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PCC 1 NRSE-2350-001 > Final exam part 2 > Flashcards

Final exam part 2 Flashcards

1
Q

What does Pallor mean?

A

Decreased hematocrit

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2
Q

This type of laxative/cathartic can lead to dependence for defecation

A

Stimulant

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3
Q

what enema solution is isotonic?

A

Normal saline

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4
Q

stimulation of the vagus nerve can cause:

A

A decrease in HR

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5
Q

which laxative is least likely to cause fluid and electrolyte shifts?

A

Bulk forming

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6
Q

which type of enema pulls fluid into the intestine to stimulate peristalsis?

A

Hypertonic

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7
Q

A BMI of 31.2 indicates what?

A

Obese

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8
Q

which finding indicates a client with a nutritional deficit?
A well healing wound
Triglycerides of 200 mg/dL
Positive Nitrogen balance
Albumin of 2.9 g/dL

A

Albumin of 2.9 g/dL (normal is 3.4-5.4)

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9
Q

a potato is an example of what specific type of nutrient?

A

Polysaccharide

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10
Q

Beef contains what type of fat?

A

Saturated

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11
Q

what is minimum daily intake of water for adults?

A

1,500 mL

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12
Q

What vitamin is spinach a major source for?

A

Vitamin E

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13
Q

clients with cancer have what metabolic needs?

A

Increased

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14
Q

what is essential to clients with AIDS bc of their reduced resistance to infection?

A

Food safety

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15
Q

popsicles can be given for which diet?

A

Clear liquid

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16
Q

a client with heart failure or hypertension will often prescribed a diet limiting what?

A

Sodium and saturated trans fats

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17
Q

what is not limited on a renal diet?

A

Carbohydrates

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18
Q

what liquid consistency is as thick as heavy syrup and can be sipped through a straw?

A

Nectar

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19
Q

orthopnea

A

SOB when lying down

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20
Q

Dyspnea

A

Difficulty breathing, SOB

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21
Q

Hemoptysis

A

Bloody sputum

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22
Q

tachypnea

A

RR >24 and shallow

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23
Q

hyperventilation

A

RR >24 and deep

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24
Q

Bradypnea

A

RR<10

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25
Q

RR <10 and irregular and shallow

A

Hypoventilation

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26
Q

wax and wean with apnea (regular)

A

Cheyne-stokes

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27
Q

Biot respiration

A

Wax and wean with apnea (regular)

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28
Q

COPD respiration

A

Prolonged expiration with dyspneic episodes

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29
Q

palpable vibration assessment

A

Tactile fremitus

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30
Q

What breath sound is high-pitched monophonic crowing on inspiration (possibly life threatening)

A

stridor, upper airway obstruction, croup or acute eipiglottitis, foreign body inhalation

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31
Q

Dysmetria

A

Incoordination

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32
Q

dyskinesia

A

Involuntary movement

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33
Q

Spinothalmic tract

A

Pain, temperature, light touch

34
Q

posterior column tract

A

Vibration, kinesthesia, tactile discrimination

35
Q

Stereognosis

A

identify objects in hand with eyes closed

36
Q

Graphesthesia

A

Draw picture on client with their eyes closed, can distinguish shape

37
Q

two point discrimination

A

Can distinguish two separate touches at two locations of same stimuli

38
Q

extinction

A

Whether they can sense one stimuli in the presence of another (does it disappear)

39
Q

point location

A

Determine if same stimuli is at same place (two interactions)

40
Q

Ramadan

A

Islam

41
Q

ash Wednesday’s and lent

A

Roman Catholics

42
Q

You kippur

A

Judaism

43
Q

Kosher

A

Orthodox Judaism and islam

44
Q

religious vegetarians

A

Seventh day Adventist, Hinduism, buddhism

45
Q

What do you start with amount wise for feeding someone with dysphagia?

A

1/4 tsp

46
Q

Which QSEN competency is being demonstrated when the staff nurses research and implement new safety guidelines?
Quality improvement
Patient centered care
Teamwork
Safety

A

Quality improvement

47
Q

which role is the nurse performing when they call the primary care provider to report a change in a client’s status?
Scholarly inquiry
Collaboration
Leadership
Stewardship

A

Collaboration

48
Q

which strategies should the nurse take to improve critical thinking? (Select all that apply
Use a journal to write about the outcomes of clinical judgements
Find a mentor
Limit consultations with other professionals involved with a clients care
Make quick decisions when unsure about a clients needs
Review articles about evidence-based practice

A

Use a journal to write about the outcomes of clinical judgements, find a mentor, review articles about evidence-based care

49
Q

After receiving pain medication, a client report’s their pain as not relieved. Based on this evaluation, which action should the nurse take, according to the nursing process?

