HESI EXAM

Podcast Beta

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What is the primary use of calcium alginate dressings?

To manage significant exudate (correct)

To minimize pain during dressing changes

To encourage scar tissue development

To provide a moisture barrier

Which dressing is recommended for an unstageable wound covered with eschar?

Hydrocolloid dressing

Calcium alginate

Adherent film (correct)

Hydrogel covered with foam dressing

What dressing should be used with enzymes for debridement of eschar?

Caustic solutions

Gauze plus ordered solution (correct)

Foam dressings

Hydrocolloid dressings

Which type of dressing provides adequate protection for an intact Stage 1 pressure injury?

Transparent dressing Signup and view all the answers

What should be the primary action for a dry and intact eschar if debridement is not part of the wound care plan?

Leave the eschar without dressing Signup and view all the answers

What is the primary purpose of hydrocolloid dressings in wound care?

Heals through reepithelialization while maintaining moisture Signup and view all the answers

Which dressing is recommended for a Stage 2 pressure injury?

Hydrogel covered with foam Signup and view all the answers

Which type of drainage indicates that a wound is actively bleeding?

Sanguineous Signup and view all the answers

What type of dressing is NOT appropriate for an intact Stage 1 pressure injury?

Hydrocolloid dressing Signup and view all the answers

What is a significant characteristic of purulent wound drainage?

Thick and colored in yellow, green, or brown Signup and view all the answers

Why should dressing be changed when the seal of a dressing breaks?

To maintain a moist environment for healing Signup and view all the answers

What does a hydrocolloid dressing NOT allow?

Visual assessment of the wound Signup and view all the answers

Which dressing is suitable for chronic clean wounds healing through granulation?

Hydrogel covered with foam dressing Signup and view all the answers

What property does a hydrocolloid dressing possess regarding moisture?

It redistributes moisture. Signup and view all the answers

What limitation is associated with hydrocolloid dressings in relation to visual assessment?

They completely block the view of the underlying tissue. Signup and view all the answers

What happens when the seal of a hydrocolloid dressing breaks?

It allows for bacteria to proliferate and enter the wound. Signup and view all the answers

What is the maximum wear time for a hydrocolloid dressing?

7 days Signup and view all the answers

How does a hydrogel dressing primarily aid in wound healing?

By maintaining a moist environment conducive to epithelialization. Signup and view all the answers

What is a key disadvantage of using hydrocolloid dressings?

They can cause excessive lateral tension on the skin. Signup and view all the answers

What is the primary action of a hydrocolloid dressing related to shear forces?

It limits shear to protect the wound area. Signup and view all the answers

What material is commonly used with hydrocolloid dressings to enhance their efficacy?

Foam Signup and view all the answers

What is a primary characteristic of calcium alginate dressings?

They absorb moisture from wounds and maintain a moist environment. Signup and view all the answers

When should gauze dressings be used?

For wounds with significant exudate. Signup and view all the answers

What is the recommended maximum wear time for hydrocolloid dressings?

7 days. Signup and view all the answers

Which statement about hydrogel dressings is accurate?

They promote reepithelialization in moist environments. Signup and view all the answers

What happens when the seal of a hydrocolloid dressing breaks?

The dressing needs to be replaced to protect the wound. Signup and view all the answers

What are common symptoms associated with hypomagnesemia?

Muscle weakness and irritability Signup and view all the answers

Which condition is primarily indicated by lethargy, myoclonic jerks, and confusion?

Hyponatremia Signup and view all the answers

What is the primary purpose of collecting a 24-hour urine sample?

To assess kidney function Signup and view all the answers

Which is a characteristic feature of an N95 respirator?

Offers efficient filtration of airborne particles Signup and view all the answers

In what scenario should a face mask be used instead of an N95 respirator?

For source control by the general public Signup and view all the answers

What is a common effect of hyperphosphatemia?

Osteoporosis and cardiovascular disease Signup and view all the answers

Which of the following symptoms are associated with hypernatremia?

Lethargy and tachycardia Signup and view all the answers

What should be done with a 24-hour urine collection after completion?

Label it and return it to the lab promptly Signup and view all the answers

What is a common purpose of hydrogel dressings in wound care?

To provide a moist environment that facilitates healing. Signup and view all the answers

When using a calcium alginate dressing, what is a critical consideration for effective use?

It can manage moderate to high exudate levels. Signup and view all the answers

What effect does an enzymatic agent have on eschar during wound care?

It helps to break down the eschar for debridement. Signup and view all the answers

What is indicated by the presence of eschar in a wound?

The wound is in a state of necrosis. Signup and view all the answers

For a wound that heals through granulation, which dressing would be the most appropriate?

Calcium alginate dressing. Signup and view all the answers

What should be the first action taken when dealing with a wound that has a significant amount of exudate?

Use a calcium alginate dressing. Signup and view all the answers

In wound care, what role does a secondary dressing play when used with a primary dressing?

Provides additional absorption and holds the primary dressing in place. Signup and view all the answers

Which of the following statements about surgical consultation for wound management is true?

It may be necessary for wounds that require closure. Signup and view all the answers

What is a key benefit of using hydrocolloid dressings in wound care?

They provide a moist environment that aids in healing. Signup and view all the answers

What happens to the hydrocolloid dressing when it breaks its seal?

The risk of infection increases as moisture escapes. Signup and view all the answers

Which statement best describes the use of hydrocolloid dressings?

They can be used for wounds healing through granulation. Signup and view all the answers

What is a significant limitation of hydrocolloid dressings?

They may trap excessive moisture, leading to maceration. Signup and view all the answers

How long can hydrocolloid dressings typically remain in place?

Up to 7 days. Signup and view all the answers

What is NOT a characteristic of hydrocolloid dressings?

They provide a dry environment that inhibits healing. Signup and view all the answers

What role does hydrocolloid dressing play in managing skin integrity?

It enhances the body's natural healing process by providing hydration. Signup and view all the answers

In which situation are hydrocolloid dressings particularly recommended?

For superficial wounds healing through granulation. Signup and view all the answers

What defines obesity in terms of Body Mass Index (BMI)?

BMI of 30 or greater Signup and view all the answers

What is the primary focus of hospice care?

Offering supportive care for terminal illnesses Signup and view all the answers

Where can hospice care be provided?

In various settings including home and nursing homes Signup and view all the answers

What is NOT a characteristic of eschar when it is dry and intact?

It requires frequent dressing changes Signup and view all the answers

What is the condition of a patient entering hospice care?

In the terminal phase of illness Signup and view all the answers

How does dry eschar contribute to wound management in specified cases?

It serves as a natural barrier to infection Signup and view all the answers

Which of the following statements about overweight is true?

It is diagnosed with a BMI of 25 to 29 Signup and view all the answers

What role does family play in hospice care?

Family-centered care is essential in hospice services Signup and view all the answers

What is the main advantage of using calcium alginate dressings?

They absorb moisture and manage exudate effectively. Signup and view all the answers

When should gauze dressings be specifically indicated?

When there is significant exudate present. Signup and view all the answers

What is a critical consideration for the effective use of hydrogel dressings?

They help in re-epithelialization and maintaining moisture. Signup and view all the answers

What happens when the seal of a hydrocolloid dressing breaks?

