Do respond to feeling tone.
Do provide information.
Do focus on the client.
Do use silence.
Do use presence.
What is the prioroty assessment in the unconscious client ?
The airway, as increases in arterial carbon dioxide levels will increase intracranial pressure
___________________communication often causes fatigue for the client diagnosed with MS.
Verbal
the client is taught to make important points first prior to the onset of fatigue.
Impaired balance or coordination
Enteral tube feedings should be administered if bowel sounds are absent.
TRue or false
FALSE
Feedings should not be administered if bowel sounds are absent
For gastrointestinal tube feedings, we do not hang more solution that is required for a _________________ hour period
4
This is done to reduce the risk of bacterial growth
The gastrostomy tube should be rotated 360 degrees daily to reduce the risk of skin irritation and breakdown.
TRUE OR FALSE
TRUE
We should check for slight in-and-out movement of the gastrostomy tube.
TRUE OR FALSE
TRUE
A slight in-and-out movement indicates that the gastrostomy tube is not embedded in the wall of stomach
a common and disabling condition following brain damage in which patients fail to be aware of items to one side of space. Neglect is most prominent and long-lasting after damage to the right hemisphere of the human brain, particularly following a stroke. Such individuals with right-sided brain damage often fail to be aware of objects to their left, demonstrating neglect of leftward items.
Unilateral neglect syndrome
The client who is recovering from a stroke may have a short attention span or visual difficulties, making reading with comprehension a difficult task. The nurse should provide verbal instructions with _______________________.
short sentences.
During DKA, osmotic diuresis occurs and the client is at significant risk for ___________________–
fluid volume deficit.
decreased circulation is a _______________-for anti-embolism stockings
Venous thromboembolism is a ________________for anti-embolism stockings
contraindication; contraindication
The best indication of peripheral arterial disease and circulation to extremities is to monitor the client’s _____________________-
pedal pulses
Vital signs should be within ___________—of preprocedure values
20%
Anesthesia nursing considerations
vital signs every 15-30 minutes
An involuntary eye movement which may cause the eye to rapidly move from side to side, up and down, or in a circle, and may slightly blur vision
Nystagmus
a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern — face, chest and back.
hirsutism
overgrowth of gum tissue around the teeth.
gingival hyperplasia
can be an adverse effect of phenytoin sodium
Metoclopramide
antiemetic; cab be given 30 minutes before antineoplastic agents such as Cisplatin
Expected findings for Rheumatoid arthritis
joint swelling, stiffness and pain
elevated ESR
anemia
joint deformities, muscle atrophy, and decreased range of motion in affected joints
positive rheumatoid factor
exacerbations of rheumatoid arthritis occur
during periods of physical or emotional stress and fatigue
rheumatoid arthritis weakens the ____________, leading to dislocation and permanent deformity of the _____________
joint
this is the speed at which RBC settle in well-mixed venous blood. Higher levels indicate inflammation
what are normal values ?
Erythrocyte sedimentation rate
males less than 50 yrs: less than 15 mm/hr
males greater than 50 years: less than 20 mm/hg
female less than 50 years: less than 25 mm/hr
females greater than 50 years: less than 30 mm/h
one contraindication of Etanercept to remember
active infection
Etanercept is an antiarthritic agent
Any heat source, including hot baths and electric blankets, will increase the absorption of medication through the skin
TRUE OR FALSE
TRUE
A fever increases absorption of medication through the skin
TRUE OR FALSE
TRUE
When providing care for a client diagnosed with acute kidney injury, it is important for the nurse to monitor circulation by reviewing the client’s __________________-, which is a good indicator of fluid volume.
urine specific gravity
this is a urine test that measures the ability of the kidneys to concentrate urine
what is the normal range
Urine specific gravity
1.005-1.030
a higher specific gravity reflects more concentrated urine
a lower specific gravity reflects a less concentrated urine (this could indicate renal disease or the kidney’s inability to concentrate urine)
The client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which assessment findings for this client?
Hypotension, low back pain, fever, nausea/vomiting
The health care provider prescribes an increase in the parenteral nutrition (PN) infusion rate from 50 mL/hour to 100 mL/hour. The PN is infusing through a peripherally inserted central catheter (PICC) device. Which is the priority action for the nurse?
Parenteral nutrition is hyperosmolar and will pull fluid into the intravascular space, thereby causing osmotic diuresis. Fluid volume affects the ABCs (airway, breathing, circulation). Therefore, monitoring urine output is the priority nursing action.
this is the rapid emptying of the gastric contents into the small intestine that occurs following gastric resection
Dumping syndrome
Dumping syndrome symptoms
nausea/vomiting
feelings of abdominal fullness and abdominal cramping
diarrhea
palpitations & tachycardia
perspiration
weakness/dizziness
Borborygmi (loud gurgling sounds resulting from bowel hypermotility)
Client Education: Preventing Dumping Syndrome
avoid sugar, salt and milk
eat a high protein, high fat, low carbohydrate diet
eat small meals and avoid consuming fluids with meals
lie down after meals
take antispasmodic medications as prescribed to delay gastric emptying
During a urinary bladder catheter insertion, with a size 16 French catheter on an older adult male, the nurse feels increased resistance. Which is the most appropriate action for the nurse to take?
Stop the insertion and instruct the client to take deep breaths.
Instructing the client to take deep breaths will relax the urethral muscles and facilitate passage through the prostate gland
When drawing blood from a PICC line, what are appropriate guidelines.
discard 3 to 5 mL of blood prior to obtaining the sample in order to prevent contamination of the blood sample with IV fluids or medications.
