Nursing Quiz: Patient Positions & Catheterization
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Questions and Answers

Which precaution should be taken to ensure effective range of motion (ROM) exercises?

  • Repeat each movement 10 times during a session
  • Perform exercises using head-to-toe sequence (correct)
  • Perform exercises quickly for effectiveness
  • Carry out movements slowly and smoothly (correct)
  • What priority nursing action aligns with The Joint Commission's standards for safe administration of enteral feeding via nasoenteric tube?

  • Identifying the patient using two identifiers (correct)
  • Checking the expiration date on the patient's formula
  • Performing hand hygiene after touching the patient
  • Explaining the procedure to the patient after starting the feeding
  • Which statement accurately describes a component of medication prescriptions?

  • Route of administration (correct)
  • Chemical name of medication
  • Administering nurse's name
  • Generic name of medication (correct)
  • Which act is violated by keeping a visible patient names listing at the front desk?

    <p>Health Insurance Portability and Accountability Act (HIPAA) (C)</p> Signup and view all the answers

    What is the most appropriate nursing action to prevent pressure injuries in a patient with urinary incontinence?

    <p>Managing moisture around the area (A)</p> Signup and view all the answers

    Which patient position should be avoided to reduce the risk of aspiration in a patient with dysphagia?

    <p>Supine (C)</p> Signup and view all the answers

    Which factor does NOT influence bowel elimination?

    <p>Gender (B)</p> Signup and view all the answers

    What are potential complications of dysphagia that the nurse should monitor for?

    <p>Aspiration pneumonia (A), Dehydration (D)</p> Signup and view all the answers

    Which statement indicates a nursing student may need further education regarding the evaluation phase of urinary catheterization?

    <p>The nurse discusses the importance of the catheter with the patient. (D)</p> Signup and view all the answers

    What is the primary use for double-lumen catheters?

    <p>Indwelling catheterization (B)</p> Signup and view all the answers

    What is the normal pH range for urine?

    <p>4.6 to 8 (D)</p> Signup and view all the answers

    What are recommended measures to prevent urinary tract infections in females?

    <p>Proper handwashing (A), Wiping from front to back after voiding (D)</p> Signup and view all the answers

    Which of the following suggestions would NOT help a patient prevent urinary tract infections?

    <p>Take frequent baths (C)</p> Signup and view all the answers

    Which type of laxative works by causing stool to absorb water and swell?

    <p>Bulk-forming (A)</p> Signup and view all the answers

    What component's presence in urine suggests glomerular injury?

    <p>Large proteins (A)</p> Signup and view all the answers

    Which condition is likely caused by frequent straining during defecation?

    <p>Hemorrhoids (D)</p> Signup and view all the answers

    What is considered a short-term solution to constipation?

    <p>Cathartics (A), Laxatives (D)</p> Signup and view all the answers

    Which condition has the highest risk for constipation?

    <p>Patient receiving opioid analgesics (C)</p> Signup and view all the answers

    What defines a stage 2 pressure injury during wound assessment?

    <p>Reddish-pink wound bed without slough (C)</p> Signup and view all the answers

    Which right regarding medication administration does a patient not possess?

    <p>The right to prescribe their own medication (A)</p> Signup and view all the answers

    What should a nurse do first upon discovering a medication error?

    <p>Assess the patient's condition (C)</p> Signup and view all the answers

    Which sign indicates early pressure that resolves without tissue loss?

    <p>Blanchable erythema (D)</p> Signup and view all the answers

    What statement regarding nutrition is correct?

    <p>Nutrition is essential for organ function. (D)</p> Signup and view all the answers

    Which rights of medication administration are NOT recognized?

    <p>Right color (A)</p> Signup and view all the answers

    What is a recommended way to prevent medication errors?

    <p>Read labels at least 3 times before administration (D)</p> Signup and view all the answers

    Which preliminary assessment should the nurse perform to minimize the risk of aspiration while administering oral medications?

    <p>Ability to swallow (A), Presence of intact gag reflex (B), Ability to cough (D)</p> Signup and view all the answers

    Which patient condition is safe for administering oral medication?

    <p>Patient with skin abrasions (A)</p> Signup and view all the answers

    Which dietary recommendations should the nurse include to help prevent obesity?

    <p>Controlling sodium intake (B), Eating low-fat dairy (C)</p> Signup and view all the answers

    Which chronic disease accounts for the highest healthcare costs?

    <p>Diabetes (D)</p> Signup and view all the answers

    What statement is an example of a nonmodifiable risk factor for heart disease?

