NR 224 Fundamentals Final UPDATED ACTUAL Questions and CORRECT Answers

NR224 EXAM 2 REVIEW UPDATED
ACTUAL Questions and CORRECT
Answers
How to determine Post Void Residual (PVR)?

What is it? - CORRECT ANSWER - Bladder Scan
- s/s: distension, urinary retention


What is a normal Post Void Residue?

Post residual higher than mormal? - CORRECT ANSWER - 10-15 ml
- catheter


Aspiration precaution instruction? - CORRECT ANSWER - - maintain upright position
during feeding.
- 45- 90 degree


how to determine if patient at risk for Pressure Ulcer?

- explain - CORRECT ANSWER - Braden scale <16
- less than 16 meaning at risk
- turn pt every 1-2 hr


How to assess for tolerance to Enteral Nutrition? - CORRECT ANSWER - Checking
gastric residual volume


A sign of delayed gastric emptying? - CORRECT ANSWER - gastric residual of 250-500
ml
- meaning not tolerating well
- stop feeding if greater than 500

,Checking placement of NG tube? - CORRECT ANSWER - - X Ray
- pH


pH level of stomach content - CORRECT ANSWER - <5



pH level of intestinal content? - CORRECT ANSWER - <6



pH levels of lungs? - CORRECT ANSWER - >7



what is an activity of daily living? ADL - CORRECT ANSWER - transferring



what is an instrumental activity of daily living? IADL - CORRECT ANSWER --
medication manegement
- etc....
- refer to Blooms taxonomy


Obese BMI? - CORRECT ANSWER - 30-39.9



Normal BMI? - CORRECT ANSWER - 18.5-24.9



Wound Healing Vitamins? - CORRECT ANSWER - A, C, Zinc, Protein



Vitamin A foods? - CORRECT ANSWER - - carrot
- greens
- fortified cereal
- yam

,Vitamin C foods? - CORRECT ANSWER - -oranges
- potatoes
- strawberries
- tomatoes


Zinc foods? - CORRECT ANSWER - shellfish, meats, poultry, milk and cheese, whole
grains etc...


Protein Foods - CORRECT ANSWER - Meat, fish, ,eggs, cheese, dairy products, and
poultry, beans


intervention for stage 2 pressure ulcer?

what kind of dressing? - CORRECT ANSWER - - transparent dressing



treatment for stage 2, 3 pressure ulcer - CORRECT ANSWER - - hydrogel or hydrocolloid
dressing


If we cannot see the wound bed it is? - CORRECT ANSWER - unstageable



hydro colloid - CORRECT ANSWER - A water and gelatinous material for pressure ulcer


patient gas NG tube placed to decompress the stomach before surgery, client is at highest risk
for? - CORRECT ANSWER - altered oral mucous membrane
- bc of dehydration


nurse is given pt bed bath, which action is most important? - CORRECT ANSWER -
apply breaks on bed
- pt safety

, nurse id preparing to bathe feet of client with diabetes. Which action should nurse take next? -
CORRECT ANSWER - - inspect feet for signs of impaired skin integrity daily.
- pt with diabetes make sure you inspect their feet.


Mechanical soft diet - CORRECT ANSWER - - texture has been modified
- pt with dentures, or no teeth


pureed diet - CORRECT ANSWER - - someone who has difficulty swallowing aka
dysphagia


when giving pt bed bath nurse washes client extremities from distal to proximal. which rationale
supports this action? - CORRECT ANSWER - stimulated venous return



clear liquid diet? - CORRECT ANSWER - a diet that consists of foods that are liquid at
room temperature


nurse plans to shave a male client's facial hair with razor, which should the nurse implement? -
CORRECT ANSWER - - ensure client is not receiving an anticoagulant
- bc they may start bleeding


pt with osteoporosis, which fat soluble vitamin should pt take? - CORRECT ANSWER -
D


Carbonhydrates? - CORRECT ANSWER - energy



Week 5 content - CORRECT ANSWER -



Urinary elimination assessment - CORRECT ANSWER - •Characteristics: Color, Odor,
Clarity
•Abdomen