NSG 1400 - Final
Study online at https://quizlet.com/_9rr44t
1. The immediate response to tissue injury and is short in duration (minutes
to days): Acute inflammation
2. Localized signs and symptoms of inflammation include:: -Swelling
-Pain
-Heat
-Redness
-Loss of function
3. Systemic signs and symptoms of inflammation include:: -Fever
-Leukocytosis
-Malaise
-Fatigue
-Increased pulse & respirations
-Anorexia
-Nausea
4. Occurs when inflammation continues for weeks to years after the initial
injury: Chronic inflammation
5. What are the labs to assess inflammation?: -CBC with WBC differential
-C-reactive Protein (CRP)
-Erythrocyte Sedimentation Rate (ESR)
-Serological tests to detect specific antibodies or viruses
6. What are the WBC lab consequences of inflammation?: -Elevated WBC (>11,100
cells/mm^3)
-Elevated neutrophils (>8,000 cells/mm^3)
-Elevated monocytes (>700 cells/mm^3)
-Elevated lymphocytes (>4,000 cells/mm^3)
7. A nonspecific protein, produced in the liver, that becomes elevated during
episodes of acute inflammation or infection: C-reactive protein
8. A nonspecific test for inflammation that measures how quickly blood cells
will settle to the bottom of a test tube; a faster than normal rate may indicate
inflammation in the body: Erythrocyte sedimentation rate (ESR)
9. What factors place a patient at risk for infection?: -Age: very young and very old
-Low socioeconomic status
, NSG 1400 - Final
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-Geographic location where infection is prevalent
-Immunodeficiency
-Chronic disease
-Environmental conditions: crowded living conditions, absence of clean food/water, insufficient air ventilation, unsafe
sanitary conditions
10. What are the appropriate labs to determine the presence of infection?: -CBC
with WBC differential
-Culture & sensitivity
-C-reactive protein (CRP)
-Erythrocyte sedimentation rate (ESR)
-Serological tests to detect specific antibodies or viruses
11. What are the WBC lab consequences of parasitic infections?: -Elevated basophils
(>100 cells/mm^3)
-Elevated eosinophils (>500 cells/mm^3)
12. What are the WBC lab consequences of bacterial or viral infections?: -Elevated
WBC (>11,100 cells/mm^3)
-Elevated neutrophils (>8,000 cells/mm^3)
-Elevated monocytes (>700 cells/mm^3)
-Elevated B & T lymphocytes (>4,000 cells/mm^3)
13. What nursing interventions are necessary for a low Braden score?: Implemen-
tation of pressure injury prevention measures:
-Minimize or eliminate friction & shear (sliding on sheets)
-Minimize pressure through repositioning, establish turning schedule Q2H
-Pressure-relieving devices
-Assess and manage moisture on skin surfaces
-Maintain adequate nutrition and hydration; offer protein supplements between meals
-Elevate heels off bed
14. Criteria for a Stage 1 pressure ulcer include:: -Intact, non-blistered skin with non-blanch-
able erythema or persistent redness
-An area that is painful and differs in firmness or temperature from the surrounding tissue
15. Criteria for a Stage 2 pressure ulcer include:: -Partial-thickness skin loss with exposed
dermis
, NSG 1400 - Final
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-Involves the epidermis and/or dermis but does not extend below the level of the dermis
-Shallow and superficial, with a pink wound bed
-Intact or ruptured blisters may be present
16. Criteria for a Stage 3 pressure ulcer include:: -Full-thickness skin loss
-Extends into the subcutaneous tissue but does not extend through the fascia to muscle, bone, or connective tissue
-Undermining and tunneling may be present
17. Criteria for a stage 4 pressure ulcer include:: -Full-thickness skin and tissue loss
-Deeper than stage 3; involves exposure of muscle, bone, or connective tissue
-The considerable depth of the wound and exposure of bone make osteomyelitis likely
18. Criteria for an unstageable wound include:: -Obscured full-thickness skin and tissue loss
-The amount of necrotic tissue (eschar) in the wound bed makes it impossible to assess the depth of the wound or
the involvement of underlying structures
-Wound cannot be staged until the necrotic tissue is removed (debrided)
19. The 10 warning signs of primary immunodeficiency include:: 1.) Four or more ear
infections within one year
2.) Two or more serious sinus infections within one year
3.) Failure of an infant to gain weight or grow normally
4.) Recurrent, deep skin, or organ abscesses
5.) Persistent oral thrush or fungal infections on the skin
6.) The need for IV antibiotics to clear infections
