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Fundamentals Test 1

Exam 1

QuestionAnswer
This is an oxygen delivery system delivering between 1-6 L/M and an O2 concentration of 24- 44%. Nasal Cannula
This oxygen delivery system delivers between 6-12 L/M and an O2 concentration of 35- 50% Simple Face Mask
This oxygen delivery system has a bag that should remain inflated at all times and delivers between 10-15 L/M and an O2 concentration of 60- 90%. Partial Nonrebreather or Non rebreather
This oxygen delivery system has attachable colorful adapters that delivers variable liters with O2 concentrations from 24 to 50%. Venturi Mask
The NAP reports that your patient who uses an oxygen delivery system has had a change in vital signs, has become disoriented, and they are extremely fatigued. What do you expect the patient is experiencing? Hypoxia
You inject a medication into an area of poor circulation on the patient. What portion of pharmacokinetics are you most worried about ? Absorption
Which form of topical medication is applied over a long period and should be removed before administering another dose? Transdermal Patch
After seeing a patient, the physician gives the nursing student a verbal order for a new medication. What should the nursing student do first? Explain to the physician that the order should be given to a registered nurse. Students can not take orders.
The nurse has delegated the task of applying O2 to the NAP. What statement by the NAP indicates a need for further teaching? "I will increase the flow rate if the patient's O2 saturation level decreases."
An incentive spirometer helps a patient to deep breathe, but what does it measure? Inspiratory volume
What assessment tool is used for early detection of pressure ulcers? Braden Scale
A higher score on the Braden Scale indicates what? Patient is not at risk for pressure ulcers.
The nurse must use what technique to determine if a patient is developing a pressure ulcer? Blanch Test
What are the pressure points that contribute to the development of pressure ulcers? Select all that apply: Hips (trochanter), Hinny (buttocks), Heels, Coccyx, Sacrum, Elbows, Beneath medical devices
Patients located at what two facilities are most at risk for developing pressure ulcers? Nursing homes and ICUs
To prevent the development of pressure ulcers, it is important to keep the skin ___________ and _________ AT ALL TIMES! Clean and dry
What are the six risks for pressure ulcers? Impaired Mobility, Sensory Perception, LOC, Nutrition, Friction, Shear
It is best to put a patient in what position to avoid developing a pressure ulcer on the sacrum? SIMs
What’s desirable to include in a diet for a patient on bed rest? Bran cereal and milk
During a transfer from bed to stretcher, a patient's skin and subcutaneous tissue adhered to the surface of the bed while the layers of muscle and bone slid in the direction of body movement. What occurred? Shear
What occurs when the patient's skin is dragged rather than lifted during a position change? Friction
What nutrients are needed for pressure ulcer healing? Calories, Protein, Minerals, Vitamins, Fluids
When assisting a patient with meals, what position should the patient be in? High-Fowlers (Head of bed 60 degrees)
A patient with dementia or parkinsons disease may be placed on what type of diet? Soft diet
The NAP is assisting a stroke patient with meals, the patient has right sided weakness. The NAP should help the patient feed on the ___________ side. Unaffected/Left
A patient with edentulism is given pudding, apple sauce, cereal and gummy worms. Which of these items should not be on the patient's place? Gummy worms
A patient with hypertension should be ordered what type of diet? Low sodium
What resources are available for patients with Rheumatoid Arthritis who may need assistance with meals? Occupational Therapy, Spoons w/ straps
This type of diet consists of broth, ice chips, sprite, coffee, jello-o, and clear fruit juice Clear Liquid
This type of diet consists of ice cream, milkshake, cream of chicken, yogurt and pudding Full Liquid
This type of diet consists of pureed foods. Soft Diet
It is important to make sure a patient with dementia is not _____________ their food. Pocketing
What are the landmarks for a deltoid injection? Acromion process and Axilla
What are the landmarks for a ventrogluteal injection? Greater Trochanter of the Femur, Anterior Superior Iliac Spine, Iliac Crest
What are the landmarks for a vastus lateralis injection? Greater Trochanter of the Femur and Lateral Femoral Condyle
What are the landmarks for an abdomen injection? Below costal margins to iliac crests, at least 2 inches away from umbilicus
Why does the student nurse that states, "I will document my medication administration prior to going in to the patients room," need more teaching? You are required to document any medication administration AFTER giving the medication.
What are the 8 rights of medication administration? Right patient, medication, dose, route, time, documentation, reason, and response
How long should it take for a patient to see effects from a anxiety or depression medication? A couple weeks.
What should be included in medication administration documentation? Time, route, site of injection, and any labs or vital signs.
After pulling the medication from the pyxis that new nurse immediately begins drawing up the medication. Where did she go wrong? Before the medication is drawn up the nurse is supposed to check if the medication is expired and also compare the medication to the MAR
This type of injection is given intradermal and requires 0.1mL or medication. TB skin test.
A nurse has an order to administer a TB skin test. During her initial assessment the nurse realizes that the patient previously had the BCG vaccine what should she do next? The nurse should not give the skin test and notify the provider. The BCG vaccine will cause for the test to show a false positive.
What are the contraindications for the Tb skin test? Previous prior test and BCG vaccine.
What are the patient teachings for the PPD test? You will come back within 48-72 hours for your results to be examined.
A health care worker comes in to have their PPD test read 2 days after administration and she has 10+ mm induration what does this mean? The test results are positive. A person with some risk would be a healthcare worker or a person who comes from an area where Tb is prevalent.
The nurse had an order for Heparin, she has completed the proper steps for medication administration she is assess the abdomen and notices that the patient has a large tattoo in the lower right quadrant what should she do next? She should administer the medication in the lower left quadrant 2 inches away form the umbilicus and rotate the site slightly from the last injection.
Created by: KimeleS