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100

What stage wound is below?  

How would you define that stage wound?



Stage II  Partial thickness loss of dermis

Dressing

You could use a hydrogel dressing for wounds stages II-IV.  Rehydrates the wound bed and promotes debridement

100

What are five things the nurse can do to prevent skin breakdown? 

Reposition q 2hrs

Special beds/mattress 

Keep the skin dry 

Use draw sheets

Braden skin breakdown scale 

Hydration and nutrition 

Mobility 




100

What is a clear liquid diet?


List 4 things on a clear liquid diet 

Foods that have no residue and are liquid at room temp. 

Ice chips

Water based pulp free popsicles 

Tea and black coffee

Sports drinks

Water

Pulp free juice 

Broth 

Jello 

100

Use the image below:  What is the patients score are they at risk for pressure ulcers?

Your client scores a 1 in sensory 

                             2 in moisture 

                             2 in activity 

                             2 in mobility 

                             1 in nutrition

                             1 in friction and shear

 

9  Yes they are at high risk. 

6   is the highest risk score a patient can receive 

100

What is an entreal feed?  What are some precautions the nurse should take when admistering an  entreal feed.


Provide nutritional support to people who are unable to eat or swallow safely, or who are unable to meet their nutritional needs through oral intake.  STILL USES THE GI TRACT 

HOB 30 to 45 degrees.  If client is having problems with breathing stop the feed and put the clients HOB at 90 degrees 

Flush with 30ml of water before and after feed

Change bag and tubing every 24 hours

Only 4 hours of feed hanging at a time. 

Note the difference a patient receiving entreal feeds will need their blood glucose regulated more often cause they are at risk for hyperglycemia.   

This is different than a risk for a patient recieving parenteral nutrition.   REVIEW THIS DIFFERENCE 



200

What kind of precautions would a nurse place the client who has have clostridoides difficile (CDiff)

What types of PPE is included in in the above precaution? 

Contact Precautions 

Clean hands entering and leaving the room  with soap and water 

Contact 

gown, and gloves

200

What is the highest score on the Braden scale?

What does this score indicate?

What is the lowest score on the Braden scale?

What does this score indicate? 

The highest number is 23 - Low risk for pressure ulcer

The lowest number is 6 - High risk for pressure ulcer 

200

A client is going home with a nasogastric tube what instructions should the nurse provide to prevent the tube from becoming clogged?

Flush tube before and after a feed

Flush tube before and after meds

Flush with 30ml of water 

200

A client reports abdominal cramping while receiving an enema.  What should the nurse do?

Cramping is normal in patients receiving an enema.  Lower the bag to slow the infusion. 


Stop the infusion for severe abdominal cramping, abdominal rigidity, or bleeding.   


200

Client is placed on a full liquid diet what can this client have on their meal tray?  

Everything on the clear liquid diet plus 

Protein shakes

Custards 

Puddings

Ice  cream

Cream soups 

Milk in coffee or team

Veg juice 

Sherberts

300

A client is a fall risk.  What prevention strategies should the nurse plan to implement?

List 4 

Bed in lowest position 

Bed Alarm 

Assess fall risk factors 

Educate the client 

Provide no-slip socks

Place call light in reach 

Place immobility equipment within reach 

Fall risk band 


300

A clients abdominal wound has dehisced what should the nurse do?

Remain Calm 

Stay with the patient 

Apply NS 0.9 soaked sterile gauze to the site

Place client NPO 

Call the MD/ OR 


300

What are 4 actions the nurse should take when caring for a patient on aspiration precautions?

Chin-to-chest swallowing 

Thickened liquids - Special diets 

Elevate HOB, semi-high fowlers, 

Place food on the good side for chewing 

Assess gag response after sedation 


300

List 3 factors that influence bowel elimination. 

Age 

Diet 

Physical activity 

Bowel pattern

Meds, diagnostics, surgery  

300

What is a parenteral feed?

A person receiving parentreal feeds  total parentreal nutrition (TPN) is at risk for what condition if is stopped abruptly?


Parenteral nutrition (PN) is a method of providing nutrients directly into the bloodstream through a vein when a person cannot eat or drink by mouth, or when their digestive system is impaired. 

Client is at risk for hypoglycemia.  The nurse must wean the patient off TPN by using a fluid with dextrose. 

Note the difference between a patient receiving entreal feeds vs parentreal nutrition  REVIEW THE DIFFERENCE   


 

400

Where do you start when providing a bed bath?

How do I clean the eyes?

Head to toe

Cleanest to dirties 

Distal to proximal on extremities this facilitates and promotes good blood return 

inner canthus to outer canthus eyes 

Ask client what they can do to help 

Provide privacy 

400

What stage wound is this?


How would you define this wound stage?

Stage 3

Full-thickness tissue loss; subcutaneous fat is visible. 

Dressing:  

Hydrogel could be used on this wound

Hydrogel  rehydrates and promotes wound healing and debrement used for stage II through Stage IV.

If you have a stage three and you’re the nurse and it is healing.  How do you document that?

Stage 3 pressure ulcer healing new measurements it does not become a stage II 

400

What is a full liquid diet?


What can the patient have on a full-liquid diet?

Liquid at room temp

Ice cream 

Pudding

Cream soups 

Everything on the clear liquid diet 

Juice with pulp 

400

What education should the nurse provide a client who is going home with a Guaiac Fecal Occult Blood Test?

No citrus drinks or food for 3 days before test

No red meat 3 days before test. 

No NSAIDS or ASA 

Test should be repeated 3 times 

400

The nurse is providing intermittent feeds to a client via g tube.  The nurse checks for residual before administering the feed. 

When should the nurse contact the provider regarding residuals?  

Residual greater than 200 mL on two separate assessments indicates that the client is unable to tolerate the feeding at the prescribed rate. 

Therefore, the nurse should contact the provider.

500

What type of precautions is needed for varicella?


What type of precaution is needed for respiratory syncytial virus (RSV)?


Varicella is Contact and Airborne

What type of mask do you need with airborne precautions?  N95

RSV is contact and droplet precautions 

What type of mask do you need with droplet precautions?  surgical mask

500

What are the 6 risk factors on the Braden Scale?

Sensory 

Moisture 

Activity 

Mobility 

Nutrition 

Friction and Shear

500

What food should a client with crohn's avoid?

Crohns is an inflammatory bowel disease.  

It is managed with a low fiber high protein, high calorie and low fat diet.  

Avoid nuts, corn, high fat foods, spicy foods, fried foods, high fiber foods (no salad) alcohol, Caffeine 

500

A client has had multiple episodes of diarrhea and the nurse supects Clostidiodes difficle (CDiff).  

What are some things the nurse should include in the plan of care?

Increase fluids  to decrease the chance of dehydration

Keep the skin and area dry and clean

Use barrier creams 

Put the client on contact precautions

Wash hands with soap and water 

500

A nurse notices a medication error during the administration process. The most ethically accountable action for the nurse to take is: "

  • A) Ignore the error and continue with medication administration as planned.
  • B) Inform the patient about the error and apologize, but do not report it to the supervisor.
  • C) Immediately report the error to the supervising nurse and follow appropriate protocols to rectify the situation.
  • D) Discreetly document the error in the patient's medical record and monitor the patient closely.

Answer: C - Reporting the error to the supervising nurse and following proper protocols is the most ethically accountable action

Answer: C - Reporting the error to the supervising nurse and following proper protocols is the most ethically accountable action