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Nursing 200 Foundations > Questions practice exam > Flashcards

Questions practice exam Flashcards

1
Q

To motivate pt to commit a chronic illness lifestyle changes, must first help to identify ways of having positive personal outcome, then can do other things like identify the risk of no adherence, or give info easy to read and understand and schEdule sessions with them

A

Yes

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2
Q

Physical findings indicate pt death is imminent

A

Cold extremities

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3
Q

Ice bag should be filled up to 2/3 of the bag. Numbness is always a bad sign that skin gets too cold.

A

True

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4
Q

Protein normal intake

A

1-1.5g/day would promote healing

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5
Q

True or False: vitamin E do not essentially promote in healing

A

True. But still promote in like scar healing

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6
Q

Fluid intake mL/kg?

A

30-35 mL/kg

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7
Q

What time should nurse discuss discharge planning?

A

At the time of admission to the facility care

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8
Q

Unemancipated minors (Ex:15 year old kid) can sign consent form for treatment if suspicion is leading. Don’t wait parents for severe case. Other family members who is available now at the hospital do not have the consent to sign form unless they are the legal guardian

A

True

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9
Q

Warm milk to give pt is ok, however, if have chocolate or cocoa, should not bc they are stimulants. Temperature cool and dark environment generally preference for people to sleep in. Don’t exercise for 2-3 hours before sleep

A

True

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10
Q

Normal volume to collect for a sputum collection?

A

4-10 mL, when client rises in the morning. Should not be in the evening.

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11
Q

Restorative health care

A

Rehab facilities, skilled nursing facilities, home health care

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12
Q

Federally funded health care

A

Medicare
Medicaid

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13
Q

Tertiary care health service

A

ICU
Oncology treatment center
Burn center

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14
Q

It is nurse basic understanding to give pt full liquid diet after the 24 hour post operative inguinal hernia repair

A

True

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15
Q

What data support patient is having pain and pain management is not reinforced?

A

Pt is nonadherent with coughing, deep breathing and dangling
Pain may have pain every 4 to 6 hr but accept it every 6 to 7 hours (stronger dose suggestion?)
The client vital signs HR 110/min, RR 20/min, temp 98.6, BP 136/80 (when having pain, generally have high heart rate and respiratory rate)

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16
Q

Nurse review meds and effects it may have on the pt is what component of critical thinking?

A

Knowledge

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17
Q

What critical thinking attitudes nurse use when they conduct a head to toe approach of a physical assess,ent on a patient who will need to undergo treatment?

A

Discipline

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18
Q

What is crede maneuver?

A

A technique helps person to drain bladder that involve putting pressure in the lower abdomen to help person to urinate

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19
Q

Person having stress incontinence, what to help to control the elimination of incontinence?

A

Decrease caffeine, perform kegel exercise, avoid drinking alcohol

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20
Q

24 hour urine collection process rule

A

Discard first voiding and keep refrigerated or cold on ice
Don’t urinate in toilet but urinate in the urinal or cup then pour into storage container big one

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21
Q

Risk of UTI factors with recurrent UTI due to

A

Frequent sexual intercourse, location of urethra in relation to the anus, frequent catheterization

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22
Q

Bladder training

A

Want to increase intervals of urination, have the pt to record the interval time, remind pt to hold urine until next scheduled urination to decrease frequency hopefully

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23
Q

Is advance directives mean not keep person on a breathing machine or CPR?

A

Yes

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24
Q

A nurse was seen taking break, drowsy when not her break, what to do?

A

Report her?

