LATEST Hondros Nursing Nur 150: Exam 2 REVISED 2023//2024

Stage 1 pressure ulcer - ANSWER Intact skin with nonblanchable redness Stage 2 pressure ulcer - ANSWER Partial loss of dermis. Shallow open ulcer, usually shiny, or dry. Red-pink wound bed without sloughing or bruising. Stage 3 pressure ulcer - ANSWER Full thickness tissue loss, subcutaneous fat may be visible. Possible undermining and tunneling. Stage 4 pressure ulcer - ANSWER Full thickness tissue loss with exposed bone, tendon,or muscle. Slough or eschar may be present as well as undermining and tunneling. Unstageable pressure ulcer - ANSWER Full thickness tissue loss, wound base covered by slough and eschar therefor dull depth cannot be determined. Slough - ANSWER Fibrous tissue in wound bed that can be yellow, tan, gray, green, or brown. Nursing interventions to prevent pressure unlcers - ANSWER Reposition bed bound pt every two hours, instruct pt in wheelchair to shift their weight every hour. Use of cushions and barrier cream. Manage moisture, optimize nutrition and hydration. Cognition - ANSWER All the processes involved in human thought External nutrition - ANSWER Nutrition support via tube feedings Parenteral nutrition - ANSWER Nutrition supplied intravenously DRI - ANSWER Refers to a set of nutritional based values that serve for both assessing and planning diets Three ways to confirm proper NG placement - ANSWER Chest x-ray, PH test gastric contents, air bolus. With tube feeding what must be monitored daily - ANSWER I/O, daily weight, daily labs Fatal risk of dysphagia - ANSWER Aspiration pneumonia Nectar thickened - ANSWER A little slower of the spoon than water Honey thickened - ANSWER Very much slower off the spoon than water Spoon thickened - ANSWER Will not drop off spoon Puréed - ANSWER Pudding consistency such as mashed potatoes, vegetables, pasta in pudding consistency Mechanical soft - ANSWER All foods except hard, crunchy, or sticky Dysphagia advanced - ANSWER Includes moist and soft foods such as cooked cereal, canned fruit, noodles in sauce. Cold therapy NC - ANSWER Recommended for first 24-48 hours after injury. Do not apply to red or blue areas. Check condition of skin every 5 minutes when using electrical cooling device. What color should the contents be when aspirating an NG tube - ANSWER Green, brown, or tan Caution with digital impaction removal - ANSWER Cardiac patients How many enemas should you do in a row - ANSWER Until everything comes out clear, no more than 3 HILDA - ANSWER Pain assessment: how does pain feel? Intensity? Location? Duration? Aggregating or alleviating factors? The fifth vital sign - ANSWER Pain Organ that inacativates and metabolizes drugs - ANSWER Liver Organ that eliminates the metabolites of the drug from the body - ANSWER Kidneys