    <p>My family has a history of heart disease. (A)</p> Signup and view all the answers

    Which law mandates that healthcare agencies provide emergency care before transferring patients to other hospitals?

    <p>Emergency Medical Treatment and Active Labor Act (EMTALA) (A)</p> Signup and view all the answers

    Which condition is older adults more likely to experience due to proprioceptive changes?

    <p>Increased difficulty with balance (C)</p> Signup and view all the answers

    What is an effective communication strategy for a patient with expressive aphasia?

    <p>Offering pictures or a communication board (A)</p> Signup and view all the answers

    What factors contribute to wound healing?

    <p>Protein and Vitamins A &amp; C (A), Adequate hydration (C)</p> Signup and view all the answers

    Which organization is responsible for enforcing medication laws to ensure safety and efficacy of medications?

    <p>Food and Drug Administration (FDA) (B)</p> Signup and view all the answers

    Which statement about medication trough level is correct?

    <p>Trough indicates minimum serum concentration before the next dose. (D)</p> Signup and view all the answers

    Which patient condition may result from reduced tactile sensation due to being confined to bed?

    <p>Skin breakdown (D)</p> Signup and view all the answers

    Loosening the tubing of a patient's nasal cannula aims to prevent which complication?

    <p>Skin irritation (A)</p> Signup and view all the answers

    Which actions can help a nurse avoid malpractice and professional negligence?

    <p>Regularly updating nursing knowledge (B), Proper documentation of assessments (D)</p> Signup and view all the answers

    What is essential to perform for a patient with hemiparesis to support musculoskeletal health?

    <p>Passive range-of-motion (ROM) exercises (D)</p> Signup and view all the answers

    Flashcards

    ROM Exercise Precautions

    Precautions to ensure effective range of motion exercises include avoiding forcing joints beyond their capacity, carrying out movements slowly and smoothly, and being mindful that mild pain may occur.

    Patient Identification

    Using two identifiers (e.g., name and date of birth) is crucial to ensure the correct patient receives treatment.

    Medication Prescription Components

    Medication prescriptions include the generic name, route of administration, and dose/frequency.

    HIPAA Violation

    Displaying patient names publicly in a healthcare unit violates HIPAA guidelines.

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    Urinary Incontinence Pressure Injury Prevention

    Managing moisture is the most appropriate action to prevent pressure injuries in a patient with urinary incontinence.

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    Patient position for dysphagia

    Avoid supine position to prevent aspiration.

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    Factors influencing bowel elimination

    Pain, position, and age influence bowel elimination, but gender does not.

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    Dysphagia complications

    Dysphagia can lead to weight loss, aspiration pneumonia, decreased nutrition, and dehydration.

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    Urinary catheter evaluation phase

    The nurse assesses urination patterns, patient expectations, and potential permanent changes in elimination, not the procedure's explanation.

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    Double-lumen catheters

    Used for indwelling catheterization, not intermittent catheterization or irrigation.

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    Normal urine pH

    A normal urine pH range is 4.6 to 8.

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    Preventing UTIs in females

    Wiping from front to back, proper handwashing, and adequate fluid intake prevent UTIs, not frequent sex or indwelling catheters.

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    Advice for UTI prevention

    The nurse's advice focuses on hygiene and hydration, not other factors irrelevant to UTI prevention.

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    Glomerular injury

    Damage to the glomeruli (tiny filters in the kidneys).

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    Constipation short-term solutions

    Solutions for constipation that don't address the underlying cause but provide immediate relief.

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    Bowel Elimination Influence (incorrect statement)

    A statement that shows a need for more teaching about bowel elimination.

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    Bulk-forming laxatives

    Laxatives that increase stool size by absorbing water.

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    Hemorrhoids cause

    Swollen blood vessels in the anus and rectum often caused by straining during bowel movements.

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    Medication for defecation

    Medication used to help stimulate or regulate bowel movements.

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    Constipation risk factor

    Factor that increases the likelihood of a patient experiencing constipation.

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    Nutrition importance

    Essential for maintenance, repair of body tissues, organ functions, growth and development

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    MyPlate (incorrect statement)

    A statement about the MyPlate program that needs correction.

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    Stage 2 pressure injury

    A pressure injury where the skin is broken, exposing underlying tissues.

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    Braden Scale score (11)

    A Braden Scale score of 11 indicates a high risk for pressure injuries.

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    Early pressure indication

    Early sign of pressure that resolves if pressure is released

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    Medication error first action

    First step after discovering a medication error

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    Patient medication rights

    Rights patients have regarding medication administration.

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    Anti-dote for meds

    The reason why the antidote is kept at the bedside of the patient

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    Aspiration risk reduction

    Strategies to prevent choking or inhaling food/liquids while swallowing.

