Exam 3: NUR 204/ NUR204 Leadership and Management VERSION 1| Q & A (NEW 2026/ 2027 Update) Grade A | 100% Correct (Verified Solutions)- Fortis

…..DLDD Exam 3: NUR 204/ NUR204 Leadership and Management VERSION 1| Q & A (NEW 2026/ 2027 Update) Grade A | 100% Correct (Verified Solutions)- Fortis Q. on initial assessment of a patient the nurse notices an area of redness over the right trochanter that when pressed lightly does not blanch. what does this assessment cue indicate to the nurse? Answer the presence of a stage 1 pressure injury Q. Four days after abdominal surgery, the patient is getting out of bed and feels something "pop" in his abdominal wound. An increase in amount of drainage from the wound is seen, and further examination shows that the sutured incision is now partially open, with tissue protruding from the wound. What is the nurse's next action? Answer cover the wound with saline moistened gauze Q. Which features are characteristic of a closed drainage system such as a Jackson-Pratt (JP) drain? (Select all that apply.) Answer - usually is inserted in surgery - allows for accurate measurement of wound drainage Q. Based on knowledge of areas at greatest risk for development of a pressure ulcer in the bedridden patient, the nurse identifies which position to minimize this risk? Answer 30 degree side lying Q. A patient who has suffered a stroke is unable to maintain his position while seated in a chair without sliding down. His physician has ordered him to be up in a chair for part of the day. What does the nurse recognize as the patient's greatest risk factor for development of pressure ulcers? Answer pressure and shear Q. A patient has a stage III pressure ulcer on the coccyx. Which food will be most beneficial in improving the healing process? Answer high calorie high protein drink Q. Which technique is used to collect an aerobic culture specimen from a wound? Answer irrigate the wound before collecting the culture material Q. which patient is at highest risk for impaired wound healing Answer a 72 year old with diabetes and cardiovascular disease who has surgical repair of a broken hip Q. which best describes a fresh surgical wound that has been closed with sutures or staples making the two edges of the wound meet Answer approximated Q. cognition Answer knowing influenced by awareness and judgement it comprises skills that include language calculation memory and attention Q. sensation Answer is a feeling within or outside the body of conditions resulting from stimulation of sensory receptors Q. stimulus Answer a change in the environment sufficient to evoke a responce Q. perception Answer the way the brain perceives the information Q. decussate Answer The cross-over of sensory pathways as they ascend the spinal cord before reaching the brain Q. stratum corneum Answer outermost layer of the epidermis, which consists of flattened, keratinized cells Q. stratum germinativum Answer innermost layer or basal layer only single layer of cells Q. rete ridges Answer papillary dermis irregular interconnected projections that extend from the dermis and link with the epidermis Q. subcutaneous layer Answer layer of adipose tissue or fat Q. wounds Answer disruptions that may occur in the skin's integrity, leading to a loss of the skin's normal functioning Q. factors that lead to the development of wounds and decay in wounds are Answer -vascular disease - diabetes -malnutrition -medication Q. tactile receptors Answer Nerve fibers that detect by touch and pressure Q. olfacation Answer sense of smell Q. chemoreceptors Answer sensory nerve endings that react to chemicals gustation sense of taste auricle the outer ear ossicles -3 bones of the middle ear (malleus, incus, stapes) -transmit and amplify vibrations from tympanic membrane to inner ear -Malleus is attached to the tympanic membrane and acts on the incus (anvil) which acts on the stapes (stirrup) -Stapes rests on oval window of cochlea labyrinth intricate communicating passageways that compose the inner ear semicircular canal a second set of labyrinths in the inner ear retina innermost layer of the eye rods more sensitive to light can provide vision in the dim lights cones detect sharp color delirium reversible state of acute confusion sensory deprivation means decreased stimulation from the environment. dementia permanent decline to mental function alzheimers most common type of dementia amyloid plaques protein fragments, build up between brain nerve cells, blocking electrical and chemical connections between neurons neurofibrillary tangles twisted fragments of protein that clog the nerve cells sundowning worsening of agitation and confusion in the evening clean contaminated wound Similar to a clean wound, but because the surgery involves organ systems that are likely to contain bacteria, the risk for infection is greater. contaminated wound Results from a break in sterile technique during surgery infected wound A wound showing clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus) colonized wound A wound that has one or more organisms present on the surface, but when a swab culture is obtained there is no overt sign of an infection in the tissue below the surface 3 phases of healing inflammatory, proliferative, maturation inflammatory phase phase begins with the body initial response to wounding of the skin and also about 3 days proliferative phase The purposes of this phase are to repair the defect; fill the wound bed with new tissue, called granulation tissue; and resurface the wound with skin. maturation phase the last phase of wound healing which lasts for up to a year scar tissue avascular mass of collagen that gives strength to the repaired wound factors that affect wound healing include Disease processes Nutrition Age Infection colloidal healing scar keloid scars are smooth , hard , benign growth that also form when scar tissue grows excessively fistula An abnormal connection between two internal organs or between an internal organ and, through the skin, the outside of the body pressure ulcer Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear the nursing assistant asks you the difference between a wound that heels by primary or secondary invention you will reply that a wound heals by primary intention when the skin edges approximate stage 2 pressure ulcer partial thickness skin loss involving epidermis does not extend below the level of the dermis stage 3 pressure ulcer full thickness wound that extends Into subcutaneous tissue but does not extend to the muscle or bone stage 4 pressure ulcer wound deeper than stage 3 and does have exposure to the muscle and bone unstageable pressure ulcer A full-thickness wound in which the amount of necrotic tissue, or eschar, in the wound bed makes it impossible to assess the depth of the wound or the involvement of underlying structures suspected deep tissue injury area of intact skin that is purple or maroon or a blood-filled blister a nurse conducts a through physical assessment for all patients exhibiting a change in cognitive or sensory status the assessment includes - vital signs -neurological assessment - lab test who is uncharge of measuring a wound UAP impaired skin integrity related to compromised nutritional status and immobility as evidenced by pressure ulcers on the hip and heel impaired physical mobility Related