NSG 300 EXAM 2 FULL ACTUAL TEST QUESTIONS WITH WELL DETAILED SOLUTIONS
|GRADED A+
what places patients at risk for pressure ulcers/impaired skin integrity
pressure intensity, pressure duration, tissue tolerance, impaired sensory perception,
impaired mobility, alteration in LOC, shear, friction, moisture
layers of the skin
epidermis, dermis (collagen)
BWAT tool is used for
assessing wound status
garbage cells
macrophages (ingest bacteria, dead cells, and debris from wounds)
kinetic therapy
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
portable noninvasive bladder ultrasound device
,fecal incontinence
the inability to control the passage of feces and gas through the anus
fecal impaction
collection in the rectum of hardened feces that cannot be passed due to the patient having
unrelieved constipation
constipation
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
cytoscopy
what may help determine the function of the kidneys
intravenous pyelography (IVP)
what assessment finding may indicate a problem with bowel elimination
a bowel movement every 5 days (constipation)
,what assessment finding may indicate altered bowel elimination
abdominal distention (taut/stretched abdominal skin)
ways to prevent a UTI
proper handwashing, wiping from front to back, adequate fluid intake
where does normal defecation begin
colon
normal findings in a pt. receiving enteral feedings via a small-bore nasogastric tube
-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)
-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)
A nutritional assessment designed for patients ages 65 and older.
12-14pts: normal nutritional status
8-11pts: at risk for malnutrition
>7pts: indicates malnutrition
what factor contributes to peptic ulcers
helicobacter pylori infection (enzymatic degradation of mucous layer and promote
elaboration of a cytotoxin that damages mucosal cells; may facilitate infiltration of
neutrophils/other inflammatory cells in response to bacterium's presence)
what exam may be used to examine the structure and motility of the upper GI tract
barium swallow
what exam may be used for a pt where fecal impaction is suspected
digital exam of the rectum
what exam may be used to test to measure microscopic amounts of blood in the feces
occult blood test
a hypertonic solution in an enema is best for what pt.
a pt who can't tolerate a large volume of fluid
|GRADED A+
what places patients at risk for pressure ulcers/impaired skin integrity
pressure intensity, pressure duration, tissue tolerance, impaired sensory perception,
impaired mobility, alteration in LOC, shear, friction, moisture
layers of the skin
epidermis, dermis (collagen)
BWAT tool is used for
assessing wound status
garbage cells
macrophages (ingest bacteria, dead cells, and debris from wounds)
kinetic therapy
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
portable noninvasive bladder ultrasound device
,fecal incontinence
the inability to control the passage of feces and gas through the anus
fecal impaction
collection in the rectum of hardened feces that cannot be passed due to the patient having
unrelieved constipation
constipation
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
cytoscopy
what may help determine the function of the kidneys
intravenous pyelography (IVP)
what assessment finding may indicate a problem with bowel elimination
a bowel movement every 5 days (constipation)
,what assessment finding may indicate altered bowel elimination
abdominal distention (taut/stretched abdominal skin)
ways to prevent a UTI
proper handwashing, wiping from front to back, adequate fluid intake
where does normal defecation begin
colon
normal findings in a pt. receiving enteral feedings via a small-bore nasogastric tube
-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)
-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)
A nutritional assessment designed for patients ages 65 and older.
12-14pts: normal nutritional status
8-11pts: at risk for malnutrition
>7pts: indicates malnutrition
what factor contributes to peptic ulcers
helicobacter pylori infection (enzymatic degradation of mucous layer and promote
elaboration of a cytotoxin that damages mucosal cells; may facilitate infiltration of
neutrophils/other inflammatory cells in response to bacterium's presence)
what exam may be used to examine the structure and motility of the upper GI tract
barium swallow
what exam may be used for a pt where fecal impaction is suspected
digital exam of the rectum
what exam may be used to test to measure microscopic amounts of blood in the feces
occult blood test
a hypertonic solution in an enema is best for what pt.
a pt who can't tolerate a large volume of fluid
