Health & Wellness
The nurse measures blood pressures for clients during a community health fair
What is secondary prevention
The location in which you place the bell of the stethoscope on the arm when taking a blood pressure
Over the Brachial Artery located in the antecubital space of the arm
Two nursing interventions used to prevent the development of pressure injuries.
Turn and reposition every 2 hours
Good Skin Care
Good Nutrition
Wrinkle Free bed linens
The application of ice packs is kept on the skin how long?
20 minutes on.
PPE stands for__________?
Personal Protective Equipment
Name the 5 steps of the nursing process
What are assessment, analysis, planning implementation and evaluation
patient, drug, dose, route, time (frequency)
What are the 5 rights of medication administration
NPO stands for ?
Nothing by Mouth
This type of care gives patients with a life-threatening illness the best quality of life using aggressive management of symptoms and treats the whole person - body, mind, and spirit
PALLIATIVE CARE
What are the 6 Normal Characteristics and Special Considerations for Observation of Stool
Volume
Color
Odor
Consistency
Shape
Constituents
Mr. Smale is having difficulty breathing due to his Congestive Heart Failure. What position would help to improve his breathing?
High Fowler's
When providing oral care to an unconscious resident, what position would best prevent aspiration?
Lateral Position
Name two words that describe the relationship of fluid and electrolytes
What is balance and homeostasis
Something that increases an individuals risk for disease or injury. May be modifiable or unmodifiable
What are risk factors
The Top number of a blood pressure reading reflects the heart at work.
Systolic
The rubbing of one surface against another
Friction
What safety precaution should be used when applying ice to the skin?
Make sure there is a barrier between the ice pack and the skin
Frequent checks to the skin.
Apply only 20 minutes
The best way to prevent the spread of infection is by __________?
Handwashing
What the clients states "I have pain, nausea, and itching."
What are subjective statements (symptoms)
Shake before pouring this type of liquid medication
What is a suspension
What 4 risk factors for dysphagia?
Risk Factors:
neurologic condition - stroke, head injury, progressive neurologic disorder
Dementia
obstructive condition
COPD
Aging
Childhood syndrome (down syndrome, cerebral palsy)
Care provided for people with limited life expectancy., often in the home.
HOSPICE CARE
Medical term for urine with a bloody tinge
HEMATURIA
Your resident has a difficult time hearing. To better assist him with communication, and conserve his oxygen/energy, what should the Nurse do?
Use simple words and sentences
State the topic of conversation first
Keep conversations short and quick.
Moving an extremity away from the body and then toward the body
What is abduction and adduction
potatoes, oranges, bananas, avocados
What are examples of foods high in potassium
According to Maslow's hierarchy of basic human needs, these need to be met before all others
This number of a blood pressure reading reflects the heart at rest
Diastolic
This stage of the pressure injury is reddened and nonblanchable. What is this stage?
Stage 1
Mrs. Jones fell, and injured her left pinky finger, causing some swelling. The ice pack is applied. What is the rationale?
It constricts the vessels to reduce swelling.
redness, heat, swelling, pain
What is the inflammatory response
SMART goals
What are specific, measurable, attainable, realistic and timely
The simultaneous use of multiple drugs by a single client for one or more conditions and increases the risk for drug interactions
What is polypharmacy
What are 4 signs and symptoms of dysphagia?
Signs and symptoms -
difficulty swallowing foods or liquids
coughing or choking when eating or drinking
frequent throat clearing
wet gurgling voice after eating
feeling of food or liquids "stuck" in throat
KUBLER-ROSS 5 STAGES OF GRIEF
DENIAL
ANGER
BARGAINING
DEPRESSION
ACCEPTANCE
Mrs. Green is complaining of pain with urination. What is the medical term for this condition?
Dysuria
A noninvasive technique that measures the peripheral arterial oxyhemoglobin saturation (SpO2) of arterial blood.
What is PULSE OXIMETRY?
mass, tone, and strength
What is a muscle assessment
The swelling of body tissues (interstitial spaces) with excessive water
What is edema
A nurse is participating in a flu immunization program.
