Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

PCC 1 NRSE-2350-001 > Final exam > Flashcards

Final exam Flashcards

1
Q

Oliguria

A

Painful urination

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Dysuria

A

Difficulty urinating

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Nocturia

A

Urinating at night

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

polyuria

A

Frequent urination

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Urinary frequency

A

How frequent you urinate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Urinary hesitancy

A

Difficulty starting stream

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is urge incontinence?

A

(Overactive bladder) sudden urge to urinate followed by involuntary urinary leakage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is reflex incontinence?

A

Urinary incontinence caused by trauma or damage to nervous system

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is detrusor hyperreflexia?

A

Increased detrusor muscle contractility, occurs even when no sensation to void

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is mixed incontinence?

A

Symptoms of more than one incontinence type is experienced

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Overflow incontinence

A

Inability to empty bladder, retention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are other indications of overflow incontinence?

A

Dribbling, urine and weak urine stream, chronic over distension

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Functional incontinence

A

Occurs in many older adults, mental/ADL impairment that effects voiding in time

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Transient incontinence

A

Results form temporary condition, caused by delirium, infection,etc.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Gross total incontinence

A

Continuous leaking of urine day and night/periodic uncontrollable leaking of large volumes of urine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Intake and output assessment

A

Monitor fluids PO and IV; measure output; is it more intake than output? Vice versa?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

I&O interventions

A

NPO, fluid restrictions, increase fluid intake, indwelling catheter to measure output, graduated cylinders

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What is a CAUTI?

A

Catheter associated UTI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Do you use sterile gloves when dong Catheter care?

A

NO

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

When do you use sterile gloves with catheters?

A

When inserting a new catheter

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What do you assess when using a condom catheter?

A

Penile circulation, discoloration, secure positioning, tip has 1-2 inches from border of bag

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

How many types of enemas are there?

A

4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is an emollient enema?

A

Stool softener, increase intestinal secretion of water, short term benefit only

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is an osmotic enema?

A

Pulls fluid into intestine and causes distension and increased peristalsis- can be used for chronic constipation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What is a bulk forming enema?

A

High fiber, powder mixes with water to form normal feces, least irritating-> caution for clients with fluid restriction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What is the stimulant enema?

A

Causes local irritation to increase intestinal motility and inhibit reabsorption of water in large intestine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Interventions for incontinence

A

Kegel/pelvic floor exercises, scheduled toileting times, indwelling catheter, monitoring output

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

How do you assess the ABD?

A

Inspect, auscultate, palpate, percussion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What are expected findings of an abdominal assessment?

A

Round/flat contour, no visible peristalsis or pulsations, no discoloration, normoactive BS X 4 quadrants, no pain,tenderness, masses, or guarding with light palpation, no organomegaly, pain, tenderness, guarding with deep palpation. No lesions.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Risk factors for bowel elimination issues

A

Decreased physical activity, dehydration, malnutrition, diet issues, increased age,pregnancy, surgery and anesthesia, opioids and antibiotics, holding it in, depression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Laxatives

A

Used to increase stool motility, bulk forming, or increase Bowel movement frequency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Digital disimpaction

A

Use if enemas fail to remove impaction, last resort for constipation, provider order is necessary to remove impaction. Watch out for heart rate to increase and BP to drop bc of vagus nerve stimulation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Intestinal obstruction assessment

A

Abdominal distension, hyperactive bowel sounds (early), or hypoactive bowel sounds (late). No gas or bowel movements

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Anabolic rxn

A

Synthesis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Catabolic rxn

A

Breaking down

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Essential nutrient recommendations

A

Protein, whole wheats and grains, fruits, dairy.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

What religions do not consume pork?

A

Buddhism, Judaism, Islam

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Nutrient therapy

A

used to treat conditions like diabetes, kidney disease, heart disease, etc.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Dysphagia assessment

A

Voice change after swallowing, drooling, coughing, feeing of food stuck in throat

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Dysphagia interventions

A

High-fowler’s position, smaller bites, thickened/altered diets

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

How do you calculate a BMI?

A

(lb/in squared) times 703

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

How many kilocalories are in a gram of fat?

