question

The diaphragm of the stethoscope is better for listening for what

answer

High-pitched sounds such as the heart and lungs

question

The bell of the stethoscope is best for hearing what

answer

Low pitched sounds

question

When using an otoscope blank millimeters for pediatric exams and blank for adult exams

answer

Two, four

question

A patient with a BMI of blank or above is considered overweight, one with a BMI of blank or above is considered obese and a patient with a BMI of less than blank is considered underweight

answer

25, 30, 18.5

question

Pupils should blank with far gaze and blank with near gaze

answer

Dilate, constrict

question

What is nystagmus

answer

Shakey Eye motion

question

What is a normal respiration rate in adult

answer

12-20 breaths per minute

question

What kind of breath sound should you here anteriorly over the trachea and large bronchi

answer

Loud, high-pitched hollow sound called a bronchial breath sounds

question

Over the mainstem bronchi, which are relatively large diameter airways, you should hear blank sounds called bronchovesicular breath sounds

answer

Medium pitched and quieter sounds

question

Over most of the lung tissue, you should hear blank called vesicular breath sounds

answer

Soft, fine, breezy low pitched sounds

question

Low pitched wheezes are sometimes called blank

answer

Rhonchi

question

What is Stridor

answer

A high-pitched sound typically generated when a larger airway is blocked by a foreign body, severe inflammation or a mass

question

What does a friction rub sound like

answer

Scratching or squeaking sound that persist throughout the respiratory cycle and does not clear with coughing

question

S1 is the closing of the tricuspid and mitral valve and indicates

answer

The beginning of systole

question

S2 is the closing of the aortic and pulmonic valves which is heard best at the base of the heart and indicates

answer

The beginning of diastole

question

What could an S III heart sound indicate

answer

Congestive heart failure

question

What could an s4 heart sound indicate

answer

Hypertension, coronary artery disease and myocardial infarction

question

What is your primary goal in performing a comprehensive physical assessment

answer

To develop a plan of care

question

Over which abdominal quadrant are bowel sounds most active and therefore easiest to auscultate

answer

Right lower quadrant

question

What is a rebound tenderness

answer

An increase in pain when deep palpation over a tender area is released

question

What is antipyretic

answer

An agent that reduces fever

question

What is eupnea

answer

Normal respiration

question

What is febrile

answer

Feverish

question

What are korotkoff sounds

answer

A series of five sounds heard during the Auscultatory determination of blood pressure and produced by sudden distention of the artery because of the proximally placed pneumatic cuff

question

What is the pulse deficit

answer

Difference between the apical and radial pulse rates

question

In general in oral body temperature range of blank to blank is acceptable

answer

96.4-99.1

question

How many degrees higher is a rectal temperature than an oral temperature

answer

.9

question

How many degrees lower is an axillary and tympanic temperature then an oral temperature

answer

.9

question

How do you convert Fahrenheit to Celsius

answer

Subtracting 32 and then dividing by 1.8

question

How do you convert Celsius to Fahrenheit

answer

C x 1.8 (+ 32)

question

Where is the apical pulse located

answer

Left side of the sternum to the fifth intercostal space midclavicular line

question

To calculate the pulse deficit what should you do

answer

Subtract the radial pulse rate from the apical pulse rate

question

According to ATI the normal respiratory rate for an adult is what

answer

12-18

question

For most adult patients you will document the fifth korotkoff sound as what

answer

Diastolic blood pressure

question

Normal oxygen saturation for a healthy adult is above what

answer

95-100

question

Appropriate documentation of temperature includes what

answer

Degrees, scale, assessment site

question

Appropriate documentation of pulse includes

answer

Rate, rhythm, and volume

question

Appropriate documentation of respiration includes

answer

Rate, rhythm and depth

question

The appropriate documentation of blood pressure includes

answer

S/d, The limb was performed on, and the position of the patient

question

When taking blood pressure and unsupported arm can cause what kind of reading

answer

False hi

question

When taking blood pressure and arm positioned above the heart level can cause what kind of reading

answer

False low

question

You are assessing a patient's vital signs. The patient has a temperature of 102. Which of the following do you expect to find

answer

And elevated pulse rate. A fever increases metabolic rate and peripheral vasodilation, resulting in increased pulse rate

question

The difference between a patient systolic and diastolic blood pressure is called

answer

Pulse pressure

question

When taking a patient's blood pressure, why is it important to notice the pressure on the manometer when you hear the fourth korotkoff sound or phase

answer

You might not hear a fifth korotkoff sound

question

When you are measuring a patient's temperature Orally where do you place the probe

answer

In the posterior lingual pocket lateral to the midline

question

How far should you insert the probe into an adult when taking the temperature rectally

answer

1.5 inches

question

A private room is important component of what kind of precautions

answer

Contact precautions

question

Blink, are directed at protecting the patient from contact with micro organisms transmitted from staff, other patients or visitors. This form of protection includes the use of personal protective equipment as well as a private room and disposable or patient dedicated equipment

answer

Protective isolation precautions

question

Standard precautions mandate that you should do what after removing your gloves

answer

Disinfect hands immediately

question

Contact precautions would be mandated for a hospitalized adult patient diagnosed with what

answer

Infectious diarrhea

question

You are caring for a patient diagnosed with mycoplasmal pneumonia. Droplet precautions have been instituted so you must do what

answer

Protect your eyes

question

After completing a procedure that required wearing personal protective equipment consisting of a gown, respirator, face shield and gloves which of the following should the nurse remove first when removing PPE separately

answer

The gloves

question

You were about to irrigate a patient's open wound. Besides gloves which other item of PPE must you wear

answer

A face shield

question

When do you put on a sterile gown when going into a surgical procedure

answer

Immediately after completing a surgical hand scrub and drying your hands and forearms thoroughly with a sterile towel

question

Why is hot water not recommended for surgical handwashing

answer

Because it has a drying effect that can result in cracking of the skin and it is too uncomfortable to wash for the recommended amount of time

question

When removing surgical contaminate PPE what order is it

answer

Gloves, gown, mask

question

The recommended pouring distance for pouring fluid on the edge of the sterile field is how many inches

answer

4-6

question

Prior to entering the surgical scrub area, which of the following PPE items do the team members Don

answer

Protective eyewear, hair cover, mask, shoe covers

question

A nurse putting on sterile gloves knows that the proper technique for gloving the dominant hand prevents contact between the contaminated hand and the non-contaminated glove because

answer

The inner edge of the cuff will lie against the skin and thus will not be sterile

question

What is a nociceptor

answer

A peripheral sensory receptor for pain, stimulated by various types of tissue injury

question

What is somatic pain

answer

Generally well localized pain that results from activation a peripheral pain receptors without injury to the peripheral nerve or CNS, such as musculoskeletal pain

question

What is the process of nociception pathway

answer

Transduction, transmission, perception and modulation

question

What is neuropathic pain? And what is it better controlled with

answer

Pain that arises from abnormal or damaged pain nerves. Better controlled with adjuvant medications such as anticonvulsants, antidepressants, and local anesthetics

question

The benefit of applying cold is that it causes vasoconstriction and reduces swelling. It helps reduce blank pain and blank initially from an injury

answer

Acute, swelling

question

Heat causes vasodilation, fuss improving circulation and promoting healing. Heat is often used to reduce blank and blank pain

answer

Muscle, joint

question

Blank, delivers an electric current over a painful region via electrodes applied to the skin. The patient activates the unit when feeling pain. The tingling sensation it creates helps reduce pain perception

answer

TENS

question

What is contralateral stimulation

answer

Involves stimulating the skin in an area opposite of the painful region. Such as the patients left ankle is casted and itchy, scratching the corresponding area on the right ankle can sometimes relieve the unpleasant sensation

question

What is biofeedback

answer

A process that involves collecting data about the bodies physiological responses of the autonomic nervous system to various thoughts, feelings and other forms of stimuli.

question

What are two examples of non-opioid medication

answer

Toradol and Celebrex

question

What are some anticonvulsants that are used for chronic neuropathic pain

answer

Tegretol, klonopin, gabapentin

question

What are two antidepressants that are used for chronic neuropathic pain

answer

Cymbalta, elavil

question

What are two corticosteroids that are used for an anti-inflammatory effect

answer

Dexamethasone, prednisone

question

Prolonged exposure to severe pain can have long-lasting effects on the neurological system. If this process is not controlled what can happen

answer

It can contribute to the development of chronic pain by leaving an imprint on the nerves, which may result in long term nerve damage and chronic neuropathic pain

question

What happens with global aphasia

answer

Patient is unable to understand speech or express themselves verbally in a meaningful manner

question

What is talwin

answer

Opioid agonist - antagonist agent that can trigger opioid withdrawal date opioid dependent patient

question

Many studies have suggested that pain ratings above blank increased stress and reduce immune system function

answer

3

question

A nurse is about to use the faces pain scale to assist a patient in assessing his pain level. Which of the following should the nurse know in order to use this pain scale

answer

This scale is useful for adult patients of cognitive impairments

question

A nurse is caring for two patients of different cultural backgrounds. Both patients returned from the same type of surgery two hours ago. Which of the following should the nurse expect to be the same for both patients

answer

Class of medication used to treat acute postoperative pain

question

A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter blood is spilled on the floor. What solution to the nurse use to clean the spill

answer

Bleach

question

A nurse is conducting a breast examination on a patient who has a family history of breast cancer. Which of the following should the nurse report to the provider?

answer

Dimpling of the tissue in the upper outer quadrant

question

Nursing knowledge is based on which of the following

answer

Nursing research, discipline specific research

question

A nurse is collecting data on a patient who is diagnosed with schizophrenia and is taking clozapine which of the following findings indicate the patient is experiencing an adverse effect of the medication

answer

White blood cell count lower than normal. Because clozapine blocks h1 histamine receptors

question

A nurse is caring for a patient was experiencing night sweats and hemoptysis it is expected to have active pulmonary tuberculosis. What test would you use to confirm this diagnosis

answer

Sputum culture for acid-fast bacillus

question

A client that is competent and has requested a DNR. Which of the following is necessary to legally change the clients code status to DNR

answer

A written prescription from the provider

question

What is the disease that requires a patient to be placed on droplet precautions

answer

Rubella

question

A nurse discovers that a patient who is diagnosed with dementia received the wrong medication. Which of the following should be the nurses first action

answer

Determine the patient's condition

question

What is a side effect of the tuberculosis drug ethambutol that we require immediate discontinuation

answer

Ocular toxicity. Examples include changes of color vision and loss of visual acuity

question

A nurse and a local clinic is caring for a female patient who is 35 years old. What screening should the nurse recommended to the patient

answer

Dermatologist evaluation every three years to detect skin cancer

question

What age should women began having annual mammograms

answer

40

question

A nurse is caring for a patient who had a cerebrovascular accident two days ago. Which of the following is the first sign of increased intracranial pressure

answer

Lethargy

question

Mass casualty event tagging system

answer

...

