VN 15 Study Guide Test 3-done

Question 1

1. What are complementary proteins? Give 3 examples that a nurse would suggest.

Answer 1

Incomplete proteins that when combined provide a complete protein.

Generally from plant sources.

• beans w/rice
• hummus w/crackers
• peanut butter & enriched bread

Question 2

2. Which vitamins are important in wound healing?

Answer 2

• Vitamin A
• Vitamin C
• Zinc

Question 3

3. List foods high in fiber

Answer 3

• fruits w/skin
• strawberries
• oranges
• whole wheat grains (black beans/lentils/kidney beans)

Question 4

4. Give examples of the following diets:

a. Regular

Answer 4

Normal diet doesnt need dietary restrictions.

-nuts, steak, apples, bread ect.

Question 5

4b. clear liquid

Answer 5

(consists of food items that may be colored but are generally transparent and don’t contain any pulp or bits of food)

Ex: water, tea, coffee,broth, soft drinks, clear juices, ,and gelatin

Question 6

4c. full liquid

Answer 6

Fruit & vegetable juices, creamed or blended soups, milk, ice cream, yogurt w/out bits of fruit, pudding, milkshakes, gelatin,custards and cooked cereals

Question 7

4d.Pureed

Answer 7

(consists of liquids & foods that are pureed to liquid form)

Ex: pureed vegetables,mashed potatoes, pudding

Question 8

4f. Dysphagia

Answer 8

(prescribed when swallowing is impaired-following a stroke)

Ex: pudding, applesauce, pureed fruits, soups, scrambled eggs, pureed veggies & meats

Question 9

5. What diet instructions would you give to a client on a potassium-wasting diuretic?

Answer 9

Consume potassium rich foods like oranges, dried fruits, tomatoes, avocados,dried peas, meats, broccoli, bananas,dairy products, meats, whole grains & potatoe

Question 10

6. What is the Mediterranean diet and give examples of food choices?

Answer 10

Everything in moderation.

Ex: lean cuts of meat & fish, olive oil, eggs , red wine.

Red meats only a few times a month.

Question 11

7. What are nursing considerations for nutrition in the older adult?

Answer 11

• serve small, frequent meals
• Diminished senses of smell & taste
• Require fewer calories
• Nutritional supplements should be evaluated

Question 12

8. What are nursing considerations for nutrition in the toddler?

Answer 12

• have a decrease in appetitie
• have a decrease in nutritional needs due to slower growth rate
• small meals at meal time to avoid being overwhelmed

Question 13

9. List 6 need to know for restraint use

Answer 13

• Secure restraints to movable part of bed frame & use slip knot for easy release.
• Remove, offer toileting needs & assess skin care & circulation every 2 hrs.
• Document, reposition
• Educate family about use
• Provide passive ROM exercises
• New provider referral needed every 24hrs

Question 14

10. List 7 interventions for fall risks

Answer 14

• well lit room
• floor clear from cords or tripping hazards
• Use skid resistant rugs
• Skid resistant socks
• lower bed
• call light in reach for client
• do not have items in walkways

Question 15

11. List the sequence of actions in a fire (RACE)

Answer 15

• Rescue
• Alarm
• Confine the fire
• Extinguish

Question 16

12. Laceration

Answer 16

torn or jagged wound

Question 17

12b.abrasion

Answer 17

An area that has been rubbed away by friction(surface is scraped)

Question 18

12c.Puncture

Answer 18

An opening of skin, underlying tissue, or mucous membrane caused by a narrow, sharp, pointed object

Question 19

13. How are pressure ulcers treated?

Answer 19

• relieve pressure
• encourage frequent turning & repositioning
• Use pressure reduction surfaces (air mattress,foam mattress)
• keep client dry,clean, well-nourished & hydrated.

Question 20

14. What are lab signs that a wound or ulcer is infected?

Answer 20

High WBC

C &S (culture and sensitivity)

Question 21

15. What type of dressing is appropriate for a stage 1 pressure ulcer?

Answer 21

Transparent dressings

Question 22

16. What are nursing interventions for evisceration?

Answer 22

• Call for help, stay w/client
• Place warm sterile dressings moistened with normal saline over the protruding organs and tissues & notify physician immediately.
• position client supine w/hips & knees bent
• observe for indications of shock
• keep client on NPO in preperation for return to surgery.

Question 23

17. What are the steps of staple removal? (wound care slideshow)

Answer 23

1. remove the wound dressing
2. wipe cleansing solution directly over the surgical inscision.
3. clean the skin along the sides of the incision
4. Count staples before removing them
5. remove every other staple
6. remove remaining staples.
7. Count how many staples were removed in the end.

Question 24

18. List 5 things that can delay wound healing

Answer 24

Increased age
Infection & high WBC
Medications & malnourishment
Tissue perfusion & low HGB levels
chronic disease & smoking (obesity)

Question 25

19. When is humidification necessary in O2 therapy?

Answer 25

oxygen is humidified only when more than 4 L/minute is administered for an extended period.

Question 26

20. List early and late signs of hypoxia

Answer 26

Early Signs: • tachypnea, restlessness, anxiety, pale skin, elevated BP Late Signs: Stupor(fog), cyanotic skin, bradypnea,bradycardia,hypotension,cardiac dysrhythmias, use of accessory muscles to breathe, diaphoresis(excessive sweating)

Question 27

21. List 5 at home instructions for o2 use (slide 25 & 31 oxygen management wk 6 pp)

Answer 27

* use w/caution around heat sources * avoid oils- petroleum jelly,lotions * avoid synthetic,wool,nylon clothing * place no smoking signs * clean mask w/water every 4-6 hrs PRN * call PCP if difficult to concentrate * check straps are secure, skin breakdown. *Check flowmeter periodically to make sure flow matches orders.

Question 28

4e.soft

Answer 28

(contains whole foods that are low in fiber,lightly seasoned & easily digested) Ex: ground meats, canned fruits,softly cooked veggies