Week 2 Flashcards
1
Q
Why should you not lance the middle of the finger?
A
It has more nerves than the side of the finger, so it will hurt more than lancing the sides
2
Q
What should fasting blood glucose levels be?
A
74 to 106 mg/dL
3
Q
What blood glucose levels require retesting, and the blood sample to be sent to a laboratory for analysis?
A
A blood sample higher than 400 or less than 60 
4
Q
How much sputum should be collected in a sputum culture?
A
1 to two teaspoons
5
Q
What is the difference between point of care test and laboratory tests?
A
point of care tests are not as accurate as laboratory tests, and they are recommended for a positive findings
6
Q
What time of day is sputum specimen collection most accurate?
A
In the morning before the client has had anything to eat or drink
7
Q
What color on a gastric secretion test indicated blood?
A
Blue
8
Q
What medication should people avoid before taking a stool sample?
A
Aspirin, anticoagulants, and NSAIDs seven days before 7 sample collecting
9
Q
What foods should people avoid before taking a stool sample?
A
Sumrall vegetables, red meat, poultry, and fish
10
Q
What chemical is detected in pregnant women urine?
A
Human chorionic gonadotropin (hcG)
11
Q
What is the expected range for urine specific gravity?
A
1.0053 to 1.030
12
Q
What does urine specific gravity test for?
A
Higher specific gravity indicate concentrated urine and an indicator or dehydration
13
Q
What component in the urine indicates an infection?
A
Leukocyte esterase
Glucose- diabetes
Nitrogen-infection
Ketones- fate metabolism and diabetes mellitus
14
Q
When should urine be kept on ice?
A
Time urine specimens to measure creatinine, protein, or hormones
15
Q
What are some indications of UTI before doing a urine reagent strip test or requesting a urinalysis prescription? (15)
A
Frequent urination,
Urgency
Hesitancy
Difficulty initiating a stream
Retention
Feeling of incomplete emptying
Burning
Low pack flank pain
Hematuria
Pyuria
Cloudiness
Fever
Incontinence
Confusion
Behavioral changes
16
Q
What should a client who is being sent home it fecal occult blood test card be given?
A
Three FOBT cards for three separate non-contaminated stool collections
Name, date, and time of collection, and DOB
17
Q
Why should urine sample be placed on ice?
A
Non iced urine can increase alkalinity and bacterial growth
18
Q
Why are some home pregnancy test give false readings?
A
Too soon after menstrual cycle
Did not have enough hormones
Waited too long or too little before reading the home test
19
Q
What is the expected pH of urine?
A
4.6 to 8.0
20
Q
What is the bell portion of the stethoscope best for hearing?
A
Heart murmurs and vascular bruits, and atherosclerosis
21
Q
What speculum size should people use for otoscopes?
A
Four mm for adults and 2 mm for adults
22
Q
Irritating scents can trigger what nerve?
A
Trigeminal nerves
23
Q
When are monofilament sensitivity tests useful for?
A
Diabetics and those with neurological problems
24
Q
What does a lack of body hair below the mid calf mean?
A
Peripheral vascular mean?
25
What does even bilateral facial movement indicate?
Cranial nerve seven is intact
26
If the patient can shrug shoulders and turn their head side to side, what does this mean?
Cranial nerve eleven is intact
27
If the patient is able to swallow, what does this mean?
It means that the glossoparyngeal and vagus cranial nerves CN IX and X are intact
28
Reactive to light, round, and equal pupils mean what?
The oculomotor nerve CN III is intact
29
What does the ophthalmoscope look for?
Red reflex to see if the fungus of the eyes looks red tinged
30
The words: light, tight, and dynamite, are used to indicate what?
That cranial nerve XII is intact
31
How far should you insert the tip of the otoscope?
1 to 1.5 cm into the ears canal
32
What kind of breathing patterns are you looking for?
Rate
Rhythm
Depth
Distress
Inspiration vs expiration
33
How many spots on the chest should you auscultation for respiration?
12, going in a zig-zag pattern
34
Why should a patient hug themself with their arms across their chest when palpating back respirations?
Pulls the scapula apart so it is easier to hear the lung sounds underneath
35
How many spots on the back should you auscultate respirations?
10, starting from upper left.
36
What does a friction rub sound like?
When pleural membranes covering the lungs and lining of the thoracic cavity are inflamed, a scratching or squeaking sound can persist and does not clear with coughing
37
What is a thrill of the hear feel like?
Vibration
38
Where is the best place to listen to the tricuspid area?
Fourth intercostal space
39
What is the aortic area?
Right of the angle of Louis
40
Where is the pulmonic area
Left of the angle of Louis is the second intercostal space
41
Where is Erb’s point and what is it good for listening?
