Week 4 Flashcards
Which instruction would the nurse give when asking nursing assistive personnel (NAP) to give a complete bed bath to a patient?
A. Do not massage any reddened areas on the patient’s skin.
B. Be sure to wash the patient’s face with soap.
C. Disconnect the intravenous tubing when changing the gown.
D. Wear gloves if necessary.
A. Do not massage any reddened areas on the patient’s skin.
The nurse has washed a patient’s arms. Which area should the nurse wash next?
A. Hands
B. Chest
C. Abdomen
D. Legs
A. Hands
A patient is being given a bed bath. The nurse realizes that another washcloth is needed to complete the bath. What is one way in which the nurse can ensure the patient’s safety?
A. Use the call light to ask someone else to bring a washcloth.
B. Raise all four side rails on the patient’s bed.
C. Make sure the call light is within the patient’s reach.
D. Raise the bed to its highest position.
C. Make sure the call light is within the patient’s reach.
Which patient should not have his or her feet soaked during a complete bed bath?
A. A patient with arthritis
B. A patient who has just complained of shoulder pain
C. A patient with diabetes mellitus
D. A patient who is nauseated
C. A patient with diabetes mellitus
The nurse is bathing a patient who is unconscious. What should the nurse do to ensure safe care of the patient’s eyes?
A. Remove eye crusts with soapy water.
B. Avoid closing the patient’s eyes.
C. Use eye patches or shields taped in place.
D. Tape the patient’s eyelids closed.
C. Use eye patches or shields taped in place.
The nurse is delegating to nursing assistive personnel (NAP) the perineal care of a female patient who is totally dependent and confined to bed. Which statement by the NAP requires the nurse’s follow-up?
A. “I’ll ask for assistance if I need help positioning her.”
B. “I’ll see if she’s up to the care right now.”
C. “I’ll let you know if I notice any signs of redness or discharge.”
D. “I’ll be sure to use hot, soapy water, since she has been incontinent.”
D. “I’ll be sure to use hot, soapy water, since she has been incontinent.”
[Warm water should be used]
The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care?
A. Supine
B. Prone
C. Side-lying
D. Dorsal recumbent
D. Dorsal recumbent
As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, “I can do that myself.” Which action would be the priority?
A. Provide all the necessary supplies and linen for this task.
B. Assess the patient’s ability to perform proper perineal care.
C. Ensure that the patient has privacy while performing perineal care.
D. Document any complaints of irritation or pain in the perineal area.
B. Assess the patient’s ability to perform proper perineal care.
How can the nurse promote infection control while providing perineal care for a female patient who has a catheter?
A. By avoiding the application of tension on the catheter.
B. By patting, not rubbing, the skin dry after thoroughly rinsing it.
C. By cleansing the patient’s labia from the pubic area toward the rectum.
D. By using warm water to cleanse the patient’s entire perineal area.
C. By cleansing the patient’s labia from the pubic area toward the rectum.
The nurse is delegating a female patient’s perineal care to nursing assistive personnel (NAP). Which instruction would the nurse give to ensure the NAP’s safety while performing this care?
A. Wear sterile gloves.
B. Wear clean gloves.
C. Wear an isolation gown.
D. Use hot water.
B. Wear clean gloves.
Which of the following interventions directly related to patient safety must the nurse consider when providing perineal care to an elderly male patient with a catheter?
A. Wear clean gloves during care.
B. Assess the patient’s ability to provide self-care.
C. Encourage the patient to report any pain originating from the catheter.
D. Monitor the amount of urine in the drainage bag to prevent overflow.
A. Wear clean gloves during care.
The nurse observes the nursing assistive personnel (NAP) providing perineal care to a male patient. Which observation of care requires the nurse’s follow-up?
A. Assisting the patient into the supine position in bed.
B. Cleansing the tip of the penis with a circular motion, starting at the meatus.
C. Reserving the cleansing of the tip of the penis as the final step in perineal care.
D. Using a gloved hand to grasp the shaft of the penis in order to retract the foreskin.
C. Reserving the cleansing of the tip of the penis as the final step in perineal care.
A male patient receiving perineal care tells the nurse “It has started to hurt a little down there.” What is the nurse’s best response?
A. “When did you start experiencing the pain?”
B. “Rate the pain on a scale of 1 to 10.”
C. “I’ll assess your perineal area for the possible cause of the pain.”
D. “Would you like some pain medication before I continue with your care?”
A. “When did you start experiencing the pain?”
The nurse has delegated a male patient’s perineal care to the nursing assistive personnel (NAP). Which statement made by the NAP requires the nurse’s follow-up?
A. “I will check to see if he cleans himself well.”
B. “I will let you know if I see any redness or drainage.”
C. “I will ask him if he is experiencing any pain in that area.”
D. “I will be sure to use hot, soapy water to be sure he’s clean.”
D. “I will be sure to use hot, soapy water to be sure he’s clean.”
What is the primary reason for performing perineal care on a male patient with incontinence?
A. To provide comfort and a relaxed, refreshed feeling
B. To promote personal hygiene while minimizing perineal odor
C. To remove all microorganisms from the patient’s perineal area
D. To reduce the risk of skin breakdown in the patient’s genital and perineal area
D. To reduce the risk of skin breakdown in the patient’s genital and perineal area
The nurse is preparing to make an occupied bed for a patient who is on aspiration precautions. What will the nurse do to ensure the safety of this patient during the bed change?
A. Keep the head of the bed no lower than a 30-degree angle.
B. Fold a pillow in half and place it under the patient’s head.
C. Lower the bed to a flat position and place two pillows beneath the patient’s head.
D. Ask another caregiver to hold the patient’s head during the bed change.
A. Keep the head of the bed no lower than a 30-degree angle.
The nurse is directing nursing assistive personnel (NAP) to make an occupied bed. What will the nurse say to minimize the risk of disease transmission to staff and patient during the bed change?
A. “You’ll need to apply Standard Precautions during this task.”
B. “Soiled linen should be rolled toward your uniform.”
C. “Soiled linen should be kept away from your uniform.”
D. “Keep the linen bag at the foot of the bed.”
A. “You’ll need to apply Standard Precautions during this task.”
Which action ensures that a patient will not have unnecessary pain during a linen change?
A. Discontinue the bed change if the patient expresses or displays physical signs of pain.
B. Explain the procedure to the patient before beginning the linen change.
C. Administer a prescribed analgesic 30 to 60 minutes before the bed change if needed.
D. Postpone the bed change if the patient reports having physical pain before you begin.
C. Administer a prescribed analgesic 30 to 60 minutes before the bed change if needed.
The nurse is changing the bed linen of a patient on bed rest. When the nurse is ready to make the other side of the bed, what will the nurse do before having the patient turn onto the side that has already been made?
A. Lower the head of the bed
B. Raise the side rails
C. Apply the topsheet
D. Discard the soiled linen in the linen bag
B. Raise the side rails
What will the nurse do right after placing a clean topsheet on the patient?
A. Make a cuff with the top of the sheet.
B. Make a horizontal toe pleat.
C. Tuck the remaining portion of the sheet under the foot of the mattress.
D. Remove the bath blanket.
D. Remove the bath blanket.
The nurse who is preparing to make an unoccupied bed should do what to ensure his or her personal safety?
A. Put on sterile gloves.
B. Place the call light within the nurse’s reach.
C. Place the bed at a comfortable working height.
D. Place a laundry bag on the bedside chair.
C. Place the bed at a comfortable working height.
The nurse is preparing to change the soiled linen of a patient’s unoccupied bed. Which precaution minimizes the risk of transmitting microorganisms?
A. Perform hand hygiene and apply clean gloves.
B. Place fresh linen on a clean bedside table or chair.
C. Put soiled linen in a pillow case before placing in a hamper.
D. Roll soiled linen together with the dirty sides toward the center.
A. Perform hand hygiene and apply clean gloves.
What would the nurse instruct the nursing assistive personnel (NAP) to do before making an unoccupied bed if the mattress is soiled?
A. Wash the mattress with hot water.
B. Wipe off moisture with antiseptic solution, and dry thoroughly.
C. Flip the mattress.
D. Apply a waterproof pad over the soiled area.
B. Wipe off moisture with antiseptic solution, and dry thoroughly.
The nurse is reviewing placement of an unfitted bottom sheet with nursing assistive personnel (NAP) assigned to make an unoccupied bed. What should the nurse include in this teaching?
A. The lower hem of the sheet should lie seam down and even with the bottom edge of the mattress.
B. Keep enough material to miter the lower mattress corners.
C. Apply the drawsheet on the cleaned mattress first.
D. Make the top of the bed first, moving to the bottom of the bed.
A. The lower hem of the sheet should lie seam down and even with the bottom edge of the mattress.
When making an unoccupied bed, where would the nurse place a waterproof pad?
A. Directly on the mattress.
B. Beneath the drawsheet.
C. Over the bottom sheet.
D. Over the top sheet.
C. Over the bottom sheet.
To which patient might the nurse apply a physical restraint?
A. An 83-year-old patient with dementia and a history of wandering whose fall risk assessment indicates a high risk of falling.
B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt.
C. A 74-year-old patient confined to bed who is at risk of pressure ulcers.
D. A 60-year-old patient with dementia who seemed increasingly confused shortly after having had restraints applied for 1 hour that morning.
B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt.
Why does the nurse instruct nursing assistive personnel (NAP) to remove the wrist restraint of a confused patient every 2 hours?
A. To try a less restrictive type of restraint if a more confining restraint has proved effective
B. To double-check the size by inserting one finger between the wrist and the restraint
C. To check the skin integrity and range of motion of the wrist
D. To comply with Joint Commission standards
C. To check the skin integrity and range of motion of the wrist
What would the nurse instruct nursing assistive personnel (NAP) to report when caring for a patient in a wrist restraint?
A. “Tell me if the patient’s pulse changes.”
B. “Tell me if the skin under the restraint becomes abraded or raw.”
C. “Let me know if you think she’s ready for them to come off.”
D. “Let me know if the patient needs anything for pain.”
B. “Tell me if the skin under the restraint becomes abraded or raw.”
The nurse is discussing the risk of falling with the wife of a patient with cognitive impairment. What is the nurse’s best response when the patient’s wife says, “I don’t like him being tied down in the bed?”
A. “I’m sure you don’t want him to fall again.”
B. “Can you suggest an alternative?”
C. “What did you do to prevent him from falling when he was at home?”
D. “We will try all other alternatives before using physical restraints.”
D. “We will try all other alternatives before using physical restraints.”
When a nursing assistive personnel (NAP) enters the room of a patient in a belt restraint, he finds the patient’s gown bunched around the patient’s chest and the patient asking for help. What would the NAP do?
A. Check the patient’s blood pressure and pulse before smoothing the gown
B. Untie the restraint and smooth the patient’s gown
C. Put on the call light for help
D. Ask the patient what specific help she would like
B. Untie the restraint and smooth the patient’s gown
Which statement demonstrates the patient’s ability to perform incentive spirometry correctly?
A. The patient inhales slowly and deeply.
B. The patient inhales rapidly.
C. The patient exhales rapidly.
D. The patient holds a breath for 15 seconds
A. The patient inhales slowly and deeply.
The RT walks into a postoperative patient’s room with an incentive spirometer and the patient asks, “What is the purpose of that?” What is the most appropriate response describing the purpose of incentive spirometry?
A. It administers aerosolized medications.
B. It prevents postoperative pulmonary complications.
C. It measures the patient’s peak flow
D. It improves expiratory flow.
B. It prevents postoperative pulmonary complications.
An RT is assessing the patient’s ability to perform incentive spirometry correctly by viewing a return demonstration. When is additional patient education needed?
A. When the patient examines the sputum expectorated
B. When the patient creates a complete seal over the mouthpiece
C. When the patient holds a breath for 5 seconds after maximum inhalation
D. When the patient performs a series of short inspirations
D. When the patient performs a series of short inspirations
A patient had a preoperative inspiratory capacity volume measurement of 6000 ml, which was equal to the patient’s predicted value before an appendectomy. What is the minimum acceptable postoperative volume to be achieved with an incentive spirometer?
A. 1000 ml
B. 2000 ml
C. 4000 ml
D. 5000 ml
B. 2000 ml
Rationale: Spirometry is not recommended for patients with a vital capacity of less than 10 ml/kg or an inspiratory capacity less than one third of predicted. The patient performed 6000 ml before surgery; therefore, one third of predicted would be 2000 ml. The patient may not return completely to baseline in the postoperative period. The patient probably will not exceed baseline after surgery.
