Week 4 Lab
Signs include, redness around the wound, purulent drainage, bad smell (malodorous) and increased pain or fever for patient indicate this.
What is an infected wound or infection?
These are the two categories of functional ability.
What are ADL's and IADL's?
The nurse recommends which of the following as PRIMARY prevention tools for her 45 year old patient. SATA
A. Healthy diet found on MYPLATE.org
B. A body mass index of 17
C. Getting a yearly flu shot
D. Getting a yearly mammogram
A and C
B is too low healthy BMI is 18.5-24.9
D is a good suggestion but it is secondary screening (even though insurance considers it prevention)
Three of the medication rights.
What are right patient, right medication, right route, right time, right dose, and right to refuse?
You should educate your patient to do this when you give them an enema.
What is try to hold it in for up to ten minutes?
This scale includes categories including sensory perception, moisture, mobility and friction and shear.
What is the Braden Scale?
The patient is given a regular diet tray even though they have been prescribed a mechanical soft diet with thickened liquids for swallowing difficulties. The nurse is concerned about THIS occurring.
What is the patient aspirating or What is aspiration?
In report the nurse is told the patient has called our for pain medication. The nurse handing the patient off(ending shift) states, She looks comfortable I think her pain is about a 3. The nurse assuming care knows this is the most reliable indicator of pain.
What is the patient's report? Or What is what the patient says?
Your patient refuses his medication for hypertension. You should take these steps.
What is assess, educate and document?
Assess why he is refusing, educate benefits of taking and risks of not taking, document your education and his refusal
This is how often you reposition a dependent patient in a wheel chair to prevent skin injuries.
What is every hour?
A nurse is checking a patient who yesterday had a stage III pressure injury on his tailbone. Today she sees their is eschar tissue covering the bottom of the wound so she will stage it as this.
What is unstageable?
Your patient may have this problem if you notice they are pocketing food, repeatedly attempting to swallow, coughing when eating or drinking, and decreased oxygen when eating or drinking. (the medical word)
What is dysphagia?
In preparing to perform a routine head to toe assessment, the nurse realizes this system will be assessed first.
What is the neurological system? or What is neuro?
(Walking in room, asking patient name and DOB)
When considering a patient with pain and stress, the nurse knows lack of this essential is likely to make both of these worse.
What is sleep?
When administering eye ointment to a patient you begin here on the eye.
Where is the inner canthus?
When a red spot, on intact skin, does not change color when pressure is applied it is called non-blanchable and is this stage Pressure Injury.
What is stage 1 pressure injury?
You are assessing your patient for ability to feed , bathe and transfer independently using this scale.
What is the Katz Scale?
When admitting a new stable patient, it is critical to assess these two things as soon as possible.
What is assess skin and fall risk?
Substance use, violence and denial are examples of this type of coping.
What is maladaptive or poor coping?(Ineffective)
This is the order of assessing the abdomen in head to toe assessment.
What is inspect, auscultate, palpate?
A nursing student reports a patient has an area of redness on his heal that does not blanch and she has applied heel boots, massaged the heel, measured and documented the area and notified the provider. Of these the action that requires further education.
What is massaging the area?
Of the following, the one that increases a patient's risk of cognitive impairment
a. patient eating a healthy diet
b. patient taking vitamin supplements
C . febrile patient with a UTI
d. Patient who wears a helmet bicycling
What is C?
Febrile-fever and infection (UTI)
Your patient states his pain is 8/10 sharp in his left wrist after falling. His heart rate is 115 and he states he is nauseated. The objective sign of pain is this.
What is the Heart rate of 115?
Your patient has an NG tube and are ordered the following. This one requires clarification with the provider.
A. Lisinopril 5 mg NG daily
B, Aspirin 325 mg EC via NG daily
C. Amoxicillin 500mg suspension via NG daily
What is B? We do not crush Enteric coated or extended release.
Your patient states their pain is currently 8 out of 10 and they can tolerate a 4/10. The tolerable level is an example of which OPQRSTUV.
What is V? Value is the patients level of tolerating and any other symptoms.