Abnormal Assessment
What is the artery pulse located posterior to the patella
What is the popliteal artery pulse?
The client has been diagnosed with active tuberculosis. Which precaution does this client fall under?
What is airborne?
Which pain scale is most appropriate for clients aged 3 years and up?
What is the Wong Baker FACES scale?
To confirm the absence of bowel sounds, the nurse must listen to all four quadrants for a total of this many minutes.
What is 2 minutes?
What kind of tissue traumas are associated with "boosting" a patient up in bed?
What are friction and shearing?
Restlessness, anxiety, confusion, tachycardia, dyspnea, and initial elevated BP are (early or late) signs of hypoxia?
What are early signs?
The client has a MRSA infection in a wound on their right lower leg. The wound is weeping and soaks through the dressings every couple of hours. Which precaution category does this client fall under?
What is contact?
With regard to nasogastric tube feedings, X bore = decompression/suction, while X bore = feeding?
What are large bore and small bore?
This is the medical term for a painful or difficult urination, often described by patients as a "burning" sensation.
What is dysuria?
What are the three levels of contamination used to classify wounds?
What are clean, clean-contaminated, and contaminated?
Abnormal respirations characterized by rapid, deep, labored breathing as the body attempts to "blow off" excess CO2 is called what?
What are Kussmaul respirations?
A client is on contact precautions due to suspected C. Difficile infection. What does the nurse use to perform hand hygiene?
What is soap and water only, no hand sanitizer?
In which type of dialysis is blood removed from body, filtered through machine (dialyzer), and returned to patient?
What is hemodialysis?
The nurse observes stool that is black and tarry, which typically indicates bleeding in this part of the gastrointestinal tract.
What is the upper GI tract?
Wound healing occurs by what mechanism if it is delayed, and when the wound that was previously open is now closed? This process is usually associated with large, infected, and contaminated wounds.
What is tertiary intention?
Name the cyclic respiratory pattern that gradually increases in depth & rate, followed by a gradual decrease, and then a period of apnea.
What is Cheney Stokes?
List the proper order of doffing PPE.
What are gloves, gown, goggles, and mask?
Which catheter type allows dialysis to begin quickly, but carries the highest risk for infection and other complications?
What is a central venous catheter?
When administering a cleansing enema, the nurse should position the patient in this specific position to follow the natural curve of the sigmoid colon.
What is the Left Sims' (or Left Lateral) position?
What is negative pressure?
These risk factors lead to what condition?
Medications, obesity, low protein levels, sitting/standing in the same position too long, and pregnancy?
What is edema?
A white blood cell count differential may show an increase in immature neutrophils, indicating a burgeoning acute bacterial infection commonly referred to as what?
What is a shift to the left?
Which ostomy type bypasses the large intestine, drains liquid continuously, has no sphincter control, and the bag is worn at all times?
Following a TURP, the nurse must maintain this type of intervention to prevent blood clots from obstructing the urinary catheter.
What is continuous bladder irrigation (CBI)?
A classification of wounds that have arrested in one of the wound healing stages, usually the inflammatory phase.
What is chronic?