Final Exam Flashcards
(259 cards)
1
Q
What is the first step if a patient is having difficulty breathing?
A
Elevate the head of the bed to promote lung expansion and ease breathing.
2
Q
What PPE is required for contact precautions?
A
Gloves and gown (e.g., for C. diff, MRSA, VRE).
3
Q
What is the correct sequence for donning PPE?
A
Gown → Mask → Goggles/Face Shield → Gloves.
4
Q
What is the correct sequence for doffing PPE?
A
Gloves → Goggles/Face Shield → Gown → Mask.
5
Q
What is the appropriate response to a needlestick injury?
A
Wash area, notify supervisor, fill out incident report, seek medical evaluation.
6
Q
What are standard precautions?
A
Used for all patients—includes hand hygiene and PPE based on exposure risk.
7
Q
How do you properly transfer a patient using a gait belt?
A
Place the belt snugly at the waist, stand to the weaker side, use a rocking motion to assist.
8
Q
What are the signs of fluid volume deficit?
A
Tachycardia, hypotension, dry mucous membranes, decreased urine output, weight loss.
9
Q
What electrolyte imbalance is indicated by muscle cramps and cardiac arrhythmias?
A
Hypokalemia.
10
Q
What is the priority nursing action for a patient with low oxygen saturation?
A
Apply oxygen as ordered and assess airway and respiratory status.
11
Q
When is it appropriate to use a restraint?
A
Only when all alternatives have failed, with a provider’s order, and with frequent monitoring.
12
Q
What are the stages of pressure injury?
A
Stage 1: Non-blanchable redness
Stage 2: Partial thickness loss
Stage 3: Full thickness skin loss
Stage 4: Full thickness tissue loss with exposed bone/muscle
13
Q
What are the signs of hypoglycemia?
A
Sweating, shaking, confusion, irritability, dizziness, hunger, tachycardia.
14
Q
What is a normal range for blood glucose?
A
70–110 mg/dL fasting.
15
Q
What are the stages of grief (Kubler-Ross)?
A
Denial, Anger, Bargaining, Depression, Acceptance.
16
Q
What are the types of loss?
A
Actual, perceived, maturational, situational, and anticipatory.
17
Q
What is the role of the nurse in informed consent?
A
Witness the signature and ensure the patient understands the procedure, but do not explain it (provider’s job).
18
Q
What is the nurse’s role in HIPAA compliance?
A
Protect patient information, only access need-to-know info, and ensure secure communication.
19
Q
What is the normal range for vital signs in adults?
A
Temp: 97–99°F (36.1–37.2°C)
Pulse: 60–100 bpm
Respirations: 12–20
BP: <120/80 mmHg
20
Q
What are isotonic fluids used for?
A
To replace fluid loss (e.g., 0.9% NS, Lactated Ringers) – no fluid shift occurs.
21
Q
What type of communication builds therapeutic rapport?
A
Active listening, open-ended questions, empathy, silence, clarification.
22
Q
What does SBAR stand for?
A
Situation, Background, Assessment, Recommendation.
23
Q
What are the early signs of hypoxia?
A
Restlessness, anxiety, tachycardia, confusion.
24
Q
What is the purpose of incentive spirometry?
A
To prevent atelectasis by encouraging deep breathing post-operatively.
25
What is the best method to assess pain in a non-verbal patient?
Use non-verbal cues (facial expressions, vitals), and a pain scale appropriate for non-verbal patients (e.g., FLACC).
26
What are the five rights of delegation?
Right task, right circumstance, right person, right direction/communication, right supervision/evaluation.
27
What lab values indicate infection?
Elevated WBC (>10,000/mm³), elevated neutrophils, positive cultures.
28
When do you use surgical asepsis?
During invasive procedures (e.g., catheter insertion, dressing change for central lines, OR procedures).
29
What are the signs of impaired skin integrity?
Redness, edema, open areas, drainage, warmth, pain at the site.
30
What factors increase the risk of pressure injuries?
Immobility, poor nutrition, incontinence, decreased sensory perception.
31
What are the components of a neurological assessment?
LOC (level of consciousness), orientation, PERRLA, motor strength, reflexes, and sensation.
32
What does 'bradycardia' mean?
Abnormally slow heart rate (below 60 bpm).
33
What does 'tachypnea' mean?
Rapid breathing (respiratory rate > 20 breaths/min).
34
What does 'dysuria' mean?
Painful or difficult urination.
35
What does 'edema' mean?
Swelling caused by fluid accumulation in tissues.
36
What does 'cyanosis' indicate?
Bluish discoloration of skin/mucosa from lack of oxygen.
37
What does 'hematuria' mean?
Blood in the urine.
38
What is the normal range for sodium (Na⁺)?
135–145 mEq/L
39
What is the normal range for potassium (K⁺)?
3.5–5.0 mEq/L
40
What is the normal range for calcium (Ca²⁺)?
8.5–10.5 mg/dL
41
What is the normal range for chloride (Cl⁻)?