A patient with COPD is recovering from postoperative abdominal surgery. The prescribing practitioner has ordered an incentive spirometer to decrease the chance of pneumonia. Which is an unexpected long-term outcome?
A. Shortness of breath after the use of the incentive spirometer
B. Correct patient demonstration of use of the incentive spirometer
C. Improved breath sounds after the use of the incentive spirometer
D. Patient achievement of target volume and number of repetitions per hour after the use of the incentive spirometer
A. Shortness of breath after the use of the incentive spirometer
While providing care for a client who is postoperative, the nurse observed a pulse deficit during physical assessment. Which pulses would the nurse use to assess the pulse deficit?
Radial and apical pulse
Apical and carotid pulse
Radial and brachial pulse
Apical and temporal pulse
Radial and apical pulse
A client arrives at a health clinic reports, “I am here to have my tuberculin skin test read.” The nurse notes a 7-mm indurated area at the injection site. Which nurse’s statement describes this result?
“The result indicates that you have active tuberculosis.”
“The result indicates you are infected with the tuberculosis organism.”
“The result indicates there are no tuberculin antibodies in your system.”
“The result indicates you have a secondary infection related to the tuberculin organism.”
“The result indicates you are infected with the tuberculosis organism.”
An indurated area 5 mm or larger noted 48 to 72 hours after the tuberculin test indicates that the person is infected with the tuberculin organism. A positive tuberculin skin test accompanied by fever, coughing, weakness, and positive chest x-ray are manifestations of active tuberculosis.
A client weighed 210 pounds (95.2 kg) on admission to the hospital. After 2 days of diuretic therapy, the client weighs 205.5 pounds (93.2 kg). Which numerical value reflects the liters of fluid excreted by the client? Record your answer using a whole number.
2
One liter of fluid weighs approximately 2.2 pounds (1 kg); therefore a 4.5-pound (2 kg) weight loss equals approximately 2 liters.
For the client with a closed chest tube drainage system connected to suction, which assessment finding requires additional evaluation by the nurse?
A column of water 20 cm high in the suction control chamber
75 mL of bright red blood in the drainage collection chamber
An intact occlusive dressing at the insertion site
Constant bubbling in the water-seal chamber
Constant bubbling in the water-seal chamber
Constant bubbling in the water-seal chamber is indicative of an air leak. The nurse would assess the entire length of the system from the container to the client’s chest wall tube insertion site to find the source of the air leak. If the source of the air leak is not found in the system and bubbling continues, the leak is most likely within the client’s chest or at the insertion site. This could cause the lung to collapse because of a buildup of air pressure within the pleural cavity, and the health care provider should be notified. In this type of surgical procedure, 75 mL of blood in the chest tube collection chamber is an expected finding in the early postoperative period. A column of water 20 cm high in the suction control chamber and an intact occlusive dressing at the chest tube insertion site are also expected assessment findings.
When the nurse completes a thorough assessment to identify the reason for a client’s anxiety, which critical thinking attitude is involved in this situation?
Discipline
Confidence
Responsibility
Thinking independently
Discipline
The nurse shows discipline in collecting a thorough assessment to identify the source of the client’s anxiety. Confidence involves completing a task or goal such as performing a procedure or making a diagnostic decision. Responsibility is applicable when performing a nursing skill by following standard care practices. Thinking independently involves reading the nursing literature, talking with other nurses, and sharing ideas about nursing interventions.
When assessing risk factors, which question would the nurse ask a client who has developed pneumonia?
“Are you diabetic?”
“Have you ever had pneumonia?”
“What do you use for contraception?”
“Do you have a history of intravenous [IV] drug abuse?”
“Are you diabetic?”
Chronic diseases such as diabetes are a risk factor for developing infections such as pneumonia. Inquiring about the client’s pneumonia history provides additonal information regarding the client’s knowledge but does not let the nurse understand the client’s risk factors. Contraception would be explored in sexual barrier devices for sexually transmitted infections. IV drug abuse would be explored to assess risk of exposure to blood-borne pathogens such as Hepatitis B.
During a falls risk assessment, which action would the nurse take after learning the client experienced a recent fall?
Apply restraint to prevent ambulating without assistance
Discontinue all medications to remove the risk of polypharmacy
Assess the circumstances of the fall, including feelings and setting
Require family members to remain at the bedside to watch over the client
Assess the circumstances of the fall, including feelings and setting
The circumstances of the fall, including feelings and setting, should be explored and documented to understand risk of falls for this client. Fall history alone does not warrant use of restraint. The nurse consults with the health care provider on polypharmacy but does not discontinue medications independently. The family is not required to remain at the bedside but is encouraged to understand fall risk.
Upon entering the examination room of a client and their spouse, which action would the nurse take when the client is withdrawn and appears fearful of the spouse?
Ask if there are concerns at home.
Call the client later to ensure safety.
Find a way to interview the client in private.
Assume the client is nervous in medical settings.
Find a way to interview the client in private.
Abuse is suspected when a client seems fearful of another person, and the nurse would find a way to interview the client in private. Asking about concerns at home should not be done in front of the spouse. Calling the client later does not address a possible immediate threat to the client’s safety. The nurse would investigate the safety of the client, not assume nervousness.
Upon entering an examination room for assessment of a confused client, which action would the nurse take?
Perform an assessment quickly.
Plan a focused physical assessment.
Skip the examination until the client is reoriented.
Leave the room to find the health care provider.
Plan a focused physical assessment.
A focused assessment is the most common and efficient physical examination. The nurse would not rush through an assessment because of confusion. The nurse would not skip the assessment because of confusion. The nurse would never leave a confused client unattended.
When preparing to assess a client with Clostridium difficile, which piece of personal protective equipment would the nurse put on before entering the client’s room?
Head covering
Clear eye mask
Full plastic gown
N95 respiratory mask
Full plastic gown
A client with Clostridium difficile should be on contact precautions to avoid the spread of the spores, so the nurse would wear a full plastic gown that is disposed of once the assessment is complete. A head covering, eye mask, and N95 respiratory mask are not necessary protective devices in the assessment of a client with Clostridium difficile.
When preparing to assess a client with active tuberculosis, which piece of personal protective equipment would the nurse put on before entering the client’s room?
Isolation gown
Surgical mask
Shoe covers
N95 respiratory mask
N95 respiratory mask
Active tuberculosis places a client on airborne precautions in accordance with which the nurse must wear an N95 respiratory mask to prevent personal respiratory exposure to the infectious droplets. An isolation gown, surgical mask, or shoe covers are not necessary protective devices in the assessment of a client with active tuberculosis, nor would they be sufficient to protect the nurse from infection.
While collecting a client’s urine sample, which condition would the nurse suspect if the sample has a strong odor of ammonia?
Malabsorption
Bladder cancer
Diabetic ketoacidosis
Urinary tract infection
Urinary tract infection
A strong ammonia odor in the urine can indicate that the client has a urinary tract infection, or possibly renal failure. Malabsorption can cause particularly foul-smelling stools in an infant. The ammonia odor does not indicate bladder cancer. Diabetic ketoacidosis usually causes a sweet/fruity odor on the breath.
A strong _______________ odor in the urine can indicate that the client has a urinary tract infection, or possibly renal failure.
ammonia
Diabetic ketoacidosis usually causes a ____________ odor on the breath.
sweet/fruity
A client weighs 150 lb and is 5 feet 7 inches tall. Which numerical value reflects this client’s body mass index (BMI)? Record your answer using two decimal places.
Body mass index (BMI) can be calculated by dividing the client’s weight in kilograms by the height in meters squared. A client who weighs 150 lb (68 kg) and stands 5 feet 7 inches (1.7 m) tall will have a BMI of 23.53: 68/1.7 2 = 23.53.
While providing care for a client with heat stroke, the nurse measured and noted the temperature as 39°C. Which temperature would the nurse document in Fahrenheit? Record your answer and round to tenths
Celsius is converted to Fahrenheit by multiplying the Celsius reading by 9/5 and adding the product to 32. In this case, the calculation is: (9/5)(39) + 32 = 102.2.
Which condition would the nurse suspect upon finding a bluish coloration of the skin during an assessment?
Anemia
Liver disease
Heart disease
Autoimmune disease
Heart disease
A bluish discoloration of the skin indicates cyanosis. This condition may be caused by increased amounts of deoxygenated hemoglobin, which may be due to heart disease or lung disease. In clients with anemia, the skin has a pallor due to a reduced amount of oxyhemoglobin. In clients with liver disease, the skin appears yellow or orange due to increased deposits of bilirubin. In autoimmune diseases, the skin will lose its pigmentation.
In clients with anemia, the skin has a _________ due to a reduced amount of oxyhemoglobin
pallor
After conducting a falls risk assessment education session for the staff and observing falls risk assessments on the unit, which staff action needs review for corrective action?
Using a fall risk assessment tool
Assessing the environment for fall hazards
Inquiring about the client’s history of falls
Delegating fall assessments to assistive personnel
Delegating fall assessments to assistive personnel
Falls risk cannot be delegated. The nurse needs to be the person to complete falls risk assessment, not assistive personnel. Use of a falls risk assessment tool, assessing the environment for hazards, and exploring the client’s history of falls are all appropriate actions for fall risk assessment
Which assessment item needs to be documented on a client with restraints? Select all that apply. One, some, or all responses may be correct.
Pulse near the restrained area
Temperature of the restrained area
Convenience of restraining the client
Skin integrity surrounding the restraint
Behavior leading to the need for restraint
Pulse near the restrained area
Temperature of the restrained area
Skin integrity surrounding the restraint
Behavior leading to the need for restraint
After presenting information about falls risk assessments to nursing staff, which participant’s statement needs review for corrective action?
“We will assess every admission to the unit.”
“We will implement a valid falls risk assessment tool.”
“We will apply yellow wrist bands to high-risk clients.”
“We will use the admission fall assessment for the entire stay.”
“We will use the admission fall assessment for the entire stay.”
Falls risk assessment should be updated routinely through discharge, because fall risk may change throughout the hospital stay. Falls risk assessment should be completed on every client with a valid falls risk tool. High-risk fall clients should be identified.
After reviewing otoscope use for assessment of the ear with the nursing staff, which participant’s response reflects safe follow-up care for when earwax covers the tympanic membrane?
“I will leave the wax in place.”
“I will use a cotton-tipped swab to remove the wax.”
“I will insert the tip of a hemostat to remove the wax.”
“I will perform warm water irrigation to remove the wax.”
“I will perform warm water irrigation to remove the wax.”
Earwax in front of the tympanic membrane should be removed for assessment and proper hearing, and irrigation with warm water is a safe way to remove the wax. The wax should not be left in place, because the tympanic membrane cannot be seen and it may disrupt normal hearing. Cotton-tipped swabs and pointed objects like the tip of a hemostat should not be placed into the ear canal because they can cause damage.
An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The nurse asks if the client has had a tetanus immunization. The adolescent responds that all immunizations are up to date. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Which statement describes the nurse’s responsibility in this situation?
The nurse’s judgment was adequate, and the client was treated accordingly.
The possibility of tetanus was not foreseen because the client was immunized.
Nurses would routinely administer immunization against tetanus after such an injury.
Assessment by the nurse was incomplete and, as a result, the treatment was insufficient.
Assessment by the nurse was incomplete and, as a result, the treatment was insufficient.
The nurse’s data collection was not adequate because the nurse did not ask about the date of the previous tetanus inoculation. The nurse failed to support the life and well-being of a client. The nurse’s assessment was not thorough in regard to determining the date of immunization. It was essential to determine when the client was last immunized; for a “tetanus-prone” wound, like a puncture from a rusty nail, some form of tetanus immunization usually is given. Administering immunization against tetanus is not an independent function of the nurse.
_____________ is a food-borne disease and may be due to the ingestion of milk products, seafood, or salad. The symptoms of infection include abdominal cramps and severe diarrhea and can occur 12 hours after ingestion
Shigellosis
For an older adult client with dementia who developed dehydration as a result of vomiting and diarrhea, which assessment information best reflects the client’s fluid balance?
Skin turgor
Intake and output results
Client’s report about fluid intake
Blood lab results
Blood lab results
Blood lab results provide objective data about fluid and electrolyte status, as well as about hemoglobin and hematocrit. Skin turgor is not a reliable indicator of hydration status for the older adult client because it is generally decreased with age. Intake and output results provide data only about fluid balance but do not present a comprehensive picture of the client’s fluid and electrolyte status; therefore, this is not the best answer. The client’s report about fluid intake is subjective data in general and not reliable because this client has dementia and consequent memory problems.
