Shared Flashcard Set

Details

Fundamentals Exam 1
Hygiene, mobility, wounds, infection control, nursing process, documentation, teaching
162
Nursing
Undergraduate 2
01/19/2015

Additional Nursing Flashcards

 


 

Cards

Term

The nurse delegates a patient's back massage to nursing assistive personnel (NAP). Which statement by the NAP requires the nurse to follow up?

  1. "She likes that special lotion her daughter brought. I'll see if she wants me to use it."
  2. "The muscles of her lower back twitch when I start to rub it, but they calm down if I keep massaging her.” "
  3. "She's been complaining of soreness in her shoulders. I'll give them special attention."
  4. "The family usually visits about now. I'll check and see if she wants to wait until later."
Definition
The muscles of her lower back twitch when I start to rub it, but they calm down if I keep massaging her.
Term

 The nurse would not offer back massage to which of the following patients?

  1. Patient with abdominal pain 
  2. Patient who has a controlled-release transdermal analgesic patch 
  3. Patient who receives peritoneal dialysis for renal failure 
  4. Patient who is receiving continuous epidural analgesia
Definition
Patient who is receiving continuous epidural analgesia
Term

Which instruction would the nurse give when asking nursing assistive personnel (NAP) to give a complete bed bath to a patient? 

  1. Do not massage any reddened areas on the patient's skin. 
  2. Be sure to wash the patient's face with soap. 
  3. Disconnect the intravenous tubing when changing the gown. 
  4. Wear gloves if necessary.
Definition
Do not massage any reddened areas on the patient's skin.
Term

The nurse has delegated a male patient's perineal care to the nursing assistive personnel (NAP). Which statement made by the NAP requires the nurse's follow-up? 

  1. "I will check to see if he cleans himself well."
  2. "I will let you know if I see any redness or drainage."
  3. "I will ask him if he is experiencing any pain in that area"
  4. "I will be sure to use hot, soapy water to be sure he's clean."
Definition
"I will be sure to use hot, soapy water to be sure he's clean."
Term

Which of the following interventions directly related to patient safety must the nurse consider when providing perineal care to an elderly male patient with a catheter?

  1. Wear clean gloves during care.
  2. Assess the patient's ability to provide self-care.
  3. Encourage the patient to report any pain originating from the catheter.
  4. Monitor the amount of urine in the drainage bag to prevent overflow.
Definition
Wear clean gloves during care.
Term

The nurse observes the nursing assistive personnel (NAP) providing perineal care to a male patient. Which observation of care requires the nurse's follow-up?

  1. Assisting the patient into the supine position in bed
  2. Cleansing the tip of the penis with a circular motion, starting at the meatus
  3. Reserving the cleansing of the tip of the penis as the final step in perineal care
  4. Using a gloved hand to grasp the shaft of the penis in order to retract the foreskin
Definition
Reserving the cleansing of the tip of the penis as the final step in perineal care
Term

When preparing to delegate a patient's back massage to nursing assistive personnel (NAP), the nurse would do what first?

  1. Observe the NAP performing the skill
  2. Determine if the NAP has enough muscle endurance to give a complete back massage
  3. Assess the NAP's understanding of the proper technique for back massage
  4. Have the NAP determine whether the patient is interested in a back massage
Definition
Assess the NAP's understanding of the proper technique for back massage
Term

A male patient receiving perineal care tells the nurse "It has started to hurt a little down there." What is the nurse's best response? 

  1. "When did you start experiencing the pain?"
  2. "Rate the pain on a scale of 1 to 10."
  3. "I'll assess your perineal area for the possible cause of the pain."
  4. "Would you like some pain medication before I continue with your care?"
Definition
"When did you start experiencing the pain?"
Term

A patient is being given a bed bath. The nurse realizes that another washcloth is needed to complete the bath. What is one way in which the nurse can ensure the patient's safety?

  1. Use the call light to ask someone else to bring a washcloth.
  2. Raise all four side rails on the patient's bed.
  3. Make sure the call light is within the patient's reach.
  4. Raise the bed to its highest position.
Definition
Make sure the call light is within the patient's reach.
Term

 As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, "I can do that myself." Which action would be the priority?

  1. Provide all the necessary supplies and linen for this task.
  2. Assess the patient's ability to perform proper perineal care.
  3. Ensure that the patient has privacy while performing perineal care.
  4. Document any complaints of irritation or pain in the perineal area.
Definition
Assess the patient's ability to perform proper perineal care.
Term

How can the nurse promote infection control while providing perineal care for a female patient who has a catheter?

  1. By avoiding the application of tension on the catheter
  2. By patting, not rubbing, the skin dry after thoroughly rinsing it
  3. By cleansing the patient's labia from the pubic area toward the rectum
  4. By using warm water to cleanse the patient's entire perineal area
Definition
By cleansing the patient's labia from the pubic area toward the rectum
Term

The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care? 

  1. Supine
  2. Prone
  3. Side-lying 
  4. Dorsal recumbent
Definition
Dorsal recumbent
Term

What is the primary reason for performing perineal care on a male patient with incontinence?

