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ATI
End of Semester Test
| Question | Answer |
|---|---|
| the coordinated effort of muscles, bones, and the nervous system to maintain balance, posture, and alignment during movement, especially bending, lifting, and walking | Body Mechanics |
| circular movement of a limb or of the eye | Circumduction |
| a deformity that results from abnormal shortening of muscle tissue, making the muscle highly resistant to stretching | Contracture |
| You’ll use a ______ ______ for patients who need help with ambulation or with transferring from the bed to a chair. You’ll use a ____ _____ to move a patient from a stretcher to a bed. You’ll use a ________ ______ to reposition a patient in bed. | gait belt, transfer board,draw sheet |
| ___________ not only maintains muscle tone, muscle strength, and joint flexibility, but it also stimulates the respiratory, circulatory, and gastrointestinal systems to help each one function properly | Ambulation |
| Patients who have been immobile or on bed rest often experience _______ and __________ _____________ the first few times they sit up in bed or try to stand | vertigo and orthostatic hypotension |
| If a patient becomes weak or dizzy during ambulation and begins to fall, it is important to protect both yourself and her from injury. What should you do if a patient starts to fall? | place your arms on the gait belt or around the patient's waist and then place one leg forward and allow patient to use it for support and ease them to the floor. To help prevent injury to your lower back, bend at the knees while lowering |
| Patients who are on bed rest or immobile because of an illness, injury, or surgery are at risk for developing venous thromboembolism (VTE). What is the best way to prevent these?What other things can you do? | Ambulation is the best way to prevent DVTs. when ambulation is not an option, elastic stockings, sequential compression devices, and venous foot pumps are used to promote venous return. |
| ___________ are contraindicated for patients who have severe arterial disease. | Sequential compression devices (SCDs) |
| These provide intermittent compression to the lower extremities to promote venous return and to help prevent DVT. They can be applied to one or both lower extremities, depending on the patient’s specific needs | Sequential compression devices (SCDs) |
| For elastic stockings and sequential compression devices to be effective, they must what? | Fit properly |
| For patients who wear elastic stockings or sequential compression devices, it is important to remove them at least every ________, or according to your facility’s policy. Why should they be removed? | 8 hours, to assess skin condition and circulatory status. |
| What is a foot board and what is it used for? | A footboard is a flat panel composed of either wood or plastic. To help prevent footdrop, place it at the foot of the bed to keep the patient’s feet dorsiflexed. |
| This position is most often used when patients are receiving an enema or for an examination of the perineal area. | Sim's Position |
| For this position, the patient sits in bed or on the side of the bed with an overbed table in front to lean on and several pillows on the table to rest on. | Orthopneic position |
| Patients who have breathing problems are often placed in the ___________ or ______________ position since it allows maximum expansion of the chest. | orthopneic, or tripod, position |
| Patients are often placed in_________ position to increase comfort, to improve ventilation, and to promote relaxation after thoracic surgery or for patients with cardiovascular problems. For this position, the head of the bed is elevated ___degrees. | Fowler’s, 45 |
| This position is useful for patients who have cardiac, respiratory, or neurological problems and is often optimal for patients who have a nasogastric tube in place. What is the degree of elevation? | semi-Fowler’s position, the head of the bed is elevated 30 degrees. |
| Patients with poor peripheral circulation can benefit from this position because it promotes venous return. What position and how is the bed situated? | Trendelenburg’s position involves lowering the head of the bed and raising the foot of the bed |
| This is often a position of comfort for patients with gastrointestinal problems, and it can help prevent or minimize esophageal reflux. | Reverse Trendelburg's - raising the head of the bed and lowering the foot of the bed. |
| This is used to restore range of motion in a variety of joints, including the ankle, knee, shoulder, and wrist. Most commonly used after knee surgery. | continuous passive range of motion (CPM) device. |
| T or F - When patients are able to get out of bed, sit in a chair, or leave the room, their physical and psychological well-being improves. | True |
| Mechanical lifts are used to transfer patients who weigh more than _____pounds, are unable to assist with transfer, or are uncooperative | 200 |
| What leg to do you move first when walking with a cane? | The affected leg |
| How should a patient place crutches? | about 6 inches to the side and about 6 inches in front |
