D439 Foundations of Nursing Test Questions and Answers Already Passed Latest Update

D439 Foundations of Nursing Test Questions and Answers Already Passed Latest Update what can cause high blood pressure readings? - Answers Anxiety, wrong cuff size, talking, legs crossed, arm not being level with heart, pain, dehydration, fever/infection, hyponatremia, weight, alcohol/smoking, opioids, hypovolemia, hyper/hypokalemia, hyper/hypocalcemia no radial pulse at 90 - Answers PUMP TO 120 how much to pump cuff - Answers at least 30 mm Hg above the point the radial pulse disappears potassium levels involved - Answers heart: helps the heart squeeze high potassium levels - Answers high apical pulse rate and rhythm nursing charts by exception- lungs - Answers LUNG SOUNDS DIMINISHED IN LEFT LUNG not normal nasal cannula care: if patient has reddened areas around cheekbones - Answers PLACE PADDING AROUND THE CANNULA TUBING nasal cannula care: if patient's O2 readings improve with movement - Answers place the nasal cannula in the nose securely nasal cannula care: O2 levels low - Answers VERIFY PLACEMENT OF PULSE OXIMETER Oxygen chamber - Answers store in a cool area Fall Prevention "H" - Answers Hourly rounds: check on patient HOURLY Fall prevention "O" - Answers Organize belongings: use bed alarms Fall Prevention "P" - Answers Position changes slow: ensure slow position changes and keep everything needed within reach Fall Prevention "E" - Answers Ensure lighting is sufficient: For elderly patients keep a well lit room patient has sleep apnea and given sedative - Answers MAKE SURE AIRWAY PRESSURE DEVICE IS ON restraint types - Answers chemical & physical restraint knot - Answers slip knots restraint tying area - Answers BED FRAME ONLY chemical restraints - Answers meds such as benzos first thing to assess after restraint - Answers CAPILLARY REFILL when to check capillary refill when restrained - Answers immediately and every 15 mins other checks when restrained - Answers skin integrity, vital signs, ROM every 2 hours; offer bathroom every 2 hours restraint documentation - Answers reasoning, mental status, care offered, time in restraints restraint order time - Answers ONLY last 24 hours urine specific gravity test use - Answers identify dehydration, kidney problems, conditions like diabetes insipidus urine specific gravity test & range - Answers concentration of particles in urine; 1.005- 1.030 high urine specific gravity test - Answers HIGH = YOU'RE DRY/ DEHYDRATED = VOMITING/DIARRHEA low urine specific gravity test - Answers "overflow" kidney damage, kidney failure pressure ulcers - Answers "1 red, 2 broken, 3 deep, 4 bone" red intact skin, break with blister, deep tissue, bone visible pressure ulcers stage 1 - Answers red intact skin pressure ulcers stage 2 - Answers skin breaks & blisters; 2 layers affected (epidermis, dermis) pressure ulcers stage 3 - Answers full thickness skin loss; 3 layers affected (epi, dermis, sub-q tissue) pressure ulcers stage 4 - Answers goes down into muscle and bone; 4 layers pressure ulcers unstageable - Answers eschar (black/brown dead tissue) and slough (yellow and stringy) make it impossible to see; perform debridement pressure ulcers deep tissue - Answers purple and dead; over bony prominences; thirty degree lateral inclined position releases pressure scale used to measure risk of ulcers - Answers braden scale; 1=high risk, 4=low to none MRSA (methicillin-resistant staphylococcus aureus) - Answers "MRS. A" mask, red swelling, separate room, antibiotics (vancomycin)" MRSA precautions - Answers INSTITUTE CONTACT PRECAUTIONS: mask, gloves, gown, spreads through contact separate room MRSA prevention - Answers PPE, hand hygiene MRSA S/S - Answers red swollen area, drainage, abscess, can cause sepsis MRSA increased risk - Answers weakened immune system, extended hospital stays, surgeries MRSA Tx - Answers CULTURE WITH SENSITIVITY, antibiotics (vancomycin), topical antibiotic,