Nursing Fundamentals Quiz

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Questions and Answers

What is a key consideration when using restraints on a client?

They can only be applied with a nurse's order.

They must be checked every 15-30 minutes. (correct)

The client cannot refuse their use.

Restraints can be used as a first-line intervention.

Which statement is true about the use of oxygen in patients with chronic respiratory illnesses?

It is common to apply grease around oxygen equipment.

Long-term use of oxygen does not need humidification.

Oxygen is ordered in Liters per minute. (correct)

They typically require higher settings of O2 delivery.

What is the primary intention of wound healing?

Healing through secondary intention.

Healing with tissue loss.

Healing without complication. (correct)

Healing that involves granulation tissue.

When using a lift to aid a client, what should be done first?

Lock the wheels of the lift. Signup and view all the answers

What is an important safety measure regarding oxygen usage?

Never use oil or grease around oxygen. Signup and view all the answers

What is the primary purpose of monitoring the access site post procedure?

To check for bleeding and vital signs Signup and view all the answers

Which of the following laboratory values indicates a normal white blood cell (WBC) count?

5,000-10,000 cells/mcL Signup and view all the answers

What is the therapeutic range for APTT when monitoring Heparin therapy?

1.5-2.5 times the control Signup and view all the answers

What should be the position of the patient during a thoracentesis procedure?

Sitting upright with arms supported Signup and view all the answers

Which of the following tests requires patients to be NPO (nothing by mouth)?

Hepatic function tests Signup and view all the answers

What is the normal fasting blood sugar level range?

60-110 mg/dl Signup and view all the answers

Which hematology value indicates a normal platelet count?

150,000-400,000 Signup and view all the answers

What is the significance of the international normalized ratio (INR)?

Monitors Coumadin therapy effectiveness Signup and view all the answers

What is the proper method for administering a bolus in enteral feeding?

Administer by gravity. Signup and view all the answers

What should be monitored to assess a patient's response to pain management?

Pain level before and after medication. Signup and view all the answers

Which of the following is NOT part of the nursing responsibility when obtaining consent?

Obtaining the patient’s permission for unrelated procedures. Signup and view all the answers

Which soap application guideline is appropriate while bathing a patient?

Soap should be rinsed completely from the body. Signup and view all the answers

Which statement about weight monitoring is correct?

Same scale, clothing, and time must be maintained for consistency. Signup and view all the answers

What defines assault in a healthcare context?

Threat of bodily harm without physical contact. Signup and view all the answers

What must a nurse always assess before administering medication?

Allergies and prior reactions. Signup and view all the answers

Which type of law involves wrongs against individuals or property?

Civil law, specifically torts. Signup and view all the answers

What is the maximum liter flow for a nasal cannula?

6 liters Signup and view all the answers

Which type of face mask delivers the most precise amounts of oxygen?

Venturi mask Signup and view all the answers

What is a key feature of an oxygen tent?

It requires constant monitoring of oxygen flow rate. Signup and view all the answers

What is a common sign of oxygen toxicity?

Non-productive cough Signup and view all the answers

Which of the following is a method to prevent transmission of pathogens?

Wearing a mask whenever appropriate Signup and view all the answers

What should be used when collecting a mid-stream urine sample?

Void a little, then collect urine Signup and view all the answers

Which is NOT a type of face mask mentioned?

Reflex Signup and view all the answers

What should be monitored after the administration of a dye in certain tests?

Respiratory difficulties Signup and view all the answers

How often should vital signs be monitored post procedure after certain tests?

Every 30 minutes Signup and view all the answers

Which of the following is a requirement before performing a non-invasive test?

Jewelry or metal must be removed Signup and view all the answers

What is required in the handling and processing of a venipuncture?

Apply no pressure before removing the needle Signup and view all the answers

Which oxygentation method allows for the highest concentration of oxygen?

Ambu bag Signup and view all the answers

What measure should be taken to ensure effective skin care around the nares when using a nasal cannula?

Apply water-soluble lubricant Signup and view all the answers

What precaution should be taken when using a hyperbaric chamber?