question

What is a class one

answer

Patients that have injury that pose a threat to life but a potential for survival exist with treatment

question

What is a class 2

answer

Patients have injuries that may be extensive but do not pose a threat to life even with delayed treatment

question

What is a class III

answer

Non-urgent, patients have injuries that are not extensive and do not pose a threat to life even with delayed treatment

question

What is a class 4

answer

Patients who's injuries are extensive and not compatible with life, even with treatment

question

A blank is expected for 2-3 days following an abdominal aortic aneurysm repair and is indicated by the absence of bowel sounds

answer

Paralytic ileus

question

What is the earliest manifestation of fat embolism syndrome

answer

A change in level of consciousness's

question

What are the components of a medical prescription

answer

Date and time of order, dosage of medication, route of administration, generic name of medication, providers signature

question

A nurse should never administer medication that she did not

answer

Prepare

question

A nurse is preparing to administer a medication subcutaneously. Which size needle should she use

answer

5/8 inch, 25 gauge needle

question

Typically facility policy permits the nurse to administer medications within blank minutes of schedule time for administration

answer

30

question

A nurse is planning atraumatic care for a preschooler who has a prescription for an intramuscular medication. A parent is with the child. Which of the following actions should the nurse include in the plan of care

answer

Provide an explanation of the hospital alarm system, suggest that a parent bring the child's favorite toy to the hospital, use a doll to demonstrate the procedure

question

A nurse is preparing to administer potassium chloride 40 mEq to a patient. Available is potassium chloride 20 mEq effervescent tablets. In addition to checking the correct dosage before administration what else should the nurse do

answer

Check the amount of liquid in which to dissolve the tablet, the type of liquid in which to dissolve the tablet, and the acceptable does range of the medication

question

When a walker is properly fitted the upper bar of the Walker should be blank

answer

Slightly below your waist

question

Which action is appropriate when transferring the patient to the gurney using a slide board and three team members

answer

Have one person holds the slide board study while the other to pull the patient onto the gurney

question

A nurse is observing an assistive personnel who is using a mechanical lift with a hammock sling to transfer a patient from the bed to a chair. The nurse should intervene if the AP does what

answer

Leaves the bed in the lowest position throughout the procedure

question

Crutches should be held on what side when preparing to sit in a chair

answer

The unaffected side

question

Which body movement should indicate to a nurse that a patient has full range of motion of the shoulder

answer

Flexing the shoulder by raising the arm from a side position to 180° angle

question

Which action is appropriate for a nurse was witnessed a breach of patients privacy in a primary care providers office

answer

Complete a health information privacy complaint form and submit it to the appropriate agency

question

Nurses on a clinical unit wish to research the incidence of falls among patients following joint replacement surgery. Which of the following should they do to ensure the study complies with the HIPPA privacy rules

answer

Submit their proposal to the institutional review board for review and describe how they will D identify patients information

question

Who do you report HIPPA violations do

answer

Office of civil rights (OCR)

question

Which route of drug administration are there no barriers to absorption

answer

Intravenous

question

An uncommon, unexpected or individual drug response thought to result from a genetic predisposition is called

answer

Idiosyncratic effect

question

Which of the following is the highest priority action for ensuring overall safety during medication administration

answer

Identify the patient by two acceptable methods

question

After checking placement of an NG tube also check gastric residual. Connect the syringe to the end of the tube and gently aspirate some of the content. If the aspirate is more than what has been given enterally in the past two hours what should you do

answer

Returning to the stomach withhold medications and notify the patient's physician. A large volume of aspirin can indicate delayed gastric emptying, which can cause gastric distention, reflex and vomiting

question

Medicated eyedrops are distributed more evenly after installation if the patient does what with his eyes

answer

Closes his eyes gently

question

Which of the following should the nurse assess before administering medications through a nasogastric tube

answer

Amount of residual volume left in stomach

question

The primary reason insulin is injected via the subcutaneous route is that

answer

Medication absorption is slower from subcutaneous tissue, and important factor in the effectiveness of insulin therapy

question

To determine the best needle length for a subcutaneous injection, you gently pinch the patient's skin at the injection site and select a needle that is

answer

One half the length of the skinfold

question

Since IM injection delivers medication into the muscle, you best determine the appropriate needle length by assessing what

answer

The patient's muscle mass and weight

question

What is the angle for an IM injection

answer

90°

question

The proper needle length when giving an intramuscular injection into the ventrogluteal Area to an average size adult is which of the following

answer

One and a half inches

question

What is the equation for IV flowrate

answer

Volume/time multiplied by drop factor

question

What is PICC stand for

answer

Peripheral inserted central catheter

question

Patients with P ICC lines should not have what done to them

answer

Blood pressure measurements, venipunctures, or injections in the extremity with the PICC

question

Central venous catheter's are most often placed in the blank or blank

answer

Internal jugular or subclavian vein

question

To prevent backflow into an IV line that could cause clotting, you should do what

answer

Maintain pressure on the plunger while withdrawing it from the port, clamp off the tubing before removing the syringe from the port

question

It is common practice to hang the blank bag higher than the blank bag and mandatory for infusions by gravity

answer

Secondary, primary

question

A PICC line is a long catheter inserted through the veins of what

answer

Antecubital fossa

question

The nurse should understand that a disadvantage of parenterally administered medications is that they are

answer

Irreversible

question

A nurse is assessing a patient receiving IV normal Celine at 125 milliliters/hour which of the following should the nurse recognize as a possible complication related to the intravenous therapy

answer

Patient reports cough and shortness of breath

question

A patient was admitted to the hospital for same day surgery and has orders for continuous IV therapy. Before performing a venipuncture, the nurse should

answer

Inspect the IV solution for fluid color, clarity, and expiration date

question

How far above a venipuncture should the tourniquet be placed

answer

4 to 6 inches above

question

According to recent estimates, which of the following sources of healthcare Waze has had the largest financial impact

answer

Unwarranted use of medical resources or services

question

With an anaphylactic reaction, blank or blank is more likely than Peripheral edema

answer

Angioedema or facial swelling

question

What are signs of anaphylactic reaction

answer

Low blood pressure, wheezing, difficulty swallowing

question

Grapefruit juice can increase the amount of drug available for blank

answer

Absorption

question

A healthcare professional is caring for a patient who is about to begin taking Mirapex to treat Parkinson's disease. The healthcare professional should recognize that which of the following laboratory tests require monitoring

answer

CPK

question

What is the side effect that should be monitored for a patient who is taking Aricept for Alzheimer's disease

answer

Nausea

question

What is an adverse side effects of Dantrium taken for skeletal muscle spasms

answer

Diarrhea

question

What kind of drug is thiopental

answer

Short acting barbiturate

question

What are side effects of interferon Beta drugs

answer

Fever, chills, headaches and muscle aches

question

When a patient is beginning an Imitrex therapy to treat migraine headaches which of the following adverse side effects should the patient look out for

answer

Chest pain, Imitrex is not appropriate choice for patients have a history of coronary artery disease

question

What is a potentially serious side effect of lidocaine

answer

Hypotension

question

What is baclofen

answer

A centrally acting muscle relaxant that can cause CNS depression

question

Valproic acid can cause which two side effects

answer

Drowsiness and rash

question

Amitriptyline is a tricyclic antidepressant and can cause side effects such as

answer

Orthostatic hypotension and anticholinergic effects so the person should increase fiber and fluid intake

question

What diagnostic test should a healthcare professional recommend periodically for a patient receiving lithium

answer

Thyroid function tests

question

Lithium toxicity can occur if a patient is also taking this kind of medication

answer

Diuretic

question

Indications of serotonin syndrome include blank, blank and blank

answer

Agitation, confusion and anxiety

question

Echothiophate can cause blank

answer

Cataracts

question

A person who is taking betaxolol eyedrops to treat glaucoma should expect this adverse side effect

answer

Bradycardia

question

A patient taking Nardil should avoid tyramine enriched foods because it increases the risk for what

answer

Hypertensive crisis

question

Disease modifying antirheumatic drugs are initially given with what when beginning therapy

answer

NSAIDs

question

Glucocorticoids may reduce the absorption of what

answer

Calcium

question

What is one rare but serious side effect of alendronate

answer

Dysphagia

question

Alendronate works by

answer

Reducing bone resorption

question

Methotrexate causes bone marrow suppression and increases the risk for blank

answer

Infection

question

A nurse observes and assistive personnel make a clients bed while the client is out of the room. Which of the following actions by the AP is appropriate for this task

answer

The AP reuses the patients blanket and spread

question

While performing a complete bed bath for a patient the nurse should do what

answer

Raised the room temperature

question

Bathing of the patient should be completed from blank to blank and not side to side

answer

Top to bottom

question

What is a bulla

answer

Large blister, as seen with burns

question

What is dehiscence

answer

Spontaneous opening of the edges of the surgical wound with partial or total separation of wound layers

question

What is ecchymosis

answer

Hemorrhagic spot, or bruise, caused by bleeding under the skin and irregularly formed in blue, purple or brown patches

question

What is exudate

answer

Material such as fluid with a high content of protein and cellular debris that has escaped from blood vessels and has been deposited into issues or on tissue services, usually as a result of inflammation oh

question

What is eschar

answer

Slough produced by a thermal burn, a corrosive application or gangrene

question

What is slough

answer

Hard crust or mass of dead tissue

question

What is granulation

answer

Development of red voice tissue made up of new blood vessels, indicating the progression of wound healing

question

What is fistula

answer

Any abnormal tubelike passage in the body

question

What is maceration

answer

Softening or dissolution of tissue after lengthy exposure to fluid

question

What is petechiae

answer

Minute reddish or purpleish spots containing blood that appear in skin or mucous membranes as a result of localized hemorrhage

question

What are the phases of wound healing

answer

Inflammatory phase usually last 24 hours, epithelialization, proliferative, remodeling

question

What is suspected deep tissue injury guidelines

answer

It pertains to tissue with discolored but intact skin caused by damage to underlying tissue

