While assessing your client you note a red/pink soma on the right side of the abdomen. You know that this is what type of assessment finding?
What is normal assessment of a stoma?
100
Upon admission of a 99 year old male diagnoised with a CVA, the nurse conducts this type of assessment relating to his impaired mobility and sensory impairment.
What is fall risk assessment?
100
A wound that heals with well approximated edges.
What is primary intention.
100
A subjective gathering of information on a patient prior to beginning wound care.
What is pain assessment?
200
After completing a physical assessment on a client, the nurse identifies the need to complete a dressing change on the client every 8 hours. What phase of the nursing process does the dressing change fall?
What is implementation?
200
What is not a function of the large bowel?
What is absorb nutrients?
200
Implementing a call light within reach, bed alarm, non skid slippers are a what type of intervention?
What is priority nursing interventions for increased fall risk.
200
A building block in the body that helps with wound healing.
What is protein?
200
A pressure ulcer on the coccyx where bone can be seen.
What is stage IV pressure ulcer?
300
You are planning on changing a client dressing. Prior to the dressing change you administer 2 PO Percocet for the client's complaints of pain. After 30 minutes have passed what would be your next nursing action?
What is re-assess your client.
300
You are caring for a client who takes laxatives on a daily basis, what is a risk of this behavior?
What is laxative dependence?
300
This device is placed around a patient's waist and utilized for safe transfer and walking.
What is gait belt.
300
Immobile clients are at high risk for skin breakdown. How many hours does it take for skin breakdown to occur?
What is 3 hours?
300
You are caring for a client who complains of soreness to both elbows from moving up and bed, upon assessment you notice a 2.5 cm area with the epidermis missing. You document this as what stage pressure wound.
What is a stage II pressure wound?
400
The nurse recognizes that she gave the wrong dosage of a medication to a client and immediately informs the provider. This nurse is exercising
What is accountability?
400
When assessing a clients stoma, he notes liquid fecal debris in the drainage bag. The nurse identifies the stoma to be most likely connected to what part of the GI system?
What is ilium?
400
There is a fire at nursing station 2, the nurse removed the client from the immediate area of concern, what would be the next appropriate step for the nurse to take?
What is activate the alarm.
400
You are caring for a client who recently had a bowel resection. The client calls you to their room complaining of a ripping sensation in their incision after sneezing. What do you expect the wound has done as a result of this pressure?
What is wound dehiscence?
400
How does a nurse assess for the healing of a wound?
What is assess and measure the wound.
500
While working through the assessment process, the nurse creates a plan of care that can be measured, what might this be called?
What is measurable goal?
500
A client tells you during your assessment the she frequently looses urine when she sneezes, you know this is what type of incontinence?
What is stress incontinence.
500
You just learned how to use a fire extinguisher with the PASS accronym, what does this accronym stand for?
What is pull pin, aim and squeeze side to side
500
The phase in wound healing that causes vasoconstriction, plates to gather and clots to form
What is hemostasis?
500
A medical emergency where an organ protrudes through a wound dehiscence.