VN 15 Test 3 Study Guide

Question 1

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

Answer 1

Complementary proteins 
are incomplete proteins that, when combined, provide a complete protein.
•	Beans and Rice
•	Peanut butter and enriched bread
•	Hummus and crackers

Question 2

Which vitamins are important in wound healing?

Answer 2

Vitamin C:

Vitamin A:
Zinc

Question 3

List foods high in fiber

Answer 3

• Fruit with skin
• Strawberries
• Kidney beans
• Whole wheat grains

Question 4

allows unrestricted food selections

Answer 4

Regular diet

Question 5

water, broth, fruit juices, gelatin, popsicles, clear soft drinks, tea, and coffee

Answer 5

Clear liquid diet

Question 6

fruit and vegetable juices, creamed or blended soups, milk, ice cream, yogurt, pudding, milkshakes, gelatin, junket, custards, and cooked cereals

Answer 6

Full liquid diet

Question 7

Consists of liquids and foods that are made to

liquid form

Answer 7

Puréed diet

Question 8

contains foods soft in texture; is usually low in residue and readily digestible; contains few or no spices or condiments; provides fewer fruits, vegetables, or meats than a light diet

Answer 8

Soft diet

Question 9

LEVELS OF SOLID TEXTURES
Level 1: Pureed. Foods are totally pureed to a smooth consistency with a pudding-like texture
Level 2: Mechanically altered. Soft-textured, moist, semi-solid foods that are easily chewed and swallowed
Level 3: Advanced. Near-normal textured foods that are moist Hard, sticky foods are eliminated.

Answer 9

Dysphagia

Question 10

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

Answer 10

High potassium foods include potatoes, bananas, oranges, prunes, raisins, apricots peaches, tomatoes, Brussels sprouts, spinach, dried beans, peas and nuts.

Question 11

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

Answer 11

Everything in moderation.
Ex: 
lean cuts of meat & fish, olive
oil, eggs, red wine.
Red meats only a few times a month.

Question 12

What are nursing considerations for nutrition in the older adult?

Answer 12

• Serve small, frequent meals
• Diminished senses of smell and taste; require fewer calories; nutritional supplements should be evaluated; if sedentary, teach benefits of exercise; oral and dental problems
• Chronic conditions; food–drug interactions; dysphagia; socioeconomic barriers; psychosocial impairments

older adults have difficulty tolerating large meals.

Question 13

What are nursing considerations for nutrition in the toddler?

Answer 13

• Have a decrease in appetite
• Have a decrease in nutritional needs due to slower growth rate
• Small meals at mealtime to avoid overwhelme

Toddler’s needs are less due to slower growth rate than infants

Question 14

List 6 need to know for restraint use

Answer 14

1. Secure restraints to movable part of bed frame and use slip knot for easy release.
2. Remove, offer toileting needs and assess skin care and circulation every 2 hours
3. Document checks every 2 hours,release, toileting, reposition
4. Educate family about use
5. Provide passive ROM exercises
6. Every 24 hours need new provider referral

Question 15

List 7 interventions for fall risks

Answer 15

1. fall risk wristband
2. Hourly checks
3. Bed in low position and overbed tables close (no reach)
4. Have some lighting available
5. wear rubber-soled shoes or slippers
6. lock beds and WC
7. Call light within reach and instruct to use for assistance

Question 16

List the sequence of actions in a fire (RACE)

Answer 16

• Rescue
• Alarm
• Confine the fire
• Extinguish

Question 17

clean smooth edges

Answer 17

Incision

Question 18

separation skin and torn tissue and irregular edges

Answer 18

Laceration

Question 19

surface are scraped

Answer 19

Abrasion

Question 20

stripping away of large areas of skin-bone exposed

Answer 20

Avulsion

Question 21

shallow crater

Answer 21

Ulceration

Question 22

opening caused by sharp pointed object

Answer 22

Puncture

Question 23

How are pressure ulcers treated?

Answer 23

• Avoid rubbing area
• Keep clean and dry, but no heat to ‘dry out’
• Barrier ointment
• Irrigate open ulcers with 0.9% sodium chloride

Question 24

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

Answer 24

Culture and sensitivity

WBC

Question 25

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

Answer 25

Transparent dressing work well

Question 26

What are nursing interventions for evisceration?

Answer 26

* Abdominal organs protrude through an opened incision * Patient is to remain in bed * wound and contents should be covered with warm, sterile saline dressings * The surgeon is notified immediately * This is a medical emergency, and the wound requires surgical repair

Question 27

What are the steps of staple removal?

Answer 27

1) Remove the wound dressing. 2) Wipe cleansing solution directly over the surgical incision. 3) Clean the skin along the sides of the incision. 4) Remove every other staple. 5) Remove remaining staples.

Question 28

List 5 things that can delay wound healing

Answer 28

1. Age and overall wellness 2. Infection and high WBC 3. Medication and malnutrition 4. Tissue perfusion and low Hgb levels 5. Chronic disease and smoking

Question 29

When is humidification necessary in O2 therapy?

Answer 29

When administering more than 4L/min humidification is necessary

Question 30

List early and late signs of hypoxia

Answer 30

Early Tachypnea; tachycardia; restlessness, anxiety, pale skin and mucous membranes; elevated BP, Late Stupor; cyanotic skin, bradypnea, bradycardia;diaphoresis hypotension, cardiac dysrhythmias, use of accessory muscles (retractions)

Question 31

List 5 at home instructions for o2 use

Answer 31

* Cleanse mask with warm water every 4-8 hours prn * Check straps are secure * Check ears for skin breakdown * Post no smoking signs * Apply water-based lubricant only to nares * Wear cotton clothing and bedding (avoid synthetic) * Check the flowmeter periodically to confirm it matches order * Call provider if difficult to concentrate