Hondros Nur150 Exam 2 Question And Answers Verified
100% Correct
how can the nurse assess a patients skin for skin impairment - ANSWER blanching
the area
a pressure ulcer in a localized area of skin, typically over a bony prominence , that is
intact with nonblanchable redness. Areas may be painful, firm, soft, warm or cool
compared with adjacent tissue. difficult to detect in patients with dark skin tones -
ANSWER Stage 1
partial thickness loss of dermis. shallow open ulcer, usually shiny or dry, with a red-pink
wound bed without slough or bruising. some may present as serum- filled blisters -
ANSWER Stage 2
full tissue thickness loss in which subcutaneous fat is sometimes visible, but bone,
tendon, and muscle are not exposed. if slough is present it does not obscure the depth
of tissue loss. possible undermining and tunneling - ANSWER Stage 3
full thickness loss with exposed bone, tendon, or muscle. sometimes slough or eschar is
present on some parts of the wound. Includes undermining and tunneling. - ANSWER
Stage 4
which stage of pressure ulcer would put a patient at risk for osteomyelitis - ANSWER
stage 4 pressure ulcer
the true depth and stage of this ulcer can not be determined. wound bed is covered by
slough this is yellow, tan, gray, green or brown. eschar wound bed is tan, brown or
black. stable eschar on the heels provide a natural biologic cover. DO NOT REMOVE
IT! - ANSWER unstageable/unclassified
the wound appears as a localized purple or maroon area of discolored intact skin or a
blood filled blister. painful, firm, mushy, boggy, or warm to cool compared with adjacent
tissue. the wound is sometimes covered in thin eschar - ANSWER suspected deep
tissue injury
If chair bound patients are able to adjust their weight how often should they change their
position - ANSWER every 15 minutes
interventions for someone with a pressure ulcer - ANSWER nutrition ( protiens and
,vitamin c), oral intake teachings, repositioning of the patient every 2 hours in a 30
degree lateral-incline position.
intact without abrasions, warm and moist, localized changes in texture across surface,
good turgor (elastic and firm), generally smooth and soft - ANSWER characteristics of
normal skin
what should sputum not be mixed with during the specimen collection - ANSWER
saliva
a laboratory test involving cultivation of microorganisms or cells in a special growth
medium - ANSWER culture
a laboratory method of determining the effectiveness of antibiotics, usually performed in
conjunction with culture, cytologic analysis, and examination and testing for acid-fast
baccillus - ANSWER sensitivity
should you have the patient drink extra fluids the night before collecting a sputum
collection - ANSWER yes
should a wound culture sample be collected from old drainage - ANSWER NO
what are the 6 classes of essential nutrients - ANSWER carbs, fats, proteins,
vitamins, minerals and water
which nutrients play an important role in building and tissue repair - ANSWER
proteins, fat and vitamin c
a diet used as a medical treatment - ANSWER therapeutic diet
a diet that includes foods from all food groups. all meats are grounds and fruits and
vegetables are cooked and pureed. - ANSWER soft diet
what is a normal BMI - ANSWER 18.5 to 24.9
considered underweight - ANSWER BMI below 18.5
considered over weight - ANSWER 25 to 29.9
considered obese - ANSWER 30 or more
how should the treatment of obesity be like - ANSWER complex, chronic, relapsing
, disease
Are tube feeding used if the GI tract is not functioning at all? - ANSWER No
what is the most dependable means of checking the placement of a tube before feeding
or giving medications - ANSWER XRAY
Other than an Xray what is the next best way to confirm tube placement - ANSWER
checking the pH, listening for the swoosh sound, visual inspection of the gastric fluid
aspirated
what is another word for intravenous feedings - ANSWER parenteral nutrition (
hyperalimentation)
how are parenteral feedings given - ANSWER peripheral veins such as those in the
arms, legs and through a large central vein
when should you withhold a feeding - ANSWER no bowel sounds are present
normal pH of gastric contents - ANSWER 0 to 4
normal pH of the J tube - ANSWER 7 or greater
what should you do if gastric contents are above 250mL - ANSWER call the provider
should you only use 8 to 12 hours of food at a time - ANSWER yes
should you wipe the top of the can off before pouring the formula - ANSWER yes
how often should closed (premixed) systems be changed - ANSWER every 24 to 48
hours
should you wear gloves when handling a tube feeding - ANSWER yes
how high should you keep the syringe when giving a bolus feeding - ANSWER 18
inches
how often should you flush the patients tubing - ANSWER 30-60mL after each
infusion is complete or every 4 hours for a continuous drip feeding
How often should you check residual for a tube feeding - ANSWER before each
feeding or every 4 hours for a continuous drip feeding
