Vital Signs
Assessment
Wounds/PI's
Safety
Labs
Odds&Ends
Infection Control
Med Admin
100

Where should the arm be placed when checking the BP?

at the level of the heart 

100
Name 3 signs of infection:
erythema, swelling, purulent drainage, Leukocytosis
100

A laceration which has edges that do not approximate must heal by:  

Secondary intention

100

A nurse needs to turn/reposition a very heavy patient. What is the best action to prevent injury?

Ask for help!

100

What lab will be draw for patients who are on warfarin (coumadin)?

PT/INR

100
Placing a calendar in a confused patient's room is an example of:

reorientation therapy

100

What part of the sterile field is considered contaminated or dirty?

The 1 inch border

Tip: You can touch any part of the 1 inch border with 'dirty hands' and once you don sterile gloves you can not touch that 1 inch border

100

The 6 rights must be verified how many times?

3

200

A patient has a bp reading of 130/80. What stage of hypertension is this considered?

pre-hypertension

A blood pressure reading of 124/84 mm Hg places this client in the prehypertension category.  This includes a systolic pressure of 120 to130 mm Hg and a diastolic pressure of 80 to 89 mm Hg.


200
If the nurse assess rales in the bases, what is the first thing the nurse should instruct him/her to do?

cough and deep breathe

(sometimes this can clear the fluid)

200

This stage pressure injury can be described as a shallow open ulcer. 

stage II

200

What is the 1st intervention the nurse should do if a patient complains of difficulty breathing?

raise the head of the bed
200

What might a WBC of 15 indicate?

Infection

200

The sharing of life stories & memories in a group of elderly patients is a behavioral approach to dementia known as:

reminiscence

200

What type of precautions are required for VRE +/- MRSA of a wound?

contact

200
This is the most common symptom of an allergic reaction to a medication?

hives

300

The carotid pulse indicates circulation to which organ?

Brain

300

What is the term for a respiratory pattern that goes from faster, to slower, to periods of apnea?

Cheyne Stotkes

300

A full thickness skin loss with a 'crater' but no visible bone or muscle is what stage PI?

Stage III

300

Safety hazzards in the elderly patient's environment include:

throw rugs

scatter rugs

cords


300

A patient has bloody stools. What lab does the nurse expect will be drawn?

CBC

TIP: this contains hgb&hct, plateletes = all should be assessed when bleeding is suspected

300
The term for blood in the stool which is hidden to the naked eye is:

occult blood

300

Airborne precautions such as for TB requires the use of what type of mask?

N95

Tip: and negative pressure room for the pt; also use gown gloves and eye protection

300

The first thing the nurse should offer the patient when trying to determine ability to swallow for a med pass is what?

a sip of water

400

A pulse felt over the just posterior to the ankle bone on the inner aspect of the ankle

posterior tibial

400

When a patient is dehydrated, what does the nurse expect the USG level to be?

elevated
400

How does the nurse treat a wound evisceration? 

Cover with NSS soaked gauze

400

The nurse notes a urine output of 180 in an 8hr shift and performs a bladder scan which also shows 180 ml. What should the nurse expect when calling the provider?

possibly an order for IV fluids (to rehydrate if that is the issue) & an order for labs like a BMP to assess kidney function 

Tip: remember, normal urine output is ___ml per hour

400

A patient's INR is 4.0. 

What will the nurse assess?

Signs of bleeding such as bloody stools, melena, bleeding gums, distended abdomen, hematuria

400

Order: 300,000 units of drug X; available is 100,000 units of drug X per 2 ml. How many ml would you give? Round to nearest 10th.

6 ml

400

Droplet precautions such as for the flu requires what type of mask?

surgical mask

Tip: also requires gown, gloves & eye protection

400

The pinna are pulled "_&_" when giving ear drops to an adult.

up and back

500

What will the BP and HR do when a patient is in shock?

Heart rate up, bp down

500

When the nurse pinches an area of skin over the clavicle and it doesn't bounce back quickly this is known as?

skin tenting

Tip:  a sign of dehydration but not 100% accurate- it is only 1 clue that must be examined 

500

What type of dressing is recommended for a stage I pressure injury?

either no dressing or a transparent (clear) dressing

this is a dressing that will protect from shearing. This dressing will also allow the nurse to visualize the area for assessment purposes.

500
Nurses are often stuck with used needles due to not taking the appropriate safety precautions. What is the best way the nurse can prevent needlestick injuries after giving injections?

DO NOT RECAP! Place the used needle in a sharps container immediately

500

A 24 hour urine specimen is collected in a specific manner. When should the specimen collection begin?

After the pt discards the first urine of the day (the 1st urination after awakening)

500

Order: 1 L NSS to infuse over 8 hours. How many mls/hr would the nurse administer?

125 mls/hr

Remember the formulas!


500

What type of precautions are required for pertussis?

Droplet

500

Prior to administering meds that effect the heart rate, the nurse must assess what and for what time frame?

apical, 1 full minute

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