HONDROS NUR150 EXAM 2 WITH QUESTIONS AND ANSWERS (VERIFIED ANSWERS) LATEST UPDATE

HONDROS NUR150 EXAM 2 WITH QUESTIONS AND ANSWERS (VERIFIED ANSWERS) LATEST UPDATE Cold therapy - CORRECT ANS decreases edema, muscle spasms, pain Hot therapy - CORRECT ANS Increases circulation, blood flow when is cold therapy recommended for an injury - CORRECT ANS first 24 to 48 hours whose responsibility is it to evaluate proper application, adverse signs and symptoms and is also responsible for the patient's safety - CORRECT ANS LPN where should you not apply a cold pack to - CORRECT ANS red or blue areas how often should you check the skin of a patient who is using an electrical cooling device or an electrical heating device - CORRECT ANS every 5 minutes what are common symptoms when using an electrical cooling device - CORRECT ANS numbness and tingling How long should you leave a cooling device in place - CORRECT ANS 15 to 20 minutes what are some adverse skin reactions when using a cooling device - CORRECT ANS mottling, redness, burning, blistering and numbness what should you record when using a cooling device or heating device - CORRECT ANS what device you used, location, duration, patient response, patient teaching and patients response to teaching when should you immediately stop application of a cooling device - CORRECT ANS areas become mottled, red or blue/purple, or if the patient Is complaining of pain/numbness when should you immediately stop application of a heating device - CORRECT ANS skin becomes reddened and sensitive to touch, extreme warmth noted at the area, and body part becomes painful to move How long should you leave the heating device in place - CORRECT ANS 20 to 30 minutes or as prescribed whose responsibility is it to assess skin areas prior to applications of heating and cooling device and assess for risks - CORRECT ANS LPN what is one of the nurse's highest priority of care - CORRECT ANS prevention and treatment of skin impairment how often should you reposition a chair bound patient - CORRECT ANS every hour how often should you reposition a patient that is bed bound - CORRECT ANS every 2 hours at a 30 degree angle whose responsibility is it to properly collect a culture of the pressure ulcer - CORRECT ANS nurse how do you properly label a specimen - CORRECT ANS patients name, medical record number, date of birth, date and time of collection, what the collection is for, your name and initials. send as quickly as possible to the lab what are anaerobic collections of - CORRECT ANS inside of body cavities what are aerobic collections of - CORRECT ANS wound secretions What occurs when the tissue layers of skin slide on each other , causing subcutaneous blood vessels to kink or stretch resulting in an interruption of blood flow to the skin - CORRECT ANS shearing force What is the rubbing of skin against another surface produces what - CORRECT ANS friction what are the 2 mechanical factors that play a common role in the development of pressure ulcers - CORRECT ANS shearing force and friction which patients are at risk for pressure ulcers - CORRECT ANS chronically ill, debilitated, older, disabled, or incontinent patients, patients with spinal cord injuries, circulatory impairment or poor overall nutrition how can the nurse assess a patients skin for skin impairment - CORRECT ANS blanching the area Wound Stage 1 - CORRECT ANS over a bony prominence , that is intact with nonblanchable redness. Warm to touch 1hr of sitting Wound Stage 2 - CORRECT ANS partial thickness skin loss w/ serous drainage may present as serum- filled blisters clear 2hr bed bound Wound Stage 3 - CORRECT ANS full tissue thickness loss subcutaneous fat is sometimes visible, but bone, tendon, and muscle are not exposed Wound Stage 4 - CORRECT ANS full thickness loss with exposed bone, tendon, or muscle. sometimes slough or eschar is present on some parts of the wound tunneling 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. - CORRECT ANS unstageable/unclassified the wound appears as a localized purple or maroon area of discolored intact skin or a blood filled blister shiny. painful, firm, mushy, boggy, or warm to cool compared with adjacent tissue. the wound is sometimes covered in thin eschar - CORRECT ANS deep tissue injury interventions for someone with a pressure ulcer - CORRECT ANS 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 - CORRECT ANS characteristics of normal skin NEVER COLLECT A WOUND SPECIMEN FROM - CORRECT ANS Old wound drainage If a patient is incontinent applying what will prevent skin breakdown - CORRECT ANS Moisture skin sealant barrier what should sputum not be mixed with during the specimen collection - CORRECT ANS saliva What test is used to determine infection - CORRECT ANS C&S should you have the patient drink extra fluids the night before collecting a sputum collection - CORRECT ANS yes should a wound culture sample be collected from old drainage - CORRECT ANS NO what are the 6 classes of essential nutrients - CORRECT ANS carbs, fats, proteins, vitamins, minerals and water which nutrients play an important role in building and tissue repair - CORRECT ANS proteins, fat and vitamin c what does dietary fiber help with - CORRECT ANS lowers cholesterol, glucose levels and helps with weight loss oat bran, barley, nuts, seeds, citrus, apples, strawberries, and many vegetables are what - CORRECT ANS soluble fibers whole wheat and grains, vegetables and wheat bran are what - CORRECT ANS insoluble fibers inability to absorb B12 vitamin - CORRECT ANS pernicious anemia a diet used as a medical treatment - CORRECT ANS therapeutic diet liquid diet that is non irritating and consists of liquids that are easily digested and leave little residue in the GI tract. used for 2-3 days or less. you can drink any type of liquid you can see through, broth, apple sauce, plain gelatin, tea and black coffee. usually given every 2-3 hours - CORRECT ANS clear liquid diet Mild dysphasia liquid diet - CORRECT ANS Nectar a little slower off the spoon than water can't be sipped from a cup Moderate dysphasia liquid diet - CORRECT ANS Honey, much slower off the spoon than water consumed with a spoon, but still retain liquid texture Severe dysphasia liquid diet - CORRECT ANS Do not drip off the spoon putting extra thick consistency needs a spoon to eat with Dysphasia advanced diet - CORRECT ANS Moist and soft foods such as cooked cereals, canned fruit, well cooked noodles in sauce Puréed dysphasia diet - CORRECT ANS Hot cereals, mashed potatoes, certain meats, vegetables, and pasta and pudding, consistency yogurt Mechanical, soft dysphasia diet - CORRECT ANS Moist braids, well moisten cereal, tender/thin, sliced meats, baked potato Diets that are used for people with conditions affecting the GI tract such as acute diverticulitis, IBS, gastritis, esophageal varices and during periods of indigestion and diarrhea - CORRECT ANS soft and low residue diets a diet that includes foods from all food groups. all meats are grounds and fruits and vegetables are cooked and pureed. - CORRECT ANS soft diet what is a normal BMI - CORRECT ANS 18.5 to 24.9 considered underweight - CORRECT ANS BMI below 18.5 considered over weight - CORRECT ANS 25 to 29.9 considered obese - CORRECT ANS 30 or more how should the treatment of obesity be like - CORRECT ANS complex, chronic, relapsing disease Are tube feeding used if the GI tract is not functioning at all? - CORRECT ANS No where can ostomies be placed - CORRECT ANS esophagus, stomach and the jernunum a continuous feeding is usually given over how many hours? - CORRECT ANS 16 to 24 a specific volume of formula given over a short period of time usually 20 to 30 minutes. done 4 to 6 times daily - CORRECT ANS intermittent feeding 4 to 6 hour volume of formula is administered in a matter or minutes - CORRECT ANS bolus feeding what is the most dependable means of checking the placement of a tube before feeding or giving medications - CORRECT ANS XRAY Primary prevention - CORRECT ANS Exercise, optimal nutrition,social activity, vaccines. Rule out Secondary prevention (screening) - CORRECT ANS Check BP, using assessment and obtaining lab work . Detect 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 If residual greater than notify health care provider to determine - CORRECT ANS 150ml During tube feeding what do u do to prevent fluid and electrolyte imbalances - CORRECT ANS Aspirate residual, measure amount, then return residual Always administer formula at room temperature never cold true or false - ANSWER : True After administering the feed, patient should remain in the Fowler position for how many minutes - CORRECT ANS 30 How much should you flush the NG tube with? - CORRECT ANS 30ml water NG tube feeding