  1. To provide comfort and a relaxed, refreshed feeling
  2. To promote personal hygiene while minimizing perineal odor
  3. To remove all microorganisms from the patient's perineal area
  4. To reduce the risk of skin breakdown in the patient's genital and perineal area.
Definition
To reduce the risk of skin breakdown in the patient's genital and perineal area.
Term

The nurse is assisting a patient with a tub bath. After the patient has been safely positioned in the tub, he tells the nurse, "I'll call you when I'm done." What is the nurse's best response? 

  1. "All right. Just holler when you're ready, and I'll come help you get out of the tub."
  2. "Well, I'll check back with you in about 5 minutes to see if you need anything."
  3. "That's not safe. I'll wait right outside the door for you to finish."
  4. "I'll be back in 15 minutes. That should be enough time for you to finish up."
Definition
"Well, I'll check back with you in about 5 minutes to see if you need anything."
Term

 A patient with difficulty breathing requests a back massage. In which position would the nurse instruct nursing assistive personnel (NAP) to place the patient during the massage? 

  1. Prone 
  2. Side-lying 
  3. Supine 
  4. Fowler’s
Definition
Side-lying 
Term

When preparing to help a male patient shave, why does the nurse first review the patient’s medical history? 

  1. To determine the patient’s risk of bleeding 
  2. To see how often he prefers to shave 
  3. To learn which is his dominant hand 
  4. To determine whether he can perform the task himself
Definition
To determine the patient’s risk of bleeding
Term

Why would the nurse encourage a male patient to use an electric razor for shaving? 

  1. To reduce the use of hospital supplies
  2. To reduce the risk of infection 
  3. To reduce the risk of bleeding from a disposable razor 
  4. To encourage him to shave himself
Definition
To reduce the risk of bleeding from a disposable razor 
Term

Which action is most important in minimizing the patient's risk for injury when preparing to shave a patient with a history of bleeding?

  1. Fully explain the process to the patient in order to secure his cooperation.
  2. Pay particular attention to technique in order to avoid nicks and cuts.
  3. Ensure that the provider has ordered the intervention.
  4. Review current platelet count and anticoagulation studies.
Definition
  1. Review current platelet count and anticoagulation studies.
Term

What is the best way for the nurse to ensure that the patient is comfortable while he is being shaved?

  1. Administer a prescribed analgesic 30 minutes before beginning the procedure.
  2. Gently pull the skin taut in order to avoid nicks and cuts.
  3. Ask the patient if he is comfortable several times during the procedure.
  4. Encourage the patient to shave himself if he is capable of doing so.
Definition
Ask the patient if he is comfortable several times during the procedure.
Term

When preparing to provide mouth care to a patient who is in a coma, the nurse first ensures patient safety by doing what?

  1. Assessing the patient’s gag reflex
  2. Inspecting the patient’s oral cavity
  3. Placing the bed in a flat position
  4. Connecting the suction equipment
Definition
Assessing the patient’s gag reflex
Term

The nurse is planning to insert an oral airway into an unconscious patient before performing mouth care. In which direction is the airway initially inserted into the patient’s mouth?

  1. Upside down, or with the curve facing up 
  2. Right side up, or with the curve facing down 
  3. With the curve angled toward the patient’s left cheek 
  4. With the curve angled toward the patient’s right cheek
Definition
Upside down, or with the curve facing up 
Term

When preparing to clean a patient’s dentures using the sink, the nurse first protects the dentures by doing what?

  1. Padding the sink basin with a washcloth 
  2. Performing hand hygiene 
  3. Filling the sink with cold water
  4. Filling the sink with hot water
Definition
Padding the sink basin with a washcloth 
Term

 Under what circumstances would the nurse assume responsibility for providing denture care for a patient? 

  1. Assessment of the oral cavity shows mucositis due to chemotherapy.
  2. The patient’s previous set of dentures was misplaced or thrown away. 
  3. The dentures belong to the hospital or other facility, rather than to the patient. 
  4. The patient is unable to care for the dentures on his or her own.
Definition
The patient is unable to care for the dentures on his or her own.
Term

A patient tells the nurse that at home he cleans his dentures after every meal and before going to bed. When would denture care be planned for this patient while hospitalized? 

  1. After breakfast and before going to bed 
  2. With morning care 
  3. With morning and evening care 
  4. After every meal and before going to bed
Definition
After every meal and before going to bed
Term

 What is the primary reason the nurse encourages the patient to participate in hair care? 

  1. To free up the staff’s time for patient care
  2. To make sure the care is performed according to the patient’s preferences 
  3. To encourage the patient’s sense of independence 
  4. To allow the nurse to evaluate the patient’s ability to manipulate objects
Definition
To encourage the patient’s sense of independence 
Term

What is the purpose of parting the patient’s hair into sections?

  1. To identify the areas to be groomed
  2. To style the hair attractively
  3. To check for pediculosis (head lice)
  4. To make brushing and combing more effective
Definition
To make brushing and combing more effective
Term

For which of the following patients would it be necessary to use a disposable shampoo cap, rather than a shampoo board?

  1. An older adult woman with a drainage tube in place following a mastectomy 
  2. An older adult man with a history of bleeding problems 
  3. A young woman whose arm and leg have been immobilized on the right side following a car accident
  4. A young man who has sustained a fracture of the upper spine in a football game
Definition
A young man who has sustained a fracture of the upper spine in a football game
Term

Which action should be avoided when providing hair care for a bed-bound patient with a history of dizziness? 

