Exam #1
What is the correct order of the nursing process?
ADPIE - assessment, diagnosis, planning, implementation, evaluation
Upper GI bleed stool color vs. lower GI bleed stool color?
Upper GI bleed = black, tarry stool (melena)
Lower GI bleed = bright red, bloody stool
What is healing by tertiary intention?
Letting the tissue heal a little before stitching it closed
What kind of injection is insulin & heparin? What is the preferred injection site?
Subcutaneous / abdomen
What is palliative care vs. hospice care?
Pallitive - used for patients with over 6 months to live. Can be implemented at any stage of illness. Used for symptom management but not to cure disease
Hospice - used for patients with less than 6 months to live. Focus solely on comfort
What is Subjective vs. Objective data?
Subjective - what patient says
Objective - what you observe using your senses
List 3 causes of constipation
Decreased activity level/ ignoring urge to defecate
• Changes in food intake
• Decreased fluid intake
• Medication side effects
• Surgery
• Pregnancy
• Depression
• Aging
• Laxative overuse
• Nerve damage or impairment
Describe a stage 1 pressure ulcer?
Intact skin over bony prominence that is red and does not blanch
What is the preferred site for an IM injection?
Ventrogluteal
How do you apply a wrist restraint?
- Make sure 2 fingers can fit under
- Tie using a slip-knot
- Attach to a non-moveable part of the bed
Must have an order for this
Primary - what patient says
Secondary - all other sources
List 3 signs & symptoms of a vagal response?
Monitor for low HR/BP, or s/s of dizziness, pallor, clammy skin.
List 3 signs & symptoms of a wound infection
Signs & symptoms:
• Redness or increased warmth of the wound
• Swelling
• Wound drainage (purulent = pus)
• Wound has an unpleasant smell
• Pain around the wound
• Fever above 100°F (37.7°C)
• Labs – WBCs over 11,100/mm3
What is required to draw up medication from an ample?
A filtered needle
Which should you do first: palpate or auscultate the abdomen
Always auscultate before palpating
What does the acronym RACE stand for?
Rescue
Alarm
Conceal
Evacuate
What stool is expected in a colostomy vs. ileostomy
Colostomy- soft, formed stool
Ileostomy- loose, liquid stool
Describe sanguineous vs. serosanguinous drainage
Sanguineous = dark red & bloody
Serosanguinous = light red, pink
How do you inserted eardrops in an adult vs. a child?
Adult = pull pinna up & back
Child = pull pinna down & back
What is the order of the stages of grief?
Denial, anger, bargaining, depression, acceptance
How long should you listen to the abdomen to determine absent bowel sounds?
3 - 5 minutes
What is wound dehiscence vs. wound evisceration?
Dehiscence = closed wound opens up
Evisceration = closed wound opens up & abdominal organs protrude out
List 3 types of medications you cannot crush
•Buccal or sublingual tablets
•Effervescent tablets
•Enteric-coated tablets
•Liquid-filled gel caps
•Medications that may taste too bitter
•Mucous membrane irritants
•Neoplastic agents (chemotherapy)
•Orally disintegrating medications
•Sustained-release tablets
What is respite care?
For caregivers when they need a break