Wound Care
This type of wound healing occurs when wound edges are neatly approximated, like in surgical incisions, and heals quickly with minimal scarring.
What is primary intention?
This intervention is essential to prevent complications like pressure ulcers in a bedridden patient.
What is repositioning the patient every 2 hours?
This is a common sign of a localized infection, often accompanied by redness and swelling.
What is warmth or heat?
What is the abdomen?
This is the preferred site for insulin administration in adults.
This oxygen delivery device provides a flow rate between 1-6 L/min and delivers 24-44% oxygen.
What is a nasal cannula?
This legal term refers to a nurse’s failure to meet the standard of care, resulting in harm to a patient.
What is negligence?
This process moves chyme from the stomach to the large intestine, where nutrients are absorbed, and waste is formed.
What is peristalsis?
This is the correct method for going up stairs using crutches.
What is leading with the good leg and then following with the crutches?
This is the most common cause of hospital-acquired urinary tract infections.
What is catheterization?
This is the first action a nurse should take when vital signs are abnormal during a routine check.
What is re-measuring or reassessing the vital signs?
This is the primary goal of hospice care for terminal patients.
What is promoting comfort and quality of life?
In this stage of pressure ulcers, partial-thickness loss of dermis presents as an open ulcer or blister.
What is Stage II?
This scale is used to assess the risk of developing pressure ulcers.
What is the Braden Scale?
his systemic sign of infection indicates that the body is fighting off bacteria or viruses.
What is fever?
This is the first step a nurse should take when preparing to administer a medication.
What is verifying the medication order?
This oxygen delivery system provides up to 100% oxygen with a reservoir bag, typically used in critical care.
What is a non-rebreather mask?
This term describes the duty of healthcare providers to protect patient privacy and confidentiality under the Health Insurance Portability and Accountability Act (HIPAA).
What is HIPAA compliance?
Difficulty swallowing, a condition common in older adults and patients with neurological disorders, puts individuals at higher risk for malnutrition.
What is dysphagia?
This is the term used for the basic movement pattern when walking with crutches, placing weight on hands rather than the armpits.
What is the three-point gait?
This technique is essential to prevent CAUTI when inserting and caring for urinary catheters.
What is sterile technique?
This is the normal range for an adult's respiratory rate at rest, measured in breaths per minute.
What is 12 to 20 breaths per minute?
These signs, such as Cheyne-Stokes breathing, mottling of the skin, and decreased urine output, indicate this stage in a dying patient.
What are symptoms of imminent death?
This is the name for the condition where an incision partially or fully separates due to wound stress or improper healing.
What is wound dehiscence?
This process involves removing dead or damaged tissue from chronic wounds to promote healing.
What is debridement?
This practice is the single most important action to prevent the spread of infections in healthcare settings.
What is hand hygiene?
This step ensures the medication is safely administered through a nasogastric (NG) tube.
What is verifying the placement of the NG tube?
This device delivers a precise amount of oxygen and is particularly useful for patients with COPD.
What is a Venturi mask?
This is the ethical principle that requires nurses to act in the best interest of their patients and do no harm.
What is nonmaleficence?
This type of nutrition provides nutrients directly into the gastrointestinal tract via a tube when a patient cannot consume food orally.
What is enteral nutrition?
These items are often used to maintain proper body alignment by supporting different parts of the body, such as the head, back, or legs, especially for patients in bed for prolonged periods.
What are pillows?
Removing this as soon as possible is the most effective way to reduce the risk of CAU
What is the urinary catheter?
This condition is characterized by a consistently elevated resting heart rate above 100 beats per minute.
What is tachycardia?
This decision involves stopping all curative treatments and focusing solely on comfort measures for terminal patients.
What is palliative care or transitioning to hospice care?
This term refers to redness of the skin that does not turn white when pressed, often a sign of the first stage of pressure ulcers.
What is nonblanchable erythema?
This type of diet, rich in this macronutrient, is important for patients at risk of pressure ulcers to promote skin integrity and tissue repair.
What is a high-protein diet?
This type of dressing change technique is required to prevent infection in surgical wounds healing by primary intention.