What is primary prevention
This is the medical term describing a blood pressure that is below the normal values.
What is HYPOTENSION?
What is a Stage 2 pressure injury?
When heat is applied to the skin, the blood vessels will________________
Dilate the blood vessels, and increase the circulation to the area.
airborne, droplet, and contact
What are types of transmission-based precautions
An assessment completed after an action is implemented
What is evaluation
XR, ER, XL, LA at the end of a medication name.
What are extended release "DO NOT CRUSH" meds
Giving fluids/nutrients through the GI tract via feeding tube
Enteral Nutrition
When a person imagines what is would be like in another person's situation
Empathy
Another name for overactive bladder.
Urge Incontinence
Continuous musical sounds, produced as pair passes through airways constricted by swelling, narrowing, secretions or tumors. Often heard in patients with Ashtma, tumors or a build up of secretions.
What are WHEEZES?
The loss of muscle strength and function due to inactivity
Muscle Atrophy
What is sodium
An individual's response to a disease state
What is an illness
This is the medical term for a blood pressure that is higher than the normal blood pressure values.
What is HYPERTENSION?
In the normal aging process, the skin loses elasticity, and oil-producing glands diminish production. As a result, the elderly have dry skin. What measures are taken to alleviate this issue?
Baths or shower every other day.
Lotions applied to the skin
Use of non-irritating soaps, rinse off skin after washing.
Increase oral fluids
This is when the body temperature is below normal
Hypothermia
Precautions used in the care of all patients regardless of their diagnosis or possible infection status when exposure to body fluids is possible
What are standard precautions
In developing outcomes, the nurse bases the goals on what the _____________ would like to achieve
What is client (patient)
What is pharmacodynamics
COMPARE AND CONTRAST
Name 5 clinical observations for nutritional assessment indicating the signs of good and poor nutrition.
General appearance
Weight
Hair
Eyes
Tongue
Teeth
Gums
Skin
Nails
Muscles
Abdomen
Nails
This stage of grief is when the person refuses to accept the diagnosis or feels that a mistake has been made. What is this stage of grief?
Denial
What is the difference between a urostomy and a colostomy?
Urostomy is urinary
Colostomy is bowel
Frequently heard on inspiration, are soft, high-pitched, discontinuous (intermittent) popping sounds.
What are CRACKLES?
What are the principles of good body mechanics?
Good Body Alignment, Good posture and balance
Wide base of support
Use of muscles in your thighs, hips, shoulders, upper arms
Bend your knees and squat to lift a heavy object
Hold items close to your body and base of support
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What are sign of hypovolemia (isotonic FVD)
Symptoms of a chronic illness that re-appear after having been absent for a time period.
What is exacerbation.
A pulse that is slow, less than 60 beats per minute
What is BRADYCARDIA?
Name 7 risk factors for pressure injury development
Poor skin hygiene
Diminished sensory perception (pain awareness)
Fractures
Poor Health
Immobility 2 to paralysis or injury
Increased body temperature
Inontinence
Sedation or Coma
Significant obesity or thinness
Smoking
Terminal illness/End of Life/Dying process
What is the medical term for a Body temperature above normal?
Hyperthermia if from the environment
Pyrexia or febrile if from infection
Name the 6 steps of the chain of infection in order
pathogen, reservoir host, portal of exit, transmission, portal of entry, susceptible host.
What QSEN competency takes priority when entering/leaving the client's room.
What is safety
The steps of pharmacokinetics
What are absorption, distribution, metabolism and excretion
List 5 age-related changes and the nursing strategies to address age-related changes affecting nutrition.
altered ability to chew related to teeth, ill fitting dentures and gingivitis
loss of sense of smell and taste
decreased peristalsis in esophagus
Gastroesophageal reflux
decreased gastric secretions
slowed peristalsis
reduction in appetite and thirst
loss of appetite related to depression and loneliness
physical disability
low income
A breathing pattern of rapid-low respirations with periods of apnea
Cheyne-Stokes Respirations
What are the steps to performing a bowel assessment?
What are the rationales for this order?