96–106 mEq/L
42
What is the normal range for magnesium (Mg²⁺)?
1.5–2.5 mEq/L
43
What is the normal range for BUN (Blood Urea Nitrogen)?
7–20 mg/dL
44
What is the normal range for creatinine?
Male: 0.6–1.2 mg/dL
Female: 0.5–1.1 mg/dL
45
What is the normal range for fasting blood glucose?
70–110 mg/dL
46
What is the normal range for hemoglobin (Hgb)?
Male: 13.5–17.5 g/dL
Female: 12–16 g/dL
47
What is the normal hematocrit (Hct)?
Male: 41–53%
Female: 36–46%
48
What is the normal platelet count?
150,000–400,000/mm³
49
What is the normal white blood cell (WBC) count?
5,000–10,000/mm³
50
What is the normal red blood cell (RBC) count?
Male: 4.7–6.1 million/µL
Female: 4.2–5.4 million/µL
51
What is orthostatic hypotension?
Drop in BP when standing up; may cause dizziness or fainting.
52
What is the difference between subjective and objective data?
Subjective: What the patient reports (e.g., pain, nausea)
Objective: What you observe or measure (e.g., vitals, labs)
53
What does 'prn' mean in medication orders?
'As needed'
54
What does 'NPO' mean?
Nothing by mouth (nil per os)
55
What does 'q4h' mean?
Every 4 hours
56
What is the normal urine output per hour?
At least 30 mL/hr
57
What is the purpose of TED hose or compression stockings?
Prevent DVT by promoting venous return in the legs.
58
What are the ABCs of nursing priority?
Airway, Breathing, Circulation – in that order.
59
What does ADL stand for?
Activities of Daily Living (e.g., bathing, dressing, eating)
60
What is a nosocomial infection?
An infection acquired in the hospital (healthcare-associated infection).
61
What does the term 'asepsis' mean?
Absence of germs or pathogens.
62
What is the difference between medical and surgical asepsis?
Medical asepsis: 'Clean technique' (e.g., hand hygiene)
Surgical asepsis: 'Sterile technique' (e.g., OR procedures)
63
What is the purpose of a care plan?
Guides patient-centered nursing interventions and outcomes.
64
What does 'PO' mean in medication administration?
By mouth (per os)
65
What does 'IV' mean?
Intravenous – into a vein.
66
What does 'IM' mean?
Intramuscular – into a muscle.
67
What does 'subQ' or 'SQ' mean?
Subcutaneous – into the fat layer under the skin.
68
When should nurses delegate tasks?
When the patient is stable
## Footnote
Delegation is appropriate when patient conditions are not at risk.
69
When should nurses NOT delegate tasks?
When:
* Thinking or complex tasks are required
* The task is within the worker's assessment
* Judgement is required
* Teaching and supervision are necessary
* Unpredictable outcomes are present
* Increased risk of harm exists
* Creativity and problem-solving are required
## Footnote
These factors indicate that the task requires professional nursing judgment.
70
What is the first step in the delegation process?
Assess and Plan
## Footnote
This involves evaluating the situation and determining the appropriate tasks to delegate.
71
What is the second step in the delegation process?
Communicate
## Footnote
Clear communication is essential for effective delegation.
72
What is the third step in the delegation process?
Ensure Surveillance and Supervision
## Footnote
Monitoring the delegated tasks is crucial for patient safety.
73
What is the fourth step in the delegation process?
Evaluate and Give Feedback
## Footnote
Providing feedback helps improve future delegation and task performance.
74
What are the 5 Rights of Delegation?
* Right Task
* Right Situation
* Right Worker
* Right Direction and Communication
* Right Teaching, Supervision and Evaluation
## Footnote
These rights ensure that delegation is performed correctly and safely.
75
What is the ethical principle of autonomy?
Respect for an individual's right to make their own decisions
## Footnote
Autonomy emphasizes the importance of personal choice and self-determination in healthcare.
76
Define the ethical principle of nonmaleficence.
Obligation to do & cause no harm to others
## Footnote
Nonmaleficence is a foundational principle in healthcare ethics, requiring practitioners to avoid causing harm.
77
What does beneficence mean in nursing ethics?
Duty to do good to others
## Footnote
Beneficence involves taking actions that benefit patients and promote their well-being.
78
Explain the principle of justice in healthcare.
Distribution of benefits & services fairly
## Footnote
Justice in healthcare refers to the fair allocation of resources and treatment among patients.
79
What is veracity in the context of nursing ethics?
Obligation to tell the truth
## Footnote
Veracity is crucial for building trust between healthcare providers and patients.
80
Define fidelity in nursing.
Following through with a promise
## Footnote
Fidelity emphasizes the importance of loyalty and keeping commitments in the nurse-patient relationship.
81
What does HIPAA stand for?
Health Insurance Portability & Accountability Act
## Footnote
HIPAA protects patient privacy and the confidentiality of health information.
82
What rights do clients have under HIPAA?