to pain during position changes as evidenced by the patient grimacing when turned in bed impaired tissue integrity Related to pressure secondary to immobility as evidenced by a stage III pressure ulcer on the coccyx acute confusion related to cerebral hypoxia secondary to a clot in the cerebral artery as evidenced by being oriented to person and confused about place and time. chronic confusion related to progressive brain degeneration secondary to Alzheimer disease as evidenced by poor judgment, wandering, loss of ability to compute numbers, memory loss, and change in personality. disturbed thought process related to degenerative brain disorder as evidenced by inaccurate history and medical deficit drains nurse is responsible for understand the different types of drains and the care required by the patient with a drain JP drain soft drains attached to a bulblike hemovac drain springlike suction device closed wound drain drains extra fluid from inside of body to the outside most used for orthopedic and abdominal surgeries Penrose drain an open drain that is a flexible piece of tubing; is usually not sutured into place a surgical wound requires a hydrogel dressing the primary advantage of this type of dressing is that it provides moisture needed for wound heeling sutures used to bring the edges of a wound together in order to speed up wound feelings and reduce scar formation wounds may be closed with steri strip dermabond suture staples heat therapy causes vasodilation muscle relaxation decrease stiffness cold therapy causes vasoconstriction decrease swelling decrease blood flow pressure injury prevention is paramount steps wound irrigation sterile dressing wet to damp wound culture negative pressure tx wraps and bandages wound irrigation -clean -apply heat and antibiotics -remove debris -30-50mL syringe and 18 gauge catheter debriedment removal of necrotic tissue wet/ damp to dry gauze may what remove healthy tissue vacuum assister therapy used for acute and tramatic wounds pressure ulcer or chronic open wounds helps with fewer dressing changes localized subatmospheric pressure draws wound edges toward the center of the wound, leading to reduced edema and bacterial colonization and promotion of granulation tissue formation in the wound what test has the doctor ordered to examine whether mrs Rees is losing blood from a GI source stools x3 for occult blood what instructions will the nurse provide mrs Rees regarding her preparation for the procedure this morning select all that apply - provided with clear liquids today to maintain a clear GI tract for viewing - will be NPO after midnight to prevent aspiration during the procedure - given going to the lab with an iv running the nurse will administer a sedative through the IV when the lab calls the unit tomorrow morning before the EGD - provided with preparation information including spraying her throat with an anesthetic to numb it before the doctor inserting the scope for the EGD which doctors order is written to support the patient if this. physiologic change presents secondary to anemia o2 204 L per nasal cannula tiltrate to keep pO2 93% tissue load pressure friction shear Sally makes ongoing rounds, recommending prevention strategies and treatments for a wide variety of wounds, including pressure ulcers. A pressure ulcer is a/an: localized area of tissue necrosis which of the following contribute to Mr. Esserman's risk for development of pressure ulcers select all that apply - paralysis of arm and leg - loss of sensation - difficulty swallowing - slurred speech - urinary incontinence what scale is used to for pressure ulcer risk braden scale With Sally, you prepare to teach the Essermans about pressure ulcer prevention. Which of the following approaches is best? provide printed material about preventing pressure ulcers and spending time with the essermans explaining pressure ulcer prevention which of the following modifications are recommended when teaching older persons select all the above -use of large print - presentation and discussion should be slow and unrushed - slight louder low pitched voice may be needed What should the Essermans be taught about moving and positioning? -a soft sheet or towel applied under mr esserman can be used to assist with turning - when moving mr esserman the person doing the moving should bend his/her knees mr essermans bed should be changed every 2 hours reactive hyperemia result of a compensatory rush of blood to an area that has been deprived of blood flow when assessing a reddened area it is important that it be checked for blanching sensation When Mr. Esserman is in a chair, his weight should be shifted every: 15 mins blanch able erythema area has been deprived of oxygen but damage has not occurred which of the following techniques can be used to determine if the air filled static overlay on mr essermans bed is adequate in reducing pressure place a hand between mattress and the overlay Mr. Esserman needs nutrients of all types to provide calories and energy, but especially protein. What strategies do you appropriately encourage Mrs. Esserman to use in providing extra protein in her husband's diet? -at each meal, feed protein rich foods first - offer yogurt or seasoned soft cooked scrambled eggs to provide protein Mrs. Esserman asks, "How will I know if my husband is getting one of these bedsores?" Which of the following advice is appropriate? "when your husbands position is changed check for reddened areas" using the Braden scale which of the following score would indicate that a person was at low risk for developing a pressure ulcer 23 A written care plan for pressure ulcer prevention, which includes a repositioning schedule, is established for Mr. Espreaux. Important components include: -use of support surfaces - use of positioning devices -having Mr. espreaux shift his weight periodically in back lying positioning in bed head elevation at ____ degrees or lower will reduce the risk for shearing from sliding down the bed 30 in the side lying position skin to skin pressure an be avoided with a pillow placed between the knees at what degree 30 in assessing mr. espreaux because he is African American and dark skinned which of the following indicators of a stage 1 pressure ulcer apply - warmth to touch - induration Sally reminds the nurses caring for Mr. Espreaux about the importance of staging any pressure ulcers. Which of the following are true about staging? -pressure ulcer should be staged using a staging system - pressure ulcers should be staged when discovered -staging is a primary criterion that guides treatment which dressing choice is acceptable for a stage 2 pressure ulcer - sacral specific hydrocolloid dressing -transparent film membrane dressing The nurse is teaching a patient with diverticulitis about increasing fiber intake. Which of the following foods should the nurse recommend? banana A patient is prescribed furosemide and is at risk of hypokalemia. Which food choice would be beneficial to manage this potential side effect? oranges Which of the following actions should be taken by the nurse when caring for a patient receiving total parenteral nutrition (hyperalimentation)? (Select all that apply.) - change in the iv tubing every 24 hours according to facility protocol - monitor patients blood glucose levels every 6 hours - use an