SI exam review

Question 1

what is the nurses role in informed consent

Answer 1

witnessing

Question 2

list the principles of basic aseptic technique

Answer 2

inch border
chest to table level, up 2 inches above elbow
all materials entering sterile field must be sterile
can’t cross over field with a contaminated object

Question 3

what is malignant hyperthermia

Answer 3

rare metabolic disease that causes rigidity of muscles

Question 4

what medication would the nurse give if the patient is experiencing malignant hyperthermia during surgery

Answer 4

dantrolene

Question 5

you are caring for a patient who is coming out of anesthesia what are your priority assessments

Answer 5

airway
breathing
circulation

Question 6

what is steroteyping

Answer 6

viewing member of a culture, race or ethnic group as being alike and sharing all the same beliefs

Question 7

what is the most reliable indicator of pain

Answer 7

patients self report

Question 8

post surgery drainage is expected to change from

Answer 8

sanguinous to serosanginus to serous

red to pink to clear

Question 9

what if your patient is a chinese women and you re unsure of their cultural preference what do you do

Answer 9

ask

Question 10

what four things does cultural competence consist of

Answer 10

skill
knowledge
awareness
encounter

Question 11

in community based nursing care is directed to

Answer 11

individuals, families, and communities

Question 12

in prochaska change theory, if a person is planning for a change they are in stage

Answer 12

preparation

Question 13

if a person is deomstrating a newly learned task what learning domain in blooms taxonomy is this

Answer 13

psychomotor

Question 14

what is a communicating fracture

Answer 14

open fracture with external envionrment

Question 15

what is a comminuted fracture

Answer 15

2 or more fragment from a crushing injury

Question 16

what is the cardinal sign of a fracture

Answer 16

deformity

Question 17

what is traction

Answer 17

pulling force on a distal fragment to maintain it with a proximal fragment

Question 18

what are the 6 ps of compartment syndrom

Answer 18

pain 
pressure
pallor
pulselessness
peristhesia
paralysis

Question 19

what are some s/s of a hip fracture

Answer 19

external rotation
tenderness/severe pian
limited mobility
leg could be shorter
muscle spasms

Question 20

what are two medication that my be used for anticoagulant therapy

Answer 20

warfarin

enoxapairin

Question 21

if the use is suspecting a fat embolism in her patent what is one s/s that sets it apart from a pulmonary embolisms

Answer 21

petechiae

neck and chest

Question 22

if your patient is expierincg compartment syndrome would you elevate the extremity

