Foundations (Flash cards) Test 3

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  1. Which solution does not cause edema?
    Isotonic solution
  2. Which type of data is this:
    Clients description
    Use of quotes
    Question to gain information: onset, location, duration, frequency, precipitating/aggravating factors
    Use their terms in description
    Subjective data
  3. Which type of data is this:
    What you find: rash, decub ulcer, irregular hert sounds.
    Onset, location, description
    What you observe and measure
    Objective data
  4. When documenting subjective data, document with ____ and ____ when possible.
    Parenthesis and exact wording
  5. What is this?
    Any event that is not consistent with the routin operations of a health care unit or "routine care" of a client.
  6. These are an example of what?
    Pt fall
    needle stick
    med errors
    omissions of errors
    pt/staff injury or risk for
  7. What is this?
    Any adverse outcome for a patient, including an injury or complication directly associated with the care or services provided to a patient.
    Ex: rash
    Adverse event
  8. What is this?
    Any incident resulting in serious harm (loos of life, limb, vital organ). There is a need for immediate investion and response
    critical incident
  9. What is this?
    An event that could have adverse consequences by did not.
    Near miss
  10. The nurse is preparing the information that will be provided to the staff on the next shift. Which of the following should the nurse include in the inter-shift report to the nursing colleagues?
    A) audit of client care procedures
    B) the clients diagnostic care procedures
    C) all routine care procedures required by the client
    D) instructions given to the client in a teaching plan
    • D)
    • A change-of-shift report should include instructions given in a teaching plan and the client’s response. This should not include detailed content unless staff members ask for clarification. The nurse should relay to staff significant changes in the way therapies are given, but should not describe basic steps of a procedure. The client’s diagnosis-related group is not essential background information to be shared in an inter-shift report. The nurse should not review all routine care procedures or tasks.
  11. The nurse makes a late entry in a client’s record. Which of the following is the best example of how to document this type of situation?
    A) “2:45 PM—ASA gr X given for temperature of 38.1° C.”
    B) “8:30 AM—Client received Percodan (1 tablet) PO an hour before going to radiology.”
    C) “12:15 PM—I gave the client morphine 10 mg IM at 11:10 AM but did not document it then.”
    D) “8:30 PM—Abdominal dressing change at 7:30 PM. No s/s of infection, and wound edges approximating well.”
    • A)
    • This is the best example of a late entry. The time (2:45 PM) is indicated along with the action and an objective observation. This notation (8:30 AM) is not complete. It does not indicate why the Percodan was given. What was the client’s level of pain? Where was the pain located? The nurse does not need to document about herself; only the client. In this option (12:15 PM), the nurse does not indicate why the morphine was given (client’s level of pain? location of pain?). This entry (8:30 PM) is not complete. It does not state the size of the wound, type of dressing used, or the client’s tolerance of the procedure.
  12. The nurse has made an error and is documenting such on the client’s record and notes. The action that the nurse should take is to:
    A) Draw a straight line through the error and initial it.
    B) Erase the error and write over the material in the same spot.
    C) Use a dark color marker to cover the error and continue immediately after that point.
    D) Footnote the error at the bottom of the page.
    • A)
    • If a nurse has made an error in documentation, the nurse should draw a single line through the error, write the word error above it, and sign his or her name or initials. Then record the note correctly. The nurse should not erase, apply correction fluid, or scratch out errors made while recording because charting becomes illegible. Also, entries should only be made in ink so they cannot be erased. Using a dark color marker to cover the error is not correct. It may appear as if the nurse was attempting to hide something or deface the record. Footnotes are not used in nursing documentation.
