Fundamentals_Comprehensive_Final

Fundamentals Comprehensive Final   Fundamentals Comprehensive Final 1. What is the Nursing Process? a. A way of thinking and acting based on scientific method. Dynamic, overlapping, and continuous process which centers on the patient. 2. What is Dynamic? a. Ever changing, ever adapting 3. What is it called when you’re the nurse that develops good clinical judgement based on decision making? a. Critical thinking 4. SOB patient would be what priority? a. High priority 5. What are the 5 steps of the nursing process? a. Assessing, Analyzing, Planning, Implementing, Evaluating 6. The Analyze step of the nursing process is also known as what? a. Nursing Diagnosis 7. A direct quote from a patient is “ “ what? a. Subjective 8. Etiology means? a. The Cause 9. Feed patient, clean them up, pain meds. This is an example of what? a. Prioritize options. What are the consequences if I do one before the other? 10. Gathering, organizing, and documenting the data in a database is which step? a. Assessing 11. Analyzing and identifying health problems a. Nursing Diagnosis 12. Dependent nursing action a. You need a doctors order 13. Independent a. No doctor order needed 14. NANDA a. North American Nursing Diagnosis Association 15. Can a nurse use a medical diagnosis in their care plan? a. No, they can reference a medical diagnosis (under R/T) but can not use it in a care plan 16. Standing Order a. An order that is always there 17. Time fixed order a. Time associated. i.e. q4h or at a specific time of day 18. Short term goals must be…. a. Realistic, attainable, and have a time frame attached to them. Up to 7-10 days. 19. Long term goals will be…. and time is measured in… a. Will be case specific and weeks-months and maybe years. 20. I want my patient who has imbalanced nutrition to eat 50% of their meal within a week and I want them to eat 6 small meals a day. This is what type of goal? a. Short term 21. NANDAS that deal with ventilation will probably be what priority? a. High priority. (Not breathing----brain hypoxia) 22. Blind patient, what is something I could do to help them out? a. Clear pathways, orient them to the room, explain food on the plate like a clock 23. Nursing care plan consists of… a. Collect patient data (assessment); Analyze the database; choose appropriate NANDA; prioritize NANDA; construct appropriate goals; Plan; Implement; evaluate 24. All patient teaching is what type of nursing action? a. Independent 25. 3 things all goals must have? a. Attainable, realistic, time frame 26. Name a tool a nurse can use all the time to help you critically think? a. Patient Chart 27. Pneumococcal pneumonia is what type of infection and how do you treat it? a. Bacterial infection and you treat it with antibiotics 28. When you have an infectious agent (wound) where is it contained? a. Reservoir 29. What does it mean if you have more leukocytes present in your body? a. You have an infection 30. What is Artificially acquired immunity? (ex. Hep B) a. Given when you are not sick so your body will fight off the disease or virus later 31. What type of asepsis would you use for an IV? a. Surgical Asepsis 32. Sterile Technique kills… a. ALL microorganisms 33. Teach hand hygiene, what can you do to minimize bacteria on your hands? a. Wear gloves, no polis, short nails, no rings (take everything off hands), no bracelets, wear short sleeves or roll up long sleeves 34. What PPE would you wear if your patient has diarrhea and is vomiting? a. Gloves, gown, mask 35. What shape of bacteria is cocci, coccus? a. Round 36. CDC says use standard precautions when? a. ALL THE TIME 37. What do you NEVER do with a used needle? a. NEVER recap; you ALWAYS dispose of needle in a sharps container 38. When leaving your patients room, what do you do right after you take your gloves off? a. Wash your hands 39. What are some things you can do to disrupt transmitting of infections? a. Hand washing; Immunization; Sterilization; Kill vectors; Wear PPE; Isolation; Standard precaution; Aseptic technique 40. Someone gets injured, what is the first response of the body? a. Inflammatory response 41. What is the first line of defense? a. Skin 42. Stages of infection; you are starting to get fatigue, malaise, and you have a slight temp. What stage of infection are you in? and are you contagious? a. Prodromal; yes, highly contagious 43. What are 2 physical things the nurse gives that makes a patient more susceptible to nosocomial infections? a. IV and a Foley 44. Care for TB, something