| When teaching crutch walking where should the nurse stand? | slight behind and to the side |
| You determine that the patient performs the prescribed three-point gait appropriately when using his crutches because A:leans his upper torso forward slightly in the tripod position. B:advances the crutches first, followed by the unaffected leg. | B - When performing a three-point gait, the correct procedure is to advance the crutches while bringing the affected leg forward. The patient then advances the unaffected leg. |
| Which of your four patients should you see first? A - pt who had a hip arthroplasty and needs one person to help him get out of bed to the chair B- pt with quadriplegia who had sacral redness when last turned 2 hours ago | B - Patients who have quadriplegia are at an increased risk for skin breakdown due to impaired mobility, infrequent repositioning, impaired sensation, and skin exposure to such irritants as rough linen, urine, and stool |
| When teaching the patient how to ambulate with a cane a nurse should say place the cane on your ________ side for support. | Stronger |
| After the G-tube feeding is complete, which action will you direct the nursing assistant to perform next? Why? A. Range-of-motion exercises B. Assistance out of bed via a mechanical/hydraulic lift | A- This is the nursing action you should perform next. It is easiest to perform full range of motion of all the patient’s joints and limbs while the patient is positioned in bed. |
| What action is appropriate when getting a pt out of bed w/ mechanical/hydraulic lift? A.Place the sling under the patient’s center of gravity and greatest portion of body weight. B/Remove the sling from under the patient once he is safely in the chair. | A - The sling (or hammock) is supplied with the lift. Hammocks that provide neck support are best for patients who are flaccid or have poor muscle tone. |
| what is appropriate when transferring the pt to the gurney with a slide board and 3 team members? A- Have 1 person hold the slide board steady while the other 2 pull the pt onto the gurney. B-Position the slide board under the pt & over the draw sheet | A - Using this method, the slide board remains stationary as two team members pull the draw sheet and move the patient. This slippery surface reduces friction and makes it easier for the staff to pull the patient onto the gurney. |
| A nurse is about to transfer to a chair a patient who has a weak left leg. What actions by the nurse would demonstrates correct transfer technique? | Aligning the nurse's knees with the patient's knees just before transfer. - helps the nurse safely stabilize the patient while moving to a standing position. |
| How should a chair be placed when transferring a patient out of bed? | The chair should be placed at a 45° angle to the bed so that the patient can safely and easily be pivoted to it. |
| For active range of motion, how would a nurse demonstrate hyperextension of the hip? | Move the leg behind the body |
| This movement demonstrates flexion of the hip. | Move the leg forward and up |
| This movement demonstrates adduction of the hip. | Move the leg medially toward the other leg |
| This movement demonstrates external rotation of the hip. | Turn the foot and leg away from the other leg. |
| A nurse in the emergency department is caring for a patient who has a knee injury. The patient will be discharged and will be using a pair of axillary crutches for the first time. What should the nurse teach the patient when he is going to sit? | The crutches should be held on the unaffected side when preparing to sit in a chair. |
| T or F - explain - Lean on the crutches to support body weight when standing. | F - Leaning on the crutches when standing puts excessive pressure on the axillae and may cause nerve injury. |
| The crutches should be fitted so that the patient’s arms are flexed about ____ degrees at the elbows when holding onto the hand grips. | 30 |
| T or F - Explain -When using a mechanical lift leaves the bed in the lowest position throughout the procedure. | F - The bed should be raised to its highest position in order to prevent injury to nursing staff and to properly position the lift under the patient’s bed. |
| Who has issued a guide for nurses regarding the use of ocial media? | National Council of State Boards of Nursing (NCSBN) |
| What enables patients to find out how their information may be used and how it has been disclosed. | HIPAA |
| If de-identified health information cannot be used for research, covered entities can obtain each individual participant’s written permission for the research with what 3 things. | an authorization document describing the research uses, disclosures of PHI the rights of the research subject. |
| The pt has a big family & they have been calling frequently asking about her status. She only want her medical treatment shared w/ her husband. How should you respond to the patient’s sister? | Tell her she must speak to the patient’s spouse to obtain information.- The pt indicated her spouse as her representative. You must give information only to him, making him the only source (besides the patient herself) of information for the family. |