In the emergency department, the nurse assessed a client who is unconscious, experiencing severe bleeding due to a motor vehicle accident, and in hypovolemic shock. At which site would the nurse obtain the client’s pulse rate? Select all that apply. One, some, or all responses may be correct.
Apical
Carotid
Brachial
Femoral
Popliteal
Carotid
Femoral
Clients with severe bleeding may develop hypovolemic shock. The carotid and femoral pulses are easily accessible sites to measure pulses in clients with hypovolemic shock. Both the apical and brachial pulses may not be palpable in a client with hypovolemic shock. The popliteal site is used to assess the status of the circulation in the lower leg.
Which clinical indicator is most commonly used to determine whether the client has a fluid deficit when reporting vomiting and diarrhea for three days?
Presence of dry skin
Loss of body weight
Decrease in blood pressure
Altered general appearance
Loss of body weight
Dehydration is measured most readily and accurately by serial assessments of body weight; 1 L of fluid weighs 2.2 lb (1 kg). Although dry skin may be associated with dehydration, it also is associated with aging and some disorders (e.g., hypothyroidism). Although hypovolemia eventually will result in a decrease in blood pressure, it is not an accurate, reliable measure because there are many other causes of hypotension. Altered appearance is too general and not an objective determination of fluid volume deficit.
Which scenario would contribute to health disparities?
An English-speaking critical care nurse assesses a Hispanic client in a coma.
An English-speaking nurse plans the nursing procedures for a Black Latino client.
An English-speaking nurse provides discharge instructions to an English-speaking client who is hard of hearing.
An English-speaking nurse conducts an admission interview of a Puerto Rican immigrant with limited knowledge of English.
An English-speaking nurse conducts an admission interview of a Puerto Rican immigrant with limited knowledge of English.
While conducting an assessment, the nurse finds the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. Which temperature would the nurse associate with these findings?
29°C (84.2°F)
33°C (91.4°F)
36°C (96.8°F)
38°C (100.4°F)
33°C (91.4°F)
A body temperature in the range of 36°C (96.8°F) to 38°C (100.4°F) is normal. When skin temperature drops below 35°C (95.0°F), the client may exhibit uncontrolled shivering, loss of memory, depression, and poor judgment as a result of hypothermia. A body temperature lower than 30°C (86.0°F) represents severe hypothermia. In this condition, the client will demonstrate a lack of response to stimuli and extremely slow respiration and pulse. Based on the signs given, the client’s temperature is most likely 33°C (91.4°F).
Which client would have a health promotion nursing diagnosis?
The client with acute pain due to appendicitis
The client who is willing to take a 30-minute walk daily
The older adult client with dementia admitted to the health care facility
The client with reduced cognitive ability while recovering from surgery
The client who is willing to take a 30-minute walk daily
A health promotion nursing diagnosis is a clinical judgment of an individual’s desire to increase well-being. A client who is willing to take a 30-minute walk daily is expressing a desire to improve health behavior. The nurse identifies a health promotion nursing diagnosis for this client. Acute pain due to appendicitis is an actual nursing diagnosis. The nurse selects an actual nursing diagnosis when there is sufficient assessment data to establish the nursing diagnosis. It describes the client’s response to a particular health condition. A risk nursing diagnosis describes an individual’s response to health conditions that may develop in a vulnerable individual. The older adult client with dementia may have a risk nursing diagnosis for confusion. The client recovering from surgery has reduced cognitive ability and may have a risk nursing diagnosis for confusion or falls.
The nurse assesses a client’s pulse and documents the strength of the pulse as 3+. Which pulse strength does this documentation refer to?
Diminished
Normal
Full
Bounding
Full
The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. A 3+ rating indicates a full increased pulse. A zero rating indicates an absent pulse. A rating of a 1+ indicates a diminished pulse that is barely palpable. A 2+ rating is an expected or normal pulse, and a 4+ rating is a bounding pulse.
The nursing student, under the supervision of the registered nurse (RN), plans to perform a pulse assessment. While preparing to assess the client, the RN asks the student to check the apical pulse after assessing the radial pulse. Which rationale supports the RN’s request?
The client may have a dysrhythmia.
The client may have physiologic shock.
The client underwent surgery earlier in the day.
The client may have peripheral artery disease.
The client may have a dysrhythmia.
A client with dysrhythmia may have an intermittent or abnormal radial pulse. For this condition, the RN would advise the nursing student to assess the apical pulse because it will be more accurate. If the client is in shock, then assessing the carotid or femoral pulse would be appropriate. The femoral pulse is preferred to assess a client with peripheral artery disease.
Which related factor would the nurse attach to a nursing diagnosis?
Prostatectomy
Trauma of incision
Acute renal failure
Knee replacement surgery
Trauma of incision
The related factor or etiology of a nursing diagnosis is always within the nursing domain. The nurse must ensure the related factor is a condition responding to nursing interventions. Trauma of incision is an appropriate related factor for a nursing diagnosis. A prostatectomy is a medical condition that cannot be influenced by nursing actions. Similarly, acute renal failure is also a medical condition. Nursing interventions should be directed toward behaviors or conditions that can be managed or treated by the nurse. Knee replacement surgery is a medical condition that cannot be managed by nursing interventions
When assessing a client reporting shortness of breath, which activity best ensures the nurse obtains accurate and complete data to prevent a nursing diagnostic error?
Assess the client’s lungs.
Assess the client for pain.
Obtain details of smoking habits.
Ask about the onset of shortness of breath.
Assess the client’s lungs.
The nurse would assess the client’s lungs to gather objective data that will support subjective data provided by the client. The nurse can obtain objective data for this client by auscultating for lung sounds, assessing the respiratory rate, and measuring the client’s chest excursion. The nurse would review the data for accuracy and completeness before grouping the data into clusters. The nurse may also assess the client for pain, which is subjective data. The client may provide details about smoking habits, which is also subjective data. It is important for the nurse to identify what causes shortness of breath; however, the client’s statement is subjective data. All subjective data must be supported by measurable objective data.
Which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client?
The nurse understands the client has pain due to a tracheostomy.
The nurse identifies the client is anxious about the cardiac catheterization.
The nurse realizes the client has diarrhea and needs the bedpan frequently.
The nurse identifies the client is not aware of perineal care and has impaired skin integrity.
The nurse identifies the client is not aware of perineal care and has impaired skin integrity.
The nurse observes the client has impaired skin integrity due to lack of knowledge about perineal care. The nurse identifies the need for educating the client about perineal care. This nursing diagnosis is correct because it will help enhance the client’s health outcomes. The nursing diagnosis would identify the problem caused by a treatment such as tracheostomy, not the treatment itself. A tracheostomy is a medical condition and should not be included in the nursing diagnosis. This client is likely to have pain after the trauma of the surgical incision. The nursing diagnosis would contain the client’s response to the medical procedure rather than the medical procedure itself. The client is probably anxious due to lack of knowledge about the need for cardiac catheterization or the outcome of the procedure, rather than the catheterization itself. A correct diagnosis helps the nurse put the client at ease by providing necessary teaching. The nurse would plan nursing interventions after identifying the client’s problem. The nurse would identify that the client has diarrhea due to food intolerance. This helps the nurse select appropriate interventions rather than just one intervention of offering bedpan.
The registered nurse (RN) measures the client’s blood pressure as 130/80 mm Hg. When the unlicensed assistive personnel (UAP) measured the same client’s blood pressure, the measurement was 120/90 mm Hg. Which rationale would explain the measurement difference? Select all that apply. One, some, or all responses may be correct.
Poor fitting of the cuff
Inflating the cuff too slowly
Deflating the cuff too quickly
Inflating the cuff inadequately
Applying the stethoscope too firmly
Poor fitting of the cuff
Deflating the cuff too quickly
Poor fitting of the cuff or deflating the cuff too quickly causes false low systolic and false high diastolic readings. Inflating the cuff too slowly results in false high diastolic readings. Inadequately inflating the cuff yields false low systolic readings. Applying the stethoscope too firmly against antecubital fossa yields false low diastolic readings.
Which client would the nurse anticipate needing a referral to a support group for people with vision loss?
Cloudy vision
Crossing of the eyes
Obstruction of central vision
Difficulty seeing things that are far away
Obstruction of central vision
Obstruction of central vision may indicate that the client has macular degeneration, a disruption of the macula causing permanent blindness. This client likely will need a referral for help living with vision loss. Cloudy vision is usually a sign of cataracts, which can be removed with a simple surgical procedure. Crossing of the eyes, or strabismus, does not cause vision loss. Difficulty seeing things that are far away usually indicates nearsightedness; the person can see things that are up close but has difficulty with distance vision. This can be corrected easily with glasses or contact lenses.
When assessing an older client as they walk into the examination room, which finding would the nurse document as abnormal?
The client is wearing extra layers of clothing.
The client is wearing an excessive amount of cologne.
The client walks smoothly with arms swinging at the side.
The client is bent over slightly with the elbows and knees bent.
The client is wearing an excessive amount of cologne.
Wearing an excessive amount of cologne or makeup can indicate that the client is having an alteration in self-perception. It is normal for an older adult to wear extra layers of clothing because they tend to get colder than a younger adult. Older adults sometimes can experience an alteration in their posture, causing them to bend over slightly and stand with the hips and knees flexed and elbows bent. A normal gait is one where the client walks smoothly with the arms swinging at the sides.
Most common cancer in males:
prostate cancer
[age, family history, genes]
ANAL CANAL
- Outlet of the gastrointestinal tract
- Layers of muscles and sphincters – ensures tightly closed canal
- Highly vascular
-Sphincters – 2 present (internal and external – voluntary control)
RECTUM
- Distal portion of the large intestines
- Review of the anatomy
PROSTATE
- Lies in front of the anterior wall of the rectum
- Surrounds the bladder neck and urethra
- With increased age, the prostate enlarges due to hormonal changes (BPH)
Benign Prostatic Hyperplasia
___________ DATA
- Bowel routine
- Any change in bowel habits
- Any rectal bleeding or blood in stool
- Pt taking: laxatives, stool softeners, iron
- Conditions: pruritus (irritating sensation with urge to scratch), hemorrhoids, fissure (split/crack), fistula (abnormal tunneling)
- Family History
- Last examination
SUBJECTIVE
______________ GI
- Usually an advanced skills not performed by bedside RN (internal).
- Visual assessment is warranted at the bedside
- Administering suppository – flexed finger – aim towards umbilicus
- Related to hospitalization
- Colonoscopy – visualize internal organs.
ASSESSMENT
____________ FINDINGS
- Hemorrhoids
- Prolapsed rectum
- Black Tarry Stool
- Steatorrhea – Fat in the stools, oily in appearance and floats
- Pinworms
- Pale stool
ABNORMAL
Pepto bismol can turn stool:
black
Male genital structures include:
External
- Penis and ________
Internal
- Testis, epididymis, and vas deferens
Glandular structures _____________ to genital organs:
- Prostate, seminal vesicles, and bulbourethral glands
External
- Penis and scrotum
Internal
- Testis, epididymis, and vas deferens
Glandular structures accessory to genital organs:
- Prostate, seminal vesicles, and bulbourethral glands
MALE GENITOURINARY Anatomy review
_____________ – Fat in the stools, oily in appearance and floats
Steatorrhea
PENIS
Composed of three cylindric columns of erectile tissue:
*_______: at distal end of shaft
*___________ conduit for both genital and urinary systems.
*___________ or prepuce forms hood or flap over glans.
-Often removed shortly after birth by circumcision
-Smegma – cheesy type substance found under foreskin
*Glans: at distal end of shaft
*Urethra conduit for both genital and urinary systems.
*Foreskin or prepuce forms hood or flap over glans.
-Often removed shortly after birth by circumcision
-Smegma – cheesy type substance found under foreskin
Scrotum
-Loose protective ______; continuation of abdominal wall
-Scrotal wall consists of thin skin lying in folds, or ________
-____________ muscle controls size of scrotum by responding to ambient temperature.
-Septum inside separates sac into halves; in each is a testis, which produces ________
-Loose protective sac; continuation of abdominal wall
-Scrotal wall consists of thin skin lying in folds, or rugae
-Cremaster muscle controls size of scrotum by responding to ambient temperature.
-Septum inside separates sac into halves; in each is a testis, which produces sperm
Testes
-Have a solid oval shape, suspended vertically by spermatic cord
-Left testis is _______ because left spermatic cord is longer.
-Tunica vaginalis: double-layered membrane covers each testis and separates it from scrotal wall
-Have a solid oval shape, suspended vertically by spermatic cord
-Left testis is lower because left spermatic cord is longer.
