PNUR 1102 Midterm

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72 Terms

1
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EKGs are used to determine ____________ cardiac functioning, response to cardiac _____________ or interventions, investigate chest __________, or evaluate the ___________ of the heart.

baseline, medications, pain, condition

2
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1. The normal expected EKG rhythm is __________________.

Normal Sinus Rhythm

3
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Nurses can help ensure an accurate reading by applying the leads in the correct _______________, ensuring the leads are _______________ well, instructing the patient to __________________.

positions, adhered, hold still

4
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______________ is an unexpected reading that often results from lead ______________ or patient ______________.

artifact, nonadherence, movement

5
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When applying a 3 or 5 lead EKG, the nurse places the __________ lead on the right and uses snow over ___________, ____________ over fire, and __________ near the heart to place the remaining lead colors

white, grass, smoke, chocolate

6
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With a 12 lead EKG the nurse places the first lead to the ________________ of the sternum at the ________________ intercostal space.

right, fourth

7
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Infection control is important because it helps prevent complications that often require additional therapies and ___________________ or have the potential to __________ the patient or _____________ their stay.

treatment, harm, extend

8
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Standard precautions, including donning ________________ or a _____________, are utilized for any and ______________ patients when there is a risk for exposure to _____________________________ .

gloves, gown, all, bodily substances

9
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Nurses help decrease the spread of infection by eliminating one or more of the pieces in the ___________ of infection.

chain

10
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Vital signs are an excellent indicator of the presence of health _______________ or changes in the health ______________ of a patient

stressors, status

11
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What can happen if a nurse uses a BP cuff that is too small or too large for a patient?

elevated = too small, decreased = too large

12
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The ______________ pulse is the most accurate site for counting a heart rate;

apical

13
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In addition to the rate, the _________, ___________, and ______________ should also be noted for respirations.

depth, rhythm, effort

14
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What is the greatest concern when obtaining a rectal temperature?

15
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A stage I pressure ulcer is red, non-_____________ and closed/intact,

blanchable

16
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stage IV pressure ulcer is open and extends all the way to ________ or internal structures

bone

17
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The nurse can help prevent and treat pressure ulcers by providing frequent turning and ________________, assessing for signs of ____________, keeping skin clean and dry, utilizing ____________ aids and barrier devices, and ______________ medical equipment.

repositioning, breakdown, padding, positioning

18
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List 3 common areas for pressure ulcers to develop for a patient in a side lying position:

Ear, shoulder, hip

19
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What factors increase the risk of developing a pressure ulcer?

incontinence, inability to move, malnutrition (advanced age, diabetes etc.)

20
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Poor oxygenation poses many risks since it can result in confusion, decreased level of ___________________, diminished system _______________, or tissue _________.

consciousness, functioning, death

21
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Supplemental oxygen also poses risks as the equipment can cause _____________ sores and increase the risk for falls and fires

pressure

22
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Prolonged or too much oxygenation can also cause ______________ damage or decrease a patient's ____________ drive.

tissue, respiratory

23
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_________________, confusion, and ___________ are often early indicators of respiratory distress while oxygen ____________ changes, and ___________, or retractions are late signs of distress.

restlessness, anxiety, saturation, cyanosis

24
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The nurse's initial response to respiratory concern should be to ____________ the patient and promote ________ conservation.

position, energy

25
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Oxygen should be applied ___________ according to the patient's needs

incrementally

26
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Typically, the nurse should start with a __________________ before applying a face mask or ___________.

nasal cannula, non-rebreather

27
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The venturi mask is used to deliver a ___________ amount of oxygen.

specific

28
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Suctioning can be utilized for patients with difficulty maintaining and clearing their airway, such as those with ______________ impairment, a weak or __________________ cough, or those with decreased _______________ capabilities.

neurologic, non-productive, swallowing

29
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The nurse should stop suctioning if the patient becomes _________________ or displays signs of respiratory distress, such as _____________ or a drop in ______________________.

bradycardic, cyanosis, oxygen saturation

30
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Peak flow meter

test those with asthma to measure how quickly the patient can expel air (prompts adjustment to medications/treatments)

31
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Incentive spirometer

device that helps patients exercise their breathing muscles (inhale to expand lungs)

32
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Chest physiotherapy

consists of coughing, chest wall percussion, vibration, postural drainage, designed to improve airway clearance

33
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Coughing and Deep Breathing

Exercises help persons with res piratory problems.