100% Correct
how can the nurse assess a patients skin for skin impairment - ANSWER blanching
the area
a pressure ulcer in a localized area of skin, typically over a bony prominence , that is
intact with nonblanchable redness. Areas may be painful, firm, soft, warm or cool
compared with adjacent tissue. difficult to detect in patients with dark skin tones -
ANSWER Stage 1
partial thickness loss of dermis. shallow open ulcer, usually shiny or dry, with a red-pink
wound bed without slough or bruising. some may present as serum- filled blisters -
ANSWER Stage 2
full tissue thickness loss in which subcutaneous fat is sometimes visible, but bone,
tendon, and muscle are not exposed. if slough is present it does not obscure the depth
of tissue loss. possible undermining and tunneling - ANSWER Stage 3
full thickness loss with exposed bone, tendon, or muscle. sometimes slough or eschar is
present on some parts of the wound. Includes undermining and tunneling. - ANSWER
Stage 4
which stage of pressure ulcer would put a patient at risk for osteomyelitis - ANSWER
stage 4 pressure ulcer
the true depth and stage of this ulcer can not be determined. wound bed is covered by
slough this is yellow, tan, gray, green or brown. eschar wound bed is tan, brown or
black. stable eschar on the heels provide a natural biologic cover. DO NOT REMOVE
IT! - ANSWER unstageable/unclassified
the wound appears as a localized purple or maroon area of discolored intact skin or a
blood filled blister. painful, firm, mushy, boggy, or warm to cool compared with adjacent
tissue. the wound is sometimes covered in thin eschar - ANSWER suspected deep
tissue injury
If chair bound patients are able to adjust their weight how often should they change their
position - ANSWER every 15 minutes
interventions for someone with a pressure ulcer - ANSWER nutrition ( protiens and
,vitamin c), oral intake teachings, repositioning of the patient every 2 hours in a 30
degree lateral-incline position.
intact without abrasions, warm and moist, localized changes in texture across surface,
good turgor (elastic and firm), generally smooth and soft - ANSWER characteristics of
normal skin
what should sputum not be mixed with during the specimen collection - ANSWER
saliva
a laboratory test involving cultivation of microorganisms or cells in a special growth
medium - ANSWER culture
a laboratory method of determining the effectiveness of antibiotics, usually performed in
conjunction with culture, cytologic analysis, and examination and testing for acid-fast
baccillus - ANSWER sensitivity
should you have the patient drink extra fluids the night before collecting a sputum
collection - ANSWER yes
should a wound culture sample be collected from old drainage - ANSWER NO
what are the 6 classes of essential nutrients - ANSWER carbs, fats, proteins,
vitamins, minerals and water
which nutrients play an important role in building and tissue repair - ANSWER
proteins, fat and vitamin c
a diet used as a medical treatment - ANSWER therapeutic diet
a diet that includes foods from all food groups. all meats are grounds and fruits and
vegetables are cooked and pureed. - ANSWER soft diet
what is a normal BMI - ANSWER 18.5 to 24.9
considered underweight - ANSWER BMI below 18.5
considered over weight - ANSWER 25 to 29.9
considered obese - ANSWER 30 or more
how should the treatment of obesity be like - ANSWER complex, chronic, relapsing
, disease
Are tube feeding used if the GI tract is not functioning at all? - ANSWER No
what is the most dependable means of checking the placement of a tube before feeding
or giving medications - ANSWER XRAY
Other than an Xray what is the next best way to confirm tube placement - ANSWER
checking the pH, listening for the swoosh sound, visual inspection of the gastric fluid
aspirated
what is another word for intravenous feedings - ANSWER parenteral nutrition (
hyperalimentation)
how are parenteral feedings given - ANSWER peripheral veins such as those in the
arms, legs and through a large central vein
when should you withhold a feeding - ANSWER no bowel sounds are present
normal pH of gastric contents - ANSWER 0 to 4
normal pH of the J tube - ANSWER 7 or greater
what should you do if gastric contents are above 250mL - ANSWER call the provider
should you only use 8 to 12 hours of food at a time - ANSWER yes
should you wipe the top of the can off before pouring the formula - ANSWER yes
how often should closed (premixed) systems be changed - ANSWER every 24 to 48
hours
should you wear gloves when handling a tube feeding - ANSWER yes
how high should you keep the syringe when giving a bolus feeding - ANSWER 18
inches
how often should you flush the patients tubing - ANSWER 30-60mL after each
infusion is complete or every 4 hours for a continuous drip feeding
How often should you check residual for a tube feeding - ANSWER before each
feeding or every 4 hours for a continuous drip feeding