  1. Raising the patient quickly into a sitting position after completing a bed shampoo
  2. Getting water into the patient’s ears during the rinsing phase of the shampoo
  3. Placing the neck in a hyperextended position during the shampoo process
  4. Having the entire shampooing process last longer than 15 minutes
Definition
Placing the neck in a hyperextended position during the shampoo process
Term

For which patient would the nurse most likely ask for a podiatrist consult for nail care? 

  1. A middle-aged man with type 2 diabetes mellitus who feels tingling in his right foot
  2. A middle-aged man with mobility impairment that has lasted several weeks after a fall from a ladder
  3. An older adult woman with dementia who has broken her pelvis after falling on the kitchen floor
  4. A 12-year-old girl with a broken foot
Definition
  1. A middle-aged man with type 2 diabetes mellitus who feels tingling in his right foot
Term

Why would the nurse plan to perform foot care for a patient with peripheral vascular disease (PVD), rather than delegate this activity to nursing assistive personnel (NAP)? 

  1. The patient prefers that the nurse provide the care. 
  2. NAP are not trained to perform foot care. 
  3. The patient’s elevated risk of infection makes it unsafe for NAP to perform the care. 
  4. The patient’s condition requires that he remain on bed rest.
Definition
The patient’s elevated risk of infection makes it unsafe for NAP to perform the care. 
Term

Which action would the nurse encourage an older adult with foot problems to take at home? 

  1. Apply oval pads to treat corns. 
  2. Wear socks made of natural fibers. 
  3. Carefully shave off calluses with a razor blade. 
  4. If a bandage is needed, apply gauze squares with adhesive tape.
Definition
Wear socks made of natural fibers. 
Term

In providing foot care, the nurse would soak the feet and hands of which patient? 

  1. A 30-year-old man with type 1 diabetes
  2. An 86-year-old woman with generalized weakness 
  3. A 56-year-old patient with vascular insufficiency who was bathed the day before
  4. A 56-year-old patient with vascular insufficiency who was not bathed the day before
Definition
An 86-year-old woman with generalized weakness 
Term

A patient with diabetes remarks during foot care that she has been letting her skin air-dry after bathing at home because her doctor told her to use plenty of moisturizer on her hands and feet. What should the nurse teach the patient?

  1. To apply moisturizer after air-drying thoroughly
  2. To apply moisturizer while the skin is still wet 
  3. To skip the moisturizer 
  4. To towel-dry thoroughly before applying moisturizer
Definition
To towel-dry thoroughly before applying moisturizer
Term

The nurse is preparing to perform a sterile procedure for a patient. Which action will best minimize the risk of infection during the procedure?

  1. Administer a prophylactic antibiotic before the procedure, as prescribed.
  2. Follow sterile technique during the procedure.
  3. Ensure proper hand hygiene before the procedure.
  4. Educate the patient in order to minimize movement and talking during the procedure.
Definition
Follow sterile technique during the procedure.
Term

While preparing a sterile field, the nurse determines that additional supplies are needed. What will the nurse do to ensure that the sterile field is maintained? 

  1. Cover the field with a sterile drape before leaving the room.
  2. Collect the necessary supplies after preparing a new sterile field.
  3. Retrieve the supplies, but instruct the patient not to touch anything on the field.
  4. Ask the assistant who has been helping with the procedure to bring the necessary supplies.
Definition
Ask the assistant who has been helping with the procedure to bring the necessary supplies.
Term

 What direction would the nurse provide to nursing assistive personnel (NAP) while establishing and maintaining a sterile field? 

  1. “This work surface is too low. Choose a surface that’s above your waist.”
  2. “Begin to establish the sterile field here on the overbed table.”
  3. “Be careful to touch only the outer 1-inch edge of the sterile drape.”
  4. “Remember, reaching over the sterile field constitutes a break in sterile technique.”
Definition
“Remember, reaching over the sterile field constitutes a break in sterile technique.”
Term

While preparing a sterile field, the nurse notes that a portion of the sterile drape has come into contact with the patient’s gown. Which action is most appropriate in this situation?

  1. Place the sterile supplies only on the portion of the drape that did not touch the gown.
  2. Collect the supplies necessary and establish a new sterile field.
  3. Determine if the contact occurred within the outer 1-inch perimeter of the drape.
  4. Establish the sterile field on the opposite side of the drape.
Definition
Collect the supplies necessary and establish a new sterile field.

Term

Why might the nurse offer the patient a bedpan before establishing a sterile field? 

  1. Anticipating what the patient might need during a lengthy sterile procedure will minimize patient movement.
  2. A patient’s becoming incontinent constitutes a breach in sterile technique.
  3. Refocusing the patient’s attention on a task decreases anxiety.
  4. Assessing the patient’s ability to follow instructions will help the nurse maintain the sterile field.
Definition
Anticipating what the patient might need during a lengthy sterile procedure will minimize patient movement.
Term

The nurse is placing supplies on a sterile field that is being prepared for a dressing change. Which action is likely to contaminate the field?