-Tunica vaginalis: double-layered membrane covers each testis and separates it from scrotal wall
Transillumination – ____ glow
red
______________
-Lymphatics of penis and scrotal surface drain into inguinal lymph nodes
-Lymphatics of testes drain into abdomen.
-Abdominal lymph nodes are not accessible to clinical examination
LYMPHATICS
INGUINAL AREA OR GROIN
-Juncture of lower abdominal wall and thigh
-Potential site for ________ development
-Borders are the anterior superior iliac spine and symphysis pubis.
-Between these landmarks lies inguinal ligament.
-Inguinal canal is ___ - ___ cm long in adult.
-Juncture of lower abdominal wall and thigh
-Potential site for hernia development
-Borders are the anterior superior iliac spine and symphysis pubis.
-Between these landmarks lies inguinal ligament.
-Inguinal canal is 4 to 6 cm long in adult.
DEVELOPMENTAL COMPETENCE: GENDER IDENTITY
-Do not assume sexual orientation or gender identity by _________.
-Be aware of definition of “sexual minority.”
-Self-identify as gay, lesbian, bisexual, and transgender
-Provide accepting attitude while providing factual information that is confidential in nature.
-Identify and provide supportive resources.
-Do not assume sexual orientation or gender identity by appearance.
-Be aware of definition of “sexual minority.”
-Self-identify as gay, lesbian, bisexual, and transgender
-Provide accepting attitude while providing factual information that is confidential in nature.
-Identify and provide supportive resources.
CULTURE VARIATIONS: _____________
During pregnancy or immediate neonatal period, parents may ask whether or not to circumcise male infant.
- Religious and cultural as well as medical indications
- Circumcision versus non-circumcised patients
CIRCUMCISION
_____________ DATA
-Frequency, urgency, and nocturia
-Dysuria
-Hesitancy and straining
-Past genitourinary history
-Penis—pain, lesion, discharge
-Scrotum—self-care behaviors, lump
-Sexual activity and contraceptive use
-Sexually transmitted infection (STI) contact
SUBJECTIVE
SEXUALLY TRANSMITTED INFECTION (STI)
- Any sexual contact with a partner having an STI, such as gonorrhea, herpes, AIDS, chlamydia,
venereal warts, or syphilis?
-When was this contact? Did you get the disease?
-How was it treated? Were there any complications?
-Do you use condoms to help prevent STIs?
-Do you have any questions or concerns about any of these diseases?
- Any sexual contact with a partner having an STI, such as gonorrhea, herpes, AIDS, chlamydia,
venereal warts, or syphilis?
-When was this contact? Did you get the disease?
-How was it treated? Were there any complications?
-Do you use condoms to help prevent STIs?
-Do you have any questions or concerns about any of these diseases?
SELF-CARE: TESTICULAR SELF-EXAMINATION (TSE)
Encourage self-care by teaching every male from ____ years old through adulthood how to examine his own testicles.
Early detection of cancer enhanced if male is familiar with his normal consistency.
Points to include during health teaching are:
-T—
-S—
-E—
Testicular Torsion – emergency situation
Cancer – enlarged testicle or painless lump
Encourage self-care by teaching every male from 13 years old through adulthood how to examine his own testicles.
Early detection of cancer enhanced if male is familiar with his normal consistency.
Points to include during health teaching are:
-T—timing, once a month
-S—shower, warm water relaxes scrotal sac
-E—examine, check for, and report changes immediately
Testicular Torsion – emergency situation
Cancer – enlarged testicle or painless lump
ABNORMAL FINDINGS: PENIS
_____________ – opening of the penis is on the underside rather than tip
_____________ – opening of the penis is on the top aspect of penis rather than tip
Hypospadias – opening of the penis is on the underside rather than tip
Epispadias – opening of the penis is on the top aspect of penis rather than tip
ABNORMAL FINDINGS: PENIS
_____________ – painful erection lasting for hours, not related to sexual arousal
______________ – narrowing of the foreskin, inability to retract
Priapism – painful erection lasting for hours, not related to sexual arousal
Phimosis – narrowing of the foreskin, inability to retract
ABNORMAL FINDINGS: PENIS
_______________ – only affects uncircumcised males, inability to pull foreskin forward, results in swollen and stuck – leads to no blood flow to penis tip
Paraphimosis – only affects uncircumcised males, inability to pull foreskin forward, results in swollen and stuck – leads to no blood flow to penis tip
_____________ FINDINGS: SCROTUM
-Absent testis, cryptorchidism – failure to descend
-Testicular torsion
-Epididymitis – inflammation of the tube that carries sperm
- Testicular tumor
- Orchitis - inflammation of the testes
-Scrotal edema
ABNORMAL
FEMALE GENITOURINARY SYSTEM: EXTERNAL STRUCTURES REVIEW
-Vulva, or pudendum
-Mons pubis
-Labia majora
- Labia minora
- Frenulum or fourchette
-Clitoris
-Vestibule
-Urethral meatus
-Skene’s glands
-Vaginal orifice
-Hymen
-Bartholin’s glands
-Vulva, or pudendum
-Mons pubis
-Labia majora
- Labia minora
- Frenulum or fourchette
-Clitoris
-Vestibule
-Urethral meatus
-Skene’s glands
-Vaginal orifice
-Hymen
-Bartholin’s glands
FEMALE GENITOURINARY SYSTEM: INTERNAL STRUCTURES - REVIEW
-Vagina
-Cervix
-Squamocolumnar junction
-Anterior fornix
-Posterior fornix
-Rectouterine pouch, or cul-de-sac of Douglas
-Uterus
-Fallopian tubes
-Vagina
-Cervix
-Squamocolumnar junction
-Anterior fornix
-Posterior fornix
-Rectouterine pouch, or cul-de-sac of Douglas
-Uterus
-Fallopian tubes
DEVELOPMENTAL COMPETENCE
-Lesbian, bisexual and transgendered patients
-Access to care
-Myths and misconceptions - Education
-Risk for cancer
-Cervical screening guidelines (pap smear)
-Stress incontinence – dribble of urination with coughing, laughing, exercise (especially after vaginal births)
-Lesbian, bisexual and transgendered patients
-Access to care
-Myths and misconceptions - Education
-Risk for cancer
-Cervical screening guidelines (pap smear)
-Stress incontinence – dribble of urination with coughing, laughing, exercise (especially after vaginal births)
____________ DATA
-Menstrual history
-Obstetric history
-Menopause
- Acute pelvic pain
-Urinary symptoms
-Vaginal discharge
-Past history
-Sexual activity
-Contraceptive use
-Sexually transmitted infection (STI) contact
SUBJECTIVE
EXTERNAL GENITALIA ____________
-Pediculosis pubis (crab lice)
-Herpes simplex virus—type 2 (herpes genitalis)
-Syphilitic chancre
-Red rash—contact dermatitis
-HPV warts
-Urethritis
-UTI
ABNORMALITIES
ABNORMALITIES: INTERNAL
Pelvic musculature
-Cystocele – __________ prolapse
-Rectocele – __________ prolapse
-Uterine prolapse
Pelvic musculature
-Cystocele – bladder prolapse
-Rectocele – rectum prolapse
-Uterine prolapse
_____________ : INTERNAL
Cervix
-Bluish cervix—cyanosis
-Erosion
-HPV (condylomata)
-Polyp
- Cervical cancer
ABNORMALITIES
MENOPAUSE
-Reproductive tract changes occur naturally with increased age
-_________ related – decreased
-Age range from _________
-Loss of cardiac protective effect of estrogen
-Uterine and ovarian atrophy
-Perimenopause – changes in sleep patterns, hot flashes, night sweats, headaches, palpitations
-Reproductive tract changes occur naturally with increased age
-Estrogen related – decreased
-Age range from 45 to 55
-Loss of cardiac protective effect of estrogen
-Uterine and ovarian atrophy
-Perimenopause – changes in sleep patterns, hot flashes, night sweats, headaches, palpitations
ABNORMAL FINDINGS
________________________ Disease – painful inflammation of uterus and pelvic walls
Pelvic Inflammatory Disease – painful inflammation of uterus and pelvic walls
ABNORMAL FINDINGS
_______________ – masses, small firm nodules, tender with palpation
Endometriosis – masses, small firm nodules, tender with palpation
ABNORMAL FINDINGS
____________________ – asymptomatic, bloating, mild discomfort, excessive bleeding, back ache
Uterine fibroids – asymptomatic, bloating, mild discomfort, excessive bleeding, back ache
ABNORMAL FINDINGS
________ Pregnancy – sharp, stabbing pelvic pain, spotting, positive pregnancy test
Ectopic Pregnancy – sharp, stabbing pelvic pain, spotting, positive pregnancy test
NURSING CONSIDERATIONS
___________ Use –
- Itching burning – subjective data
-Changes in normal flora with antibiotic use
[Finish your course; take probiotic for diarrhea]
Antibiotic
NURSING CONSIDERATIONS
_____________ use –
-Protection, frequency, education of STI
-Risk factors: smoking
Infertility –
- Classified – 1 year of unprotected intercourse prior to seeking medical attention
___________
-Yeast infection
-White discharge, curdlike
Contraception use –
-Protection, frequency, education of STI
-Risk factors: smoking
Infertility –
- Classified – 1 year of unprotected intercourse prior to seeking medical attention
Candidiasis
-Yeast infection
-White discharge, curdlike
Med administration - SAFETY
- If you don’t know - don’t do!!!
- Use your medication administration text for ALL meds
- ALWAYS 3 checks!
- Refuse
- Expiration date
10 rights
- Right person [bracelet, name, DOB]
- Right med
- Right dose
- Right time
- Right route
- Right documentation
- Right reason
- Right response
NURSING KNOWLEDGE BASE
-Safe administration is imperative.
-Nursing process provides a framework for medication administration.
-Clinical calculations must be handled without _______.
-Conversions within and between systems
-Dose calculations
-Pediatric calculations require special caution.
-Safe administration is imperative.
-Nursing process provides a framework for medication administration.
-Clinical calculations must be handled without error.
-Conversions within and between systems
-Dose calculations
-Pediatric calculations require special caution.
MEDICATION ERRORS
-________ all medication errors.
-Patient ________ is top priority when an error occurs.
-____________ is required.
-The nurse is responsible for preparing a written occurrence or incident report: an accurate, factual description of what occurred and what was done.
-Nurses play an essential role in medication reconciliation
-Report all medication errors.
-Patient safety is top priority when an error occurs.
-Documentation is required.
-The nurse is responsible for preparing a written occurrence or incident report: an accurate, factual description of what occurred and what was done.
-Nurses play an essential role in medication reconciliation
ROUNDING
Always round to the _____ place (but use common sense)
Always round to the tenth place (but use common sense)
_______: Time it takes for a medication to produce a response
Onset: Time it takes for a medication to produce a response
________: Minimum blood serum concentration before next scheduled dose
Trough: Minimum blood serum concentration before next scheduled dose
_________: Point at which blood serum concentration is reached and maintained
Plateau: Point at which blood serum concentration is reached and maintained
______ : Time at which a medication reaches its highest effective concentration
Peak
__________ : Time medication takes to produce greatest result
Duration
__________________: Time for serum medication concentration to be halved
Biological half-life
ROUTES OF ADMINISTRATION
[4]
Enteral [Oral, buccal, rectal]
Parenteral [IV, IM..]
Topical [skin, eyes, ears, nose]
Inhalation [mouth, nose]
Oxygen is needed to sustain life.
Blood is oxygenated through ventilation, perfusion, and transport of respiratory gases.
Neural and chemical regulators control the rate and depth of ______________.
Oxygen is needed to sustain life.
Blood is oxygenated through ventilation, perfusion, and transport of respiratory gases.
Neural and chemical regulators control the rate and depth of respiration.
