PERFUSION
The location in which you place the bell of the stethoscope on the arm when taking a blood pressure
Over the Brachial Artery located in the antecubital space of the arm
Two nursing interventions used to prevent the development of pressure injuries.
Turn and reposition every 2 hours
Good Skin Care
Good Nutrition
Wrinkle Free bed linens
PPE stands for__________?
Personal Protective Equipment
Name the 5 steps of the nursing process
What are assessment, analysis, planning implementation and evaluation
patient, drug, dose, route, time (frequency), documentation
What are the 6 rights of medication administration
NPO stands for ?
Nothing by Mouth
What are the 6 Normal Characteristics and Special Considerations for Observation of Stool
Volume
Color
Odor
Consistency
Shape
Constituents
Mr. Smale is having difficulty breathing due to his Congestive Heart Failure. What position would help to improve his breathing?
High Fowler's
When providing oral care to an unconscious resident, what position would best prevent aspiration?
Lateral Position
The Top number of a blood pressure reading reflects the heart at work.
Systolic
The rubbing of one surface against another
Friction
The best way to prevent the spread of infection is by __________?
Handwashing
What the clients states "I have pain, nausea, and itching."
What are subjective statements (symptoms)
Shake before pouring this type of liquid medication
What is a suspension
What 4 risk factors for dysphagia?
Risk Factors:
neurologic condition - stroke, head injury, progressive neurologic disorder
Dementia
obstructive condition
COPD
Aging
Childhood syndrome (down syndrome, cerebral palsy)
Medical term for urine with a bloody tinge
HEMATURIA
Your resident has a difficult time hearing. To better assist him with communication, and conserve his oxygen/energy, what should the Nurse do?
Use simple words and sentences
State the topic of conversation first
Keep conversations short and quick.
Moving an extremity away from the body and then toward the body
What is abduction and adduction
This number of a blood pressure reading reflects the heart at rest
Diastolic
This stage of the pressure injury is reddened and nonblanchable. What is this stage?
Stage 1
redness, heat, swelling, pain
What is the inflammatory response
SMART goals
What are specific, measurable, attainable, realistic and timely
The simultaneous use of multiple drugs by a single client for one or more conditions and increases the risk for drug interactions
What is polypharmacy
What are 4 signs and symptoms of dysphagia?
Signs and symptoms -
difficulty swallowing foods or liquids
coughing or choking when eating or drinking
frequent throat clearing
wet gurgling voice after eating
feeling of food or liquids "stuck" in throat
Mrs. Green is complaining of pain with urination. What is the medical term for this condition?
Dysuria
A noninvasive technique that measures the peripheral arterial oxyhemoglobin saturation (SpO2) of arterial blood.
What is PULSE OXIMETRY?
mass, tone, and strength
What is a muscle assessment
This is the medical term describing a blood pressure that is below the normal values.
What is HYPOTENSION?
Partial-thickness loss of skin with exposed dermis. May also present as an intact or ruptured serum-filled blister.
What is a Stage 2 pressure injury?
airborne, droplet, and contact
What are types of transmission-based precautions
An assessment completed after an action is implemented
What is evaluation
What needs to be part of a PRN medication order?
The indication for the medication
What is it called to give fluids/nutrients through the GI tract via feeding tube
Enteral Nutrition
Another name for overactive bladder or the passing of urine/stool without control
Urge Incontinence
Continuous musical sounds, produced as pair passes through airways constricted by swelling, narrowing, secretions or tumors. Often heard in patients with Ashtma, tumors or a build up of secretions.
What are WHEEZES?
The loss of muscle strength and function due to inactivity
Muscle Atrophy
This is the medical term for a blood pressure that is higher than the normal blood pressure values.
What is HYPERTENSION?
In the normal aging process, the skin loses elasticity, and oil-producing glands diminish production. As a result, the elderly have dry skin. What measures are taken to alleviate this issue?
Baths or shower every other day.
Lotions applied to the skin
Use of non-irritating soaps, rinse off skin after washing.
Increase oral fluids
Precautions used in the care of all patients regardless of their diagnosis or possible infection status when exposure to body fluids is possible
What are standard precautions
In developing outcomes, the nurse bases the goals on what the _____________ would like to achieve
What is client (patient)
What do we do when we get a medicationoder from a physician
What is repeat the order back
COMPARE AND CONTRAST
Name 5 clinical observations for nutritional assessment indicating the signs of good and poor nutrition.
General appearance
Weight
Hair
Eyes
Tongue
Teeth
Gums
Skin
Nails
Muscles
Abdomen
Nails
What is the difference between a urostomy and a colostomy?
Urostomy is urinary
Colostomy is bowel
Frequently heard on inspiration, are soft, high-pitched, discontinuous (intermittent) popping sounds.
What are CRACKLES?
What are the principles of good body mechanics?
Good Body Alignment, Good posture and balance
Wide base of support
Use of muscles in your thighs, hips, shoulders, upper arms
Bend your knees and squat to lift a heavy object
Hold items close to your body and base of support
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A pulse that is slow, less than 60 beats per minute
What is BRADYCARDIA?
Name risk factors for pressure injury development
Poor skin hygiene
Diminished sensory perception (pain awareness)
Fractures
Poor Health
Immobility 2 to paralysis or injury
Increased body temperature
Inontinence
Sedation or Coma
Significant obesity or thinness
Smoking
Terminal illness/End of Life/Dying process
Name the 6 steps of the chain of infection in order
pathogen, reservoir host, portal of exit, transmission, portal of entry, susceptible host.
What QSEN competency takes priority when entering/leaving the client's room.
What is safety
What is an important part of drawing up fluids from a vial
Push the amount of air equal to the medication you wish to draw up.