Clients have the right to ensure their medical information is not shared without permission
## Footnote
Patients can also obtain a copy of their personal health information.
83
List three patient rights.
* Privacy
* Considerate & respectful care
* Be informed
## Footnote
Patient rights ensure that individuals receive dignified and informed healthcare.
84
What is required for treatment to be administered?
Client's consent must be obtained
## Footnote
Consent is a legal and ethical requirement in healthcare.
85
What are the types of consent in healthcare?
* Admission agreement
* Immunization consent
* Blood transfusion consent
* Surgical consent
* Research consent
* Special consents
## Footnote
Each type of consent serves specific purposes in patient care.
86
When can consent be implied?
In cases of emergency when a client cannot give consent
## Footnote
Emergency laws allow for implied consent to provide necessary treatment.
87
Who must provide consent for minors?
A parent or legal guardian
## Footnote
Minors are not legally able to provide consent for treatment without a guardian's approval.
88
Before signing consent, what must clients be informed of?
Risks & benefits of surgery, treatments, procedures, & plan of care in layman's terms
## Footnote
Clear communication ensures that clients understand what they are consenting to.
89
How many times should a nurse perform tracheal suctioning with an interval in between passes?
Up to 3 times with an interval of 60 seconds in between passes.
90
What is chest physiotherapy (CPT)?
A respiratory treatment that vibrates secretions loose from airways so patients can cough them up.
91
Is chest physiotherapy necessary before every suctioning?
No, it is not necessary before every suctioning.
92
What does BNP stand for?
Brain natriuretic-type peptide.
93
What does a rise in BNP indicate?
It indicates heart failure and reflects the amount of cardiac wall stretch.
94
What should a nurse do when securing restraints?
Secure to an area of the bed frame that moves with the client, not to the side rail.
95
How often should restraints be removed?
At least every 2 hours or more frequently according to facility policy.
96
What is the appropriate way to secure restraints?
Using a quick-release tie for easy removal in an emergency.
97
Can restraints be prescribed PRN for an elderly patient with a history of falls?
No, restraints are not prescribed PRN.
98
Who is legally responsible for obtaining informed consent?
The provider who is performing the procedure or treatment.
99
What must be explained to a patient prior to obtaining informed consent?
The procedure, expected outcomes, risks and benefits, alternative treatments, and the right to refuse.
100
What are advance directives?
Legal documents where a client’s decisions related to health care are documented.
101
What are the two types of advance directives?
* Living will * Durable power of attorney for health care
102
What is the goal of the Renin-Angiotensin-Aldosterone System (RASS)?
To regulate blood pressure and fluid balance in the body.
103
How should ice chips be counted for fluid intake?
As half of the mL in ice chips given.
104
What is the correct height for a walker in relation to a client's waist?
Just below the level of the client's waist.
105
What is the first action a client should take when using a walker?
Move the walker first.
106
What is mandatory reporting?
Healthcare workers are legally required to report any suspicions of child abuse.
107
Are healthcare workers protected from civil liability for good faith reports of abuse?
Yes, they are protected.
108
What should be avoided to maintain good skin integrity?
Massaging the skin over bony prominences.
109
What should the nurse do first in any type of patient treatment?
Assess the patient.
110
What should a nurse do if a lab value is barely low and a supplement has been ordered?
Administer the supplement and inform the MD later.
111
What can fluid volume excess cause in a client?
Increased blood pressure.
112
What are the signs of infiltration of IVs?
* Coolness * Edema * Pallor around the insertion site
113
What does warmth around the IV site indicate?
Phlebitis.
114
What does blanching at the insertion site indicate?
An infiltration.
115
What can blood in the IV tubing indicate?
Disconnection of the catheter from the tubing.
116
What are the signs and symptoms of fluid overload (hypervolemia)?
Signs include:
* Swelling (edema)
* Shortness of breath
* High blood pressure
* Rapid weight gain
* Increased heart rate
## Footnote
Fluid overload can lead to serious complications, necessitating prompt interventions.
117
What are the interventions for managing fluid overload?
Interventions include:
* Diuretics
* Monitoring fluid intake and output
* Assessing vital signs
* Elevating the legs
* Restricting sodium intake
## Footnote
The priority is to ensure patient safety and prevent complications.
118
What are the signs and symptoms of dehydration?
Signs include:
* Thirst
* Dry mouth
* Dark urine
* Fatigue
* Dizziness
## Footnote
Dehydration can lead to serious health issues if not addressed promptly.
119
List the types of diets and foods included in each group.
Types of diets include:
* Clear liquid: water, broth, gelatin
* Full liquid: milk, fruit juices, ice cream
* Soft diet: mashed potatoes, cooked carrots, pudding
## Footnote
Each diet serves specific medical needs and recovery processes.
120
What are the signs and symptoms of hypovolemia?
Signs include:
* Low blood pressure
* Rapid heart rate
* Weakness
* Confusion
* Thirst
## Footnote
Hypovolemia can lead to shock if not treated effectively.