What is sterile dressing change?
his muscle, located in the upper outer quadrant of the buttock, is a common site for intramuscular injections.
What is the Vastus lateralis muscle site?
This is the first intervention a nurse should perform when a patient has an oxygen saturation level of 86%.
What is repositioning the patient to high Fowler’s position?
This type of consent is required before performing any invasive procedure or surgery on a patient.
What is informed consent?
This diet is the first stage in diet progression, consisting only of clear liquids such as broth, tea, and clear juices.
What is a clear liquid diet?
This condition occurs when muscles waste away due to lack of use, often seen in bedridden or immobilized patien
What is muscle atrophy?
This intervention helps prevent constipation in patients taking opioids.
What is increasing fluid intake and dietary fiber, along with administering a stool softener?
A respiratory rate greater than 24 breaths per minute in an adult is referred to by this term and may indicate respiratory distress.
What is tachypnea?
This symptom, common at the end of life, involves difficulty breathing and is managed with medications and positioning.
What is dyspnea?
This type of wound healing happens when a wound is left open to heal from the bottom up, typically seen in pressure ulcers or large wounds.
What is secondary intention?
These devices are used to prevent this condition by improving venous circulation in the lower extremities.
What are blood clots (or deep vein thrombosis, DVT)?
This action can spread airborne microorganisms in healthcare settings, and should be avoided when handling used linen.
What is shaking the linen?
This route of medication administration provides the fastest onset of action.
What is the intravenous (IV) route?
This nursing intervention encourages deep breathing and prevents atelectasis, typically done every hour.
What is incentive spirometry?
This legal concept refers to providing care to a patient without obtaining proper consent.
What is battery?
his time limit is recommended for how long enteral feeding tubing and formula should hang to prevent bacterial growth and contamination.
What is 24 hours?
This body position involves the patient lying flat on their stomach with their head turned to one side, often used to improve oxygenation or for certain therapeutic procedures.
What is the prone position?
This type of program is implemented to manage patients with chronic constipation, focusing on regular toileting times and diet modifications.
What is a bowel training program?
When taking a patient's blood pressure, it is important to have the patient's arm at this level to ensure an accurate reading.
What is shortness of breath (or dyspnea)?
This feeling is common in terminal patients and involves fear or worry about the dying process.
What is anxiety about dying?
This type of drainage from a wound suggests the presence of an infection.
What is purulent drainage?
This nursing diagnosis is used when there is a disruption in skin structure and function, often due to pressure ulcers, wounds, or prolonged moisture exposure.
What is impaired skin integrity?
This infection requires contact precautions and soap and water for hand hygiene, as alcohol-based sanitizer is ineffective.
What is Clostridium difficile (C. diff)?
This is the nurse's priority action when a patient refuses to take their prescribed medication.
What is educating the patient about the benefits and consequences of not taking the medication?
This symptom combination indicates the early and late signs of hypoxia
What are restlessness and cyanosis?
This ethical principle emphasizes the patient's right to make their own healthcare decisions.
What is autonomy?
This plasma protein, produced by the liver, is used to assess long-term nutritional status and is commonly measured in patients with chronic illnesses.
What is albumin?
This term refers to the manner in which a person walks, including rhythm, cadence, and speed, and is often assessed to evaluate mobility and balance.
What is gait?
This test measures the amount of urine left in the bladder after a patient voids, helping to assess bladder function.
What is a post-void residual (PVR) test?
A blood pressure cuff that is too small for the patient's arm can result in this type of error.
AWhat is a falsely high reading?
This type of care focuses on comfort and quality of life for patients with terminal illnesses, typically when life expectancy is six months or less.
What is hospice care?
This is an early sign of infection, particularly in wounds, characterized by redness around the wound site.
What is erythema?
This is a common nursing diagnosis for patients who are immobile, have decreased fluid intake, or take medications that slow down bowel motility.
What is risk for constipation?
This type of mask is required when caring for patients with tuberculosis, measles, or other airborne diseases.
What is an N95 respirator?