The dressing may no longer adequately protect the wound. Signup and view all the answers

What is the maximum wear time recommended for hydrocolloid dressings?

Up to 7 days. Signup and view all the answers

What does a hydrocolloid dressing prevent when applied to a wound?

Visual assessment Signup and view all the answers

What happens if excessive moisture accumulates under a hydrocolloid dressing?

Dressing breakdown Signup and view all the answers

What is the primary concern when changing hydrocolloid dressings?

Maintaining the seal of the dressing Signup and view all the answers

What is the maximum wear time for a hydrocolloid dressing?

7 days Signup and view all the answers

Which feature of hydrocolloid dressings is essential for patient comfort?

Cushioning effect Signup and view all the answers

In which situation is a hydrocolloid dressing NOT recommended?

Wounds with heavy exudate Signup and view all the answers

What contributes to the hemostatic properties of certain wound dressings?

Pressure redistribution Signup and view all the answers

What is a critical consideration when using hydrocolloid dressings on wounds?

Minimizing tension on the dressing Signup and view all the answers

What is the primary reason for using a calcium alginate dressing?

To facilitate healing in chronic wounds with heavy drainage Signup and view all the answers

Which dressing is suitable for unstageable wounds covered with eschar?

Enzymatic dressing Signup and view all the answers

What is a characteristic feature of adhering film dressings?

They provide a moist environment for healing Signup and view all the answers

In which scenario would gauze dressings be particularly beneficial?

Wounds that require regular observations and applications Signup and view all the answers

What is a significant limitation of using hydrocolloid dressings?

Difficulty in visual assessment of the wound Signup and view all the answers

How does a primary dressing function in wound care?

Provides a protective barrier over the wound Signup and view all the answers

What will happen if the seal of a hydrocolloid dressing is compromised?

The dressing may promote further infection Signup and view all the answers

What is the role of enzymatic agents in wound care?

To break down eschar and necrotic tissue Signup and view all the answers

What is the primary method for preparing a calcium alginate dressing for application?

Wringing out excess solution and unfolding it Signup and view all the answers

Which type of saline solution is appropriate for use with a calcium alginate dressing?

Normal saline solution Signup and view all the answers

What is an important step after applying a calcium alginate dressing?

Covering it with a dry dressing and tape Signup and view all the answers

What is a critical consideration when using gauze with calcium alginate dressings?

Follow manufacturer’s instructions for the gauze use Signup and view all the answers

What is the purpose of wringing out excess solution from a calcium alginate dressing?

To avoid excessive moisture causing skin maceration Signup and view all the answers

When applying a calcium alginate dressing, what should be done to ensure proper contact with the wound?

Unfold the dressing to make contact with the wound Signup and view all the answers

What is indicated by covering a calcium alginate dressing with a dry dressing?

To prevent infection Signup and view all the answers

Why is it important to follow manufacturer instructions when using dressings?

It maximizes the effectiveness of the dressing Signup and view all the answers

What is the definition of obesity in terms of body mass index (BMI)?

A BMI of 30 or greater Signup and view all the answers

Which statement accurately reflects the focus of hospice care?

It is centered on family-centered comfort care. Signup and view all the answers

What is the approach taken if eschar is dry and intact and debridement is not part of the care plan?

Allow eschar to remain as a physiological cover. Signup and view all the answers

In what type of settings can hospice care be provided?

At home, nursing homes, or assisted-living facilities Signup and view all the answers

What role does eschar play in wound management when left untreated?

It forms a barrier to infection. Signup and view all the answers

What aspect is NOT part of the definition of being overweight?

Having a BMI of 20 to 25 Signup and view all the answers

How does hospice care ensure dignity for terminally ill patients?

By allowing patients to make care decisions. Signup and view all the answers

What implication does a patient's entry into hospice care indicate?

They have chosen to stop curative treatments. Signup and view all the answers

What is the primary requirement before applying a calcium alginate dressing to a wound?

Wring out excess solution before application Signup and view all the answers

Which action must be taken after applying a calcium alginate dressing?

Cover it with a dry dressing tape Signup and view all the answers

When should saline or prescribed solution be utilized with calcium alginate dressings?

To cleanse the wound before dressing application Signup and view all the answers

What is a crucial step to facilitate effective contact of the calcium alginate dressing with the wound?

Unfolding the dressing to improve contact Signup and view all the answers

What is the recommended method for managing the moisture level around the wound once a calcium alginate dressing is applied?

Change the dressing only when it shows signs of saturation Signup and view all the answers

Which dressing should be utilized with calcium alginate dressings to follow manufacturer instructions effectively?

Gauze dressing Signup and view all the answers

What may occur if the calcium alginate dressing does NOT make full contact with the wound?

Increased healing time due to lack of moisture control Signup and view all the answers

What role does the secondary dressing play when applied over a calcium alginate dressing?

It keeps the primary dressing intact and in place Signup and view all the answers

What is defined as having a body mass index (BMI) of 25 to 29?

Overweight Signup and view all the answers

What is the primary focus of hospice care?

Palliative support Signup and view all the answers

If eschar is dry and intact, what is the recommended action when debridement is not part of the care plan?

Leave the eschar untreated Signup and view all the answers

In what settings can hospice care be provided?

In various facilities including home and hospitals Signup and view all the answers

Which BMI classification indicates obesity?

30 or greater Signup and view all the answers

What role does eschar play when it is allowed to act as a physiological cover?

Acts as a natural barrier to infection Signup and view all the answers

What agreement must be reached for a patient to enter hospice care?

That no further treatment can reverse the disease Signup and view all the answers

What is true about eschar in wound care?

It acts as a protective layer in certain cases Signup and view all the answers

What is the most appropriate response for a nurse when a client is reluctant to look at a surgical wound?

Indicate that it is normal to have such feelings. Signup and view all the answers

How many teaspoons should the nurse administer when giving Reglan liquid 10 mg?

2 teaspoons Signup and view all the answers

Which position is most appropriate for an unresponsive client receiving feeding through a gastrostomy tube?

Semi-sitting (Fowler's) position Signup and view all the answers

Which technique is the most efficient for a nurse to gather information about a client's health problem?

Closed-ended questions Signup and view all the answers

In a situation where a client refuses to discuss their surgery, which approach should a nurse avoid?

Forcing discussion on the surgery Signup and view all the answers

What should the nurse indicate to a client who expresses reluctance to discuss their feelings about a surgical procedure?

It is common to feel this way. Signup and view all the answers

Considering medication administration, how does the conversion from ml to teaspoons work in this scenario?

5 ml is equivalent to 1 teaspoon. Signup and view all the answers

What is a potential risk when positioning a client in a supine position during feeding through a gastrostomy tube?

Increased risk of aspiration Signup and view all the answers

When delivering medication through a metered inhaler, when should the client remove the mouthpiece and hold their breath?

Immediately after inhalation. Signup and view all the answers

What is the best initial action for a nurse when a hospitalized client reports a severe coughing incident while receiving nasogastric tube feedings?

Check the pH of the fluid withdrawn from the tube. Signup and view all the answers

What response should a nurse give to a client who refuses to look at their mastectomy incision?

"It's okay to not want to talk about your surgery; I'm here when you're ready." Signup and view all the answers

Why is checking the pH of fluid withdrawn from a nasogastric tube an important step after a client coughs during feedings?