A

9

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

How many kilocalories are in a protein?

A

4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

how many kilocalories are in a carbohydrate?

A

4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

what is nutrient therapy used for?

A

To treat and prevent conditions such as diabetes, heart disease, kidney disease, arthritis, obesity, and depression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

What is the number one cause of food borne illness?

A

Improper/lack of handwashing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

What type of urinary incontinence may require the nurse to insert an indwelling catheter?

A

Overflow (caused by retention which is one of few reasons we insert catheter)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Kegels are performed by contracting the pelvic floor muscles, how many quick flicks and how many sustained contractions are performed?

A

5 quick flicks and 10 sustained contractions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

what VS changes need to be monitored when performing digital disimpaction?

A

HR and BP; heart rate increases (arrhythmias) and BP decreases

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

What does a positive fluid wave and shifting dullness mean?

A

Abdominal ascites

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

What 4 things are being assessed for during deep palpation?

A

Organomegaly, tenderness, masses, guarding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

What should the nurse perform last for a client with ABD pain?

A

Deep palpation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

The nurse is calculating urinary output. What mL/hr should be reported to the physician ?

A

30 mL/hr

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

The nurse applies a condom catheter to a client. What finding means immediate removal?

A

Discoloration and pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

what head/neck position should a client with dysphagia use?

A

Head tilt forward chin down

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

what will the nurse teach the client with stress incontinence?

A

Kegel exercises

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

does unpasteurized juice cause food borne illness?

A

Yes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

What food is a full and nectar based liquid?

A

Cream based soup

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Which laxative stimulates peristalsis by irrigating bowels. Can become dependent upon for voiding.

A

Stimulant

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Which vitamin is found in high citrus and fruits?

A

C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

What does a protuberant abd indicate (when not a pregnant person)?

A

Swelling, organomegaly, abdominal distension

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

A client on a heart healthy diet should avoid this type of specific nutrient?

A

Sodium, saturated trans fats

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

Which food should not be increased for a client on blood thinners?

A

Vitamin K

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

Which type of incontinence is caused by a UTI?

A

Transient (may have urge)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

What will a client not do if they have a bowel obstruction?

A

No gas or bowel movement at all

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

What diet requires carbohydrate monitoring?

A

ADA/Diabetic diet

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

What are three nursing interventions to reduce risk of CAUTI?

A

Peri care, bag below the waist, maintain closed system

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

What common type of medication is given after surgery that causes constipation?

A

Opioids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

What type of enema solution is contraindicated for a client in fluid overload?

A

Tap water, hypotonic solutions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

Name a complete protein

A

Soy or chicken

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

How many kilo calories are in a fat?

A

9

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

a client is on bed rest with a catheter, how often should you empty the bag?

A

Bag gets half full

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

what is it called when a client has difficulty urinating?

A

Hesitancy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
74
Q

Which assessment skill is used to hear tympany?

A

Percussion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
75
Q

What specific type of food should a vegetarian eat to maintain anabolism?

A

Soy (protein)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
76
Q

What is the term used to describe the symptom of urinary incontinence?

A

Dribbling or leaking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
77
Q

What is QSEN?

A

Quality and safety education for nurses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
78
Q

What are the five steps of the nursing process?

A

ADPIE- assessment, nursing diagnoses, planning, implementing, evaluating

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
79
Q

What part of the nursing process entails recognizing and analyzing cues, prioritizing hypotheses, generating solutions, and evaluating the outcomes?

A

clinical judgement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
80
Q

what requires self-reflection of bias and stereotypes, is self motivated, evolving, and bridges cultural gaps?

A

Cultural competence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
81
Q

what are the 8 critical factors of history of present illness?

A

Location, character/quality, quantity/severity, timing, setting, aggravating/relieving factors, associated factors, client’s perception

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
82
Q

What are the modes of transmission?

A

Contact, droplet, airborne, vector borne

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
83
Q

What is the contact mode of transmission?

A

indirect(object to person) and direct(person to person), fecal-oral (handling food after using the restroom and failing to wash hands)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
84
Q

What is the droplet mode of transmission?

A

When microorganisms 5 mcg or larger can spread <6 feet, sneezing, coughing, talking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
85
Q

What is the airborne mode of transmission?