121
What are the normal values for Sodium (Na+), Potassium (K+), Calcium (Ca+), Magnesium (Mg+), and Chloride (Cl-)?
Normal values are:
* Sodium (Na+): 136-145 mEq/L
* Potassium (K+): 3.5-5.0 mEq/L
* Calcium (Ca+): 9-11 mg/dL
* Magnesium (Mg+): 1.3-2.1 mEq/L
* Chloride (Cl-): 98-106 mEq/L
## Footnote
These values are critical for assessing electrolyte balance.
122
What is the typical low Hemoglobin (Hgb) level for someone with a gastrointestinal bleed?
Typically under 9 gms/dL
## Footnote
Blood transfusions are often considered under 7 gms/dL.
123
What is the main electrolyte imbalance suspected with vomiting or NG tube suction?
Hypokalemia (low potassium)
## Footnote
This can result from loss of gastric contents.
124
What are common causes of constipation?
Causes include:
* Low fiber diet
* Dehydration
* Sedentary lifestyle
* Medications
* Ignoring the urge to defecate
## Footnote
Recognizing these causes is essential for effective treatment.
125
What does a positive stool guaiac test indicate?
Presence of blood in the stool
## Footnote
This finding requires further investigation to determine the source of bleeding.
126
What are the highest sources of dietary protein?
Sources include:
* Chicken
* Fish
* Eggs
* Beans
* Nuts
## Footnote
Protein is essential for muscle repair and overall health.
127
How is Body Mass Index (BMI) calculated?
BMI = weight (kg) / height (m)^2
## Footnote
BMI categories include underweight, normal weight, overweight, and obesity.
128
What are the components of SBAR?
Components include:
* Situation
* Background
* Assessment
* Recommendation
## Footnote
SBAR is a communication framework used in healthcare.
129
What are types of adventitious breath sounds?
Types include:
* Wheezing
* Crackles
* Rhonchi
* Stridor
## Footnote
Each sound is associated with specific respiratory conditions.
130
What steps are prioritized during the admission assessment of a patient?
Steps include:
* Assessing airway, breathing, circulation
* Gathering medical history
* Conducting a physical examination
## Footnote
Ensuring patient stability is the primary focus.
131
What types of events need to be documented with an incident report?
Events include:
* Medication errors
* Patient falls
* Equipment malfunctions
* Unexpected patient outcomes
## Footnote
Incident reports help improve patient safety and care quality.
132
What is the purpose of the Renin-Angiotensin-Aldosterone System (RAAS)?
Purpose is to regulate blood pressure and fluid balance
## Footnote
RAAS components include renin, angiotensin, and aldosterone, each playing a critical role.
133
What is the difference between subjective and objective data in SOAP documentation?
Subjective data: patient-reported symptoms
Objective data: measurable or observed findings
## Footnote
Both are essential for comprehensive patient assessment.
134
What are acceptable abbreviations in documentation?
Acceptable abbreviations include:
* BP (blood pressure)
* HR (heart rate)
* WBC (white blood cells)
## Footnote
Unacceptable abbreviations can lead to misunderstandings and errors.
135
What are the legal regulations regarding medical records?
Regulations include:
* HIPAA compliance
* Patient privacy
* Confidentiality
## Footnote
Violations can result in legal consequences for healthcare providers.
136
What are the standards of documentation?
Standards include:
* Timely
* Factual
* Detailed
* Clear
## Footnote
Adhering to these standards ensures quality patient care.
137
Who can access a client’s medical record without the patient’s consent?
Only those directly involved in patient care
## Footnote
Family members cannot access records without patient consent.
138
What are signs and symptoms of a Urinary Tract Infection (UTI)?
Signs include:
* Frequent urination
* Urgency
* Dysuria
* Cloudy urine
* Hematuria
## Footnote
Awareness of these symptoms aids in early detection and treatment.
139
What are the steps for placing an indwelling (Foley) catheter?
Steps include:
* Gather supplies
* Position the patient
* Clean the area
* Insert the catheter
* Secure the catheter
## Footnote
Proper technique minimizes infection risk.
140
What interventions are necessary for urinary incontinence?
Interventions include:
* Bladder training
* Pelvic floor exercises
* Medications
* Lifestyle modifications
## Footnote
Tailoring interventions to the patient’s needs enhances effectiveness.
141
What are the signs of UTI in the elderly?
Signs include:
* Confusion
* Agitation
* Fatigue
* Increased urinary frequency
## Footnote
Symptoms can differ from younger populations, requiring careful assessment.
142
What is an ileal conduit?
An ileal conduit is a surgical procedure to divert urine to an external pouch after bladder removal
## Footnote
It is commonly performed due to cancer or severe bladder dysfunction.
143
What are the laboratory findings in kidney dysfunction patients?
Key findings include:
* Elevated BUN
* Elevated Creatinine
* Decreased eGFR
## Footnote
Creatinine is the best indicator of kidney function.
144
What are the normal values for arterial blood gases (ABG) components?
