The nurse documents this area of unblancheable redness as a stage ______________ pressure injury
one - 1
What is the best route for administration of TPN?
IV - Centrally
Which lab result indicates the presence of malnutrition?
Hematocrit 56% (ref 40-59%)
Serum albumin 2.8 g/dL (ref 3.5-5 g/dL)
Hemoglobin 11.3 g/dL (ref 11.5-16)
Creatinine 1.9 mg/dL (ref 0.8-1.4 mg/dL)
True or False? Abdominal assessment is performed in the following order: inspection, auscultation, palpation, and percussion?
False
What type of diet is seen in this picture?
Pureed
For a sigmoidoscopy procedure the nurse should place the patient in what kind of position?
Sims' position or left lateral
The nurse documents this drainage as
serous
True or false? The best judge of the existence and severity of a patient’s pain is the physician or nurse caring for the patient.
False
A hospitalized patient has been NPO with only IV fluid intake for a prolonged period. What assessment might indicate protein calorie malnutrition?
Weight gain visual deficits, erythema of skin
Sleep disturbances, increased output, anger
Fever, joint pain, dehydration
Poor Wound healing, apathy, edema
What type of diet is seen in this picture?
Full Liquid
A nurse is looking at a patient's labs and notices that their calcium levels are at 7.4mg/dl, which sign is expected from the patient?
Depressed respirations
Seizure
Trousseau's Sign
Dysrhythmias
A patient’s labs return with a sodium level of 150. The nurse anticipates which of the following orders?
IV 5% saline
IV 0.9% salin
IV 0.3% saline
IV 3% saline
A nurse is teaching an alert client how to use a PCA system in the home. How will the nurse explain what they must do to self-manage pain?
"The medicine is going into your body all of the time"
"I will teach your family what they need to do"
"When you push the button, you will get the medicine."
"You don't have to do anything, the machine does it all."
The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis best addresses the greatest concern of complication from this sensory deficit?
Fear
Risk for fall
Social isolation
Body image disturbance
True or False? A hypertonic solution has a greater osmolarity, causing water to move out of the cells and to be drawn into the intravascular compartment, causing the cell to shrink.
True
Processed foods such as canned soup and frozen pizza have high levels of
potassium
water
sodium
sugar
What type of diet is seen in this picture?
Mechanical Soft
The outward social expressions of loss often dictated by cultural norms, customs, rituals, and tradition is known as _______
mourning
Carb Counting. Patient blood sugar is 175 before breakfast. They ate 30 gms of carbs for breakfast. The physician ordered (1 unit of Humalog regular insulin/20 grams of carb eaten) Also needs correctional insulin. How much do you give?
1
2
3
5
A nurse is teaching a patient about foods that are included on a clear liquid diet. Which of the following food choices made by the patient indicates the need for further teaching?
Yogurt
Popsicle
Gelatin
Broth
True or False? Dementia is a normal sign of aging
False
The nurse documents this wound as pressure injury as
unstageable
A newly graduated nurse is assigned to care for a team consisting of herself and a certified nursing assistant. When delegating skills, she needs to
Asking them to perform skills that the RN is able to teach
Assess the knowledge of the certified nursing assistant.
Assign only bed-making and feeding skills.
Remind the staff member that she is working under the RN
Leslie has had right lower abdominal pain for the past 2 weeks from a surgical wound. How would the nurse classify this pain?
Somatic, Acute
Viseral, Acute
Somatic, Chronic
Viseral, Chronic
In a patient with elevated PT, PTT or INR, on dressing change the nurse may expect
increased bleeding
The nurse documents this wound as a
cut
abrasion
wound
laceration
What is the best way to prevent the spread of infections?
hand hygiene or hand washing
The nurse is caring for a patient with depression. Which statement by the patient indicates a need for further education?
“Depression is a mood disorder.”
“Depression can be caused by chemical changes in the brain
"Depression is always treated with medication.”
“Depression can have a rapid onset.”
An 82-year-old male presents to the ED c/o excess thirst, 2+ pitting edema, and decreased urine output. He states he has had a cold and has been taking Alka-Seltzer every 4 hours for the past week. The nurse suspects
Hypokalemia
Hyponatremia
Hypernatremia
Hyperkalemia
When might someone have rigor mortis?
Over the age of 50
In early adulthood
After birth
After death
True or False. A patient with severe bowel impaction or chronic constipation may have bowel incontinence
True
A nurse checks a patients sodium levels and notices the sodium levels are at 150 mEq/L, which is an expected finding from that patient?
Diarrhea
Increased deep tendon reflexes
Edema
Chvostek's Sign
A nurse calculates the BMI of a client during a general survey as 26. Under what category would this client fall?
Overweight
This bulb drain is known as a ___________
JP Drain or Jackson-Pratt Drain
Legal documents that allow people to convey their wishes for end-of-life care and include living wills, durable powers of attorney for healthcare, and healthcare proxies are known as _____
advance directives
What is this a picture of?
Hematuria
A period of time or state of mind where feelings of loss, grief, or mourning are experienced by the survivor after the death of a loved one is known as _________
bereavement
A nurse may suspect that a patient is experiencing urinary retention when the patient has:
Spasms and difficulty during urination
Burning Pain in the suprapubic region
Small amounts of urine voided 2 to 3 times per hour
Large amounts of voided cloudy urine
The nurse documents this wound as a stage ___ pressure injury
three - 3
The nurse caring for a patient with Tuberculosis. What type of precautions would the nurse implement?
Airborne Precautions
The nurse documents this this thin, red-tinged drainage as
serosanguineous
On assessment, the lower extremity demonstrates 2+ pitting edema. The nurse documents this wound as
Venous stasis ulcer
Which assessment finding is NOT associated with approaching death?
Loss of appetite
Progressive weakness
Increased blood pressure
Increased drowsiness
The nurse documents this wound as a stage ___ pressure injury
2 - two
The nurse is caring for a young patient whose mother has only a week to live. The patient has been misbehaving at school recently and is suspended after picking fights with students & defying teachers. Which stage of grieving is he in?
Anger
A resident points at the water pitcher and asks if you could hand her the blanket, what is this an example of?
Expressive aphasia
What is an occult blood test?
It tests for blood in stool that cannot be seen