It assesses if the tube is in the stomach or intestines. Signup and view all the answers

What is the safest method to assess the placement of a small-bore feeding tube after a client experiences coughing?

Checking the pH of aspirated content. Signup and view all the answers

Which action should be avoided when a client reports coughing during nasogastric feedings?

Assessing tube placement through auscultation. Signup and view all the answers

What should the client be reassured about regarding the stoma appearance over time?

The stoma will become smaller as swelling decreases. Signup and view all the answers

Which method is the most reliable for confirming proper placement of a nasogastric tube?

Examining a chest x-ray obtained after tube insertion. Signup and view all the answers

What is a common emotional response a client may experience after a mastectomy that may lead to them avoiding looking at their incision?

Anger, depression, or anxiety surrounding the surgery. Signup and view all the answers

What initial information should be obtained from a young mother of three children experiencing increased anxiety?

Nutritional history. Signup and view all the answers

What should be prioritized in nursing care for a client recovering from a mastectomy who is silent about their feelings?

Providing a safe space for them to express feelings when ready. Signup and view all the answers

Which instruction should be included when teaching a client with numerous allergies how to avoid allergens?

Avoid any types of sprays, powders, and perfumes. Signup and view all the answers

What is a common emotional response a client may have towards their colostomy initially?

Anxiety about the appearance and care of the stoma. Signup and view all the answers

Why is it important to encourage a client to handle stoma equipment?

To gain confidence with the stoma care procedure. Signup and view all the answers

What could be a potential concern for a mother of three children that might contribute to her anxiety?

The safety and well-being of her children. Signup and view all the answers

Which statement about managing dietary factors in anxiety is accurate?

Sugars can also elevate anxiety if consumed in excess. Signup and view all the answers

What is the primary function of the frontal lobe of the cerebrum?

Controlling higher mental activities such as memory and intellect Signup and view all the answers

Which intervention is appropriate for a client with dark amber urine indicating fluid volume deficit?

Encourage additional intake of juices and water Signup and view all the answers

What role does the thalamus play in the brain?

Directing impulses to the cerebral cortex Signup and view all the answers

Which function is associated with the hypothalamus?

Regulating appetite and body temperature Signup and view all the answers

What characteristic of dark amber urine suggests about the client's hydration status?

The client is experiencing a fluid volume deficit Signup and view all the answers

What should the nurse do first when a client's oxygen saturation decreases from 94% to 88% while ambulating?

Assist the ambulating client back to the bed. Signup and view all the answers

What is the next step a nurse should take after identifying a client's problem?

Determine the etiology of the problem. Signup and view all the answers

When administering a prescription for azithromycin 500 mg when the available tablets are 250 mg each, how many tablets should be given per dose?

2 tablets Signup and view all the answers

A client is upset upon observing their colostomy for the first time. What is the most appropriate response by the nurse?

Instruct the client that the stoma will become smaller as swelling diminishes. Signup and view all the answers

What physiological change does a decrease in oxygen saturation indicate for a client with pneumonia?

Inadequate oxygenation. Signup and view all the answers

In the context of nursing care, why is determining the etiology of a problem essential?

It guides the development of appropriate goals and plan of care. Signup and view all the answers

What is a common emotional response a client may experience after surgery when seeing a colostomy for the first time?

Upset Signup and view all the answers

After identifying the oxygen saturation drop in a patient, what is the first action a nurse should take?

Assist the client back to bed to reduce activity demands. Signup and view all the answers

What is the best nursing response when a client is reluctant to discuss their surgery?

Reflect that their feelings are acceptable and be available when they are ready. Signup and view all the answers

How many teaspoons should the nurse administer if metoclopramide 10 mg is prescribed while it's available as 5 mg/5 ml?

2 teaspoons Signup and view all the answers

What is the most appropriate position for an unresponsive client receiving bolus tube feeding?

Fowler's position to reduce aspiration risk. Signup and view all the answers

Which questioning technique is best for efficiently obtaining specific information about a client's health problem?

Closed-ended questions for specific details. Signup and view all the answers

How many tablets of metolazone should the nurse administer if the prescription is 7.5 mg and it comes in 5 mg tablets?

1.5 tablets Signup and view all the answers

If a grandmother describes her grandson's pain as 'miseries', what should the nurse focus on during the assessment?

Inquire about the source and type of pain. Signup and view all the answers

What is the first action the nurse should take if a client's fingers are blue due to wrist restraints?

Loosening the right wrist restraint. Signup and view all the answers

What should the nurse initially do when a client removes the covering from an ice pack applied to their knee?

Assess the skin for possible injury. Signup and view all the answers

For a client with a fractured hip on strict bed rest, which nursing measure is essential?

Lift the client gently while repositioning. Signup and view all the answers

In a mental assessment, which area of the brain is primarily responsible for slow thought processes and personality changes?

Frontal lobe Signup and view all the answers

What defines an unresponsive client after a cerebral vascular accident during feeding?

Must be fed in a sitting position to reduce aspiration risk. Signup and view all the answers

What is the most effective way to conduct a focused assessment when culturally specific symptoms are expressed?

Tailor the assessment to the specific cultural description of symptoms. Signup and view all the answers

When witnessing cyanosis in a client's fingers caused by a wrist restraint, which action should be avoided until the restraint is loosened?

Apply a pulse oximeter to check oxygen saturation. Signup and view all the answers

What action should be prioritized when dealing with a patient on a feeding tube who is unresponsive?

Ensure the patient is in a safe feeding position. Signup and view all the answers

What is the most accurate method to confirm proper placement of a nasogastric tube?

Examining a chest x-ray after insertion. Signup and view all the answers

During an annual physical exam, which information should the nurse obtain first from a client reporting increased anxiety?

Nutritional history. Signup and view all the answers

Which instruction is crucial for a client with numerous allergies to avoid allergens?

Avoid any types of sprays or perfumes. Signup and view all the answers

If a client is prescribed Dantrolene 0.1 grams PO for spasticity, how many 100 mg capsules should be given?

1 capsule. Signup and view all the answers

What finding should a nurse expect to measure using a goniometer on a client with severe osteoarthritis?

Degree of knee flexion and extension. Signup and view all the answers

How many additional tablets should be administered to a client if their prescription of aripiprazole is increased from 15 mg to 30 mg and one tablet has already been given?

1 additional tablet. Signup and view all the answers

When should a client administer inhaler medication to ensure effective usage?

During the inhalation process. Signup and view all the answers

What is the best action for a nurse to take after a client receiving continuous nasogastric feedings reports severe coughing?

Check pH of fluid withdrawn after clearing the tube. Signup and view all the answers

After a client refuses to look at her mastectomy incision, which response from the nurse would be most appropriate?

Discussing the healing process more thoroughly. Signup and view all the answers

Which response is NOT an indication of proper use of a hydrocolloid dressing?

Requires frequent changes like gauze dressings. Signup and view all the answers

Which of the following is a common symptom associated with hypernatremia?

Irritability. Signup and view all the answers

What indicates the presence of eschar in a wound?

Necrotic tissue formation. Signup and view all the answers

What is an essential consideration for using a calcium alginate dressing effectively?

It should be soaked in saline before application. Signup and view all the answers

What action should be taken after completing a 24-hour urine collection?