special you must do a. Wear an N95 mask; airborne precautions; negative pressure room 45. Standard precaution for emptying catheter bag? a. Gloves 46. Incubation period are you infectious? a. Yes 47. When you are pouring liquid in a sterile field, you pour no more than how many inches above the sterile field? And how do you pour? a. No more than 6 inches above; avoid splashing by rolling instead of dumping 48. How do you open a sterile package? a. Away from your body 49. How often do you turn and reposition, CDB, etc? a. Every 2 hours 50. Where do you discard all infectious material? a. Red biohazard bag 51. How long do you vigorously scrub your hands for? a. 15-30 seconds 52. What is bacteriostatic and bactericidal? a. Bacteriostatic means bacteria can’t form (prevents ex. Silver) b. Bactericidal is a solution that destroys bacteria 53. What are the four rules of sterile technique? a. Know what is sterile; Know what is not; Keep it separated; Get rid of contaminated items 54. Example of a Naturally acquired immunity a. Chicken Pox 55. Why do we CDB every 2 hours? a. Prevent infection; lowers the chance of getting a nosocomial 56. Order to apply and remove PPE a. Apply: gown, mask, goggles, head and feet coverings, gloves b. Remove: gloves, goggles, mask, gown 57. What is colonization and Normal Flora? a. Colonization is bacteria growing out of control and Normal Flora keeps it from happening 58. Prion- mad cow disease 59. Protozoa- malaria 60. Rickettsia- vector; rocky mountain spotted fever and typhus 61. Helminths- worms 62. The longer you are on antibiotics, the higher the chance something is…. a. Opportunistic 63. Example of a vector a. Mosquitos 64. If a patient is in the hospital with anything internal wrong they are at risk for what and why? a. Nosocomial infection because they will need to be in the hospital for longer than 3 days 65. Natural acquired immunity a. Your own body makes the antibodies. You come into contact with and get the disease, your body fights it off ex. Chicken pox 66. Passive acquired immunity a. You are given antibodies developed by another person. Ex Tetanus 67. Naturally acquired passive immunity a. A baby receives antibodies from the mother by birth or breastfeeding only lasts until baby has its own immune system 68. Artificially acquired immunity a. (vaccines) dead or inactivated pathogens are injected into the body and the body produces antibodies ex. Polio, hep b, flu 69. Artificially acquired passive immunity a. Occurs when injected with antibodies derived from the infected blood of people or animals. Lasts short time then the body will produce antibodies on its own 70. If a patient falls, what is one thing that has to be in your nurse’s note? a. Any patient statement about the fall 71. During a bed bath, why do we wash distal to proximal? a. Venous return stimulation 72. What is the difference between active and passive ROM? a. Active- patient does it b. Passive- nurse does it 73. How do we move a patient who has a spinal injury? a. Log roll 74. You are performing ROM exercises on your patient when a family member ask you why you are doing this, what do you say? a. Prevent contractures 75. Patient in side lying position, what is the area with the greatest concern for pressure ulcers? a. Ileum 76. Eschar over pressure ulcer prevents you from doing what? a. Staging it 77. You are about to give your unconscious patient a bed bath, you have gathered all your supplies, where do you start? a. Eyes 78. What do you have to do before shaving your patient? a. Double check for an order and see if you need a safety razor or an electric razor. 79. A patient who is confused and over the age of 70 is at risk for what? a. Falls 80. Braden Scale a. At risk – 15-18 b. Moderate – 13-14 c. High risk – 10-12 d. Severe – 9 81. Oral care on an unconscious patient, what is the order of steps? a. Explain b. Prepare suction c. Swab/clean mouth d. Rinse e. Chapstick/lip ointment 82. How do you cut a patient’s nails? a. Check for an order- if there isn’t one, don’t cut b. If there is an order- cut straight across and file edges 83. Know procedure for transferring from bed to stretcher 84. What equipment do you need to ambulate a patient? a. Gait belt, nonslip footwear 85. You are moving a patient from the bed to wheelchair, you have them standing, but they cannot walk, how do you get them to the chair? a. Pivot 86. Know fowlers degrees a. Low-fowlers – 15-30 b. Semi-fowlers – 30-60 c. High-fowlers- 60-90 87. What are you assessing for when you are dangling