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25
A whistle sound of hearing aid mean?
Excessive wax in the ear canal.
26
Does prescription of a transfusion of RBCs needed informed consent form?
Yes
27
Low BP can lead to dilates pupil
Yes
28
True or False, UTI can cause confusion
True
29
People who practice Judaism stay with decreased until burial
True
30
Heat brings more blood to the area, ice reduce bleeding
True
31
To treat phlebitis, what to do?
Apply warm, moist heat compress to the site Remove the IV catheter Change the infusion tubing when suspect the infusion tubing is punctured, contaminated, occluded or expired Flush IV catheter might worsen the situation
32
Length hold dropper to otic
1 cm (0.5 inch)
33
Should nurse only apply pressure to nasolacrimal duct when applying eye drop, not optic antibiotics
True
34
Nurse can apply a cotton ball into the most outer part of ear canal and remove after 15 minutes of applying an otic antibiotics
True
35
Why inflate cuff of endotracheal tube?
To stabilize the position of the tube, prevent aspiration of secretions, prevent air leaks
36
Calcium range
8.5-10.5
37
Hypercalcemia
Depressed deep-tendon reflexes, nausea, vomit, bone pain, Lethargy, and weakness
38
Hypocalcemia
Positive chvostek’s: spasm of muscles when using blood pressure cuff around arm and inflate the cuff for 1-4 mins trousseau’s signs: facial twitching when tap the face in just below and in front of the ear. Numbness and tingling of the mouth and in the extremity
39
What is chest physiotherapy for left lower lobe atelectasis
Right sided trendelenburg position Percussions done should be over a single layer of clothes and should use cupped hand to provide percussions
40
What is scoliosis?
A lateral curved of the spine
41
What is kyphosis?
Hunchback- exaggerated posterior curvature of the thoracic spine
42
Lordosis
Exaggerated lumbar curvature
43
Young adult vs older adult concept of death consider
Young adult: death is viewed as an interruption of what might have been Older adult: death is a natural consequence of a deterioration of the body.
44
To use incentive spirometer, must
Inhale to the spirometer to elevate balls in the device Clean the mouthpiece with water and dry after use Use incentive spirometer every hour while awake
45
Magnesium level
1.3-2.1
46
Auscultation of bruits sound of arteries for bell of stethoscope
True
47
Log roll technique is used for what patient?
Immobilized pt on the neck, back or spine.
48
Position of pt when transfer from the stretcher to bed?
Should cross his arms across the chest to prevent injury Stretcher should be no more than 1.3 (0.5 in) above the height of the bed
49
Should change the colostomy bag before meal because drainage from the ostomy is less likely to occur
True
50
Don’t clean stoma with soaps bc they leave residue on the skin and poor adherence of the skin
True
51
Should use vastus lateralis (anterior thigh) for IM injection of infants (5 months) and children
True Ventrogluteal muscle is safe for infants who are 7 months older Deltoid muscle is for children with 18 months older
52
Health promotion and disease prevention for patient who is sexually active is
Determine client’s risk factors
53
How often should do Pap smear- a brush on cervix to check for cervical cancer? If pt don’t have family history of cancer or DM. 45 year old pt
Every 2-3 years
54
How often they should do a mammogram? 45 year old pt. If pt don’t have family history of cancer or DM
Every year
55
How often do colon cancer procedure? 45 year old pt . If pt don’t have family history of cancer or DM
Every 10 years
56
High cholesterol level: more than 200
Primary intervention is nutrition presentation
57
Bed rest patient needs what every 2 hours
Perform anti emboli exercise
58
Urine specific concentration
1.005 to 1.030
59
Enteral feeding NG tube tip
Slow the delivery rate to intervene with diarrhea Lower fat delivery is an intervention for abdominal distention and bloating Lactose-free formula is intervention for nausea and vomiting
60
Infiltrated IV line symptoms
Taut skin around the IV catheter site that is cool to touch Swelling, pain
61
Infiltration IV intervention
Should stop Iv infusion, elevate extremity, and apply moist compress or cold compress
62
Redness at the site of IV catheter entry might mean there might have been a local infection. So intervention?
Remove IV, clean the site with alcohol and start a new IV line in another location
63
Pt has a palpable cord along the veins mean having a phlebitis which is inflammation of the layer of the vein. What to do?
Should discontinue infusion and start new IV line in another location
64
Bleeding at IV insertion site might mean having IV system not intact and should check to determine if the IV system is intact or not and if the catheter is within the clients’s veins. Intervention?
