Test 2

Question 1

Administer ear drops procedure

Answer 1

1. Instill 1 cm (1/2 inch above ear canal) 2. People 4 years and older - pull auricle up and out People under 4 years - pull auricle down & back 3. Remain side-lying 2-3 minutes. If cotton ball used, remove after 15 minutes 4. Apply gentle massage or pressure to targus unless contraindicated due to pain

Question 2

Peak level

Answer 2

Time at which a medication reaches its highest effective concentration

Question 3

Trough level

Answer 3

Minimum blood serum concentration before next scheduled dose

Question 4

Absorption rates related to way medication is administered, slowest to fastest

Answer 4

Oral and topical - slower Subq - a little faster, but still slowly absorbed IM - faster IV - fastest

Question 5

Therapeutic effect

Answer 5

Expected or predicted physiological response

Question 6

Side effect

Answer 6

Unavoidable secondary effect, predictable, may be harmless or may cause injury

Question 7

Adverse effect

Answer 7

Unintended, undesirable, often unpredictable, effects are immediate, whereas others take weeks or months to develop.

Question 8

Toxic effect

Answer 8

Accumulation of medication in the bloodstream develop after prolonged intake of medication, or wen a medication accumulates in the blood because of impaired metabolism or excretion. Excessive amounts sometimes have lethal effects.

Question 9

Idiosyncratic reaction

Answer 9

over-reaction or under-reaction or different reaction from normal

Question 10

Allergic reaction

Answer 10

unpredictable response to a medication. Medication or chemical acts as an antigen, triggering release of antibodies in the body

Question 11

Types of medication orders

Answer 11

*Standing or routine: administered until the dosage is changed *prn: as needed *Single (one-time): given one time only for a specific reason *STAT: Single dose of a med given immediately in an emergency *Now: When a med is needed right away, but not STAT (within 90 minutes) *Prescriptions: medication to be taken outside of the hospital

Question 12

Medication error and what are the nursing implications and responsibility of care for patient

Answer 12

*Report all medication errors - incident report *the nurse first assesses and examines the patient’s condition & notifies the health care provider asap. Then reports the incident to the appropriate person in the institution

Question 13

Needle stick prevention

Answer 13

*After drawing medication into syringe, use the scoop method to place cap back on needle. After administering the injection, engage safety cap (if available) and immediately discard in sharps container

Question 14

Topical medication administration

Answer 14

*Use gloves *Use sterile technique if pt has open wound *Clean skin first *Transdermal patches *Remove old patch *Document location of new patch *Apply label to new patch

Question 15

Potential complications of immobility

Answer 15

metabolic, atelectasis & hypostatic pneumonia, orthostatic hypotension, loss of muscle mass, urinary stasis, pressure ulcer

Question 16

Definition of stages of decubitus ulcer

Answer 16

*Stage I-intact skin with nonblanchable redness *Stage II-Partial-thickness skin loss involving epidermis, dermis or both *Stage III-Full-thickness tissue loss with visible fat *Stage IV-Full-thickness tissue loss with exposed bone, muscle, or tendon *Unstageable-if you can’t see how deep it is

Question 17

Passive ROM

Answer 17

Patient is unable to move independently, and the nurse moves each joint through its ROM

Question 18

Active ROM

Answer 18

Patient moves all joints through their ROM unassisted

Question 19

Purpose of trochanter roll

Answer 19

Prevents external rotation of the hips when patient is in supine position.

Question 20

Purpose of trapeze bar

Answer 20

Allows patient to pull with the upper extremities to raise the trunk off the bed, assist in transfer from bed to wheelchair, or perform upper-arm exercises

Question 21

Purpose of hand rolls

Answer 21

Maintain the thumb in slight adduction and in opposition to the fingers, which maintain a functional position

Question 22

Purpose of foot boots

Answer 22

to keep feet in proper alignment and to prevent foot drop

Question 23

Purpose of compression devices or compression hose

Answer 23

decreases venous stasis by increasing venous return through the deep veins of the legs.

Question 24

Procedure for logrolling patients

Answer 24

*Place pillow between patient’s knees *Cross patient’s arms on chest *Position two nurses on side of bed which patient will be turned. Third nurse is positioned on other side. *Fanfold or roll drawsheet along side of patient *Move patient as one unit in a smooth, continuous motion on the count of three *Nurse on opposite side of bed places pillows along the length of patient *Gently lean patient as a unit back towards pillows for support *Perform hand hygiene

Question 25

What is footdrop?