Ensure the chamber is airtight Signup and view all the answers

Which of the following is NOT a client right?

Right to education Signup and view all the answers

What must be proven to establish negligence in a healthcare context?

Proximate cause of injury Signup and view all the answers

Which group is specifically defined as unlicensed personnel to whom nursing tasks can be delegated?

Unlicensed Assistive Personnel (UAP) Signup and view all the answers

In the delegation process, what is the primary responsibility of the nurse?

To ensure communication and evaluation Signup and view all the answers

Which medication has a therapeutic drug level of 0.8-2.0 ng/ml and is associated with risk of toxicity?

Digoxin Signup and view all the answers

What is a common side effect of nitrates?

Hallmark headache Signup and view all the answers

Which of the following calcium channel blockers is commonly used to treat hypertension?

Diltiazem HCL Signup and view all the answers

What should be monitored when a patient is taking digoxin?

Potassium levels Signup and view all the answers

Which medication classes can lead to hypotension as a side effect?

Beta-blockers and calcium channel blockers Signup and view all the answers

What is a necessary precaution when taking SL nitroglycerin for angina?

Call a doctor if pain persists after three doses Signup and view all the answers

What side effect could commonly result from the use of anti-adrenergic drugs?

Dry mouth Signup and view all the answers

Which of the following drugs is used specifically for managing hypertensive emergencies?

Nitropress Signup and view all the answers

What is an important guideline to follow regarding the administration of antihypertensive medications?

Take blood pressure before administering Signup and view all the answers

What adverse effect is commonly associated with the use of cardiac glycosides?

Visual disturbances Signup and view all the answers

Why is it important to monitor potassium levels in patients taking digoxin?

Low potassium levels can increase the risk of digoxin toxicity. Signup and view all the answers

What is the recommended therapeutic drug level range for digoxin?

0.8-2.0 ng/mL Signup and view all the answers

Which of the following is a common side effect of nitrates?

Headache Signup and view all the answers

What is the primary action of calcium channel blockers in cardiovascular therapy?

Slow conduction and dilate coronary arteries Signup and view all the answers

With nitroglycerin administration, what should a patient do if chest pain persists after taking three tablets?

Call the physician immediately. Signup and view all the answers

What is a critical safety guideline regarding the storage of nitroglycerin?

Keep in a brown bottle. Signup and view all the answers

Which class of antihypertensive medications is associated with water retention and nasal congestion as adverse effects?

Peripheral Vasodilators Signup and view all the answers

What symptom indicates possible digoxin toxicity in a patient?

Green/yellow visual disturbances Signup and view all the answers

Which medication is specifically indicated for the treatment of hypertensive emergencies?

Nitroglycerin Signup and view all the answers

Which adverse effect is commonly associated with centrally acting antiadrenergic drugs?

Fluid retention Signup and view all the answers

What is a potential adverse effect of angiotensin II receptor antagonists?

Abdominal pain Signup and view all the answers

What is a crucial nursing consideration before administering antihypertensive medication?

Take the blood pressure Signup and view all the answers

Which symptom should a patient report while receiving antihypertensive therapy to avoid complications?

Dizziness Signup and view all the answers

What common adverse effect should a patient on ACE inhibitors be made aware of?

Cough Signup and view all the answers

What adverse effect is least likely associated with peripheral antiadrenergic drugs?

Sedation Signup and view all the answers

Which of the following is not typically considered an adverse effect of antihypertensive medications?

Increased respiratory rate Signup and view all the answers

Which statement reflects appropriate patient teaching for a person newly prescribed antihypertensive medication?

It is important to attend all follow-up appointments. Signup and view all the answers

What is an essential precaution regarding the administration of antihypertensive medications?

Dangle the patient's legs before standing Signup and view all the answers

What approach should a nurse take when a patient is prescribed hypertensive emergency medications?