A 10 mL syringe is recommended to reduce pressure on the lumen of the PICC line during the flush
Clean gloves are used when drawing blood from a PICC line
The push-pause technique reduces the risk of clot formation and damage to the PICC line.
The nurse expects how many ml of water in the water seal chamber of the chest tube
2 cm
______________-gloves are used for tracheostomy suctioning
Sterile
In order to ensure the client does not experience______________ during tracheostomy suctioning, the nurse _____________the client before and after each time the airway is entered for suctioning.
hypoxia; hyperoxygenates
Which position is ideal for tracheostomy suctioning?
A semi-Fowler, not high-Fowler, position is ideal for this client during tracheostomy suctioning.
Elevating the head of the bed will allow for a ____________-
more open airway.
_______________________is the earliest indication of poor cardiac output.
A change in LOC and/or alertness
How to care for an evisceration following surgery?
Cover the area with sterile gauze soaked in normal saline
immediately cover the site with a sterile dressing soaked with normal saline and contact the health care provider.
The use of “why” questions is not therapeutic
TRUE OR FALSE
TRUE
The client with altered mental status is at risk for aspiration, TRUE OR FALSE
TRUE
The nurse provides care for a client who is prescribed assist-control mechanical ventilation with positive end-expiratory pressure (PEEP) of 5 cm H 2O. Which actions will the nurse include in the client’s plan of care?
Changing client position every 2 hours to reduce risk of atelectasis, pneumonoia and skin breakdown
strict handwashing before suctioning to prevent VAP
Administering Pantoprazole (will decrease the risk of aspiration of gastric contents)
Elevate head of bed at least 30 degrees
oral care and teeth brusing should be done at least every 8 hours
dysphonia
muffled voice
Do all unemancipated minors presenting to the ED for treatment require guardian consent for treatment?
NO
Unemancipated minors may consent to medical treatment if they have specific medical conditions (i.e. pregnancy, pregnancy-related conditions, minor treatment for custodial child, sexually transmitted infection information and treatment, substance abuse treatment, and mental health treatment).
Depending on why the minor is seeking treatment, guardian consent may not be necessary and could breach HIPAA (Health Insurance Portability and Accountability Act) guidelines.
The nurse works on the medical surgical unit. The nurse-to-client ratio is 1:10. Which action does the nurse take first?
- Document the situation in writing.
- Refuse the client assignment.
- Delegate tasks to the LPN/LVN.
- Notify the nursing supervisor.
Notify the nursing supervisor
This is the priority action, as the nurse-to-client ratio is proportionately high. This action alerts the nursing supervisor of the situation so nurses can be “floated” from other departments, if available.
The nurse maintains responsibility for client outcomes. The problem is nurse-to-client ratio. Therefore, the nursing supervisor can provide more staffing, if needed.
notifying the supervisor is the priority. The nurse should provide the documentation to the nursing administrators, but the documentation does not relieve the nurse of responsibility if clients suffer harm because of inattention
Fetal heart tones cannot be heard with Doptone until ________________weeks gestation.
8-12
this is postpartum discharge from the uterus that consists of blood from the vessels of the placental site and debris from the decidua
Lochia
Lochia rubra - bright red discharge that occurs from day of birth to day 3
Lochia serosa- brownish pink discharge that occurs from days 4-10
Lochia Alba- white discharge that occurs from days 11-14
Discharge decreases daily in amount
The competent client has the right to make personal choices without interference.
TRUE OR FALSE
TRUE
The nurse completes documentation for a client and realizes the entry has been placed in the wrong client’s medical record. Which action by the nurse is most appropriate
2.Draw a single line through each line of the incorrect entry and write a new note explaining what occurred.
Draw 1 line through the error, initial and date
The nurse provides care for an adolescent client reporting arm pain after a fall. The nurse notes bruising in multiple stages of healing. The nurse accesses the client’s medical record and notes the client was treated twice last month for reported back pain after two separate falls. The client was treated two months ago for a perforated eardrum. Which action by the nurse is the priority?
Contact social services
The adolescent client’s history suggests that there may be abuse. The law mandates that the nurse report known or suspected child abuse by collaborating with social services and law enforcement. Therefore, this is the priority action.
While the nurse should assess the client’s anxiety level, a professional assessment of the client’s situation takes priority over psychosocial nursing actions.
Individuals who have a BMI lower than ______________–are at increased risk for problems associated with poor nutritional status.
18.5
a low BMI is associated with higher mortality rate among hospitalized clients.
Individuals who experience spousal ______________often accept blame, become compliant, and feel helpless
abuse
Herpes Zoster is also known as ___________________
It is contagious to anyone who has not had __________________ or who is ____________________-
What kind of infection precautions do we take ?
Shingles; chickenpox; immunosuppressed
Contact precaution
The nurse must verify the client’s ________________before administering medications
identity
Older adult clients need visual examinations every _____________–years
1 to 2
safety and infection control : the priority is to prevent the spread of _________________
contamination
Restraints should be discontinued as soon as the client becomes
alert and oriented
A client with an endotracheal tube requires suctioning. How should it be done?
insert suction catheter until resistance is met without applying suction, withdraw 0.4 to 0.8 inches (1 to 2 cm), and apply intermittent suction with twirling motion
never suction longer than 10–15 seconds
2) use twirling motion when withdrawing catheter
suction is never applied when catheter is inserted
Hyperoxygenates the client before and after
attributing one’s thoughts or impulses to another
projection
shifting of emotion concerning person or object to another neutral or less dangerous person or object)
displacement
shifting of emotion concerning person or object to another neutral or less dangerous person or object)
sublimation
incorporation of someone else’s opinion as one’s own
internalization