  1. Placing a role of sterile tape on the field 
  2. Holding a prepackaged sterile item in the nondominant hand while opening it
  3. Adding supplies that will expire in 2 days
  4. Placing the needed supplies near the back of the sterile field
Definition
Placing the needed supplies near the back of the sterile field
Term

A patient requires all of the following interventions. Which one would the nurse perform last?

  1. Change the dressing on the patient’s newly established suprapubic catheter.
  2. Administer the patient’s prescribed medication.
  3. Offer the patient a bedpan.
  4. Position the patient for maximum comfort and ease of breathing.
Definition
Change the dressing on the patient’s newly established suprapubic catheter.
Term

Which direction to nursing assistive personnel (NAP) would help to maintain a sterile field while conducting a sterile procedure? 

  1. “Please see to it that nothing contaminates this sterile field while I get some additional supplies.”
  2. “I’d like you to make sure that the patient doesn’t reach toward the sterile field while I’m changing the dressing.”
  3. “Hand me the item closest to the edge of the sterile field.” 
  4. “Place a sterile drape over these supplies for a moment while I answer my other patient’s call light.”
Definition
“I’d like you to make sure that the patient doesn’t reach toward the sterile field while I’m changing the dressing.”
Term

While preparing supplies on a sterile field, a gauze pad falls off the sterile field. What should the nurse do? 

  1. Nothing 
  2. Create a new sterile field 
  3. Use sterile forceps to move the gauze pad toward the center of the sterile field
  4. Dispose of the gauze before continuing the procedure
Definition
Nothing 
Term

Which action would minimize the risk of infection when placing prepackaged supplies on an established sterile field? 

  1. Wear clean treatment gloves.
  2. Collect supplies with sterile gloves to avoid contamination.
  3. Do not allow the wrapper to touch the sterile field.
  4. Place the supplies in the 1-inch perimeter of the sterile field.
Definition
Do not allow the wrapper to touch the sterile field.
Term

When adding a sterile liquid to a sterile field, which action will contaminate the field? 

  1. Extending your arm over the sterile field to pour the liquid into the receptacle
  2. Holding the bottle with the label facing the palm 
  3. Adding a liquid with a usable period that expires in 2 days
  4. Placing the receptacle 1 inch (about 2.5 cm) from the edge of the sterile field
Definition
Extending your arm over the sterile field to pour the liquid into the receptacle
Term

Which action is the most effective in minimizing the risk of contamination when using sterile liquids during a sterile procedure?

  1. Touch only the outer 1½ -inch margin of the sterile field unless you are wearing sterile gloves
  2. Avoid splashing when pouring sterile liquids onto the sterile field
  3. Compare the label of the solution with the specific solution necessary for the procedure
  4. Assess the patient for any known allergies to the sterile solution
Definition
Avoid splashing when pouring sterile liquids onto the sterile field
Term

What direction would the nurse provide to nursing assistive personnel (NAP) assisting with a sterile procedure in which sterile solutions are being used? 

  1. "Hand me that cup of water so I can pour it over my sterile field."
  2. "Would you please get me another bottle of sterile water?"
  3. "Pour the sterile water into the container at the edge of the field.” 
  4. "Open the sterile water bottle and hold the label so that I can see it.”
Definition
"Would you please get me another bottle of sterile water?"
Term

What would the nurse do if a sterile solution splashed onto a sterile field and contaminated the field during a dressing change? 

  1. Complete the dressing change in a timely manner
  2. Collect new supplies and prepare another sterile field
  3. Move the lip of the bottle closer to the receptacle when pouring the remaining liquid
  4. Reposition the receptacle closer to the edge of the sterile field
Definition
Collect new supplies and prepare another sterile field
Term

When pouring a sterile liquid into a container on a sterile field, why does the nurse hold the bottle with the label facing the palm of the hand? 

  1. The label is not sterile and will contaminate the field if it is splashed.
  2. The label may become illegible if it is splashed.
  3. The pour spout faces down when the bottle is held with the label facing the palm. 
  4. The hand grips on the bottle are molded to fit correctly when the label is facing the palm.
Definition
The label may become illegible if it is splashed.
Term

 What is the best reason for a nurse to select a prepackaged sterile kit for a sterile procedure? 

  1. Sterile prepackaged kits do not have expiration dates.
  2. The wrapper of the sterile kit can be used as a sterile field.
  3. Adding supplies to the sterile field takes less time than using a prepackaged kit.
  4. The prepackaged sterile kit will take up less space on the bedside table.
Definition
The wrapper of the sterile kit can be used as a sterile field.
Term

Which action is the most important step the nurse can take to keep the field sterile when using an overbed table as the work surface for a sterile field?

  1. Position the table out of the patient's reach
  2. Assess the table for stability
  3. Position the height of the table to be above waist level
  4. Assemble ahead of time any supplies and equipment not included in the kit.
Definition
Position the height of the table to be above waist level
Term

While opening a prepackaged sterile kit, a package of sterile 4 x 4s falls to the floor. What will the nurse ask ancillary staff to do to ensure the quality of the sterile field?