question

What is a stage one pressure ulcer

answer

Defined as non-blanchable redness caused by pressure or sheer typically over a bony prominence

question

What is a stage to pressure ulcer or

answer

Involves partial thickness skin loss with a visible ulcer

question

What is a stage III pressure ulcer

answer

Involves Full thickness tissue loss without exposed muscle or bone

question

What is a stage for pressure ulcer

answer

Involves a full thickness tissue loss with exposed bone, muscle, the possibility of tunneling and sometimes eschar or slough

question

What is eschar

answer

Black scab like material

question

What is slough

answer

Tan, yellow or green scab like material

question

The final stage of pressure ulcers is the unstageable. Who's stage cannot be determined because

answer

Eschar or slough obscures the wound

question

What is debridement

answer

Mechanical cleansing of a pressure ulcer with sterile instruments

question

What is biologic debridement

answer

Uses larvae or maggots to help remove necrotic tissue

question

What are Penrose drains

answer

Commonly used as open drainage systems for wound care. Downside is it's difficulty in assessing the amount of drainage and in controlling the transmission of micro organisms

question

Closed drainage systems use what and advantage is they reduce the risk of infection and allow more accurate measurement of drainage

answer

Compression and section to remove drainage and collected in a reservoir

question

What is one example of a closed drainage system

answer

Jackson - Pratt drain

question

Dry dressings generally work well for wounds with small amounts of exudate. However what is the issue of large amounts

answer

They can stick to the wound bed of heavily exudative wounds or expose the wound to the outside environment

question

What is the disadvantage of wet to dry dressing

answer

They are nonselective with debridement; therefore, they take healthy as well as necrotic tissue with them

question

Wet to dry dressing's are time-consuming to apply and are generally painful to remove. Surrounding wound edges can become macerated because of the moisture contained in the dressing and that can lead to

answer

Enlargement of the wounds diameter. Cross-contamination is also an issue

question

Foam dressings are absorptive and provide a moist healing environment while protecting wounds that resulted from pressure, friction or shear. These dressings are widely used for

answer

Early-stage pressure ulcers

question

Alginate dressings are composed of calcium, calcium or sodium salts or seaweed within a gel dressing. Alginates provide a moist environment for healing and good absorption of exudate, establish hemostasis and do not adhere to the wound. They are helpful in treating wounds with large amounts of exudate including

answer

Ulcers, donor sites, tunneling wounds and some bleeding wounds

question

Do not blink alginates before applying them to a wound. contact with the wound bed should help activate the gel and to protect the wound bed fully apply a secondary dressing

answer

Moisten

question

What are Hydro fiber dressings

answer

Similar to alginate dressing's however they do not affect hemostasis

question

What are Hydro fiber dressings composed of and what do they do when they come in contact with exudate

answer

Composed of polymer carboxymethylcellulose A substance that can absorb exudate vertically. This sheet material swell on contact with exudate

question

What are transparent film dressings and what are the benefits of them

answer

They have a thin layer of plastic that covers the wound area. This dressing type provides no absorption but does create a barrier to the environment. They allow some oxygen exchange to reduce anaerobic bacteria growth and a wet environment to promote healing

question

What are transparent film dressings commonly used for

answer

Dry eschar or for superficial skin tears and not recommended for infected wounds. Removal of transparent dressings can cause damage to underlying skin and the uniform application can cause maceration of wound edges

question

What are hydrogel dressings and how do they work

answer

They are used for autolytic debridement or promoting the bodies own natural function of removing necrotic tissue. They work by maintaining a moist wound environment.

question

What are hydrogel dressings used for and what do you not use them on

answer

Used for wounds with necrosis, infection and moderate amounts of exudate and a need for a moist healing environment. Do not use to treat dry gangrene or dry ischemic wounds

question

Hydrocolloid dressings are used for? And what do they not allow

answer

Autolytic debridement. They do not allow oxygen to into the wound which could lead to anaerobic bacterial growth. They are not recommended for infected wounds but are helpful for wounds that are vulnerable to infection. Do not use these dressings to treat dry gangrene or dry ischemic wounds

question

Binders are a form of bandaging that provides support to the body area they surround. Assess binders every blank hours and rewrap them every blank hours or sooner if needed

answer

Four, eight

question

Negative pressure wound therapy systems should be used cautiously in patients who have

answer

Decreased sensation, taking anticoagulants, or have wounds with tracks or tunneling

question

Anti-septic agents include products such as

answer

Betadine, silver agents and hydrogen peroxide

question

What are three types of antibiotic ointment

answer

Bacitracin, neomycin and polymyxin B

question

What are some antifungal agents

answer

Nystatin, ketoconazole, miconazole

question

What are two common debridement ointments

answer

Panafil, accuzyme

question

What are common barrier creams

answer

Zinc oxide, vitamin A & D

question

While assessing a patient's abdomen, you note that the Jackson - Pratt drains reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time

answer

Empty the reservoir

question

To maintain your patient safety and to prevent dislodgment of the drain you secure the Jackson - Pratt drainage system to what

answer

The patients gown

question

When checking the dressing you note that the Jackson-Pratt drain is intact and draining and that there is also a quarter sized area of fresh Red bloody drainage noticeable on the dressing. The appropriate action for you to take at this time is to

answer

Mark the edges of the area of drainage with tape and document with date and time you marked the dressing in the patient's record

question

Using too much force while irrigating a wound can cause

answer

Tissue trauma and lead to further bleeding

question

What helps maintain an airtight seal for the wound VAC device

answer

Shave the hair along the wound borders, use strips of transparent film to patch any air leaks, avoid wrinkling the transparent film while applying it to the foam, Cut the transparent film to extend 3 to 5 cm beyond the wound borders

question

In general, keeping some moisture within a wound reduces pain. Blank, dressings work by maintaining a moist wound environment, so they are good choice for helping to reduce the pain associated with dressing changes

answer

Hydrogel

question

A nurse is caring for a patient who was admitted with multiple wounds sustained in a motor vehicle crash. Understanding the patient specific needs during this initial stage of wound healing, the nurse should incorporate which of the following into the patient's plan of care to prevent a prolongation of this phase

answer

Apply oxygen at 2L/minutes via nasal cannula

question

Vitamin C aids in tissue building and many metabolic reactions, such as

answer

Wound and fracture healing

question

What is the normal serum albumin level range

answer

3.4-5.4 G/DL

question

How do you assess a patient for adequate swallowing

answer

Place fingers on the patients throat at the level of the larynx and ask them to swallow, A nurse should be able to palpate the movement of the pharynx

question

Blank, is a poor short-term indicator of protein status

answer

Albumin

question

What is the general onset, peak and duration of rapid acting insulin's such as Humalog, NovoLog and Apidra

answer

10-30 minutes, 30 minutes to three hours, 3-5 hours

question

Regular insulin is short acting and has an onset, peak and duration of what

answer

30-60 minutes, 1-5 hours, up to 10 hours

question

Intermediate acting insulin's such as NPH have an onset, Peak, and duration of what

answer

60-1 20 minutes, 6-14 hours, 16-24 hours

question

Another intermediate acting insulin such as Levemir has an onset, peak, and duration of what

answer

Slow onset, 12-24 hours and duration varies the dosage

question

Long acting insulin glargine has an onset, peak and duration of what

answer

70 minutes, peakless , 24 hours

question

Blank, is an incretin mimetic medication available for treating type two diabetes. This medication is prescribed for patients who are already taking metformin, a sulfonylurea, or both and have not achieved adequate blood glucose control

answer

Exenatide

question

Exenatide is it a jacked up on medication with some risk of hypoglycemia and delayed gastric emptying. Most patients experience some blank with this medication which is an advantage over insulin therapy

answer

Weight loss

question

What are side effects of exnatide

answer

Hypoglycemia, nausea and pancreatitis

question

Blank is an amylin mimetic medication used to supplement the effects of insulin in patients who have type one or type two diabetes. It works by

answer

Pramlintide, reduce postprandial glucose by delaying gastric emptying and suppressing glucagon secretion

question

What are common sulfonylureas

answer

Glyburide, Glipizide, and glimepiride

question

What are some side effects of sulfonylurea

answer

Weight gain and hypoglycemia

question

How do sulfonylureas work

answer

By increasing insulin secretion by the beta cells of the pancreas

question

What are Meglitinides

answer

Work by increasing insulin secretion by the beta cells of the pancreas

question

Meglitinides Target post Crandall glycemia and you're less likely to cause blank but nevertheless there is still a risk with this medication

answer

Hypoglycemia

question

What are two examples of Meglitinides

answer

Repaglinide, and nateglinide

question

How do thiazolidinediones work

answer

Increase the cellular response to insulin by decreasing insulin resistance

question

What are some side effects of thiazolidinediones

answer

Weight gain, edema, impaired liver function, elevated lipid levels and reduction in the effectiveness of oral contraceptives

question

How do alpha glucosidase inhibitors work

answer

By delaying carbohydrate digestion

question

How did gliptins work

answer

By augmenting naturally occurring incretin hormones, which promote the release of insulin and decrease the secretion of glucagon

question

Which variables can contribute to hypoglycemia in adolescence who have type one diabetes

answer

Physical activity, diet fluctuations

question

After confirming hypoglycemia a nurse can give a patient what to raise the blood sugar

answer

4-6 ounces of fruit juice, 8 ounces of skim milk, 1 tablespoon of honey, or 3 to 4 commercially prepared glucose tablets

question

What are straight catheters

answer

One time use in a removed immediately after insertion and drainage of urine

question

What are retention catheters

answer

Most commonly used postoperatively because they have multiple lumens to allow for drainage of urine, irrigation of the bladder and installation of medications into the bladder

question

What are coude catheters

answer

A catheter that has A curved tip to allow for easier installation. Most commonly used for patients with prostatic hyperplasia

question

What are suprapubic catheter's

answer

Similar to indwelling catheters except that they are placed surgical opening in the abdomen rather than through the urethra

question

What a condom catheters

answer

Have a latex or rubber sheets to place over the penis

question

How often do you need to assess catheters

answer

Minimum of every eight hours

question

Collection bags from catheters need to be emptied how often

answer

Every six hours

question

What are the steps for obtaining a urine sample from a closed system catheter

answer

Locate the collection port in the drainage tubing, cleanse the port thoroughly with aseptic solution and use the appropriate syringe/needle to draw urine out of the port

question

When introducing fluid into the bladder that is significantly below body temperature what can result