Myocardial pump
Two atria and ventricles
A healthy heart stretches in proportion to the ________________________ (Starling’s Law)
Myocardial pump
Two atria and ventricles
A healthy heart stretches in proportion to the strength of contraction (Starling’s Law)
Myocardial blood flow
______________ through four valves
S1: mitral and tricuspid
S2: aortic and pulmonic
Unidirectional through four valves
S1: mitral and tricuspid
S2: aortic and pulmonic
Coronary artery circulation
Coronary arteries supply the ____________ with nutrients and remove wastes
myocardium
___________ circulation
Arteries and veins deliver nutrients and oxygen and remove waste products
Systematic
_________________
Amount of blood ejected from the left ventricle each minute
Cardiac Output
__________
End diastolic volume
Preload
_________________
Amount of blood ejected from the left ventricle with each contraction
Stroke Volume
____________
Resistance to left ventricular ejection
Afterload
___________ nervous system
Increases the rate of impulse generation and impulse transmission and innervates
all parts of atria and ventricle
Sympathetic
_____________ nervous system
Influences the rate of impulse generation and speed of conduction pathways
Autonomic
______________ system
Decreases the rate and innervates atria, ventricles, sinoatrial and atrioventricular nodes
Parasympathetic
___________ system
Originates with the SA node or pacemaker, transmitted to the AV node, bundle of his and
Purkinje fibers
Conduction
____________
The process of moving gases into and out of the lungs
Ventilation
________________________
An active process stimulated by chemical receptors in the aorta and a passive process for
expiration
Inspiration/expiration
____________ circulation
Moves blood to and from the alveolar capillary membranes for gas exchange
Pulmonary
____________
Exchange of respiratory gases in the alveoli and capillaries
Diffusion
_________ transport
Lungs and cardiovascular system
Oxygen
_______________ transport
Diffuses into red blood cells and is hydrated into carbonic acid
Carbon dioxide
Factors affecting _____________
Physiological factors
◦ Decreased oxygen-carrying capacity
◦ Hypovolemia
◦ Decreased inspired oxygen
◦ Increased metabolic rate
Conditions affecting chest wall movement
◦ Pregnancy
◦ Obesity
◦ Musculoskeletal abnormalities
◦ Trauma
◦ Neuromuscular disease
◦ CNS alterations
◦ Chronic lung disease
oxygenation
Disturbances in conduction
Caused by electrical impulses that do not originate from the ___________ (dysrhythmias)
SA node
__________ cardiac output
Insufficient volume is ejected into the systemic and pulmonary circulation
Altered
Impaired __________ function
Is acquired or congenital disorder of a cardiac valve by stenosis or regurgitation
valvular
Myocardial __________
Coronary artery flow to the myocardium insufficient to meet myocardial oxygen demands
ischemia
______________
Ventilation in excess of that required to eliminate carbon dioxide produced by cellular metabolism
Hyperventilation
________________
Alveolar ventilation inadequate to meet the body’s oxygen demand or to eliminate sufficient carbon dioxide
Hypoventilation
_________
Inadequate tissue oxygenation at the cellular level
Hypoxia
___________
Blue discoloration of the skin and mucous membranes
Cyanosis
_____________
◦ Rapid respirations
____________
◦ Abnormally slow respiratory rate
_________
◦ Absence of breathing
tachypnea
◦ Rapid respirations
Bradypnea
◦ Abnormally slow respiratory rate
Apnea
◦ Absence of breathing
___________
◦ Sitting upright or standing to breathe easier
_________
◦ Difficulty breathing or shortness of breath (SOB)
Orthopnea
◦ Sitting upright or standing to breathe easier
Dyspnea
◦ Difficulty breathing or shortness of breath (SOB)
____________ breathing
◦ DEEP, LABORED, rapid respirations
_____________ respirations
◦ Rhythmic waxing and waning of respirations with periods of apnea
______________ respirations
◦ Shallow breaths interrupted by apnea
Kussmaul breathing
◦ DEEP, LABORED, rapid respirations
Cheyne-Stokes respirations
◦ Rhythmic waxing and waning of respirations with periods of apnea
Biot’s (cluster) respirations
◦ Shallow breaths interrupted by apnea
____________
◦ Decreased oxygen levels in the blood
___________
◦ Insufficient oxygen anywhere in the body (e.g. tissues)
____________
◦ Bluish discoloration of the skin, nail beds, and mucous membranes
Hypoxemia
◦ Decreased oxygen levels in the blood
Hypoxia
◦ Insufficient oxygen anywhere in the body (e.g. tissues)
Cyanosis
◦ Bluish discoloration of the skin, nail beds, and mucous membranes
Nursing measures to promote _____________ function
-Encouraging deep breathing & coughing and incentive spirometer
-Encourage ambulation
-Promote comfort
-Hydration
-Medications - E.g. bronchodilators
-Positioning for maximum chest expansion
respiratory
__________ management
-Airway management
-Mobilization of pulmonary secretions
-Humidification
-Nebulization
-Chest physiotherapy
Dyspnea
_____________
◦ A catheter placed through the thorax to remove air and fluids from the pleural space or to prevent air from reentering or to reestablish intrapleura and intrapulmonic pressures
Chest tubes
____________ airway
◦ Short-term use to ventilate, relieve upper airway obstruction, protect against aspiration, clear
secretions
Endotracheal
Oral airway
◦ Prevents obstruction of the trachea by displacement of the tongue into the ____________
oropharynx
Tracheostomy
◦ Long-term assistance, surgical incision made into ________
trachea
___________
Oropharyngeal and nasopharyngeal
◦ Used when the client can cough effectively but is not able to clear secretions
Orotracheal and nasotracheal
◦ Used when the client is unable to manage secretions
Tracheal
◦ Used with an artificial airway
Suctioning
To safely and accurately administer medications you need knowledge related to:
◦ Pharmacology
◦ Pharmacokinetics
◦ Life sciences
◦ Human anatomy
◦ Mathematics
◦ Pharmacology
◦ Pharmacokinetics
◦ Life sciences
◦ Human anatomy
◦ Mathematics
Factors Affecting Med _______
-Developmental
-Gender
-Culture, Ethnic, Genetic Factors
-Diet
-Environment
-Psychologic Factors
-Illness & Disease
-Time of Administration
Action
Pharmacokinetics
The study of how medications:
◦ ______ the body
◦ Are absorbed and ___________into cells, tissues, or organs
◦ Alter physiological ____________
The study of how medications:
◦ Enter the body
◦ Are absorbed and distributed into cells, tissues, or organs
◦ Alter physiological functions
____________
The passage of medication molecules into the blood from the site of administration
Absorption
Factors that influence ___________:
◦ Route of administration
◦ Ability to dissolve
◦ Blood flow to site of administration
◦ Body surface area
◦ Lipid solubility of medication
absorption
After absorption, ____________ occurs within the body to tissues, organs, and to specific sites of action.
Distribution depends on:
◦ Circulation
◦ Membrane permeability
◦ Protein binding
After absorption, distribution occurs within the body to tissues, organs, and to specific sites of action.
Distribution depends on:
◦ Circulation
◦ Membrane permeability
◦ Protein binding
Metabolism
Medications are metabolized into a less potent or an inactive form.
Biotransformation occurs under the influence of enzymes that detoxify, degrade, and remove active chemicals.
Most biotransformation occurs in the _______.
liver
Medications are __________ through:
◦ Kidney
◦ Liver
◦ Bowel
◦ Lungs
◦ Exocrine glands
excreted
Medication ______________
Occur when one medication modifies the action of another
A synergistic effect occurs when the combined effect of two medications is greater than the effect of the medications given separately.
Interactions
Common Reasons for Med _________
-Incomplete patient information
-Miscommunication
-Inappropriate labeling
-Noise, interruptions
Errors
__________ __________
Not a part of the patient’s medical record
◦ Client info
◦ Date, time, place of incident
◦ Facts of incident (avoid conclusions or blame)
◦ Client’s account of incident
◦ Identify witnesses
◦ Identify medication/equipment
Incident Reports
Lucy Lu is a 77-year-old Asian patient who is admitted to the surgical unit after a colon resection this morning. Mrs. Lu has been in the United States for 30 years and speaks fluent English. She still values her Asian heritage. Her health has been deteriorating lately because of chronic bronchitis and stable angina. She smokes 1½ packs of cigarettes per day. She is 10 pounds underweight for her height. Jim Stone is a 24-year-old senior nursing student and has been assigned to care for Mrs. Lu postoperatively. He takes her vital signs upon return from the postanesthesia unit: blood pressure is 110/58 mm Hg, temperature 99.8° F orally, pulse 112 beats/min, and respirations 26 breaths/min. He asks her to rate her pain, and she states that it is a 6 on a scale of 1 to 10. She has a patient-controlled analgesia pump. Her surgical dressing is dry and intact.
- Jim decides to check with the primary nurse and see if he can start administering oxygen to Mrs. Lu. The nurse tells Jim that it would be good. What is the preferred method of oxygen administration for this patient?
A. Simple face mask
B. Venturi mask
C. Nasal cannula
C. Nasal cannula
- The primary nurse asks Jim to take Mrs. Lu an incentive spirometer and teach her what it is and how to use it properly. What should Jim include in his teaching plan?
Teach her proper technique for using it
Watch them demonstrate
- Mrs. Lu complains of being short of breath. Three hours after she was admitted to her room Jim assesses her temperature and it is 101.2° F orally. Jim takes her other vital signs: blood pressure is 100/70 mm Hg, pulse 112 beats/min, and respirations 30 breaths/min. Her pulse oximetry is 88%. What nursing actions should Jim initiate to treat
Jim should do a thorough respiratory assessment. He should place her in Fowler’s position, check that the oxygen is flowing through the nasal cannula, and encourage frequent coughing and deep breathing.
- Later, while Jim is listening to Mrs. Lu’s lung through the stethoscope, he hears a high- pitched musical sound. What does this indicate?
A. Mrs. Lu is wheezing.
B. Mrs. Lu has a pleural friction rub.
C. Mrs. Lu has fine crackles.
D. Mrs. Lu has course crackles.
A. Mrs. Lu is wheezing.
When preparing to administer a new medication, what would the nurse do first to ensure the patient’s safety?
A. Perform hand hygiene.
B. Compare the written order with the medication administration record (MAR).
C. Inform the patient about the medication.
D. Review appropriate nursing considerations.
A. Perform hand hygiene.
What is the most important step the nurse can take to ensure that the patient is getting the correct medication?
A. Assess the patient’s ability to swallow oral medications without difficulty.
B. Question the patient about his or her experience with this or similar medications.
C. Compare the medication label with the MAR three times.
D. Evaluate the patient’s understanding of the safety issues related to the specific drug.
C. Compare the medication label with the MAR three times.
Which statement or question best illustrates the nurse’s understanding of the role of nursing assistive personnel (NAP) in medication administration?
A. “Does the patient need her pain medication?”
B. “Let me know if she complains of any nausea.”
C. “What is the quality of her pain now?”
D. “Tell her she doesn’t have an order for the drug she’s asking for.”
B. “Let me know if she complains of any nausea.”
As the nurse is administering medication to a patient, the patient states, “I’ve never seen that pill before.” What is the nurse’s most appropriate response?
A. Reassure the patient that the pharmacy sent the right medication.
B. Tell the patient that it is probably a different brand than what he takes at home and not to worry.
C. Tell the patient that you will review the physician’s order to clarify any discrepancies.
D. Tell the patient that the doctor probably ordered a new medication.
C. Tell the patient that you will review the physician’s order to clarify any discrepancies.
What is the nurse’s best response after noticing that the route of administration has been omitted from a medication order?
A. Ask which route the patient prefers.
B. Immediately notify the prescriber to request that the order be completed.
C. Refer to a current drug book to determine the most commonly prescribed route.
D. Contact the pharmacy to determine the most appropriate route for this patient.
B. Immediately notify the prescriber to request that the order be completed.
While preparing to apply a topical medication to a toddler with dermatitis, the nurse notes several open scratches and oozing lesions. What is the appropriate action?
A. Bandage the compromised skin and delay topical application until the skin is fully healed.
B. Apply the medication to the injured skin because the increased absorption offered by the break in skin integrity enhances the medication’s effect.
C. Cleanse the lesions with warm water and leave them open to dry before applying the medication.
D. Confirm with the practitioner that the medication can be applied.
D. Confirm with the practitioner that the medication can be applied.
Which is the appropriate technique for applying a transdermal patch?
A. Touch only the edges of the transdermal patch.
B. Touch only the adhesive part of the transdermal patch.
C. Apply the patch in the same general area with each application.
D. Ascertain that the protective covering is firmly in place.
A. Touch only the edges of the transdermal patch.
What should the nurse emphasize when teaching the family about the use of a transdermal patch for their child?
A. Dispose of the old patch by adhering it to a paper towel and discarding it.
B. Remove the old patch before placing the new one.
C. Use lotion on the skin to prevent irritation from the frequent patch changes.
D. Repeatedly use the same area on the patient’s body to enhance absorption.
B. Remove the old patch before placing the new one.
Which is an accurate statement about how much topical medication is required for application?
A. A thick layer is usually required.
B. Too much can negate the medication’s effectiveness.
C. Each dose should be layered over the previous dose.
D. Adverse systemic reactions are minimal if extra medication is applied.
B. Too much can negate the medication’s effectiveness.
A mother notices that the child’s rash has been getting worse since topical treatment was started and notes inflammation and edema. Which is an accurate statement?
