What type of diet is seen in this picture?
Mechanical Soft
A patient’s labs return with a sodium level of 150. The nurse anticipates which of the following orders?
IV 5% saline
IV 0.9% salin
IV 0.3% saline
IV 3% saline
A period of time or state of mind where feelings of loss, grief, or mourning are experienced by the survivor after the death of a loved one is known as _________
bereavement
The nurse documents this area of unblancheable redness as a stage ______________ pressure injury
one - 1
Carb Counting. Patient blood sugar is 175 before breakfast. They ate 30 gms of carbs for breakfast. The physician ordered (1 unit of Humalog regular insulin/20 grams of carb eaten) Also needs correctional insulin. How much do you give?
3
1
2
5
A newly graduated nurse is assigned to care for a team consisting of herself and a certified nursing assistant. When delegating skills, she needs to
Assess the knowledge of the certified nursing assistant.
Remind the staff member that she is working under the RN
Assign only bed-making and feeding skills.
Asking them to perform skills that the RN is able to teach
True or False? The evaluation phase of the nursing process is to determine whether nursing interventions have enabled the patient to meet the desired goals.
True
The nurse documents this wound as pressure injury as
unstageable
True or False? Dementia is a normal sign of aging
False
Legal documents that allow people to convey their wishes for end-of-life care and include living wills, durable powers of attorney for healthcare, and healthcare proxies are known as _____
advance directives
In the movie Tuesdays With Morrie, why does Morrie choose to stay in his chair?
It makes it easier to lift him for moving
So he can sit upright to see his guest
He has fewer coughing spells up in the chair
He feels that he has surrended to death if he stays in bed
The nurse documents this wound as a
abrasion
cut
wound
laceration
In a patient with elevated PT, PTT or INR, on dressing change the nurse may expect
increased bleeding
True or False? Abdominal assessment is performed in the following order: inspection, auscultation, palpation, and percussion?
False
A nurse calculates the BMI of a client during a general survey as 26. Under what category would this client fall?
Overweight
For a sigmoidoscopy procedure the nurse should place the patient in what kind of position?
Sims' position or left lateral
A nurse is teaching a patient about foods that are included on a clear liquid diet. Which of the following food choices made by the patient indicates the need for further teaching?
Popsicle
Yogurt
Broth
Gelatin
True or False? A hypertonic solution has a greater osmolarity, causing water to move out of the cells and to be drawn into the intravascular compartment, causing the cell to shrink.
True
The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis best addresses the greatest concern of complication from this sensory deficit?
Fear
Risk for fall
Social isolation
Body image disturbance
A hospitalized patient has been NPO with only IV fluid intake for a prolonged period. What assessment might indicate protein calorie malnutrition?
Weight gain visual deficits, erythema of skin
Poor Wound healing, apathy, edema
Fever, joint pain, dehydration
Sleep disturbances, increased output, anger
The nurse is caring for a young patient whose mother has only a week to live. The patient has been misbehaving at school recently and is suspended after picking fights with students & defying teachers. Which stage of grieving is he in?
Anger
A nurse may suspect that a patient is experiencing urinary retention when the patient has:
Small amounts of urine voided 2 to 3 times per hour
Spasms and difficulty during urination
Burning Pain in the suprapubic region
Large amounts of voided cloudy urine
An 82-year-old male presents to the ED c/o excess thirst, 2+ pitting edema, and decreased urine output. He states he has had a cold and has been taking Alka-Seltzer every 4 hours for the past week. The nurse suspects
Hypokalemia
Hyperkalemia
Hyponatremia
Hypernatremia
Processed foods such as canned soup and frozen pizza have high levels of
water
sugar
sodium
potassium
The nurse documents this this thin, red-tinged drainage as
serosanguineous
The nurse documents this drainage as
serous
The nurse caring for a patient with Tuberculosis. What type of precautions would the nurse implement?
Airborne Precautions
True or false? The best judge of the existence and severity of a patient’s pain is the physician or nurse caring for the patient.
False
The nurse documents this wound as a stage ___ pressure injury
three - 3
What type of diet is seen in this picture?
Pureed
A resident points at the water pitcher and asks if you could hand her the blanket, what is this an example of?
Expressive aphasia
On assessment, the lower extremity demonstrates 2+ pitting edema. The nurse documents this wound as
Venous stasis ulcer
What is this a picture of?
Hematuria
What type of diet is seen in this picture?
Full Liquid
The nurse documents this wound as a stage ___ pressure injury
2 - two
What is the best way to prevent the spread of infections?
hand hygiene or hand washing
Which lab result indicates the presence of malnutrition?
Hematocrit 56% (ref 40-59%)
Creatinine 1.9 mg/dL (ref 0.8-1.4 mg/dL)
Serum albumin 2.8 g/dL (ref 3.5-5 g/dL)
Hemoglobin 11.3 g/dL (ref 11.5-16)
A nurse is teaching an alert client how to use a PCA system in the home. How will the nurse explain what they must do to self-manage pain?
"When you push the button, you will get the medicine."
"The medicine is going into your body all of the time"
"You don't have to do anything, the machine does it all."
"I will teach your family what they need to do"
When might someone have rigor mortis?
After death
In early adulthood
After birth
Over the age of 50
This bulb drain is known as a ___________
JP Drain or Jackson-Pratt Drain
Leslie has had right lower abdominal pain for the past 2 weeks from a surgical wound. How would the nurse classify this pain?
Somatic, Chronic
Viseral, Acute
Viseral, Chronic
Somatic, Acute
What is the best route for administration of TPN?
IV - Centrally
A nurse is looking at a patient's labs and notices that their calcium levels are at 7.4mg/dl, which sign is expected from the patient?
Seizure
Dysrhythmias
Depressed respirations
Trousseau's Sign
A nurse checks a patients sodium levels and notices the sodium levels are at 150 mEq/L, which is an expected finding from that patient?
Edema
Chvostek's Sign
Diarrhea
Increased deep tendon reflexes
Which assessment finding is NOT associated with approaching death?
Loss of appetite
Increased blood pressure
Progressive weakness
Increased drowsiness
The nurse is caring for a patient with depression. Which statement by the patient indicates a need for further education?
“Depression can have a rapid onset.”
“Depression can be caused by chemical changes in the brain
"Depression is always treated with medication.”
“Depression is a mood disorder.”
The outward social expressions of loss often dictated by cultural norms, customs, rituals, and tradition is known as _______
mourning