List age-related changes and the nursing strategies to address age-related changes affecting nutrition.
altered ability to chew related to teeth, ill fitting dentures and gingivitis
loss of sense of smell and taste
decreased peristalsis in esophagus
Gastroesophageal reflux
decreased gastric secretions
slowed peristalsis
reduction in appetite and thirst
loss of appetite related to depression and loneliness
physical disability
low income
What are the steps to performing a bowel assessment?
What are the rationales for this order?
Inspect
Auscultate
Palpate
Nursing interventions that promote optimal oxygenation
Healthy Lifestyle
Vaccination
Reducing Anxiety
Good nutrition
Positioning
Name 3 complications of immobility - identify at least one from each system
What is increased risk of DVT, pneumonia, contractures, pressure injuries, constipation
A medical term for a pulse that is above 100 beats per minute
What is TACHYCARDIA?
When changign a wound dressing, it should be examined for what 4 things?
COCA:
color, odor, consistency, amount
The nurse needs to disinfect her hands after caring for the resident. If the hands are not visibly soiled, what method of disinfecting hands between patients is acceptable?
Alcohol-Based Hand Sanitizer.
physical assessment, vital signs, lab tests
What are examples of objective signs
The process of reviewing a client's medications, especially at points of transitions of care to reduce medication errors
What is medication reconciliation
What steps should the nurse take to prevent the complication of aspiration in a patient receiving enteral feeding?
Check tube placement
Elevate HOB 30-35 degrees during feeding and for 1 hour after
Give small, frequent amounts
Avoid over sedation
Check residual volume per policy/orders
Urine leaks during exercise, sneezing, coughing, and a sudden urge to void
Stress Incontinence
The respiratory secretion expelled by coughing or clearing the throat.
What is SPUTUM?
A nurse is caring for a client with lower extremity paralysis. Which action will the nurse take to prevent external rotation of the hip and legs.
What is place a trochanter roll at the side of the legs
This is a medical term for an irregular heart rhythm.
What is ARRHYTHMIA?
Full-thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar?
What is an UNSTAGEABLE Pressure Injury?
Practices that remove pathogenic organisms - considered "clean technique"
What is medical asepsis
The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process?
Diagnosis
What locations are appropriate for an IM injection?
Deltoid, vastus lateralis, and the ventrogluteal
What should be monitored if a patient is receiving TPN
Blood sugars
What are things the nurse can do to promote regular bowel habits?
Timing
Positioning
Privacy
Hygiene
Nutrition
Exercise
Patients who experience dyspnea and feelings of panic can often reduce these symptoms by doing this.
What is PURSED-LIP BREATHING?
You are to perform ROM exercises after the bath. Which exercises are completed for the ankle?
Dorsiflexion and Plantar Flexion
In this scenario, the Nurse is taking vital signs and discovers the blood pressure to be 88/60.
The Nurse would take what actions next?
Ask the client what their normal BP is
Perform further assessment
Check other vital
Ask about meds the patient is taking
What are the psychological effects of Wounds and Pressure Injuries?
Pain
Anxiety and Fear
Activities of Daily Living
Changes in Body Image
Name 2 types of laboratory data that identifies an infection
C & S
increased WBC count >10,000
independent, dependent and collaborative
What are types of nursing interventions
What angles should be used when doing a subQ injections?
45 or 90 degrees
What is the difference between the modified diets?
Clear-liquids you can see through
Full liquid-creamy items, soups
Pureed-like baby food
Mechanical soft-mashed foods
What assessments need to be done prior to inserting an indwelling catheter?
Order
Trauma
Drainage
Infection
Skin integrity
Bladder
Dyspnea
ELEVATED BP with small pulse pressure
Increased respiratory rate and pulse rate
Pallor and Cyanosis
LATER SIGNS: anxiety, restlessness, confusion and drowsiness
What is HYPOXIA?
Describe the proper use of a cane
What is: Support weight on the stronger leg and cane and move the weaker leg forward.
The Nurse is having difficulty hearing the resident's blood pressure. She has attempted to try to take the pressure on both arms. What action is next for the Nurse?
Ask another nurse to verify.
A. What are the local factors affecting wound healing?
B. What are the systemic factors affecting wound healing?
LOCAL: Pressure, Dessication, Maceration, Trauma, Edema, Infection, excessive bleeding, necrosis, biofilm
SYSTEMIC: Age, Circulation and Oxygenation, Nutritional Status, Wound Etiology, Medications, Immunosuppression or Proinflammatory conditions, Adherence to treatment plan,
Practices that removal all micro-organisms and spores and used for invasive and surgical procedures.
What is sterile technique or surgical asepsis.
Name the 6 steps of the NGN clinical judgement model
Recognize cues, analyze cues, prioritize problems, identify outcomes, take action, evaluation
Where are the safety check completed for medication administration
When pulling the medication
When preparing the medication
At the bedside, when administering the med
If one has positive bowel sounds, this tubes can be used for long-term nutritional support (greater than 4 weeks).
PEG - percutaneous endoscopic gastrostomy tube
PEJ - percutaneous endoscopic jejunostomy tube
Name the characteristics of urine to be assessed.
Color - pale yellow, straw-colored or amber
Odor - aromatic - can develop amonia smell when it stands
Turbidity - clear or transparent
pH - 5-6
Specific gravity - 1.015 to 1.025
Constituents - NO albumin, glucose, ketone bodies, gross bacteria, blood, pus
Extra, abnormal sounds of breathing
ADVENTITIOUS
A client has ROM exercises performed on the left shoulder after morning care. What exercises are performed on the shoulder joint?
Flexion and Extension
Adduction and Abduction
Circumduction