| T or F - Explain - It is ok to receive and send patient information via text message. | False -It is not appropriate to send or receive text messages containing patient information. Generally speaking, the messages sent in this form are not encrypted and therefore are vulnerable to disclosure. No way to identify the identity of the sender. |
| a substance that reduces the number of pathogens present on a surface | Antiseptic |
| able to destroy or suppress the growth of pathogens and other micro-organisms | antimicrobial |
| methods used to assure that an environment is as pathogen-free as possible | asepsis |
| an antibacterial compound with substantial residual activity that is used as a liquid antiseptic and disinfectant | Chlorhexidine |
| T or F - Healthcare workers and patients who have a sensitivity or allergy to kiwifruit, papayas, avocados, bananas, potatoes, or tomatoes should be screened carefully as they have a higher chance of having a sensitivity or allergy to latex. | True |
| Avoid____________ creams or lotions while using latex gloves. This may cause break down of the gloves. | oil-based |
| Contact precautions include the use of personal protective equipment. What is the PPE for contact precautions? These patients should also be in a private room to prevent cross-contamination. | gloves and gowns |
| List some example of infections that would need contact precautions. | VRE, MRSA, C. difficile, wound infections, and herpes simplex |
| Droplet precautions are used when a disease is transmitted by large droplets expelled into the air and travels __ to __ feet from the patient. | 3 to 6 |
| Examples of a patient who requires droplet precautions include those who have _____ or Mycoplasma ______________. | influenza or pneumonia. |
| This form of isolation requires a negative airflow. What type of precaution is taken? | Airborne |
| T or F - African or Asian decent might be sensitive to the toxic effects of antihypertensive and antipsychotic drugs and might require dose adjustments to provide therapeutic effects. | True - Remember that genetics can effect the rate at which a drug is absorbed or how much of the drug must be given to have a therapeutic effect. |
| Remember that the liver inactivates and metabolizes most drugs, while the kidneys eliminate the byproducts (metabolites) of the drugs from the body. What is an important consideration for the young and elderly when giving meds? | Young children lack fully developed hepatic and renal function. They metabolize and excrete drugs inefficiently, making children more susceptible to toxic effects. In elderly, diminishing hepatic and renal function prolongs drug action. |
| Take the patient’s_____ ______ before giving any IV medication. Why? | vital signs -I V medication administration can alter blood pressure, heart rate or rhythm, respiratory rate, or ventilatory function. |
| what is the possible cause of a IV site that is swollen, red, and warm? | Inflammation of the vein with possible clot formation due to trauma, bacteria, or irritating solutions |
| If you suspect clot formation at an IV site what should you do and why? | -cold compress to decrease blood flow & to increase platelet aggregation -follow it w/ a warm compress & elevate extremity to help reduce/ eliminate irritation. - new IV access proximal to original site or in the other extremity if therapy is continued |
| What is the possible cause if the tissue surrounding the IV insertion site is swollen, pale, and cool to the touch? | Unintentional administration of solution or medication into the surrounding tissue |
| What might you suspect with an IV site that leaking with slowing or occlusion of fluid flow. The patient reports blanching, burning, tenderness, discomfort, and coolness in the area surrounding the IV insertion site. | Unintentional administration of solution or medication into the surrounding tissue |
| what is the intervention for the unintentional administration of solution or medication into the surrounding tissue | stop the IV infusion and discontinue the IV line. Elevate the extremity. Warm or cold compresses may be used according to the solution infiltrated and the facility policy. Encourage active range of motion. |
| the leakage of intravenously (IV) infused, and potentially damaging, medications into the extravascular tissue around the site of infusion. | Extravasation |
| What would you suspect if the pale or discolored tissue surrounding the IV insertion site shows signs of progressing to blistering and inflammation that could ultimately become necrosed. Blistering and tissue sloughing may not appear for a few days. | Extravasation |
| While administering an IV bolus (push) medication, cloudiness or precipitation forms in the tubing. What is the possible cause? | The line was not flushed properly with normal saline prior to injecting an incompatible medication. |
| What should you do if Precipitation happens during administration | Stop the medication push immediately. Aspirate to withdraw fluid from the access line until you see blood return to the line. Precipitates can cause thrombophlebitis, so discontinue the IV line and restart it in the opposite extremity. |
