Nutrition
Identify the six of classes of nutrients.
Carbs, Proteins, Fats, Vitamins, Minerals, Water.
What is the difference between an antigen and an antibody?
Antigens- foreign material that enters the body
ex. bacteria, virus, fungi, parasites
acts as the infectious agent in the cycle of infection
Antibody- responders to an antigen
A specialized protein produced by the immune system ex. immunoglobulins
Define the difference between negligence and malpractice
Negligence is failure to perform expected care that results in harm. Malpractice is breach of professional duty.
Using a blood pressure cuff too small for a paitents arm will result in what?
The blood pressure will read as falsely high.
70-80%
A person has a BMI of 32, based on standard ranges, what classification does this patient fall under?
A BMI of 32 is considered obese.
underweight- <18.5
normal- 18.5-24.9
overweight- 25-29.9
obesity- 30=<
greater than 40 is extreme obesity
In what order do you perform donning for contact precautions?
gown, mask, goggles/face shield (if splashing is expected), gloves
A nurse discovers a medication error and notifies the provider. The client is not harmed. Which ethical principle is the nurse upholding by being truthful about the error?
veracity
the obligation to tell the truth and not deceive the client
A nurse is assessing a client's radial pulse and notes that the rhythm is irregular. What is the priority nursing action?
Auscultate the apical pulse for 1 full minute.
What are the phases of therapeutic communication?
1. Pre-introduction Phase: Prepare, discussions with
instructor, review materials.
2. Introduction Phase: First nurse/patient meeting.
Establish rapport. Role clarification, contract, self
awareness, confidentiality, goals, termination.
3. Working Phase: Data, promote change, evaluate
progress, discuss alternatives.
4. Termination Phase: Summarize goals, strategies,
review situations, closure.
A nurse is caring for a client who has a malabsorption disease. The nurse should understand that which structure in the gastrointestinal system absorbs the majority of digested food and minerals?
Small Intestine
What are the stages of infection?
Incubation-period between pathogens invasion and the onset of symptoms
Prodromal-early signs and symptoms of disease- often vague, most likely to spread at this time
Full stage-presence of infections and specific signs and symptoms
Convalescent-recovery from infection
A nurse tells a client, 'If you don't stay in bed, I will have to put you in restraints.' This statement is an example of which legal tort?
Assault
an intentional threat that causes a person to fear harmful or offensive contact
A nurse is assessing the length of contractions, how do they determine the length of contractions.
From the beginning of one contraction until the beginning of the next.
What is the primary disadvantage of using electronic communication in the healthcare setting?
The risk of compromising patient confidentiality and HIPPA standards
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central line. The nurse notes that the client has developed a bounding pulse, crackles in the lungs, and a weight gain of 2 lbs in 24 hours. What is the priority nursing intervention?
The symptoms described are hallmarks of the body being unable to handle the current volume of fluid.
The nurse should slow the TPN infusion rate and notify the provider.
A nurse is caring for a client with a localized wound infection. What should the nurse expect to see at the specific site of the wound?
Redness, swelling, heat, purulent drainage.
A nurse is caring for a client who is a devout Jehovah's Witness and requires surgery. The client tells the nurse, 'I cannot receive a blood transfusion under any circumstances.' Which ethical principle is the nurse upholding by respecting this decision?
Autonomy
A nurse is caring for a client admitted to the hospital for dehydration. Which physical findings should the nurse acknowledge as nonverbal communication concerning this diagnosis?
Easy wrinkling of the skin and sunken eyes.
A client says, 'I'm so worried about my surgery tomorrow.' What response by the nurse demonstrates the therapeutic communication technique of 'reflection'?
"You are feeling worried about your procedure?"
-NOT why questions as they may make client feel defensive
-Reflection involves repeating or paraphrasing the clients feeling back to them in order to initiate further discussion
A client's laboratory report shows a Blood Urea Nitrogen (BUN) of 32 mg/dL and a Creatinine of 1.0 mg/dL. How should the nurse interpret these findings?
Normal Values:
BUN- 10-20 mg/dL
Creatinine- 0.7-1.4 mg/dL
The client is likely dehydrated.
Explanation:
When a patient is dehydrated, the fluid part of their blood shrinks. WBCs, RBCs, and BUN will look falsely high since they are in less liquid (ratio is off). BUN is reabsorbed by the kidneys when dehydrated as it attaches itself to the water molecules that are REcirculating through the kidneys.
Creatinine reflects kidney function and is a stable variable. Since its levels are in normal range, dehydration is the cause of BUNs elevated levels.
If the BUN is high (reabsorbed due to thirst) but the Creatinine is normal (still being filtered perfectly), the problem is volume (Dehydration), not the filter (Kidney Failure).
Alternatively, if both labs were high, it would be a sign of renal failure.
What is happening during inflammation of a wound at a cellular level?
what cell, cell doing what, result
WBCs (leukocytes specifically) move to the area to perform phagocytosis, this forms exudate
An alert and oriented client with a terminal illness is refusing further curative treatment. The family, who has Power of Attorney, demands the treatment continue. What is the nurse's most appropriate legal and ethical action?
Support clients rights and organize a meeting with hospital ethics committee.
A durable power of attorney in healthcare only takes effect if client is deemed incapacitated.
A nurse is performing a physical assessment on a client suspected of having a Deep Vein Thrombosis (DVT). Which assessment finding in the lower extremity is considered a classic sign of this condition?
Unilateral calf swelling and tenderness
DVT typically occurs on one side and has localized inflammation, edema, and pain
A nurse is preparing for a clinical interview. What seating arrangement best facilitates eye congruency and a therapeutic environment?
side by side in similar seating