Exam #1
What is the correct order of the nursing process?
ADPIE - assessment, diagnosis, planning, implementation, evaluation
Upper GI bleed stool color vs. lower GI bleed stool color?
Upper GI bleed = black, tarry stool (melena)
Lower GI bleed = bright red, bloody stool
What is healing by tertiary intention?
Letting the tissue heal a little before stitching it closed
What kind of injection is insulin & heparin? What is the preferred injection site?
Subcutaneous / abdomen
What is palliative care vs. hospice care?
Pallitive - used for patients with over 6 months to live. Can be implemented at any stage of illness. Used for symptom management but not to cure disease
Hospice - used for patients with less than 6 months to live. Focus solely on comfort
What is Subjective vs. Objective data?
Subjective - what patient says
Objective - what you observe using your senses
List 3 causes of constipation
Decreased activity level/ ignoring urge to defecate
• Changes in food intake
• Decreased fluid intake
• Medication side effects
• Surgery
• Pregnancy
• Depression
• Aging
• Laxative overuse
• Nerve damage or impairment
Describe a stage 1 pressure ulcer?
Intact skin over bony prominence that is red and does not blanch
What is the preferred site for an IM injection?
Ventrogluteal
How do you apply a wrist restraint?
- Make sure 2 fingers can fit under
- Tie using a slip-knot
- Attach to a non-moveable part of the bed
Must have an order for this
Primary - what patient says
Secondary - all other sources
List 3 signs & symptoms of a vagal response?
Monitor for low HR/BP, or s/s of dizziness, pallor, clammy skin.
List 3 signs & symptoms of a wound infection
Signs & symptoms:
• Redness or increased warmth of the wound
• Swelling
• Wound drainage (purulent = pus)
• Wound has an unpleasant smell
• Pain around the wound
• Fever above 100°F (37.7°C)
• Labs – WBCs over 11,100/mm3
What is required to draw up medication from an ample?
A filtered needle
Which should you do first: palpate or auscultate the abdomen
Always auscultate before palpating
What does the acronym RACE stand for?
Rescue
Alarm
Conceal
Evacuate
What stool is expected in a colostomy vs. ileostomy
Colostomy- soft, formed stool
Ileostomy- loose, liquid stool
Describe sanguineous vs. serosanguinous drainage
Sanguineous = dark red & bloody
Serosanguinous = light red, pink
How do you inserted eardrops in an adult vs. a child?
Adult = pull pinna up & back
Child = pull pinna down & back
What is the order of the stages of grief?
Denial, anger, bargaining, depression, acceptance
A nurse admitting a client to the intensive care unit with a stroke. The nurse assess, vital signs, pupils, and orientation every few minutes. What type of assessment is being performed by the nurse?
Focused assessment
How long should you listen to the abdomen to determine absent bowel sounds?
3 - 5 minutes
What is wound dehiscence vs. wound evisceration?
Dehiscence = closed wound opens up
Evisceration = closed wound opens up & abdominal organs protrude out
List 3 types of medications you cannot crush
•Buccal or sublingual tablets
•Effervescent tablets
•Enteric-coated tablets
•Liquid-filled gel caps
•Medications that may taste too bitter
•Mucous membrane irritants
•Neoplastic agents (chemotherapy)
•Orally disintegrating medications
•Sustained-release tablets
What is respite care?
For caregivers when they need a break