7.) Two or more deep-seated infections, including septicemia
8.) Two or more pneumonias within one year
9.)Two or more months of antibiotic use with little effect
10.) Family history of PI
20. A loss of immune functioning (in a person with previously normal immune
function) as a result of an illness or treatment: Secondary immunodeficiency
21. Secondary immunodeficiency may be caused by:: -Medication in order to avoid rejection
of transplanted tissue
-Treatment for various types of cancer
22. Independent nursing interventions for a patient in respiratory distress
include:: -Place patient in semi-Fowler's position to optimize lung expansion
-Monitor vital signs
, NSG 1400 - Final
Study online at https://quizlet.com/_9rr44t
-Perform focused respiratory assessment
-Stay with patient to provide reassurance
-Encourage slow, deep breathing, coughing, and use of an incentive spirometer to aid in airway clearance
-Administer supplemental oxygen and medication therapies as ordered
-Monitor effectiveness of treatment
-Monitor labs/diagnostics as ordered
23. What is included in a focused respiratory assessment?: -Respiratory rate, rhythm, and
depth
-Use of accessory muscles when breathing
-Auscultate lung sounds
-Assess for cyanosis of the tongue, oral mucosa, and skin
-Assess for cough
-Assess patient's energy level and changes in LOC
24. Dependent interventions for a patient in respiratory distress include:: -Sup-
plemental oxygen therapy
-Medication therapy
-Order lab/diagnostic tests: CBC (Hgb), BMP, ABGs, chest x-ray
25. What is the priority lab for gas exchange?: Hemoglobin
26. What is the role of hemoglobin in the body?: It is the part of the red blood cell that transports
oxygen to the tissues and carbon dioxide from the tissues
27. Independent interventions for a patient with impaired perfusion include:: -
-Monitor vital signs
-Assess for signs & symptoms of impaired perfusion
-Ambulation
-Positioning
-Monitor labs and diagnostics as ordered
-Administer medications and fluids as ordered
-Encourage adequate and appropriate nutrition
-Encourage activity and exercise
28. What assessments should be performed for a patient with impaired perfu-
sion?: -Vital signs
-Inspect for color, respiratory effort, and distress
Study online at https://quizlet.com/_9rr44t
1. The immediate response to tissue injury and is short in duration (minutes
to days): Acute inflammation
2. Localized signs and symptoms of inflammation include:: -Swelling
-Pain
-Heat
-Redness
-Loss of function
3. Systemic signs and symptoms of inflammation include:: -Fever
-Leukocytosis
-Malaise
-Fatigue
-Increased pulse & respirations
-Anorexia
-Nausea
4. Occurs when inflammation continues for weeks to years after the initial
injury: Chronic inflammation
5. What are the labs to assess inflammation?: -CBC with WBC differential
-C-reactive Protein (CRP)
-Erythrocyte Sedimentation Rate (ESR)
-Serological tests to detect specific antibodies or viruses
6. What are the WBC lab consequences of inflammation?: -Elevated WBC (>11,100
cells/mm^3)
-Elevated neutrophils (>8,000 cells/mm^3)
-Elevated monocytes (>700 cells/mm^3)
-Elevated lymphocytes (>4,000 cells/mm^3)
7. A nonspecific protein, produced in the liver, that becomes elevated during
episodes of acute inflammation or infection: C-reactive protein
8. A nonspecific test for inflammation that measures how quickly blood cells
will settle to the bottom of a test tube; a faster than normal rate may indicate
inflammation in the body: Erythrocyte sedimentation rate (ESR)
9. What factors place a patient at risk for infection?: -Age: very young and very old
-Low socioeconomic status
, NSG 1400 - Final
Study online at https://quizlet.com/_9rr44t
-Geographic location where infection is prevalent
-Immunodeficiency
-Chronic disease
-Environmental conditions: crowded living conditions, absence of clean food/water, insufficient air ventilation, unsafe
sanitary conditions
10. What are the appropriate labs to determine the presence of infection?: -CBC
with WBC differential
-Culture & sensitivity
-C-reactive protein (CRP)
-Erythrocyte sedimentation rate (ESR)
-Serological tests to detect specific antibodies or viruses
11. What are the WBC lab consequences of parasitic infections?: -Elevated basophils
(>100 cells/mm^3)
-Elevated eosinophils (>500 cells/mm^3)
12. What are the WBC lab consequences of bacterial or viral infections?: -Elevated
WBC (>11,100 cells/mm^3)
-Elevated neutrophils (>8,000 cells/mm^3)
