Oxygenation
What is Dyspnea on Exertion?
Shortness of breath with exercise or movement
Pressure injury: blistering or a shallow break in the skin; partial thickness loss
What is stage 1
.................
Free Points
Pain is what kind of data
subjective
Describe False Reassurance
Telling someone that everything will be ok when you can not guarantee the outcome
The correct use of an incentive spirometer is
Inhale through the attached tube slowly and steadily, keeping the ball within the parameters until you reach the goal or can no longer take in any more air
Name 3 ways to prevent pressure injuries
Frequent patient repositioning, adequate skin care, assessing pressure areas frequently, elevating heels off of bed, applying protective dressings.
Drainage of a wound that is a pale pink / yellow color
What is serosanguinous drainage
the best way to get an accurate picture of the patients pain
ask the patient to rate, describe, or communicate their pain
..........
free points
The lung sound heard as a complication of atelectasis is......
Hint: its not nothing or diminshed
What is Crackles (Rales)
Pressure injury: full-thickness skin and tissue loss, cannot be determined due to eschar or slough
What is Unstageable pressure sore
Signs and Symptoms of a infected wound
What is fever, swelling, pain, erythema, purulent drainage
Cold Therapy considerations: name 3
no longer than 20 minutes, something between cold and skin, assess skin integrity, not used with neuropathy patients, discontinue with increased pain
Describe Empathy
the best approach for a nurse to use to encourage a client to express feelings and to develop increased awareness about what those feelings.
The nurse is caring for a client with pneumonia who has rhonchi throughout his right lung and a moist, non-productive cough. The client tells the nurse “I have a lot of mucus but I just can’t seem to cough it out”. The nurse’s plan of care for this patient will include: Select all that apply:
Assisting the patient out of bed to sit in the chair 3 times a day
Encouraging the patient to decrease fluid intake throughout her shift
Teaching effective deep breathing
Assessing the client’s lung sounds
Administering an expectorant as ordered
A,C,D,E
Risk factors for pressure injuries: name at least 3
Over 65 years old, incontinence, diabetes, bed bound or limited mobility, head traumas, decreased LOC
Describe what Purulent drainage consists of
What is white blood cells, bacteria, and debris
You are caring for a post-operative patient. When you enter the room, the patient states, “I’ve been in pain at my surgical site all night and I couldn’t sleep.” As a professional nurse accountable for competent and caring practice, which action should you perform first?
Administer her prescribed pain medication
Assist her to a more comfortable position
Ask her to rate her pain on a scale of 0 to 10
Offer to give her a back rub for comfort
c
Allowing an older adult client to ......... can lead to better and more open communication
What is Reminisce
The nurse is caring for a client who has asthma and difficulty breathing. How should the nurse prioritize his/her care?
1- Administer medications as ordered such as bronchodilators to open the airways
2- Teach the client how to use the incentive spirometer.
3- Position the client for maximum ventilator function.
4- Stimulate respiratory function through ambulation.
3,1,2,4
The wound care clinical nurse specialist has been consulted to evaluate a pressure wound on the leg of a client with diabetes. The wound care nurse determines that damage to the subcutaneous tissues has occurred. How would the nurse document this wound?
Stage 3 pressure injury
Tunneling vs. Undermining
Undermining: Destruction of underlying tissue surrounding some or all of the wound margins
Tunneling: A narrow opening or passageway that can extend in any direction through soft tissue
Describe Chronic pain
gradual onset, long duration, psychological depletion, has no anticipated end
Non-therapeutic communication may interfere with professional nursing care by hindering the client-nurse relationship. Which of the following are examples of nontherapeutic communication? Select all that apply.
A nurse provides education on smoking cessation and states: “The same thing happened to me and I was able to quit.”
A nurse attempts to distract a client at the end of their life and states: “Let’s focus on your walking for the day, not your worries about death.”
A nurse states during report that “the client should not get an abortion because it is wrong.”
A nurse is sending a pediatric client for cardiac surgery. As he leaves she states “Don’t worry, everything will be fine!”
A nurse is discussing care options with the family of a client and says: “What have your experiences been like with home healthcare in the past?”
A, B, C, D