| The IV fluid or solution appears cloudy or has visible precipitate after medication has been added. What is the possible cause? | Incompatibility of the drug to the solution or the drug-to-drug mix |
| To minimize the risk of incompatibility of IV bolus (push) medications, be sure to do what? | flush before and after each medication with at least 10 mL of sterile normal saline or according to your agency’s policy. |
| These are usually used for therapies lasting 1 to 4 weeks. They range from 3 to 8 inches long and may be single or double lumen. They are inserted via the veins in the upper arm, preferably the basilica vein due to its large diameter and straight path. | Midline catheters |
| These are especially useful for IV therapy to help manage chronic health problems at home. In acute-care settings, these can provide central access with fewer and less severe complications than can develop with central venous catheters. | Peripherally inserted central catheters (PICCs) |
| PICC lines are ideally inserted percutaneously into the cephalic or basilic anticubital fossa, then advanced into the_________________ ______ ______ . PICC lines are available in single, dual, or triple lumen configurations. | superior vena cava |
| Placement of a _________ is contraindicated for patients who have sclerotic veins and in extremities affected by mastectomy or radial artery surgery, a hemodialysis graft, or an arteriovenous fistula. | PICC |
| Patients with______ _____ should not have blood-pressure measurements, venipunctures, or injections in the extremity with the PICC. | PICC Line |
| With a PICC what must be taken to indicate that the tip of the catheter resides in the lower superior vena cava before the PICC line can be used for IV infusion. | chest x-ray must be obtained |
| ________ __________ after medication administration is the most important factor for preventing the occlusion of a PICC by blood, fibrin, or medication residue. | Adequate flushing |
| These are most often placed in the internal jugular or subclavian vein, then advanced into the superior vena cava. | Central venous catheters |
| What is the most common complication related to central venous catheters? What should you do to prevent this? | infection - Assess the insertion site for signs of inflammation or infection at the start of each shift and every 4 to 8 hours or as indicated by the patient’s condition. |
| To create a vacuum in the IV delivery system what do you need to do? | Prime the drip chamber by gently squeeze the drip chamber to introduce enough fluid to fill it approximately halfway. This creates the vacuum needed to initiate the fluid flow. |
| You check the label on the IV bag -“cefazolin 1 g in 50 mL D₅W.” You are not sure this this is the med . What do you do? a- Call an in-house pharmacist to confirm that the drug b- Use the unit’s drug book to confirm the drug’s generic & trade names. | B- Medications have both a generic and one or more trade names, and this can cause confusion for nurses and patients. “Looking up” the drug is the initial step to take when you have any doubts about any aspect of the drug |
| To assure that the patient’s IV site provides the appropriate vascular access, you ask the pt if he is experiencing any pain or tenderness at the site. You then inspect the site for A. erythema. B. edema. C. dark blood. D. temperature variations | A. erythema - commonly seen with phlebitis (inflammation of a vein) B. edema - sign of infiltation, leakage of the IV solution into the tissue that surrounds IV site. D. temperature variations - Warmth- sign of phlebitis- coolness= infiltration |
| To infuse 1 g of medication in 50 mL of fluid over 30 minutes using tubing with a drop factor of 60 gtt/mL, you must regulate the fluid to infuse at how many drops per minute? | 100gtt/min |
| A patient was admitted to the hospital for same day surgery and has order for continuous IV therapy. Before preforming the venipuncture what should the nurse do? | Inspect the IV solution for fluid color, clarity, and expiration date. |
| Which of these is true about a PICC? - catheter that allows for infusion of fluids w/out an infusion pump. - line is a long catheter inserted through the veins of the antecubital fossa. - line is a catheter that is used for emergent situations | A PICC line is a long catheter inserted through the veins of the antecubital fossa. - PICC lines have lower complication rates because they are inserted in the upper extremity. |
| A nurse is assessing a pt receiving IV normal Saline at 125mL/hr. What could be a complication related to the IV therapy? -Petechiae over the IV site -The skin is cool over the IV site. -Patient reports cough and shortness of breath. | Patient reports cough and shortness of breath. - This is a sign of fluid overload. You should slow the IV and notify the provider. |
| When putting in a nasogastric tub have the patient breathe through one naris at a time; select the more _________ naris for tube insertion | Patent - Open, unobstructed, affording free passage |
