MDC 1 Final Study Guide/ MDC 1 Final Exam Review Fall2021
What is the nurses priority if a patient falls?
What is an injury to the skin and
... [Show More] underlying tissue resulting from prolonged pressure on the skin?
What are precautions a patient with low platelets should take in their everyday life?
What are interventions/preventions for pressure ulcers?
What is the best source of information when assessing pain?
What is PQRST in reference to pain assessment?
-What makes the pain worse? What helps the pain subside?
Q: Quality - What does it feel like?
R: Region/Radiation - Where is your pain?
S: Severity - 0 / 10
T: Timing - How long has it been bothering you?
Identify the different types of therapeutic communication
Establishing trust
Being assertive
Validating messages
Exploring issues
Using silence
Open ended questions
Identify communication enhancements for those with visual, hearing, speech, and cognitive disabilities :
use gestures
use short specific sentences
Be concrete and specific
Call client by name
Minimize environmental noise
Face the client when speaking
speak slow and clear
What is RACE in fire safety?
Activate alarm
Contain fire
Extinguish
What are the ABCs of priority care?
Breathing
Circulation/Cardiovascular function
What medications put a pt. at risk for falling?
ACE-inhibitors
Diuretics
Antidepressants
Opioids
What are examples of interventions for confused pt. that is trying to get out of bed?
Bed and chair alarms
Call light within reach
Bed lowest height
Adequate lighting
The Joint Commission, established in 2003, has implemented what program to address patient safety?
Identify "normal" vitals
Temp:
BP:
Respirations
SPO2:
Pulse: :
BP: 120/80 - systolic: 90-120 / diastolic: 60-80
Respirations: 12-20
SPO2: 94-100%
Pulse: 60-100 bpm
What is a movement that increase the angle between two body parts and straightens the joint?
What movement is conducted in a circular manner, often seen at a ball and socket joint?
What movement of bones rotates around its longitudinal axis?
What movement decreases the angle between bones? (bending of the joint)
What movement is away from the midline?
What movement is towards the midline?
What movement involves grasping of the thumb and fingers?
What movement of rotation is done towards the center of the body?
What movement of rotation is done away from the center of the body?
What is the ability to move joints?
What is ROM?
What is P-ROM?
What is A-ROM?
How far should a patient move a walker in front of them while walking?
What angle should a wheelchair be placed when transitioning from a bed?
What are the priority interventions for a pt. in bucks traction?
Identify risk factors for assessing a pt. with immobility.
Pressure ulcers
Pulmonary embolism
Atelectasis
Muscle atrophy
Depression
What is the rationale of nursing interventions to improve respiratory function?
Identify interventions to improve respiratory function
Position the pt. in semi Fowler's position
Encourage coughing, and deep breathing
Things to remember when lifting a pt.
What should a nurse do if they are unable to feel a pts. pulse?
Try to find the pulse in a different location
Doppler test a chain of pulses
What is an intervention to promote patient independence?
Nursing priorities for an infected wound
Irrigate the wound
Assess for bleeding
Obtain vitals
Get a wound culture
Immobility of the GI system can cause what?
An effect of the GI system due to immobility is?
Compressed capillaries related to external pressure can cause what?
What is the purpose of a sequential compression devise?
What are the positive affects of mobility on the cardiovascular system?
Semi fowlers Position :
High Fowler's Position :
Orthopneic position (tripod)
Lateral position
Lateral recumbent position :
Prone positioning :
SIMS position :
Supine positioning :
Dorsal recumbent positioning :
DVT Risk facts
Interventions for DVT risk
What pulse would you assess for suspected DVT
Osteoarthritis causes what?
Patient education and intervention for osteoarthritis
Causes of osteoporosis
At what age should women have a simple bone density test conducted for osteoporosis?
What are preventions, and self treatment for osteoporosis?
What is rheumatoid arthritis?
Non-pharmacologic interventions for rheumatoid arthritis?
What is osteomyelitis?
Expected lab finding for someone with osteomyelitis?
Interventions for osteomyelitis?
What are benefits of excercise?
Improves mood and energy
Improves pulmonary circulation and skeletal development
What is the main concern for a pt. with diabetic neuropathy?
What is the nurses priority assessment for a pt. who has kyphosis and had a total knee repair?
