Foundations, Health, Illness, Nursing Process
A chronic condition suddenly worsens after exposure to a trigger. This is the correct term.
What is exacerbation
This stage involves full-thickness tissue loss with exposed fat.
What is stage III
This fluid imbalance causes hemoconcentration, tachycardia, and orthostatic hypotension, and is most often seen in dehydration.
What is hypovolemia?
This electrolyte imbalance is characterized by muscle weakness, peaked T waves, and risk for fatal dysrhythmias.
What is hyperkalemia
This sound is high-pitched and musical, often heard in asthma exacerbations.
What are wheezes
This term describes an individual's view that optimal health requires treating the body, mind, AND spirit.
What is holism
Scale that is used to evaluate patients risk for pressure injury (1) _____ and a (2) high/low score indicated increased risk.
1. What is Braden
2. What is low score
A COPD patient becomes drowsy after oxygen is increased to 5 L/min. This is the most likely cause.
What is CO₂ retention / hypoventilation due to oxygen-induced respiratory depression?
Dry mucous membranes, tachycardia, and poor skin turgor are classic signs of this condition.
What is hypovolemia
A complication of COPD where oxygen levels are chronically low and CO2 is retained.
What is respiratory acidosis
The nurse prepares and administers a medication to a client. This occurs during which phase of the nursing process?
What is implementation
A nurse is treating a wound and notices the drainage is pale pink, thin, and contains both plasma and red blood cells. The nurse documents this drainage using this term, and it is considered this type of expected/unexpected finding in a healing wound.
What is serosanguineous drainage — and it is an expected finding in an early healing wound? (Serous drainage is clear/pale yellow; sanguineous is bright red/bloody; purulent contains white cells and indicates infection. Serosanguineous falls between serous and sanguineous and is normal in the early stages of wound healing.)
This assessment finding is the earliest sign of respiratory distress in a patient who is still maintaining oxygen saturation.
What is increased respiratory rate (tachypnea)?
This vital sign trend often changes first in early hypovolemia.
What is increased heart rate (tachycardia)
What side effects would you expect in a patient receiving nebulized bronchodilators in the hospital, Q4
What is tachycardia - bonus What is hypokalemia
What must be done before delegating (1). Name the parts
A patient on long-term prednisone therapy undergoes surgery. The nurse anticipates delayed wound healing because corticosteroids suppress this phase of wound healing.
What is the inflammatory phase? (Corticosteroids blunt inflammation, which is required to initiate healing — WBCs cannot adequately move into the wound.)
A patient with asthma is wheezing and using accessory muscles. What is (1) the priority medication, and (2) the expected immediate response?
(3) What will we evaluate if they tell us their inhaler isn't helping?
1. Albuterol (short-acting beta agonist)
2. Improved airflow / decreased wheezing
3. How they use their inhaler - do they need a spacer/can't afford/don't understand proper use
A patient has Na⁺ 122 mEq/L. They are confused and vomiting. The nurse’s priority intervention should focus on this risk.
What is seizure risk / neurologic complications?
This assessment finding suggests severe respiratory distress and impending failure.
What is use of accessory muscles
A nurse is triaging four patients. Using Maslow's hierarchy to prioritize, rank these needs in order: a patient requesting a chaplain visit, a patient with an O₂ sat of 84%, a patient afraid of a procedure having an anxiety attack, and a patient who hasn't eaten in 12 hours.
What is the correct priority order: O₂ sat of 84% (physiological/airway) → hasn't eaten in 12 hours (physiological/nutrition) → afraid of a procedure (safety/psychological) → chaplain visit (love/belonging or spirituality)? (Maslow always prioritizes survival-level physiologic needs first.)
The nurse notes that an older adult's skin has decreased turgor, fewer eccrine glands, and reduced subcutaneous fat. These changes place the patient at increased risk for this triad of skin-related complications.
What is hypothermia, pressure injury, and skin tears/breakdown? (Reduced eccrine glands impair temperature regulation; less subcutaneous fat reduces cushioning; poor turgor and fragility increase tear risk.)
A patient is tripod positioning, cyanotic, and has absent breath sounds in one lung.
What is (1) the priority concern, and (2) the first nursing action?
1. Pneumothorax / respiratory failure risk (accept other answers ie; diphtheria, obstructed airway)
2. Call rapid response / administer oxygen/ Get intubation ready
A patient with hyper(1)____ has peaked T waves and muscle weakness.
What is the priority concern (2)_____, and (3) the medication likely to be given first?
1. Hyperkalemia
2. Cardiac dysrhythmias/cardiac arrest
3. Calcium gluconate (accept insulin/dextrose) or kayexalate
A patient has fluid overload. Crackles are heard bilaterally and oxygen saturation is dropping.
What is (1) the expected lung sound, and (2) the priority nursing intervention?
1. Crackles (rales)
2. Elevate HOB / oxygen administration / diuretics per order