Show:
O2
Nutrition/Sensory
Urinary/Bowel
F/E
Skin
100
What is a priority nursing assessment pertaining to oxygenation?
What is maintaining a patent airway pg 311
100
What is dorsiflexion?
What is flexing the foot and toes upward. pg 165
100
What is a fecal occult guaiac test?
What is testing for blood in stools. serial testing from 3 different specimens. pg 239
100
What is the difference between Isotonic FVD and dehydration?
What is isotonic (loss and water and lytes from the ECF - hypovolemia) and dehydration (loss of water without loss of lytes -> hemoconcentration) pg 343
100
What is an example of a secondary intention healing wound?
What is pressure ulcer. pg 329.
200
What are some assessment findings associated with hypoxemia?
What is increased workload of breathing, wheezing, coughing, cyanosis, change in respiratory rate/rhythm, adventitious breath sounds, restlessness, irritability, and confusion pg 311
200
What are the expected findings of a negative Romberg test?
What is the patient is able to stand with minimal swaying for at least 5 seconds. pg 168
200
What are some interventions to prevent constipation in older adults?
What is adequate fluid and fiber intake with proper exercise. pg 239
200
What are the expected VS findings during fluid volume excess?
What is tachycardia, bounding pulse, HTN, tachypnea, increased CVP. pg 344
200
What are 3 age related factors that affect wound healing?
What is loss of skin turgor, skin fragility, decreased peripheral circulation, slower tissue regeneration, decreased absorption of nutrients, decrease in collagen, impaired immune response, dehydration related to decreased thirst response. pg 329
300
You are assessing a patient's O2 sats when you find reading of 85%. What should you do?
What is confirm placement of the probe, make sure O2 is being delivered correctly if in place, semi-fowlers/fowlers position, encourage deep breathing, stay with patient. pg 311
300
What does a 2+ DTR indicate?
What is expected findings (normal). pg 168
300
Approximately how many mL of urine per day do adults produce?
What is 1,500 - 2,000 mL/d
300
What are some expected neuromuscular findings in hyponatremia?
What is headache, confusion, lethargy, muscle weakness, respiratory compromise, fatigue, decreased DTRs, seizures, and coma. pg 347
300
On assessment, you that the patient has clear watery drainage from his wound. How do you document this?
What is serous drainage. pg 330
400
What assessment findings would indicate that a patient needs supplementary oxygenation? 3 findings
What is tachypnea, tachycardia, restlessness, anxiety, confusion, pale skin, elevated BP, use of accessory muscles, cyanosis -> bradypnea, bradycardia, hypotension, cardiac dysrhythmias pg 312
400
What is the difference between a clear and full liquid diet?
What is clear (liquids that have very little residue or are clear - clear fruit juices, gelatin, and broth) and full (clear liquids plus liquid dairy products - all juices, pureed foods) pg 215
400
What are some interventions to prevent UTIs?
What is for females cleaning from front to back, clean underneath the foreskin in males, provide frequent catheter care. pg 245.
400
A patient has a serum potassium level of 3.4. What dietary changes should you recommend to this patient?
What is encouraging foods high in potassium - avocados, dried fruit, cantaloupe, bananas, potatoes and spinach. pg 349
400
On assessment you find that you patient has a stage I pressure ulcer. What are some interventions you can start to implement? (2)
What is relieving the pressure, frequent turning/repositioning, pressure relieving devices (free floating heels, heel/elbow pads, etc.), pressure-reducing surfaces (air mattress), keep patient clean, dry, hydrated and well nourished. pg 334
500
What is the max amount of liters you should use with a nasal cannula?
What is 6L/min pg 312
500
What is the most significant risk factor for vision problems?
What is age. pg 253.
500
You have a patient that has not voided since 0800 and it is currently 1300. He ate and drank all of the foods/liquids on both his breakfast and lunch tray. You take the patient to the bathroom, and he voids 50mL. What should be your next intervention?
What is encourage the patient to void again (wait a few minutes and try again), distractions (running water, privacy), assess bladder for retention (bladder scan for PVR), etc.
500
What are the expected GI findings with a magnesium level of 1.2.
What is hypoactive bowel sounds, constipation, abdominal distention, and possible ileus. (slowed down significantly) pg 352
500
Describe the differences in the stages of pressure ulcers. (DTI, stage 1-4, and unstageable)
What is DTI (discoloration but skin intact), stage I (nonblanchable erythema with intact skin that may be tender, cool/warm to the touch), stage II (partial thickness - visible open area that is pink/red - possibly a blistered appearance), stage III (full-thickness - into subcutaneous tissue), stage IV (full thickness - to muscle/bone), unstageable (too much drainage/eschar to assess damage to wound bed). pg 332