A

Organisms smaller than 5 mcg can travel greater than 6 feet, sneezing and coughing, wear an N95!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
86
Q

What is the vector borne mode of transmission?

A

Animals and insects carry the disease/illness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
87
Q

What causative agents infect the respiratory system frequently?

A

Myobacterium tuberculosis, streptococcus pneumonia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
88
Q

What causative agents infect the GI tract frequently?

A

Shigella, salmonella enteritidis, salmonella typhi, hepatitis A

89
Q

What causative agents infect the genitourinary system frequently?

A

Escherichia coli, hepatitis A, herpes simplex virus(type 1), HIV

90
Q

What causative agents infect the skin/mucous membranes frequently?

A

Herpes simplex virus, varicella

91
Q

What causative agents infect the blood/ body fluids frequently?

A

HIV, hepatitis B and C

92
Q

What PPE is used for contact precautions?

A

Gown and gloves for contact with patient or environment of care

93
Q

What PPE are used for droplet precautions?

A

Surgical masks within 3 feet of patient

94
Q

What PPE are used for airborne infection isolation patients?

A

N95 respirator, negative pressure isolation room also required

95
Q

What causes Pallor?

A

Lack of color in skin, vasoconstriction, decreases in RBCs (oxygenated hemoglobin)

96
Q

What causes erythema (red skin change)

A

Hyperemia (increased blood flow), polycythemia (increase in RBCs)

97
Q

what causes cyanosis (blue skin color change)

A

Decreased perfusion, increased deoxygenated hemoglobin

98
Q

what causes jaundice (yellow skin color change)

A

Increase in serum bilirubin (liver inflammation or disease)

99
Q

What is objective data?

A

Can be seen, heard, or felt and measured; i.e. skin palpation, texture, thickness, edema, turgor

100
Q

what is the ABCDE tool used for?

A

Evaluating skin lesions for cancer

101
Q

What does the ABCDE skin tool stand for?

A

A- asymmetrical (abnormal)
B- Borders (are they smoothe or irregular?)
C- color (does it change over time?)
D- diameter (is it greater than 6 mm?)
E- elevation (is it elevated?)

102
Q

what do you wash first when giving a bath?

A

Client’s face

103
Q

How do you determine the order in which you wash a patient?

A

Wash cleanest to dirtiest

104
Q

How do you wash a client’s extremities?

A

Long firm strokes distal to proximal

105
Q

how do you wash the lower extremities on a client with a history of DVT?

A

Light strokes avoiding massaging or hard pressure

106
Q

What are the things you should educate your client in diabetic foot care?

A

Do not walk barefoot, keep feet clean and dry, wash them in lukewarm water, dry them thoroughly, clean dry socks at all times, wear footwear that fits, check the inside of the shoes for rough objects, inspect the entire foot surface, with mirror or caregiver daily for Signs of redness, lesions, dryness, and infection. Don’t soak your feet! Cut your toenails straight across (not without a physician order) and file short with emery board

107
Q

A lactovegetarian will eat which food?
Chicken
Fish
Milk
Eggs

A

Milk

108
Q

What does it mean to provide patient centered care?

A

Try to see a client’s worldview

109
Q

What describes the client as the full partner in compassionate and coordinated care?

A

Patient centered care

110
Q

Which describes the conclusion about a client’s needs that leads to taking action?
Critical thinking
Diagnostic reasoning
Clinical judgement
Evaluating outcomes

A

Clinical judgement

111
Q

How do nurses make clinical decisions?

A

By thinking about EBP

112
Q

What clinical judgement skill causes the nurse to collect, categorize, and clarify data?

A

Interpretation

113
Q

Which of the following is a QSEN competency?
Population health
Evidence-based practice
Genomics
Self-health care

A

Evidence-based practice

114
Q

What do nurses evaluate during ADPIE?

A

Client outcomes

115
Q

The nurse provides a bed bath and then asks the client how they feel. Which ADPIE is this?

A

Evaluation

116
Q

Which is the analysis of the assessment data to determine actual or potential problem?