In the third intercostal space and good for just listening
42
How are murmurs graded?
Grade 1: difficult to here in a quiet room
Grade 2: clearly audible, the quiet
Grade 3: moderately loud
Grade 4: loud and associated with a thrill!
Grade 5: very loud and easy to palpate the thrill
Grade 6: very loud, may be audible without touching the clients, chest, associated with a visual thrill and palpable thrill. 
43
How are edemas graded?
1+ edema: 2 mm indentation
2+ edema: 4 mm indentation
3+ edema: 6 mm indentation
4+ edema: 8 mm indentation
44
Where are common sites for hernias?
Groin
Previous sites of surgery
45
Why should an abdominal assessment the left to the last assessment?
It may trigger peristalsis and may alter other assessment findings
46
What is AVPU?
Alert
Verbal stimulus response
Pain stimulus response
Unresponsive
47
What is the acoustic cranial nerve?
Eight
48
What is the motor and sensory branch nerve?
CN V
49
What does cranial nerve three control?
Pupillary constriction
Dilation of the pupils
Elevation of the upper lid
I movements

50
What does cranial nerve two indicate?
The sensory nerve for visual acuity
51
How often should compression stockings be removed?
At least every eight hours
52
What is a gait belt used for?
To move the position from the bed to a chair or to ambulate
53
What patients can benefit from semi-Fowlers’ - 30-45 degrees
NG tube
Neuro, cardiac, respiratory
54
What position can help reduce the effects of esophageal reflux?
Reverse Trendelenburg position 
55
What is ISBARR
Identity: identify yourself, and introduced where you’re calling from
Situation: clients name, age, admitting diagnosis and chief complaint, or urgent need of rapid response to be called
Background: medical history during current medication’s in advance directives
Assessment: general, client, impression and significant findings through assessment, diagnostic test, lab work and vital signs
Recommendation: treatment provided in the clients response to the treatment
Read back: read back the message, or prescription from the provider, which allows for clarification of any miscommunication 
56
What is an unexpected event of circumstance that occurred that did not cause harm to the patient but has the potential to
Client safety event
57
What the result of a sentinel event? Aka
Never event. A critical, unexpected adverse event that caused severe physical or psychological harm to a client, including death, dismemberment, permanent injury, and severe or temporary injury.
58
What are some examples of unexpected events that must be documented in an occurrence report?
Accident or injury have a client staff member or visitor
Unexpected vaccine or drug reaction
Administration of the wrong vaccine or truck to a client
Incorrect administration of a drug or vaccine to a client
Property damage or lost items
Exposure to body, bloody fluid, or other infectious materials on the skin, eyes, or mucous membranes
Atypical behaviors, actions, and events that go against the facilities’ policy or procedures
59
What are some ways to identify a patient?
Social Security number, date of birth, because I have number phone number, name
60
What are some ways to ensure safety in radiology
Reduce time
Increase distance
Use shielding
61
What are some causes of death for children 0-4 years?
Drowning, choking, and poisonings
62
What are supplies needed for belt restraints in bed?
Additional padding to protect bony prominences if needed
Belt restrains
Additional personnel if needed
63
What vitals should be assessed before using a belt restraint on a patient? (10)
Level of consciousness
Overall health status
Level of activity
Skin, integrity and bony prominences
Color temperature in cap refill
Distal pulse
Range of motion of extremity that will be restrained
Obtain a set of vitals and O2 sat
Check any IVs or devices that will be affected by the restraint 
64
What is the purpose of an elbow restraint?
Physical restraints to limit on flexion, and prevent the client from removing necessary tubes or drains to treat the patient
65
What kind of documentation is relevant in a clients medical record for a restraint?
Focused assessment findings
Date
Type of restraint on location
Pharmacological and non-pharmacological interventions
66
When are mitten restraints used?
They are physical restraints, apply to arms, wrists, legs, or ankles to limit mobility to prevent the client from removing nasal tubes or drains at her place for treatment
67
What are belt restraints used for?
They are used to limit mobility, and to prevent the person from falling out of a chair
68
What should happen if there is an unexpected outcome for physical restraints?
Notify the provider that a different type of restraint might be needed
Treat the redness or ulceration of the skin
Ensure that the restaurant is dry and obtain if a new restraint is needed
Do not reply the restaurant, unless there’s a provider prescription to do so
69
What are some underlying fall prevention mechanisms? (6)
Nonskid footwear
Mockingbirds in wheelchairs in a little position
Clutter, free environment
Adequate lighting
Call light and belonging within reach
Basic orientation of the room
70
What is the 10th leading cause of death in the US?
