NR 224 Fundamentals Final Review Latest Update Questions and Correct Answer Guaranteed Success ____ range of motion is when the patient is unable to move independently therefore the
nurse moves each joint - Correct Answer:Passive ROM
____ range of motion is when the patient moves all joints UNASSISTED - Correct
Answer:Active ROM
_______ nitrogen balance occurs when the body loses more nitrogen than it gains from infection, trauma, burns, fever, starvation, etc. - Correct Answer:Negative Nitrogen Balance
MUST provide patient with protein and proper nutrients to put patient into positive nitrogen balance
< ___ % of fat intake of daily nutrition is considered a nutritional deficiency - Correct
Answer:< 10%
1 gram of carbohydrates = ____ kcal - Correct Answer:4 kcal
1 gram of fat = ____ kcal - Correct Answer:9 kcal
Most calorie dense
1 gram of protein = ___ kcal - Correct Answer:4 kcal
After catheter insertion, the nurse should be aware of proper bag placement to reduce the risk of acquiring a urinary tract infection. Where should the nurse NEVER place the drainage bag? - Correct Answer:Don't place bag on bedrail or floor and never above the patients waist or bladder
Ambulation Considerations - Correct Answer:- Unassisted ambulation means the
patient can ambulation independently.
- Assisted ambulation means the patient requires help to ambulate.
- They might require a gait belt if they are unsteady.
- They might need crutches (if there is a broken bone or surgery)
- Canes and walkers will also assist with ambulation depending on the patients
condition and gait.
*Remember if assisted, think safety and GAIT BELT
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*Be sure to have patient dangle at bedside to check for dizziness/lightheadedness before standing up
Breast milk or formula provides sufficient nutrition for the first _____ to _____ months
of life - Correct Answer:4 to 6 months
Breast milk benefits: fewer food allergies and intolerances; fewer infant infections; easier digestion; convenience, availability, and freshness; temperature always correct; economical because it is less expensive than formula; and increased time for mother and infant interaction. (Potter 1002)
Infants should not have regular cow's milk during the first year of life. It is too concentrated for an infant's kidneys to manage, increases the risk of milk product allergies, and is a poor source of iron and vitamins C and E. Honey and corn syrup are potential sources of botulism toxin and should not be used in an infant's diet. This toxin is potentially fatal in children under 1 year of age (Potter 1002)
Can an indwelling catheter be inserted by a NAP? - Correct Answer:NO
NAP can clean cauterization and site, monitor I&O, and empty drainage bag
Decreased urine output over time indicates _____ - Correct Answer:Dehydration
Does the temperature of the body increase or decrease depending on the time of day?
- Correct Answer:Yes
Temperature is usually lowest between 1:00 and 4:00 AM
During the day body temperature rises steadily until a maximum temperature value at
about 4:00 PM and then declines to early-morning levels
Referred to as Circadian rhythm
Hard restraints require an assessment q___ hours, the doctor must see the patient
within ___ hours. - Correct Answer:q15 minutes
- hour
How can the nurse assess for urinary retention? - Correct Answer:noninvasive bladder ultrasound device (bladder scanner) or intermittent catheterization to assess
How can the nurse or patient relieve pressure regarding positioning? - Correct
Answer:Elevate HOB 30 degrees
1.5-2 hour turning intervals Use a transfer device
- hours or LESS sedentary in a chair 2 / 4
Shift weight q15 minutes Sit on a cushion except riding or donut shaped devices DO NOT massage reddened areas
How can the patient prevent atelectasis? - Correct Answer:- perform breathing
exercises every hour with incentive spirometry
How do pressure ulcers develop? - Correct Answer:Prolonged pressure or unrelieved pressure --> obstruction of blood flow --> ischemia --> necrotic tissue
Examples: prolonged bed rest (most common), decreased mobility, decreased sensory perception, incontinence, poor nutrition, altered LOC
How does the nurse assess the wound or pressure ulcer? - Correct Answer:Size of
wound (L x W x H cm) Depth of the wound from the deepest point Presence of undermining, tunneling (document by clock method, starting at patients head) , or sinus tract Pain
Infection: Swollen/edematous, deep red color, hot, presence of drainage, presence of odor Wound edges may be separated with dehiscence present
How does the nurse measure the length of the NG tube for insertion? - Correct
Answer:Tip of the nose --> earlobe --> xiphoid process
How should ROM exercises be carried out to prevent pain and when should the
exercises be stopped? - Correct Answer:Perform exercises slowly and DO NOT push
past point of resistance/pain
Stop movement if client complains of pain or if there is resistance (document areas of pain verbalized)
How should the nurse assess the patients respirations? - Correct Answer:Look at the chest or abdomen and watch it as it rises/fall and counting.
Assess while assessing remaining 30 seconds of radial pulse
If irregular assess for one full minute
How should the nurse determine the needle length and angle of insertion for a subcutaneous injection? - Correct Answer:Based on patient's weight and estimate about of subcutaneous tissue
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How should the nurse instill ear drops for children < 3 years of age? - Correct
Answer:Pull auricle DOWN and BACK
How should the nurse instill ear drops for children > 4 and adults? - Correct
Answer:Pull auricle UP and BACK
How should the nurse properly administer oral medication? - Correct Answer:Place all the patients medications in the same cup, except for medications with pre administration assessments
Place tablets into medicine cup WITHOUT removing wrapper
ALWAYS hold bottle with label against palm of hand when pouring
Crush pills if the patient has difficulty swallowing and liquid medication is not an option (consult with pharmacists)
Administer liquid medication packaged in single-dose cup directly from the single-dose cup. Do not pour into medicine cup.
Draw up volumes of less than 10 mL in syringe designed for oral medication use without needle
How should the nurse properly clean a pressure ulcer or wound site? - Correct
Answer:Clean with each dressing change
Move from wound towards surrounding skin Wipe only once. Change gauze to repeat.Use careful, gentle motions to minimize trauma Use only 0.9% normal saline solution to clean wounds Report any drainage or necrotic tissue
How would the nurse asses a pulse deficit? - Correct Answer:assess radial and apical rates simultaneously and then compare rates.
The difference between the apical and radial pulse rates is the pulse deficit.
How would the nurse stage a pressure ulcer covers by slough or eschar with full
thickness tissue lost. - Correct Answer:Unstageable
If a patient begins to fall, which steps should the nurse take to ensure the patient and nurse have a less traumatic fall? - Correct Answer:A. Stand with feet apart to provide a broad base of support.
- Extend one leg and let patient slide against it to the floor. (Notice the nurse putting
- Bend knees to lower the body as the patient slides to the floor.
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one foot back.)