Answer 22

no

Question 23

what role does enoxaparin (lovenox) play in clotting cascade

Answer 23

prevent the conversion of fibrinogen to fibrin

prothrombin to thrombin

Question 24

warfarin (coumadin) mediation is to be taken at what part of the day

Answer 24

afternoon around 4 p.m same time every day

Question 25

what vitamin would a patient on warfarin not want to consume too much of

Answer 25

``` vitamin K leafy greens green tear prunes blueberries ```

Question 26

if your patient is on both enoxaparin and warfarin and their INR is 2.o what will you do

Answer 26

stop the enoxaparin

Question 27

what is an INR

Answer 27

person ability to clot

Question 28

what is the normal range of an INR

Answer 28

less than 1.1

Question 29

what are the 3 phases of wound care

Answer 29

inflammatory proliferative remodeling

Question 30

which phase of wound care is the retraction and scarring phase

Answer 30

remodeling

Question 31

_____ and the _____ are both part of the inflammation phase

Answer 31

vascular response and cellular response

Question 32

the vascular response begins ____ minutes after an acute injury occurs

Answer 32

10

Question 33

T/F the growth facts are the most important cell of the vascular response

Answer 33

false, platelets are the most important because they stimulate growth factor

Question 34

does histamine vasodilate or vasocontrict

Answer 34

vasodilate

Question 35

what creates pus, this usually occurs 6-8 hours post injury

Answer 35

neutrophils

Question 36

what is a shift to the left

Answer 36

a lot of immature neutrophils

Question 37

what are the two kinds of healing processes and which is easier of the body to do

Answer 37

regenreation and repair | regeneration is easiest t

Question 38

what is an example of a body part that goes under regenration

Answer 38

tongue

Question 39

a partient has just come out of knee replacement surgery and has staples holding the incision closed, what type of intention is the patients would healing by

Answer 39

primary

Question 40

what kind of intention is used when a wound that is brought together once and infection has cleared

Answer 40

tertiary

Question 41

a patient presents to the emergency room with a gunshot wound in his arm, how ill the nurse anticipate this would will heal in terms of intention

Answer 41

secondary

Question 42

T/F when a wound is healing in the proliferative stage, new capillary networks are being formed this a a very fragile stage

Answer 42

true

Question 43

you should asses your patients ____ 30 mins prior to doing wound care

Answer 43

pain

Question 44

you notice in your patients labs that he has a WBC count of 15,000 what is this called

Answer 44

leukocytosis

Question 45

what is the norma range for white blood cells

Answer 45

5,000 to 11,000

Question 46

what is is called if your patient WBC count is below 5,000

Answer 46

leukopenia

Question 47

when is a wound consider chronic

Answer 47

no specfic time frame of healing

Question 48

a ______ is when a disruption occurs in previously joined wound edges

Answer 48

dishescense

Question 49

what are things that can cause a dehiscence

Answer 49

``` infection obesity coughing albumin levels under 3. 5 jerky movments poor nutritional status ```

Question 50

what is an evisceration

Answer 50

medical emergecny | bowel protrude through incision

Question 51

what are the steps to take with evisceration

Answer 51

ask for sterile dressing and normal saline put heat of bed up to relieve pressure call surgeon pour saline on top, put dressing on abdomen put ABD on top keep it moist patient have IV and NPO

Question 52

how many stages of pressure ulcers are there

Answer 52

6

Question 53

what is normal albumin levels

Answer 53

3.5-5

Question 54

what is one of the most important roles of the nurse

Answer 54

prevent tissue injury

Question 55

the c reactive protein is indicative of infection what is a normal range

Answer 55

0-10

Question 56

wounds can be classified by 3 colors

Answer 56

red yellow black

Question 57

does your patient understand his discharge teaching when he states " my wound is classified as red meaning at home i should use hydrogen peroxide to keep it free of infection

Answer 57

no too harsh, red wound very delicate use saline or tape water

Question 58

you are getting ready to care for a patient with a yellow wound and 75% slough on it, what can the nurse anticipate she will use

Answer 58

vinegar or acidic acid if 60% or greater slough

Question 59

T/F your patient has a black found on his right elbow with eschar on it. you should lan to clean the wound first then remove the eschar

Answer 59

true

Question 60

what body part would you not want to remove eschar from

Answer 60

the heel because is already has less circulation

Question 61

your patient is using leech therapy on a wound, this is a form of ______debridement

Answer 61

biological

Question 62

if you are planning to use shape debridement on a wound, what will you expect to see. when would a nurse anticipate using this method

Answer 62

blood, only use if wound is chronic

Question 63

T/F a culture is required prior to using antimicrobial

Answer 63

false

Question 64

a _______dressing forms a soft, gel that absorbs when it comes into contact with would exudate

Answer 64

calcium aginate

Question 65

your patient ate breakfast 5 hours ago and has a blood glucose reading of 135mg/dL

Answer 65

normal

Question 66

fed state with a blood glucose reading of 210mg/dL

Answer 66

diabetes

Question 67

fasting state with a blood glucose of 92 mg/dL

Answer 67

normal

Question 68

fed state with a blood glcouse of 110mg/dL

Answer 68

normal

Question 69

fasting state with BG of 135 mg/dL

Answer 69

diabetes

Question 70

fasting state with BG 119mg/dL

Answer 70

pre diabetes

Question 71

your patient ate dinner at 7pm the next morning at 7 am she checks her blood sugar prior to eating breakfast and has a reading of 105 mg/dl