infusion pump for administration A patient is a newly diagnosed diabetic. The nurse prioritizes education focused on which of the following nutritional choices? limit carbs The nurse evaluates that nutritional education for a patient on a clear liquid diet has been effective when the patient selects which food item to comply with this order? chicken broth The nurse instructs a patient with renal failure who is receiving hemodialysis about the type of diet needed to be consumed. The nurse determines that the patient understands the education if the patient selects which diet? low in sodium phosphorous and protein The nurse has placed a nasogastric tube for a patient requiring enteral feeding. The nurse validates placement through pH measurement and using clinical judgment. What gold standard should be used to confirm placement prior to using the tube? xray Which of the following nutrients is most helpful in preventing birth defects and should be taken by women of childbearing age? folic acid The nurse is reviewing discharge instructions for a patient on a low-fat diet. The nurse determines that the patient understands the dietary instructions if the patient selects which of the following food choices containing unsaturated fat? almonds The nurse is instructing the patient in selecting food items that contain common sources of protein in the diet. Which of the following food choices can be included in the teaching as examples? (Select all that apply.) fish beans eggs avocados erthrocytes red blood cells Thrombocytes platelets Leukocytes white blood cells Neutrophils act as first defenders against bacterial and fungal infections, foreign antigens and cell debris lymphocytes recognize foreign antigen create memory cells and produce antibodies monocytes involved in phagocytosis become macrophages Eosinophils destroy parasitic organisms and play a major role in allergic reactions basophils involved in the inflammatory response to an injury release histamine plasma Fluid portion of blood electrolytes sodium(Na+) potassium(K+) calcium(Ca++) magnesium(Mg++) chloride(Cl) bicarbonate(HCO3-) phosphate(HPO4-) proteins albumin,fibrinoge,globulins albumin the major plasma protein maintains fluid balance by providing colloidal osmotic pressure in blood fibrinogen facilitates coagulation by converting into fibrin threads in the presence of ionized calcium Globulins classified as alpha, beta and gamma globulins 5 blood clotting test platelets bleeding time prothrombin time aptt fibrinogen glycosylated hemoglobin hemoglobinA1c(HgbA1c) cholesterol a steroid found in cell membranes a precursor for other steroids in the body low density lipoproteins Transporters of cholesterol from the liver to the body; "bad cholesterol" because of its role in atherosclerotic disease. high density lipoprotein cholesterol Transports excess cholesterol from the tissues back to the liver, where it is broken down and excreted in bile; "good cholesterol" triglycerides composed of fatty acids proteins and glucose LDL= TC - HDL - (TG/5) liver tests are blood test used to help monitor liver disease or damage alanine transaminase (ALT) ALT is an enzyme found in the liver that helps convert proteins into energy for the liver cells. When the liver is damaged, ALT is released into the bloodstream and levels increase. aspartate transaminase (AST) AST is an enzyme that helps metabolize amino acids. Like ALT, AST is normally present in blood at low levels. An increase in AST levels may indicate liver damage, disease or muscle damage. Alkaline Phosphatase (ALP) ALP is an enzyme found in the liver and bone and is important for breaking down proteins. Higher-than-normal levels of ALP may indicate liver damage or disease, such as a blocked bile duct, or certain bone diseases. Albumin and total protein Albumin is one of several proteins made in the liver. Your body needs these proteins to fight infections and to perform other functions. Lower-than-normal levels of albumin and total protein might indicate liver damage or disease. bilirubin a substance produced by the breakdown of red blood cells Gamma-glutamyl transferase (GGT) is an enzyme in the blood L-lactate dehydrogenase (LD) enzyme found in the liver blood urea nitrogen (BUN) urea is a byproduct of protein metabolism excreted by the kidneys Serum Creatinine waste of product of skeletal muscle metabolism and is excreted via the kidneys normal ratio of BUN to creatine 6:1 or 20:1 cardiac markers Used to detect myocardial damage resulting from coronary artery occlusion creatine kinase enzyme found primarily in skeletal muscle cardiac muscle and brain tissue isoenzyme CK-MB is found in what tissue cardiac ck levels will increase approximately 3-4 hours after a myocardial infarction stay elevated 3-4 days myoglobin oxygen transporting and storage protein found in cardiac and skeletal muscle troponin is complex of 3 proteins found in skeletal and cardiac muscle homocysteine high levels are associated with an increased risk of cardiovascular disease Brain Natriuretic Peptide (BNP) Elevated levels are often found in patients with heart failure and can be used to assess its severity c-reative protein CRP appears in the blood in response to inflammation tissue damage and infection used as a screening for coronary artery disease arterial blood gas ABG Used to assess oxygenation status and acid-base balance arterial blood gas test measures acidity or ph and the levels of oxygen and carbon dioxide from an artery steatorrhea fecal fat Urobilinogen breakdown of bilirubin upper gi series of X-rays include esophagus, stomach,duodenum, upper portion of jejunum lower gi series of X-rays include ascending, transverse, descending and sigmoid colon and rectum CT scan (computed tomography) organ scan MRI (magnetic resonance imaging) brain pathology and joint visualization Positron Emission Tomography (PET) nuclear study performed after injection of a radionuclide into a vein Electrocardiogram (ECG) recording of the electrical changes that occur in the myocardium during a cardiac cycle endoscopy examination of the interior of an organ or cavity by means of a fiberoptic scope If fecal occult blood test is positive, consider colonoscopy ultrasound visualization of soft tissue organs by recording and measuring the reflection of ultrasonic waves paracentesis involves removing fluid from the peritoneal cavity thoracentesis removes fluid from pleural space biopsy removes a large collection of cells in a tumor or mass care during lumbar puncture -side lying position with knees drawn up to chest - sterile technique - provide emotional support - label specimen in presence of patient and transport to lab post procedural care of lumbar puncture -lie flat 4-8 hours - encourage fluids - neuro assessment - assess puncture site for drainage -administer analgesics PRN what lab values show dehydration BMP BUN urinalysis CBC urine osmolality electrolytes are minerals that give off an electrical charge when they dissolve in fluids your body makes electrolytes sodium controls fluid levels and aids nerve and muscle functions potassium supports heart, nerve and muscle function it also moves nutrients into cells and waste products out of them while supporting your metabolism calcium helps blood vessels contract and expand to stabilize blood pressure. it also secretes hormones and