  13. The new staff nurse is having her documentation evaluated by the charge nurse. On review of her charting, the charge nurse notes that there is evidence of appropriate documentation when the new staff nurse:
    A) Uses a pencil to make the entries
    B) Uses correction fluid to correct written errors
    C) Identifies an error made by the attending physician
    D) Dates and signs all of the entries made in the record
    • D)
    • Each entry should begin with the time and end with the signature and title of the person recording the entry. All entries should be recorded legibly and in black ink because pencil can be erased. The nurse should never erase entries, never use correction fluid, or never use a pencil. The use of correction fluid could make the charting become illegible and it may appear as if the nurse were attempting to hide something or to deface the record. If the physician made an error, the nurse should not document it in the client’s chart. It should be documented in an incident report.
  14. What is the correct response for the licensed practical nurse that answers the phone to respond within the following scenario? The physician calls to leave orders late at night for one of his clients.
    A) “Let me get the Registered Nurse on the phone.”
    B) “I am unable to take the order at this time. Please call in the morning.”
    C) “Please repeat the order for me so I can make sure it is written correctly.”
    D) “Let me have your phone number and I will have the supervisor call you back.”
    • A)
    • A telephone order involves a physician stating a prescribed therapy over the phone to a registered nurse. Saying that an order is unable to be taken and to call back in the morning is not an appropriate response and not in the client’s best interest. It is best to repeat any prescribed orders back to the physician, who can then verify if it is correct or clarify the order. This is not the appropriate response. A registered nurse needs to take the verbal order, but it does not have to be the nursing supervisor.
  15. Which of the following is evaluated as a legally appropriate notation?
    A) “Dr. Green made an error in the amount of medication to administer.”
    B) “Verbalized sharp, stabbing pain along the left side of chest.”
    C) “Nurse Williams spoke with the client about the surgery.”
    D) “Client upset about the physical therapy.”
    • B)
    • Entries should be concise, factual, and accurate. “Verbalized sharp, stabbing pain along the left side of chest” is an example of an objective description of a client’s behavior. The nurse should not document “physician made error.” Instead, the nurse could chart that “Dr. Green was called to clarify order for medication administration.” The nurse should chart only for himself or herself. In this case, nurse Williams should write the charting entry. Only objective descriptions of the client’s behavior should be recorded. For example: Client states, “I don’t want physical therapy! I want to go home
  16. Which of the following nursing notations shows the best understanding regarding the need to document only objective client assessment data?
    A) “Client was angry because breakfast was not to her liking.”
    B) “Client is depressed; was observed crying while alone in room.”
    C) “Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists.”
    D) “Client was verbally abusive to staff when approached concerning client’s continued attempts to smoke in the bathroom.”
    • C)
    • Do not write personal opinions. Document observable, measurable client-oriented data only. The remaining options either make assumptions regarding observed client behavior or fail to objectively describe the noted client behavior
  17. TO =
    • telephone order
    • RN or physician
  18. VO =
    • Verbal order
    • Used in emergency situations
  19. T or F:
    All TO and VO must be repeated and verified
  20. When should MD verify and sign off TO or VO?
    Within 24 hours
  21. SOAP notes
    • Subjective: clients verbalization
    • Objective: what is measured/observed
    • Assessment: dx based on data found
    • Plan: what you are going to do
  22. PIE notes
    problem oriented/nursing history