Monitor for severe adverse effects Signup and view all the answers

Study Notes

Restraints

Doctor's order required
Least restrictive method used first
Not a first line intervention
Check every 15-30 mins, release every 2 hours
Signs consent
Check circulation distal to restraints
Client can refuse
Notify doctor if client refuses
Document refusal

Mechanical Lifts

Lock before using
Base of lift spread
Client in center of sling
Get training and help

Transfer Beds

Lock wheels
Place closest to client's stronger side
Don't secure tubing to movable parts

Oxygen Therapy

Odorless, colorless, non-flammable gas (supports combustion)
Flow meter regulates O2 rate; FiO2 is concentration percentage
Usually ordered in L/min
Chronic respiratory illnesses require lower settings of O2 delivery, no more than 1-2 L/M
Long term use requires humidification
No smoking allowed, know extinguisher locations
No oil, grease or flammable items near O2
Breath sounds q shift, O2 sats q 4 hours

Nasal Cannula

Documented as BNP or BNC
Fits into nares
Concentrations of 24-44%, no more than 6 L/M
Turn O2 on before placing on patient
Tubing goes over ears
Nares care with water soluble lubricant

Face Mask

Allows more control of O2 levels
Concentrations 60-100% (6-10 L/M) depending on L/M
Mist should be visible with humidified O2
Mask fits snug over nose and chin
Reservoir should not completely collapse
Types: Venturi, Non-rebreather, Simple

Oxygen Tent

Fine mist, constant temperature, high concentration
Canopy encloses upper torso
Keep patient dry and prevent chilling, change linens frequently
Temperature inside should be 70°
Adjust O2 flow to 10-12 L/M
Tuck sides of canopy under mattress

Hyperbaric Chamber

Delivers 100% O2 at 3 times atmospheric pressure
Faster tissue regeneration

Ambu Bag

Up to 100% concentration depending on reservoir
Mask seals tightly over mouth and nose
Breath delivered every 5 seconds
Ambu bag can be attached to ET tube

O2 Toxicity

Concentrations greater than 50% for more than 24-48 hours
Non-productive cough
Substernal chest pain
Nasal stuffiness
Nausea/vomiting
Fatigue
Headache
Sore throat
Hypoventilation

RACE

Rescue
Alarm
Contain
Extinguish

PASS

Pull
Aim
Squeeze
Sweep

Home Safety

Monitor at-risk individuals more closely
Use call lights, brakes, and side rails appropriately
Teach home safety

Infection Control

Handwashing is the most important way to prevent transmission
Isolation depends on how the pathogen is spread
Cycle of infection: Pathogen, reservoir, portal of exit, mode of transport, portal of entry, host

Sterile Technique

Sterile to sterile only
When in doubt, it is contaminated

Charting

Factual, subjective, and objective
Accurate, concise, pertinent
Complete and current
Organized and timely
Approved symbols/abbreviations
Correct spelling and English
Documentation is about client and their condition
Good penmanship and punctuation
Ink only, single line through errors

Communication

Verbal - includes spoken and written
Nonverbal - check for congruency
No false hopes or cliches
Acknowledge client's feelings/concerns
Special situations: Confused/agitated, blind, hearing impaired

X-Ray

Non-invasive
No prep required
No consent form required
Determine pregnancy
Remove jewelry and metal from area
Hold breath during procedure

Bone Marrow Aspiration

Consent required
CBC prior to test
Local anesthetic needed
Iliac crest most common site
Pressure dressing applied, watch for bleeding, signs of shock
Tenderness at site expected

Intravenous Pyelogram (IVP) - Kidneys

Check allergy to iodine
Do before barium studies
NPO after midnight
May require laxative pre-test
Force fluids post test
Consent usually obtained by Radiology
Respiratory difficulty after dye injection may indicate anaphylactic reaction

Arteriogram

Consent required
Assess allergies
Keep client flat 8 hours post-test with affected extremity extended
Force fluids post-test
Monitor insertion site for bleeding
Do not remove pressure from site
Renal arteriogram, lung scan, and femoral angiogram

Venipuncture

Explain procedure
Protect yourself
Get help as indicated
Clean skin appropriately
Correct collection tube and order of draw
Release tourniquet before removing needle
Apply pressure to site post test