A

Diagnoses

117
Q

Which intellectual standard describes communicating what is factual?
Clear
Relevant
Complete
Accurate

A

Accurate

118
Q

What is the nurse doing when they help improve a client’s quality of life?

A

Being a caregiver

119
Q

Which attitude is the new nurse demonstrating when looking up hospital policy for infection prevention measures?

A

Responsibility

120
Q

Which role is the nurse performing when assisting the client in getting an advance directive?
Autonomy
Advocacy
Manager
Educator

A

Advocacy

121
Q

Which of the following is a standard of professional performance?
Informatics
Nursing knowledge
Health promotion
Education

A

Education

122
Q

Which is the process of conducting self-examination of one’s own biases toward other cultures?
Cultural desire
Cultural knowledge
Cultural skill
Cultural awareness

A

Cultural awareness

123
Q

What should the nurse do to be culturally competent?

A

Examine one’s own beliefs

124
Q

What is the nurse achieving when providing a medical licensed interpreter for a client who does not speak English?

A

Linguistic competency

125
Q

What means the capacity to obtain, process, and understand basic health information and make health decisions?

A

Health literacy

126
Q

What type of health difference is closely linked to social, economic, and or environment disadvantage?

A

Health disparity

127
Q

What should the nurse do to build a therapeutic relationship with the client?

A

Use open ended questions

128
Q

“I am in so much pain that I can not sleep”. This describes
Perception
Quality
Aggrivating factor
Associated factor

A

Perception

129
Q

What is the client describing when they state “my chest feels really tight.”

A

Quality of pain

130
Q

Which type of PPE must be worn when organisms can be spread > 6feet via sneezing?

A

N95

131
Q

Which mode of transmission is characterized by germs being carried less than 6 feet via sneezing?

A

Droplet

132
Q

After nurse removes their googles they will remove their:

A

Gown

133
Q

Which is a risk factor for impaired skin integrity?
Using sunscreen
Warm and dry skin
Impaired mobility
Presence of a wound

A

Impaired mobility

134
Q

A client with hypoxia may have which of the following skin color change?

A

Cyanosis

135
Q

A client’s skin turgor test reveals tenting for 4 seconds. What does this indicate?

A

Deficient fluid volume/ dehydration

136
Q

Which is expected of lesions?
Evolving
2mm in size
Irregular shape
Asymmetrical color

A

2mm in size

137
Q

Which assessment finding should the nurse expect for a client with a fever?
Bradycardia
Hypotension
Hypothermia
Tachypnea

A

Tachypnea

138
Q

Which is true about bathing?
Stroke distal to proximal
Wash dirty to clean
Wash with cold water
Massage legs

A

Stroke distal to proximal

139
Q

Which could the nurse do when giving a bath?
Wash dirty to clean
Put up 4 side rails and leave the room
Soak all client’s feet
Use light strokes for a client with DVTs

A

Use light strokes for a client with DVTs

140
Q

Diabetic toenails should be cut

A

Straight across

141
Q

What is the clinical decision making model for nurses?

A

Nursing process

142
Q

An emic world view is intercultural from an insider perspective T/F?

A

True

143
Q

An implicit bias is when we are aware of a bias that is present T/F?

A

True

144
Q

Responsibility, discipline, creativity, and curiosity are key to components of the attitudes of critical thinking T/F?

A

True

145
Q

T/F: the most critical source of knowledge a nurse applies to critical thinking is not only from the medical record

A

True

146
Q

A culturally competent assessment includes the client’s view of their illness T/F

A

True

147
Q

what is the correct order for donning full PPE?

A

Gown, mask, goggles, gloves

148
Q

Which type of heat loss occurs from the transfer of heat from one object to another?
Radiation
Conduction
Evaporation
Diaphoresis

A

Conduction

149
Q

A client’s skin turgor test reveals tenting for 1 second. What does this indicate?

A

Good turgor, good hydration

150
Q

What tool will the nurse use to assess for pediculus capitus?