enzymes that help the nervous system send messages chloride helps maintain healthy blood levels blood pressure and bodily fluids magnesium aids nerve and muscle function. it also promotes the growth of healthy bones and teeth phosphate supports the skeletal system as well as nerve and muscle function bicarbonate helps balance acids and basic alkaline compounds in blood(ph balance) bicarbonate also helps move carbon dioxide through your blood stream do diagnostic exams require informed consent most do venipuncture puncture of a vein performed by nurses but most comply performed by phlebotomists gloves need to be worn timing of test is important arterial puncture puncture of an artery usually performed by a phlebotomist or nurse who is specially trained fingerstick capillary puncture routinely taken by nurse and sometimes by UAP depends on facility hemolysis breakdown of RBC and subsequent release of hemoglobin UAP should report for blood glucose testing -completion -time difficulties UAP should report for urine collection - completion -color -difficulties stool collection is closed on a hemoccult test strip stool specimen collection purpose issues with gastrointestinal UAP should report for stool specimen collection - positive results - completion - color,odor - difficulties what can cause a false positive for a stool specimen meds such as aspirin anti-inflammatory what can cause a false negative for a stool specimen ascorbic acid sputum Mucus coughed up from the lungs when there is inflammation or an infection is a throat culture delegated to the UAP NO laboratory studies prealbumin albumin transferrin hemoglobin and hematocrit blood urea nitrogen and creatine elimination patterns -constipation - diarrhea impaired swallowing residual effects if neurological damage secondary to CVA, gagging an choking with oral intake attemps impaired self feeding sensory and motor deficits secondary to spinal cord injury bilateral upper-extremity paralysis and inability to self-feed clear liquid diet no pulp short term full liquid diet foods that are liquid at body temp cant tolerate solid food pureed diet blended mechanical soft diet modified food consistency like mashed potatoes thickened liquids diet for dysphagia and risk of aspiration diabetic diet control carb intake cardiac diet low cholesterol, low sodium renal diet restrict potassium, sodium, protein, phosphorus preventing aspiration - Position in high fowlers - tuck chin when swallowing - keep client in semi fowlers at least 1 hr after meals -no straw heart healthy diet low in added salt, cholesterol and fat what angle do you eat at 30-45 degree nutrition the body intake and use of adequate amounts of necessary nutrients for tissue growth and energy production nutrients the necessary substances obtained from ingested food that supply the body with energy; build and maintain bones, muscles, and skin; and aid in the normal growth and function of each body system malnutrition an imbalance in the amount of nutrient intake and the body's needs basal metabolic rate (BMR) the minimum amount of energy required to maintain body functions in the resting, awake state macronutrients carbohydrates, proteins, fats, water micronutrients vitamins and minerals digestion of food enzymes absorption of nutrients catabolism pharynx swallows esophagus trasports food liver breaks down stores vitamins and iron produce bile small intestine -completes digestion -absorb nutrients stomach breaks up food pancreas Regulates the level of sugar in the blood large intestine reabsorbs water carbohydrates 4 kcal/g fats 9kcal/g protein 4kcal/g water is necessary for Helping control body temperature, maintaining acid-base balance, regulating fluid and electrolytes, transporting nutrient and waste products when water is lost without replacement Blood volume diminished; oxygen, nutrients, and wastes cannot be moved how many liters of water a day for a male 3.7 how many liters of water a day for a female 2.7 vitamins are organic compounds that contribute to important metabolic and physiologic functions within the body Do vitamins provide energy? No they do not fat soluable vitamins are A, D, E, K vitamin A growth and repair of body tissues vitamin D calcium vitamin E antioxidant vitamin K Helps blood clot water soluble vitamins vitamin c b 1,2,3,5,6,7,9,12 vitamin c ascorbic acid helps immune system Vitamin B1 (thiamine) helps with neuropathy found in pork Vitamin B2 (Riboflavin) helps RBC production reduce inflammation of nerves found in meat and dairy products Vitamin B3 (Niacin) enables release of vitamin C (ascorbic acid) needed for absorption of iron and to maintain body cells; found in citrus fruits and green vegetables Vitamin B5 (pantothenic acid) Metabolism synthesis of hormones and cholesterol (eggs, fish, milk, whole grain cereal) Vitamin B6 (pyridoxine) Helps build body tissue and aids in metabolism of protein Vitamin B7 (Biotin) helps hair growth Vitamin B9 (folic acid) lower birth defect rate Vitamin B12 (cyanocobalamin) pernicious anemia low folate levels antioxidants may protect body cells against the effects of free radicals musculoskeletal alterations •Imbalance of vitamins, particularly vitamins A and D •Deficiencies of minerals such as calcium, phosphorus, and magnesium neurologic alterations •Excess dietary intake of sodium •Deficiency of folate cardiopulmonary alterations Substances secreted from fat cells produce most of the pathologic changes digestive system alterations Conditions that affect the body's ability to process nutrients type 1 diabetes mellitus insulin dependent Type 2 disease non insulin dependent allergies immune system responce intolerance digestive system responce internal feedings may be used to -provide sole nutrition intake -provide supplemental nutritional intake - ensure adequate hydration Nasogastric and nasojejunal tubes short term nutritional therapy and bowel decompression percutaneous endoscopic gastrostomy (PEG) tube long term nutritional therapy in patients who are neurologically impaired or have a condition that affects the stomach feeding tube need to be flushed with 30 ml of water at least every 4 hours PEG tube is placed in stomach infuses food directly to stomach g tubes are replaced every 30 days PICC line Peripherally Inserted Central Catheter (PICC) CVC central venous catheter If a patient has a low number of erythrocytes, or red blood cells, the nurse expects what to be affected? oxygenation and acid-base balance 3 multiple choice options If a patient has a low number of thrombocytes, or platelets, what will be affected? the bloods ability to clot 3 multiple choice options If a patient has an elevated, white blood cell count, the nurse knows this could be a sign of.. infection or inflammation 3 multiple choice options Which protein is responsible for oxygen and carbon dioxide transport? hemoglobin What do platelets do when bleeding occurs? they clump together to form a plug and stop bleeding Where are leukocytes primarily formed? bone marrow Where are T-cells formed? thymus What is the purpose of a blood differential test? measures the percentages of each type of WBC and reveals any abnormal or immature cells What role do neutrophils play in the blood? they are the first defenders against foreign antigens What role do lymphocytes play in the blood? the produce