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NCLEX: Fundamentals Of Nursing > Set 7 > Flashcards

Set 7 Flashcards

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1
Q

What side should a patient hold their cane on?

A

Strong/unaffected side

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2
Q

At what height should a patient’s cane or walker be?

A

Height of patients wrist or greater trochanter

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3
Q

T or F: the pads of crutches should be up against the axilla (armpit)

A

False! Crutches should be 2 inches (2-3 finger width) below the axilla to prevent cutting off circulation to important nerves and blood vessels

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4
Q

Crutches patient education

A

Place weight on hands (handgrip), NOT the axilla; elbows should be flexed about 30 degrees

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5
Q

Crutch gait in which the patient moves the injured side’s crutch at the same time as the non-injured leg. Then the patient will move the non-injured side’s crutch at the same time as the injured leg

A

Two-point gait

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6
Q

Crutch gait in which the patient moves the injured side’s crutch, then moves the non-injured leg, then moves the non-injured side’s crutch, then moves the injured leg (NOTE: this is similar to the two-point gait BUT the crutch and leg move separately rather than at the same time)

A

Four-point gait

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7
Q

Crutch gait in which the patient does not let their injured leg touch the ground by moving both crutches and injured leg forward together and then moving the non-injured leg

A

Three-point gait

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8
Q

Crutch gait in which the patient moves both crutches forward, then swings both legs forward to the same point as the crutches

A

Swing-to-gait

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9
Q

Crutch gait in which the patient moves both crutches forward and then swings both legs forward and past the crutches

A

Swing-through-gait

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10
Q

Patient education for going upstairs with crutches

A

Move good/unaffected leg up onto step first, then move the bad/affected leg and crutches onto the step

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11
Q

Patient education for going downstairs with crutches

A

Move both crutches down onto the step and then moves the bad/affected leg down, then move the good/unaffected leg down

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12
Q

Patient education for sitting down with crutches

A

Back up to chair until felt with non-injured leg, move both crutches to injured side and grip for support, keep injured leg extended out and slightly bend non-injured leg, feel for chair seat with non-injured side and sit down

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13
Q

Patient education for getting up from a chair with crutches

A

Keep injured leg extended out forward and put both crutches on the injured side and group the hand grips of crutches, lean forward and push up with the arm of the non-injured site on the chair’s seat and by using the hand grips on the crutches (which is on the injured side), branch crutches into tripod position once standing

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14
Q

Describe tripod position

A

Each tip of crutch will be 6 in to the side of feet diagonally

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15
Q

Fall prevention at home

A
  • remove scatter rugs
  • have good lighting, especially over stairs and mark the edges of steps with colored or reflective tape
  • tape down electrical cords behind furniture or against a wall if possible
  • install grab bars in shower and have a nonslip Matt on shower floor
  • educate patients on using assistive devices properly
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16
Q

Order requirements for restraints

A

Provider must do an in-person assessment of the patient within 24 hours of the order; the order only lasts for 24 hours (new order must be obtained if patient continues to need restraints)

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17
Q

Restraints documentation

A

Rationale for restraints, time of restraint, patient assessment findings, what care was offered and provided to the patient

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18
Q

Nursing care for tying restraints

A

Restraint must be tied in quick-release fashion and tied to a part of the bed frame

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19
Q

How often should the nurse assess a patient in restraints?

A

Every 15 min (due to risk for positional asphyxia)

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20
Q

How often should the nurse take vitals, provide ROM, and offer fluids and toileting to a patient in restraints?

A

Every 2 hours

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21
Q

When are restraints discontinued?

A

As soon as the patient is no longer a risk to themselves or others

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22
Q

Pressure injury risk factors

A

Immobility, older age, incontinence, poor nutrition, perfusion issues, smoking, corticosteroids

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23
Q

A Braden scale less than ___ indicates a patient is at risk for pressure injury

A

18

24
Q

How often should Braden scale be done?

