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Hodge Podge
100
What stage wound is below?
How would you define that stage wound?
Stage II Partial thickness loss of dermis
Dressing
You could use a hydrogel dressing for wounds stages II-IV. Rehydrates the wound bed and promotes debridement
100
What are five things the nurse can do to prevent skin breakdown?
Reposition q 2hrs
Special beds/mattress
Keep the skin dry
Use draw sheets
Braden skin breakdown scale
Hydration and nutrition
Mobility
100
What is a clear liquid diet?
List 4 things on a clear liquid diet
Foods that have no residue and are liquid at room temp.
Ice chips
Water based pulp free popsicles
Tea and black coffee
Sports drinks
Water
Pulp free juice
Broth
Jello
100
Use the image below: What is the patients score are they at risk for pressure ulcers?
Your client scores a 1 in sensory
2 in moisture
2 in activity
2 in mobility
1 in nutrition
1 in friction and shear
9 Yes they are at high risk.
6 is the highest risk score a patient can receive
100
What is an entreal feed? What are some precautions the nurse should take when admistering an entreal feed.
Provide nutritional support to people who are unable to eat or swallow safely, or who are unable to meet their nutritional needs through oral intake. STILL USES THE GI TRACT
HOB 30 to 45 degrees. If client is having problems with breathing stop the feed and put the clients HOB at 90 degrees
Flush with 30ml of water before and after feed
Change bag and tubing every 24 hours
Only 4 hours of feed hanging at a time.
Note the difference a patient receiving entreal feeds will need their blood glucose regulated more often cause they are at risk for hyperglycemia.
This is different than a risk for a patient recieving parenteral nutrition. REVIEW THIS DIFFERENCE
200
What kind of precautions would a nurse place the client who has have clostridoides difficile (CDiff)
What types of PPE is included in in the above precaution?
Contact Precautions
Clean hands entering and leaving the room with soap and water
Contact
gown, and gloves
200
What is the highest score on the Braden scale?
What does this score indicate?
What is the lowest score on the Braden scale?
What does this score indicate?
The highest number is 23 - Low risk for pressure ulcer
The lowest number is 6 - High risk for pressure ulcer
200
A client is going home with a nasogastric tube what instructions should the nurse provide to prevent the tube from becoming clogged?
Flush tube before and after a feed
Flush tube before and after meds
Flush with 30ml of water
200
A client reports abdominal cramping while receiving an enema. What should the nurse do?
Cramping is normal in patients receiving an enema. Lower the bag to slow the infusion.
Stop the infusion for severe abdominal cramping, abdominal rigidity, or bleeding.
200
Client is placed on a full liquid diet what can this client have on their meal tray?
Everything on the clear liquid diet plus
Protein shakes
Custards
Puddings
Ice cream
Cream soups
Milk in coffee or team
Veg juice
Sherberts
300
A client is a fall risk. What prevention strategies should the nurse plan to implement?
List 4
Bed in lowest position
Bed Alarm
Assess fall risk factors
Educate the client
Provide no-slip socks
Place call light in reach
Place immobility equipment within reach
Fall risk band
300
A clients abdominal wound has dehisced what should the nurse do?
Remain Calm
Stay with the patient
Apply NS 0.9 soaked sterile gauze to the site
Place client NPO
Call the MD/ OR
300
What are 4 actions the nurse should take when caring for a patient on aspiration precautions?
Chin-to-chest swallowing
Thickened liquids - Special diets
Elevate HOB, semi-high fowlers,
Place food on the good side for chewing
Assess gag response after sedation
300
List 3 factors that influence bowel elimination.
Age
Diet
Physical activity
Bowel pattern
Meds, diagnostics, surgery
300
What is a parenteral feed?
A person receiving parentreal feeds total parentreal nutrition (TPN) is at risk for what condition if is stopped abruptly?
Parenteral nutrition (PN) is a method of providing nutrients directly into the bloodstream through a vein when a person cannot eat or drink by mouth, or when their digestive system is impaired.
Client is at risk for hypoglycemia. The nurse must wean the patient off TPN by using a fluid with dextrose.
Note the difference between a patient receiving entreal feeds vs parentreal nutrition REVIEW THE DIFFERENCE
400
Where do you start when providing a bed bath?
How do I clean the eyes?
Head to toe
Cleanest to dirties
Distal to proximal on extremities this facilitates and promotes good blood return
inner canthus to outer canthus eyes
Ask client what they can do to help
Provide privacy
400
What stage wound is this?
How would you define this wound stage?
Stage 3
Full-thickness tissue loss; subcutaneous fat is visible.
Dressing:
Hydrogel could be used on this wound
Hydrogel rehydrates and promotes wound healing and debrement used for stage II through Stage IV.
If you have a stage three and you’re the nurse and it is healing. How do you document that?
Stage 3 pressure ulcer healing new measurements it does not become a stage II
400
What is a full liquid diet?
What can the patient have on a full-liquid diet?
Liquid at room temp
Ice cream
Pudding
Cream soups
Everything on the clear liquid diet
Juice with pulp
400
What education should the nurse provide a client who is going home with a Guaiac Fecal Occult Blood Test?
No citrus drinks or food for 3 days before test
No red meat 3 days before test.
No NSAIDS or ASA
Test should be repeated 3 times
400
The nurse is providing intermittent feeds to a client via g tube. The nurse checks for residual before administering the feed.
When should the nurse contact the provider regarding residuals?
Residual greater than 200 mL on two separate assessments indicates that the client is unable to tolerate the feeding at the prescribed rate.
Therefore, the nurse should contact the provider.
500
What type of precautions is needed for varicella?
What type of precaution is needed for respiratory syncytial virus (RSV)?
Varicella is Contact and Airborne
What type of mask do you need with airborne precautions? N95
RSV is contact and droplet precautions
What type of mask do you need with droplet precautions? surgical mask
500
What are the 6 risk factors on the Braden Scale?
Sensory
Moisture
Activity
Mobility
Nutrition
Friction and Shear
500
What food should a client with crohn's avoid?
Crohns is an inflammatory bowel disease.
It is managed with a low fiber high protein, high calorie and low fat diet.
Avoid nuts, corn, high fat foods, spicy foods, fried foods, high fiber foods (no salad) alcohol, Caffeine
500
A client has had multiple episodes of diarrhea and the nurse supects Clostidiodes difficle (CDiff).
What are some things the nurse should include in the plan of care?
Increase fluids to decrease the chance of dehydration
Keep the skin and area dry and clean
Use barrier creams
Put the client on contact precautions
Wash hands with soap and water
500
A nurse notices a medication error during the administration process. The most ethically accountable action for the nurse to take is: "
- A) Ignore the error and continue with medication administration as planned.
- B) Inform the patient about the error and apologize, but do not report it to the supervisor.
- C) Immediately report the error to the supervising nurse and follow appropriate protocols to rectify the situation.
- D) Discreetly document the error in the patient's medical record and monitor the patient closely.
Answer: C - Reporting the error to the supervising nurse and following proper protocols is the most ethically accountable action
Answer: C - Reporting the error to the supervising nurse and following proper protocols is the most ethically accountable action