What is RICE?
What is a closed/simpled fracture?
What is a open/compound fracture
What should you not do when treating an open fracture?
What should you do when treating an open fracture?
Transverse fracture
spiral fracture
comminuted fracture
impacted fracture
greenstick fracture
oblique fracture
What symptoms suggest an infection under a cast?
Surgical complications
Pts. with plantar fasciitis, and foot surgery take longer to heal due to what reason?
What should you check before administering beta-blocker meds?
What is cataracts?
What medication treats glaucoma?
What is the normal finding of inter ocular pressure?
What does a miotic drug do?
What is glaucoma?
If glaucoma goes untreated, what can it cause?
What is sensorineural hearing loss?
Complication of Meniere's disease (vertigo)
What is a priority when caring for a blind patient?
Different examples of eyesight assessments
What is nearsighted?
Farsighted
If a nurse is experiencing a language barrier what should be done?
What is presbycusis?
What is tinnitus?
Preventions for home fall risk
Primary intention wound healing
Hemostasis
Inflammation
Proliferation - wound healing
secondary intention wound healing
Haemostasis
Tertiary wound healing
An example of wound bed documentation
ruptured serum-filled blister. Adipose is not visible and deeper tissues are not visible.
Granulation tissue, slough and eschar are not present."
Stage 1 pressure ulcer
stage 2 pressure ulcer
stage 3 pressure ulcer
stage 4 pressure ulcer
deep tissue injury
Post-surgical skin complications
Age related skin changes
Nutrition to promote skin healing
Zinc
Calories
Fluid
Vitamin A & C
Serous
Sanguineous
Serosanguineous : Ans - Pale, pink, watery; mixture of clear and red fluid
Purulent : Ans - producing or containing pus
Puro sanguineous : Ans - Bloody pus
dehiscence : Ans - A separation of layers, usually of a surgical incision
Evisceration : Ans - Total separation
Cellulitis : Ans - Infection of skin cells
Cellulitis Interventions : Ans - Antibiotic treatment, cool damp cloth on affected areas, elevate the affected part of the body, compression stockings
Braden Scale : Ans - sensory perception, moisture, activity, mobility, nutrition, friction and shear - used to asses risk of pressure ulcer - 1-18 (1 highest risk)
Opportunistic infection : Ans - Candidiasis, histoplasmosis, TB, Cytomegalovirus, herpes complex
What are the three types of immunity? : Ans - Innate - Skin, immune system
Adaptive - vaccine
Passive - Mother passing immunity through breastmilk
What cells are associated with inflammation? : Ans - Neutrophils, Macrophages, and Basophils
Infection prevention : Ans - Proper hand hygiene, medical asepsis, breaking the chain of infection
Virulence : Ans - degree of pathogenicity - the power of the pathogen
Airborne Isolation : Ans - - Measles (Rubella)
- Tuberculosis
- Varicella virus
chicken pox, HZV shingles
-N95 respiratory or
powered air purifying respirator, gowns, and gloves at entry point (before contact
with a patient or patient's environment) do NOT remove the mask while in the room,
the mask should be removed outside of the room.
Droplet Islolation : Ans - Larger droplets >5mcg and travel 3-6ft - Influenzas, B. pertussis, mumps, rubella, sepsis pneumonic plague
-Private room or a room with another pt. with an infectious disease. Ensure pt. has
his/her own equipment. PPE: Mask for providers and visitors.
Contact Isolation : Ans - Within 3 ft of the client. Direct or indirect (MRSA, VRE, diarrheal illnesses, open
wounds, herpes simplex, impetigo scabies, multidrug resistant organisms).
-Private room or in a room with another pt. with the infection. PPE: Gown, gloves.
Face shields should be worn if contact with bodily fluids that may splash.
Vitals that indicate infection : Ans - o High temperature.
o <90% oxygen saturation.
o Hypotension.
o High heart rate.
o Pain/discomfort.
Types of infectious agents : Ans - Bacteria, virus, fungus, prion, parasite.
What is a portal exit? : Ans - Respiratory tract, GI, GU, skin/mucous membranes, blood/bodily fluid
What is a portal of entry? : Ans - Mouth, cuts in the skin, eyes. Site through which a microorganism enters the
susceptible host.
