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Fundamentals > Quiz 6 > Flashcards

Quiz 6 Flashcards

1
Q

What does TPN have a high content of?

A

dextrose (sugar content)

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2
Q

How should TPN be stopped?

A

should not be stopped abruptly

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3
Q

If TPN is stopped abruptly, how will it affect the blood sugar of a patient?

A

blood sugar will drop (hypoglycemia)

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4
Q

What are the signs and symptoms of hypoglycemia?

A

confusion
sweating
shaking
clammy
mimic someone who is drunk

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5
Q

If TPN was stopped abruptly for a patient, what is the first action a nurse should take?

A

check patients blood sugar levels

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6
Q

If a patient’s blood sugar is low and they are conscious, what can the nurse give?

A

candy or any sugar by mouth

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7
Q

If a patient’s blood sugar is high and they are unconscious, what can the nurse give?

A

IV dextrose

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8
Q

What are the signs and symptoms of hyperglycemia?

A

hot, dry skin, fruity breath

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9
Q

Which lab represents nutrition?
What is the normal range?
What does it show?

A

albumin
3.5-5

signifies nutrition status and wound healing

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10
Q

What are isotonic movements? What are examples?

A

repetitive exercises

swimming, walking, jogging, riding a bike

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11
Q

What are instructions for the use of a cane?

A
  1. maintain two points of support
  2. keep cane on stronger side
  3. support body weight on both legs
  4. move cane forward 6-10 in
  5. move weaker leg forward toward cane
  6. advance stronger leg
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12
Q

If a patient is using a walker, what side will the nurse get on to help the patient?

A

the weaker side

(strong support the weak)

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13
Q

If a nurse is helping a patient up, what side will the nurse get on for the patient?

A

weak side to help up as patient pushes up with good leg

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14
Q

What are measures to prevent skin breakdown due to urinary incontinence?

A
  • keep area dry and clean with soap and water
  • use a skin barrier
  • assess for signs of breakdown
  • implement bladder-retraining program
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15
Q

For patients with pressure injuries, what will the nurse will be monitoring?

A

albumin levels

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16
Q

What side should the patient hold a cane if they have left hemiparesis? Where should the nurse be?

A

cane should be on the strong side (right side)

nurse should be on weak side (left side)

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17
Q

What foods promote wound healing?

A

foods high in protein

ex: meat, fish, poultry, eggs, dairy products, beans, nuts, whole grains

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18
Q

What are nursing interventions for wounds?

A
  • provide adequate hydration and meet protein and calories needs
  • perform wound cleaning and irrigation
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19
Q

What are nursing interventions for pressure injuries?

A
  • avoid skin trauma
  • use pressure-reducing surfaces or devices
  • maintain skin hygiene
  • encourage proper nutrition
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20
Q

What is a stage 1 pressure injury?

A

skin intact
nonblanchable

only epidermis affected

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21
Q

What is a stage 2 pressure injury?

A

skin intact or ruptured
wound bed is reddish pink

epidermis and dermis affected

22
Q

What is a stage 3 pressure injury?

A

visible adipose tissue with slough and eschar
possible tunneling

epidermis, dermis, and subcutaneous tissue affected

23
Q

What is a stage 4 pressure injury?

A

skin and tissue loss
tunneling and undermining

epidermis, dermis, subcutaneous tissue, muscle and bone affected

24
Q

If a patient comes back from surgery and has an abdominal wound that has eviscerated (opened up), what would the nurse do?

A

cover it with a wet saline gauze

25
Q

What is an aliginate dressing used for in wound dressings?

A

nonadherent
provides moist wound bed
absorbs exudate
pack wounds
supports debridement

26
Q

What is a collagen dressing used for in wound dressings?

A

powders, pastes, granules, sheets, gels

help stop bleeding
promotes healing

27
Q

What can the nurse educate their patient who will be getting a colonoscopy?

A

doctor will give a sedative
- you will be awake and relaxed, but you won’t remember it happened

28
Q

What are patients at risk for if they are having frequent stools?

A

electrolyte imbalances

29
Q

What will the nurse educate a patient on if they are bowel or bladder training?

A

if they have the urge to go, they should go

do not avoid the urge

30
Q

If a patient is on TPN, which is high in glucose (dextrose), and it is going at twice the rate than its ordered, what will the nurse do?

A

stop immediately and check blood sugars

31
Q

What should the normal color for the stoma of an ileostomy and colostomy be?

What should it not look like?

A

should be: beefy red

cannot be: gray, purple, green, blue

32
Q

How often should a nurse toilet patients?

A

every 2 hours and as needed

33
Q

If a patient’s catheter is discontinued, what will the patient experience?

A

they will have a hard time voiding

34
Q

If a patient’s catheter is discontinued, what will the nurse monitor for?
How can the nurse do this?

A

Nurse will monitor patient urinating (voiding) within 6-8 hrs after removal

  • take them to the bathroom
  • bladder scan (check how much urine is there)
35
Q

When an NG is inserted, how will the nurse know it is in the correct location?

A
  • x-ray
  • check pH is 4 or less
  • auscultate with stethoscope
36
Q

What will a nurse tell a patient in regards to a low fat diet?

A

Animal based foods have high saturated fats

Plant based have high amounts of unsaturated fats

37
Q

What is included in a high fiber diet?

A

whole grain bread
raw dried fruit

38
Q

If a patient cannot urinate, what will the nurse do first?

A

assess and check for bladder distention

39
Q

With foley catheter, is the system broken? Why?

A

no

to maintain a closed drainage system to prevent infections

40
Q

How is a clean catch midstream specimen done?

A

wipe from front to back / clean the urethral meatus

pee first then stop and catch the urine sample midstream

41
Q

What is a clear liquid diet?

A

liquids that leave little residue and able to see through it

  • clear fruit juice
  • gelatin
  • broth
42
Q

What is a full liquid diet?

A

clear liquids
liquid dairy products
all juices
pureed vegetables

43
Q

Define exudate

A

drainage

44
Q

What color guide is used for wound care and what should be done for each?

A

Red (cover)
Yellow (clean)
Black (debride/remove necrotic tissue)

45
Q

How is wound drainage measured accurately?

A

weigh the dressing

1g = 1mL of drainage

46
Q

Describe serous drainage

A

serum

  • watery
  • clear
  • slightly yellow (fluid in blisters)
47
Q

Describe sanguineous drainage

A

serum & red blood cells

  • thick
  • reddish (bright- newer) (dark-older)
48
Q

Describe serosanguineous drainage

A

serum & blood

  • watery and pink/red
49
Q

Describe purulent drainage

A

infection

  • yellow, tan, green, brown
  • odor
50
Q

Describe purosanguineous drainage

A

mixed drainage of pus and blood

51
Q

What is high priority for the nurse to do if a patient is bed bound?

A

turn every 2 hours and document

52
Q

What is a patient at risk for if they are bed bound?

A

pressure ulcers

Fundamentals (7 decks)

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