antibodies by creating memory cells What role do monocytes play in the body? they find and destroy germs and eliminate infected cells What role do eosinophils play in the body? protect the body from parasites, allergens, and bacteria. Too many cause inflammation in specific areas of your body What role do basophils play in the body? defend the body from allergens/parasites. work closely with the immune system by releasing enzymes to improve blood flow How long do red blood cells live in the body? 2-3 months Which diagnostic study tests the life of a red blood cell? A1c What are the electrolytes in the blood? sodium, potassium, calcium, magnesium, chloride, and bicarbonate What is plasma? -fluid portions of blood -transports electrolytes to and from cells -contains nutrients and proteins -transports hormones throughout the body -transports waste products A patient comes into the office for a yearly physical and complains of persistent fatigue over the last several months. What test is likely to be ordered for this patient? CBC to test for anemia What are the different types of blood samples? venous, arterial, and capillary When is an arterial blood sample taken? to determine arterial blood gas levels When is a capillary blood sample taken? glucose, cholesterol levels, clotting times, hgb, and hct What information does a complete blood count (CBC) provide? oxygen and carbon dioxide transport and immune/inflammatory response A patient comes into the ED and the nurse notices several large hematomas. The patient tells the nurse they are taking heparin. What test does the nurse expect to be ordered? PTT/aPTT A new patient comes in for his first visit. When reviewing medications, he tells the nurse that he takes warfarin. What test does the nurse expect to be ordered? PT/INR What education should a nurse provide for a patient taking an anticoagulant? - use a soft bristle toothbrush - use an electric razor -report any new bruising - limit contact sports A patient comes into the ER complaining of shortness of breath and lightheadedness. The nurse observes pallor, tachycardia, and hypotension. When labs come back, the hemoglobin and hematocrit levels are low. What condition might the nurse suspect? hemorrhage What does mean corpuscular volume (MCV) measure? Average size of red blood cells What does mean corpuscular hemoglobin (MCH) measure? average amount of hgb in an individual RBC What does mean corpuscular hemoglobin concentration (MCHC) measure? proportion of an individual erythrocyte occupied by hemoglobin (relative to the size of the erythrocyte) What is fibrinogen used to monitor? bleeding disorders and live disease A patient has a glucose level of 214. What other laboratory test may be ordered? liver function tests - excess glucose is converted to glycogen and stored in the liver What can high levels of BUN indicate? renal dysfunction, dehydration, or high protein diet What can high levels of creatinine indicate? renal dysfunction What can a low GFR indicate? kidney failure A patient is scheduled for a CT scan with contrast. Which laboratory values are important to check prior to the test? BUN and creatinine Why is it important to check kidney function tests in older adults? higher risk of medication toxicity What patient teaching can the nurse provide to help maintain normal cholesterol levels? follow a diet low in saturated fat and eat foods high in soluble fiber If a patient presents with suspected renal failure, which tests are important to order? BUN, creatinine, and GFR Before administering medication to a patient, why may the nurse need to check liver function laboratory tests? medication is metabolized in the liver and excreted by the kidney, so need to make sure liver can handle medication If a patient presents with suspected malnutrition, which lab tests does the nurse expect to be ordered? albumin and prealbumin What does ALT monitor? liver disease progression and the effect of hepatotoxic drugs What do ALP levels indicate? Presence of possible liver or bone disease What do AST levels monitor? severity of liver damage or disease What doe elevated levels of GGTP indicate? liver disease A nurse in the ED is reviewing the chart for one of her patients and notices troponin is one of the lab tests that has been ordered. What does this indicate? an MI is suspected or has already occured The nurse knows that troponin is the most commonly ordered test when an MI is suspected. Why? Troponin I & T are found exclusively in cardiac muscle and are released into the bloodstream with MI as early as 4 hrs after damage. A patient presents to the ER with shortness of breath and bilateral edema in their ankles. The nurse notes a diagnosis of heart failure in the patient's chart. What lab value should the nurse expect to be elevated? Brain natriuretic peptide (BNP) What vitamin deficiencies can increase homocysteine levels? folate, B6, B12 What test can check for inflammation in the body? CRP When the nurse is teaching a diabetic patient how to check their blood glucose, what is important for them to have the patient do? show they understand by demonstrating how they will check their blood glucose at home A patient has recently been diagnosed with Type II diabetes. What education should the nurse provide? -blood glucose monitoring - medication use - lifestyle changes - importance of keeping appts What does FSBS mean? fasting blood sugar What does ACHS mean? before meals and at bedtime What does hemoglobin A1c meansure? blood glucose levels over a period of 2-3 months A diabetic patient asks the nurse how often they should check their blood glucose at home. What should be the nurse's response? at least 3x daily When obtaining a capillary blood glucose sample, where should the nurse collect the sample from? side of the finger tip What tests are done on urine samples? urinalysis, pregnancy test, drug testing A nurse is performing an occult blood test on a stool sample from a patient. If blood is present, what will the nurse expect to see? filter paper will turn blue What is the purpose of a fecal fat stool test? indicates the inability to digest and absorb fats What do increased levels of urobilinogen in the stool indicate? RBC destruction, like in hemolytic anemia What do decreased levels of urobilinogen in the stool indicate? biliary obstruction or severe liver disease (clay-color stools) If a nurse is collecting a stool sample to test for ova and parasites, what is important to remember? sample must be delivered to lab ASAP while stool is still warm A patient presents to the ED with complaints of persistent abdominal pain and diarrhea after eating at a new restaurant last night. What test will likely be ordered? ova and parasites What are some examples of ova and parasites? roundworm, pinworm, tapeworm, hookworm, and trichinella spiralis What is the purpose of a culture and sensitivity? to identify the pathogen involved in the infection and identify correct antibiotic treatment What are some common specimen sources for culture and sensitivity testing? blood, throat, sputum, stool, urine, wounds What disease is a C&S sputum sample commonly collected for? TB - collect early AM What are x-rays used for? to visualize bones, organs, and soft tissues When is a chest x-ray used? -chest tube placement -central line infusion catheters -pacemakers -pneumonia -TB -Cancer -cardiac enlargement An x-ray of the abdomen can show pictures of what? kidney, ureters, bladder When are x-rays for bones used? fractures, osteoporosis, arthritis, tumors What are contrast studies most commonly used for? GI, GU systems, PE & arteriograms A patient is scheduled for a CT scan with contrast material. What allergies does the nurse need to specifically ask the patient about? iodine and shellfish What is an intravenous pyelogram? contrast x-ray that looks at kidneys, ureter, and bladder Why is a intravenous pyelogram used? helps diagnose kidney stones and abnormalities of the urinary tract A patient is post barium swallow study. What education should the nurse provide the patient? -may experience nausea and constipation - stool may look white for a few days - drink plenty of fluids -may need a mild laxative What is a CT Scan? uses xrays to complete cross-sectional images of an organ. More detail than xray. Can be done with or without use of contrast medium. A patient is scheduled for a contrast study and is taking metformin. What instructions regarding the metformin should the nurse provide the patient? Do not take your metformin for 48 hrs after the procedure (can increase nephrotoxicity) What is commonly given to patients after a contrast study to help flush out the contrast? IV 0.9% normal saline bolus A patient is brought to the ED with symptoms of slurred speech and unilateral weakness. What type of imaging study should be ordered for this patient? CT to determine if patient is having a stroke/what type What is an MRI most commonly used to diagnose? brain pathology and joint visualization How does an MRI work? uses superconducting magnets and radiofrequency waves What does the nurse need to ensure before a patient goes for their MRI? All metal has been removed and they do not have any metal in their body What is a PET scan? nuclear study performed after injection of radioactive chemicals given via IV. The radioactive chemicals are metabolized by organs creating color-coded images. The more metabolism, the redder the hue "hot spots" When is a PET scan used? to study brain and heart and oncologic pathologic issues When is an ECG used? -screening tool prior to surgery -monitoring anesthesia or conscious sedation -exercise stress testing -signs / symptoms of cardiac disease -irregular heartbeat T or F: Performing an ECG can be delegated to a UAP T What is endoscopy used for? to visualize internal organs, identify tumors, growth or inflammation, biopsy T or F: general anesthesia is used with endoscopic procedures F, conscious IV sedation is used What education does the nurse provide the patient prior to an endoscopic procedure? -NPO after midnight -prep for colo -clear liquids Post-endoscopic procedure, what does the nurse need to remember? -have O2 ready -check to see if patient can be aroused -did they have too much sedation? -can they go home the same day? What is an ultrasound used for? provides direct visualization of soft tissues organs by recording and measuring ultrasonic waves. (e.g. muscles, tendons, appendix, gallbladder, fetus, tumors, aorta, kidney stones, spleen) When is a venous duplex scan done? Done to determine blockage in blood flow such as a blood clot that can present as pain or swelling of the extremity. Test performed in the vascular lab with ultrasound and takes 45 minutes or so. No pre or post procedure care require What education does the nurse need to provide the patient prior to an ultrasound? there is likely no prep, but certain procedures ask for a full bladder What is a paracentesis used for? removing ascites fluid from the peritoneal cavity T or F: needle aspirations and biopsies are clean procedures false, they are sterile procedures What is a thoracentesis used for? removes fluid from the pleural space What is fine needle aspiration used for? to obtain samples with minimal trauma to the underlying organ or structure What other diagnostic test is used to help guide FNA? ultrasound When biopsies are obtained via fine needle aspiration, what does the nurse need to do with the specimen? -label -time collected -bring to lab STAT How long do patient's need to stay flat after a lumbar puncture? 4-8 hours When a patient is receiving a lumbar puncture, what signs and symptoms does the nurse need to watch for? -change in color -RR -headache -pain what is the job of the nurse when a patient receives a punch biopsy? bandage biopsy site What are the assessment steps for procedures? -pre-procedure assessment -collect basic health history -check facility's procedure policies and care specific to each test -home instructions What does the pre-procedure assessment involve? •ID the patient, •Review medical history, •Review allergies, •Consent form, •Assess vitals, •medications, •NPO (when appropriate), •Preparations (e.g. laxatives, cathartics), •IV access, pre-procedure medications) What is hemoconcentration? high concentration of RBC to plasma. May occur if tourniquet is left on for too long What is hemolysis? breakdown of RBCs and resulting release of hemoglobin which can occur if needle is too small of blood comes out forcefully T or F: collecting a urine sample can be delegated to UAP T When is a random clean voided urine sample ordered? random urinalysis or drug testing when Is a clean catch specimen required? when urine is cultured and examined for bacteria sterile container is used The nurse is collecting a urine sample from a foley catheter. What steps should the nurse take? clamp the catheter high, wait for urine, take sample What is the minimum amount of urine needed for specimen collection? 10 mL What instructions does the nurse provide to a female patient collecting a clean catch urine sample? -wipe front to back 3 times with three separate wipes -holding labia apart, pee into the toilet first -then, without stopping the flow of urine, pee into the specimen cup What instructions does the nurse provide a male patient collecting a clean catch urine sample? -wipe the end of the penis 3 times with 3 different antiseptic wipes -pee into the toilet first -then, without stopping the flow of urine, pee into the specimen cup What considerations for the older adult does the nurse need to take when it comes to urine specimen collection? older adults may have difficultly controlling the stream of urine and older women with arthritis may have difficulty holding the labia apart If patient is collecting a 24 hour urine specimen at home, what education does the nurse need to provide? -discard first void of the day -must collect all urine over 24 hr period -may want to stay home or only make short trips What can the UAP help with when it comes to 24 hr urine collection? UAP can collect and label, but cannot assess or educate What are the steps to collecting urine from a foley catheter? *Apply clean gloves *Clamp the drainage tubing at least 8cm (3in) below the sampling port for about 30 minutes *Wipe with alcohol wipe the area where the needle/leur-lock syringe will be inserted *Insert the needle at 30-45 degree angle to facilitate self-sealing rubber. Leur-lock syringe is inserted at a 90 degree angle into the needleless port *Unclamp the catheter *Withdraw required amount of urine T or F: Stool sample collection requires sterile technique F, requires medical asepsis or clean technique Which