answer

Bladder spasms

question

A nurse is preparing to insert an indwelling urinary catheter in for a female patient. When beginning the insertion procedure The nurse should instruct the patient to do what

answer

Bear down

question

Why do you ask a female patient to bear down when insertion begins

answer

It relaxes the external sphincter and aids in the insertion procedure

question

How much of a space should you leave between the penis and a catheter tip when applying a condom catheter

answer

2.5-5 cm should be left between the tip of the penis and the end of the catheter

question

According to ETI what are acceptable fasting blood glucose ranges

answer

70-105 mg/dL

question

What is a fecal occult blood testing

answer

Widely used screening tool for Colorectal cancer. Routinely recommended for asymptomatic patients over the age of 50 as a prerequisite to colonoscopy

question

Patients that need a stool specimen collection should avoid ingesting a blank, blank and blank because they can alter test results

answer

Barium, mineral oil and laxatives

question

When should you collect sputum samples were they will produce the most accurate results

answer

Most accurate when collected in the morning after sputum has accumulated over night from the deeper areas of the pulmonary system and before the patient has anything to eat or drink

question

Before collecting a sputum sample in the morning what should the patient do

answer

Clear their nose and throat and rinse the mouth this will help reduce contamination of the specimen

question

How often is an acid-fast bacilli test performed

answer

It is performed on three serial samples collected in the early morning on three consecutive days

question

Gastric pH should be more acidic then secretions from other areas of the body which are generally below blank

answer

5.5

question

NG tube placement is initially confirmed by chest x-ray; this is the most reliable method for checking placement. Second only to x-ray is blank

answer

Gastric pH testing

question

A nurse is collecting a blood specimen for culture from a patient hospitalized for pneumonia prior to doing a venipuncture what should the nurse do

answer

Stroke the arm from distal area to the proximal area below the proposed site to help dilate the vein

question

Urine culture and sensitivity test require what

answer

A clean catch or Catheterized specimen in a sterile collection cup

question

What kind of food can cause a false positive fecal occult blood testing result

answer

Red meat, poultry, seafood and some raw vegetables

question

What you need for a routine urinalysis

answer

A routine urinalysis can be done on a random clean voided specimen collected during normal voiding into a clean urine cup

question

What is a gastrostomy tube

answer

A hollow cylindrical device inserted through a surgically created opening in the stomach

question

A nasogastric or nasal intestinal tubes are indicated more for blank therapy meaning less then blank weeks

answer

Short term, four

question

Anything longer than four weeks would indicate the need for a blank or blank tube

answer

Gastrostomy, jejunostomy

question

Determine the portion of the tube when inserting a nasogastric tube that needs to be inserted by measuring from

answer

The tip of the patient's nose to her earlobe to the xiphoid process of her sternum

question

In addition if needing to do a duodenal or jejunal tube insertion how much should you add to the tube length after measuring from the tip of the patient's nose to the earlobe to the xiphoid process of the sternum

answer

20 to 30 cm

question

Gastric fluid from a patient was fasted for at least four hours usually has a pH range of white and the fluid would look like what

answer

One - four, fluid would be grassy green, off-white or tan with the consistency of water

question

Intestinal pH is usually higher than blank and since it contains file it will appear to look like what

answer

Six, light to golden yellow or brownish green with a syrupy consistency

question

In contrast respiratory fluid is usually clear with a pH above blank

answer

seven

question

What are polymeric formulas

answer

Deliver one - two kcal/ML and require that the patient can absorb whole nutrients. They include milk-based blenderized foods and commercially prepared whole nutrient formulas

question

What are modular formulas

answer

Contain single macronutrients such as proteins, glucose, polymers and lipids. They are not nutritionally complete. They deliver 3.8- 4.0 K CAL/ml and are used to supplement patient's nutritional needs.

question

What are elemental formula

answer

They contain predigested nutrients, making it easier for a partially dysfunctional gastrointestinal tract to absorb them. They provide 1-3 kcal/ML

question

What are specialty formulas

answer

They range from 1-2 kcal/ML and are designed to meet specific nutritional needs related to specific illnesses, such as liver failure, pulmonary disease, diabetes or HIV infection

question

To regulate the flow of the enteral formula through the NG tube you open the tubing and

answer

Raise the syringe to a height no greater than 18 inches above the patient's head

question

A patient with a gastric ileus postoperatively requires nutritional support for approximately two weeks. Which of the following types of feeding tubes is appropriate for this patient

answer

Nasal intestinal tube

question

A patient who is post operative following a laryngectomy would require what kind of feeding tube

answer

Nasogastric

question

What are side effects of vitamin B 12

answer

Diarrhea and hypokalemia

question

What are side effects of desmopressin

answer

Fluid retention and hyponatremia

question

What are side effects of antiplatelet inhibitors such as Plavix and ticlopidine

answer

Gastric upset, abdominal pain, diarrhea, nausea, gastric ulceration and bleeding, thrombotic thrombocytopeniaPurpura

question

Why would you give thrombolytic drugs

answer

To break down thrombi that have already developed

question

What is one thrombolytic drug

answer

Activase

question

What is a side effect of Activase

answer

Bleeding

question

What are side effects of erythropoietic growth factor

answer

Hypertension, cardiovascular and cerebrovascular events, malignancy progression

question

What is a side effect of the leukopoietic growth factor drug filgrastim

answer

Leukocytosis, bone pain, fever and splenomegaly

question

What does Nascobal vitamin B 12 preparation treat

answer

Pernicious anemia

question

What does a reticulocyte count do

answer

Measures the amount of immature RBCs and folic acid that is essential for erythropoiesis

question

In the early stages of hypoxia the patient is often restless and confused and may report feeling

answer

Anxious

question

The patient's vital signs in relation to hypoxia will be

answer

Elevated, with complaints of dyspnea

question

In the late stages of hypoxia the patient is likely to develop

answer

Hypotension, bradycardia and and metabolic acidosis, decreased level of consciousness, decreased activity level and cyanosis

question

Patients with chronic hypoxia will have the symptoms

answer

Clubbing of the fingers and toes, peripheral edema, right-sided HF and and O2 sat below 87%, with the respiratory acidosis

question

When patients with COPD receive oxygen at two high flow rate, blank, can result indicated by confusion, tremors, convulsions and coma which can ultimately lead to respiratory arrest

answer

Carbon dioxide narcosis

question

If the flow rate is 4 L/minute or more considered blank to decrease drying of the mucous membranes

answer

Humidification

question

How much oxygen does a nasal cannula administer to the patient

answer

Concentrations of 22% to 50% with flow rates from 1 to 6 L/minute

question

A nasal cannula is usually indicated for what kind of patients

answer

Patients who are noncritical with minor breathing problems and for patients who cannot wear an oxygen mask. Humidification is rarely required

question

A simple oxygen mask is indicated for what kind of patients

answer

Patients who require a moderate flow rate for a short period of time

question

A simple mask has the ability to deliver how much oxygen

answer

02 concentrations of 40% to 60% with flow rates from 6 to 10 L/minute

question

What should you consider doing for patients receiving a simple mask to help keep the patients mucous membranes from becoming dry

answer

Humidification

question

A non-rebreather mask, which is a low flow system, can deliver oxygen concentrations of

answer

60% to 95% with flow rates from 10 to 15 L/minute

question

When using a non-breather mask do not allow the reservoir bag to blank. If it does the patient is likely to breathe in large amounts of exhaled carbon dioxide

answer

Deflate

question

A Venturi mask can deliver oxygen concentrations from

answer

24% to 60% with flow rates from 4 to 12 L/minutes

question

Because a Venturi mask delivers a precise oxygen concentration and carbon dioxide buildup is minimal it is commonly used for patients who have blank. Humidification is usually unnecessary with this device

answer

COPD

question

A face tent is often used as an alternative to an aerosol mask, especially for patients who report feeling claustrophobic with

answer

Aerosol mask

question

A face tent delivers oxygen concentrations of

answer

28% to 100% with flow rates from 8 to 12 L/minutes

question

A face tent is convenient for delivering both humidification and oxygen however it is difficult to control that

answer

Concentration of oxygen administered since the actual concentration oxygen depends on the rate and depth of the patients respirations

question

What is a manual resuscitation bag used for

answer

To provide high concentrations of oxygen to a patient prior to the procedure, such as suctioning or intubating and during respiratory or cardiac arrest

question

What is the flow rate for a tracheostomy mask sometimes referred to as a tracheostomy collar.

answer

10 L/minute

question

Patients who have artificial airway's require continuous blink, since the airway bypasses the normal filtering and blank process of the nose and mouth

answer

Humidification

question

Noninvasive ventilation, is used to maintain positive airway pressure and to improve alveolar ventilation without the need for an artificial airway. It is commonly used for patients who have

answer

Congestive heart failure, sleep disorders, pulmonary diseases, reduce and reverse atelectasis, and improve cardiac function

question

Oxygen tense and hoods are usually used for pediatric patients who have airway inflammation, croup, or other respiratory infections. And oxygen hood delivers oxygen at

answer

28% to 85% O2 concentration

question

Airway management module

answer

...

question

What is an oropharyngeal airway used for

answer

To keep the upper airway patent when it is at risk for becoming obstructed by the tongue or by secretions.

question

Oropharyngeal airway's stimulate the gag reflex, it should be used only for patients whose

answer

Level of consciousness is altered

question

How do you determine the correct size for an oropharyngeal airway Device

answer

Measure the oropharyngeal airway from the corner of the patient's mouth to the angle of the jaw

question

When inserting an oral airway, the curved end should initially point upward. Once it reaches the back of the mouth, it is

answer

Rotated 180° so that the curved part of points down and follows the natural curve of the tongue

question

Nasopharyngeal airway's, sometimes called nasal trumpet, are also used to keep the upper airway patent. They are inserted through the nares and extend into the oropharynx. Because this type of airway does not stimulate the gag reflex it can be used for

answer

Patients who are alert

question

How do you determine the appropriate size for a nasopharyngeal airway

answer

The airway is measured from the patient's nose to the angle of the jaw

question

What are endotracheal tube used for

answer

Patients undergoing a procedure that requires general anesthesia and/or mechanical ventilation

question

Endotracheal tubes are inserted either through the nose or the mouth past the epiglottis and vocal cords into the trachea and down to

answer

Where the trachea bifurcates into the bronchi

question

What is usually the longest ET tubes are left in place

answer

14 days, to decrease risk for infection and airway injury

question

What are tracheostomy tubes used for

answer

Long term airway support

question

Most tracheostomy tubes have a blank, that is temporarily removed during tracheostomy care

answer

Inner cannula

question

Why is it important to hyper oxygenate the patient before suctioning and to assess the patient before, during and after the procedure

answer

Because sectioning can cause complications such as hypoxia, injury to the airway, nosocomial infections, and cardiac dysrhythmias

question

Any type of tracheal suctioning is considered

answer

Sterile

question

What is a yankauer suction catheter

answer

Helps clear secretions from the mouth. Patients require this type of suctioning is for patients who can cough effectively but cannot swallow or expectorate secretions

question

What does a nasopharyngeal and nasotracheal suctioning do

answer

Helps remove secretions from the lower airway of patients who cannot cough and do not have an artificial airway in place.