Reassess the client.

Wait 24 hours.

Educate the client about pain management.

Provide different pain relief.

A

Reassess the client

50
Q

Which QSEN competency is being performed when the nurse assesses a client’s need for spiritual support?

Quality Improvement

Patient Centered Care

Teamwork

Evidence-Based Practice

A

Patient centered care

51
Q

Which action will the nurse take to perform culturally competent care for a client?

Value the client’s life patterns and their meanings.

Value personal beliefs over all others.

Redirect the client to the nurses life patterns.

Teach the client about their community’s cultural norms.

A

Value the clients life patterns and their meanings

52
Q

Which attitude should the nurse display when practicing patient centered care?

Value seeing health care situations, “through the clients’ eyes”

Recognize that a client’s family and friends are not a part of providing patient centered care.

Recognize that healthcare outcomes should be the same for all clients.

Value the healthcare providers expertise above the client’s values related to thier health.

A

Value seeing healthcare situations “through the clients’ eyes”

53
Q

Which action will the nurse take when planning care for a client?
Standardize interventions to client medical diagnosis.
Never utilize previous nursing experience.
Work with the client to set realistic goals.
Only include the medical team in planning goals.

A

work with the client to set realistic goals

54
Q

Which role is the nurse taking when discussing the wishes of a critically ill client to the family?

Communicator
Educator
Caregiver
Advocate

A

Advocate

55
Q

Which step in the nursing process is the nurse taking when asking a client for their pain level 20 minutes after administering pain medication?

Evaluation
Assessment
Implementation
Diagnosis

A

Evaluation

56
Q

The nurse is admitting a client diagnosed with Mycobacterium tubuerculosis. Which type of isolation will the nurse assign for this client?

Airborne isolation
Contact isolation
Protective isolation
Droplet isolation

A

Airborne isolation

57
Q

The nurse is documenting client data. Which of the following should the nurse identify as subjective data?

Dizziness
Hypertension
Bloody drainage
Fever

A

Dizziness

58
Q

Which of the following actions will the nurse perform to implement patient centered care during a client interview?
Telling the client their goals for the day
Begin the interview with a series of close-ended questions.
Keeping the client’s room door open.
Sit face to face and make eye contact with the client.

A

Sit face to face and make eye contact with the client

59
Q

The nurse will perform which action when correctly following standard precaution recommendations?
Wear a mask when changing the linens on a client’s bed
Wear a gown when completing a physical assessment.
Wear gloves when changing a wound dressing on a client.
Wear a gown to transfer a client to the bed side chair.

A

Wear gloves when changing a wound dressing on a client

60
Q

The nurse is caring for a client who does not speak English. The nurse who is linguistically competent will take which action to ensure effective communication with the client?
Ask the client’s bilingual sister to interpret healthcare information.
Advise the client that language assistance services cost extra.
Use a qualified medical interpreter who speaks the client’s dialect.
Speak to the client slowly and in short sentences in English.

A

Use a qualified medical interpreter who speaks the client’s language

61
Q

Which of the following would the nurse note as an performing a general survey on a client. (Select all that apply)

The client grimacing.

The client’s speech is rapid.

The client’s clothing is appropriate for the weather.

The client’s hands are trembling bilaterally.
The client is sitting upright.

A

The client is grimacing, the client’s speech is rapid, the client’s hands are trembling bilaterally

62
Q

Which of the following nursing actions will the nurse perform during a physical exam?

Perform painful procedures toward the end of the assessment.

Document all findings of the assessment during the assessment.

Increase the speed of the assessment if the client is fatigued.

Assess the system most at risk for being abnormal last.

A

Perform painful procedures toward the end of the assessment

63
Q

The nurse is preparing to entering a client’s room and is going to apply complete PPE. What is the correct sequence for donning all articles of PPE?

A

Gown, mask, goggles, gloves

64
Q

Which of the following abbreviations will the nurse question?

U

TID

BID

PO

A

U- does it stand for unit? Spell it out!

65
Q

The nurse is assessing a group of clients for health disparities. Which client is at risk for health disparities?