A. Signs of inflammation should be reported to the practitioner.
B. It is normal for skin lesions to get worse before they get better.
C. There is no need to be concerned unless the patient complains of pain.
D. The topical medication should be continued unless pruritus develops.
A. Signs of inflammation should be reported to the practitioner.
The nurse is preparing to apply steroid cream to a toddler who was diagnosed with atopic dermatitis. The parent thought the child would be started on a nonsteroidal cream and questions the medication. Which is the best course of action for the nurse to take?
A. Apply the medication as ordered and ask the practitioner to talk to the parent.
B. Do not apply the medication and address the issue with the oncoming nurse.
C. Apply the medication as ordered and assure the parent the medication is correct.
D. Do not apply the medication and verify the order with the practitioner.
D. Do not apply the medication and verify the order with the practitioner.
A nurse is providing medication instructions to the family of a child being discharged. Which statement indicates understanding of the instructions?
A. “When applying the cream, you should rub the skin vigorously to ensure absorption.”
B. “When applying a powder, you should be careful to avoid inhalation of powder.”
C. “As long as the skin is clean, it is OK to apply the cream or powder to damp skin.”
D. “Absorption is improved if the new dose is applied over the previous dose.”
B. “When applying a powder, you should be careful to avoid inhalation of powder.”
The nurse is caring for a toddler with atopic dermatitis and the practitioner has prescribed a nonsteroidal cream. Which is an important teaching point when providing medication instructions to the family of the toddler?
A. Keep the medication in the freezer to prevent irritation to the skin.
B. Only apply the medication to the eyelids when the toddler is asleep.
C. Do not apply the medication to the toddler’s fingers or thumbs.
D. Apply the medication to all areas of affected skin.
C. Do not apply the medication to the toddler’s fingers or thumbs.
When teaching an adolescent about applying a topical medication cream, which is important to reinforce in the teaching?
A. Following the direction of hair growth prevents irritation of the hair follicle.
B. Following the direction of hair growth helps to ensure even distribution of medication.
C. Going against the direction of hair growth helps to prevent irritation of the hair follicle.
D. Going against the direction of hair growth helps to ensure even distribution of medication.
A. Following the direction of hair growth prevents irritation of the hair follicle.
The nurse is preparing to access a patient’s implanted port. Which is important to remember when applying the anesthetic cream for this purpose?
A. The anesthetic cream must be applied 2 hours before the procedure.
B. The anesthetic cream is not recommended for pediatric patients under 1 year old.
C. The anesthetic cream should be covered with a gauze dressing.
D. The anesthetic cream should be covered with a transparent dressing.
D. The anesthetic cream should be covered with a transparent dressing.
Before administering a liquid medication to an infant, along with the patient’s name which other identifier should the nurse use?
A. Medical record number
B. Room number
C. Admission date
D. Family members’ names
A. Medical record number
A school-age patient is receiving enteric-coated aspirin once a day. Which is the best method of administering this oral medication?
A. Dissolve the tablet in orange juice.
B. Crush the tablet and mix it in pudding.
C. Have the patient swallow the whole tablet.
D. Mix the tablet in food during mealtime.
C. Have the patient swallow the whole tablet.
Fifteen minutes after the nurse administers an oral antibiotic to a patient, the patient vomits. Which action should the nurse take?
A. Wait to give any further medications until the next dose is due.
B. Immediately readminister the current dose of the medication.
C. Administer half of the medication dose after 30 minutes.
D. Consult with the practitioner about readministration of the dose.
D. Consult with the practitioner about readministration of the dose.
The nurse is administering amoxicillin 250 mg/5 ml concentration. The patient is to receive 125 mg. Which volume should the nurse administer?
A. 5 ml
B. 2.5 ml
C. 1.25 ml
D. 3 ml
B. 2.5 ml
A patient refuses to take an oral medication. Which action should the nurse take?
A. Ask a family member to assist with medication administration.
B. Acknowledge that the patient has the right to refuse medication.
C. Hide the medication in the patient’s favorite food.
D. Wait until the patient is calm and more cooperative.
A. Ask a family member to assist with medication administration.
Which is the best way to administer oral medication to an infant using a syringe?
A. Place the syringe on the tip of the tongue for easier delivery.
B. Place the patient supine and allow the patient to hold the syringe.
C. Give the liquid medication all at one time; follow with a bottle.
D. Place the syringe along the inside of the cheek; give a little at a time.
D. Place the syringe along the inside of the cheek; give a little at a time.
A nurse is preparing to give an antibiotic to a patient when the patient’s parent states, “I think that medication was just given by the nurse on the last shift.” The nurse checks the MAR and finds it was not documented as given. Which is the best course of action for the nurse to take?
A. Give the medication as ordered since it was not documented.
B. Do not give the medication but document it as given by the other nurse.
C. Call the previous nurse and verify whether the medication had been given.
D. Tell the parent that it was not documented as given, so it can be given now.
C. Call the previous nurse and verify whether the medication had been given.
The nurse is admitting a 3-month-old patient for respiratory distress and pneumonia. The current weight on the chart is 16 kg, and the patient is due for an antibiotic medication. Which action should the nurse perform?
A. Review the MAR for all ordered medications.
B. Administer the antibiotic medication.
C. Ask the family for the patient’s most recent weight.
D. Reweigh the patient to confirm the weight
D. Reweigh the patient to confirm the weight
The nurse is preparing to give oral furosemide to a patient and notices that this current dose of medication seems cloudy and a different color than the dose given yesterday. What is the nurse’s best initial action?
A. Shake the medication thoroughly to mix it completely.
B. Administer the medication as prescribed.
C. Consult with another nurse.
D. Send the medication back to the pharmacy.
D. Send the medication back to the pharmacy.
A patient is crying and refusing to take the pain medication that was ordered. What is an appropriate next action?
A. Hold the patient down and administer the medication.
B. Discuss an alternative route with the practitioner.
C. Do not give the pain medication since the patient has refused it.
D. Ask the patient’s family to administer the medication.
B. Discuss an alternative route with the practitioner.
A patient has a prescription for a medication to be administered by pMDI. To determine whether the patient requires a spacer for the inhaler, what should the respiratory therapist assess?
A. Ability to mix medications
B. Coordination
C. Medication dosage
D. Medication schedule
B. Coordination
Which finding indicates that the patient is correctly administering the medication via pMDI?
A. The patient does not shake the canister.
B. The patient presses the canister before taking a breath.
C. The patient administers a second actuation immediately after the first.
D. The patient holds the breath for up to 10 seconds after inhalation.
D. The patient holds the breath for up to 10 seconds after inhalation.
When receiving medication through a pMDI with a spacer and mask, a young child should breathe through the mask how many times?
A. Six times
B. One time and then hold the breath for 10 seconds
C. Three times and then hold the breath for 5 seconds
D. Two times
A. Six times
When the prescribed medication is an inhaled corticosteroid, which instruction should be given to the patient?
A. Use as needed for wheezing or shortness of breath.
B. Administer the inhaled corticosteroid before the bronchodilator.
C. Rinse the mouth after administration.
D. Avoid the use of a spacer.
C. Rinse the mouth after administration.
When a bronchodilator is prescribed for a 5-year-old patient, the respiratory therapist should understand which concept?
A. A spacer is recommended.
B. The patient is too young for asthma.
C. The patient can self-administer the medication at school.
D. The patient is less susceptible to systemic effects.
A. A spacer is recommended.
A nurse is preparing to instill ophthalmic medication in a toddler. What should the nurse use as the best approach?
A. Tell the patient to open the eyes and not to blink.
B. Ask the patient to look at the ceiling and hold still.
C. Have the patient recline on a family’s member’s lap and look up.
D. Push the patient’s eyelid up toward the forehead.
C. Have the patient recline on a family’s member’s lap and look up.
A nurse is planning to administer eye drops to a school-age patient who has drainage in the eye. How should the nurse cleanse the eye?
A. Irrigate the eye with warm water.
B. Wipe the eye from the inner canthus to the outer canthus.
C. Wipe the eye from the outer canthus to the inner canthus.
D. Give the patient a warm wet washcloth and ask the patient to wipe the eyes.
B. Wipe the eye from the inner canthus to the outer canthus.
A toddler is crying and squeezing the eyes shut while the nurse is trying to instill eye drops. How should the nurse administer the medication?
A. Instill the medication in the medial corner of the eye.
B. Explain that the patient must open the eyes and stop crying.
C. Have one person hold the patient and another person open the eyelid.
D. Instill the medication in the outer canthus of the eye
A. Instill the medication in the medial corner of the eye.
A new nurse demonstrates an understanding of the teaching related to ophthalmic drop instillation by making which statement?
A. “Applying pressure to the medial corner of the eye prevents systemic absorption.”
B. “Eyes should be wiped clear of drainage from the outer canthus to the inner canthus.”
C. “Approaching the eye from the front of the patient decreases the blink reflex.”
D. “Only antiglaucoma medications can cause arrhythmias.”
A. “Applying pressure to the medial corner of the eye prevents systemic absorption.”
A nurse observes a student administering an eye ointment. Which action indicates that the student understands the correct procedure?
A. Ointment is applied on the rim of the top eyelid.
B. Ointment is applied from the inner canthus to the outer canthus.
C. Ointment is placed in the inner canthus of the eye.
D. Ointment is placed in the middle of the eye.
B. Ointment is applied from the inner canthus to the outer canthus.
A patient is to receive eye drops and ointment at the same time. Which is the correct procedure for the nurse to follow during administration?
A. Administer the ointment and wait at least 2 hours before administering the drops.
B. Administer the drops before the ointment with no waiting between preparations.
C. Administer the ointment, wait 1 to 2 minutes, and then administer the drops.
D. Administer the drops, wait 3 minutes, and then administer the ointment.
D. Administer the drops, wait 3 minutes, and then administer the ointment.
The patient states there is blurring of vision immediately after administration of eye ointment. What is the nurse’s best response?
A. “This means the ointment is working.”
B. “This means you are allergic to the medication.”
C. “This is a sign that your vision is getting worse.”
D. “This is normal and should clear in a few minutes.”
D. “This is normal and should clear in a few minutes.”
The nurse is administering antibiotic ophthalmic drops to an adolescent patient. The patient asks why a pill can’t be taken. How should the nurse respond?
A. “The doctor knows what’s best to treat your condition.”
B. “The medicine doesn’t come as a pill.”
C. “The pill would be too strong.”
D. “This is a local infection, so it’s treated locally.”
D. “This is a local infection, so it’s treated locally.”
A school-age patient becomes anxious and fearful when asked to lie down for administration of eye drops. What would be the best approach for the nurse to take?
A. Have the patient sit with the head tipped back.
B. Request a sedative to manage the patient’s anxiety and fear.
C. Have an assistant hold the patient in a supine position.
D. Request to have the medication changed to an oral route.
A. Have the patient sit with the head tipped back.
When using an ophthalmic ointment, the family member states the tip of the tube touched the patient’s cheek. How should the nurse respond?
A. Get a new tube of medication.
B. Clean the tip with a gauze pad.
C. Rinse the tip of the tube in hot water.
D. Wipe the tip of the tube with a tissue
A. Get a new tube of medication.
The nurse administers an otic medication to a 6-year-old patient. After administration, the patient states, “I taste something funny.” Which action should the nurse take first?
A. Give the patient something to drink.
B. Record what the patient said on the medication administration record.
C. Contact the practitioner immediately.
D. Ask the patient to describe the taste.
C. Contact the practitioner immediately.
The nurse is preparing to administer an otic medication to a toddler. The parent states, “This will go better if I hold my child in my lap when you put the drops in the ear.” What should the nurse ask the parent to do?
A. “Hold your child with the head resting on your shoulder.”
B. “Help restrain your child on the examination table.”
C. “Position your child side-lying in your lap.”
D. “Help to straighten the ear canal.”
A. “Hold your child with the head resting on your shoulder.”
The nurse has just administered an otic medication to an adolescent patient. The patient reports the onset of dizziness. What could be the cause of the dizziness?
A. Cerumen occluding the ear canal
B. Repeated application of pressure to the tragus
C. Keeping the patient in the recumbent position
D. Administration of an otic medication that is cold
D. Administration of an otic medication that is cold
The nurse is documenting the administration of an otic medication in an infant. Which event should be documented?
A. Resistance to positioning during ear drop instillation
B. A shrill cry when the pinna is pulled down and back
C. Voiding immediately after the ear drops are instilled
D. Sucking on a fist and pacifier while recumbent
B. A shrill cry when the pinna is pulled down and back
A nurse is preparing to administer the sixth dose of an otic medication to a patient. The nurse observes a red, swollen tragus, which is not documented in the patient’s record. Which action should the nurse take?