  1. "I will have to set up another sterile field; please take these items away."
  2. "Please go to the clean utility room and get me a package of sterile 4 x 4s."
  3. "Please watch that nothing contaminates this sterile field while I go and get a replacement item."
  4. "Explain to the patient the importance of remaining still during this procedure so no other items are contaminated."
Definition
"Please go to the clean utility room and get me a package of sterile 4 x 4s."
Term

When preparing a sterile field using a prepackaged sterile kit, what will influence the nurse’s placement of the kit on the overbed table?

  1. Tips of the flaps are easily accessible.
  2. Kit is positioned in the center of the table.
  3. Sterile contents of the kit are readily available.
  4. Outermost flap can be opened away from the nurse's body.
Definition
Outermost flap can be opened away from the nurse's body.
Term

Prior to setting up a sterile field for a sterile procedure in a patient’s room, why would the nurse ask any visitors to please leave the patient’s bedside? 

  1. Ensures that no unnecessary movement occurs that could contaminate the sterile field
  2. Limits distractions while setting up the sterile field
  3. Ensures a quiet environment during the procedure
  4. Provides privacy for the patient
Definition
Ensures that no unnecessary movement occurs that could contaminate the sterile field
Term

Which action would the nurse perform first when preparing to apply sterile gloves?

  1. Perform hand hygiene.
  2. Place the package on a stable, flat surface.
  3. Assess the glove packaging for wetness or tears.
  4. Open the outer packaging.
Definition
Assess the glove packaging for wetness or tears.
Term

When are sterile nonlatex gloves recommended for a sterile procedure? 

  1. When there is a possible sensitivity issue
  2. When the staff member prefers them
  3. When latex gloves are not conveniently available 
  4. When the patient prefers them
Definition
When there is a possible sensitivity issue
Term

What is the most important step the nurse can take to minimize the risk of tearing a sterile glove when applying it to the hands? 

  1. Using powdered sterile gloves
  2. Keeping the fingernails trimmed and smoothly filed
  3. Selecting the proper glove size
  4. Drying the hands thoroughly before applying the gloves
Definition
Selecting the proper glove size
Term

After applying sterile gloves, the patient states she is uncomfortable and would like to move to her left side. What is the best way for the nurse to keep the gloves sterile while waiting for nursing assistive personnel (NAP) to position the patient for a sterile dressing change? 

  1. Interlocking the fingers and keeping the hands above waist level
  2. Keeping the arms at the sides, with elbows bent and gloved hands pointing up
  3. Leaving the room momentarily 
  4. Stepping back from the bedside where NAP are working
Definition
Interlocking the fingers and keeping the hands above waist level
Term

 Which protocol does not vary among institutions? 

  1. Acceptability of wearing artificial nails in patient care areas
  2. Use of impervious transparent dressings to cover open lesions on nurse’s hands during sterile procedures
  3. Use of sterile gloves for sterile procedures
  4. Sterile gloves are only available in “one size fits all”
Definition
Use of sterile gloves for sterile procedures
Term

A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse’s responsibility in assessing this patient’s wound? 

  1. Remove the dressing, inspect the wound, and reapply a new dressing.
  2. Inspect the wound and reapply the surgical dressing every 2 hours. 
  3. Inspect the wound, and keep the dressing off until the health care provider arrives. 
  4. Wait until the health care provider orders the removal of the surgical dressing.
Definition
Wait until the health care provider orders the removal of the surgical dressing.
Term

Which wound would be allowed to heal by secondary intention? 

  1. Cleft lip repair
  2. Infected hysterectomy incision
  3. Exploratory laparoscopy incision
  4. Facial laceration caused by a pocket knife
Definition
Infected hysterectomy incision
Term

 Before performing a wound assessment, which nursing action would reduce the patient’s risk for infection? 

  1. Taking the patient’s temperature
  2. Applying clean gloves 
  3. Assessing the wound for drainage
  4. Assessing the dressing for drainage
Definition
Applying clean gloves
Term

Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound?

  1. Assessing the site for signs of redness or swelling
  2. Reporting the presence of wound odor
  3. Removing a soiled outer dressing
  4. Opening sterile dressings during the dressing change
Definition
Reporting the presence of wound odor
Term

The nurse notes that a patient’s surgical wound is healing slowly. Which health problem would contribute to slow wound healing?

  1. Osteoarthritis
  2. Glaucoma
  3. Deafness
  4. Diabetes mellitus
Definition
Diabetes mellitus
Term

When irrigating a wound, how would the nurse know the right amount of pressure to apply? 

  1. Calculate the wound size.
  2. Follow the general rule of keeping the pressure between 4 and 15 psi.
  3. Keep the pressure strong enough to cause moderate pain.
  4. Gentle enough that it does not create a splash off of the wound.
Definition
Follow the general rule of keeping the pressure between 4 and 15 psi.
Term

Which action should the nurse avoid before irrigating a patient’s foot wound?

  1. Assess the patient for a history of allergies to tape and irrigating solution.
  2. Review the provider’s orders for the type of irrigating solution to be used.
  3. Assess the patient’s pain on a scale of 0 to 10.
  4. Warm the irrigant to body temperature in the microwave.
Definition
Warm the irrigant to body temperature in the microwave.
Term

Which device is used for wound irrigation?