Start a new Iv line I’d bleeding doesn’t not stop.
65
Tip for feeding dysphasia pt
Give sour food or tart food to stimulate salvia production which aids in chewing and swallowing They have risk of choking when giving especially thin liquids while eating solid foods. So we prefer dry shallows to clear mouth between bites of food Should tilt the head forward to promote swallowing Minimize distractions
66
TENS stimulation helps by?
Modulates the low-voltage electrical stimulation over pain location
67
NG tube for enteral feeding insertion process?
Breath through the mouth and swallow to facilitate passage of the tube past the oropharynx Ask pt to raise index finger if need to pause during insertions
68
What time to limit fluids before bedtime?
4 hours before bedtime Avoid drink large amounts at a time and should drink plenty water during walking hours. Don’t limit fluids for even during bladder training
69
What areas of brain controlling balance and coordination?
Cerebellum
70
If pt is having trouble sleeping, pt had brain injury before, nurse should suspect which area is injured?
Injured with Hypothalamus = difficulty with sleep bc this area of the brain serves as the sleep center in the body by secreting hypocretins to promote REM sleep.
71
Injury to cerebral cortex resulted?
Difficulty with expression = contains the neural networks that facilitate complex behaviors like learning, memory and language
72
Abdominal wound has been eviscerated and you heard a pop, what you do?
Place client in supine position with hips and knees flexed. Delegate others to find doctor and stay with patient Monitor client for manifestation of shock (increase heart rate, respiratory rate, changes in blood pressure or mentation and cool or clammy skin) Cover wound and intestines with sterile, moistened dressing (to prevent contamination and also to prevent intestines from drying out)
73
MRI complications
Systems can pull metal stents like coronary artery stents, aneurysm clip to dislodge, and automated defibrillator internal to malfunction
74
Instill meds to eyes process?
Prevent blinking after give meds but close eyes and side to side eye movements Look upward toward ceiling when inserting Should instill meds into the conjunctival sac to protect cornea Apply pressure to punctuate after instill meds for 1 or 2 mins afterward to prevent systemic absorption
75
To apply tracheostomy what to consider?
Make sure it is a sterile technique To insert catheter, don’t apply suction to prevent hypoxia and tissue damage Only to lubricate suction catheter with sterile saline and rather do an oil-based lubricating jelly to reduce risk of aspiration pneumonia Apply high flow oxygen prior to the procedure
76
Awareness of the position of the body called
Proprioception
77
Ability to taste is
Gustation
78
Kinesthesia
Ability to sense position and movement of body parts without visualizing them
79
What is stereognosis?
Ability to identify object’s size, shape, and texture via tactile sensation
80
Width of cuff bladder should be % of the circumference of client’s arms?
40%
81
What findings of musculoskeletal of a young adult is expected?
Concave lumbar spine posteriorly: tend to cause bc not sitting right Muscles slight larger on the dominant side
82
Test to perform checking pt’s balance?
Heel-to-toes walk Romberg test (close eyes and standing and if falling = positive. Take out vision and vestibular function)
83
Sterile field should unfold which flap first?
Flap farthest from the body
84
Herpes zoster signs
Linear clusters of fluid containing vesicles with some crustings
85
Serous drainage
Clear, thin and watery exudate that appears during the inflammatory stage of wound healing.
86
High amount of exudate mean?
High bio ư đến count or an elevated number of potentially harmful bacteria living on a non-sterilized surface= may represent infection
87
Which type of exudate is the most common?
Serosanguineous
88
What is serosanguineous?
Thin & watery with light red or pink hue fluid represents during inflammatory stage of wound healing process as a by-product of dilated BVs = healing = not a concern in normal amounts
89
What is sanguineous?
Is bright red, fresh blood typically produced from deep wounds during inflammatory stage of healing. Outside of the wound healing, it can indicate wound trauma and damaged capillaries.
90
Continuous sanguineous drainage from a wound mean?
Hemorrhage, damage of artery or veins= hemorrhagic drainage
91
What is purulent drainage?
Thick, opaque and odorous fluid build up from infection and consists of WBCs, dead bacteria and damaged cells.
92
Alteration of wound healing by secondary intention Ex
Open burn area, stage III pressure ulcer

Nursing 200 Foundations (17 decks)

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