Label it and send it for analysis promptly. Signup and view all the answers

What types of infections necessitate the use of Contact Precautions?

Multidrug-resistant organisms and Clostridium difficile Signup and view all the answers

What is the primary requirement for a protective environment for allogeneic hematopoietic stem cell transplants?

Positive airflow with HEPA filtration Signup and view all the answers

Which of the following statements about Airborne Precautions is incorrect?

A mask is not necessary if in close proximity Signup and view all the answers

Which pathogen is associated with both Contact Precautions and respiratory transmission?

Rhinovirus Signup and view all the answers

Which scenario would not typically require Airborne Precautions?

A patient diagnosed with varicella zoster Signup and view all the answers

Which of the following infections requires Airborne Precautions?

Mycoplasma pneumoniae Signup and view all the answers

What is a necessary component of a Protective Environment for patients undergoing allogeneic hematopoietic stem cell transplants?

Positive airflow with HEPA filtration Signup and view all the answers

Contact Precautions are necessary for infections caused by which of the following organisms?

Respiratory syncytial virus Signup and view all the answers

Which of the following statements accurately describes the setting needed for patients on Airborne Precautions?

They require a negative pressure room. Signup and view all the answers

Which measure is NOT typically associated with Contact Precautions?

Staying at least 6 feet away from the patient Signup and view all the answers

What is the normal range for potassium levels in the body?

3.5 – 5.0 Signup and view all the answers

Which of the following elements has a normal range of 9.0 – 10.5?

Calcium Signup and view all the answers

What is the normal range for sodium intake in adults?

135 – 145 Signup and view all the answers

The normal range for magnesium levels in the body is?

1.3 – 2.1 Signup and view all the answers

Phosphate levels in the body are typically found in what range?

3.0 – 4.5 Signup and view all the answers

Which symptom is commonly associated with hyperkalemia?

Heart arrhythmias Signup and view all the answers

What is a common symptom of hypomagnesemia?

Irritability Signup and view all the answers

Which condition is indicated by lethargy, confusion, and myoclonic jerks?

Hypernatremia Signup and view all the answers

Which of the following symptoms is NOT associated with hypercalcemia?

Breathing problems Signup and view all the answers

What symptom may indicate hypokalemia?

Muscle weakness Signup and view all the answers

What is the first step in the correct order for removing personal protective equipment (PPE) after patient care?

Remove the gloves Signup and view all the answers

Which item is removed after the face shield or goggles when doffing PPE?

Mask Signup and view all the answers

In which order should personal protective equipment be removed after patient care?

Gloves, Gown, Goggles, Mask Signup and view all the answers

Why is it important to remove PPE in the specified order?

To prevent cross-contamination Signup and view all the answers

What should be removed last when donning and doffing PPE?

Mask or respirator Signup and view all the answers

What color and consistency characterizes purulent wound drainage?

Thick, yellow, green, tan, or brown Signup and view all the answers

What does serosanguineous wound drainage look like?

Pale, pink, watery mixture of clear and red fluid Signup and view all the answers

Which type of wound drainage indicates active bleeding?

Bright red Signup and view all the answers

Which description fits serous wound drainage?

Clear, watery plasma showing light colored stain Signup and view all the answers

How can sanguineous drainage be best described?

Bright red, indicating active bleeding Signup and view all the answers

How should the nurse begin the carotid artery assessment?

Palpate one artery while listening to the other side with a stethoscope. Signup and view all the answers

What should the nurse do next if no bruit is heard during the carotid artery assessment?

Use the bell of the stethoscope to assess for a carotid bruit. Signup and view all the answers

Which assessment data are important for the nurse to report to the client's healthcare provider?

Onset of an S3 heart sound. Signup and view all the answers

What components are included in the SBAR method used for communication with a primary healthcare provider?

Situation and Recommendation. Signup and view all the answers

What is the incorrect action to take when assessing carotid arteries?

Palpate both arteries simultaneously for volume comparison. Signup and view all the answers

What is a common reassurance that can be given to a client regarding their stoma?

The stoma will become smaller as swelling decreases. Signup and view all the answers

Which method is considered the best confirmation of correct nasogastric tube placement?

Obtaining a chest x-ray after insertion. Signup and view all the answers

When assessing a young mother's anxiety, which information should the nurse obtain first?

Her nutritional history. Signup and view all the answers

What is the first step in the correct order for removing personal protective equipment (PPE) after patient care?

Remove the gloves Signup and view all the answers

What is the purpose of wound dressings in wound care?

To provide thermal insulation Signup and view all the answers

Which guideline should be included in the teaching plan for a client with allergies?

Avoiding sprays, powders, and perfumes completely. Signup and view all the answers

What should a nurse encourage a client to do for gaining confidence with their stoma care?

Practice handling the stoma equipment. Signup and view all the answers

Which type of wound drainage is characterized by clear, watery plasma?

Serous Signup and view all the answers

What does a pH level of 4 or less in gastric contents indicate?

The nasogastric tube is correctly placed. Signup and view all the answers

Which statement is true regarding the characteristics of purulent wound drainage?

It appears thick and can be yellow, green, tan, or brown. Signup and view all the answers

What impact does nutritional history have on anxiety levels?

Certain foods can increase anxiety symptoms. Signup and view all the answers

When dressing a wound, what is one of the primary functions aimed at promoting healing?

Maintains moisture balance Signup and view all the answers

Which order of wound dressing removal is not correct?

Mask, goggles, gloves, gown Signup and view all the answers

Why is it critical to avoid allergens for a client with allergies?

Avoiding allergens can reduce the risk of severe allergic reactions. Signup and view all the answers

What does sanguineous drainage indicate about a wound?

Active bleeding is occurring. Signup and view all the answers

What is an incorrect function of a dressing in wound management?

Promotes oxygen infusion into the wound Signup and view all the answers

What should the nurse ask the client to assess if their fatigue has a cardiac cause?

Can you describe the quality of your fatigue? Signup and view all the answers

How should the nurse prepare the client for inspection of the precordium?

Help the client to a supine position on the bed with his chest exposed. Signup and view all the answers

The nurse should observe the force of the impulse at which location?

Left midclavicular line, 5th intercostal space. Signup and view all the answers

Where should the nurse begin palpation at the base of the heart?

Right sternal border, 2nd intercostal space. Signup and view all the answers

What instruction should the nurse give the client before attempting to palpate again?

Roll half-way to his left side. Signup and view all the answers

Which test result can provide information similar to precordial percussion?

Chest x-ray. Signup and view all the answers

How should the nurse continue auscultation after listening at one site?

Lift the stethoscope from one valve area to the next. Signup and view all the answers

While continuing to listen at the aortic site, what action should the nurse take?

Change the angle of the stethoscope for better sound clarity. Signup and view all the answers

How many tablets of metolazone should the nurse administer if the prescribed dose is 7.5 mg and the available tablets are 5 mg each?

1 1/2 tablets Signup and view all the answers

What is the appropriate focused assessment after a grandmother indicates her grandson is suffering with 'miseries'?

Inquire about the source and type of pain Signup and view all the answers

If a nurse observes that the fingers on a client's right hand are blue while wrist restraints are applied, what should the nurse do first?

Loosen the right wrist restraint Signup and view all the answers

What should the nurse's first action be if a male client removes the covering from an ice pack applied to his knee?