A

At least every shift

25
Q

Tool used to screen client’s risk of skin breakdown

A

Braden scale

26
Q

What risk factors are considered with the Braden scale?

A

Sensory perception, moisture, activity, mobility, nutrition, friction & shear

27
Q

Pressure injury prevention

A

Reposition patient every 2 hours, place patient on pressure redistribution mattress if possible, keep HOB less than or equal to 30 degrees, elevate feet up off bed so that heels are dangling freely through pillows or heel elevation boots, pad bony prominences

28
Q

How often should the nurse instruct the patient to redistribute their weight when sitting to prevent pressure injuries?

A

Every 15 min

29
Q

Pressure injury limited to the epidermis characterized by nonblanchable, intact skin with erythema

A

Stage 1

30
Q

Pressure injury with damage to the epidermis and dermis characterized by nonblanchable erythema and shallow erosion (may look like scrape or an open blister)

A

Stage 2

31
Q

Pressure injury with damage to the hypodermis (subcutaneous tissues) characterized by visible adipose tissue

A

Stage 3

32
Q

Pressure injury with damage extending beyond the subcutaneous tissue characterized by visible muscles, tendons, bones, etc.

A

Stage 4

33
Q

A wound is considered _________ if you cannot see the wound bed (due to slough or Eschar)

A

Unstageable

34
Q

Intact or nonintact skin that is nonblanchable and deep purple or maroon color

A

Deep tissue injury

35
Q

What are the four main phases of wound healing?

A

Hemostasis, inflammation, proliferation, remodeling

36
Q

What is the goal of hemostasis?

A

To stop bleeding

37
Q

How is hemostasis accomplished?

A

Through the process of vasoconstriction, clotting cascade and activation of platelets

38
Q

Which phase of wound healing is characterized by reddening, heat, and pain and can last up to six days?

A

Inflammation

39
Q

Which phase of wound healing is characterized by the formation of granulation tissue and can take between four and 30 days?

A

Proliferation

40
Q

Which phase of wound healing is characterized by the creation of strong skin to replace the temporary tissue in the area and can last up to 12 months?

A

Remodeling

41
Q

Wound healing by _________ intention means that the edges of the wound are well approximated (brought together well)

A

Primary (ex: surgical wounds, paper cuts)

42
Q

Wound healing by _________ intention is when a wound is intentionally left open to heal through granulation, contraction, and epithelialization (healing from the inside out)

A

Secondary (Ex: pressure injury)

43
Q

Healing by _________ intention carries a higher risk of infection and longer healing times

A

Secondary

44
Q

Healing by _________ intention is when the closure of a wound is intentionally delayed so that the wound can be irrigated, debrided, and observed usually for about a week followed by surgical closure when risk for infection is lower

A

Tertiary

45
Q

Complication of wound healing in which a previously closed wound opens back up

A

Dehiscence

46
Q

Complication of wound healing characterized by dehiscence WITH organ protrusion

A

Evisceration

47
Q

Nursing interventions for evisceration

A

Put saline-moistened gauze over the opened area, lower HOB (maybe even put patient in trendelenburg), notify the provider immediately

48
Q

Barriers to wound healing

A

Chronic illnesses (DM), immunosuppression (corticosteroids)

49
Q

Normal, watery, clear/off-white wound drainage

A

Serous drainage

50
Q

Wound drainage composed of serous fluid mixed with blood, giving it a pink tinge

A

Serous-sanguineous

51
Q

Bright red, bloody wound drainage

A

Sanguineous

52
Q

Thick, cloudy, white, yellow or beige pus that is malodorous coming from a wound

A

Purulent drainage (indicates infection)

53
Q

Describe the appearance of a healthy looking wound

A

Red, beefy appearance (indicates good circulation)

54
Q

A wound that is yellow indicates

A

The wound may need to be cleaned

55
Q

A wound that is black indicates

A

Debridement is needed

NCLEX: Fundamentals Of Nursing (14 decks)

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