This method involves administering medications directly into the eye to treat conditions like infections or glaucoma.
What is ophthalmic medication administration?
This sound is commonly heard during auscultation in a patient experiencing an asthma attack.
What is wheezing?
This term refers to the legal document that allows patients to state their preferences for end-of-life care, including resuscitation efforts.
What is an advance directive?
his practice is recommended to prevent gastrointestinal discomfort and reduce the risk of contamination when administering enteral formulas.
What is keeping the formula at room temperature?
This nursing diagnosis is given to patients who have impaired mobility, muscle weakness, or balance issues, making them more likely to experience accidents.
What is "risk for falls"?
This type of catheter, inserted through the abdominal wall into the bladder, has the advantage of reducing the risk of urethral trauma and long-term infection.
What is a suprapubic catheter?
When taking a patient's blood pressure, it is important to have the patient's arm at this level to ensure an accurate reading.
What is heart level?
This is a common respiratory pattern, characterized by periods of rapid breathing followed by apnea, seen in the final stages of dying.
What is Cheyne-Stokes respiration?
This stage of a pressure ulcer involves full-thickness skin loss, possibly extending into subcutaneous tissue but not exposing bone, tendon, or muscle.
Question: What is Stage III?
What is Stage IV?
This supportive device is used to prevent external rotation of the hips in patients who are bedridden or immobile.
What is a trochanter roll?
This type of PPE is required when performing wound care to prevent exposure to blood and body fluids.
What are gloves, gown, mask, and eye protection?
These are the terms used to describe the highest and lowest concentrations of a drug in a patient’s bloodstream, important for adjusting dosages of medications like antibiotics.
What are peak and trough levels?
his breathing technique is often used by COPD patients to help reduce air trapping and prolong exhalation.
What is pursed-lip breathing?
This multidisciplinary group in a healthcare facility is responsible for addressing and resolving complex ethical issues, such as end-of-life decisions or patient autonomy conflicts.
What is an ethics committee?
This procedure is essential to prevent tube clogging and maintain patency between enteral feedings.
What is flushing the feeding tube with water between meals?
his mobility aid is commonly used by patients who need extra stability and support when walking, and should be moved forward before taking a step.
What is a walker?
This term describes the act of bearing down during a bowel movement, which can trigger a vagal response.
What is the Valsalva maneuver?
This phenomenon occurs when a patient’s blood pressure drops significantly upon standing, often leading to dizziness or fainting.
What is orthostatic hypotension?
During the dying process, this sign often occurs, where the patient is unresponsive and has decreased awareness of their surroundings.
What is decreased consciousness?
This type of therapy increases blood flow, relaxes muscles, and helps relieve pain, often applied using warm towels or heating pads.
What is heat therapy?
This immobility-related factor increases a patient’s risk for pressure ulcers, especially in bedridden patients.
What is prolonged pressure on bony prominences?
Droplet precautions are used for this common seasonal infection, spread by large respiratory droplets.
What is influenza?
These factors, including muscle mass, medication volume, type of medication, and patient age, help a nurse decide where to give an injection.
What are factors to determine the injection site?
This respiratory therapy involves using percussion, vibration, and postural drainage to mobilize secretions in patients with respiratory conditions.
What is chest physiotherapy?
This legal concept refers to the duties and responsibilities that nurses are legally allowed to perform based on their training, licensure, and regulations.
What is scope of practice?
This type of feeding is used when a patient is unable to digest or absorb nutrients through the gastrointestinal tract and requires nutrition through a central or peripheral line.
What is parenteral nutrition?
This term refers to the full movement potential of a joint, typically measured in degrees of a circle, and is often maintained or improved through physical therapy exercises.
What is range of motion (ROM)?
This condition is a common infection in the urinary tract that causes symptoms like burning, urgency, and cloudy urine.
What is a urinary tract infection (UTI)?
This involuntary response occurs during the onset of a fever as the body attempts to raise its core temperature to the new set point established by the hypothalamus.
What is shivering?
This is typically the first organ to begin shutting down as the body approaches death, due to decreased circulation and oxygenation.
What are the kidneys?