Check the skin condition under the ice pack Signup and view all the answers

Why are closed-ended questions recommended for nurses when obtaining specific information from clients?

They provide clear, concise information about specific signs and symptoms. Signup and view all the answers

In which scenario is it most important for the nurse to understand a client's cultural terms related to health conditions?

When performing a focused assessment based on client feedback. Signup and view all the answers

After loosening the wrist restraint on a client exhibiting cyanosis in the fingers, what should the nurse assess next?

The color of the remaining fingers for continuity Signup and view all the answers

What is the possible implication of a cultural term like 'miseries' used by an African-American grandmother when describing her grandson's condition?

It reflects cultural nuances that may differ from clinical terminology related to pain. Signup and view all the answers

What defines overweight according to body mass index (BMI) standards?

A BMI of 25 to 29 Signup and view all the answers

What is a primary focus of hospice care?

Supportive care Signup and view all the answers

What is indicated by the presence of eschar in a wound?

The wound may require debridement Signup and view all the answers

In which care setting is hospice care typically not provided?

Intensive care units Signup and view all the answers

What is a key limitation of hydrocolloid dressings regarding wound assessment?

They prevent visual assessment of the wound. Signup and view all the answers

When eschar is present and dry, what should generally be the approach to wound care if debridement is not part of the plan?

Allow eschar to act as a natural cover Signup and view all the answers

Which BMI classification indicates obesity?

A BMI of 30 or greater Signup and view all the answers

When is a hydrocolloid dressing most effective?

For chronic wounds healing through granulation. Signup and view all the answers

What occurs when the seal of a hydrocolloid dressing breaks?

It requires immediate replacement. Signup and view all the answers

How is hospice care typically described?

As a system of family-centered care Signup and view all the answers

Which of the following statements is true about hydrocolloid dressings?

They can limit shear by providing a protective barrier. Signup and view all the answers

What is NOT a characteristic of hospice care?

Focus is on curative treatment Signup and view all the answers

What is the maximum wear time recommended for hydrocolloid dressings?

7 days. Signup and view all the answers

In which scenario should hydrocolloid dressings be avoided?

In the presence of excessive moisture. Signup and view all the answers

What is the primary action of hydrocolloid dressings in wound care?

They maintain a moist environment for healing. Signup and view all the answers

What precaution should be taken when using hydrocolloid dressings?

They may need monitoring for seal integrity. Signup and view all the answers

How many mL should the nurse administer for a prescribed dose of Morphine Sulfate 6 mg when it is available in 10 mg/1 mL vials?

0.6 mL Signup and view all the answers

Which assessment finding best indicates the effectiveness of the administered morphine?

Client states pain has lessened. Signup and view all the answers

What is the most appropriate pain scale to assess the intensity of the client's pain?

Numeric pain scale Signup and view all the answers

Given a report of increasing dyspnea, what should the nurse assess next?

Ask the client to stand and recheck blood pressure. Signup and view all the answers

What action should the nurse take to confirm the client's irregular pulse rhythm after palpation?

Auscultate the apical pulse for 1 minute. Signup and view all the answers

How should the nurse initially gather data about the client's history of chest pain?

Encourage description of chest discomfort. Signup and view all the answers

Which finding suggests that the morphine administered has effectively reduced the client’s pain?

The client's facial expression is calm. Signup and view all the answers

After administering morphine, which of the following is NOT an effective indicator of pain relief?

Client holds a pillow over abdomen. Signup and view all the answers

What is the most appropriate action for a nurse to take after a client receiving nasogastric tube feedings reports severe coughing?

Clear the tube with 30 ml of air and check the pH of fluid withdrawn from the tube. Signup and view all the answers

During which part of the inhalation should a client use a metered inhaler to deliver medication?

At the last part of inhalation. Signup and view all the answers

Which response is best for a nurse to give a client who refuses to discuss her mastectomy incision?

It's okay if you don't want to talk right now, I'm here when you are ready. Signup and view all the answers

What potential issue may arise from coughing while receiving nasogastric feeding through a small-bore tube?

Aspiration due to tube displacement. Signup and view all the answers

What is the correct procedure for checking the placement of a nasogastric tube?

Withdraw fluid and check the pH after clearing with air. Signup and view all the answers

How long should a client hold their breath after using a metered inhaler?

For 5 to 10 seconds. Signup and view all the answers

What could be a misconception about caring for a mastectomy incision?

Ignoring the incision will help with emotional recovery. Signup and view all the answers

What should a nurse do if a client shows signs of reluctance to address their medical condition?

Respect their choice not to speak and offer support. Signup and view all the answers

What should the nurse do after observing the P wave on the telemetry monitor?

Confirm the finding on the bedside cardiac telemetry monitor. Signup and view all the answers

Which sound should the nurse identify if a heart sound is heard following the P wave?

S3 heart sound. Signup and view all the answers

To determine the grade of a murmur, what action is most appropriate for the nurse?

Listen in surrounding areas for the extent of radiation of the sound. Signup and view all the answers

What should the nurse do next after assessing the murmur?

Document the findings and report the murmur to the charge nurse. Signup and view all the answers

Which method will help the nurse confirm the presence of a heart sound?

Use the bell of the stethoscope to continue listening at the apical site. Signup and view all the answers

What assessment should the nurse include in their examination?

Check for jugular vein distention. Signup and view all the answers

Which of the following actions will help inspect for jugular vein distention?

Lower the head of the bed while observing the neck veins. Signup and view all the answers

What is the initial action the nurse should take following the auscultation of a pulsation?

Document the findings. Signup and view all the answers

Study Notes

Personal Protective Equipment (PPE) Removal

The correct order of removing PPE, after patient care, is gloves, gown, goggles, and lastly, mask or respirator.
Gloves must be removed first, followed by the gown, then the face shield or goggles, and lastly, doff the mask or respirator.

Wound Drainage

Serous wound drainage is clear, watery plasma, and displays a light-colored circular stain.
Purulent wound drainage is thick, yellow, green, tan, or brown in color and shows a thick, yellow, green, tan, or brown stain.
Serosanguineous wound drainage is a pale, pink, watery mixture of clear and red fluid, and it stains the gauze with pale red and pink fluid.
Sanguineous wound drainage is bright red, indicating active bleeding and shows a bright red spot surrounded by a light red stain.