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    Safe oral medication administration

    Conditions where oral medication is appropriate.

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    Dietary choices for obesity prevention

    Recommendations for healthy eating encompassing various food groups.

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    Costliest chronic disease

    The most expensive chronic illness to treat in terms of healthcare costs.

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    Nonmodifiable heart disease risk factor

    A risk factor for heart disease that cannot be changed.

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    EMTALA

    Law requiring emergency care before transfer.

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    Proprioceptive change in older adults

    A common change in sensation of body position and movement in older adults

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    Expressive Aphasia communication

    A communication approach used for patients with expressive aphasia using visual aids.

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    Pressure injury classifications

    Categorization of pressure injuries by the severity of the wound.

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    Wound healing aids

    Substances or factors that promote wound healing.

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    Medication safety organization

    The organization responsible for ensuring medication safety and effectiveness.

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    Trough blood serum concentration

    The lowest blood level of a medication, taken just before the next dose

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    Risk for skin breakdown

    Condition that places a patient at increased risk for sore/damaged skin

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    Nasal cannula complication avoidance

    Preventing problems with nasal cannula use.

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    Nurse professional responsibilities

    Roles and duties of a nurse.

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    Synergistic medication effect

    When two medications combined have a stronger effect than taking them separately

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    Fastest medication absorption route

    The method of medication administration with the quickest absorption rate.

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    Malpractice avoidance

    Actions to prevent professional negligence and malpractice.

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    Study Notes

    Patient Positions and Aspiration Risk

    • Avoid the supine position when feeding patients with dysphagia to minimize aspiration risk.
    • The high-Fowler position is better suited for feeding patients with swallowing difficulties.

    Bowel Elimination Factors

    • Factors influencing bowel elimination include age, pain, and position, but gender is not a factor.

    Dysphagia Complications

    • Dysphagia can lead to weight loss, aspiration pneumonia, decreased nutritional status, and dehydration.

    Urinary Catheterization Evaluation

    • During the evaluation phase of urinary catheterization, the nurse reassesses urination patterns and asks patients about their experiences and if their expectations have been met regarding the catheterization. Nurses should also inquire about if there have been any permanent changes in elimination patterns.
    • Explaining the procedure and importance is part of the initial phase, not the evaluation phase.

    Catheter Types

    • Double-lumen catheters are used for indwelling catheterization, not intermittent catheterization or irrigations.

    Normal Urine pH

    • Normal urine pH ranges from 4.6 to 8.

    Preventing Urinary Tract Infections (UTIs) in Females

    • Proper hand hygiene, wiping from front to back, adequate fluid intake, and avoiding indwelling catheters are important preventative measures.
    • Frequent sexual intercourse is not a factor for UTI prevention.

    Preventing UTIs

    • Adequate fluid intake to produce pale yellow urine is crucial for preventing UTIs.

    Glomerular Injury Indicators

    • The presence of large proteins in urine suggests potential glomerular injury.

    Short-Term Constipation Solutions

    • Cathartics, laxatives, and enemas are short-term solutions for constipation.
    • Diet change and altered defecation schedules provide long-term solutions.

    Bowel Elimination Factors (Further Teaching Needed)

    • A recommended daily fluid intake of 1.5 liters for women is crucial for normal bowel function; however, other factors such as position, emotional stress, and muscle tone are also important.

    Types of Laxatives

    • Bulk-forming laxatives work by absorbing water and swelling the stool.
    • Frequent straining during defecation can lead to hemorrhoids.

    Medications for Defecation

    • Laxatives are used to promote defecation.

    Constipation Risk Factors

    • Patients taking opioid analgesics have a higher risk of constipation.

    Nutrition Importance

    • Adequate nutrition supports organ function, growth, development, and maintenance of body tissues.

    MyPlate Program

    • The MyPlate program recommends grains to make up half the plate, not all. To maintain a healthy diet avoid excess fat and cholesterol and choose lean protein sources. Include a variety in color and type of vegetables and fruits for a varied diet.

    Pressure Injury Characteristics

    • Stage 2 pressure injuries show a reddish-pink wound bed without slough.

    Braden Scale and Pressure Injuries

    • A Braden Scale score of 11 indicates a high risk for pressure injuries.

    Early Signs of Pressure

    • Blanchable erythema is an early indicator of pressure that resolves without tissue loss if the pressure is eliminated.

    Medication Error Management

    • Immediately assess and examine the patient's condition after discovering a medication error.

    Patient Rights Regarding Medications

    • Patients have the right to know the name and purpose of medications and to refuse them.

