NSG 300 Exam 2 from Grand Canyon University
(GCU) includes accurate and verified questions
covering foundational nursing concepts such as the
nursing process, critical thinking, patient safety,
communication, evidence based practice
what is an early indication of pressure that resolves without tissue loss
if pressure is eliminated - ****answer***blanchable erythema
sign of persistent hypoxia - ****answer***pallor or molting
assessing development of pressure injuries in darker skinned individuals
- ****answer***-blanching is not distinctly visible
-differentiate skin color changes to baseline skin color
-use GNASC tool
shear injury - ****answer***underlying muscle and tissue are involved.
presents as necrosis in deep tissues with intact skin; shear force: sliding
movement of skin and subcutaneous tissue while underlying muscles
and bones remain stationary
,friction injury - ****answer***epidermis of skin is affected. presents as
denuded epidermis and torn skin (redness and pain); frictional force:
force between 2 surfaces moving against each other when patient is
being transferred (skin and bedsheet)
GNASC tool is used for - ****answer***stage 1 pressure ulcers on dark
skinned individuals
BWAT tool is used for - ****answer***assessing wound status
garbage cells - ****answer***macrophages (ingest bacteria, dead cells,
and debris from wounds)
kinetic therapy - ****answer***Provides continuous passive motion to
promote mobilization of pulmonary secretions and low air loss and
provides pressure redistribution (for pt with acute respiratory
conditions)
what device is used to assess PVR - ****answer***portable
noninvasive bladder ultrasound device
fecal incontinence - ****answer***the inability to control the passage
of feces and gas through the anus
,fecal impaction - ****answer***collection in the rectum of hardened
feces that cannot be passed due to the patient having unrelieved
constipation
constipation - ****answer***infrequent bowel movements (less than
3/week); may be caused by improper diet, reduced fluid intake, lack of
exercise and certain meds (opioid analgesics)
what device helps visualize the structures of the urinary tract -
****answer***cytoscopy
what may help determine the function of the kidneys -
****answer***intravenous pyelography (IVP)
what assessment finding may indicate a problem with bowel
elimination - ****answer***a bowel movement every 5 days
(constipation)
what assessment finding may indicate altered bowel elimination -
****answer***abdominal distention (taut/stretched abdominal skin)
ways to prevent a UTI - ****answer***proper handwashing, wiping
from front to back, adequate fluid intake
, where does normal defecation begin - ****answer***colon
normal findings in a pt. receiving enteral feedings via a small-bore
nasogastric tube - ****answer***-gastric pH of 4.0 during placement
check
-weight gain of 1 pound in a week
-active bowel sounds in all 4 quadrants
North American Summit on Aspiration in the Critically Ill Patient
recommendations for gastric residual volumes (GRVs) - ****answer***-
stop feeding immediately if aspiration occurs
-withhold feedings and reassess pt tolerance to feedings if over 500mL
for 2 successive measurements
-routinely evaluate the pt for aspiration and use nursing measures to
reduce the risk of aspiration if GRV is between 250-500mL
Mini Nutritional Assessment (MNA) - ****answer***A nutritional
assessment designed for patients ages 65 and older.
12-14pts: normal nutritional status
8-11pts: at risk for malnutrition
>7pts: indicates malnutrition
(GCU) includes accurate and verified questions
covering foundational nursing concepts such as the
nursing process, critical thinking, patient safety,
communication, evidence based practice
what is an early indication of pressure that resolves without tissue loss
if pressure is eliminated - ****answer***blanchable erythema
sign of persistent hypoxia - ****answer***pallor or molting
assessing development of pressure injuries in darker skinned individuals
- ****answer***-blanching is not distinctly visible
-differentiate skin color changes to baseline skin color
-use GNASC tool
shear injury - ****answer***underlying muscle and tissue are involved.
presents as necrosis in deep tissues with intact skin; shear force: sliding
movement of skin and subcutaneous tissue while underlying muscles
and bones remain stationary
,friction injury - ****answer***epidermis of skin is affected. presents as
denuded epidermis and torn skin (redness and pain); frictional force:
force between 2 surfaces moving against each other when patient is
being transferred (skin and bedsheet)
GNASC tool is used for - ****answer***stage 1 pressure ulcers on dark
skinned individuals
BWAT tool is used for - ****answer***assessing wound status
garbage cells - ****answer***macrophages (ingest bacteria, dead cells,
and debris from wounds)
kinetic therapy - ****answer***Provides continuous passive motion to
promote mobilization of pulmonary secretions and low air loss and
provides pressure redistribution (for pt with acute respiratory
conditions)
what device is used to assess PVR - ****answer***portable
noninvasive bladder ultrasound device
fecal incontinence - ****answer***the inability to control the passage
of feces and gas through the anus
,fecal impaction - ****answer***collection in the rectum of hardened
feces that cannot be passed due to the patient having unrelieved
constipation
constipation - ****answer***infrequent bowel movements (less than
3/week); may be caused by improper diet, reduced fluid intake, lack of
exercise and certain meds (opioid analgesics)
what device helps visualize the structures of the urinary tract -
****answer***cytoscopy
what may help determine the function of the kidneys -
****answer***intravenous pyelography (IVP)
what assessment finding may indicate a problem with bowel
elimination - ****answer***a bowel movement every 5 days
(constipation)
what assessment finding may indicate altered bowel elimination -
****answer***abdominal distention (taut/stretched abdominal skin)
ways to prevent a UTI - ****answer***proper handwashing, wiping
from front to back, adequate fluid intake
, where does normal defecation begin - ****answer***colon
normal findings in a pt. receiving enteral feedings via a small-bore
nasogastric tube - ****answer***-gastric pH of 4.0 during placement
check
-weight gain of 1 pound in a week
-active bowel sounds in all 4 quadrants
North American Summit on Aspiration in the Critically Ill Patient
recommendations for gastric residual volumes (GRVs) - ****answer***-
stop feeding immediately if aspiration occurs
-withhold feedings and reassess pt tolerance to feedings if over 500mL
for 2 successive measurements
-routinely evaluate the pt for aspiration and use nursing measures to
reduce the risk of aspiration if GRV is between 250-500mL
Mini Nutritional Assessment (MNA) - ****answer***A nutritional
assessment designed for patients ages 65 and older.
12-14pts: normal nutritional status
8-11pts: at risk for malnutrition
>7pts: indicates malnutrition