sequence - CORRECT ANS Check placement, check residual, flush, administer tube feed, flush You must give pill separately and flush between each pill true or false - CORRECT ANS True Where does measurement for the NG tube start at? - CORRECT ANS The nose what is another word for intravenous feedings - CORRECT ANS parenteral nutrition ( hyperalimentation) how are parenteral feedings given - CORRECT ANS peripheral veins such as those in the arms, legs and through a large central vein when should you withhold a feeding - CORRECT ANS no bowel sounds are present normal pH of gastric contents - CORRECT ANS 0 to 4 normal pH of the J tube - CORRECT ANS 7 or greater what should you do if gastric contents are above 150mL - CORRECT ANS call the provider should you only use 8 to 12 hours of food at a time - CORRECT ANS yes should you wipe the top of the can off before pouring the formula - CORRECT ANS yes how often should closed (premixed) systems be changed - CORRECT ANS every 24 to 48 hours should you wear gloves when handling a tube feeding - CORRECT ANS yes how high should you keep the syringe when giving a bolus feeding - CORRECT ANS 18 inches how often should you flush the patients tubing - CORRECT ANS 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 - CORRECT ANS before each feeding or every 4 hours for a continuous drip feeding How can you provide a comfortable eating atmosphere for a patient - CORRECT ANS remove unpleasant odors or equipment, place patient in a comfortable upright position, provide oral hygiene, allow patient to wash hands and face, provide for prayer if indicated and assess patients need for pain medication and use of bathroom how should you describe the food on a tray to a patient who is visually impaired - ANSWER : like the hands on the clock how should you direct food for a patient who has had a stroke - CORRECT ANS towards side of the mouth not affected by the stroke what position should you put the patient in before feeding them - CORRECT ANS high fowlers (90 degree) what are some signs of dysphagia - CORRECT ANS coughing, dyspnea and drooling how many times should you have the patient swallow before the next bite - ANSWER : 2 times how long should the patient sit upright for after a meal or tube feeding - CORRECT ANS 30-60 minutes what do basic active daily living skills consist of - CORRECT ANS bathing, toileting, ambulating, personal hygiene, dressing what do instrumental daily living skills consist of - CORRECT ANS managing money, using the telephone, taking medications, shopping, driving what are the categories of functional ability - CORRECT ANS physical domain, psychosocial domain, cognitive domain, social domain what are the assessment components that fall under the physical domain - ANSWER : nutrition, hearing, vision, mobility, incontinence, fall history, home environment what are the assessment components that fall under the psychological domain - ANSWER : affect, hearing, mobility, vision, incontinence what are the assessment components that fall under the cognition domain - CORRECT ANS cognition, incontinence, vision, hearing, mobility, fall history what are the assessment components that fall under the social domain - CORRECT ANS social participation, vision, hearing, incontinence, home environment, mobility what are some risk factors for impaired functional ability - CORRECT ANS age, cultural factors, lifestyle ( fall risk, cleanliness, drug use, do they live alone, level of depression, level of cognition, not asking for help, chronic disease what are some ways to reduce the risk factors of functional ability - CORRECT ANS exercise, eat better ( nutrition), routine check ups, engage in meaningful activities ( things they like to do), avoid tobacco, alcohol and other recreational drugs a deficiency in this vitamin could cause heart problems - CORRECT ANS potassium a deficiency in this vitamin could cause brittle bones - CORRECT ANS calcium a deficiency in this vitamin could cause nausea, muscle weakness - CORRECT ANS magnesium a deficiency in this vitamin could cause dizziness and light headedness - CORRECT ANS sodium a deficiency in this vitamin could cause goiters, low blood counts and risk for anemia - CORRECT ANS iron what are the functions of proteins - CORRECT ANS wound healing, tissue growth and repair, building bocks for blood and bone, builds connective tissue