    Antidotes and Medication Toxicity

    • Keeping medication antidotes at the patient's bedside is vital for treating medication toxicity.

    Medication Administration Rights

    • The "right nurse," "right medication," "right patient," "right dose," "right time," "right reason," "right route," and "right documentation" are crucial parts of safe medication administration. The "right color" should not be part of consideration.

    Preventing Medication Errors

    • Carefully reviewing medication labels at least three times before administration.

    Medication Action Intervals

    • Medication intervals are not defined in the provided questions.

    Aspiration Risk Assessment

    • Assessing a patient's ability to cough, swallow, and have an intact gag reflex is crucial to prevent aspiration.

    Oral Medication Administration

    • Patients with skin abrasions, but without swallowing problems, can safely be administered oral medications. Be sure to check for ability to swallow.

    Dietary Recommendations for Obesity Prevention

    • Controlling alcohol and sodium intake, choosing low-fat dairy, and eating fruits and vegetables are beneficial dietary choices for preventing obesity. Avoiding grains is not a healthy option.

    Costliest Chronic Disease

    • Diabetes is the most costly chronic disease in terms of healthcare.

    Nonmodifiable Heart Disease Risk Factor

    • Family history of heart disease is a nonmodifiable risk factor.

    Emergency Medical Treatment and Active Labor Act (EMTALA)

    • EMTALA makes it mandatory for healthcare agencies to provide emergency care to patients before transferring them to other hospitals.

    Proprioception in Older Adults

    • Older adults often experience increased difficulty with balance due to proprioceptive changes.

    Communicating with Patients with Expressive Aphasia

    • Offering communication aids, such as pictures or a communication board, is essential when communicating with patients with expressive aphasia.

    Pressure Injury Staging

    • Stage 1 pressure injuries are characterized by non-blanchable erythema.
    • Stage 2 involves partial-thickness skin loss with exposed dermis.
    • Stage 3 exhibits full-thickness skin loss, with visible fat.
    • Stage 4 involves full-thickness tissue loss, with exposed bone, muscle, or tendon.
    • Unstageable pressure injuries have obscured necrotic tissue and may be difficult to stage.
    • Deep tissue injuries have a darker appearance than stage 1-4 injuries.

    Wound Healing and Nutrition

    • Protein, vitamins A & C, zinc, and copper are crucial for wound healing. Adequate hydration and calorie intake also play valuable roles.

    Medication Safety and Regulations

    • The Food and Drug Administration (FDA) ensures medication safety and efficacy.

    Medication Blood Levels

    • Trough is the minimum blood serum concentration of a medication, not the maximum.

    Pressure Injury Risk and Reduced Tactile Sensation

    • Patients with reduced tactile sensation are at greater risk of skin breakdown.

    Nasal Cannula Safety

    • Loosening a nasal cannula's tubing prevents skin irritation.

    Nurse's Responsibilities and Roles

    • Nurses are caregivers, educators, advocates, and managers.

    Medication Interactions

    • When one medication modifies the action of another, a medication interaction occurs. Synergistic effects result in a combined action greater than the individual effects.

    Pressure Injury Staging (Heel Wound)

    • A heel wound with partial-thickness skin loss has exposed dermis. This is a Stage 2 pressure injury.

    Medication Absorption Rates

    • Intravenous (IV) administration is the fastest way to absorb medications.

    Avoiding Malpractice and Negligence

    • Proper documentation, maintaining current knowledge, adhering to standards of care, thoroughness and timely completion of documentation are critical to avoiding malpractice and professional negligence.

    Passive Range-of-Motion (ROM) Exercises for Patients with Hemiparesis

    • A head-to-toe approach, avoiding forced movements, slow and smooth movements, and awareness of potential discomfort are crucial for passive ROM exercises for patients with hemiparesis.

    Enteral Feeding Safety

    • Identifying the patient using two identifiers is crucial for ensuring patient safety when administering enteral feedings.

    Medication Prescription Components

    • Medication prescriptions include generic name, route, dose, frequency, and instructions, but not the chemical name (unless in a specific circumstance) or the administering nurse's name. This is usually a physician.

    HIPAA Violation

    • Listing patient names at the front desk for easy access constitutes a HIPAA violation.

    Urinary Incontinence and Pressure Injury Prevention

    • Managing moisture is crucial for preventing pressure injuries in patients with urinary incontinence.

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    Description

    Test your knowledge on the best practices for patient positioning during feeding, the implications of dysphagia, and the evaluation of urinary catheterization. This quiz covers essential nursing considerations to minimize risks and ensure patient comfort and safety.

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