Endoscopic Procedures

Lighted instrument to view internal structures
All require NPO post-midnight and consent
Bowel prep for colonoscopy
NPO after midnight for bronchoscopy and EGD until gag and swallow returned
Vital signs post procedure every 30 mins until stable
Monitor for respiratory distress with bronchoscopy
Monitor for bleeding if polyps are removed (colon)

Urine Specimen Collection

Don't touch inside of container
Label container, not the top
Mid-stream - clean, void a little, then collect
Sterile - only real way is to catheterize
If C&S and antibiotics are ordered, collect specimen first
24-hour urine - discard first, keep last and every amount in between, keep on ice

Invasive Procedures

Sterile procedure performed by provider
Informed consent
Position according to procedure
Monitor access site for bleeding and VS
Monitor for respiratory distress or breath sounds with thoracentesis or hemoptysis
Empty bladder with paracentesis and amniocentesis

Ultrasound

Sound waves bounce off solid structures to produce an image
Must be done before Barium studies or after post-Barium laxative
Non-invasive
Most patients must be NPO except for echocardiogram and pelvic

Complete Blood Count (CBC)

No special prep
WBC 5,000-10,000: Neutrophils, Basophils, Monocytes, Eosinophils, Lymphocytes
RBC - 4.2-6.1 million (males), 4.2-5.4 million (females)
HCT: 42-52% (males), 37-47% (females)
Hgb: 14-18 g/100 mL (males), 12-16 g/100mL (females)
Platelets: 150,000-400,000

Coagulation Studies

APTT: Used to monitor Heparin therapy, therapeutic range 1.5-2.5 times control
PT: Used to monitor Coumadin therapy, therapeutic range 1.5-2.0 times control
INR used with PT for clients on Coumadin, therapeutic range 2.0-3.0

Blood Glucose

60-110 mg/dL (normal fasting levels)
No special prep unless ordered fasting, then NPO overnight
Fasting, Accuchek, Post-prandial

Glycosylated Hemoglobin

Gives accurate picture of blood sugar levels over previous 120 days
Can be drawn at any time, no prep needed
Elevated with diabetes mellitus
Normal values: Adult 4-7%, Child 1.8-4%, Poor diabetic control 10-20%

Gastric Tube Feeding

Recheck blood sugar frequently, hold for more than 100 mL unless otherwise ordered
Return residual to stomach
Flush before and after
Give bolus by gravity
Monitor weight, breath sounds, I & O

Bathing

No soap on face unless requested
Rinse all soap from body
Dry by patting
Use long strokes toward heart

Assessments

Includes pain and weight
Know normal values
Weights: Same scale, clothing, and time of day
Pain: Always assess before and after medication; vital signs (except temp) are usually elevated with acute pain, narcotics more likely for acute pain; believe the patient

Med Administration

6 rights: Right patient, drug, dose, route, time, documentation
Verify order
Routes affect absorption
Assess for allergies
Instruct on drug, dose, route, purpose, special instructions
Life threatening allergic reactions

Physician discusses risks, benefits, etc.
Nurse witnesses signature
Ensure questions are answered before signing
Usually with invasive procedures

Incident Reports

No report in nursing notes
Documents unusual events
Factual information only

Legal and Ethical Concepts

Assault - intentional threat of bodily harm
Battery - unlawful touching without consent
Defamation: Slander (spoken), Libel (written)
Tort - civil law concerning wrongs against a person or property

Client Rights

Privacy and confidentiality
Right to information
Right to refuse treatment
Right to adequate and competent care
Right to have bill explained
Right to confidentiality

Delegation

Transferring authority to a competent individual to perform a task
Accountability - responsible for actions of oneself or others
Unlicensed Assistive Personnel (UAP) - any unlicensed personnel to whom nursing tasks are delegated
Supervision

The Nursing Process

Assessing
Diagnosing
Planning
Implementing
Evaluating

Five Rights of Delegation

Right task
Right circumstances
Right person
Right direction/communication
Right supervision/evaluation

Delegation - General Principles

Clear instructions initially and for periodic reassessment
RNs can delegate to RNs, LPNs, and AP
LPNs can delegate to LPNs and AP
Only delegate tasks appropriate to educational level.
RNs cannot delegate nursing process, client education, or tasks requiring nursing judgment

