Skin
Name four common bony prominences.
What are sacrum, heels, hips, elbows? (other correct answers may also be accepted)
Intact skin with a localized area of non-blanchable erythema (redness that does not turn white when pressed).
What is stage 1?
As needed
What PRN?
The use of precise practices to eliminate ALL microorganisms from an object or area and prevent contamination.
What is sterile technique?
A nurse is caring for a client who has diabetes and a new prescription for 18 units of regular insulin and 36 units of NPH insulin subcutaneously at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the insulin syringe?
What is 54 units?
How often should patient be turned to minimize pressure injuries?
What is every 2 hours?
Full-thickness tissue loss where the actual depth of the ulcer is completely obscured by slough (yellow/stringy) or eschar (brown/black/leathery necrotic tissue).
What is Unstageable?
A/O x4
What is alert and oriented x4 (person, place, time &situation?
Clean technique to reduce the number and spread of microorganisms.
What is aseptic technique?
A nurse is preparing to administer potassium chloride 20 mEq suspension PO daily. The amount available is potassium chloride suspension 10 mEq/mL. How many mL should the nurse administer?
What is 2ML?
What assessment tool do we use to assess patient risk level for acquiring a pressure injury?
What is the Braden Scale?
Full-thickness skin loss extending to subcutaneous (adipose) tissue. Adipose is visible, but muscle, tendon, or bone is not exposed. May include undermining and tunneling.
What is stage 3?
MAR
What is medication administration record?
After inserting a Foley catheter using sterile technique, urine return is observed. The nurse should advance the catheter this additional distance before inflating the balloon.
What is 2 inches?
A nurse is caring for a client who is to receive liquid medications via a gastrostomy tube. The client is prescribed phenytoin 250 mg. The amount available is phenytoin oral solution 25 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number.
What is 50ml?
A patient with a Braden Scale score of 8 is considered to be at this level of pressure injury risk.
What is Very High risk?
Partial-thickness skin loss with exposed dermis. The wound bed is pink or red, moist, and may present as an intact or ruptured serum-filled blister
What is Stage 2?
TID
What is three times a day?
How does the nurse determine the appropriate length for inserting a nasogastric tube (NGT)?
What is measuring the tube from the tip of the nose, to the earlobe, and then to the xiphoid process?
A nurse is preparing to administer levothyroxine 0.175 mg PO once a day. The amount available is levothyroxine 88 mcg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number.)
What is 2 tablets?
This patient would likely have a Braden Scale score in this range: walks independently, repositions self in bed, has no sensory impairment, and eats 100% of meals.
What is a low-risk (19-23)?
Intact or non-intact skin with a localized, persistent area of deep red, maroon, or purple discoloration. Results from intense and/or prolonged pressure and shear at the bone-muscle interface
What is Deep Tissue Injury (DTI)?
HIPPA
Health Insurance Portability and Accountability Act
This important action should be performed before, during, and after any type of suctioning procedure to promote patient safety and reduce complications.
What is assessing the patient's oxygenation status and providing oxygen ?
A nurse is caring for a client who is prescribed amoxicillin 1.5 grams daily PO in three divided doses every 8 hr. Available is amoxicillin 500 mg capsules. How many capsules should the nurse administer per dose?
What is 1 capsule?