Answer 71

pre diabetes

Question 72

what is normal fasting state BG

Answer 72

less than 100

Question 73

what is pre diabetes fasting state BG

Answer 73

greater than or equal to 100 | less than 126

Question 74

what is diabetes fasting state BG

Answer 74

greater than or equal to 126

Question 75

what is normal fed state BG

Answer 75

less than 140

Question 76

what is pre diabetes fed state BG

Answer 76

less than 200 | greater than or equal to 140

Question 77

what is diabetes fed state BG

Answer 77

greater than or equal to 200

Question 78

during morning rounds you notice your patient is showing sign of reduced condition and very grumpy, he is sweating, without taking his blood sugar what do you anticipate your patient is expiericngin

Answer 78

hyporglycemia

Question 79

what are the s/s of hyperglycemia

Answer 79

``` the polys dehydration weightloss fatigue fruity odor to breath poor wound healing ```

Question 80

insulin resistance starts at a BMI of ___ what race is an exception to this and why

Answer 80

25 asian is 23 bc due to where they carry adipose tissue

Question 81

what 3 anabolic things happen in the body after a meal

Answer 81

stimulates storage of flcuose as glycogen in liver/muscle enhances fat deposit in adipose tissue promotes protein syntheis

Question 82

what is the purpose of the counter regularly hormones

Answer 82

oppostie action of insulin

Question 83

what are the count regulatory hormones

Answer 83

glucagon epinephrine growth hormone cortisol

Question 84

T/F counterregulatory hormones decrease glucose levels

Answer 84

false

Question 85

what are incretins and why are they important

Answer 85

hormones that secrete insulin secretion in repose to meal | type 2 have a deficiency

Question 86

taking what we know about incretins, why would carbohydrates taken orally work quicker to secrete insulin than when given IV

Answer 86

because IV drugs bypass the GI tract

Question 87

type1/type2 will experience the honeymoon period

Answer 87

type 1

Question 88

type 1/type2 require exogenous insulin to live

Answer 88

type 1

Question 89

what are some characteristics of type 2

Answer 89

delayed onset, geneticc, obesity

Question 90

what are some symptoms of type 2

Answer 90

poly plus fatigue, visual changes because dehydrated

Question 91

T/F the higher someone blood sugar the more dehydrated they are

Answer 91

true

Question 92

is type 1/type2 ketosis resistance

Answer 92

type 2

Question 93

recommendaton to prevent or delay the onset of type 2

Answer 93

150 min/week physical activity weight loss of 7% body weight healhty diet

Question 94

health belief model predicts behavior based on what 4 factors

Answer 94

precieved illnes from a threat belief threat has serious or nonserious consequences belief is that required recommendation will be effective belief that there are a few barriers

Question 95

what are the 5 goals of nutritional therapy

Answer 95

``` near normal blood sugars optinmum serum lipid levels reasonable weight revention/treatment of acute/chronic complications improvemnnts of overall health ```

Question 96

which type of diabetes should not drink alochol

Answer 96

they both care but people with type 1 should eat while drinking

Question 97

exercise can lead to hypoglycemia if your patient has type 1 what should you recommend they do prior to working out

Answer 97

check BG levels and if low eat 15 g of carbs before

Question 98

the goal of diabetes is

Answer 98

euglycemia

Question 99

what are some SMBG goal for control

Answer 99

80-130 before meals 100-140 bedtime goal of A1C is 7%

Question 100

you go into your patients room and notice that she is displaying shakiness, is confused and irritable with slurred speech what you doh suspect is happening g

Answer 100

hypoglycemia

Question 101

risk factor for diabetes

Answer 101

overwight physical inactive high risk race first degree relative

Question 102

s/s of hypoglycemia

Answer 102

``` tremors, reducted cognition diaphysis- sweating hunger weakness heacache seizure iritabiltly coma/death ```