Quiz 6

Question 1

What does TPN have a high content of?

Answer 1

dextrose (sugar content)

Question 2

How should TPN be stopped?

Answer 2

should not be stopped abruptly

Question 3

If TPN is stopped abruptly, how will it affect the blood sugar of a patient?

Answer 3

blood sugar will drop (hypoglycemia)

Question 4

What are the signs and symptoms of hypoglycemia?

Answer 4

confusion
sweating
shaking
clammy
mimic someone who is drunk

Question 5

If TPN was stopped abruptly for a patient, what is the first action a nurse should take?

Answer 5

check patients blood sugar levels

Question 6

If a patient’s blood sugar is low and they are conscious, what can the nurse give?

Answer 6

candy or any sugar by mouth

Question 7

If a patient’s blood sugar is high and they are unconscious, what can the nurse give?

Answer 7

IV dextrose

Question 8

What are the signs and symptoms of hyperglycemia?

Answer 8

hot, dry skin, fruity breath

Question 9

Which lab represents nutrition?
What is the normal range?
What does it show?

Answer 9

albumin
3.5-5

signifies nutrition status and wound healing

Question 10

What are isotonic movements? What are examples?

Answer 10

repetitive exercises

swimming, walking, jogging, riding a bike

Question 11

What are instructions for the use of a cane?

Answer 11

1. maintain two points of support
2. keep cane on stronger side
3. support body weight on both legs
4. move cane forward 6-10 in
5. move weaker leg forward toward cane
6. advance stronger leg

Question 12

If a patient is using a walker, what side will the nurse get on to help the patient?

Answer 12

the weaker side

(strong support the weak)

Question 13

If a nurse is helping a patient up, what side will the nurse get on for the patient?

Answer 13

weak side to help up as patient pushes up with good leg

Question 14

What are measures to prevent skin breakdown due to urinary incontinence?

Answer 14

• keep area dry and clean with soap and water
• use a skin barrier
• assess for signs of breakdown
• implement bladder-retraining program

Question 15

For patients with pressure injuries, what will the nurse will be monitoring?

Answer 15

albumin levels

Question 16

What side should the patient hold a cane if they have left hemiparesis? Where should the nurse be?

Answer 16

cane should be on the strong side (right side)

nurse should be on weak side (left side)

Question 17

What foods promote wound healing?

Answer 17

foods high in protein

ex: meat, fish, poultry, eggs, dairy products, beans, nuts, whole grains

Question 18

What are nursing interventions for wounds?

Answer 18

• provide adequate hydration and meet protein and calories needs
• perform wound cleaning and irrigation

Question 19

What are nursing interventions for pressure injuries?

Answer 19

• avoid skin trauma
• use pressure-reducing surfaces or devices
• maintain skin hygiene
• encourage proper nutrition

Question 20

What is a stage 1 pressure injury?

Answer 20

skin intact
nonblanchable

only epidermis affected

Question 21

What is a stage 2 pressure injury?

Answer 21

skin intact or ruptured
wound bed is reddish pink

epidermis and dermis affected

Question 22

What is a stage 3 pressure injury?

Answer 22

visible adipose tissue with slough and eschar
possible tunneling

epidermis, dermis, and subcutaneous tissue affected

Question 23

What is a stage 4 pressure injury?

Answer 23

skin and tissue loss
tunneling and undermining

epidermis, dermis, subcutaneous tissue, muscle and bone affected

Question 24

If a patient comes back from surgery and has an abdominal wound that has eviscerated (opened up), what would the nurse do?

Answer 24

cover it with a wet saline gauze

Question 25

What is an aliginate dressing used for in wound dressings?

Answer 25

nonadherent provides moist wound bed absorbs exudate pack wounds supports debridement

Question 26

What is a collagen dressing used for in wound dressings?

Answer 26

powders, pastes, granules, sheets, gels help stop bleeding promotes healing

Question 27

What can the nurse educate their patient who will be getting a colonoscopy?

Answer 27

doctor will give a sedative - you will be awake and relaxed, but you won't remember it happened

Question 28

What are patients at risk for if they are having frequent stools?

Answer 28

electrolyte imbalances

Question 29

What will the nurse educate a patient on if they are bowel or bladder training?

Answer 29

if they have the urge to go, they should go do not avoid the urge

Question 30

If a patient is on TPN, which is high in glucose (dextrose), and it is going at twice the rate than its ordered, what will the nurse do?

Answer 30

stop immediately and check blood sugars

Question 31

What should the normal color for the stoma of an ileostomy and colostomy be? What should it not look like?

Answer 31

should be: beefy red cannot be: gray, purple, green, blue

Question 32

How often should a nurse toilet patients?

Answer 32

every 2 hours and as needed

Question 33

If a patient's catheter is discontinued, what will the patient experience?

Answer 33

they will have a hard time voiding

Question 34

If a patient's catheter is discontinued, what will the nurse monitor for? How can the nurse do this?

Answer 34

Nurse will monitor patient urinating (voiding) within 6-8 hrs after removal - take them to the bathroom - bladder scan (check how much urine is there)

Question 35

When an NG is inserted, how will the nurse know it is in the correct location?

Answer 35

- x-ray - check pH is 4 or less - auscultate with stethoscope

Question 36

What will a nurse tell a patient in regards to a low fat diet?

Answer 36

Animal based foods have high saturated fats Plant based have high amounts of unsaturated fats

Question 37

What is included in a high fiber diet?

Answer 37

whole grain bread raw dried fruit

Question 38

If a patient cannot urinate, what will the nurse do first?

Answer 38

assess and check for bladder distention

Question 39

With foley catheter, is the system broken? Why?

Answer 39

no to maintain a closed drainage system to prevent infections

Question 40

How is a clean catch midstream specimen done?

Answer 40

wipe from front to back / clean the urethral meatus pee first then stop and catch the urine sample midstream

Question 41

What is a clear liquid diet?

Answer 41

liquids that leave little residue and able to see through it - clear fruit juice - gelatin - broth

Question 42

What is a full liquid diet?

Answer 42

clear liquids liquid dairy products all juices pureed vegetables

Question 43

Define exudate

Answer 43

drainage

Question 44

What color guide is used for wound care and what should be done for each?

Answer 44

Red (cover) Yellow (clean) Black (debride/remove necrotic tissue)

Question 45

How is wound drainage measured accurately?

Answer 45

weigh the dressing 1g = 1mL of drainage

Question 46

Describe serous drainage

Answer 46

serum - watery - clear - slightly yellow (fluid in blisters)

Question 47

Describe sanguineous drainage

Answer 47

serum & red blood cells - thick - reddish (bright- newer) (dark-older)

Question 48

Describe serosanguineous drainage

Answer 48

serum & blood - watery and pink/red

Question 49

Describe purulent drainage

Answer 49

infection - yellow, tan, green, brown - odor

Question 50

Describe purosanguineous drainage

Answer 50

mixed drainage of pus and blood

Question 51

What is high priority for the nurse to do if a patient is bed bound?

Answer 51

turn every 2 hours and document

Question 52

What is a patient at risk for if they are bed bound?

Answer 52

pressure ulcers