your patient? a. Orthostatic hypotension 88. Your patient is at risk for injury, what is the safest what for them to get around while limiting the risk for injury? a. Wheelchair 89. Your goals/outcomes need to be patient oriented, and to help them get better. If you want your patient to be able to walk by the end of the week, what would you use to help them ambulate and what would you not use? a. You want to avoid a wheel chair, and instead use a gait belt, cane, walker, etc. 90. Know positions and what they are used for a. Supine – after spinal injury, cardiac catheterization, and after some spinal anesthetics b. Fowler- for a patient who had a stroke and has paresis to swallow food and secretions; any patient that is eating; somebody with eternal feeding tube c. Dorsal recumbent – variety of procedures and examinations d. Lithotomy- examining the pelvic organs; cath of a female patient e. Lateral position- to remove pressure from bony prominences f. Sims- rectal exams, enemas, inserting suppositories g. Prone – somebody who is on prolonged bed rest or who is immobilized, spinal cord injury h. Knee-chest – rectal exams, restore the uterus to a normal position 91. What can you always do to promote body mechanics? a. Work together 92. What are 2 things that can cause infections? a. Bacteria and viruses 93. Foot over head position? a. Trendelenburg 94. Signs and symptoms of Orthostatic hypotension? a. Dizziness 95. What would your nursing diagnosis be for a patient who wears hearing aids, glasses, has an unsteady gait, and walks with a cane? a. At risk for falling 96. Patient most at risk for pressure ulcer? a. Geriatric 97. How often do unconscious patients need oral care? a. Should be done every 4 hours but at least every 8 hours 98. What type of fire extinguisher do we have? a. ABC or C (does all) 99. Pt who is most at risk for burns a. Diabetes, mental status, immobility 100. How many times do you do each ROM exercise? a. 15-30 times per item 101. Your arthritis patient is complaining of being cold, what do you do? a. Turn temp up, give them a blanket 102. You have a blind patient, how do you prevent them from falling? a. Clear pathways and orient them to the room 103. What is the best way to keep a patient sitting without any restraints? a. Have a family member sit with them 104. Evaluate restrained limbs for? a. Pressure ulcers, edema, circulation 105. A patient with restraints has swelling around the restrained limbs what do you do? a. Take off restraints, call the physician 106. Immobility complications a. Constipation, contractures, skin break down, respiratory complication 107. Staging of pressure Ulcers: a. Stage 1: intact red, deep pink, or molted skin that does not blanch. Warmth, edema, and induration b. Stage 2: Partial thickness skin loss. Exposed epidermis, pink or red and moist. Appears intact or ruptured blister c. Stage 3: Full thickness skin loss. Looks like a deep crater. May extend to fascia. Subcutaneous layer is damaged or necrotic; fat is visible. Underlying and tunneling may be present; damage to surrounding tissue possible d. Stage 4: Full thickness skin loss with extensive tissue necrosis or damage to muscle, bone, or supporting structure. Sinus tracts may be present. Infection usually wide spread, may appear dry and black, with build up of necrotic tissue or can be wet and oozing. e. Unstageable: loss of full thickness of tissue. Base of injury is covered by eschar in the wound bed or base. Contains slough (yellow, tan, gray green, or brown) f. Deep tissue: localized discolored intact skin. Maroon or purple or blood-filled blister resulting from damage to underlying soft tissue from pressure of shearing. May be painful, firm, mushy, boggy, warmer or cooler when compared to adjacent tissue 108. Damage to the hypothalamus, what vital sign would change? a. Temperature 109. Where would you assess dorsal pedal pulse? a. Arch of the foot 110. Because of something severe and a significant loss of blood, what vital sign would change? a. Blood pressure 111. Breathing pattern of increasing then decreasing depth: a. Cheyne-stokes 112. Pulse ox of 92, what would you do: a. Monkey see monkey do, deep breath, monitor, document all steps taken 113. What is the best way to take a temperature? a. Temporal 114. Older patient with lower body temp: a. Give them blankets, turn up room temp 115. Difference between manual BP cuff and electronic BP cuff: a. Manual needs a stethoscope and its more accurate with a trained professional 116. Best way to count