Wound Dressings: Purposes

Protect wounds from microorganism contamination
Aid in hemostasis (stopping bleeding)
Promote healing by maintaining wound moisture
Promote healing by absorbing drainage and debriding a wound (removing dead tissue)
Support or splint a wound site
Promote thermal insulation of the wound surface

Wound Dressings by Pressure Injury Stage

Stage 1: Intact Skin, no visible wound.
- Dressings: Transparent dressing or hydrocolloid.
- Comments: Allows visual assessment. Protects from shear. Hydrocolloid does not allow visual assessment. Resolves slowly without epidermal loss over 7-14 days.
- Adjuvants: Turning schedule, support hydration, nutritional support, pressure-redistribution bed or chair cushion.
Stage 2: Partial-thickness skin loss involving epidermis and/or dermis.
- Dressings: Composite film, hydrocolloid, hydrogel covered with foam or gauze dressing.
- Comments: Limits shear. Change when seal of dressing breaks; maximal wear time 7 days. Provides moist environment. Heals through reepithelialization.
- Adjuvants: See stage 1. Manage incontinence.
Stage 3: Full-thickness skin loss involving damage to subcutaneous tissue, possibly extending down to, but not through, underlying fascia.
- Dressings: Hydrocolloid Hydrogel covered with foam dressing, Calcium alginate, Gauze.
- Comments: Change when seal of dressing breaks; maximum wear time 7 days, apply over wound to protect and absorb moisture, use with normal saline or prescribed solution, use with significant exudate.
- Adjuvants: See previous stages. Evaluate pressure-redistribution needs, Growth factors.
Stage 4: Full-thickness skin and tissue loss with exposed bone, tendon, or muscle.
- Dressings: Hydrogel covered with foam dressing, Calcium alginate, Gauze.
- Comments: Heals through granulation, scar tissue development, and reepithelialization.
- Adjuvants: See stages 1, 2, and 3. Surgical consultation may be necessary for closure.
Unstageable Wound covered with eschar (dead tissue):
- Dressings: Adherent film, Gauze plus ordered solution, Enzymes.
- Comments: Facilitates softening of eschar. Eschar lifts at edges as healing progresses. Delivers solution and may soften the eschar. May be considered for slow debridement. Breaks down eschar, providing debridement.
- Adjuvants: See previous stages. Surgical consultation may be considered for debridement.

Hypomagnesemia

can cause muscle weakness, twitches, tremors, irritability, insomnia, and drowsiness

Hyperchloremia

can cause diarrhea and vomiting

Hypochloremia

can cause diarrhea and vomiting

Hyperphosphatemia

can cause Osteoporosis and cardiovascular disease

Hypophosphatemia

can cause changes in mental state, bone pain, fragility, fatigue, weight loss, and weakness

Hypernatremia

can cause lethargy, myoclonic jerks, confusion, nystagmus, and tachycardia

Hyponatremia

can cause nausea, vomiting, lethargy, seizures, and neurological deficits

24-Hour Urine Sample

Measure amount of protein or other substances in urine to check kidney function.
Start collection after waking up and emptying bladder.
Collect all urine in a special container.
Collect last urine sample within 10 minutes before or after the first morning void time.
Store urine container in the refrigerator or a cool place.
Label container with name, date, and time of completion.
Return container to the lab as soon as possible.

Face Mask vs. Respirator Mask

N95 respirator: very close facial fit, very efficient filtration of airborne particles.
Face mask: covers mouth and nose, provides source control.

Wound Stages and Dressing

Stage 1: Clean site, limit shear, and manage incontinence.
Stage 2: Clean site, allow for healing through re-epithelialization, maximize wear time up to 7 days, provide moist wound environment.
Stage 3: Clean site, allow for healing through granulation and re-epithelialization, maximize wear time up to 7 days, protect wound with foam dressing and use calcium alginate for significant exudate.
Stage 4: Clean site, manage significant exudate, use foam dressing with calcium alginate or hydrogel, consult surgeon for closure.
Unstageable: Eschar lifts at edges as healing progresses, use adherent film, gauze and ordered solution, enzymes, or no dressing depending on eschar condition, surgical consultation may be considered for debridement.

BMI

Overweight: BMI of 25 to 29.
Obesity: BMI of 30 or greater.

Hospice Care

Focuses on comfort, independence, and dignity for patients with terminal illness.
Patient, family, and provider agree no further treatment will reverse the disease process.
Provided in patient's home, nursing homes, assisted-living facilities, freestanding hospices, or hospitals.
Focus on supportive care, not curative treatment.

Wound Care Dressing Choices

Hydrocolloid dressings are opaque and are not used in the presence of excessive moisture.
Hydrocolloid dressings do not allow for visual assessment of the wound.
Hydrocolloid dressings, including those with foam or gauze, are considered a good choice for Stage 2 wounds and can stay in place for up to 7 days.
Hydrogel dressings can be used for Stages 2 and 3. They provide a moist environment.
Calcium alginate dressings are used when there is significant exudate.
Gauze dressings can be used in various wound stages; however, there is no specific stage they are most often used in.
Growth factors can be used in Stage 4 wounds.
Adherent films are useful for unstageable wounds, softening eschar and facilitating its detachment.
Gauze dressings can be used with ordered solutions to deliver moisture to unstageable wounds.
Enzymes can be used to break down eschar in unstageable wounds.
No dressings are required in unstageable wounds when there is no eschar and debridement is not part of the care plan.

Body Mass Index

Overweight is defined as having a BMI of 25 to 29.
Obesity is defined as having a BMI of 30 or greater.

Hospice Care

Hospice is a system of care that allows patients to live with comfort, independence, and dignity while easing terminal illness pain.
Hospice care is for patients in the terminal phase of illness, and all parties involved agree on no further treatment to reverse the disease process.
Hospice care is provided in various settings including the patient's home, nursing homes, assisted-living facilities, freestanding hospices, and hospitals.
The focus of hospice care is supportive care, not curative treatment.

Wound Care

Use normal saline or other prescribed solution to cover wound with secondary dressing
Wring out excess solution, unfold and make contact with wound.
Cover with a dry dressing and tape in place
Utilize gauze per manufacturer's instructions
If eschar is dry and intact, and debridement is not part of the plan of care, no dressing should be used.
Allow eschar to act as physiological cover.

Body Mass Index (BMI)

Overweight BMI is 25 to 29
Obesity BMI is 30 or greater.

Hospice Care

Hospice is family-centered care that allows patients to live with comfort, independence, and dignity while easing the pain of terminal illness.
Hospice care is provided in patient's home, nursing homes, assisted-living facilities, freestanding hospices, and hospitals.
The focus of hospice care is supportive and not curative.

Colostomy

Postoperative swelling causes enlargement of the stoma
Stoma will become smaller over time as the swelling subsides.

Nasogastric Tube Placement

Aspirating gastric contents to assure a pH value of 4 or less
Hearing air pass in the stomach after injecting air into the tubing
Examining a chest x-ray obtained after the tubing was inserted
Checking the remaining length of tubing to ensure that the correct length was inserted.

Anxiety

Nutritional history should be obtained first as caffeine, sugars, and alcohol can lead to increased anxiety.
Sexual activity patterns and leisure activities can aid in stress management.
Financial stressors can also be a source of anxiety.

Allergies

Avoid sprays, powders and perfumes
Wash all clothing before wearing
Pollen count is related to hay fever, not allergens

Metered Inhaler Medication

Deliver medication through a metered inhaler during the last part of inhalation
Remove the mouthpiece, keep lips closed and hold breath to allow for distribution of the medication.

Nasogastric Feeding Tube

Coughing, vomiting and suctioning can displace the small-bore feeding tube.
The auscultating method is unreliable for small-bore feeding tubes.

Mastectomy

Clients may feel angry and depressed after surgery, but it is okay if they don't want to talk about it.

Metoclopramide (Reglan) Dosage

Administer 2 teaspoons of Reglan.

Gastrostomy Tube Feeding

Position the client in Fowler's position to decrease the chances of aspiration.
Prone, Sims' and supine positions increase the risk of aspiration.

Client Interview

Obtain information about signs and symptoms of a client's primary health problem using open-ended questions.