    • Problem
    • Intervention
    • Evaluation

    Notes are labeled/numbered according to patients problems. If problem resolved - dropped. Continued problems - addressed daily.
  23. Focus charting
    • Narrative form
    • Use of DAR notes

    • Data
    • Action/nursing intervention
    • Response of client/evaluation

    A different approach not designed for just problems includes clients concerns, not just problem area
  24. Which notes are labeled/numbered according to patients problems?
    PIE notes
  25. Which appraoch is not deisgned for just problems. but also includes clients conerns?
    Focus charting
  26. What is infiltration?
    Tip of catehter has poked out of vein and into surrounding tissue
  27. What does infiltration cause?
    • Swelling
    • Pale color
    • Cool to touch
    • Pain
    • Bruised-like skin
  28. How do you tell the difference between infiltration and phlebits?
    • Phlebitis - red area
    • Infiltration - pale area
  29. What interventions should you use if IV site if infiltrated?
    • 1. Discontinue infusions.
    • 2. Insert new IV into another extremity
    • 3. To redue pain, raise arm to promote venous drainage an decrease edema
    • 4. Heat therapy - wrap arm in warm moist towel for 20 min to promote venous return, increase circulation, and reduce pain/edema.
  30. What is phlebitis?
    Inflammed vein
  31. You see a red streak tracking upstream from IV site. What is this?
  32. What does phlebitis cause?
    • Increase temp in vein
    • redness
    • pain
    • edema
  33. What are some nursing interventions for phlebitis?
    • 1. Discontinue IV
    • 2. insert a new line in a nother vein
    • 3. warm moist heat redeuces pain
  34. With phlebitis, how often whould ou rotate periiheral venous cannulas and sites?
    Evrey 72 hours
  35. Diffusion/osmosis is from ___ to ___ concentration
    High and low
  36. Which solution does not promote the shift of fluids into or out of the cells, causing them shrink or swell?
    Isotonic solutions
  37. Which solution has the same number of particles as plasma?
    Isotonic solution
  38. Which solution doesn't cause edema?
  39. Normal saline, D5W, and lactated ringers solution are two of the most commonly used ________
    Isotonic solutions
  40. The location of ostomies determines _______
    stool consistency
  41. When the ileostomy bypasses the large intestine, stools will be _____
    liquid and frequent
  42. Colostomy is within the _____
  43. If colostomy is within transverse colon, stools will be _____
    solid and formed
  44. If colostomy is within sigmoid, stools will be _____
    near normal
  45. A loop colostomy is for:
    • medical emergency
    • temporary
  46. An end colostomy is a _______
    • surgical type of colorectal cancer.
    • often rectum is removed
  47. Dr. Smith has determined that the client with hepatitis has contracted the infection form contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis?
a. Hepatitis A

    b. Hepatitis B

    c. Hepatitis C
d. Hepatitis D
    a. Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.
  48. A female client being seen in a physician’s office has just been scheduled for a barium swallow the next day. The nurse writes down which instruction for the client to follow before the test?
a. Fast for 8 hours before the test

    b. Eat a regular supper and breakfast

    c. Continue to take all oral medications as scheduled
d. Monitor own bowel movement pattern for constipation
    a. A barium swallow is an x-ray study that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal tract. The client should fast for 8 to 12 hours before the test, depending on physician instructions. Most oral medications also are withheld before the test. After the procedure, the nurse must monitor for constipation, which can occur as a result of the presence of barium in the gastrointestinal tract.
  49. Polyethylene glycol-electrlyte solution (GoLYTELY) is prescribed for the female client scheduled for a colonoscopy. The client begins to experience diarrhea following administration of the solution. What action by the nurse is appropriate?

    a. Start an IV infusion
b. Administer an enema
c. Cancel the diagnostic test

    d. Explain that diarrhea is expected
    d. *KNOW!* The solution GoLYTELY is a bowel evacuant used to prepare a client for a colonoscopy by cleansing the bowel. The solution is expected to cause a mild diarrhea and will clear the bowel in 4 to 5 hours. Options A, B, and C are inappropriate actions.
  50. The nurse is caring for a hospitalized female client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician?

    a. Hypotension

    b. Bloody diarrhea
c. Rebound tenderness

    d. A hemoglobin level of 12 mg/dL
    c. Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the physician.
  51. The nurse is caring for a male client postoperatively following creation of a colostomy. Which nursing diagnosis should the nurse include in the plan of care?