respirations: a. Have patient cross their arms, count for 30 secs and multiply by 2 117. What is the most important think when taking a BP? a. Listen the entire time until the BP cuff completely deflates 118. During a head to toe assessment you have unusual findings, what do you do? a. Document, report to the nurse, recheck 119. Dry and rattling lung sounds? a. Ronchi 120. High pitched, whistling lung sounds? a. Wheezing 121. First thing you do before doing anything to your patient? a. Explain procedure to the patient, ensure privacy, and hand hygiene 122. BP of 98/66 what would you do? a. Low reading, check baseline for patients typical BP range 123. Arterial pulse: a. Bounding - +3 b. Weak and Thready - +1 c. Normal - +2 124. What vital sign could be pain indicator? a. Pulse/heart rate 125. IAPP: a. Inspect, auscultate, percuss, palpate 126. Rice Krispies lung sounds: a. Crackle 127. Apical heart rate, where do you find it? a. 5th intercostal space midclavicular 128. Where should you always hear bowel sounds? a. 1st quadrant; lower right 129. Sequence of listening to bowel sounds: a. 1 (LR), 2(UR), 3(UL), 4 (LL) 130. Check for edema in: a. Lower tibia region, around ankles 131. Generalized edema: a. Swollen fingers, menstruation 132. Dependent edema: a. Pitting i. +1 = 2mm ii. +2 = 4mm iii. +3 = 6mm iv. +4 = 8mm 133. Consensual response: a. Pupils equal and reactive 134. Test lower extremity strength: a. Planter and dorsal flexion 135. BP cuff that is too small results in a. A higher than actual result 136. Order of head to toe assessment: a. Pupils, heart sounds, bowel sounds, urinary, lower extremity strength 137. What has to be done before head to toe assessment? a. Vital signs 138. Average respirations: a. 12-20 BPM 139. Signs of hypotension a. Dizzy, blurred vision, cool clammy skin 140. How do you put the ear pieces of the stethoscope in? a. Angle towards the nose 141. Definition of pulse deficit: a. Difference between apical and radial pulse 142. Pre-hypertension: a. 120-139/80-89 143. Stage 1 hypertension a. 140-159/90-99 144. Stage 2 hypertension: a. 160/100 145. Heart beat sounds a. Lub; S1; systolic; mitral valve and tricuspid valves b. Dub; S2; diastolic; pulmonic and aortic valves 146. Normal cap refill: a. Less than 3 seconds 147. How long do you check apical and radial pulses: a. One minute 148. When checking for apical HR, you can also check for: a. Irregular heart rates; heart sounds 149. Rate of BP cuff deflation: a. 2mmHg/second 150. Last Korotkoff sound in BP: a. Diastolic 151. Patient on coumadin. What are the 2 lab values we are concerned with? a. Pt and INR b. 10-14 secs .08-1.2 152. In the hospital what is the anticoagulant? What is the test? a. Heparin, b. aPtt 21-35sec 153. UTI- what laboratory test a. Urinalysis….culture and sensitivity 154. How to do/obtain a mid-stream catch(urine specimen): a. Begin voiding and then catch 155. Hgb is 8.2 and Hct 24.1: a. Anemia 156. What would you do if the lab results came back with Hgb 8.2 and Hct 24.1? a. Get/tell the physician. Tell them values, vitals, and what you suspect 157. Taking a patient down to MRI what are you making sure of? a. Make sure they take off all metal/jewelry 158. Feeding your stroke patient (CVA), what position do you put them in? a. High Fowlers-90 degrees 159. CT scan with contrast dye what am I asking if they are allergic to? a. contrast dye, iodine, shellfish 160. Just put in an NG tube, you check placement by putting 30 ml of air but no whoosh sound. You have tried this twice now what do you do? a. take it out all the way and try it again, recheck your measurements 161. Highest priorities when you are assessing before you give an enteral feeding a. 1. Check placement of the tube 162. You have a BUN of 43 and Cr 2.2 a. compromised kidney function 163. RBC, WBC, Plt, Hct, Hgb What is the test name for all of these a. CBC complete blood count 164. Taking someone’s blood sugar a. Don’t take the first drop of blood, it can be contaminated 165. Wound Culture, tube with a long sterile swab. How do you do it? a. swab the deepest portion of the wound (wound bed). Without touching anything, place the sample into the container and send it off to the lab 166. Immediately after taking someone’s blood sugar: a. discard the lancet in the sharps container 167. What do you have to do, before you give someone a tray? a. Check the specific order for their nutrition/diet they are on and make sure the tray is appropriate 168. Pre procedure patient education for duodenum nasal tube using a fluoroscope a. drink radiopaque fluid and it becomes an image that you can see 169. 