Wound healing stages : Ans - o Stage I: Hemostasis.
o Stage 2: Scabbing over (clotting).
o Stage 3: Rebuilding (growth and proliferative).
o Stage 4: Maturation (strengthening).
Purulent drainage is a symptom of what? : Ans - Infection
Assessment findings for infection : Ans - Warmth, erythema, edema, pain, decreased function of the
area of injury.
What is CREST syndrome? : Ans - C—Calcinosis (Calcium deposits)
R—Raynaud's phenomenon (1 st symptom that occurs) A condition in which some areas of
the body feel numb and cool in certain circumstances.
E—Esophageal dysmotility (contractions occurring in the esophagus)
S—Sclerodactyly (scleroderma of the digits) localized thickness and tightness of the skin on
the fingers and toes.
T—Telangiectasia (spider-like hemangiomas) dilated small blood vessels on the skin or
mucous membranes, anywhere on the body.
What is Lupus? : Ans - Inflammatory autoimmune disorder, affects multiple organ systems
What is fibromyalgia? : Ans - Chronic pain and stiffness involving entire body, minor exertion aggravates pain and fatigue
What are the steps of the nursing process? : Ans - Assess, nursing diagnosis, planning, implementing, evaluating
What is the next step after KWIPES: : Ans - Assess
If we get called away what does the patient need to know: : Ans - where the call light is
Things we can delegate to LP/CNA: : Ans - cleaning, feeding, vitals, bathing
When would one reassess a patient? : Ans - If vitals are abnormal
Pressure ulcers interventions: : Ans - turn them every two hours, no frictions, keep them dry,
nutrition
What should a nurse do if their patient attempts to ambulate and becomes immediately dizzy? : Ans - lay or sit them back down, and take their vitals. We should be getting them up slowly, and when we change each position, we
should let them take a few min. in each position before moving forward
Nonverbal signs of pain: : Ans - increase heart rate, guarding, distracted, grumpy
Negatively affect sleep patterns: : Ans - stress, meds, eating late at night, nutrition, travel
● What are: Open and close ended questions
A nurse finds a pts. O2 sat to be low, what should they do? : Ans - o2 therapy, tripod, deep breathing and coughing
Medication administration follow up time : Ans - 30-60 min
How often should smoke detector batteries be changed? : Ans - twice a year
Forms of communication tools in the healthcare setting: : Ans - SBAR, nonverbal ques, rounding
reports, therapeutic
What is the greatest danger to toddlers? : Ans - Pools
If a patient is high risk for aspiration what intervention should be done? : Ans - Ensure the head of their bed is raised
When would you evaluate your pt? : Ans - Before and after admin pain meds - 30-60mins
What questions should be asked prior to an MRI? : Ans - Are you pregnant, claustrophobic, or wearing jewelry?
What is the most common broad-spectrum antibiotic? : Ans - Vancomycin
What is the highest risk for an elderly patient post-op? : Ans - DVTs
What position encourages the best administration of an enema? : Ans - SIMs
What must diabetic pt always wear? : Ans - Closed toed shoes
Review emergent, intermediate and non-emergent care : Ans - ● Emergent- pt is statting at 90 with chronic COPD but presenting with NEW onset chest pt
● Intermediate- pt is scheduled for colostomy in morning (pt needs to eat @ certain time and be prepped 4-8
hours prior)
● Non emergent- new pt with osteomyelitis explains of pain 5/10
How many mL of potable water should be flushed after each meal for a feeding tube? : Ans - 30 mL
Hallux Vargus : Ans - bunion
Fracture healing stages : Ans - Fracture hematoma
Granulation tissue
Callus formation
Ossification
Consolidation
Remodeling
What type of fracture has the highest risk for infection? : Ans - Open/Compound
What test is used to test for glaucoma? : Ans - Tonometry
What are risk factors for musculoskeletal trauma? : Ans - Age, falls, improper safety equipment
What are normal processes of aging? : Ans - Osteopenia, decreased blood flow, and skin integrity?