  1. 19-gauge needle attached to a 10-mL syringe 
  2. 19-gauge needle attached to a 35-mL syringe
  3. Sterile container held 30.5 cm (12 inches) above the wound
  4. Foley irrigating syringe
Definition
19-gauge needle attached to a 35-mL syringe
Term

Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient’s left heel is infected?

  1. White blood cell count
  2. Complete blood count
  3. X-ray of left foot
  4. Culture and sensitivity test
Definition
Culture and sensitivity test
Term

A nurse is irrigating a patient’s abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider?

  1. Drainage that was not present previously
  2. Redness at the abdominal suture line
  3. Granulation tissue in the wound bed
  4. The patient reports less pain
Definition
Drainage that was not present previously
Term

A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient’s pain?

  1. Premedicate the patient with a prescribed analgesic 30 minutes before the intervention.
  2. Use a distraction technique to divert the patient’s attention during the procedure.
  3. Position the patient comfortably before the intervention.
  4. Thoroughly explain the procedure to the patient.
Definition
Premedicate the patient with a prescribed analgesic 30 minutes before the intervention.
Term

Which action reduces the nurse’s risk for infection when changing the dressing of an infected abdominal wound?

  1. Begin antibiotic therapy before the dressing change.
  2. Use appropriate personal protective equipment (PPE).
  3. Adhere to sterile technique during the intervention.
  4. Complete the dressing change in an effective, timely way.
Definition
Use appropriate personal protective equipment (PPE).
Term

What is the nurse’s best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago?

  1. Notify the surgeon of the bleeding.
  2. Remove the dressing, and assess the wound.
  3. Assess the patient for signs of shock.
  4. Further assess the patient and the wound.
Definition
Further assess the patient and the wound.
Term

When changing a patient’s surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves?

  1. After performing hand hygiene at the start of the procedure
  2. Before removing the inner dressing
  3. After removing the original dressing materials and performing hand hygiene a second time
  4. Just before cleansing the wound with sterile water
Definition
After removing the original dressing materials and performing hand hygiene a second time
Term

Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound?

  1. Cleansing the wound with sterile water 
  2. Blotting the incision with dry gauze
  3. Wearing sterile gloves to cleanse the wound
  4. Using a new gauze pad for each stroke while cleansing the wound
Definition
Using a new gauze pad for each stroke while cleansing the wound
Term

What is the proper method for cleansing the evacuation port of a wound drainage system?

  1. Cleanse it with normal saline.
  2. Wash it with soap and warm water.
  3. Rinse it with sterile water.
  4. Wipe it with an alcohol sponge.
Definition
Wipe it with an alcohol sponge.
Term

What is the nursing action to set up suction for a hemovac drainage system?

  1. Set the suction to lowest level possible.
  2. Hemovacs are always set to medium suction.
  3. Connect to the wall on intermediate suction.
  4. Compress the hemovac, creating suction.
Definition
Compress the hemovac, creating suction.
Term

When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel (NAP) report immediately to the nurse as a potential abnormality? 

  1. The drainage is odorless.
  2. The drainage is straw colored.
  3. The patient doesn’t like looking at the drainage tubing.
  4. The amount of drainage was greater today than yesterday.
Definition
The amount of drainage was greater today than yesterday.
Term

Which action might the nurse perform to ensure that the wound drainage tubing does not pull on the insertion site? 

  1. Attach the tubing to the patient’s gown with a safety pin.
  2. Tape the tubing to the patient’s bed.
  3. Attach the tubing to the nearest side rail.
  4. Loop the tubing through the bed frame.
Definition
Attach the tubing to the patient’s gown with a safety pin.
Term

Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied?

  1. Pinning the tubing to the patient’s hospital gown
  2. Compressing the bulb while replacing the port cap
  3. Emptying the drainage container only when it is 90% full
  4. Placing the drainage container below the wound site
Definition
Compressing the bulb while replacing the port cap
Term

Which practice protects the nurse from infection when changing the dressing on an infected pressure ulcer?

  1. Begin antibiotic therapy before the dressing change.
  2. Use appropriate personal protective equipment.
  3. Adhere to sterile technique during the intervention.
  4. Complete the dressing change in an effective, efficient manner.
Definition
Use appropriate personal protective equipment.
Term

The wound bed of a patient’s pressure ulcer is red. What does this finding indicate to the nurse?

  1. Necrotic tissue
  2. Presence of slough
  3. Granulation tissue
  4. Development of an infection
Definition
Granulation tissue
Term

Which measurements would the nurse use to calculate the surface area of a patient’s pressure ulcer?

  1. Height and weight
  2. Length and width
  3. Length and depth
  4. Width and depth
Definition
Length and width
Term

How would the nurse safely apply an enzyme debridement ointment?

  1. Daub ointment on dead tissue at the wound edges.
  2. Put ointment on a tongue blade, and gently spread it on the center of the wound.
  3. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.
  4. Apply a gauze dressing to ensure contact with the ointment.
Definition
Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.
Term

Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure ulcers in an older adult patient?

  1. Reposition the patient at least every 2 hours.
  2. Assess the patient’s bony prominences every shift.
  3. Educate the family about the importance of healthy skin.
  4. Assist the patient in the selection of high-protein foods.
Definition
Reposition the patient at least every 2 hours.
Term

The licensed practice nurse (LPN) provides you with the 

change-of-shift vital signs on four of your patients. Which 

patient do you need to assess first?

1. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%

2. 54-year-old woman admitted after surgery for fractured 

arm, BP 160/86 mm Hg, HR 72

3. 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84

4. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62

Definition
1. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%
Term

A 56-year-old patient with diabetes admitted for communityacquired pneumonia has a temperature of 38.2° C (100.8° F) via the temporal artery. Which additional assessment data are needed in planning interventions for the patient’s infection? 

(Select all that apply.)

1. Heart rate

2. Presence of diaphoresis

3. Smoking history

4. Respiratory rate

5. Recent bowel movement

6. Blood pressure in right arm

7. Patient’s normal temperature

8. Blood pressure in distal extremity

 

 

 

Definition

1. Heart rate

 

2. Presence of diaphoresis

4. Respiratory rate

7. Patient’s normal temperature

Term
normal temperature range
Definition
96.8-100.4; 36-38
Term
avg oral/tympanic temp
Definition
98.6 (37)
Term
average rectal temp
Definition
99.5 (37.5)
Term
avg axillary temp
Definition
97.7 (36.5)
Term
order of temp sites from low to high
Definition
axillary, oral/tympanic, rectal
Term
pulse pressure
Definition
30-50 mm Hg; difference b/w systolic and diastolic pressures
Term
avg temp range of newborn
Definition
95.9-99.5 (35.5-37.5)
Term
avg temp of older adult
Definition
96.8 (36)
Term
What hormone changes a woman's body temp, and what does it do during ovulation?
Definition
progesterone-low levels lower the temp right before ovulation, and then during ovulation levels rise as to bring the temp back up to normal levels
Term
When (time of the day) is temp the lowest/highest in humans?
Definition
lowest from 1-4 am, highest at 4 pm
Term
At what temp does a fever become harmful?
Definition
above 102.2 (39)
Term
What positive things happen in the body during pyrexia?
Definition
WBC production stimulated, decreased conc. of Fe in blood (suppressing bacteria growth), and stimulates interferon to kill viruses
Term
sustained fever
Definition
constant temp above 100.4 (38) with little fluctuation
Term
intermittent fever
Definition
fever spikes interspersed with usual temp level (temp returns to acceptable value at lease once in 24 hrs)
Term
remittent fever
Definition
fever spikes and falls without a return to normal temp levels
Term
relapsing fever
Definition
periods of febrile episodes and periods with acceptable temp values (each episode lasts often longer than 24 hrs, distinguishing it from intermittent)
Term
body metabolism r/t fever
Definition
body metabolism inc. 10% for every degree C temp inc., so O2 consumption also increases
Term
difference b/w hyperthermia and fever
Definition
hyperthermia is an overload of thermoregulatory mechanisms in body whereas fever is an upward shift in the set point
Term
heatstroke
Definition
prolonged exposure to sun or environmental heat that overwhelms the heat-loss mechanisms, causing temp over 104 (40)
Term
mild, moderate, and sever hypothermia
Definition
mild is down to 93.2 (34), moderate is down to 86 (30), and severe is anything less than 86
Term
stroke volume
Definition
60-70 mL of blood enters the aorta with each ventricular contraction
Term
cardiac output
Definition
volume of blood pumped by the heart during 1 min, product of HR and SV of the ventricle; ~5000 mL/min
Term
If HR inc. without a change in SV, what occurs?
Definition
BP decreases bc the heart has less time to fill
Term
As HR slows and SV doesn't change, what occurs?
Definition
BP increases because filling time is increased
Term
If a patient's condition suddenly worsens, what site is recommended to check the pulse?
Definition
carotid
Term
When a patient takes meds that affect HR, what pulse site is recommended?
Definition
apical provides a more accurate assessment of heart function
Term
best sites for assessing infant's or child's pulse
Definition
brachial or apical because peripheral pulses are deep and difficult to palpate
Term
bell of stethoscope
Definition
transmits low-pitched sounds created by the low-velocity movement of blood; used to hear the heart and vascular soudns
Term
S1 vs S2 heart sounds
Definition
S1 is low pitched and dull, S2 is higher pitched and shorter
Term
What dysrhythmia does children often have?
Definition
sinus dysrhythmia-irregular heartbeat that speeds up with inspirations and slows with expiration
Term
elevation of arterial CO2
Definition
causes respiratory control system to inc. rate and depth of breathing to inc. expiration to remove excess CO2 (resp. acidosis caused by hypoventilation and corrected by hyperventilation)
Term
tidal volume
Definition
inhalation of usually 500 mL of air during a normal relaxed breath
Term
eupnea
Definition
aka sighing; a protective physiological mechanism for expanding small airways and alveoli not ventilaed during a normal breath; interrupts the normal rate and depth of ventilation
Term
Cheyne-Stokes respirations
Definition
irregular resp. rate and depth w/ alternating periods of apnea and hyperventilation
Term
Kussmaul's respirations
Definition
abnormally fast and deep, but regular
Term
Biot's respirations
Definition
abnormally shallow for a few breaths followed by irregular apnea
Term
SpO2 is a reliable estimate of SaO2 when ____
Definition
SaO2 is over 70%
Term
prehypertension
Definition
120 - 139/80 - 89
Term
Stage 1 hypertension
Definition