A

Comb

151
Q

Which of the following is correct?
U is approved for unit
2.2lb=1Kg
BID means four times a day
1 in. Is = to 2.45 cm

A

2.2lb=1Kg

152
Q

T/F your client’s verbal description of their health problem is collected as objective data

A

False

153
Q

Which is the nurse performing when asking the client what they preferred to be called?
Courtesy
Comfort
Connection
Confirmation

A

courtesy

154
Q

T/F an open ended question is used to seek specific information about a problem

A

False

155
Q

which WBC count ins expected for a client with an acute infection?
2,ooomm3
6,000mm3
9,000mm3
15,000mm3

A

15,000mm3 ( normal is 5,000-10,000 mm3)

156
Q

What physical assessment technique uses touch to gather information?

A

palpation

157
Q

What is the assessment of appearance and behavior?

A

General survey

158
Q

Which temp alteration occurs when pyrogens trigger the immune system causing the hypothalamus to raise the set point?
Hyperthermia
Heatstroke
Hypothermia
Pyrexia

A

Pyrexia

159
Q

Which finding is expected for an older client?
Increased subcutaneous fat
Increased cap refill
Decreased skin turgor
Increased body hair

A

decreased skin turgor

160
Q

a microorganism that is transmitted by small, evaporated particles suspended in the air during needing requires:

A

Airborne isolation

161
Q

what does delegate mean?

A

Entrust a task to another person

162
Q

T/F make sure the client has all 4 bed rails up to ensure safety

A

False

163
Q

Which action should the nurse take to auscultate heart sounds?
Assess in a W shaped pattern
Identify S1 but not S2
Use the diaphragm first
Begin at the 2nd ICS and LSB

A

Use the diaphragm first

164
Q

Oxygenated blood is pumped from the left ventricle to the

A

aorta

165
Q

What is the extra heart sound heard right before S1?

A

S4

166
Q

S1=closure of the aortic and pulmonic valves T/F

A

False

167
Q

What is a blowing or swishing sound over the mitral valve?

A

Murmur

168
Q

The nurse knows that S1 is the sound of:

A

The tricuspid and mitral valves closing

169
Q

What is a swishing or blowing sound heard over an artery?

A

Bruit

170
Q

The nurse auscultating over the 2nd ICS RSB will hear:

A

Aortic valve area

171
Q

The nurse may suspect right sided heart failure on which assessment findings?
Pale extremities
+0 pitting edema
+1 pedal pulses
JVD

A

JVD

172
Q

The nurse may suspect right sided heart failure based on which assessment findings?
Pale extremities
+4 pitting edema
+1 pedal pulses
Crackles in the lungs

A

+4 pitting edema

173
Q

The nurse auscultating over the 5th ICS L midclavicular will hear:

A

Mitral valve

174
Q

what is assessed when measuring a radial pulse?

A

Rate, rhythm, strength

175
Q

The nurse knows that S2 is the sound of:

A

The closure of the semilunar valves

176
Q

What is an extra heart sound at the beginning of diastole?

A

S3

177
Q

Deoxygenated blood is pumped from the right ventricle to

A

The lungs

178
Q

A Doppler is used to detect a peripheral pulse undetectable through palpation T/F

A

True

179
Q

A client with atherosclerosis is at risk for tissue ischemia T/F

A

True

180
Q

What helps to promote venous return?
Increased fluid
Bed rest
Ambulating
Dangle feet

A

Ambulating

181
Q

Which assessment finding indicates venous insufficiency
Red/brown color on legs
Cap refill time of 4 sec
Deep sharp calf pain with activity
+1 peripheral pulses

A

Red/brown color on legs

182
Q

Which finding indicates arterial disease?
+3 pretibial edema
Red/brown discoloration
Weeping irregular wounds
+1 pedal pulses Bilaterally

A

+1 pedal pulses bilaterally

183
Q

Which finding indicates arterial disease?
+3 pretibial edema
Shiny hairless legs
Weeping irregular wounds
+2 pedal pulses Bilaterally

A

Shiny hairless legs

184
Q

Which assessment finding indicates venous insufficiency?
Leg aching relieved by elevation
Cap refill time of 4 sec
Deep sharp calf pain with activity
Shiny hairless skin on legs

A

Leg aching relieved by elevation

185
Q

How is a 4mm moderate pitting edema grading?

A

+2

186
Q

Which assessment findings indicate a DVT?