Answer 25

Foot is permanently fixed in plantar flexion, patient cannot dorsiflex. Cannot correct it. Patient is no longer ambulatory.

Question 26

What is primary intention?

Answer 26

Edges are approximated. Surgical incision, wound that is sutured or stapled

Question 27

What is secondary intention?

Answer 27

Wound heals with scar tissue. (Pressure ulcer, severe laceration) Wound is left open until it becomes filled by scar tissue.

Question 28

Tertiary intention

Answer 28

Wound left open for several days, then wound edges are approximated. (Wounds that are contaminated & require observation for signs of inflammation.)

Question 29

Nutrition implications in wound healing, for example, what type of diet

Answer 29

Patients need 1500 kcal/day. Vitamins A & C, calories and proteins are needed to heal.

Question 30

Braden scale

Answer 30

Total score range from 6 to 23. The lower the total score, the higher the risk for developing pressure ulcer

Question 31

What is a hydrocolloid dressing and what is it used for?

Answer 31

Dressings with complex formulations of colloids, elastomeric, and adhesive components. The wound contact layer of this dressing forms a gel as fluid is absorbed; maintains a moist healing environment. PURPOSE: support healing in clean granulating wounds and autolytically debride necrotic wounds.

Question 32

What type of drainage is this?

Answer 32

serous drainage-clear fluid

Question 33

What type of drainage is this?

Answer 33

Sanguineous drainage-blood

Question 34

What type of drainage is this?

Answer 34

serous sanguineous drainage-mixture of blood and serous

Question 35

What type of drainage is this?

Answer 35

purulent drainage-infected; green, yellow, brown

Question 36

Procedure to obtain wound culture

Answer 36

Never obtain culture from old drainage.

1. Cleanse wound with sterile normal saline to remove old drainage and skin flora.
2. Use sterile culture swab from culturette tube.
3. Rotate swab in 1cm of clean tissue in the open wound.
4. Apply pressure to swab to elicit tissue fluid.
5. Insert swab into appropriate sterile container, label and send to lab.

Question 37

What is Dehiscence

Answer 37

Partial or total separation of wound layers.

Question 38

What is Desiscence?

Answer 38

Partial or total separation of wound layers. Nurse should place a folded thin blanket ro pillow over an abdominal wound when the patient is coughing

Question 39

What is evisceration?

Answer 39

protrusion of visceral organs through a wound opening. This condition is an emergency. The nurse should place sterile towels soaked in sterile saline over the extruding tissues to reduce chances of bacterial invasion and drying of the tissues.

Question 40

Restraints and electronic monitoring devices nursing implications, orders, procedures, documentation

Answer 40

Must be clinically justified and part of the patient’s prescribed medical treatment and plan of care.

Question 41

Person’s comfort zone

Answer 41

between 65 and 75 degrees F

Question 42

Falls, fall preventions and nursing implications

Answer 42

Falls are leading cause of deaths in adults 64 years or older

Fall Risk Prevention:

• Fall risk bracelet
• Hourly rounds
• Safety rails in bathroom
• Call lights
• Bed in low position
• Restraints as a last resort
• Restraint alternatives (Ambularm, posey bed)

Question 43

What is equipment related accident?

Answer 43

Result from malfunction, disrepair, or misuse of equipment.

Question 44

What is patient-inherent accident?

Answer 44

Self-induced; nothing medical personnel could have done to prevent

Question 45

What is procedure-related accident?

Answer 45

occur during therapy; they include med admin errors, IV therapy errors, improper use of external devices, improper performance of procedure

Question 46

Seizures (types) and nursing implications in the care of the patient, family teaching

Answer 46

Paroxysmal-

tonicity - rigidity

clonicity - jerking

Should not last more than 5 minutes.

Postictal phase - amnesia or confusion and falls into deep sleep

Status epilepticus - prolonged or repeated seizures - MEDICAL EMERGENCY THAT CAN LEAD TO DEATH

DO NOT PLACE ANYTHING IN THE PATIENT’S MOUTH DURING SEIZURE