Oxygen Saturation

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating.
This indicates inadequate oxygenation.
The client should be assisted to return to bed to minimize oxygen demands.
Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions.
Increased activity increases respiratory effort.

Etiology of the Problem

The nurse should determine the etiology, or cause, of the problem.
Etiology helps determine goals, plan of care, and prioritize interventions.

Medication Calculations

Azithromycin (Zithromax) is available as 250 mg scored tablets.
A client receives a prescription for azithromycin (Zithromax) 500 mg PO x 3 days.
The nurse should administer 2 tablets per dose.

Swelling of Stoma

Postoperative swelling causes enlargement of the stoma.
The stoma will become smaller when the swelling is diminished.

Nasogastric Tube Placement

The most accurate way to determine the proper placement of a nasogastric tube is by confirming with a chest x-ray.

Anxiety and Nutritional History

Caffeine, sugars, and alcohol can lead to increased levels of anxiety.
A nutritional history should be obtained first from a client with increased anxiety, so that health teaching can be initiated if indicated.

Allergens

Clients with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes.
Pollen count is related to allergens.

Dantrolene Dosage Calculation

Dantrolene (Dantrium) is available in 100 mg capsules.
A client with multiple sclerosis is prescribed Dantrolene (Dantrium) 0.1 grams PO bid for spasticity.
The nurse should administer 1 capsule.

Goniometer

A goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device.
It is used to measure degrees of flexion and extension of a joint.

Aripiprazole Dosage Calculation

A client’s daily PO prescription for aripiprazole (Abilify) is increased from 15 mg to 30 mg.
The medication is available in 15 mg tablets.
After administering one tablet, the nurse should administer 1 additional tablet to reach the new prescribed total dose.

Inhaler Administration

The client should administer inhaler-delivered medication during the last part of inhalation.
After the medication is delivered, the client should remove the mouthpiece, keep their lips closed, and hold their breath for several seconds to allow for distribution of the medication.

Small-Bore Feeding Tube

Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus.
Checking the sample of fluid withdrawn from the tube for acidity or alkalinity is a more sensitive method for these tubes.

Mastectomy Incision

Clients may feel apprehensive about looking at their surgical wound or talking about the surgery.
The nurse should acknowledge and validate these feelings.

Pericardial Effusion

Clients with pericardial effusion may have phrenic nerve compression resulting in recurrent hiccups.
Metoclopramide (Reglan) is prescribed for hiccups.

Metoclopramide Dosage Calculation

Metoclopramide (Reglan) liquid 10 mg PO q 6 hours is prescribed.
The medication is available as 5 mg/5 ml.
The nurse should administer 2 teaspoons.

Gastrostomy Tube Feedings

An unresponsive older client with a fractured left hip is receiving bolus enteral feedings through a gastrostomy tube (GT).
The client should be positioned in a semi-sitting (Fowler's) position during feeding to decrease the occurrence of aspiration.

Closed-Ended Questions

During admission interviews, use closed-ended questions to obtain specific information about a client’s health problems.

Metolazone Dosage Calculation

The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO.
Zaroxolyn is available in 5 mg tablets.
The nurse should administer 1 1/2 tablets.

“Misery” Term

African-American clients may refer to pain as "the miseries."
Conduct a pain assessment when this term is used.

Wrist Restraint

If a client’s fingers are blue distal to a wrist restraint, the priority nursing action is to restore circulation by loosening the restraint.

Ice Pack Application

When a client removes the covering from an ice pack applied to their knee, the nurse should first observe the appearance of the skin under the ice pack for any signs of thermal injury.

Bedrest and Fractured Hip

When repositioning a client with a fractured left hip on strict bedrest, the client should be lifted gently to avoid shearing forces.

Frontal Lobe

The frontal lobe of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality.

Dark Amber Urine

Dark amber urine is characteristic of fluid volume deficit.
Encourage the client to increase fluid intake.

Airborne Precautions

Droplets larger than 5 micrometers can travel up to 3 feet.
Diseases requiring airborne precautions include influenza, adenovirus, group A streptococcus, Neisseria meningitides, pertussis, rhinovirus, mycoplasma pneumoniae, pertussis, diphtheria, pneumonic plague, rubella, mumps, and respiratory syncytial virus.
Patients should be placed in a private room or with other patients with the same disease.
Healthcare personnel should wear a mask or respirator following agency policy.

Contact Precautions

Direct patient or environmental contact can spread diseases.
Diseases spread through contact include colonization or infection with multidrug-resistant organisms, such as VRE and MRSA, Clostridium difficile, shigella and other enteric pathogens, major wound infections, herpes simplex, scabies, varicella zoster (disseminated), and respiratory syncytial virus.
Patients should be placed in a private room or with other patients with the same disease.
Healthcare personnel should wear gloves and gowns.

Protective Environment

This isolation precaution is used for patients receiving allogeneic hematopoietic stem cell transplants.
The patient must be in a private room with positive airflow and at least 12 air exchanges per hour.
Air entering the room must be HEPA filtered.
Healthcare workers must wear a mask, gloves, and gowns.

Airborne Precautions

Droplet size: less than or equal to 5 micrometers (μm)
Distance: within 3 feet of the patient
Infections: influenza, adenovirus, group A streptococcus, Neisseria meningitides, pertussis, rhinovirus, mycoplasma pneumoniae, pertussis, diphtheria, pneumonic plague, rubella, mumps, respiratory syncytial virus
Recommendations: Private room or cohort patients; mask or respirator (refer to agency policy)

Contact Precautions

Direct contact with patient or contaminated environment required for transmission
Infections: Colonization or infection with multidrug-resistant organisms, such as VRE and MRSA, Clostridium difficile, shigella and other enteric pathogens, major wound infections, herpes simplex, scabies, varicella zoster (disseminated), respiratory syncytial virus
Recommendations: Private room or cohort patients (see agency policy); gloves, gowns

Protective Environment

Patient population: Allogeneic hematopoietic stem cell transplant recipients
Recommendations: Private room; positive airflow with ≥12 air exchanges per hour; HEPA filtration for incoming air; mask, gloves, gowns

Electrolyte Ranges

Potassium: 3.5 – 5.0 mEq/L, common food source is Bananas
Magnesium: 1.3 - 2.1 mEq/L, common food source is leafy greens
Calcium: 9.0 - 10.5 mg/dL, common food sources include dairy products
Chloride: 97 - 107 mEq/L,
Phosphate: 3.0 - 4.5 mg/dL,
Sodium: 135 – 145 mEq/L, decrease sodium intake as you age

Hypercalcemia

Symptoms include: bone pain, muscle weakness, excessive thirst, lethargy, nausea, numbness, tingling in digits, muscle cramps, wheezing, and fatigue.

Hyperkalemia

Symptoms include: heart arrhythmias, numbness and tingling, and breathing problems.

Hypokalemia

Symptoms include: muscle weakness, fatigue, and heart arrhythmias.

Hypermagnesemia

Symptoms include: diminished deep tendon reflexes, flushing, headache, nausea, and drowsiness.

Hypomagnesemia

Symptoms include: muscle weakness, twitches, tremors, irritability, insomnia, and drowsiness.

Hyperchloremia

Symptoms include: diarrhea and vomiting.

Hypochloremia

Symptoms include: diarrhea and vomiting.