S/s of infection : Ans - Increased temperature, edema, erythema,
NSAIDs adverse effects : Ans - Blood thinning, delays healing
Maslow's Hierarchy of Needs : Ans - (level 1) Physiological Needs
(level 2) Safety and Security
(level 3) Relationships, Love and Affection
(level 4) Self Esteem
(level 5) Self Actualization
How do you administer eye drops? : Ans - Place drops in conjunctival sac and tell patient to keep eye closed
If med can have unwanted systemic affects, hold nasolacrimal duct for 30-60 seconds
Acetaminophen adverse effects : Ans - Rash, fever, chest pain, liver toxicity and failure, bone marrow suppression.
Do not take more than 4000mg daily
What are antiretroviral drugs? : Ans - Used to treat infections caused by HIV, the virus that causes AIDS
In teaching a client with acute secondary gout, which instruction about preventing recurrence is most important for the nurse to include? : Ans - Weight Watchers has healthy meal plans.
Assessment findings reveal that an older adult client with severe osteoarthritis of the left hip can no longer perform activities of daily living (ADLs) and has had several falls in the home over the past month. To which community resource does the nurse refer the client? : Ans - Home health care agency
Which factor indicates to the nurse the only similarity between discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE)? : Ans - Disfiguring and embarrassing rash
The nurse is caring for a middle-aged client diagnosed with rheumatoid arthritis. Which client statement requires further assessment for unproductive coping strategies? : Ans - "My husband is getting used to having sex only once a month."
A client diagnosed with rheumatoid arthritis (RA) is started on methotrexate (Rheumatrex). Which statement made by the client indicates to the nurse that further teaching is needed regarding drug therapy? : Ans - "Any side effects of this drug will be mild."
Which statement indicates to the nurse that a client with fibromyalgia syndrome is using a complementary therapy to help relieve symptoms? : Ans - "Focusing on the slow stretching movements and my breathing in tai chi helps me relax."
The nurse is reviewing the medication history for a client diagnosed with rheumatoid arthritis (RA) who has been ordered to start sulfasalazine (Azulfidine) therapy. The nurse plans to contact the health care provider if the client has which condition? : Ans - Sulfa allergy
The nurse is caring for a postoperative client with total joint arthroplasty. What actions does the nurse take to prevent venous thromboembolism (VTE) postoperatively?
Select all that apply.
Massage the legs
Keep the legs slightly abducted
Use the knee gatch on the bed
Apply elastic stockings.
Administer anticoagulants : Ans - Apply elastic stockings.
Administer anticoagulants.
The nurse is teaching a client about the difference between rheumatoid arthritis (RA) and osteoarthritis (OA). Which statement by the client indicates a need for further teaching? : Ans - "The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints."
An alert client who recently underwent total hip arthroplasty and is on anticoagulants is preparing for discharge from the hospital. Which information is most important for the nurse to provide to the client and caregiver? : Ans - Avoid using a straight razor.
The nurse assesses a client diagnosed with Sjögren's syndrome. The nurse anticipates that the client will also have which common condition? : Ans - Dry eyes
Which instructions for joint protection does the nurse recommend for a client with a connective tissue disease?
Select all that apply.
Use long-handled devices such as a reacher
When getting out of bed, use fingers to push off.
Sit in a low back chair
Bend at the waist while keeping the back straight
Use adaptive devices such as Velcro closures.
Turn a doorknob clockwise. : Ans - Use long-handled devices such as a reacher
Use adaptive devices such as Velcro closures.
Before administering low-molecular-weight heparin (LMWH) to an older adult client after total knee arthroplasty, the nurse notes that the client's platelet count is 50,000/mm3 (50 x 109/L). What action is most important for the nurse to take? : Ans - Notify the health care provider of the platelet count.
The nurse is caring for an older, alert adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies? : Ans - "The bus is coming to pick me up from the senior center three times a week so I can play cards."
A client has symptoms of rheumatoid arthritis (RA). Which laboratory finding indicates to the nurse that the client may have RA? : Ans - Positive total antinuclear antibody (ANA)
A client diagnosed with exacerbation of systemic sclerosis (SSc) asks the nurse why a foot board and a bed cradle have been placed on the bed. The nurse explains that they are used for what purpose? : Ans - Prevent foot drop and contractures
The home health nurse conducts a community presentation on Lyme disease for the residents of an assisted-living facility. Which statement from the audience indicates to the home health nurse that further instruction is needed? : Ans - "I will gently remove the tick with tissue and then burn it to prevent the spread of the disease."