-Elevated monocytes (>700 cells/mm^3)
-Elevated B & T lymphocytes (>4,000 cells/mm^3)
13. What nursing interventions are necessary for a low Braden score?: Implemen-
tation of pressure injury prevention measures:
-Minimize or eliminate friction & shear (sliding on sheets)
-Minimize pressure through repositioning, establish turning schedule Q2H
-Pressure-relieving devices
-Assess and manage moisture on skin surfaces
-Maintain adequate nutrition and hydration; offer protein supplements between meals
-Elevate heels off bed
14. Criteria for a Stage 1 pressure ulcer include:: -Intact, non-blistered skin with non-blanch-
able erythema or persistent redness
-An area that is painful and differs in firmness or temperature from the surrounding tissue
15. Criteria for a Stage 2 pressure ulcer include:: -Partial-thickness skin loss with exposed
dermis
, NSG 1400 - Final
Study online at https://quizlet.com/_9rr44t
-Involves the epidermis and/or dermis but does not extend below the level of the dermis
-Shallow and superficial, with a pink wound bed
-Intact or ruptured blisters may be present
16. Criteria for a Stage 3 pressure ulcer include:: -Full-thickness skin loss
-Extends into the subcutaneous tissue but does not extend through the fascia to muscle, bone, or connective tissue
-Undermining and tunneling may be present
17. Criteria for a stage 4 pressure ulcer include:: -Full-thickness skin and tissue loss
-Deeper than stage 3; involves exposure of muscle, bone, or connective tissue
-The considerable depth of the wound and exposure of bone make osteomyelitis likely
18. Criteria for an unstageable wound include:: -Obscured full-thickness skin and tissue loss
-The amount of necrotic tissue (eschar) in the wound bed makes it impossible to assess the depth of the wound or
the involvement of underlying structures
-Wound cannot be staged until the necrotic tissue is removed (debrided)
19. The 10 warning signs of primary immunodeficiency include:: 1.) Four or more ear
infections within one year
2.) Two or more serious sinus infections within one year
3.) Failure of an infant to gain weight or grow normally
4.) Recurrent, deep skin, or organ abscesses
5.) Persistent oral thrush or fungal infections on the skin
6.) The need for IV antibiotics to clear infections
7.) Two or more deep-seated infections, including septicemia
8.) Two or more pneumonias within one year
9.)Two or more months of antibiotic use with little effect
10.) Family history of PI
20. A loss of immune functioning (in a person with previously normal immune
function) as a result of an illness or treatment: Secondary immunodeficiency
21. Secondary immunodeficiency may be caused by:: -Medication in order to avoid rejection
of transplanted tissue
-Treatment for various types of cancer
22. Independent nursing interventions for a patient in respiratory distress
include:: -Place patient in semi-Fowler's position to optimize lung expansion
-Monitor vital signs
, NSG 1400 - Final
Study online at https://quizlet.com/_9rr44t
-Perform focused respiratory assessment
-Stay with patient to provide reassurance
-Encourage slow, deep breathing, coughing, and use of an incentive spirometer to aid in airway clearance
-Administer supplemental oxygen and medication therapies as ordered
-Monitor effectiveness of treatment
-Monitor labs/diagnostics as ordered
23. What is included in a focused respiratory assessment?: -Respiratory rate, rhythm, and
depth
-Use of accessory muscles when breathing
-Auscultate lung sounds
-Assess for cyanosis of the tongue, oral mucosa, and skin
-Assess for cough
-Assess patient's energy level and changes in LOC
24. Dependent interventions for a patient in respiratory distress include:: -Sup-
plemental oxygen therapy
-Medication therapy
-Order lab/diagnostic tests: CBC (Hgb), BMP, ABGs, chest x-ray
25. What is the priority lab for gas exchange?: Hemoglobin
26. What is the role of hemoglobin in the body?: It is the part of the red blood cell that transports
oxygen to the tissues and carbon dioxide from the tissues
27. Independent interventions for a patient with impaired perfusion include:: -
-Monitor vital signs
-Assess for signs & symptoms of impaired perfusion
-Ambulation
-Positioning
-Monitor labs and diagnostics as ordered
-Administer medications and fluids as ordered
-Encourage adequate and appropriate nutrition
-Encourage activity and exercise
28. What assessments should be performed for a patient with impaired perfu-
sion?: -Vital signs
-Inspect for color, respiratory effort, and distress