| What positions should a patient be in when putting in a nasoastric tube? What might the patient experience when the tube is being inserted as it passes though the throat? | high-Fowler’s, May gag or experience nausea |
| Determine the length of a nasogastric tube - measure the nasogastric tube from the tip of the patient’s_____ to the tip of the _______, then to the ________ process. | Nose, ear, xiphoid |
| What is the gold standard for ascertaining accurate placement of a nasogastric tube? How can you also determine placement? | radiographic confirmation, Also, determine placement by aspirating fluid from the tube at the time of the insertion and testing its pH. If the pH is 0 to 5, the tube is most likely in the stomach. |
| Nasogastric intubation is used for: give 3 more reasons - decompress stomach & remove gas & fluid, - lavage the stomach to remove ingested toxins other than poison -diagnose problems w/ gastrointestinal motility/other disorders | - treat an obstruction - compress a bleeding site when endoscopy is not immediately available -to aspirate contents for analysis - to administer radiographic contrast media to the gastrointestinal tract. |
| With ______________ __________ stomach contents are removed to relieve the stomach and intestines of pressure caused by the accumulation of gastrointestinal air and fluid | gastric decompression - use of a nasogastric tube |
| Gastric lavage is the irrigation of the stomach. When is this typically performed? | - in acute-care settings, especially in cases of drug overdose for which swift removal of stomach contents is required. In that situation, an orogastric or nasogastric tube is inserted to aspirate gastric contents or to administer activated charcoal. |
| What type of tubes are used for gastric lavage, aspiration, and decompression? Give a specific name and the general name. | Orogastric tubes, Large-bore tubes (14 to 22 French |
| The most common nasogastric tube is the _____________ ___________________ ___________ _________ tube made of clear plastic and sized according to the French method. | double-lumen (two-channeled) gastric (Salem) sump |
| The double-lumen (two-channeled) gastric (Salem) sump is mainly used for what? | useful for irrigating the stomach but is most often used for drawing out fluid and gas from the stomach. Decompression - unique because it can be on continuous suction. |
| With a double-lumen gastric (Salem) sump - To prevent reflux, keep the tube above the patient’s _______; otherwise, it will act as a siphon | waist |
| What tube is a three-lumen tube used to treat upper gastrointestinal bleeding from esophageal varices when endoscopy is not available. | Sengstaken-Blakemore tube- Made of rubber and has two lumens used to inflate the gastric and esophageal balloons, with one tube reserved for gastric suction or drainage |
| T or F - Sengstaken-Blakemore tube can be inserted only though the mouth. | It can be inserted orally or nasally, and endotracheal intubation is strongly advised to secure the airway before insertion. |
| The __________ ___________ tube is a temporary measure for treating upper gastrointestinal bleeding and is reserved for emergency settings only when endoscopy is not immediately available. | Sengstaken-Blakemore |
| Contraindications to nasogastric tube placement include what 3 things? | severe midface trauma, recent nasal surgery, and esophageal perforation. |
| With a nasogastric tube frequent __________ ______ is imperative both for patient comfort and to reduce the risk of infection | oral hygiene |
| with Nasogastric tubes Do not use an ____________, such as ___________ __________, which can inadvertently be aspirated into the lungs and possibly result in lipid pneumonia. | oil-based lubricant, petroleum jelly |
| You explain to the patient that the provider has prescribed a special tube called a sump tube rather than another type of nasogastric tube because the sump tube what? | can be used for continuous suctioning |
| Which of the following should you do to keep gastric output out of the blue vent’s lumen? A. Instill 20 mL of air into the vent tube and position it above the level of the patient’s waist. B. Flush the vent tube with 10 to 20 mL of irrigant | A: After you flush the main lumen, you can use air insufflation to establish the function of the vent’s lumen. Keeping the vent tube above the level of the patient’s waist prevents gastric output from coming out of the vent tube. |
| Which type of tube should you select in preparation for gastric lavage for drug overdose? A. Orogastric tube B. Nasogastric tube C. Salem sump tube | A - An orogastric tube is inserted through the mouth and facilitates the rapid removal of stomach contents. |
| In what position will you place the patient prior to beginning lavage to facilitate pooling and removal of gastric contents? | Left lateral position with the head of the bed down about 15 degrees - This position allows stomach contents to pool and facilitates their removal by gastric lavage. |
| To reduce the risk of overfilling the stomach with irrigant and inducing vomiting, you A. remove stomach contents before instilling any irrigant. B. suction the airway with a tonsil-top suction device. | A - The stomach contents should be emptied before you initiate gastric lavage to minimize the risk of overfilling the stomach and inducing vomiting. |
| You understand that the primary purpose for continuing gastric lavage for the patient is to A. remove maximum stomach contents. B. prevent further drug absorption. | B - In the case of drug overdose, it is desirable to remove as much from the stomach as possible, but the primary purpose it to prevent drug absorption. |
| _______ _______bowel sounds are associated with an obstruction. This sound is made when peristalsis attempts to move fluids and other material through a narrowed bowel lumen. | High-pitched |
| You know that the most common electrolyte disturbance associated with nasogastric decompression is A. hyperchloremia. B. hyponatremia. C. hypokalemia | C - Since gastric contents are rich in potassium, chloride, and hydrogen ions, nasogastric decompression can result in several electrolyte disturbances. Potassium is one of the major cations removed by decompression |
| While advancing the tube past the nasopharynx, you have the patient A. lie in a left lateral position with the head of the bed lowered. B. place her chin on her chest. C. hold her breath | B - This position closes the epiglottis, which reduces the risk of the tube passing into the trachea |
| Low intermittent suction is most often used because it A. prevents tube occlusion, especially with viscous gastric fluids. B. minimizes the risk of damage to the gastric mucosa. C. is the most efficient method of withdrawing gastric contents. | Low intermittent suction can be used with any type of nasogastric tube and it lowers the risk of damage to the gastric mucosa by allowing periods of rest and time for the tube to migrate away from the gastric tissue. |
| What are the parts of anthropometry | (measurements such as weight/height and waist circumference) |
| ___ _______index is an indicator of total body fat. | Body mass |
| How do you calculate BMI? | Using the metric system, divide the patient’s weight in kilograms by his height in meters squared: Or, divide the patient’s weight in pounds by his height in inches squared and multiply by 703: |
| Patients at risk for aspiration, such as those with an altered level of alertness, decreased cough or gag reflexes, or motor deficits may require close observation while eating. Before initiating oral feedings what should happen? | they should undergo a swallowing examination. |
| Thickened liquids are easier to swallow, and straws should not be used for patients with dysphagia. Why should a straw not be used? . | dysphagia patients cannot always control the amount of fluid they take in through a straw, thus it can increase their risk for aspiration |
| What should you do for patient with visual deficits during meal times? | Describe the food tray as though it were a clock. |
| What type of diet: broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, and popsicles | Clear liquid |
| What type of diet: clear liquids with the addition of smooth-textured dairy products, custards, refined cooked cereals, vegetable juice, and all fruit juices | Full Liquid diet |
| What type of diet: full liquids with the addition of scrambled eggs and pureed meats, vegetables, fruits, as well as mashed potatoes and gravy | Pureed Diet |
| What type of diet: pureed diet with the addition of ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, and peanut butter | Mechanical soft |
| What type of diet: Low-fiber, easily digested foods, including pastas, casseroles, moist tender meats, canned cooked fruits and vegetables, and desserts without nuts or coconut | soft/low residue |
| what type of diet: Addition of fresh uncooked fruits, steamed vegetables, bran, cornmeal, and dried fruits | high fiber |
| diet type: dysphagia pts, nectar consistency: thicker than water but can be sipped through a straw, including nectar, vegetable jucie, cream soups; honey consistency: can be eaten with a spoon but do not hold their shape -honey, tomato sauce, yogurt | Modified fluid consistency diets |
| _________ are the chief source of energy for the body. | Carbohydrates |
| ____________ ___________ is the delivery of nutrients through a central line catheter for patients who do not have a functioning gastrointestinal system or have a critical illness or major trauma. | Parenteral nutrition (PN) |
| You teach the patient that, to facilitate healing of her fracture, she must increase her intake of A. folic acid. B. vitamin C. C. thiamine. | B - vitamin C (ascorbic acid) aids in tissue building and many metabolic reactions, such as wound and fracture healing. |
| You recognize which of the following as relating to the nutritional needs of an older adult patient? A. Vitamin supplementation becomes increasingly essential in advancing age. B. Older adults require fewer calories per day than younger adults do. | B - . It is generally true that advancing age results in a slower metabolic rate, thus lowering daily caloric requirements. |
| When visiting the pt 3 weeks after discharge, the nurse reports her concerns about nutritional status based on which findings? A. Open bags of cookies and soda cans B pt has a noticeable red rash on arms C. pt states, "Tell me again why you're here." | C - Altered mental status, in this case confusion and poor short-term memory, is a possible indication of poor nutrition. In addition, altered mental status can further impair the patient’s ability to ingest sufficient nutrients. |
| Which of the following is likely to be the most reliable indicator that the patient is at risk for poor nutrition? A. A bowel movement every 3 days B. A serum albumin level of 3.2 g/dL C. An unwillingness to eat meat | B - A serum albumin level within the normal range (3.4 to 5.4 g/dL) reflects that the body has access to and is absorbing sufficient amounts of protein. A low serum albumin level indicates that the patient is at risk for poor nutrition. |
| What points should you stress to the pt’s family to minimize risk of aspiration at home? A.Offering the pt frequent sips of water btw meals B.Checking the patient’s cheeks for pocketed food | |
| T or F - Aspiration is more likely with thin liquids than with thickened liquids. | True |
| Tilting the head_________ facilitates swallowing. Why? | Tucking the chin to the chest opens up the esophagus, thus facilitating the passage of the food or liquid. |
| To assess a stroke pt for complications secondary to inadequate swallowing which should the nurse do? Why? A. Auscultate the lungs B. Place the tip of the togue depressor on the patient's posterior tongue. C. With a penlight, inspect the pt's uvula | A - "Silent" aspirations are a common complication of swallowing impairment. |
| Placement of a tongue depressor on the posterior tongue is likely to elicit the gag reflex. Testing the gag reflex helps confirm the function of cranial nerve ___________ , but it does not demonstrate the act of swallowing. | IX, the glossopharyngeal |
| albumin level is a poor short term indicator of protein status. Why? | Albumin is not sensitive to acute changes in nutritional status. Its long half-life (21 days) makes it a better indicator of chronic illness states than of current protein status at a given point in time. |
| Albumin level is determined by a __________ __________. | blood test. |
| Normal albumin levels range from ____________ g/dL. | 3.5 to 5.4 |
| 1 fluid oz = ___ mL | 30 |
| T or F - Fat needs are increased for adolescents engaging in sports. | F - not increased |
| Oxygen therapy is indicated for patients who are at risk for developing_____________ | hypoxia |
| Many patients with ________conditions are also at risk of developing hypoxia and benefit from oxygen therapy. | cardiac |
| What are some early signs of hypoxia? | - restless and confused - might report feeling anxious. |
| With early stage hypoxia will heart rate, respiratory rate, and blood pressure be increased or decrease? What generally happen with late stage hypoxia? | increased in early stage. In the late stages of hypoxia, the patient is likely to develop hypotension, bradycardia, and metabolic acidosis. |
| For patients who have chronic hypoxia, the manifestations differ and develop over time. These patients often have _____ of their fingers and toes, peripheral edema, __________ heart failure, and an oxygen saturation below ____%. | clubbing, right-sided, 87 |
| With COPD Positioning is very important. How should the patient be positioned? | having the patient in a semi- or high-Fowler’s position helps facilitate lung expansion |
| The __________ attaches to the oxygen outlet and regulates the amount of oxygen delivered to the patient | flow meter |
| What are the air and oxygen label color designations. | Green = oxygen Yellow = Air |
| With oxygen high flow rates (FiO₂ of 4 L/min or more) what is required? | humidification is required. |
| A______ _______ is the device most often used to administer oxygen therapy. It consists of a length of tubing, (7 to 14 feet long,) with two small prongs to insert into one of the patient’s nares and a plastic piece at the neck that slides up or down | nasal cannula |
| A nasal cannula delivers oxygen concentrations of ____ to ___ with flow rates from 1 to 6 L/min through the cannula. They are usually used for patients who are what? | 24% to 44% - noncritical with minor breathing problems and for patients who cannot or will not wear an oxygen mask. |
| This device requires a fairly high oxygen flow to prevent rebreathing of carbon dioxide | A simple mask |
| A _________ ______ is usually used for patients who require a moderate flow rate for a short period of time | simple mask |
| A simple mask has the ability to deliver oxygen concentrations of __________ to___________ with flow rates from 5 to 8 L/min. | 40% to 60% |
| When using a simple mask why should you not use a flow rate lower than 6 L/min. | Because carbon dioxide can build up in the mask at low flow rates, do not use a flow rate lower than 6 L/min with this type of mask. |
| his device is used to deliver high flow rates and high concentrations of oxygen. | A nonrebreather mask |
| A nonrebreather mask can deliver oxygen concentrations of ______ to _____ with flow rates from 10 to 15 L/min. When using a nonrebreather mask, do not allow the reservoir bag to _______ or ____________. | 80% to 95% - deflate or the oxygen source to deplete |
| __________ ___________ is most often used for critically ill patients who require administration of a specific concentration of oxygen. | A Venturi mask |
| A _________ __________ can deliver accurate oxygen concentrations from 24% to 50% with flow rates from 4 to 10 L/min. This is the most accurate form of oxygen delivery. Used often with COPD paitents,. | Venturi mask |
| This device uses different size adaptors to deliver a fixed or predicted FiO₂. | Venturi mask |
| This soft aerosol mask fits loosely around the patient’s face and neck. It is an alternative to an aerosol mask for patients who feel claustrophobic, !!oxygen concentration cannot be controlled!!! | face tent |
| The two types of noninvasive ventilation are _______ and ________ | CPAP and BiPAP. |
| Oxygen_________ and ______ are usually used for pediatric patients who have airway inflammation, croup, or other respiratory infections. | tents and hoods |
| When you turn the knob on the flow meter to the left, oxygen begins to flow from the cylinder to the patient, and you can increase the flow rate. When you turn the knob to the right, you _________ the flow rate. | decrease |
| The liquid oxygen systems also deliver oxygen up to 6 L/min. These also do not require electricity. Liquid oxygen is stored in a large stationary vessel from which the patient can fill a small portable tank. This is a good option for what type of pt? | Active patient or frequently mobile patients |
| During the__________ phase, the nurse collects and verifies data to formulate a database reflecting the patient’s problems and concerns. | assessment |
| During the__________ phase, the nurse analyzes and interprets data gathered from the nursing assessment to formulate a nursing diagnosis, in this case, impaired gas exchange. | diagnosis |
| During the ___________ phase, the nurse determines patient outcomes, establishes priorities, and identifies nursing interventions. | planning |
| During the ____________phase, the nurse determines whether or not the planned patient outcomes have been met and revises the plan of care if indicated. | evaluation |
| T or F - Distilled water is used for humidification. | False - Sterile water, not distilled water, is used for humidification. |
| When would you use an Aerosol masks? | Aerosol masks, used when high humidity levels are required, fit over the patient’s mouth and nose, not over a tracheostomy. |
| ____________ are dry, low-pitched, snore-like noises produced in the throat or bronchial tube due to a partial obstruction, such as by secretions. | Rhonchi |
| ____________ __________ is a scratching or squeaking sound that persists throughout the respiratory cycle. | Friction rub |
| ______________ are discontinuous sounds heard primarily during inhalation and resulting from air bubbling through fluid or mucus in the airways. | crackles (also called rales) |
| An ____________stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment. | allogeneic |
| __________is a complementary and alternative therapy that helps promote wound healing. . | Feverfew |
| T or F - Aloe is a complementary and alternative therapy that can help improve disorders and can have wound healing effects. | True |
| A client dies. Place the nursing steps in order. -place a name tag on the body -obtain the death pronouncement from the provider -remove tubes and indwelling lines prior - ask the family members if they wish to view the body. -Wash the body | -obtain the death pronouncement from the provider -remove tubes and indwelling lines prior -Wash the body ask the family members if they wish to view the body. -place a name tag on the body |
| ___________ planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility. | Discharge |
| Pain __________ is the point at which a person perceives pain. Pain __________is the level of pain a person is willing to endure. | Pain threshold Pain tolerance |
| pain that defies relief | intractable pain, |
| pain that originates elsewhere but is felt in another location considerably removed from the pain’s origin | referred pain, |
| chronic pain that persists in the absence of a detectable cause | idiopathic pain |
| PQRST, may help you remember to assess pain comprehensively. What does PQRST stand for? | Provoked: What causes pain? What makes it better or worse? Quality: What does it feel like? Dull? Sharp? Stabbing? Burning? Crushing? Region/radiation: Where is the pain? Is it always only in that spot or does it spread? Severity: Timing: |
| T or F - for diabetic clients an emollient lotion can be applied over all surfaces of feet but not between the toes. | True |
| ________________is the correct solution to use for daily oral care for the unconscious patient because evidence-based practice indicates it improves patient outcomes by preventing microbial build-up. | Chlorhexidine |
Created by:
sbertelsen