Normal values are:
* pH: 7.35-7.45
* paCO2: 35-45 mmHg
* HCO3: 22-26 mEq/L
* paO2: 80-100 mmHg
## Footnote
ABG values are crucial for assessing respiratory and metabolic function.
145
What are physical assessment findings in the immobile client?
Findings include:
* Skin breakdown
* Muscle atrophy
* Decreased circulation
* Joint stiffness
## Footnote
Regular assessment helps prevent complications in immobile patients.
146
What are the signs indicating a gastrointestinal (GI) bleed?
Signs include:
* Hematemesis (vomiting blood)
* Melena (black tarry stools)
* Abdominal pain
## Footnote
Prompt recognition and intervention are vital.
147
What are the risk factors for hypokalemia?
Risk factors include:
* Diuretics use
* Vomiting
* Diarrhea
* Malnutrition
## Footnote
Identifying these factors aids in prevention and management.
148
When should the provider be called regarding hyperkalemia?
Call if potassium level <3.5 or >5.0 mEq/L
## Footnote
Hyperkalemia can lead to life-threatening cardiac issues.
149
What indicates peristalsis in the gastrointestinal tract?
Signs include:
* Bowel sounds
* Abdominal cramping
* Passage of stool
## Footnote
Normal peristalsis is essential for digestive health.
150
How do you convert ounces to milliliters?
1 ounce = 29.57 milliliters
## Footnote
Accurate conversion is essential for medication and fluid administration.
151
What fluids are included in clear liquid diets?
Included fluids:
* Water
* Broth
* Gelatin
* Clear juices
* Tea or coffee (without cream)
## Footnote
Clear liquid diets are often used preoperatively or for gastrointestinal issues.
152
What are the different types of IV solutions?
Types include:
* Isotonic
* Hypotonic
* Hypertonic
## Footnote
Each type serves different clinical purposes based on patient needs.
153
What are the physical findings associated with bradycardia?
Findings include:
* Low heart rate
* Dizziness
* Fatigue
* Confusion
## Footnote
Bradycardia may require further evaluation to determine underlying causes.
154
How do you assess for orthostatic hypotension?
Assessment includes:
* Measuring blood pressure while lying, sitting, and standing
* Positive finding is a drop in BP upon standing
## Footnote
This assessment helps identify dehydration or hypovolemia.
155
What are lab value changes that indicate infection?
Changes include:
* Elevated white blood cell count
* Increased neutrophils
* Positive cultures
## Footnote
Recognizing these changes is crucial for timely treatment.
156
What are common organisms and their isolation requirements?
Common organisms include:
* MRSA: contact isolation
* TB: airborne isolation
* C-diff: contact isolation
## Footnote
Proper isolation prevents the spread of infections.
157
What are the steps of hand hygiene?
Steps include:
* Wet hands with water
* Apply soap
* Lather and scrub for at least 20 seconds
* Rinse and dry hands
## Footnote
Effective hand hygiene is critical in preventing healthcare-associated infections.
158
What is the purpose of denture cleaning?
Purpose is to maintain oral hygiene and prevent infections
## Footnote
Regular cleaning is essential for patients with dentures.
159
What is the priority in safety as a care provider?
Help a patient with an immediate safety need first
## Footnote
Prioritizing safety ensures patient well-being.
160
What are the reasons for placement of an NG tube?
Reasons include:
* Gastric decompression
* Nutritional support
* Medication administration
* Aspiration prevention
## Footnote
Understanding indications aids in appropriate use.
161
What are reportable findings of a colostomy?
Findings include:
* Changes in stoma color
* Excessive bleeding
* Signs of infection
## Footnote
Timely reporting of findings ensures patient safety.
162
Where does a sigmoid colostomy exit on the abdomen?
Typically exits in the lower left quadrant
## Footnote
The location is important for stoma care and patient education.
163
How do you collect a mid-stream urine specimen?
Clean the genital area, start urinating, then catch urine mid-stream in a sterile container
## Footnote
This method minimizes contamination.
164
How do you collect a urine specimen from a Foley catheter?
Collect from the port, not the drainage bag, to avoid contamination
## Footnote
Proper technique ensures accurate results.
165
What is the nursing care priority for a patient unable to urinate after catheter removal?
Monitor for bladder distension and encourage fluid intake
## Footnote
Timely intervention is critical to prevent complications.
166
What is included in a complete cardiac assessment?
Includes:
* Heart rate and rhythm
* Blood pressure
* Auscultation of heart sounds
* Peripheral pulses
## Footnote
Comprehensive assessment is essential for cardiac health.
167
What are normal versus abnormal physical assessment findings?
Normal findings:
* Regular heart sounds
* Clear lung sounds
* Normal bowel sounds
Abnormal findings:
* Murmurs
* Wheezing
* Absent bowel sounds
## Footnote
Recognizing abnormalities is crucial for diagnosis.
168
What is the nursing care for confused, older patients?