A. Gently straighten the patient’s ear canal.
B. Saturate a piece of cotton with the medication.
C. Withhold the medication and notify the practitioner.
D. Avoid pressing on the tragus after the medication is administered.
C. Withhold the medication and notify the practitioner.
How would the nurse manipulate a 12-month-old patient’s pinna when administering an otic medication?
A. Pull down and back.
B. Pull down and forward.
C. Pull up and back.
D. Pull up and forward.
A. Pull down and back.
When preparing to administer an otic medication to a patient, which action would the nurse take if there is cerumen occluding the outer portion of the patient’s ear canal?
A. Proceed with medication administration.
B. Perform an ear irrigation.
C. Wipe the cerumen with cotton-tipped applicator.
D. Notify the practitioner.
C. Wipe the cerumen with cotton-tipped applicator.
Which condition would the nurse expect following administration of an otic medication to a school-age patient?
A. Increased pain
B. Reported hearing loss
C. Reported popping sensation
D. Tinnitus
C. Reported popping sensation
Which action would the nurse take if the otic medication to be administered appears cloudy?
A. Request a replacement bottle.
B. Dilute the medication with 0.9% sodium chloride solution.
C. Warm the medication to room temperature.
D. Proceed with medication administration.
A. Request a replacement bottle.
When teaching how to administer an otic medication, the family member asks why it is important to avoid touching the ear canal with the dropper. Which rationale would the nurse provide?
A. Maintains pH of otic medication
B. Ensures proper administration angle
C. Avoids contamination of the dropper
D. Avoids contamination of the ear canal
C. Avoids contamination of the dropper
What would the nurse do first when preparing to begin oxygen therapy for a patient?
A. Educate the NAP about the oxygen orders.
B. Review the medical prescription for delivery method and flow rate.
C. Place a “No Smoking” sign outside of the hospital room.
D. Ensure that suction equipment is present in the room.
B. Review the medical prescription for delivery method and flow rate.
When preparing the patient’s environment for safe oxygen therapy, which intervention is a priority to minimize the patient’s risk for injury?
A. Place appropriate signage to alert staff and visitors to the presence of oxygen in the patient’s room.
B. Instruct nursing assistive personnel (NAP) to immediately correct or report safety hazards.
C. Inspect all electrical equipment in the patient’s room for the presence of safety-check tags.
D. Ensure that the patient receives the prescribed amount of oxygen via the appropriate method.
C. Inspect all electrical equipment in the patient’s room for the presence of safety-check tags.
When a patient is receiving oxygen at home, which instruction to the family would help them understand how to use the oxygen safely?
A. Increase the oxygen level as needed for the patient’s comfort.
B. Store extra oxygen cylinders horizontally.
C. Place a “No Smoking” sign at the entrance to the house.
D. Keep oxygen 5 feet (about 1.5 meters) away from anything that could generate a spark.
C. Place a “No Smoking” sign at the entrance to the house.
What would the nurse do first when preparing to educate the patient about safe administration of oxygen therapy at home?
A. Evaluate the patient’s understanding of the combustible nature of oxygen.
B. Arrange for a capable family member to be present during the initial discussion.
C. Collect written information to present to the patient as supplemental instructional materials.
D. Assess the patient’s emotional readiness and physical ability to provide autonomous care.
D. Assess the patient’s emotional readiness and physical ability to provide autonomous care.
Which statement by the patient would indicate that he or she understands the safe use of oxygen?
A. “The nurse told me that my oxygen saturation must be maintained at 85% or above.”
B. “I know that oxygen is a medication I can adjust whenever I need to.”
C. “I’ll alert the nurse immediately if I have any increased difficulty breathing.”
D. “I often experience difficulty breathing for no apparent reason, but that is expected.”
C. “I’ll alert the nurse immediately if I have any increased difficulty breathing.”
An admitted patient requires supplemental oxygen to treat respiratory distress. The authorized practitioner orders an FIO2 of 35%. What is the most appropriate delivery device for this patient?
A. Partial rebreather mask
B. Venturi mask
C. Non-rebreather mask
D. Simple face mask
B. Venturi mask
An infant requires oxygen therapy at 28% FIO2. What is the appropriate setup and flow rate?
A. Oxygen hood at greater than 7 L/min
B. Nasal cannula at 5 L/min
C. Simple face mask at 4 L/min
D. Partial rebreather mask at 4 L/min
A. Oxygen hood at greater than 7 L/min
A patient with a history of chronic obstructive pulmonary disease is admitted for cardiac monitoring. Which oxygen delivery device should the respiratory therapist anticipate using?
A. Simple face mask
B. Non-rebreather mask
C. Venturi mask
D. Nasal cannula
D. Nasal cannula
What is an early sign of hypoxia?
A. Cyanosis
B. Nail bed clubbing
C. Apprehension
D. Decreased blood pressure
C. Apprehension
During the afternoon assessment, the respiratory therapist determines that the patient has become increasingly confused and is complaining of a severe headache. The respiratory therapist realizes that the patient is breathing at a rate of 40 breaths per minute and is extremely anxious. Further assessment reveals that the patient’s oxygen saturation is 95%. What is the most appropriate intervention?
A. Administer a breathing treatment.
B. Notify the authorized practitioner of the patient’s potential carbon dioxide retention.
C. Place the head of the patient’s bed into a high-Fowler position.
D. Notify the authorized practitioner that the patient is hypoxic.
B. Notify the authorized practitioner of the patient’s potential carbon dioxide retention.
Left main ____________________ is the main supplier of blood to the left ventricle
coronary artery
Volume coming back to heart is called
preload
The resistance that the left ventricle pushes against to get blood out to the body is called
afterload
___ wave reflects the the electrical depolarization of the atria
SA node > atria
P
_____ wave represents depolarization of ventricles
QRS
____ wave represents repolarization of the ventricular myocardium
T
Hypoxia VS Cyanosis
Hypoxia
Definition: Not enough oxygen in the tissues.
First Clue: Shortness of breath, confusion, or rapid heart rate.
Cyanosis
Definition: Bluish color of the skin and lips due to low oxygen in the blood.
Relation to Hypoxia: Cyanosis is a visible, later sign that hypoxia is severe.
Most heart attack research was done on white males;
Females may present differently with:
Epigastric/ GI distress, significant fatigue
___________ will help mobilize secretions to get out of the chest to avoid pneumonia
Coughing
What position makes it easiest for patients with chronic lung disease to breathe?
Tripod position
What steps could the nurse take to prepare the environment for a genitalia examination?
Cool the speculum
Close the door and draw the privacy curtain
Ask all chaperones to leave the room to ensure patient privacy
Turn the temperature up because the patient will be exposed
Close the door and draw the privacy curtain
How would the nurse test pelvic muscle tone of the female patient during an external genital examination?
Having the patient bear down
Palpating over the abdominal region
Palpating over the patient’s suprapubic region
Having patient squeeze vaginal opening around the examiner’s finger
Having patient squeeze vaginal opening around the examiner’s finger
How should the speculum be inserted into the vaginal opening for a female internal examination?
Insert along a straight path.
Insert along a slight upward path.
Insert along a slight downward path.
Insert along a steep downward path.
Insert along a slight downward path.
After the patient relaxes her internal muscles and buttocks, what is the next step of the vaginal examination to prepare for speculum insertion?
Warm the speculum
Separate the labia minora with fingers
Manipulate the speculum to expose the cervix
Insert finger into vagina and apply pressure downward
Separate the labia minora with fingers
Which technique assesses anal sphincter tone during a rectovaginal examination?
Ask patient about bowel habits
Gently palpate around Anus with fingers
Have Patient tighten and relax Anal sphincter naturally
Have patient tighten and relax anal sphincter around the examiner’s finger
Have patient tighten and relax anal sphincter around the examiner’s finger
During a newborn genital examination, what elements of the labia minora are assessed by the nurse?
Color
Presence of edema
Presence of atrophy
Presence of malformations
Presence of edema
Which findings would the nurse consider normal on palpation of the perineum of a woman who has borne five children?
Thin tissue
Inflammation
Tenderness
Smooth tissue
Thin tissue
When assessing the Bartholin glands, which finding is considered normal?
Edema
Non-tender mass
They are nonpalpable
Presence of odor-free discharge
They are nonpalpable
Which finding is considered normal when palpating the cervix of a non-pregnant patient?
Firm
Soft
Offset
Pear-shaped
Firm
When palpating the uterus, which characteristics would be considered normal?
Pink in color
Tenderness
Limited motility
Motility in the anteroposterior plane
Motility in the anteroposterior plane
Which female genitalia finding is normal in newborns?
Thinning cervix
Protruding hymen
Edema of Skene glands
Urinary meatus within the vaginal introitus
Protruding hymen
Which characteristics of the newborn hymen are considered normal?
Absent
Imperforate
Opening of 2 cm in diameter
Opening of 0.5 cm in diameter
Opening of 0.5 cm in diameter
When palpating the uterus, which findings would be considered abnormal in a nonpregnant woman?
Firm walls
Smooth walls
3.0 cm in length
Rounded contour
3.0 cm in length
The uterus is expected to be 5.5-8.0 cm in length; 3.0 cm would be considered abnormal.
For which patient would providing a weekly medication organizer be an appropriate intervention?
Forgetful patient
Near-sighted patient
Wheelchair-bound patient
Patient whose first language is not English
Forgetful patient
The nurse instructs a patient for whom a transdermal patch has been prescribed to rotate sites of application. For which hypothesis is this instruction an intervention?
Risk for Cross-Infection
Risk for allergic reaction
Risk for impaired tissue integrity
Risk for Adverse Medication Interaction
Risk for impaired tissue integrity
A newly admitted patient tells the nurse “I can’t swallow medicines; they all need to be crushed.” Based on this statement, the nurse would contact the health care provider about a prescription for which form of medication?
Troche
Sublingual medication
Enteric-coated tablet
Capsule
Enteric-coated tablet
Enteric-coated tablets are coated to prevent dissolution in the acidic environment of the stomach. They dissolve in the intestine, thereby preventing the drug from irritating the stomach lining or preventing the drug from being digested by gastric enzymes. If the medication is crushed, the protective coating is destroyed.
A patient has a prescription for 2.5 mL of a liquid medication to be administered orally. In accordance with best practice guidelines, which device would the nurse use when preparing this medication?
Oral syringe calibrated in metric only
Measuring spoon calibrated in metric
Syringe calibrated in both metric and household units
Medicine cup calibrated in both metric and household units
Oral syringe calibrated in metric only
When administering an otic medication to an adult, which action would the nurse take to facilitate the spread of the medication to the entire ear canal?
Press on the tragus.
Pull up and back on the pinna.
Ask the patient to hold their breath.
Tell the patient to tilt their head forward.
Pull up and back on the pinna.
The nurse directs a patient who needs two puffs of medication from a metered-dose inhaler to wait how many minutes between puff one and puff two? Record your answer as a whole number.
min
1 min
Which characteristic is an advantage of a transdermal patch?
No adverse systemic effects
No preparation needed for use
Almost-immediate onset of action
Long-term continuous administration
Long-term continuous administration
Which action would the nurse take as part of the procedure for administering a vaginal suppository?
Place the patient in a high Fowler’s position.
Lubricate the applicator with a water-soluble gel.
Warm the suppository to room temperature before administration.
Instruct the patient to remain in a side-lying position for 10 minutes.
Lubricate the applicator with a water-soluble gel.
A patient preparing to insert her prescribed vaginal suppository is reviewing the procedure with the nurse. Which statement made by the patient alerts the nurse that further explanation is required?
“I need to urinate before I put the suppository in.”
“I’ll watch television for the half hour I have to lie still after I put this in.”
“I have a tampon ready to insert after the suppository to catch any drips.”
“I need to put the suppository in along the back wall of my vagina about a finger length.”
“I have a tampon ready to insert after the suppository to catch any drips.”
A diagram of which injection site would be most helpful when teaching a patient how to use of an EpiPen?
Deltoid
Dorsogluteal muscle
Ventrogluteal muscle
Vastus lateralis
Vastus lateralis
For how many minutes would a nurse monitor a patient for an immediate allergic reaction following medication administration? Record your answer as two whole numbers separated by a hyphen. __ minutes
20-30 min
An immediate allergic reaction occurs within 20 to 30 minutes after administration.
Which data would be obtained by the nurse preparing to perform a cough assessment on a patient with a respiratory disorder?
Sputum characteristics
Pulse oximetry
Capillary refill
Respiratory rate
Sputum characteristics
The complete blood count results for a patient with chronic obstructive pulmonary disease (COPD) show an elevated red blood cell count. Which clinical manifestation would the nurse associate with this finding?