stool studies only require a small amount of stool? hemoccult and cultured specimens When obtaining a sample for ova and parasites stool testing, what is important for the nurse to remember? collect a large sample from different areas f the stool A patient needs to collect a stool sample. What instructions should the nurse provide? *Defecate in a clean bedpan/commode/toilet hat *Void prior to the specimen collection *Do not place toilet tissue in the bedpan *Specimens must be sent to the lab immediately What does the nurse need to consider when it comes to older adults and collecting stool samples they may need assistance, especially with serial stool specimens When is a sputum sample usually ordered? when an infectious disease is suspected Where is sputum collected from? sputum found in lungs, bronchial tubes, and trachea What is the process of collecting a sputum specimen? Offer mouth care so that specimen will not be contaminated with microorganisms from the mouth Ask the client to breathe deeply and then cough up 1-2 teaspoons (4-10mL) of sputum Wear gloves and PPE to avoid direct contact with the sputum special precautions if TB suspected Ask the client to expectorate the sputum into the specimen container Following sputum collection offer mouthwash to remove any unpleasant taste Document the collection and include amount, color, consistency, presence of hemoptysis, odor, and any discomfort experienced by a client How is a throat culture specimen collected? Depress the tongue and use a light to see interior of the mouth and throat Run the swab over reddened or draining areas Procedure may cause gagging What does the nurse need to document when obtaining a throat culture specimen? any swelling, redness, presence &color of discharge, pustules, pain What are some of the conditions a throat culture is looking for? -Strep -candida (thrush_ -diphtheria -gonorrhea -rheumatic or scarlet fever -pertussis What is a nasopharyngeal swab used to detect? respiratory viruses such as flu, RSV and COVID What are the steps to collecting a nasopharyngeal swab? •Have patient blow their nose beforehand •Wear personal protective equipment - follow facility policy •Swab is inserted into nares parallel with the palate until resistance is met •Rotate swab for several seconds •Place the swab into the culturette tube •Post procedure continue to monitor the patient's vital signs, airway & oxygenation status •Communicate test results promptly to the PCP Where should a wound culture specimen be collected from? center of the wound before collecting a wound culture specimen, what does the nurse need to do? •Remove dressing and irrigate wound with normal saline (NS). Ensure that all drainage is removed •Moisten collection sterile swab with NS solution What are the proteins found in plasma? albumin, globulin, fibrinogen What is the role of albumin? the major plasma protein, primarily responsible for maintaining fluid balance by providing colloidal osmotic pressure in the blood What is the role of fibrinogen? plays an integral part in blood coagulation by converting into fibrin threads in the presence of ionized calcium; essential component of blood clots What is the role of globulins? some function as antibodies, others are responsible for enzymatic functions and transport of lipids, iron, and copper in the blood What information does a complete blood count diagnostic test provide? information about oxygen and carbon dioxide transport capabilities, possible infection or inflammatory response, and status of immune response What tests are included in a CBC? -RBC -Hgb -Hct -MCV -MCH -MCHC -WBC What foods enhance healing? protein and vitamin C What are some food sources of protein? milk, eggs, cheese, fish, meat, and poultry, soybeans, beans, peas, nuts, seeds, fruits, vegetables, bread, bread products What are some food sources of vitamin C? fresh yellow and orange fruits, papaya, kiwi, broccoli, and sweet and white potatoes. What is dysphagia? difficulty swallowing What is one of the biggest risks for someone experiencing dysphagia? aspiration What are some of the causes of dysphagia? obstruction from mass or tumor, stroke, neuro damage, psychological disorders If a nurse suspects a patient has dysphagia, what should be their next step? notify the PCP Who usually diagnoses dysphagia? speech pathologist What type of diet is used for patients with dysphagia? thickened liquids What is a clear liquid diet? anything that is clear or see through. ex. Bouillon, fat-free broth, grape, apple, cranberry juice. fruit drinks, popsickles, gelatin, tea, coffee, ginger ale, lemon-lime soda, supplemental formulas. and HARD CANDY What is a full-liquid diet? Foods liquid at room temperature or that melt at body temperature. includes juices with and without pulp, milk and milk products, yogurt, strained cream soups, and liquid dietary supplements. Full-liquid diets are often ordered for patients who have GI disturbances, dental work performed, or who cannot tolerate solid food when they do not need to be NPO or limited to a clear liquid diet. What is a pureed diet? consist of food that is placed into a blender and made into a pulplike mixture. This type of diet is used for individuals who cannot safely chew or swallow solid food. The addition of raw eggs, nuts, and seeds should be avoided. What is a mechanical soft diet? include food consistencies that have been modified, such as ground meat or soft-cooked foods. They are used for those who have difficulty chewing effectively. What is a thickened liquid diet? used for patients who have difficulty swallowing and are at risk for aspiration. Liquids can be thickened by adding a commercially prepared thickening agent. Nuts, seeds, and other hard or raw foods should be avoided to decrease the risk of aspiration. What is a regular diet? commonly referred to as diet as tolerated. There are no dietary restrictions, but foods should supply patients with a balanced diet of essential nutrients. What is a diabetic diet? prescribed to control the amount of calories by controlling carbohydrate intake. Foods that have a high glycemic index and rapidly raise the body's blood glucose concentration should be avoided. High-fiber complex carbohydrates from vegetables and fruits are preferred to simple carbohydrates, sugars, and starchy foods (such as bread or pie). What is a cardiac diet? They typically consist of low-cholesterol and low-sodium dietary items. Cardiac diets minimize the intake of animal products, which contain cholesterol, and soups and processed foods (such as pickles and lunchmeats), which are high in sodium. Patients with hypertension, high cholesterol, atherosclerosis, chronic kidney disease, or similar diseases may be placed on some type of cardiac (low-cholesterol, low-sodium) diet. What is a renal diet? restrict potassium, sodium, protein, and phosphorus intake. Fresh fruits (except bananas) and vegetables are excellent dietary choices for people on a renal diet. Meats, processed foods, and peanut butter, cheese, nuts, caramels, ice cream, and colas typically are allowed in limited quantities or contraindicated. Why are enteral feeding tubes used? to provide short-term nutritional support for patients who have a functional GI tract but cannot swallow, refuse to eat, or need additional nutrients to meet the body's needs. T or