3 Things you have a patient tube feedings aspirate and it was 160 a. Stop feeding, put it back in, call the doctor 170. By the book pt going to full liquid diet can they have oatmeal or milkshake? a. yes 171. What do you check for a TPN (banana bag) hanging? a. looking for redness and swelling at the iv site 172. Occult stool sample, after you obtain the sample what do you do now? a. put it on the card, put the solution on it, read the results/evaluate 173. If you checked placement of patients tube? a. document EVERYTHING you did, ex. Inject 30 mL of air, hear swoosh sound or aspirated and test the ph test 174. Pt on tube feeding is starting to feel nauseated what do you do? a. Stop feeding, Call the doctor, get a bag or emesis basin ready 175. Can your patient with a pacemaker go to an MRI? a. NO 176. Inserting a Nasalgastric tube in the right nare of the patient. They start to cough, and they give you the sign to stop. What do you do? a. Stop, pull back a little bit, if the coughing still persists -pull it all they way out. If the coughing stops-try to continue forward 177. Potassium sodium BUN glucose a. Know all the lab values 178. Before you start a wound culture, what are you wearing? a. sterile gloves, face mask, gown 179. Blood sugar of 75? a. document 75 within normal range 180. What is a fluoroscope you use to visualize? a. body tissue, organ movements, and structures 181. You are in the middle of putting in an NG tube, you are at the back of the throat. What position do you tell your patient to move to? a. drop their head forward and have swallow 182. After you start a enteral feeding the bed needs to be at least a. 30 degrees…..45 is best (semi fowlers) 183. Liver biopsy how should you position your patient afterwards? a. Right side for 2 hours 184. Know range for CBCs a. RBC- 4-5.5 b. WBC- c. Plt- - d. Hgb- 12-18 e. Hct- 37-50 185. Gave pt bolus feed through NG tube: a. Would you put 50mL into tube and squeeze NO b. allow feed to flow gravity Yes c. flush with 100 mL of water NO d. would you ck for content Yes 186. On enteral tube feedings what would the body be lacking? a. protein and Albumin ****Know these lab results 187. Inserting NG tube a. Tape, gloves, water soluble lubricant, 60 mL syringe, glass of water with straw, stethoscope, make sure they are not allergic to latex, pen light, towels, suction tubing, tubing, emesis basin 188. Pt that you have to help feed, they are visually impaired a. set up their plate like a clock 189. Before going from liquid to a puree diet, what would the doctor would order? a. swallow test done by a speech therapist 190. How many minutes from getting urine sample till it goes to the lab a. 15 mins to the lab, 10 mins for temperature 191. 24 hour urine collection a. has to go on ice, b. Dump the first one, then collect the rest and put it on ice. If a urine sample what dumped in toilet instead of in container on ice, you must dump and start all over again 192. Collecting urine specimen, 2 ways for urine culture a. mid stream, catheter 193. Know the range for specific gravity a. if its high, sediment, solute, solvent inside, kidneys filter is not working right 194. You have a patient with suspected electrolyte imbalance, what test would be ordered a. CMP- complete metabolic panel 195. Respiratory distress patient will be at risk for hypoxemia, early sign of hypoxemia a. Restlessness, irritability, confusion 196. Trying to get a good reading for pulse ox, you are patient teaching, what would you tell them might give a bad reading? a. Fake nails, nail polish 197. What would you do at the end of the 8 hour shift when you document that your patient with a chest tube has 400mg of drainage a. Document the normal range, the amount, color, consistency. (Know the normal value) 198. Requires sterile technique Nasotracheal or Nasopharyngeal a. Nasotracheal 199. What could lead to atelectasis? a. Pneumothorax 200. There are invasive methods of airway management and there are noninvasive methods of airway management. a. Chest pt: noninvasive b. Nebulizer: noninvasive c. Nasopharyngeal suctioning: invasive d. Postural drainage: noninvasive (post nasal drip) e. Tracheal suctioning: invasive f. Inline tracheal suctioning: invasive 201. If I wanted oxygen saturation of 82% what would I put them on? a. Non rebreather 202. Know what type/parameters of each oxygen mask 203. COPD a. Chronic obstructive pulmonary disease 204. Pt can eat through their mouth