Hyperlipidemia
Hypoxia
Infection
Hemodilution
Hypoxia
Long-term hypoxia results in stimulation of red blood cell production for increased oxygen-carrying capacity.
When assessing a patient with low hemoglobin, the nurse looks for symptoms of fluid retention, understanding that the patient may have which condition?
Hemodilution
Hypoxia
Infection
Hyperlipidemia
Hemodilution
Hemodilution occurs in cardiac failure patients when excess fluid is retained.
Which rationale explains why a patient with a recent myocardial infarction would have a basic metabolic panel drawn to monitor serum electrolytes?
Elevated levels increase the risk for atherosclerosis.
Abnormal levels can cause cardiac arrhythmias.
Reduced levels can result in decreased oxygen levels.
Normal levels suggest healing of muscle tissue.
Abnormal levels can cause cardiac arrhythmias.
Which major subjective symptom is associated with both chronic obstructive pulmonary disease (COPD) and pneumonia?
Dyspnea
Elevated arterial carbon dioxide level
Irregular heart rhythm
Chest pain
Dyspnea
Which postoperative complication can be prevented by regularly performing deep-breathing exercises?
Thrombus formation
Bronchospasm
Alveolar enlargement
Atelectasis
Atelectasis
Patients who have had abdominal or chest surgery are especially at risk for atelectasis because postsurgical pain causes them to breathe more shallowly, limiting the flow of air required to clear the airways.
cardiac enzymes are released when ________ of cardiac cells occurs.
death
Which course of action would the nurse initiate on discovering a recently discharged patient refuses to use a CPAP machine because of claustrophobia?
Teaching deep breathing exercises
Seeking readmission to the hospital for oxygen therapy
Suggesting counseling to overcome the unreasonable fear
Requesting a prescription for a high-flow nasal cannula
Requesting a prescription for a high-flow nasal cannula
For patients who are nonadherent, high-flow nasal cannulas are used to mimic positive airway pressure while promoting patient comfort by reducing the feeling of claustrophobia.
Which explanation would the nurse give when preparing a patient for placement of an oropharyngeal tube?
“There will be a small incision made to help you breathe”
“This will help facilitate clearing secretions from your mouth and throat.”
“This will remain in place only as long as you are under general anesthesia.”
“Your nares will be lubricated to ease insertion.”
“This will help facilitate clearing secretions from your mouth and throat.”
An oropharyngeal tube is used to help with suctioning secretions to keep the airway clear.
Which alteration resulting from improper tube placement and found by palpating the skin around the stoma site during tracheostomy care would prompt the nurse to call the primary health care provider?
Excessive secretions
Reddened incision
Respiratory infection
Subcutaneous emphysema
Subcutaneous emphysema
Subcutaneous emphysema indicates air trapped in the skin surrounding the stoma from improper tube placement, and the nurse would notify the primary health care provider.
Which information would the nurse give to a postsurgical patient who states that performing incentive spirometry is uncomfortable and wants to know why it is necessary?
It facilitates gravity drainage of secretions.
It prevents atelectasis.
It removes mucus from the respiratory tract.
It drains fluid from the pleural space.
It prevents atelectasis.
Incentive spirometry is an effective means of expanding the lungs, thereby reducing the risk for atelectasis and pneumonia.
Which type of chest physiotherapy involves percussion?
Aerobic exercise
Postural drainage
Incentive spirometry
Coughing/deep breathing
Postural drainage
Postural drainage involves techniques such as percussion and vibration while a patient is placed in a series of specific positions that facilitate gravity drainage from a lung area.
The nurse would instruct a patient to hold each breath for
seconds when explaining coughing/deep breathing chest physiotherapy?
3-5
When coughing/deep breathing, the nurse would instruct the patient to take a series of deep breaths, holding each breath for 3 to 5 seconds, and then releasing the breath with a series of coughs.
Which route would the nurse use when administering medication to a patient with non–life-threatening lower airway inflammation?
Subcutaneous
Nasal
Intravenous
Inhalation
Inhalation
The preferred route for administering pulmonary medications for non–life-threatening airway inflammation is inhalation. It is routinely provided by respiratory therapists with a prescription from the patient’s primary health care provide
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) and administers a bronchodilator. Which primary action would the nurse conclude is relieving the wheezing?
Decreases inflammation
Increases the diameter of the bronchi
Decreases the thickness of secretions
Protects against disease
Increases the diameter of the bronchi
Bronchodilators increase the diameter of the bronchi and bronchioles.
Which explanation would the nurse give to a patient experiencing an abnormally rapid heartbeat who asks about the purpose of an antiarrhythmic medication?
It promotes increased urine flow.
Low doses prevent blood clot formation.
It is needed to reduce high blood pressure.
It suppresses abnormal rhythms of the heart.
It suppresses abnormal rhythms of the heart.
Antiarrhythmics treat or prevent tachyarrhythmias (heart arrhythmias with a rapid rate) including ventricular tachycardia and atrial fibrillation.
Which benefit is important for the nurse to include when educating a patient about antihypertensive medications?
Control an irregular heart rate
Reduce the risk for stroke
Reduce the risk for blood clots
Control swelling of the feet
Reduce the risk for stroke
Antihypertensives reduce blood pressure, which reduces the risk for complications associated with hypertension such as stroke and heart disease.
Which discharge instruction would be included during patient education of a patient prescribed anticoagulant therapy?
Expect bleeding and bruising while taking the medication.
Limit intake of green, leafy vegetables.
Monitor blood pressure daily.
Take daily weights at the same time every day.
Limit intake of green, leafy vegetables.
Vitamin K, found in green, leafy vegetables, can alter the effects of anticoagulant therapy and should be limited.
The highest risk nursing skill is
medication administration
Parenteral medications are always
injected
Checking for ________:
Inspect and palpate
Person standing and straining down
Palpation techniques
Inguinal lymph nodes
hernias
Testicular Self-exam
T= Timing (__________)
S= Shower ( ______________ relaxes scrotal sac)
E= Examine (report _________)
T= timing (1x month)
S= Shower (warm water relaxes scrotal sac)
E= Examine (report changes)
Urino I/Os - measuring :
what goes in and what comes out
Pee colors
ideal - ____________
Red/pink - blood - trauma/lesion
Dark amber - _______________
Orange - jaundice
Cloudy - ___________ - WBCs
ideal - pale yellow, clear
Red/pink - blood - trauma/lesion
Dark amber - dehydration
Orange - jaundice
Cloudy - infection - WBCs
High levels of Creatinine indicate:
kidney damage
High levels of BUN blood urea nitrogen indicate:
decreased kidney function
During a speculum inspection of the vagina, the nurse would expect to see what at the end of the vaginal canal?
Cervix
Which of these genital structures is external?
Testis
Scrotum
Vas deferns
Epididymis
Scrotum
During an interview, a patient reveals she has some vaginal discharge. She is worried it may be an STI. The nurse’s most appropriate response is:
A. This isn’t concerning. Some cyclic vaginal discharge is normal.
B. Have you been engaging in unprotected sexual intercourse?
C. I’d like some more information. What color is the discharge?
D. Have you had any urinary incontinence associated with the discharge?
C. I’d like some more information. What color is the discharge?
Which of these statements is more appropriate when the nurse is obtaining a genitourinary history from an older man?
A. Do you experience wet dreams?
B. Do you know how to perform a testicular self-exam?
C. Do you need to get up at night to urinate?
D. Has anyone ever touched your genitals when you didn’t want them to?
C. Do you need to get up at night to urinate?
What age should a male start TSEs?
15 years
S1 sound :
Mitral and tricuspid
S2 sound:
aortic and pulmonic
Sterlings law: a healthy heart stretches in proportion to
the strenght of contraction
When do the coronary arteries recieve blood?
diastole
which of the coronary artieries is the killer?
the left main
[primary supplier of blood to the left ventricle]
Within the RBC, oxygen binds to:
Hemoglobin
Cardiac output =
Hr x SV
Causes of hypoventilation
atelectasis
collapsed alveoli
Hypoxia is life threatening.
Causes include:
anemia
carbon monoxide poisoning
septic shock
cyanide poisoning
pneumonia
atelectasis
cardiomyopathy
spinal cord injury
head trauma
Causes of hyperventilation:
anxiety
infection
drugs
acid-base imbalance
fever
aspirin poisoning
amphetamine use
Most common oxygen delivery device
nasal cannula
BID means
Twice a day
Which of the following promote respiratory function (SATA)
A. Using the incentive spirometer to practice exhalation.
B. Sitting the patient upright to at least 45 degrees.
C. Encourage ambulation.
D. Encourage proper hydration.
E. Use of bronchodilators when appropriate.
B. Sitting the patient upright to at least 45 degrees.
C. Encourage ambulation.
D. Encourage proper hydration.
E. Use of bronchodilators when appropriate.
The nurse is caring for a patient who has decreased mobility. Which intervention is a simple cost effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?
A. Antibiotics.
B. Frequent change of position.
C. Oxygen humidification.
D. Chest Physiotherapy
Frequent change of position
A patient has been diagnosed with severe iron deficiency. During physical assessment for which of the following symptoms would the nurse assess to determine the patient’s oxygen status?
A. Increased breathlessness, but increased activity tolerance.
B. Decreased breathlessness, but decreased activity tolerance.
C. Increased activity tolerance, and decreased breathlessness.
D. Decreased activity tolerance, and increased breathlessness
D. Decreased activity tolerance, and increased breathlessness
Which nursing intervention is the most appropriate to prevent respiratory complications in a post-op patient?
A. Postural drainage.
B. Chest percussion.
C. Incentive spirometer.
D. Suctioning.
Incentive spirometer
the nurse is inserting an oropharyngeal airway for a patient, who vomits when it is inserted. Which action should be taken first by the nurse?
A. Put on sterile gloves and suction the airway.
B. Quickly position the patient on their side.
C. Put on clean gloves and remove the oral airway.
D. Check that the airway is the appropriate size for the patient.
Quickly position the patient on their side
what is the best way for the nurse to make sure that the right patient is receiving the prescribed drug, when the patient is alet and oriented?
A. Ask the patient to state their name.
B. Check the patient’s wrist band.
C. Look at the patient’s chart.
D. Ask the patient to state their name and date of birth.
Ask the patient to state their name and DOB
What is the most important role of the nurse in preventing drug errors?
A. Always checking the patient’s diagnosis before giving a drug.
B. Always follow the six rights of drug administration.
C. Being the one defense for detecting and preventing drug errors.
D. Being most likely to detect that a drug error has occurred
Always follow the six rights of drug administration
A buccal drug is adminstered in which part of the body?
A. Placed under the tongue.
B. Placed in the rectum.
C. Placed against the inside of the cheek.
D. Placed on the lower eyelid
Placed against the inside of the cheek
Braden scale for predicting :
pressure sore risk
Braden scale (pressure injuries) scores
19-23- no added interventions
15-18- some prevention
13-14- some interventions
10-12- more interventions
6-9- ALL interventions
Pressure injuries (ulcers): breakdown of skin integrity due to unrelieved _________
pressure
Risk factors for _________________:
Poor nutrition, immobile, neuro issues. Spine injury/ decreases LOC, Diabetics, Incontinence (Stool or urine), activities cause friction & shear
pressure injuries
Staging of pressure injuries
Stage 1- skin completely intact; red skin that does NOT blanch (turn white) stays the same color
Stage 2- skin is visibly damaged (not intact), partial loss of dermis
Stage 3- skin is visibly damaged, not intact, full loss of skin tissue [will not see bone, muscle, ligament, or tendon]
Stage 4- skin is visibly damaged with FULL loss of skin tissue that will expose bone, muscle, tendon & ligaments
Unstageable: slough or eschar covering a full-thickness injury
________ - yellowish or tan covering wound
_________- browning black covering wound
Slough- yellowish or tan covering wound
Eschar- browning black covering wound
DTI Deep Tissue Injury- presents as ____________________ areas over intact skin; fatty tissue below is injured
purplish or blackish
Pressure ulcer interventions
Interventions: Prevention, detection, wound care
Assess pt, assess risk every shift, keep skin dry and clean, barrier creams, clean dry linens, clean gown, turn pt every 2 hours, watch for friction and shear
Special devices: air beds, heel boots, wedges, gel cushions
Wound care: wound vacs, special dressing, hyperbaric O2
The test we use for balance is
Romberg test
Describe the Romberg test
Stand with your feet together & arms at your side or crossed in front of you.
Eyes open & eyes closed
Note any signs of imbalance, such as swaying.
Glasgow Coma Scale