greater than 140/90
Term
Stage 2 hypertension
Definition
greater than 160/100
Term
signs of hypothermia
Definition
cyanosis, shivering, cardiac dysrhythmias, dec. bp, and dec. resp.
Term
What are three ways Benazepril (Lotensin), angiotensin-converting enzyme (ACE) inhibitor, lowers blood pressure?
Definition
lowering circulating blood volume, vasodilation, and reducing aldosterone production thereby reducing water retention
Term
Spironolactone (Aldactone), a diuretic drug, lowers blood pressure by
Definition
reducing salt and water retention and lowering circulating blood volume
Term
Factors that are likely to give a false high reading of blood pressure
Definition
too small cuff, arm not supported, cuff wrapped unevenly
Term
What is the effect of slow inflation on blood pressure readings?
Definition
false-high diastolic
Term
Palpating the artery distal to the cuff, and inflating the cuff rapidly to a pressure 30 mm Hg above the point at which the pulse disappears prevents
Definition
a false low reading
Term
What factors cause xerostomia?
Definition
medications, radiation, dehydration, and mouth breathing all leading to strong sympathetic nervous stimulation inhibiting saliva release
Term
What is the single most common precursor to lower-extremity amputation among people with diabetes?
Definition
foot ulceration
Term
Oral health is a good indicator of what?
Definition
overall health
Term
tinea pedis
Definition
athlete's foot; fungal infection causing scaling and cracking of skin and small blisters with fluid; contagious and frequently recurs
Term
plantar warts
Definition
fungating lesions on the sole of the foot caused by the papilloma virus that are sometimes contagious
Term
corns
Definition
keratosis of the foot caused by friction and pressure from ill-fitting or loose shoes; usually cone shapt, round, and raised on or b/w toes and soles; soft ones are macerated
Term
pediculosis capitis
Definition
head lice
Term
How does radiation affect oral health?
Definition
it reduces salivary flow and lowers pH of saliva, leading to stomatitis and tooth decay
Term
Patients with diabetes are prone to what oral problems?
Definition
dryness, gingivitis, periodontal disease, and loss of teeth
Term
Patients on dialysis are prone to what oral problems?
Definition
halitosis, xerostomia, gingivitis, stomatitis, tooth decay, tooth loss, and jaw problems caused by decreased saliva production, uremia, and inattention to care
Term
effleurage
Definition
long, slow, gliding strokes of massage associated with reduced measured anxiety, heart rate, and respiratory rate
Term
signs of peripheral neuropathy
Definition
muscle wasting of lower extremities, absence of deep tendon reflexes, foot deformities, infections, abnormal gait, and decreased or absent vibratory sensation
Term
signs of vascular insufficiency
Definition
decreased hair growth on legs and feet, absent or decreased pulses, infection in the foot, poor wound healing, thickened nails, shiny appearance of the skin, blanching of the skin on elevation
Term
Poor oral health puts you at risk for
Definition
impaired nutrition, stroke, poor blood sugar control in diabetics, and nursing home acquired pneumonia
Term
Peridontal disease predisposes older adults to what?
Definition
systemic infection
Term
What position do you want the bed in when providing oral hygiene to patients with decreased levels of consciousness?
Definition
semi-Fowler's
Term
Patients with stomatitis should rinse their mouth with what?
Definition
normal saline, not alchoholic or commercial mouth wash
Term
PiCOT
Definition
population, intervention, comparison, outcome, time
Term
Fowler's
Definition
HOB raised to 45 or higher, semi-sitting; for eating, NG tube insertion and suction, promotes lung expansion, and eases difficult breathing
Term
Semi-Fowler's
Definition
HOB raised ~30 degrees, less than Fowler's; promotes lung expansion esp. w/ vents, gastric feeding to reduce regurgitation and aspiration risk
Term
Trendelenburg's
Definition
entire bed frame tilted with HOB down; used fro postural drainage, facilitates venous return in pts w/ poor peripheral perfusion
Term
reverse Trendelenburg's
Definition
entire bed frame tilted w/ foot of bed down; used infrequently for promoting gastric emptying and to prevent esophageal reflux
Term
flat bed position
Definition
used for pts with vertebral injuries and in cervical traction; hypotension, sleeping
Term
PICOT
Definition
patient population, intervention, comparison (to usual standard of practice), outcome, time
Term
problem-focused trigger
Definition
asking a clinical question based on a problem you see while caring for a patient or a trend you see on a nursing unit
Term
knowledge-focused trigger
Definition
clinical question regarding new information available on a topic (recent publications) or nurse experts; sources include standards and practice guidelines available from national agencies
Term
What is the highest level of experimentation?
Definition
a randomized controlled trial
Term
an increase in lymphocytes occurs when
Definition
there is a chronic viral or bacterial infection or sepsis
Term
neutrophils are increased when
Definition
there is an acute suppurative infection
Term
monocytes are increased when
Definition
tuberculous infection
Term
order of removal of PPE
Definition
outside of room: gloves, goggles, gown, mask, hand hygiene
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