Care includes:
* Providing orientation
* Ensuring safety
* Simplifying communication
* Monitoring for changes
## Footnote
Tailoring care improves outcomes for confused patients.
169
What is the process for dose/capsule calculation?
Calculate based on prescribed dosage and available concentration
## Footnote
Accurate calculations are vital for patient safety.
170
How do you calculate output at the end of the shift?
Add total fluid intake and subtract any outputs, including urine and drainage
## Footnote
Accurate calculations aid in assessing fluid balance.
171
What foods are high in iron?
High iron foods include:
* Red meat
* Poultry
* Fish
* Lentils
* Spinach
## Footnote
Iron is essential for preventing anemia.
172
What foods are high in fiber?
High fiber foods include:
* Whole grains
* Fruits
* Vegetables
* Legumes
* Nuts
## Footnote
Fiber is important for digestive health.
173
What are the types of restraints used in nursing?
Physical, chemical, environmental
## Footnote
Restraints can be classified into different categories based on their nature and application.
174
Where should restraints be applied?
To moveable parts of the body (wrists or ankles) using a quick release knot to the bed frame
## Footnote
Restraints should not be secured to side rails and must allow for circulation and range of motion.
175
What precautions should be taken when caring for a patient with MRSA?
Use contact precautions by donning gown and gloves before entering the room
## Footnote
Remove PPE before exiting to prevent the spread of infection.
176
What is the order of doffing PPE?
Remove the most contaminated first
## Footnote
This minimizes the risk of contamination.
177
When should gloves be worn?
Only if there is a chance of coming into contact with body fluids
## Footnote
Taking a BP does not require gloves.
178
What is the first step if you accidentally stick yourself with a needle?
Wash with soap and water
## Footnote
This helps to reduce the risk of infection.
179
What PPE is required for airborne precautions?
Wear an N95 respirator (or higher) and place the patient in a negative pressure room
## Footnote
This is to prevent transmission of airborne pathogens like TB or measles.
180
What is the most important preventive precaution for transmission of infection?
Hand hygiene before and after contact with the client
## Footnote
This is a key measure to prevent the spread of infections.
181
What lab values may change in the presence of an infection?
WBC, neutrophils
## Footnote
These values are typically elevated during infections.
182
What should you do if a medication error occurs?
Immediately assess the patient's condition, notify the healthcare provider, report the error to the charge nurse, complete an incident report, and monitor for adverse effects
## Footnote
Prompt action is critical to ensure patient safety.
183
What is involved in medication reconciliation?
Double check the list of medications the patient takes at home and ensure it matches the in-hospital medication list
## Footnote
Contact the provider if a medication's dosage is different.
184
What home safety tips should be recommended for a client with a history of falls?
Remove tripping hazards, ensure adequate lighting, install grab bars in the bathroom, use non-slip footwear, and keep frequently used items within reach
## Footnote
These measures help to prevent future falls.
185
What is the normal range for ABG interpretation?
7.35-7.45, 35-45, 22-26
## Footnote
These ranges refer to pH, PaCO2, and HCO3 respectively.
186
What is the definition of ventilation?
The movement of air in and out of the lungs (breathing)
## Footnote
This is essential for gas exchange in the body.
187
What is oxygenation?
The process of adding oxygen to the body, especially the blood
## Footnote
This is crucial for cellular metabolism.
188
What is diffusion in the context of respiratory function?
The movement of gases (like oxygen and carbon dioxide) between alveoli and blood across the alveolar-capillary membrane
## Footnote
This process is vital for effective gas exchange.
189
What is perfusion?
The delivery of oxygen-rich blood to the tissues and organs through the circulatory system
## Footnote
This is essential for maintaining tissue health.
190
What are the principles of fall prevention?
Call lights within reach, bed in the lowest position with brakes locked, non-slip footwear, adequate lighting, and regular rounding
## Footnote
These measures help to ensure patient safety and reduce fall risk.
191
What is the protocol for recapping needles?
Never recap a dirty, used needle; only recap prior to giving an injection after preparation of medication in syringe
## Footnote
This prevents needlestick injuries and contamination.
192
What type of precautions is required for C. difficile?
Contact precautions
## Footnote
Alcohol-based agents are ineffective against C. difficile; soap and water should be used.
193
What should be assessed when transferring a weak patient from bed to chair?
Assess their strength, use a gait belt, position the chair on their strong side, assist to a sitting position, and support closely while pivoting
## Footnote
This ensures a safe transfer.
194
What does the Braden Scale assess?
Moisture, activity, mobility, nutrition, friction, perception
## Footnote
A lower number indicates a higher risk for skin integrity issues.
195
What can occupational therapy assist patients with?
Fine motor skills and completing activities of daily living (ADLs)
## Footnote
This is particularly beneficial for patients with limited hand motion.
196
What should be recorded during intake/output?
Conversions for ounces and milliliters
## Footnote
Accurate recording is essential for patient monitoring.
197
What is the first action to take when a patient has pain?