Which element is a risk factor for osteoarthritis (OA)? : Ans - Obesity
Before administering prednisone IV push to a middle-aged adult with rheumatoid arthritis (RA), the nurse notes that the client's random blood glucose level is 139 mg/dl (7.7 mmol/L). Which action is most important for the nurse to take? : Ans - Administer the prescribed prednisone on schedule.
The nurse is developing a teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan? : Ans - Wear supportive shoes.
TB, measles, and varicella require airborne precautions. True or False : Ans - True
Definition of Hyperthermia : Ans - High body temp
What is eschar? : Ans - Black and necrotic tissue
Compartment syndrome is : Ans - paresthesia, pain, paralysis, pallor, pulselessness
Acetaminophen is .... : Ans - an analgesic & should not take more than 4000mg a day
Urinary output should be at least 30 mls/hr. True or False : Ans - True
Anticoagulant safety : Ans - use electric razor
Prevention of pressure ulcers include all of the following with a bed ridden client: (SATA) : Ans - Keep skin clean, dry and apply lotion as needed
Head of bed no higher than 30 degrees
Use a Hoyer for transfers
Which type of wound closes by primary intention? : Ans - Surgical incision
What are characteristics of a purulent discharge? : Ans - Creamy thick and yellow, pale green or white
A client has sustained an injury in the right leg, the priority is to check the pulse closest to the injury... True or False : Ans - True
Which of the following actions by the RN may cause a shearing injury to the surgical patient? : Ans - Dragging the patient to the procedure bed-
If a patient has a fall or after surgery : Ans - Perform neuro checks
What is the nurse's priority assessment with a client who has kyphosis and has had a total hip repair? : Ans - Auscultate lung sounds
A client is having chest pain with osteoarthritis. What priority assessment would you as the nurse focus on? : Ans - Cardiac issues
What should the nurse include in her education for a client with fibromyalgia? : Ans - Exercise & establish a regular sleep pattern
what is an opportunistic infection? : Ans - Infection that occurs when the body's defense is weak
The Primary Assessment always begins with an assessment of: : Ans - The airway, breathing & circulation
A RN is changing a dressing and providing wound care. Which activity should she perform first? : Ans - Wash hands thoroughly and assess the client's pain
What is evisceration? : Ans - Protusion of organs from a wound
Dehiscence is: : Ans - when a surgical incision reopens.
Which lab value would the nurse expect to be order for clients with connective tissue disorders?
CRP
ERS
Stage I pressure ulcer
Proper PPE for attending the patient infected with MRSA include...
Carpal Tunnel Syndrome is caused by...
Treatment of osteoarthritis includes
documentation of a wound drainage include
Triggers for Gout
Serosanguineous
Passive natural immunity is?
Raynaud phenomenon occurs:
The Braden Scale assesses all of the following EXCEPT?
Raynaud's is characterized by
Patients at risk for pressure injuries: Select all that apply
What is systemic lupus erythematosus?
What is not a characteristic of Rheumatoid arthritis ?
What is the most common symptom of Lupus?
Non-pharmacological modalities can be used to manage the chronic pain of a client with rheumatoid arthritis? : Ans - Heat, rest, immobilization for short periods
Antiretroviral drugs are used to...
Signs of inadequate perfusion include
What is an example of a mode of transportation in the Chain of infection?
The signs and symptoms of a systemic infection include :
Cellulitis in L. arm, which assessment data requires immediate intervention?
When is healing by primary intention expected?
Treatment for Cellulitis would not include
How does nutrition affect wound healing?
Ossification/Bony Callus is what stage of bone healing? :
PHASES OF WOUND HEALING: Inflammatory Phase
damaged cells, pathogens, and bacteria are removed from the wound area
leukocytes arrive
will see redness, swelling, heat, pain, loss of function
Neuropathic pain is:
Stage of pressure injury with intact skin that has non-blanching erythema.
Crepitus in osteoarthritis is due to?
How often do you approximately apply cold therapy for?
A person who has the following is a susceptible host.
immunosuppressed
Which of these is considered a primary defense against infection? [Show Less]