what would be the best way to administer low dosage of oxygen a. Nasal cannula 205. Precisely 40% of oxygen a. Venturi mask 206. Which kind of suctioning do you do to prevent tongue from going to the back of the throat a. Nasopharyngeal, Oropharyngeal 207. Pt with history of hypoxia what will we see a. Restlessness, irritability, confusion, HR increase, 208. How many liters is 4% a. 1L of oxygen (know math for all other percent’s/and liters) 209. Nasotracheal, you insert it, you get a gag a. Intermittent suction and rotation of the tube no more than 10 seconds, put them on oxygen for one minute, go back in for another 10 secs ex. Hyper oxygenate in between. No more than 3 times of suctioning 210. Neat thing about inline suction a. Its reusable 211. Doctor says, we need to remove chest tube, what supplies a. Dry gauze, petroleum jelly gauze, tape, suture removal kit 212. Mobilize pt respiratory secretions, less viscus a. Increase fluid intake by 213. Femur fracture every two hours a. CDB, because they are prone to pneumonia 214. Spirometer a. Tell patient 10 times an hour, have them do it during commercial breaks 215. Describe your emphysema patient, how would you position for orthopneic a. Sit up, lean forward over bedside table with pillow 216. Trach care solution a. 50% NS 50%peroxide (half strength) 217. What do you have to make sure is going on in all the tubing a. No leaking in the tube, tape all connections around it to contain the system 218. Oxygen has the tendency to, a. Dry out, so inspect for skin breakdown, mucus membranes (nose, oral mucosa(mouth), throat(airway passages) 219. Up the order, pt has been on 2L nasal cannula air. Doc says take it to 4L what do you have to do first before you do that? a. Humidify (screw the normal saline, mark date, open up, connect it) 220. In normal individuals, what’s the RR and the drive to breathe a. 12-20BBP CO2 levels 221. How to do CDB 222. Ways to know that my patient will need suction a. You can see mucus or stuff, Pulse ox is below 93%, you can hear it with a stethoscope, 223. With a trach cuff, there is a little tiny balloon that you have to a. deflate before you can suction 224. Water seal drainage chest drain, if you are constantly seeing some bubbling a. Document that it is normal 225. What would change in someone’s respiratory system when someone ages a. They don’t have as much cilia, 226. Nasal cannula a. Look for break down on chin, face, ears 227. Which on of the tubes is used for short term 48-72 hours a. Endotracheal if they then decided to have it longer term they would change it to, tracheostomy 228. Chocking can cause (obstruction of an air way) a. Hypoxia, 229. Pt with dysphagia and have to suction what would you use a. Yankuer 230. Pt stops breathing every 2 hours a. Apnea 231. Is postural drainage invasive a. No 232. Can a pillow be used for splinting a. Yes 233. Respiratory destress what position do I put them in a. High fowlers 90 234. If I don’t reduce the anxiety of my patient a. Muscle tension which causes more oxygen 235. Increase of negative pressure in the thoracic cavity a. Inhalation 236. Magic number for kidney function a. 30 cc/hr 237. You have taken a urine sample and need to get a urinalysis, how long do you have to send it off to the lab? a. 5-10 mins 238. Hypoactive pituitary gland = lower than normal levels of ADH. a. Increase in urinary output 239. Specific to ostomy care, what can your patient drink to lower the odor? a. Buttermilk 240. Specific gravity is high, what change to urine would you suspect? a. Dark amber color urine 241. What type of ostomy would the patient have for removal of the entire colon? a. Ileostomy 242. Need for teaching to CAN about a bed pan? a. If they put the bed pan on backwards, left them flat, or left them on bed pan for more than 15 minutes 243. How often do you change the ostomy bag? a. When the bag is half full 244. When you are inserting a Foley cath, what is the last thing you do? a. Secure it to the upper thigh to prevent it from being pulled out 245. Pt teach clean catch a. Clean peritoneal area. Then midstream catch. You don’t want any contamination 246. Are you overly concerned about constipation for a patient who has? a. Diabetes – NO b. IV antibiotics – NO (diarrhea) c. PRN laxatives – NO d. Barium swallow - YES 247. Are you concerned with a patient who does not have a distended abdomen, and you heard + bowel sounds in all 4 quadrants? a. No 248. A dementia patient with incontinence would be which type of incontinence? a. Functional