Factors Affecting Delegation

Predictability of outcome
Potential for harm
Complexity of care
Need for problem-solving
Level of interaction with the client

Delegation - Factors Determining Competence

Education, training, experience
Knowledge and skill to perform task
Level of critical thinking needed
Communication ability
Demonstrated competence
Facility policies and procedures
Licensing legislation

Cardiac Medications

Positive inotropic activity (increases force of myocardial contraction)
Negative chronotropic effect (slows conduction and decreases heart rate)
Uses: Heart failure, atrial fibrillation

Cardiac Glycosides

Side effects: Headache, weakness, drowsiness, visual disturbances, arrhythmias, GI upset, anorexia
Lanoxin (digoxin): Loading dose, therapeutic level 0.8-2.0 ng/mL; toxicity green/yellow visual disturbances, anorexia, nausea, vomiting, changes in cardiac function; monitor potassium levels; Antidote digibind (digoxin immune)
Primacor (milrinone lactate): IV only

Vasodilators

Nitrates: Relax smooth muscles (vessels) increasing blood flow to myocardium
Calcium Channel Blockers: Slow conduction, dilate coronary arteries, depress contractility of the heart

Nitrates

Uses: Relieve angina pain, prevention of anginal attacks, treatment of chronic stable angina
Side effects: Headache, dizziness, weakness, hypotension, flushing
Examples: ISMO, Imdur (isosorbide mononitrate), Isordil (isosorbide dinitrate), Nitro-Bid, Nitrostat (nitroglycerin)

Calcium Channel Blockers

Uses: Anginal pain, hypertension
Side effects: Dizziness, lightheadedness, fatigue, nausea, constipation, peripheral edema, hypotension, bradycardia, nasal congestion, cough
Examples: Norvasc (amlodipine), Cardizem (diltiazem HCL), Plendil (felodipine), Cardene (nicardipine HCL), Procardia, Adalat (nifedipine), Calan, Isoptin (verapamil HCL)

Nitroglycerin Admin

Give SL nitroglycerin 1 tablet every 5 minutes x3, call doctor if pain persists
Monitor VS, take apical pulse
Protect safety
Monitor and document chest pain

Nitroglycerin Safety

New bottle every 3 months
Keep in brown bottle
Rise slowly from lying or sitting position
Nitro should tingle or sting when used
Rotate patch sites, remove old
Keep with you at all times

Antihypertensive Medications

Uses: Hypertension, hypertensive emergencies, Pheochromocytoma
Peripheral Vasodilators: Hypotension, dizziness, angina, headache, hirsutism, nasal congestion, fatigue, sodium and water retention
Beta-blockers: CHF, dizziness, bradycardia, arrhythmias, decreased libido, impotence

Anti-Adrenergic Drugs

Centrally acting: Drowsiness, sedation, headache, dry mouth, hypotension, syncope, fluid retention, constipation
Peripherally acting: Headache, fatigue, hypotension, lethargy, dyspepsia
Alpha-Adrenergics: Headache, fatigue, hypotension, sexual dysfunction, lack of energy

ACE Inhibitors

Side effects: Nausea, cough, hypotension, headache, fatigue
Examples: '-pril' drugs

Angiotensin II Receptor Antagonists

Side effects: Diarrhea, abdominal pain, hypotension, fatigue, headache, lightheadedness, URI symptoms, cough.
Examples: '-sartan' drugs

Hypertensive Emergency Drugs

Side effects: Dizziness, weakness, nausea/vomiting, sodium and water retention, apprehension, headache
Examples: Hyperstat (diazoxide), Nitropress (Nitroprusside sodium)

Antihypertensive Medication Administration

Take BP before giving medication
Monitor for adverse effects
I&O
Dangle before getting out of bed

Antihypertensive Medication Safety

Don't stop abruptly
Report adverse effects
Take as directed
Follow up care
Report HF s/s (weight gain, swelling, SOB)
Don't use OTC cold preparations without clearing with physician