Skin Integrity
A patient after surgery falls and has a total separation at the incision site with viscera protruding out, what is the term used for this complication?
Evisceration
What nursing intervention is a last resort to ensure patient and staff safety, requiring strict adherence to an in-person provider order, the least restrictive method, and continuous monitoring of the patient's physical and psychological state
restraints
What is the body's first line of defense?
Skin, mucous membranes
A nurse is caring for a 73-year-old male patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity?
a. Dorsal recumbent position
b. Lateral position
c. Fowler's position
d. Sims' position
C. Fowler's position
What interventions promote sleep?
consistent sleep schedule, dark, quiet environment, avoid caffeine before bed, avoid intense activity close to bedtime, reduce bright light exposure in the evening, etc.
While assessing a new wound, the nurse notes red, bloody drainage. What type of drainage will the nurse document this as?
Sanguineous
A nurse is caring for an elderly patient who is at high risk for falls. What are some interventions that the nurse should implement to best reduce the risk of falls for this patient?
place the call light within reach, orient patient to surroundings, encourage non-slip shoes/socks, provide a night light, keep floors dry and free of clutter, utilize bed and chair monitoring devices, educate family and patient about fall prevention strategies
Airborne precautions include...
Isolation room with negative pressure, keep room door closed, gown, gloves, eye protection, N-95
A nurse evaluates correct cane use when the patient:
A. Holds cane on weaker side
B. Moves cane and strong leg together
C. Holds cane on stronger side
D. Leans heavily on cane
Holds cane on stronger side
Rapid eye movement and vivid dreaming occurs in what stage of sleep?
REM sleep
A patient had a CVA (stroke) 2 days ago, resulting in decreased mobility to her left side. During the assessment, the nurse discovers a stage I pressure area on the patients left heel. What is the initial nursing intervention for this pressure ulcer?
Elevate the left heel off the bed, frequent reposition, etc.
Provide an example of a specific, critical type of adverse event that results in death, serious harm, or the risk thereof
sentinel event:
Receiving a flu vaccine provides what type of immunity?
Active artifical immunity
Immobility can cause what conditions?
Deep Vein Thrombosis, Pressure injury, muscle atrophy, contractures, etc.
Which of the following factors has the greatest positive effect on sleep quality?
A. Sleeping hours in synchrony with the persons circadian rhythm
B. Sleeping in a quiet environment
C.Spending additional time in stage IV of the sleep cycle
D.Napping frequently during the day hours
A. Sleeping hours in synchrony with the persons circadian rhythm
A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as?
Unstageable pressure ulcer
PASS steps
pull, aim, squeeze, and sweep
What disease process warrants the need for the nurse to wear a gown and gloves when entering the patient's room?
Contact precautions: MRSA, C. Diff
What are examples of correct body mechanics to educate patient on?
Minimize bending and twisting of back, keep objects close to your body, squat to lift heavy objects, use wide base of support (feet spread apart)
What is the correct order of PPE removal:
gown --> gloves --> mask