The client with a high paying job
The client who regularly sees their primary care physician.
The client without health insurance.
The client who is a Caucasian heterosexual.

A

The client without health insurance

66
Q

A client with dark skin who is experiencing a reduced amount of oxyhemoglobin may appear to have a yellow-brown or ashen grey skin tone. (True or False)

A

True

67
Q

The nurse is assessing the integumentary system of an adult client for signs of decreased systemic fluid volume. Which intervention will the nurse correctly perform?
Tap the client’s skin over the mid-clavicle.
Press a thumb into the skin over the sternum.
Pinch up the client’s skin over the mid clavicle or sternum
Feel for warm and dry skin with the dorsa of the hand.

A

pinch up the client’s skin over the mid clavicle or sternum

68
Q

Which temperature measurement site will the nurse use to take the most accurate temperature of a client who is short of breath and diaphoretic?

Oral

Tympanic membrane

Temporal artery

Rectal

A

Tympanic membrane

69
Q

How will the nurse document the client’s single elevated nevus, 0.5 cm in size, on the right shoulder of a client?

Nodule
Macule.
Wheal
Papule.

A

papule

70
Q

The nurse is inspecting a client’s tympanic membrane with an otoscope. What findings should the nurse expect in a healthy adult? A tympanic membrane which is:
Transparent and yellow, bulging, with drainage.
Cloudy white
Translucent and pink with a dark oval center.

Translucent pearly gray

A

Translucent pearly gray

71
Q

Prior to performing eye irrigation, the nurse should remove crust on the external eye by wiping the eye from the outer canthus to the inner canthus with a moistened sterile gauze pad. T/F

A

False

72
Q

The nurse is performing percussion on a healthy adult client’s lung fields. Which finding should the nurse expect?

Dullness.

Tympany.

Resonance.

Hyperresonance.

A

Resonance

73
Q

Which test will the nurse perform to test a client’s cerebellar function?

Muscle size and strength.

Finger to nose test.

Spinothalamic test.

A

Finger to nose test

74
Q

Which nursing interventions should be implemented to reduce the effects of immobility on the respiratory system.
Turn the client Q2 hrs.
Increase fluid intake
Coughing and deep breathing.
Bed rest.

Place the client supine.
Teach incentive spirometry

A

turn the client Q 2 hours
Increase fluid intake
Coughing and deep breathing
Teach insentive spirometer

75
Q

The nurse receives an order to “discontinue NPO status and advance diet as tolerated” for a client. Which food is the client going to first offer this client?

Chicken broth
Crackers
Ice cream
Applesauce

A

Chicken broth

76
Q

A client asks the nurse to recommend a nutrient dense food. The nurse should recommend which of the following foods to this client
broccoli
beef
beer
butter

A

Broccoli

77
Q

The nurse is caring for a client who is post operative and has a large surgical incision. To best promote wound healing, the nurse should encourage the client to:
decrease carbohydrate intake.
decrease fat intake.
increase protein intake.
increase calorie intake.

A

increase protein intake

78
Q

The nurse knows that on Mondays the hospital serves pork for dinner so the culturally competent nurse will inquire about alternative dinner options for the clients of which religions? (Select all that Apply)

Mormon

Buddhism

Catholic

Judiam

Islam

A

Buddhism,Judaism,Islam

79
Q

The nurse is providing education to a client about the benefits of eating whole grains and oats. Which statement represents correct understanding of the client education?

“Eating more fiber can increase my fecal bulk.”

“I should eat polysaccharides to maintain tissue repair.”

“Eating more monosaccharides will decrease my cholesterol.”

“Simple carbohydrates do not have calories.”

A

Eating more fiber can increase my fecal bulk

80
Q

The nurse is teaching an adolescent client about their nutritional needs based on their stage of development. Which statement by the client indicates understanding of the teaching?

“I should regulate my calorie intake by following a low carbohydrate diet.”

“I should increase my caloric intake of lean meats and dairy.”

“I should decrease my caloric intake by limiting meat and whole grains.”

“I should increase my calcium and iron intake by only eating fresh fruit.”

A

I should increase my caloric intake of lean means and dairy

81
Q

Vitamin K is a fat-soluble vitamin that is stored in the fatty compartments of the body increasing risk for toxicity.

A) True
 	B) False
A

True

PCC 1 NRSE-2350-001 (5 decks)

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