incontinence – caused by extreme depression, dementia, inability to reach bathroom, inability to recognize the urge to void 249. Stress incontinence a. Caused by menopause or having a big baby. Voiding in response to sneezing, laughing, coughing, or exercise 250. Urge incontinence a. Voiding in response to strong sensation to empty bladder 251. You need a urine sample from a patient with a Foley cath, where do you NOT take it from? a. The drainage bag 252. How many mL of fluid do you prepare for an enema? a. 500-1000 mL 253. Oil retention enema, how long do you retain it for? a. 20 mins 254. Know the steps for inserting a catheter 255. Giving more than 3 enemas can cause a. Electrolyte imbalance 256. Bowel retraining a. Schedule time, increase fluids to 2000 mL, exercise, high fiber diet, suppository, stool softener, laxative, privacy, assistance 257. Irrigate Foley, You clamp the tube and Flush with NS, you then unclamp the tube, what do you do next? a. Make sure that the bag is lower than the patient for it to flow/flush into the bag 258. Female stress incontinence what can you teach to lessen the frequency? a. Kegels (pelvic muscles) 259. How many days without a BM is it before someone is officially constipated? a. 3 days 260. What would require your immediate attention of a stoma? a. Pallor (lack of blood flow) 261. How would you alter a patient’s, who has an ileostomy, diet? a. High calorie (increase 500-1000 calories) 262. When you are cleaning and replacing a colostomy bag, how do you remove the face plate? a. Push on skin and pull away. Repeat 263. Your patient has a strict I&O, what order from the doctor do you suspect next? a. Foley Cath 264. You have an order to DC a Foley, what is the first thing that you do? a. Completely deflate the balloon 265. You are getting up 4-5 times a night to void a. Nocturia 266. Super pubic Cath, what is the major advantage? a. Less likely to lead to an infection 267. mL of urine per day a. Polyuria 268. Hyperactive BS = diarrhea, what causes this? a. Antibiotics, infections 269. Bladder irrigation ordered most often after a. Bladder surgery 270. What would indicate infection in urine? a. Pyuria (puss in the urine) 271. Know the steps of changing a colostomy bag 272. Documenting inflammation, what wording would you use? a. Edema; swelling 273. How wounds heal, surgical incisions heal by: a. Primary or first intention 274. Know the intentions of healing a. First intention- (closure) A wound with little tissue loss, such as a surgical incision. The edges of the wound approximate (close together), and there is only a slight chance of infection b. Second intention- A wound with tissue loss, such as a decubitus (pressure) injury or a severe laceration. The edges of the wound do not approximate, and the wound is left open and fills with scar tissue. Because of the longer healing period, the chance of infection is higher. c. Third intention- (AKA delayed or secondary closure) occurs when there is delayed suturing of a wound. Such wounds are sutured after the granulation tissues has began to form. An abdominal wound left open for drainage and then later closed is an example. 275. Motorcycle accident; what kind of injury is this? a. Abrasion 276. Your patient has a wound that has creamy yellow puss, how would you describe it? a. Purulent 277. Wound that evolved from origin point and tunneled into adjacent organ (sigmoid colon etc.) a. Fistula 278. 3 physical signs/symptoms that would make you suspect an internal hemorrhage a. Elevated HR, restlessness, drop in BP 279. Stage 4 pressure ulcer, what type of dressing would you use? a. Wet to dry 280. Abdominal surgical incision day 2, internal organ protruding through incision. What is this called and what do you do about it? a. Evisceration; cover with sterile and wet NSS, and call the surgeon 281. Secondary intention a. Wound with tissue loss, heals by granulation ex. Laceration, pressure ulcers, burns 282. Healing process know what stage you are in a. Initial- inflammatory response (minutes-hours) b. Platelet aggregation fibrin formation, from the action of thrombin on fibrinogen and epithelial cell migration and clotting to form scabs (24-96 hours) c. Proliferation- starts day 3-4 and lasts 2-3 weeks. Wound is filled with new connective tissue. Macrophages continue to clean the wound. Collagen is synthesized. New capillary networks are formed. d. Maturation- begins 3 weeks after injury. Scar maturation or remodeling is the process of collagen lysis. Scar tissue thins slowly and becomes paler in color. At the end, the scar is firm and inelastic. 