Suicide
71
What are four hospital acquired infections monitored by the CDC?
Central line associated bloodstream infections
Catheter associated urinary tract =infection
Surgical site infection
Ventilator associated pneumonia
72
What are to work practices that have increase the amount of time the nurse spend at a clients bedside
Hourly rounding
Bedside handoff, communication
73
What are some conditions that would require the nurse to notify the rapid response team?
A sudden change in vital signs
Low oxygen saturation, despite efforts to oxygenate the client
Chest pain despite nitroglycerin administration
Seizure
Concern about the clients condition
Change in mental status
74
What is the pneumonic to remember how to use a fire extinguisher?
Pause
Pull the pin
In the nozzle
Squeeze a handle
Sweet from side to side at the base
75
What are some interventions that can be implemented to avoid the use of restraints? (9)
Engage the client and social interactions
Divert attention
De-escalate the situation
Play the client near the nurses station
Have family members present at the bedside
Have a Center at the clients bedside
Use bed or chair alarms
Keep IV tubing urinary catheter or other medical devices out of the clients views
Remind, and re-orient the client not to pull on the medical device or to get out of bed
76
What are some physical factors that would increase in clients risk of falling?
Stroke
Amputation
Recent surgery
Multiple
Vision impairment
Chronic pain
Malnutrition
Weakness
Unsteady gait
77
What are three cognitive factors that would increase a clients risk of falling?
Sleep disorders
Impulsiveness
Disorientation
Dementia
Depression 
78
What is a device that Laura take care giver when a client moves and is often used with the dementia patients?
Ambulation alarm 
79
Why is it important to place dentures in water at night?
So that the dentures don’t dehydrate and warp due to loss of moisture. It also helps remove any remaining debris or adhesive on the dentures. Don’t forget to label the dentures with the patients name.
80
What cranial nerve is involved to move the eye in all directions?
Cranial nerve six. Abducens
81
What cranial nerve is involved in visual acuity and visual fields?
Cranial nerve two- the optic nerve
82
What is a hygiene concern for incontinent patients?
Skin breakdown
83
When does an order for hard restraints expire?
4 hours
84
When does an order for soft restraints expire?
24?
85
When does an order for hard restraints expire?
4 hours
86
When does an order for soft restraints expire?
Every four hours
87
When should you reassess?
Depends on hospital protocol
88
What is the reflex that is initiated by striking the forearm just above the wrist?
Brachioradialis
89
What is a Romberg test?
Test balance
90
What is a common therapeutic technique?
Silence
Clarification
91
What arteries usually move on inspection?
Carotid
92
Which ribs are considered “floating”?
Eleven and twelve
93
What CN is responsible for symmetry of facial movements?
VII
94
What does the cover and uncover test on a client?
Determines the balance mechanism that keeps the eyes parallel 
95
What is the hypoglassal nerve? And what is it responsible for?
XII and swallowing and tongue movement
96
Reflexes are graded on a scale of what to what?
0 to four, 2 being normal and four being hyperreflexia
97
What are skin lesions with a wavy border?
Serpiginous
98
What kind of lesions are ring like and have raised borders around the flat clear center of normal skin?
Annular lesions
99
What lymph nodes are to be palpated during a breast exam?
Brachial nodes
Subclavicular, nodes
Supraclavicular notes
Internal mammary nodes
100
Why should lymph nodes be assessed simultaneously?
To compare one side to another
101
What drug is a CNS depressant that causes dizziness and orthostatic hypotension?
Alprazolam
102
How warm should bat water be?
110 F and 115 F
103
What direction should a client’s extremities be washed?
Distal to proximal to stimulate venous return
104
Why should you not raise all the rails on a bed?
In case of the patient may try to climb out of bed, and the risk of fall is greater when all the side rails are raised
105
What visual impairment is associated with halos?
Glaucoma
106
What kind of percussion sounds should be heard over the lungs
Resonance a low pitched sound
107
Over which organs would you hear dullness a soft, high-pitched tone during percussion of assessment?
Solid organs such as the liver
108
When would you hear a sound like timpani?
Hollow air filled organs such as intestines and abdomen
109
When would you hear hyperresonance?
Air trapped in lungs
110
Why should you not use the part of the flex your finger to percuss a lung?
The tip of the middle finger will produce the clearest sound 
111
When a client is on their left side, what Heart sounds should the nurse anticipate to hear?
S3 and S4
112
What severity of a pitting edema is an 8?
4+
113
What causes the S2 heart sound?
Closing of the aortic and pulmonic valves
114
Where should you auscultate to hear the lungs on the chest?
Above the substernal notch
115
Between what heart sounds would you hear a systolic murmur?
S1 and S2 heart sounds