Assess, assess, assess their pain
## Footnote
Use pain scale and POLD CARTS for thorough evaluation.
198
What regulates blood pressure in the body?
Various factors including aldosterone and ADH
## Footnote
These hormones play crucial roles in fluid balance and blood pressure regulation.
199
What foods are included in a clear liquid diet?
Broth, clear juices, gelatin
## Footnote
These are typically allowed in a clear liquid diet.
200
What nursing interventions are recommended for an older, constipated client?
Increase fluid intake, encourage mobility, and consider dietary fiber
## Footnote
These interventions can help alleviate constipation.
201
What is the most reliable indicator for pain?
Patient pain assessment
## Footnote
Self-reporting is crucial for accurate pain management.
202
How can you tell a patient is ready to ambulate after being on bed rest?
Assess for strength, stability, and readiness to stand
## Footnote
Gradual assessment is important after prolonged bed rest.
203
What is therapeutic communication?
Encouraging the patient to express/explore their feelings
## Footnote
Use open-ended questions to facilitate dialogue.
204
What is required by federal law for patients who speak a different language?
A medical interpreter for patient education
## Footnote
This is especially critical surrounding surgeries or procedures.
205
What are the cardiac auscultation sites for various valves?
Aortic, pulmonic, tricuspid, mitral areas
## Footnote
Identifying these sites is important for auscultation.
206
What does cyanosis look like in a dark-skinned person?
Cyanosis may present as gray or ashen coloration in the mucous membranes
## Footnote
Recognition is important for accurate assessment.
207
What are healthy sleep habits for young adults?
Regular sleep schedule, avoiding screens before bed, and creating a restful environment
## Footnote
These habits support good sleep hygiene.
208
What is the order of physical assessment of the abdomen?
Inspect, auscultate, palpate, percuss
## Footnote
This order prevents alteration of bowel sounds.
209
What should be done if a client is deoxygenating?
1) Assess for distress, 2) Sit HOB up, 3) Apply oxygen (usually start with 2 L/min)
## Footnote
This sequence prioritizes patient safety.
210
Who teaches patients about CPAP machines prior to discharge?
Respiratory therapists
## Footnote
They provide essential education for proper use.
211
What are the ethical principles in nursing?
Veracity, autonomy, fidelity, nonmaleficence
## Footnote
Each principle guides ethical decision-making in nursing practice.
212
Who can see health information?
Only healthcare team members directly caring for the patient
## Footnote
Confidentiality is crucial in patient care.
213
What is the process if family members request to see medical information?
The patient must give permission/consent
## Footnote
This protects patient privacy.
214
What constitutes false imprisonment?
Unjustified restraint of a person against their will
## Footnote
Understanding this is important for legal compliance.
215
What is mandatory reporting?
The legal obligation to report suspected abuse or neglect
## Footnote
This ensures the safety of vulnerable populations.
216
What are the stages of grief?
Denial, anger, bargaining, depression, acceptance
## Footnote
Understanding these stages aids in patient support.
217
What are the roles of healthcare givers?
Speech therapist, respiratory therapists, social workers, occupational therapists
## Footnote
Each has specific areas of expertise and referral needs.
218
What tasks can be delegated by registered nurses?
Basic care tasks to LPNs and unlicensed assistive personnel
## Footnote
Delegation must be appropriate to the skill level of the team member.
219
How do you test the 12 cranial nerves?
Through specific assessments for each nerve function
## Footnote
This is crucial for neurological evaluations.
220
What is the order of steps for Basic Life Support?
1) Check responsiveness, 2) Call for help, 3) Begin compressions, 4) Give rescue breaths
## Footnote
Following this order is vital for effective resuscitation.
221
What is the function of aldosterone?
Regulates sodium and water balance, influencing blood pressure
## Footnote
It's part of the RAAS system.
222
What is the process for initiating an enteral feeding via an NG tube?
Verify placement, assess residuals, and then administer feedings
## Footnote
This ensures safe and effective nutrition delivery.
223
What are the categories of BMI?
Underweight, normal, overweight, obese
## Footnote
These categories help assess body weight relative to height.
224
How is BMI calculated?
Weight in kilograms divided by height in meters squared
## Footnote
This formula provides a standardized measure of body mass.
225
What are the signs and symptoms of hypoglycemia?
Sweating, shaking, confusion, irritability, dizziness
## Footnote
Recognizing these symptoms is crucial for timely intervention.
226
What are the signs and symptoms of hyperglycemia?
Increased thirst, frequent urination, fatigue, blurred vision
## Footnote
Awareness of these signs is essential for diabetes management.
227
What should be done if a patient is possibly hyperglycemic?
Assess blood glucose levels and notify the healthcare provider
## Footnote
Prompt action is necessary to manage potential complications.
228
What reduces the risk of complications in diabetes mellitus?
Blood glucose control, regular monitoring, healthy lifestyle choices
## Footnote
These strategies are important for long-term health.
229
What abbreviations should NOT be used?
U for units, QD for daily, MS for morphine sulfate
## Footnote
Avoiding these abbreviations prevents medication errors.