Inspect
Auscultate
Palpate
Nursing interventions that promote optimal oxygenation
Healthy Lifestyle
Vaccination
Reducing Anxiety
Good nutrition
Positioning
Name 3 complications of immobility - identify at least one from each system
What is increased risk of DVT, pneumonia, contractures, pressure injuries, constipation
Positive Chvostek's and Trousseau's sign
What is signs of hypocalcemia
Care that helps a person regain strength and health and independence.
Tertiary prevention
A medical term for a pulse that is above 100 beats per minute
What is TACHYCARDIA?
This classification can be used for wound assessment and to help direct treatment for open wounds, or healing by secondary intention.
What is RYB?
Red = protect
Yellow = Cleanse
Black = Debride
These factors increase the risk of injury from the application of heat or cold
Time
Impaired sensation
Impaired consciousness
The nurse needs to disinfect her hands after caring for the resident. If the hands are not visibly soiled, what method of disinfecting hands between patients is acceptable?
Alcohol-Based Hand Sanitizer.
physical assessment, vital signs, lab tests
What are examples of objective signs
The process of reviewing a client's medications, especially at points of transitions of care to reduce medication errors
What is medication reconciliation
What steps should the nurse take to prevent the complication of aspiration in a patient receiving enteral feeding?
Check tube placement
Elevate HOB 30-35 degrees during feeding and for 1 hour after
Give small, frequent amounts
Avoid over sedation
Check residual volume per policy/orders
An internal emotional reaction to loss
GRIEF
Urine leaks during exercise, sneezing, coughing, and a sudden urge to void
Stress Incontinence
The respiratory secretion expelled by coughing or clearing the throat.
What is SPUTUM?
A nurse is caring for a client with lower extremity paralysis. Which action will the nurse take to prevent external rotation of the hip and legs.
What is place a trochanter roll at the side of the legs
Most common drug prescribed to reduce fluid volume excess
What is a loop diuretic - example - Furosemide
Model of health based on perception of disease susceptibility, seriousness of disease, and perceived benefits of action
What is the health belief model
This is a medical term for an irregular heart rhythm.
What is ARRHYTHMIA?
Full-thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar?
What is an UNSTAGEABLE Pressure Injury?
This occurs when the body becomes accustomed to the opioid and needs a larger dose.
What is TOLERANCE?
Practices that remove pathogenic organisms - considered "clean technique"
What is medical asepsis
Name the 6 QSEN competencies
Patient-centered care
Teamwork & collaboration
Evidence-based practice
Quality improvement
Informatics
Safety
A phenomenon in which the body physiologically becomes accustomed to opioid therapy and suffers withdrawal symptoms if the opioid is suddenly removed.
What is PHYSICAL DEPENDENCE?
small frequent meals
solicit food preferences
bring food from home when possible
control pain
schedule procedures and medication when they are least likely to interfere with meals
Encourage/provide oral hygiene
Arrange food tray so that they are easily accessible
Remove clutter from the area
Provide comfortable position
Ask about rituals during meal times at home and include them if possible
In this stage of grief, the person wants to "make a deal' with someone he feels has control over his fate, such as God, or a health care provider. What is this stage of grief?
Bargaining
What are 6 things the nurse can do to promote regular bowel habits?
Timing
Positioning
Privacy
Hygiene
Nutrition
Exercise
Patients who experience dyspnea and feelings of panic can often reduce these symptoms by doing this.
What is PURSED-LIP BREATHING?
You are to perform ROM exercises after the bath. Which exercises are completed for the ankle?
Dorsiflexion and Plantar Flexion
A decrease in the amount of water in the body tissues
What is dehydration
In an effort to help prevent health disparities, it is important for nurses to recognize, identify and focus on _____________ and plan specific and individualized care to reduce the risk for poor outcomes.
What are vulnerable populations
In this scenario, the Nurse is taking vital signs and discovers the blood pressure to be 88/60.
The Nurse would take what action next?
Perform further assessment.
What are the psychological effects of Wounds and Pressure Injuries?
Pain
Anxiety and Fear
Activities of Daily Living
Changes in Body Image
What are some of the nursing strategies used for each?