283. Abdominal wound, you have to do frequent dressing changes, what do you use? a. Montgomery strips 284. 2 types of cells that can’t regenerate. a. Nerve cells, and heart muscle cells b. Therefore, can a spinal cord injury heal by regeneration? ---NO 285. Bruise on leg from running into table a. Ecchymosis 286. What do you have to assess your patient for before applying a dressing? a. Allergy to tape 287. Partial thickness vs full thickness a. Partial thickness- through the epidermis to the dermis but does not destroy the dermis b. Full thickness- damage all the way through the dermis 288. Dressing over staples, you are having trouble removing the tape, what do you do? a. Push on it; saturate with NS 289. Predominate exudate (exudate = drainage) a. Drainage from wound; serous- fluid (serum); sanguineous- bloody; serosanguineous- bloody fluid (serum) 290. Process where we get new capillaries a. Proliferation 291. Sloughing a. Natural shedding of dead tissue; may cause drainage. A yellow wound needs to be frequently cleansed and should have a dressing that will absorb the drainage and debride the surface mechanically 292. High fever, hypothermia blanket, how often do you have to check the temp? a. Constant monitoring 293. Pen rose drain a. Safety pin so it doesn’t slide back in, secure to the tube 294. Brand name of a non-adhesive dressing a. Telfa 295. Proliferation stage a. Starts on day 3-4 and last up to 2-3 weeks 296. Least likely risk for impaired wound healing a. IV cath-YES b. Peg tube-YES c. Vascular disease-YES d. Enlarged prostate-NO 297. Heat vs cold a. Heat- vasodilates; more blood flow; do not use for risk of hemorrhage b. Cold- stops blood flow 298. Impending dehiscence, what are the first signs? a. Serosanguinous drainage 299. Stage 1 pressure ulcer, you want to be able to keep an eye on it, what type of dressing would you use? a. Transparent dressing 300. Type of scarring that is more common in African Americans after an infection on the ear a. Keloid 301. What is a Keloid composed of? a. Collagen 302. Wound progress, are these normal and healing? a. You see pink around the edges-YES b. Inflammation, red, raised-NO 303. Healing wound bed inward, you see granulation form from pink edges a. Pull scab prematurely soft pink skin = granulation 304. Jackson Pratt empty at half full, what do you have to do before closing the system by capping? a. Squeeze it together and then put lid on 305. What is the main purpose of a hydrocolloid dressing? a. Occludes air and promotes breakdown of eschar or necrotic tissue (debridement) 306. Know the types of sutures/staples a. Sutures- thread used to hold edges of a wound together. Usually Nylon, Silk, Polyester, or Dissolvable b. Retention sutures- wire used on wounds in danger of dehiscence. Outside portion of suture usually has rubber covering c. Staples- sterile staples used to hold edges of a wound together d. Steri-strips- small reinforced adhesive strips used to hold small wounds together e. Dermabond- synthetic, noninvasive (antibiotic) glue used to hold small wounds together. Loosens and comes off in 7 to 10 days 307. How does a wound vac work? a. Pulls everything together, promotes granulation drawing the edges of wound closer together by negative pressure 308. You are doing a wound irrigation, 60 mL syringe, when you are done, you notice that there is still debris left in the wound, what do you do now? a. Repeat irrigation 309. Debridement meaning a. Removal of all foreign or unhealthy tissue from a wound. A black wound need debridement of the eschar tissue. Eschar can be mechanically debrided by a surgeon softened by soaks or enzyme substances, and gradually removed as it separates 310. T or F on promoting wound healing a. Decrease fluid intake – F b. Limited activity – F c. Increase dietary protein – T d. Increase unsaturated fats – F e. Exercise D B & C – T 311. Sterile dressing change, you just took old gloves off what do you do next? a. Wash hands and don sterile gloves 312. Take dressing off wound, it is completely saturated. What can you put on top of the gauze? a. Abdominal pad 313. Walking patient after abdominal surgery. “I think I just felt something let go” What do you do? a. Set them down flat on the floor in supine position 314. Your patient has a sprain, you put an ice pack on it. T or F a. Thin covering around the icepack – T b. Continuous use – F c. Reduce muscle tension and stimulate cell metabolism – F d. Decrease blood flow - T