Hyperphosphatemia

Symptoms include: osteoporosis and cardiovascular disease.

Hypophosphatemia

Symptoms include: changes in mental state, bone pain, fragility, fatigue, weight loss, and weakness.

Hypernatremia

Symptoms include: lethargy, myoclonic jerks, confusion, nystagmus, and tachycardia

Hyponatremia

Symptoms include: nausea, vomiting, lethargy, seizures, and neurological deficits

Doffing PPE

Removing personal protective equipment (PPE) after patient care is crucial to prevent contamination and infection spread.
The correct order of removal minimizes the risk of self-contamination.

Doffing Order

Gloves: First, remove gloves to avoid contact with contaminated surfaces.
Gown: Remove the gown next, ensuring to touch only the inside of the gown to avoid contamination.
Goggles or Face shield: Follow by removing goggles or face shield to avoid touching the contaminated lenses.
Mask: Last, remove the mask by holding the ties or ear loops, avoiding touching the front of the mask.

Personal Protective Equipment (PPE) Removal Order

After caring for a patient, remove PPE in a specific order to prevent cross-contamination
The order is:
- Gloves
- Gown
- Eye protection
- Mask

Types of Wound Drainage

Serous: Clear, watery plasma
Purulent: Thick and colored, including yellow, green, tan, or brown
Serosanguineous: Pale pink, a mixture of clear and red fluid
Sanguineous: Bright red, indicating active bleeding

Personal Protective Equipment (PPE)

Face masks might not meet fluid barrier and filtration efficiency levels.
N95 respirators and Filtering Facepiece Respirators (FFRs) provide respiratory protection.
Surgical masks provide fluid barrier protection.
PPE removal order: gloves, gown, goggles, and lastly mask/respirator.

Wound Drainage

Serous: Clear, watery plasma drainage.
Purulent: Thick, yellow, green, tan, or brown drainage.
Serosanguineous: Pale, pink, watery mixture of clear and red fluid.
Sanguineous: Bright red, indicating active bleeding.

Wound Dressings

Dressings protect wounds from microorganism contamination.
Dressings aid in hemostasis (stopping bleeding).
Dressings promote healing by maintaining moisture.
Dressings absorb drainage and debride wounds.
Dressings support or splint wound sites.
Dressings promote thermal insulation of wound surfaces.

Postoperative Swelling

Postoperative swelling can cause enlargement of the stoma.
The swelling will diminish, and the stoma will become smaller.

Nasogastric Tube Placement

Aspirating gastric contents with a pH of 4 or less is a method used to determine proper placement.
Hearing air pass into the stomach after injecting air into the tubing is another method.
The most accurate method is confirming proper placement with a chest x-ray.

Anxiety in Young Mothers

A nutritional history to determine if caffeine, sugars, or alcohol consumption contributes to increased anxiety.

Avoiding Allergens

Avoid sprays, powders, and perfumes.
Wash new clothing before wearing it.
Pollen is related to hay fever, but not all allergens.

Drug Dosage Calculations

Metolazone (Zaroxolyn) 7.5 mg PO is available in 5 mg tablets.
Administer 1 1/2 tablets (7.5 mg / 5 mg x 1 tablet = 1.5 tablets).

Pain Assessment

African-American clients may refer to pain as "the miseries".

Restraints Assessment

Blue fingers (cyanosis) below a wrist restraint indicates decreased circulation and requires immediate action.
Loosen the restraint first, to restore circulation.

Ice Pack Assessment

Observe the appearance of the skin beneath the ice pack.
Instruct the client regarding the need for the covering.

Cardiac Fatigue

Clarify the quality of fatigue.

Precordial Inspection

Position the client supine on the bed with their chest exposed.

Heart Auscultation

Inch the stethoscope across the chest in a systematic pattern (Z pattern) to ensure all valve sounds are captured.

Palpation

Use less pressure for palpation.

Carotid Artery Assessment

Palpate one artery at a time.
Use the bell of the stethoscope.

Reporting Assessment Findings

Report S3 heart sound, jugular vein distention, and dyspnea to the client's primary healthcare provider.

SBAR (Situation, Background, Assessment, Recommendation)

Situation: Brief description of the situation.
Background: Relevant history and information.
Assessment: Patient's current clinical status.
Recommendation: Suggested actions or interventions.

Wound Care

Hydrocolloid dressings are opaque, limit visual assessment and are not used in the presence of excessive moisture
Hydrocolloid dressings have a maximal wear time of 7 days
Hydrogel dressings heal through re-epithelialization and are appropriate for clean wounds
Hydrogel dressings allow for visual assessment and are used in the presence of excessive moisture
A dressing change is required when a wound is sealed and it breaks, or a dressing becomes saturated
Eschar that is dry, intact, and is not undergoing debridement should be left alone to act as a physiological cover

Pressure Redistribution

Use pressure redistribution measures such as a bed/chair cushion to help prevent moisture build-up.

Body Mass Index (BMI)

Overweight is defined as having a BMI of 25 to 29.
Obesity is defined as a BMI of 30 or greater.

Hospice Care

Hospice care is family-centered and allows patients to live with comfort, independence, and dignity while easing the pain of terminal illness.
Hospice care is for patients in the terminal phase of illness, when no further treatment can reverse the disease process.
Hospice care focuses on supportive care rather than curative treatment.
Hospice care can be provided at home, nursing homes, assisted living facilities, freestanding hospices, and hospitals.

Medication Administration

Medication should be delivered through a metered inhaler during the last part of inhalation.
When administering medication through an inhaler, remove the mouthpiece after delivery and hold breath for several seconds to allow for distribution of the medication.

Nasogastric Tube Feedings

If a client is receiving nasogastric tube feedings and experiences coughing, stop the feeding and check the tube placement before resuming.
To check the tube placement, clear the tube with 30 ml of air and check the pH of the fluid withdrawn from the tube.

Post-Surgery Care

It is normal for a client to be silent and avoid talking about a recent surgery.
Allow the client to process the situation at their own pace and provide support when they are ready.

Pain Assessment

Nonverbal behavior can provide valuable data about a client's response to pain.
The FLACC behavioral pain scale is appropriate for assessing the pain of nonverbal patients.
The numeric pain scale is appropriate for assessing the pain of patients who can communicate verbally.
The Faces Pain scale is appropriate for assessing the pain of patients who are unable to communicate verbally.

Heart Issues

Assess for irregular heart rhythms by palpating both radial pulses simultaneously and auscultating the apical pulse.
Auscultating the apical pulse for 1 minute will confirm the client's heart rate.
When the client reports chest pain, encourage them to describe the discomfort by noting the location, frequency, and intensity.
Listen to the heart sounds with a stethoscope, focusing on the location that the sound is most clearly heard.
A systolic murmur is identified by a sound that is heard between the first and second heart sounds.
A diastolic murmur is identified by a sound that is heard between the second and first heart sounds.

Jugular Vein Distention

To assess for jugular vein distention, place the client in a Fowler's position with their head straight, then lower the head of the bed and observe the neck veins.
Ensure the client is sitting with their head slightly turned away.

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

This quiz covers essential topics on the correct removal of Personal Protective Equipment (PPE) and the characteristics of various types of wound drainage. It also addresses the purposes of wound dressings, emphasizing the importance of infection prevention and healing processes.