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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
Q

A whistle sound of hearing aid mean?

A

Excessive wax in the ear canal.

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26
Q

Does prescription of a transfusion of RBCs needed informed consent form?

A

Yes

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27
Q

Low BP can lead to dilates pupil

A

Yes

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28
Q

True or False, UTI can cause confusion

A

True

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29
Q

People who practice Judaism stay with decreased until burial

A

True

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30
Q

Heat brings more blood to the area, ice reduce bleeding

A

True

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31
Q

To treat phlebitis, what to do?

A

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

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32
Q

Length hold dropper to otic

A

1 cm (0.5 inch)

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33
Q

Should nurse only apply pressure to nasolacrimal duct when applying eye drop, not optic antibiotics

A

True

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34
Q

Nurse can apply a cotton ball into the most outer part of ear canal and remove after 15 minutes of applying an otic antibiotics

A

True

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35
Q

Why inflate cuff of endotracheal tube?

A

To stabilize the position of the tube, prevent aspiration of secretions, prevent air leaks

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36
Q

Calcium range

A

8.5-10.5

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37
Q

Hypercalcemia

A

Depressed deep-tendon reflexes, nausea, vomit, bone pain, Lethargy, and weakness

38
Q

Hypocalcemia

A

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
Q

What is chest physiotherapy for left lower lobe atelectasis

A

Right sided trendelenburg position
Percussions done should be over a single layer of clothes and should use cupped hand to provide percussions

40
Q

What is scoliosis?

A

A lateral curved of the spine

41
Q

What is kyphosis?

A

Hunchback- exaggerated posterior curvature of the thoracic spine

42
Q

Lordosis

A

Exaggerated lumbar curvature

43
Q

Young adult vs older adult concept of death consider

A

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
Q

To use incentive spirometer, must

A

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
Q

Magnesium level

A

1.3-2.1

46
Q

Auscultation of bruits sound of arteries for bell of stethoscope

A

True

47
Q

Log roll technique is used for what patient?

A

Immobilized pt on the neck, back or spine.

48
Q

Position of pt when transfer from the stretcher to bed?

A

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
Q

Should change the colostomy bag before meal because drainage from the ostomy is less likely to occur

A

True

50
Q

Don’t clean stoma with soaps bc they leave residue on the skin and poor adherence of the skin

A

True

51
Q

Should use vastus lateralis (anterior thigh) for IM injection of infants (5 months) and children

A

True
Ventrogluteal muscle is safe for infants who are 7 months older
Deltoid muscle is for children with 18 months older

52
Q

Health promotion and disease prevention for patient who is sexually active is

A

Determine client’s risk factors

53
Q

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

A

Every 2-3 years

54
Q

How often they should do a mammogram? 45 year old pt. If pt don’t have family history of cancer or DM

A

Every year

55
Q

How often do colon cancer procedure? 45 year old pt . If pt don’t have family history of cancer or DM

A

Every 10 years

56
Q

High cholesterol level: more than 200

A

Primary intervention is nutrition presentation

57
Q

Bed rest patient needs what every 2 hours

A

Perform anti emboli exercise

58
Q

Urine specific concentration

A

1.005 to 1.030

59
Q

Enteral feeding NG tube tip

A

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
Q

Infiltrated IV line symptoms

A

Taut skin around the IV catheter site that is cool to touch
Swelling, pain

61
Q

Infiltration IV intervention

A

Should stop Iv infusion, elevate extremity, and apply moist compress or cold compress

62
Q

Redness at the site of IV catheter entry might mean there might have been a local infection. So intervention?

A

Remove IV, clean the site with alcohol and start a new IV line in another location

63
Q

Pt has a palpable cord along the veins mean having a phlebitis which is inflammation of the layer of the vein. What to do?

A

Should discontinue infusion and start new IV line in another location

64
Q

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?

A

Start a new Iv line I’d bleeding doesn’t not stop.

65
Q

Tip for feeding dysphasia pt

A

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
Q

TENS stimulation helps by?

A

Modulates the low-voltage electrical stimulation over pain location

67
Q

NG tube for enteral feeding insertion process?

A

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
Q

What time to limit fluids before bedtime?

A

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
Q

What areas of brain controlling balance and coordination?

A

Cerebellum

70
Q

If pt is having trouble sleeping, pt had brain injury before, nurse should suspect which area is injured?

A

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
Q

Injury to cerebral cortex resulted?

A

Difficulty with expression = contains the neural networks that facilitate complex behaviors like learning, memory and language

72
Q

Abdominal wound has been eviscerated and you heard a pop, what you do?

A

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
Q

MRI complications

A

Systems can pull metal stents like coronary artery stents, aneurysm clip to dislodge, and automated defibrillator internal to malfunction

74
Q

Instill meds to eyes process?

A

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
Q

To apply tracheostomy what to consider?

A

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
Q

Awareness of the position of the body called

A

Proprioception

77
Q

Ability to taste is

A

Gustation

78
Q

Kinesthesia

A

Ability to sense position and movement of body parts without visualizing them

79
Q

What is stereognosis?

A

Ability to identify object’s size, shape, and texture via tactile sensation

80
Q

Width of cuff bladder should be % of the circumference of client’s arms?

A

40%

81
Q

What findings of musculoskeletal of a young adult is expected?

A

Concave lumbar spine posteriorly: tend to cause bc not sitting right
Muscles slight larger on the dominant side

82
Q

Test to perform checking pt’s balance?

A

Heel-to-toes walk
Romberg test (close eyes and standing and if falling = positive. Take out vision and vestibular function)

83
Q

Sterile field should unfold which flap first?

A

Flap farthest from the body

84
Q

Herpes zoster signs

A

Linear clusters of fluid containing vesicles with some crustings

85
Q

Serous drainage

A

Clear, thin and watery exudate that appears during the inflammatory stage of wound healing.

86
Q

High amount of exudate mean?

A

High bio ư đến count or an elevated number of potentially harmful bacteria living on a non-sterilized surface= may represent infection

87
Q

Which type of exudate is the most common?

A

Serosanguineous

88
Q

What is serosanguineous?

A

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
Q

What is sanguineous?

A

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
Q

Continuous sanguineous drainage from a wound mean?

A

Hemorrhage, damage of artery or veins= hemorrhagic drainage

91
Q

What is purulent drainage?

A

Thick, opaque and odorous fluid build up from infection and consists of WBCs, dead bacteria and damaged cells.

92
Q

Alteration of wound healing by secondary intention Ex

A

Open burn area, stage III pressure ulcer

Nursing 200 Foundations (17 decks)

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