230
What are normal lab values for sodium?
135-145 mEq/L
## Footnote
Abnormal values can indicate various health issues.
231
What should be done if a patient has low potassium?
Notify the healthcare provider immediately
## Footnote
Low potassium levels can lead to serious complications.
232
What are the signs and symptoms of fluid overload (hypervolemia)?
Swelling, shortness of breath, hypertension, rapid weight gain
## Footnote
These symptoms indicate fluid retention.
233
What are the signs and symptoms of hypovolemia (fluid volume deficit/dehydration)?
Thirst, dry mouth, decreased urine output, dizziness
## Footnote
Recognizing these signs is critical for timely intervention.
234
What are priority nursing interventions for a suicidal patient?
Ensure safety, establish rapport, assess risk factors, and provide support
## Footnote
These actions are vital to prevent self-harm.
235
What is the difference between delirium, depression, and dementia?
Delirium is acute and fluctuating, depression is persistent sadness, dementia is progressive cognitive decline
## Footnote
Understanding these distinctions aids in proper diagnosis and care.
236
What are risk factors for adolescents committing suicide?
Mental health issues, substance abuse, family problems
## Footnote
Awareness of these factors can aid in prevention efforts.
237
What conditions can cause a heart murmur?
Valve abnormalities, congenital heart defects, anemia
## Footnote
Understanding these conditions is important for diagnosis.
238
What lab value rises in heart failure due to cardiac wall stretch?
BNP (B-type natriuretic peptide)
## Footnote
Elevated levels indicate heart strain.
239
What are normal findings on a colostomy stoma immediately after surgery?
Pink, moist, and healthy appearance
## Footnote
Abnormal findings include excessive redness or necrosis.
240
What are critical steps for suctioning a tracheostomy?
Pre-oxygenate the patient, use sterile technique, and monitor oxygen saturation
## Footnote
These steps prevent hypoxia during the procedure.
241
What signs indicate a tracheostomy patient needs suctioning?
Increased respiratory distress, audible wheezing, or visible secretions
## Footnote
Monitoring these signs is essential for patient care.
242
What nutrient is necessary for wound healing?
Protein
## Footnote
Adequate protein intake supports tissue repair.
243
What are the signs and symptoms of phlebitis?
Redness, swelling, warmth, and pain along the vein
## Footnote
Recognizing these signs aids in timely intervention.
244
What is the priority action when caring for a patient with partial hearing loss?
Determine the level of hearing loss and what aids they use
## Footnote
This information is crucial for effective communication.
245
What is urinary catheter care to prevent infection?
Maintain a closed system, perform perineal care regularly, and ensure proper catheter positioning
## Footnote
These practices reduce the risk of urinary tract infections.
246
What is informed consent?
The process where the patient voluntarily agrees to a procedure after being informed of risks/benefits
## Footnote
The healthcare provider explains the procedure, while consent must be obtained without coercion.
247
What are advance directives?
Legal documents that outline a person's wishes regarding medical treatment when they are unable to communicate
## Footnote
A healthcare proxy can be named to make decisions on their behalf.
248
What vital sign is most important to assess prior to administering morphine IV push?
Respiratory rate
## Footnote
Monitoring is critical due to the risk of respiratory depression.
249
What type of patient has an increased risk of aspiration while eating?
Patients who most recently had surgery or those under sedation
## Footnote
These conditions can affect swallowing reflexes.
250
What are expected physiological signs of aging?
Decreased elasticity of skin, slower metabolism, and changes in muscle mass
## Footnote
These changes impact overall health and care needs.
251
What are appropriate actions while obtaining a blood pressure reading?
Ensure the patient is seated comfortably, use the correct cuff size, and avoid talking during measurement
## Footnote
These practices ensure an accurate reading.
252
What are the signs and symptoms of infiltration?
Swelling, coolness, and discomfort at the IV site
## Footnote
Recognizing infiltration is important for timely intervention.
253
What is the correct positioning for a male prior to removing a urinary catheter?
Supine or sitting position
## Footnote
Proper positioning facilitates the procedure.
254
What is the correct positioning for a female prior to removing a urinary catheter?
Supine position with knees slightly bent
## Footnote
This positioning aids in catheter removal.
255
What is an easy method for drug calculation?
Estimate the dose based on known equivalents
## Footnote
Avoid overthinking; use simple math.
256
What is the identification of wound stages by picture?
Recognize characteristics of each stage from images
## Footnote
This aids in proper wound assessment and care.
257
What is the RACE acronym in fire safety?
Rescue, Alarm, Contain, Extinguish
## Footnote
This acronym guides actions during a fire emergency.
258
What are modifiable risk factors for cardiovascular disease?
Diet, physical activity, smoking, and weight management
## Footnote
Addressing these can reduce risk.
259
What are non-modifiable risk factors for cardiovascular disease?
Age, gender, and family history
## Footnote
These factors cannot be changed but can inform risk assessment.