question

How do you insert a nasopharyngeal and nasotracheal suctioning device

answer

Insert a small, sterile, flexible catheter into the nares until the tip reaches the pharynx or the trachea

question

Critically ill patients who have an endotracheal or tracheostomy tube in place usually require suctioning of secretions via the open or closed method of suctioning. With both of these is important to insert the catheter without

answer

Applying suction, applying suction on insertion could injure the airway. After you insert the catheter apply suction while using a rotating motion to remove it (except with closed)

question

What is the advantage of using a closed suction system

answer

You do not have to disconnect the patient from the mechanical ventilator

question

Signs and symptoms of oxygen toxicity result from its effects on the

answer

CNS and pulmonary system

question

Vibration is used after percussion or alternately with percussion to increase the turbulence of

answer

Exhaled air and loosen secretion

question

When do you perform vibrations

answer

Only when the patient is exhaling

question

What is postural drainage

answer

To remove secretions by gravity from different areas of the lungs

question

Postural drainage is commonly performed 2 to 3 times a day, often before blank and at blank

answer

Meals, bedtime

question

If a patient is receiving continuous tube feedings, stop the feeding and check gastric residual at least blank minutes before performing postural drainage

answer

30

question

Before starting postural drainage and during the procedure, evaluate the patient's tolerance of the various positions. The patient usually remains in each position for how long

answer

10 to 15 minutes, however this time maybe shorter initially and then gradually increased

question

What should you do if the tracheostomy tube is migrating outward from the stoma

answer

Attempt to reposition it

question

What do you do if the tracheostomy tube completely moved out of the stoma

answer

Extend the patient's neck to allow for ventilation

question

A nurse is caring for a patient who has a tracheostomy tube in place. During tracheostomy care, which of the following should the nurse place underneath the flanges of the outer cannula

answer

Commercially prepared fenestrated dressing

question

A nurse is caring for a patient who has a tracheostomy tube with an inner cannula in place. Which of the following supplies should the nurse use to dry the inner cannula of the patients tracheostomy tube after cleaning it

answer

Folded pipe cleaners. They remain intact without leaving any particulate matter the patient could aspirate on

question

A nurse is preparing to perform endotracheal tube care in plans to use tape to secure the tube. Which of the following is an appropriate preparatory action for this procedure

answer

Have tincture of benzoin ready to apply to the patient's face

question

Closed chest drainage module

answer

...

question

What is the purpose of a chest tube

answer

To restore a collapsed long or to drain fluid from the pleural cavity

question

What is a single chamber closed chest drainage system used for

answer

The collection of smaller amounts of drainage while still providing a water seal

question

For larger amounts or more accurate measurements of chest drainage, use the blank, which allows fluid to flow in the collection chamber as air flows into the waterseal chamber

answer

Two chamber drainage system

question

When are all three Chambers Essential

answer

When using a controlled suction source to draw air or fluid out of the pleural space

question

The middle chamber is typically for the what

answer

Waterseal; it allows air to exit the plural space on exhalation and keeps air from entering the plural or mediastinal Space on inspiration

question

What does continuous bubbling in the waterseal chamber indicate

answer

An air leak

question

What is the Heimlich valve

answer

A one-way letter valve that allows air to escape and keeps it from reentering the chest cavity.

question

A nurse is assessing a patient who has a chest tube in place attached to a closed chest water - seal drainage system. When the nurse palpates the area around the chest tube insertion site she is checking for

answer

Subcutaneous emphysema

question

IV therapy module

answer

...

question

What are the most often type of catheter used for initiating IV therapy

answer

Over the needle catheters with built in safety devices

question

What size catheter gauge is adequate for diffusing fluids and medications for adults

answer

20 to 22 gauge

question

Which size gauge is most adequate for children, older adults and anyone who has small fragile veins

answer

22-24 gauge

question

If a patient will receive large quantities of fluids at a rapid rate or blood or blood products, use a larger catheter such as a blank gauge

answer

18

question

If you're patient will not have a continuous infusion, initiate a saline lock also called

answer

Heparin lock

question

Since fluids do not infuse continuously through a saline lock to maintain patency of the IV line, you must flush the lock usually with normal saline, blank to blank milliliters before and after you administer each medication or at regular intervals

answer

5 to 10 mL

question

What is the direct method for inserting a peripheral IV catheter

answer

Pierce the skin immediately over the vein and approximately 1/2 inch below the proposed IV site

question

What is the indirect method of inserting a peripheral IV catheter

answer

Pierce the skin along the side of the vein and then angling the catheter toward the vein

question

Once you have pierced the skin and thread the catheter a short distance into the vein, pull the needle back so that the tip is not extending past the end of the catheter. Then thread the catheter into the vein until

answer

The hub of the catheter is resting against the skin at the insertion site. Then remove the needle the rest of the way, activate the safety device and dispose of the needle in the sharps container. Then secure the catheter

question

If a patient is critically ill or requires long term IV therapy, the provider typically considers what kind of catheter

answer

Peripherally inserted central catheter or or PICC

question

What should you do for older adults that need an IV catheter

answer

When inserting the catheter be sure to pull the skin below the insertion site taut to stabilize the vein. Also if possible use a mesh dressing to stabilize the catheter once inserted

question

To keep air from entering the tubing and being infused, be sure to keep the drip chamber at least

answer

Half full

question

When using the piggyback set up, leave both the primary and secondary lines open. To regulate the flow of the secondary infusion what should you do

answer

Open the roller clamp on the secondary tubing completely and use the roller clamp on the primary tubing to adjust the flow rate

question

When the secondary infusion is complete the primary infusion resumes. If the primary infusion rate differs from that of the secondary infusion, remember to

answer

Adjust the rate as soon as possible after the secondary infusion is complete

question

To secure an IV site apply a transparent dressing to protect the IV site from contamination while still allowing visibility. Position the dressing over the vein so that it

answer

Extends to the lip of the hub of the catheter. Leave the connection between the catheter hub and the IV tubing uncovered to facilitate changing the tubing

question

Also do not wrap the tape around the patient's arm either because

answer

This can impair circulation if the arm swells

question

To protect the patient's skin, place a small gods pad under the hub of the IV catheter to elevate it and

answer

Keep it from exerting pressure on the patient's skin

question

When you begin your assessment of an IV site start by inspecting for

answer

Redness or swelling

question

Next palpate the area around the site and along the vein for any

answer

Pain, firmness or swelling, also note temperature

question

A peripherally inserted venous catheter is usually replace every

answer

72 to 96 hours

question

What is phlebitis characterized by

answer

Increased temperature, redness along the vein

question

What is phlebitis treated with

answer

Discontinue the IV line and apply a warm, moist compress over the area

question

Infiltration results when the IV catheter is dislodged and fluid infuses into the tissue. It is characterized by

answer

Edema, pallor, decreased skin temperature around the site and pain

question

Extravasation is characterized by

answer

Pain, stinging or burning at the site, swelling and redness

question

How do you treat extravasations

answer

Discontinue the IV line and apply a cool compress to the area. If the medication has an antidote it should be prescribed in a ministered immediately

question

A short peripheral catheter is appropriate when IV therapy is planned for up to

answer

seven days

question

To minimize personal risk of injury while inserting an IV access device into a patient's hand you stabilize the vein

answer

Below the proposed insertion site

question

You are most likely to be successful in accessing a superficial vein with an 18 gauge catheter by inserting the catheter at what angle

answer

10 to 30° angle to the skin

question

A nurse initiating a peripheral IV infusion punctures the skin and selected vein and observes blood return in the flashback chamber of the IV catheter. What action should the nurse perform next

answer

Lower the catheter until it is almost flush with the skin

question

Nasogastric intubation module

answer

...

question

What are Orogastric tubes such as ewald, lavacuator, and eldich

answer

Large bore tubes with wide proximal outlets for removing gastric contents and are primarily used in emergency departments and ICUs

question

What is the lavacurator tube

answer

Has two lumens, a larger lumen for evacuating gastric contents and a smaller lumen for instilling an irrigant

question

The most common nasogastric tube is the double lumen gastric sump tube (Salem). This type of tube is useful for irrigating the stomach but is most often used for drawing out fluid and gas from the stomach. In fact, it is the preferred tube for

answer

Gastric decompression

question

The single lumen (Levin) nasogastric tube is useful for

answer

Decompressing the stomach, withdrawing specimens for diagnostic analysis, washing the stomach free of toxic substances and irrigating the stomach to diagnose and treat upper gastrointestinal bleeding. It can also be used to administer feedings and or medications

question

There are several brands of dual purpose tubes that can provide gastric section and enteral feeding. these to allow for removal of

answer

Excess feeding formula from the stomach thereby reducing reflux

question

Some brands such as Moss include a 3rd lumen that inflates a gastric retention balloon. These tubes are used primarily for patients undergoing

answer

Surgery

question

A miller Abbet tube is a 3 m double lumen nasointestinal tube. These tubes are used to sample gastrointestinal fluid and to provide decompression for

answer

Small bowel obstruction or ileus

question

The sengstaken-blakemore tube is used to treat

answer

Upper gastrointestinal bleeding from Esophageal varices

question

What is gastric Lavage

answer

The irrigation of the stomach

question

Lavage May also be used as a therapy for blank or blank to help stabilize the body temperature

answer

Hyper or hypotherma

question

How often do you include intermittent irrigation

answer

Every four hours

question

How often do you want to assess and document intake and output

answer

Every eight hours

question

What is imperative for both the patient comfort and to reduce the risk of infection because patients usually become mouth breathers

answer

Frequent oral hygiene, or if allowed they may suck on ice chips or hard candies.

question

For a patient who is unconscious or does not have a gag reflex the link is strongly recommended, along with an oral airway to keep the patient from biting on the blank

answer

Endotracheal tube

question

What are the contraindications for gastric lavage in regards to ingestion of poisons

answer

Hydrocarbon with a high aspiration potential, ingestion of a corrosive substance such as a strong acid or alkali

question

Before beginning gastric lavage explain the procedure to the patient and obtain her verbal agreement to begin the procedure. Then

answer

Test the patients gag reflex

question

Oro or nasogastric compression is used to

answer

Control bleeding from esophageal or gastric varices

question

What is the most common electrolyte disturbance associated with nasogastric decompression

answer

Hypokalemia

question

A nurse is performing a nasogastric intubation. What with the nurse do immediately after inserting the tube to the predetermined length

answer

Inspect the oropharynx with a penlight and tongue blade

question

Enemas module

answer

...

question

What is the most common reason for administering an enema

answer

To relieve constipation

question

Before administering an enema position the patient on

answer

The left side in the Sims position with the right knee flexed

question

A cleansing enema acts by stimulating peristalsis by instilling a solution or irritating the mucosa of the colon. When administering a cleansing enema be cautious about instilling blank. Because it is a hypotonic solution therefore it pulls electrolytes from the body into the fluid and increases the risk of electrolyte imbalance

answer

Tap water

question

Soapsuds enema is act by stimulating peristalsis through intestinal irritation. As long as blank is used it is considered a safe procedure

answer

Pure Castile soap

question

Some patients having a procedure or surgery involving the bowel have an order for an enema to be administered until clear. This means

answer

You need to repeat the enema and tell the patient passes fluids that are clear of fecal matter. Do not administer more than three enemas

question

In oil retention enema is administered to lubricate the rectum and the colon. The oil is absorbed by the feces making them

answer

Softer and easier to pass

question

Medicated enemas may be given for the local effect they exert on the rectal mucosa. An example of one containing kayexalate is administered to treat patients who have

answer

Dangerously high serum potassium levels

question

Hypertonic enema solutions should be held in the bowel for how long

answer

Until the patient feels that urge to defecate which is usually in 2 to 5 minutes

question

What kind of solution is used to administer enemas until clear

answer

Normal saline

question

You evaluate that the enemas have had a desired effect when you find a

answer

Large amount of slightly brown solution with no solid fecal matter

question

How should you prepare a soapsud enema

answer

1 teaspoon of soap in a liter of fluid

question

When administering enema what should you do if the patient reports cramping

answer

Lower the height of the solution bag to slow The installation rate

question

A nurse is preparing to administer an oil retention enema to a patient who has constipation. The nurse explains that the patient should try to retain the instilled oil for

answer

At least 30 minutes but preferably as long as they can

question

Ostomy care module

answer

...

question

The opening of an ostomy is call a

answer

Stoma

question

A colostomy is created from

answer

The end of the large intestine to divert waste from the digestive system

question

With a blank the damage section of the bowel is removed and the working end is brought through the abdomen to the skins surface

answer

End colostomy. It will normally be reconnected in about 3 to 6 months

question

Why would you need an end colostomy

answer

Tumor resection, traumatic injury to the colon or inflammation of the bowel

question

With a loop colostomy, a loop of the bowel is brought through the abdomen to the skins surface and temporarily supported by a plastic bridge or Rod. It is typically created as an emergency procedure to relieve

answer

An intestinal obstruction or perforation. It can normally be removed within 1 to 2 weeks

question

A double barrel colostomy is when two separate stomas are created. They may be created because

answer

Of trauma, tumors, or inflammation and it may be temporary or permanent

question

What part of the colon is used for a temporary ostomy

answer

Transverse colon

question

What part of the colon is a more common type of colostomy

answer

Descending colon

question

What part of the colon is the most common location for a permanent colostomy particularly for cancer of the rectum

answer

Sigmoid colon

question

What is it ileostomy created for

answer

A surgical opening created in the ileum to bypass the entire large intestine

question

A procedure used to treat calling cancer, total proctocolectomy involves

answer

Surgical removal of the entire colon, rectum and anus with closure of the anus

question

Where is the stoma created for an ileostomy

answer

Right lower quadrant

question

An alternative to the standard ileostomy is Kocks continent ileostomy. During the procedure and internal pouch is created from the distal segment of the ilium, which serves as a reservoir for stool. During surgery, a one-way nipple valve is constructed through the stomal opening so that eventually the patient can insert a catheter through the stoma and through the one-way valve to drain the fecal contents of the internal pouch. This type of ostomy he is occasionally created to treat

answer

Ulcerative colitis and may be an option for patients who do not wish to wear an external pouch over the stoma

question

What is a urostomy

answer

A urinary diversion that allows urine to exit the body after removal of a diseased or damaged section of the urinary tract

question

What is the most common type of urinary diversion

answer

Ileal conduit

question

In Indiana continent urinary reserve is formed from the colon and the cecum. This allows the patient to

answer

Self Catheterize to empty the reservoir

question

A healthy stoma appears

answer

Pink or red and moist and should protrude about three quarters of an inch from the abdominal wall

question

What should patients use to clean a stoma

answer

Typically a mild, pH balanced soap or no soap at all and just water

question

How often should patients empty there pouch

answer

it is one 3rd to 1/2 full

question

What are signs and symptoms of food blockage

answer

Abdominal cramping, nausea, vomiting, high volume odorous effluent, swelling of the stoma and no ileostomy output for at least six hours

question

What should patients do if they experience symptoms of a food blockage

answer

Place moist towels on the abdomen, drink hot tea, lie down and assume a neat chest position to relieve intra-abdominal pressure and/or massage the abdominal area to promote peristalsis

question

What are signs and symptoms of dehydration or electrolyte imbalance

answer

Extreme thirst, dry skin and oral mucous membranes, decreased urine output, weakness, fatigue, headache, dizziness, muscle cramps, abdominal cramps, nausea, vomiting, shortness of breath, orthostatic hypotension

question

What type of ostomy pouching system is best for a new incision

answer

A two-piece pouching system with a cut to fit skin barrier

question

Stomal stenosis and retraction can develop as a ostomy heals by

answer

Secondary intention

question

A nurse is replacing the ostomy appliance for a patient who is newly created colostomy is functioning. After removing the pouch which of the following should the nurse do first

answer

Cleanse the stoma and the peristomal skin

question

Central venous access devices module

answer

...

question

Central access devices are inserted into

answer

Large veins in the central circulation, such as the internal or external jugular vein's or into the lower third of the vena cava that leads to an area just above the right atrium

question

How long can a central line device remain in place

answer

For more than a year

question

A fairly common MLC configuration is three ports, commonly labeled as follows

answer

Distal port: the largest lumen; used for central venous pressure or high volume or biscuits fluids, colloids or medications. The medial port: used for parental nutrition, medications. The proximal port: used for blood sampling, medications, blood component administration

question

The distal port is the largest and has the greatest flow rate which makes it ideal for

answer

Blood sampling

question

For additional insurance that laboratory results won't be altered by the solutions infusing through the central access device, turn off the distal infusions and clamp the tubing for blank minutes before obtaining the blood sample

answer

1 to 5 minutes

question

What are common manifestations of sepsis

answer

Fever, chills, hypotension, tachycardia and and confusion

question

What is pneumothorax

answer

Air in the pleural space, that is outside the lung

question

What is hemothorax

answer

Blood in the pleural space

question

What are symptoms of an air embolism

answer

Dyspnea, chest pain, tachycardia, hypertension, anxiety, nausea, dizziness and confusion

question

If you suspect in the air embolism what should you do

answer

Clamp the catheter, administer oxygen and place the patient on his left side in Trendelenburg position

question

Catheter occlusion: If you cannot flush the catheter, check to make sure it is not clamped or kinked sometimes the problem is that the catheter tip rest against the wall of the vein. Try these strategies

answer

Have the patient turn his head and cough. Ask the patient to raise his arms over his head. Place the patient in Trendelenburg position. Have the patient take a deep breath. Have the patient stand up. Have the patient change positions in bed.

question

Catheter occlusion: it may be that the sutures securing the vascular access device are constructing the catheter. If so, obtain in order to remove the sutures and apply a stabilizing device. If the obstruction is with an implantable port, check to make sure the noncoring needle is correctly placed in the port. If it is not correctly placed remove

answer

The needle and replace it with a correctly positioned needle

question

Thrombotic occlusion's are caused by clotting inside the catheter for outside around the catheter tip that blocks the catheters lumen. This can make it impossible to draw blood from the catheter, to flush it or to use it for infusion try

answer

Heparin and other chemicals might clear the blockage; when those measures do not help, the catheter must be replaced

question

When he central catheter is inserted into the subclavian vein, the clavicle and rib can move together and compress the central line catheter, causing pinch off syndrome. Warning signs include

answer

Difficulty drawing blood samples and resistance to the infusion of IV fluid. Ask the patient to change position of his arm on the catheters side by raising it or by pulling his shoulder backwards

question

What is a catheter malposition

answer

When a central catheter becomes dislodged as a result of improper technique when removing a dressing, in adequate securing of a catheter and physical activity

question

What is it advantage of the implanted port

answer

They are cosmetically appealing, low risk of infection, and allow patients to carry-on virtually all activities including swimming

question

What is a disadvantage of an implanted port

answer

Accessing it can be painful

question

What do you use to access an implanted port

answer

A non-coring, non-barred needle.

question

Implanted ports may be open ended or valved. Open ended ports require

answer

Heparin flashing while valved ports do not

question

Non-tunneled catheter's are inserted into

answer

That internal jugular or subclavian vein, with the catheter tip resting in the superior vena cava

question

What is the insertion method for non-tunneled catheter

answer

Percutaneous venipuncture.

question

How long can a non-tunneled catheter remain in place

answer

Typically 3 to 4 weeks

question

Having a non-tunneled catheter puts you at a higher risk for what

answer

Infection and pneumothorax

question

PICC's are usually intended for patients who require therapy for periods of 1 to 12 weeks but some have been known to remain in place

answer

for years

question

Most PICs are secured with

answer

Wound closure strips or a securing device

question

Your assessment includes measuring the patient's upper arm circumference to establish

answer

Baseline data

question

Also be sure to measure and document the length of the external portion of the catheter from the

answer

Insertion site to the hub of the access. Later you will compare the length of the external catheter to the previously documented Lane to detect catheter dislodgment from the insertion site

question

Ongoing care of a PIC includes a dressing change 24 hours post insertion and then

answer

On a weekly basis. Assess the site for redness, drainage, swelling and pain

question

A typical schedule for flushing a PIC site is every

answer

12 hours we medications or fluids are not being administered

question

What kind of aseptic technique do you use for changing dressings on catheter sites

answer

Surgical

question

The CDC recommends changing addressing when it is damp, Lucinda or soiled. And changing God dressings every blank hours and transparent dressing every blank days or whenever they are no longer intact

answer

48, 3 to 7 days

question

The preferred dressing is what

answer

Semi permeable membrane dressing. Typically gods dressings are not recommended unless there is drainage from the site

question

When using alcohol and povidone-iodine, to clean the catheters insertion site what should you do

answer

Move outward and apply for a minimum of 30 seconds and allow to dry completely before applying the povidone-iodine

question

When using chlorhexidine, use a back and forth motion and cleanse the site for

answer

30 seconds

question

Central venous catheter's have a special cap on the end where IV tubing or syringes connect into the line. This Is called the injection or access cap. Typically injection caps are changed every blank hours for continuous infusions and every blank days for intermittent infusions, most likely at the same time as a dressing change

answer

72-96 hours, seven days

question

Tunneled central venous access devices are designed for

answer

Long term years, months to years

question

Examples of brand names for tunneled central venous access devices include

answer

Hickman and Broviac

question

Hickman and Broviac catheters differ in women size. A Hickman catheter has a larger lumen compared with the single lumen Broviac,which is primarily used for

answer

Pediatric patients

question

A Groshong catheter differs from the Hickman and Broviac catheters because of its valve tip. Valve tip catheters are not heparinized and do not require

answer

Clamping

question

What is a Dacron cuff on tunneled catheter's

answer

It lies within the subcutaneous tunnel, where tissue granulate into the cuff there for defectively anchoring the catheter and acting as a barrier for preventing the spread of organisms along the catheter

question

What is a really good catheter to deliver parental nutrition

answer

PICC

question

The first sign that DVT is developing is

answer

Edema on the forearm

question

During a sterile procedure everyone in the room is required to

answer

A facemask

question

What immediate complications do you monitor a patient for during the insertion of a CVAD

answer

Pneumothorax, dysrhythmia, hematoma

question

You are aware that the catheter tip position for a properly placed CVAD is in the

answer

Superior vena cava

question

How often should a patient flush an implanted infusion port

answer

Every 4 to 6 weeks

question

A nurse is caring for a patient who has a central venous access device in place. Which of the following routine measures should the nurse use specifically to prevent lumen occlusion

answer

Clamping the extension tubing while removing a syringe from the injection cap

question

When implanted port remains accessed for and infusion, the needle must first be supported and incurred, then

answer

The port and needle are covered with a transparent dressing

question

Valved tips do not require

answer

Heparinized saline solutions for flush

question

A patient who sustained trauma from a motor vehicle accident is transported to an emergency department. The provider determines the need for immediate central venous access for fluid and blood replacement and prophylactic antibiotic therapy. The appropriate central venous access device for this patient is

answer

A non-tunneled percutaneous central catheter

question

When performing postural drainage what should you do

answer

First position the patient, then percuss and vibrate, then remove the secretions either by having the patient cough or by suctioning the patient's airway

question

Blood administration module

answer

...

question

Because the use of whole blood has a greater effect on fluid volume than any of the components do, it is used only when needed or when individual blood components are not available. What is the timeframe for transfusing whole blood

answer

It must be transfused within 24 hours of collection because coagulation factors deteriorate after that timeframe

question

Plasma in the blood is responsible for maintaining blood pressure and providing essential proteins, serves as a medium for cellular exchange of vital minerals and electrolytes and for the elimination of

answer

Cellular waste products

question

Red blood cells are kept refrigerated at specific temperatures and are viable for blank days but maybe frozen for extended storage up to 10 years

answer

42

question

What is plasma used for

answer

Treating bleeding and coagulation disorders, replace fluid volume in patients with massive burns and for those with liver failure and to replace platelet aggregating inhibitors in patients who have thrombocytopenic Purpura or hemolytic uremic syndrome

question

Plasma can be frozen for 1 to 7 years. Once thought it it must be transfused within

answer

24 hours

question

One fractionated product of plasma is the protein blank, essential for maintaining blood volume and blood pressure

answer

Albumin

question

What is immune globulin

answer

A concentrated solution of the anti-body IgG, is prepared from large pools of plasma

question

What is immunoglobulin used for

answer

To replace inadequate amounts of IgG for patients at risk for recurrent bacterial infections, such as those with chronic leukemia

question

What is cryoprecipitate anti-hemophilic factor used for

answer

It is transfused to prevent or control bleeding and people who have hemophilia, to correct low fibrinogen levels and to treat von willebrand disease and other clotting disorders

question

What blood types can receive AB plasma

answer

All

question

Rh system: A person who has the D antigen is classified as blank. A person who does not have the D antigen is classified as blank

answer

Rh positive, Rh negative

question

The basic rules are that the red blood cells transfuse must not have the antigens to which the patient has

answer

Anti-bodies and that the plasma and platelets transfused must not have the antibodies against the patients antigen

question

What is hemolysis

answer

The premature destruction of red blood cells within or outside of the vasculature

question

Hemolysis can occur prior to and during blood administration. To prevent hemolysis do not apply more then blank of pressure

answer

300 MM HG

question

Another way to prevent hemolysis is when you must use a pressure device for rapid infusion, make sure the IV access catheter is a blank gauge or larger to avoid vein damage

answer

18

question

When warming blood use a device approved by the FDA. Never use

answer

Microwave or hot water baths

question

Administer all blood components through a sterile, pyrogen free filter designed to retain clots and aggregates that might otherwise harm the patient. Usually a standard the link micron filter

answer

170-260 µm filter

question

Although you can administer blood safely through a 22-25 gauge catheter, use a blank gauge catheter. Larger Cathers encourage blood flow and reduce the risk of hemolysis

answer

18 to 20 gauge catheter

question

With the exception of blank, never add or infuse medications and IV solutions unless they have met two criteria by the FDA

answer

0.9% sodium chloride

question

Never use blank solutions with blood, because glucose causes red blood cell aggregation

answer

Dextrose containing solutions

question

Because they are stored at room temperature, blank are the most likely of all blood products to become contaminated with bacteria

answer

Platelets

question

From the time the integrity of the bag is broken, make sure the unit is transfused within blank. This is the maximum time a blood unit may infuse at a room temperature

answer

Four hours

question

Start the infusion within blank minutes of its issue from the blood bank. If the blood is not going to be transfused return it to the blood bank within this time also

answer

30

question

If the bag is spiked with an administration set and kept refrigerated between 34° and 43°F, keep in mind that the bag expires in

answer

24 hours

question

What is autologous transfusion

answer

The process of collecting, storing and reinfusing the patient's own blood

question

What is directed donation

answer

Patients select their own donors in an attempt to ensure safety.

question

What are febrile non-hemolytic transfusion reactions

answer

Accounts for about 90% of all reactions. Most common in patients who are immunosuppressive or pregnant. Symptoms include chills followed by a temperature increase of more than 1.8°F from baseline develop any time from 30 minutes after the transfusion is started to six hours after it is completed. In addition muscle stiffness, headache flushed appearance and nervousness can appear

question

What is acute intravascular hemolytic reaction

answer

It is an antigen - anti-body immune mediated reaction. Most common causes are errors in blood component labeling or patient identification. A potentially fatal reaction. Initial symptoms are pain at the IV site, elevated heart rate, chills, fever, anxiety, nausea, back pain and difficulty breathing

question

A reaction that results in symptoms similar to those of an acute intravascular hemolytic reaction is immune mediated hemolysis. What happens during this reaction

answer

Red blood cells become hemolyzed by high temperatures resulting from improper shipping or storage or heating of the blood, it can also result from unapproved pressurized administration devices, The use of small bore needles for administration, adding drugs or concentrated solutions to the blood or using unapproved solutions for Y set priming

question

An allergic reaction can develop at any time during the transfusion and up to one hour after completion. Most of these reactions are mild and subside with antihistamines. Symptoms include

answer

Hives, itching and Flushing

question

Transfusion related acute lung injury is the leading cause of transfusion related deaths. The symptoms may develop at any time during the transfusion to within six hours after the transfusion is completed. Symptoms include

answer

Chills and set in respiratory distress, which can lead to respiratory failure, pulmonary edema may also present

question

Graft versus host disease develops primarily in immune compromised individuals, when T lymphocytes in the transfused component attack and react against tissue antigens in the recipient. Is a rare but serious complication. Symptoms develop days to weeks following the transfusion and include

answer

Skin rash, fever, jaundice and bone marrow suppression. Irradiating blood components is the only known and approved method of inactivating T lymphocytes

question

Post transfusion Purpura is a rare complication arising 7 to 10 days after blood transfusion. A dramatic, sudden, but self limiting destruction of native and transfuse platelets results from an immune response to

answer

platelet specific antigens

question

Circulatory overload results when your patient is unable to tolerate the rate or volume of the blood product being transfused. Mild symptoms are

answer

Difficulty breathing, cough, rapid heart rate, and hypertension.

question

What should you do to reduce the incidence of circulatory overload

answer

Infuse the blood component at the prescribed rate typically no faster than 2-4 mL/kg/hr.

question

You just initiated a blood transfusion him. Your highest priority action at this point is to remain with the patient for

answer

15 to 30 minutes

question

What is a normal human platelet count range

answer

From 150,000 to 450,000 platelets per microliter of blood

question

One common definition of thrombocytopenia is a platelet count below

answer

50,000 per microliter

question

What is a classic symptom of a septic reaction from a blood transfusion

answer

Hypotension. Other symptoms include rapid onset of chills, fever

question

How often can a patient donate blood for an autologous infusion

answer

Every 3 to 4 days

question

What do you autologous infusions eliminate the risk for

answer

alloimmunization

question

Practice tests modules

answer

...

question

What must be done for any patient before pain medication can be administered

answer

Assess for pain which means you must examine the body part of a child first before you can administer medication

question

A nurse is precepting a newly licensed nurse who is preparing to help a patient perform tracheostomy care. The nurse should intervene if the equipment the preceptee gathered included

answer

Cotton balls

question

While measuring a clients vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate

answer

Count the apical pulse rate for one full minute and describe the rhythm in the chart

question

A simultaneously apical/radial pulse is used to identify a

answer

Deficit between The apical and radial pulse rates. It is not used to assess irregularity in the pulse

question

What kind of thermometer do you want for patient requiring rectal temperature monitoring

answer

One with a short, blunt insertion end

question

A nurse is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the nurse

answer

Refrigerate the collected specimen

question

Oxygen toxicity is associated with oxygen concentrations above blank for longer than 24 to 48 hours

answer

50%

question

A client is recovering from gallbladder surgery performed under general anesthesia. The nurse should encourage the client to use the incentive spirometer how many times per an hour

answer

4 to 5

question

A nurse is teaching a client with the new colostomy about how to irrigate the ostomy The nurse realizes that the client needs further teaching when the client

answer

Positions the irrigating solution bag 30 inches above the stoma

question

A critical concept related to effect of cardiac chest compressions is to

answer

Push hard and deep on the chest

question

A nurse has inserted an indwelling urinary catheter for a mail client. Where should the nurse take the catheter to prevent pressure on the clients urethra at the penoscrotal junction

answer

Lower abdomen

question

Tilting your head forward helps promote what while eating

answer

Swallowing

question

What nutrient can depress the respiratory system

answer

Magnesium

question

What classification is the drug tamoxifen

answer

Anti-estrogenic and anti-neoplastic's

question

Gemfibozil is indicated for

answer

Hyperlipidemia

question

What is the medication ergotamine tartrate indicated for

answer

Migraine headaches

question

What is a really good indicator of renal function

answer

Serum creatinine levels

question

Metoclopramide is a

answer

Antiemetic

question

Following a cerebrovascular accident, the patient is at high risk for what

answer

Airway obstruction and aspiration due to loss of muscle control

question

Antihistamines should be used cautiously in patients who have

answer

Glaucoma

question

What is a food that's contraindicated in people that have gout

answer

Lentil soup

question

The term co- morbidity refers to medical conditions knowing to

answer

Coexist in a patient

question

Adequate folic acid intake is associated with a reduced risk for

answer

Heart disease

question

What are foods that are rich with folic acid

answer

Orange juice, beans, legumes, Green leafy vegetables

question

A nurses caring for a client who is immobilized knows that, without interventions to prevent constipation and fecal impaction, this client is at risk for

answer

Intestinal obstruction

question

A patient is prescribed a hypothermia blanket. When caring for the patient the nurse should place

answer

A layer of cloth between the client and the blanket

question

When giving an enema the solution bag should be placed A maximum of blank feet above the client

answer

2

question

A post operative clients knee dressing becomes completely saturated with blood one hour after transferred to the clinical unit. What is an appropriate nursing action

answer

Apply direct pressure to the operative site

question

A nurse caring for pre-operative client and ministers atropine as prescribed to

answer

Minimize oral and respiratory secretions. Anti-cholinergic medications are given to dry the oral and respiratory mucous membranes

question

A nurses caring for a patient who has acute renal failure. The nurse knows that on a day to day basis the most accurate measure of the clients fluid status is the

answer

Daily weight

question

Active range of motion is preformed before passive range of motion to determine limitation of movement. This helps ensure that

answer

No injury will develop during passive range of motion

question

A hypothermia blanket is used to

answer

Cool a client with a high fever and responsive to antipyretics

question

Fluorouracil is an anti-neoplastic drug that is also classified as a

answer

Antimetabolite

question

Total parenteral nutrition should have a uniform, usually milky white blank and blank

answer

Consistency and appearance

question

Pepto-Bismol is used in the treatment of peptic ulcer disease because of its

answer

Antimicrobial action

question

A nurse is preparing to administer IM Iron dextran to a client. What is the appropriate site for administration

answer

The vastus lateralis muscle is a large muscle used when iron dextran is administered

question

What is cyclosporine used for

answer

Immunosuppressive agent. Patients that receive organ transplants will need to take them for the rest of their lives

question

Glucocorticoids should not be taken on it empty stomach. In addition some of the side effects of long-term glucocorticoid therapy can be avoided by using

answer

Alternate day therapy

question

Saw Palmetto is used primarily for symptoms related to

answer

Prostatic conditions such as benign prostatic hypertrophy

question

A patient taking isoniazid will need frequent monitoring of what

answer

AST as part of liver function tests

question

What is a sign of digoxin toxicity

answer

Nausea so you should assess the apical pulse if a patient complains of nausea

question

Patients are instructed to withhold digoxin at the heart rate is below

answer

60/minutes

question

The onset of action for a regular insulin is blank with a peak of blank

answer

30-60 minutes, 2 to 4 hours

question

Theophylline is a xanthine derivative bronchodilator. The earliest manifestation of toxicity is

answer

CNS stimulation often seen as tremors. Other symptoms include insomnia, confusion and irritability

question

What are the stages of grief

answer

Denial, anger, bargaining, depression, acceptance

question

What are the things that would help a bowel training program

answer

Increase of fiber, increase of fluid to 2500-3000 mL, and an increase in exercise

question

Where should transdermal medication patches be applied on older adults

answer

Hairless area of the torso

question

What is Agnosia

answer

The inability to identify familiar objects

question

Tympanometry measures variations in air pressure in the external ear canal. This test may cause

answer

Transient vertigo, nausea or dizziness

question

Oxygen can provide comfort and is not considered resuscitative when given by

answer

Nasal cannula for patients that have a no resuscitate order

question

What is oliguria

answer

Low output of urine

question

A hydraulic lift device requires how many staff members

answer

Two

question

Phases of korotkoff sounds

answer

...

question

What is phase 1

answer

Sound is sharp thump or tapping that corresponds with The patient's systolic blood pressure

question

What is phase 2

answer

The sound is blowing, swishing, or whooshing

question

What is phase 3

answer

Sound is crisp, steady, intense tapping. This phase approximates the midpoint between the clients systolic and diastolic pressure

question

What is phase 4

answer

Soft, blowing or muffled sound that fades

question

A nurses caring for a patient is post operative. Which of the following intervention should the nurse plan to prevent nausea

answer

Provide clear liquids as peristalsis returns

question

An infant should be able to hold their head steady by what age

answer

Six months

question

For patients with gastrostomy tube how often do their feeding bags need to be replaced

answer

Every 24 hours

question

The first step in reducing anxiety is to promote

answer

Relaxation

question

Process of a 24 hour urine collection

answer

The first voiding is discarded and all other subsequent voiding's are collected

question

Raltegravir just treat patients with

answer

HIV

question

What are symptoms of a Tylenol overdose

answer

Diaphoresis, nausea and diarrhea

question

What kind of medication is a macrolide an acceptable alternative to penicillin

answer

Erythromycin

question

A patient who is taking Keflex Long term should be monitored for renal function by which laboratory test

answer

Creatinine

question

What is suprainfection

answer

Infection caused by antibiotics

question

Can a nurse caring for a patient with tuberculosis use antimicrobial hand sanitizer

answer

Yes

question

A serum albumin level below 3 g/dL indicates

answer

Protein deficiency, putting a patient at risk for pressure ulcer formation and poor wound healing

question

A nurse is caring for a patient who has an NG tube that is irrigated every eight hours. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance

answer

.9% sodium chloride

question

Arterial bruits are blowing sounds resulting from

answer

Blood flowing through occluded or narrow arteries

question

A patient fluid output should approximate the

answer

Daily fluid intake

question

What is a symptom that should indicate to a nurse the need to section a clients tracheostomy

answer

Irritability

question

What are symptoms of decreased oxygen to the tissues A.k.a. hypoxemia

answer

Irritability, hypertension, pallor, tachycardia

question

Infiltration is indicated by

answer

Cool skin, blanching

question

A nurse is planning care for a patient who has dysphasia following a stroke. The nurse should initiate a referral for which of the following therapies

answer

Speech therapy

question

And adolescent who has visible accessory muscle movement while breathing is demonstrating labored breathing. Which is an

answer

Abnormal finding

question

A nurse is providing discharge teaching for a patient who has a prescription for a home oxygen concentrator. Which of the following instructions should the nurse give to the patient and his family

answer

Check the cord routinely for frays or tearing, consider purchasing a generator for back up power, monitor for signs of hypoxia

question

How far away should oxygen be kept away from a heat source

answer

At least 8 feet

question

A nurse is caring for a patient who is having difficulty voiding following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take

answer

Pour warm water over the clients perineum

question

What should patients use when they have a tracheostomy and they like to go outdoors

answer

Tracheostomy cover

question

How long should you fast before asking blood sugar test

answer

8 to 12 hours

question

A nurse has an order to remove sutures from a patient. After retrieving the suture remover Kit and applying sterile gloves what should the nurse do next

answer

Clean the sutures along the incision site

question

What kind of data she do document in the medical record

answer

Objective

question

What should the nurse do when providing medication reconciliation for a newly admitted patient

answer

Compare the patient's home medications with the providers prescriptions while performing medication reconciliation

question

Avocados are an excellent source of

answer

Potassium

question

Acceptable identifiers include

answer

A patients name, assigned identification number, telephone number, birthdate or use a barcode scanner to identify patients

question

When would you prefer a patient to a laboratory technician

answer

An example would be when a provider needs to see a patient's complete blood count results immediately

question

When would you refer a patient to an occupational therapist

answer

When a patient has difficulty using in the eating utensil with her dominant hand following a stroke (usually upper extremities)

question

When would you refer a patient to a physical therapist

answer

Following hip arthroplasty, a patient requires assistance learning to ambulate and regain strength (usually lower extremities)

question

When would you refer a patient to a respiratory therapist

answer

And example would be when a patient has a respiratory disease and is short of breath and request a nebulizer treatment

question

You should never leave dentures on

answer

A meal tray

question

Airborne precautions need to take place for diseases such as

answer

Measles, Varicella, pulmonary or laryngeal tuberculosis

question

Droplet precautions need to take place for diseases such as

answer

Streptococcal pharyngitis or pneumonia, influenza type B, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia and sepsis, pneumonic plague

question

Contact precautions need to be in place for patients that have

answer

Respiratory Syncytial virus, shigella, enteric diseases, wound infections, herpes Symplex, impetigo, scabies and multi-drug-resistant organisms

question

The Crede's maneuver helps to manage

answer

Reflex incontinence

question

What is for Borborygmi

answer

Unexpected loud growling sounds that indicate increased gastrointestinal motility, such as in cases of diarrhea

question

If gastric residual before and NG tube feeding exceeds 250 mL for each of two consecutive assessments what should you do

answer

Withhold the feeding, notify the provider, maintain semi Fowler's position and recheck residual in one hour

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