3 day post op dressing change Correct Answer -Report:
>Yellow green, purulent, odorous drainage =infection
-Expected;
>Serosanguineous (light pinkish)
>Pink incision with slight crusting
>Slight swelling around staples or sutures
Active dying cancer pt: first action Correct Answer -Moisten
the clients conjunctive with NS, artificial tears, or ophthalmic
gel
-Providing necessary dosage of pain med for comfort
-Oral care using a soft moist brush or swab (glycerin or lemon
swabs can promote drying). Petroleum jelly to maintain lip
moisture
-Anticholinergics may be prescribed to reduce amounts of
secretions (avoid using suctioning)
Alzheimers: nursing actions Correct Answer -Guide pt to quiet,
familiar area to decrease agitation
-Reminiscence therapy
-Use symbols and pictures instead of words
-Reduce distractions, decreasing confusion
-Introduce yourself, call the pt by name, and discuss time of day,
and season or holiday to help decrease anxiety b/c of short term
memory lost
Anorexia nervosa: plan of care Correct Answer -Record
amount of food the pt consumes
,-Weigh daily the first week then 3 times each week after that
-Restrict exercise until pt reaches target weight
Anticoagulant A/E Correct Answer -Bloody stools
Antihistamines A/E Correct Answer -Urinary retention
Babinski reflex Correct Answer -Stroking the sole of the
newborns foot upward, towards the great toe
-Expected age: Birth to 1 year
Bladder scan Correct Answer -Pt shouldn't experience any
discomfort
-Noninvasive
-Does not use contrast media
-Requires clean technique
Blood glucose monitoring: first action Correct Answer -Hold
finger in dependent position, to enhance blood flow
Cardiac Cath: priority question to ask Correct Answer -
Allergies to iodine
>Shellfish allergy
-Last time cholesterol levels were checked
-Family history of CAD
-How often do they experience chest pain
Chest tube: expected findings *EDIT* Correct Answer -
Fluctuation in water seal chamber with inhalation up to 2 cm
-Continuous bubbling in suction control chamber ONLY
, Chest tube: findings to report *EDIT* Correct Answer
-3mL/kg/hr of sanguineous drainage for over 3 consecutive
hours, can indicate active hemorrhaging
-Subcut emphysema, air leak under pt skin
Consent for general treatments Correct Answer -Upon admin to
acute care facility
>Noninvasive diagnostic (echocardiogram and chest
radiography)
>Insertion of indwelling Cath if prescribed
Consultation reports Correct Answer -Interprofessional info
about pt interventions
-Pt responses to consultation report
Continent urinary diversion: Plan of care Correct Answer -
Using intermittent urinary Cath at regular intervals
>Contains valves that prevent urine from exiting the pouch
Continuous gastrostomy tube: nursing action Correct Answer -
Flush tube with 30 to 50 mL of warm water in a 60 mL piston
syringe if it becomes clogged
-Flush 10 to 30 mL before and after admin of each med
-To maintain patency instill 30 mL every 4 hours
-Check for residual volume when flushing the feeding with 30
mL (too much can lead to fluid imbalances)
COPD nutrition Correct Answer -Drink high protein and high
calorie nutritional supplements