34
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PPE for contact precautions

gown and gloves

35
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PPE for droplet precautions

Gown, mask, goggles, gloves

36
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How can isolation precautions affect the holistic well-being of a patient?

Feeling of being lonely, fear, embarrassment, shame, decreased exercise

37
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Name 3 procedures that require surgical asepsis.

urinary catheterization, lumbar puncture, tracheal suctioning (CVC or wet-to-dry dressing change)

38
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Stage II pressure ulcer

partial thickness skin loss involving epidermis, dermis, or both (skin loss, abrasion, blister, shallow crater)

39
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Stage III pressure ulcer

Full-thickness tissue loss (no bone, tendon, or muscle visible, tunneling occurs)

40
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Appropriate and accurate documentation ensure a ________ source of patient information, clear _____ among the healthcare team, a way to measure patient ______ and outcomes, and legal ______ of care provided.

beneficial, communication, responses, evidence

41
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To ensure accuracy and appropriateness, the should document ______ or immediately ______ a procedure, as well as ensure the documentation is ______, _________, and organized.

during, after, thorough, fact-based

42
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Under HIPAA regulations, all sources of ______ and patient information must be protected.

charting

43
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Medical staff are not to reveal any patient information or identifying ________ without prior consent from the patient.

characteristics

44
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Dressings are selected based on their ability to _______ the wound, reduce the prescence of _______, control or contain __________, or provide immobilization or debridement.

protect, bacteria, bleeding/damage

45
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They should be able to be removed without further ______ and promote a ______ wound bed while protecting the integrity of _________ tissue.

trauma, moist, surrounding

46
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Debriding a wound is beneficial as it helps clear ______ tissue and promotes _______ and granulation.

dead, circulation

47
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This can be done with a _________ dressing or by using special _________ agents.

wet-to-dry, chemical

48
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The process should not cause extensive _______ or trauma to the wound bed.

bleeding

49
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What dressing provides wound protection and waterproofing?

Transparent dressing

50
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What dressing is useful for a wound with excessive drainage?

Alginate

51
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Elastic bandages can provide wound _______ or support, restrict _________, or stimulate _________.

pressure, mobility, circulation

52
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To promote blood return to the heart, they should always be applied in a _______ to ________ manner.

distal, proximal

53
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What tasks can the NAP perform in regards to wound and drain care?

Observation

54
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Wound healing is affected by numerous factors, including the severity and ________ of tissue involvement, the occurrence of additional or repeated ______, prescence of ________, and the overall ______ and well-being of a patient.

extent, trauma, infection, health

55
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Risk factors for impaired wound healing include decreased _________, diabetes, malnutrition, advanced ______, and _______.

circulation, age, smoking

56
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Primary intention healing

wound that is surgically closed

57
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Secondary intention healing

wound is left open to heal (from inward to outward)

58
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Tertiary intention healing

wound left open to heal for 2-3 days and then is surgically closed

59
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hemostasis phase

first phase of wound healing, blood vessels constriction

60
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Inflammatory phase

second stage of wound healing, erythema, warmth, swelling (Initial phase, occurs at time of injury)

61
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Proliferative phase

begins a couple of days after injury, wound is rebuilt with new tissue

62
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Maturation phase

the third phase of wound healing, in which scar tissue forms

63
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__________ drainage often indicates infection

Purulent

64
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________ drainage indicates a wound is healing

Serous

65
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What factors need to assessed and documented for wounds?

Drainage, redness, swelling, odor

66
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Irrigation is performed to remove _______

debry

67
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What needs to be monitored in regards to surgical drains?

Changes in drainage or drain itself and skin around the drain

68
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Negative pressure wound therapy

helps keep drainage off of a wound, stimulate granulation, and promote circulation and secondary intention in a wound.

69
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What seal is used for a negative pressure wound therapy?

air-tight seal

70
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How should the nurse intervene if a wound demonstrates dehiscence?

Reinforce with sterile moist dressing

71
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Sutures are often removed after how many days?

7-10 days

72
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Promotes continues wound intention

steri strips