A

Redness, warmth, swelling, pain in 1 leg

187
Q

Which should be done to get an accurate BP?
Place 3-4 inches above pulse
Arm above the heart
Pump 20-30 above stated systolic
Arm not supported

A

Pump 20-30 above states systolic

188
Q

Which would cause a false low BP reading?
Legs crossed
Arm above the heart
Cuff too narrow
Arm not supported

A

Arm above the heart

189
Q

Which technique will the nurse use to assess to resonance?
Auscultation
Palpation
Inspection
Percussion

A

Percussion

190
Q

what are high-pitched popping lung sounds on inspiration called?

A

Fine crackles

191
Q

What are medium pitched with equal duration lung sounds heard over the major bronchi called?

A

Bronchovesicular

192
Q

A respiratory rate of 8 bpm that is regular is called?

A

bradypnea

193
Q

The nurse hears high-pitched, musical squeaking on auscultation of the lungs and documents:
Crackles
Friction rub
Wheezing
Stridor

A

Wheezing

194
Q

A client with an SPO2 of 80% may have which skin color changes?

A

Cyanosis

195
Q

The nurse auscultates high pitched, loud, and tubular sounds over the trachea and documents:

A

Normal bronchial breath sounds

196
Q

Which will the nurse note on a client with COPD?
Nail bed angle of 160 degrees
AP diameter=T diameter
Resonance in all lung fields
Cap refill of 2 sec

A

AP=T

197
Q

Respiratory rate that is 8bpm and depth is shallow?

A

Hypoventilation

198
Q

What nail bed angle will the nurse note with a client with COPD

A

190 degrees

199
Q

The nurse hears barking or honking on inspiration on auscultation of the trachea and documents:
Crackles
Friction rub
Wheezing
Stridor

A

Stridor

200
Q

What are normal bronchial sounds?

A

High pitched, loud, and tubular sounds over the trachea

201
Q

What are low pitched bubbling lung sounds on inspiration called?

A

Course crackles

202
Q

What assessment will the nurse perform when the nurse palpates the chest wall while the client states 99

A

Tactile fremitus

203
Q

When beginning lung auscultation start at the 2nd ICS LSB T/F

A

False

204
Q

What tool is used to test visual acuity?

A

Snellen chart

205
Q

Artificial eyes should be cleaned how often?

A

As needed

206
Q

What does PERRLA stand for?

A

Pupils equal, round, and reactive to light with accommodation

207
Q

Denture care should be performed when:

A

After meals and at bedtime

208
Q

The Rinne test compares air and bone conduction T/F

A

True

209
Q

Which of the following will increase in elderly adult client
Hearing acuity
Sense of smell
Cerumen
Saliva production

A

Cerumen

210
Q

What can you use to clean artificial eyes?

A

Sterile/normal saline and soap and water

211
Q

20/20 sees better than 20/15 T/F

A

False

212
Q

Webber test indicates that there is hearing loss T/F

A

True

213
Q

what does 20/30 mean?

A

The 20/20 person sees the same at 30 feet

214
Q

To straighten the canal of an adult you pull it up and back T/F

A

true

215
Q

How should the nurse manage the effects of immobility on the respiratory system ?
Turn the client every 4 hours
Teach the client to use an IS (insentive spirometer)
Position the client supine
Always apply oxygen

A

Teach the client to use an IS (incentive spirometer)

216
Q

why apply SCDs?

A

Promote venous return

217
Q

What intervention should the nurse take with a client with orthostatic hypotension and dizziness?

A

Dangle the legs while sitting for 1-2 minutes

218
Q

Which is true for restraints?
Consent is not required
An order must be re-newed every 48 hours
Assessment is required every 4 hours
Assess for discontinuation at least every 2 hours

A

Assess for discontinuation at least every 2 hours

219
Q

Which client should be the most motivated to learn?
The client who reports pain at a 8/10 on the pain scale.
The client who stays, “I just don’t think I can tell my family about this.”
The client who believes treatment will make them feel better.
The client who has a HR of 115 and a SpO2 of 88%.

A

The client who believes treatment will make them feel better

PCC 1 NRSE-2350-001 (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions