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Test 5
| Question | Answer |
|---|---|
| It is important to follow the sequence of posterior auscultation sites starting at the right middle lobe. | True |
| Client with a high blood level of carbon dioxide. Will have an increased breathing rate for response in the body’s respiratory system. | True |
| Individual who has difficulty coordinating and organizing the words correctly in a sentence is | Dysphasia |
| A client reports voiding every hour while awake | Frequency |
| Improper instructions to give the student nurse regarding a foley Cath would be to | “secure the catheter tubing to the bed rails when they are not moving”, and to “store the catheter bag at the level of the client's waist.” |
| Indications for urinary catheterization? | • Presence of an open perineal wound • 34 yr old with urinary retention • Comfort measures for a hospice patient |
| Types of catheters | • Texas • Coude • Condom • Alock • Indwelling |
| Female clean- catch urine specimen? | - Place the cup in the urinary stream - Hold the labia open during cleaning and until the specimen is collected |
| Which of the following is FALSE regarding caring for patients with indwelling catheters? | • Irrigate the foley every 4-6 hrs • Immediate remove of the catheter at the first sign of an infection • Raise the drainage bag above the level of the heart • Empty the urinary drainage bags every 220mL of urine Lay the urinary bag on the bed |
| Glasgow coma scale | • Assesses eye, motor, and verbal response • Points range from 3-15 • Used to assess LOC • Score of 12 equals moderate deficit • The highest point possible is 15 |
| Excessive retention of sodium in ECF results in a condition termed? | Fluid volume excess or hypervolemia. |
| Signs of HYPOvalemia? | • Oliguria • Tachycardia • Dry cracked lips • Tented skin tutor |
| When initiating an IV you should assess for | • Purpose of IV • If the patient is allergic to tape, latex or iodine. |
| While flushing nurse finds fluid leaking during flush. What nursing action should come next? | • Remove IV and place a new IV in an unaffected location. • Notify prescriber IV is leaking and will be discontinued. |
| Positive trousseau signs: | Calcium 6.2 |
| Severe Diarrhea | Metabolic acidosis |
| CPAP maintains a set of continuous positive airway pressure during inspiration and expiration. | True |
| Signs of hypokalemia within a patient's ECG | Abdominal distention Arrythmias |
| Peripherally inserted central catheter | PICC |
| Fluid volume excess findings | Third spacing, SOB, weight gain, jugular vein distention |
| Spironolactone does NOT put a patient at risk for hypokalemia | TRUE |
| Tracheal suction should be performed only when clinically indicated based on assessment and not routinely | True |
| Subcutaneous emphysema | Bulging skin that feels crunchy |
| Patient with respiratory acidosis findings | drug OD, hypoventilation, PH 7.21 |
| Bladder training instructions would include: toileting Q2hr, avoiding caffenated tea and drinking less than 500 mL QD? | False |
| What is Dementia? | “It is a deuteriation of all cognitive functions.” |
| 0.9% is the ONLY fluid used to administer blood products. | True |
| When initiating a venipuncture, you must | • Inspect and palpate the veins • Apply tourniquet above the elbow • Use the veins in the left forearm |
| What should the nurse omit when performing patient care on a patient that is undergoing an autopsy? | Remove all tubing and dressings |
| Which of the following are appropriate interventions to implement so that the patient does not develop hypostatic pneumonia? | • Use an incentive spirometer • Use a pillow as a binder over their incision site when coughing • Turn and reposition the patient every 2hr |
| Rib cage does not contract or relax during inhalation (inspiration) | True |
| Isotonic fluid resembles the fluid within the human body. | True |
| Ventri mask | |
| Sputum specimen for an older adult | client is best collected BEFORE morning shower. |
| Types of IV solutions: | .45 NaCl, D5W, NS |
| During suctioning, the patient can lose fluids and electrolytes | True |
| Example of a clarifying communication technique: | “Let me make sure I understand this correctly, your meds are too expensive” |
| Personal space distance zones used in healthcare. (2 examples): | • Social consultative • Intimate |
| Older adults normally experience a decrease intestinal peristalsis. Causing constipation. Low sodium levels in ECF | |
| The human body is composed of 50%-70% of water by weight | True |
| Stridor | high pitched shrills , EMERGENT |
| During the comprehensive assessment, to detect abnormalities in external surface of the body the LPN will correctly.. | • Use diaphragms of a stethoscope to assess S1 and S2 • Observe grimacing • Palpate for tensing of abdominal muscles • Use bell to hear blood rushing through carotid arteries • Palpate tissue 2-3cm |
| A living will | is made for end-of-life decisions when you’re no longer capable to make them |
| Stages of Kubler Ross: | • Anger • Bargaining • Acceptance • Denial |
| Narrowed Airways (sata) | Wheezing Asthma attack |
| Normal respiratory assignment | • Vesicular breath sound • Bronchial breath sound • Bronchovesicular sounds |
| Hypervolemia s/s | • Coughing suddenly • Polyuria • Edema • Bounding pulse |
| Elevated K+ levels can cause Arrythmias | True |
| A comprehensive assessment | Is performed on patient admission to a medical surgical unit |
| Nursing diagnosis consists of: | • Etiology • Problem • Signs |
| Types of learners | • Kinesthetic • Visual • Auditory |
| During inspiration the rib cage EXPANDS and the rib muscles CONTRACT | True |
| During expiration the air is exhaled, rib muscles RELAX, rib cage gets SMALLER | True |
Created by:
Sarabowden1