What are
COMMUNICATION DIFFICULTIES
DENIAL OF PAIN
ALTERED PHYSIOLOGIC RESPONSE TO ANALGESICS
Name 2 types of laboratory data that identifies an infection
C & S
increased WBC count >10,000
independent, dependent and collaborative
What are types of nursing interventions
This outlines the appropriate progression of drugs to control pain
What is a PAIN LADDER?
MILD - non-opioid analgesics NSAIDS, acetaminopehn
MODERATE - non-opioid analgesics and opioids
SEVERE - non-opioid analgesics, opioids and adjuvants
What is the difference between a modified diet and a therapeutic diet?
Can you name them?
Therapeutic:
CCD, Low Fat, High Fiber, Low Fiber, Sodium Restricted, Renal
Mondified consistency:
Clear liquid, Pureed, Mechanically altered diet
For anyone 18 and older
Provides instruction for future treatment
Appoints a Health Care Representative
Guides inpatient treatment decisions when made available
ADVANCED DIRECTIVE
What assessments need to be done prior to inserting an indwelling catheter?
Order
Trauma
Drainage
Infection
Skin integrity
Bladder
Dyspnea
ELEVATED BP with small pulse pressure
Increased respiratory rate and pulse rate
Pallor and Cyanosis
LATER SIGNS: anxiety, restlessness, confusion and drowsiness
What is HYPOXIA?
Describe the proper use of a cane
What is: Support weight on the stronger leg and cane and move the weaker leg forward.
Name the 7 components of a basic metabolic panel
Na, K, Cl, CO2, BUN, Cr, Glucose
The 5 categories of social determinants of health
What is education access and quality, neighborhood and built environment, economic stability, healthcare access and quality, and social and community context
The Nurse is having difficulty hearing the resident's blood pressure. She has attempted to try to take the pressure on both arms. What action is next for the Nurse?
Ask another nurse to verify.
A. What are the local factors affecting wound healing?
B. What are the systemic factors affecting wound healing?
LOCAL: Pressure, Dessication, Maceration, Trauma, Edema, Infection, excessive bleeding, necrosis, biofilm
SYSTEMIC: Age, Circulation and Oxygenation, Nutritional Status, Wound Etiology, Medications, Immunosuppression or Proinflammatory conditions, Adherence to treatment plan,
As death approaches, this is the last of the senses to be lost.
HEARING
Practices that removal all micro-organisms and spores and used for invasive and surgical procedures.
What is sterile technique or surgical asepsis.
Name the 6 steps of the NGN clinical judgement model
Recognize cues, analyze cues, prioritize problems, identify outcomes, take action, evaluation
These function to reduce the patient's perception of pain and to alter their responses to discomfort.
What are the 3 general classes of these drugs?
What is ANALGESIC?
Opioid - controlled
Nonopioid - NSAIDS
Adjuvant - (anticonvulsants, antidepressants, multipurpose drugs)
If one has positive bowel sounds, this tube can be used for long-term nutritional support (greater than 4 weeks).
PEG - percutaneous endoscopic gastrostomy tube
PEJ - percutaneous endoscopic jejunostomy tube
For persons with serious illness - at any age
Provides medical orders for current treatment
Guides Emergency Medical Personnel when made available
Guides inpatient treatment decisions when made available
POLST
Physician Order for Life-Sustaining Treatment Form
Name the 6 characteristics of urine to be assessed.
Color - pale yellow, straw-colored or amber
Odor - aromatic - can develop amonia smell when it stands
Turbidity - clear or transparent
pH - 5-6
Specific gravity - 1.015 to 1.025
Constituents - NO albumin, glucose, ketone bodies, gross bacteria, blood, pus
Extra, abnormal sounds of breathing
ADVENTITIOUS
A client has ROM exercises performed on the left shoulder after morning care. What exercises are performed on the shoulder joint?
Flexion and Extension
Adduction and Abduction
Circumduction
Name 3 types of IV solutions and give an example for each one
What is isotonic - 0.9% NS or LR
hypotonic - 0.45%
hypertonic - D5 1/2 NS, D5 NS