F: NG tubes are used for long-term feedings F, used for short-term feedings When may a patient not be eligible for an NG tube? Patients who have had esophageal cancer or traumatic injury to the nose and mouth When preparing to insert an NG tube, how should the nurse measure the correct length of tubing for the patient? measure the length of tube needed for the patient by placing the tip of the tube at the tip of the patient's nose and extending it to the patient's earlobe and then midway between the xiphoid process and umbilicus. When advancing an NG tube, the nurse notes the tube has reached the nasopharynx, what instruction should they provide the patient? tilt your chin forward and swallow small sips of water through the straw. Once an NG tube is in place, how should the correct placement be verified initially? chest x-ray Once initial NG tube placement has been confirmed by an x-ray, how should the nurse verify placement subsequently? aspirate a small amount of gastric secretions and check the pH to make sure the acidity matches that of the stomach (around 5) The nurse is administering a tube feeding through an NG tube and the patient looks very startled and starts to gag and cough. What should the nurses next step be? stop the feeding, get another x-ray to verify placement What position should a patient be in when they have an NG tube placed for enteral feedings? the head of the bed needs to be elevated at least 30 degrees If a patient is unconscious and receiving tube feedings, how should they be positioned? elevated 30 degrees and placed on their left side What lab tests are important to look at when assessing nutrition status? prealbumin, albumin, and transferrin What do decreased levels of prealbumin, albumin, and transferrin indicate? malnutrition What blood tests are commonly used to evaluate cardiovascular health? total cholesterol, triglycerides, LDL, HDL What does a nurse need to educate a patient on prior to having an MRI? -all metal must be removed -you may experience some claustrophobia as the exam will be done in a tunnel-like machine and you will hear some loud noises -depending on anxiety level, some patients may need a sedative What is the therapeutic level for PT when a patient is on anticoagulant therapy? 1.5-2 times the control value What is the therapeutic level for PTTT and aPTT when a patient is on anticoagulant therapy? 1.5 - 2.5 times the control value When administering medications, what requires a 2 person check? medical wastage, insulin administration, blood products What are common uses for intradermal route of administration? often used to administer local anesthetics, to test for allergies, and to test for tuberculosis exposure. What are common injection sites for intradermal administration? inner forearm, upper arm, and scapular area What size syringe is used for an intradermal injection? 1 ml tuberculin syringe with 25-27 gauge needle that is 1/4 to 5/8 inch long What angle should an intradermal injection be administered at? 15 degrees What are the common uses for subcutaneous route of administration? used to administer insulin or heparin What are the sites of administration usually used for subcutaneous injection? abdomen, lateral aspects of the upper arm and thigh, scapular area of the back, and upper ventrodorsal gluteal area What angle should a subcutaneous injection be administered at? if you can pinch at least an inch of skin, 90 degrees, otherwise 45 degrees When administering insulin, what type of syringe must be used? an insulin syringe that measures in units What are the three common IM injection sites? ventrogluteal, vastus lateralis, and deltoid When should a sharps container be changed? when it is 2/3 full, or approaching the fill line. NOT WHEN IT REACHES THE TOP What does ac mean? before meals What does pc mean? after meals What does h or hr mean? hour What does bid mean? twice a day What does tid mean? three times a day What does qid mean? four times a day what does q mean? every what does g or gm mean? gram What does IM mean? intramuscular What does IV mean? intravenous What does PO mean? by mouth What does NPO mean? nothing by mouth What does PRN mean? as needed What does SL mean? sublingual What does STAT mean? immediately What are the six rights of medication administration? -right patient -right drug -right dose -right route -right time -right documentation When are the three checks of med administration done? -when removing the medication from the dispensing unit -when preparing the medication -at bedside immediately before administering What are the components of a medication prescription? -patient's name and DOB -date and time order is written -name of drug -dose of drug -route of administration -frequency -signature of prescriber How is a buccal medication administered? By placing the medication between the cheek and gum How is a sublingual medication administered? Given under the patients tongue until it is completely absorbed. What types of medication cannot be administered through a tube? enteric-coated, time-release, sublingual, and buccal How does a transdermal patch work? a topical preparation designed to deliver medication slowly for systemic effects (e.g., nicotine for smoking cessation, pain medication such as fentanyl, nitroglycerin for angina). Where would a nurse administer ophthalmic medications? in the lower eyelid When administering eye drops, what instructions does the nurse provide the patient? blink several times and nurse maintains slight pressure on inner canthus to prevent med loss When administering ophthalmic ointments, what steps does the nurse need to take? make sure the applicator tip does not touch the eyelid When administering ophthalmic ointments, what instructions does the nurse provide to the patient? close and roll eyes around and inform them their vision may be blurry temporarily What does the nurse need to consider when it comes to medication administration and older adults? Do not rush medication administration. Allow time for understanding of treatment and slower swallowing. • Crushed or liquid forms of medications may be easier to swallow. • Normal aging processes (e.g., decreased renal and hepatic function) may affect the dosage needed because drugs may be metabolized more slowly. Adverse effects may be increased in elderly individuals. • Patients may need instruction on medications to be taken at home. Focus on the name and purpose of the drug; explain that the appearance and color of the medication may vary by manufacturer. • Loss of dexterity and the ability to open pill bottles, visual impairment, and cognitive impairment in the elderly can affect safe medication administration. When administering ear drops, what is important for the nurse to remember to prevent medication loss? massage the tragus after administering drops What is important to remember about suppositories? They must be kept in a cool place until ready to administer as they melt at room temp. When it comes to medication administration, what are some things that a nurse should never do? -recap a needle -leave a medication in a patient's room -administer a medication they didn't draw up -administer an expired medication If a patient receives a medication and begins experiencing abdominal pain or urinary issues, what should the nurse check? liver and kidney function