    A. Body image, disturbed

    B. Fear related to poor prognosis
    C. Sexual dysfunction

d. Nutrition: more than body requirements, imbalanced
    A. Body image, disturbed relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). No data in the question support options A and C. ****Nutrition: less than body requirements, imbalanced is the more likely nursing diagnosis.****
    (this multiple choice question has been scrambled)
  52. In isotonic solutions, cells do not ____ or _____ water
    gain or lose water
  53. Isotonic solutions have no effect on the ________
    surrounding cells
  54. Which solution is often used for electrolyte replacement, those suffering from dehydration, excessive vomitting, and for perioperative fluid adminstration?
  55. What is the most common type of IV fluid
    isotonic solutions
  56. Water quickly shifts out of the vascular ebd and into the cells, by way of osmosis in which solution?
  57. Which solution is frequently given to correct cellular dehydration and hpernatremia?
    Hypotonic solution
  58. Which solution is routinely used in hospitals to keep patients hydrated?
  59. Which type of solution is rapidly absorbed by the body and eliminated by the renal system?
  60. Sports drinks that contain salts/electrolytes are also called ___________
    hypotonic solutions
  61. Which solution hydrates the cells by moving fluids out of the blood system and into the cells?
    hypotonic solution
  62. Which type of solution has more particles than the body's water?
  63. Which solution pulls water back into circulation from the cells and interstitial spaces, shrinking the cells?
  64. Which solution supressess inflammation and sometimes is used to prevent edema/intracranial hypertension when using IV fluids to treat horrhagic shock?
    Hypertonic solutions
  65. A client experiences a loss of intracellular fluid. The nurse anticipates that the intravenous (IV) therapy that will be used to replace this type of loss is:
    A. 0.45% normal saline (NS)
    B. 10% dextrose
    C. Dextrose 5% in NS
    D. 5% dextrose in lactated Ringer’s
    A. The client will need a hypotonic solution, such as 0.45% NS. A hypotonic solution has an osmolality that is less than body fluids, so the cells will draw the fluid in, which is the desired effect when the client has experienced a loss of intracellular fluid. Dextrose 5% in NS, 10% dextrose, and 5% dextrose in lactated Ringer’s are all hypertonic solutions that will draw fluid into the vascular space by osmosis. The client needs a hypotonic solution to rehydrate the cells.
    (this multiple choice question has been scrambled)
  66. The health care provider orders 1000 mL of D5LR with 20 mEq KCl to run for 8 hours. Using an infusion set with a drop factor of 15 gtt/mL, the nurse calculates the flow rate to be:
    A. 32 gtt/min
    B. 12 gtt/min
    C. 22 gtt/min
    D. 42 gtt/min
    A. 1000 mL ÷ 8 hr = 125 mL/hr; (15 gtt/mL ÷ 60 min) x 124 mL = 32 gtt/min.
    (this multiple choice question has been scrambled)
  67. The nurse will be starting a new intravenous infusion and needs to select the site for the insertion. In selection of a site, the nurse should:
    A. Start with the most proximal site
    B. Look for hard, cordlike veins
    C. Avoid sites on the extremity away from a dialysis graft
    D. Use the dominant arm
    C. The nurse should avoid veins in an extremity with compromised circulation, such as a dialysis graft. The nurse should use the most distal site in the nondominant arm, if possible, and should avoid hardened cordlike veins.
    (this multiple choice question has been scrambled)
  68. A client has intravenous therapy for the administration of antibiotics and is stating that the “IV site hurts and is swollen.” Which of the following information assessed on the client indicates the presence of phlebitis, as opposed to infiltration?
    A. Skin discoloration of a bruised nature
    B. Amount of subcutaneous edema
    C. Intensity of the pain
    D. Warmth of integument surrounding the IV site
    D. ***KNOW*** Signs of phlebitis may include increased temperature over the vein, erythema, pain, and edema. With phlebitis, the area is warm to the touch; with infiltration, the area is cool to the touch. The intensity of pain is not a differentiating factor between phlebitis and infiltration. Pain may occur with both. The amount of subcutaneous edema is not a differentiating factor between phlebitis and infiltration. Edema may occur with both. Skin discoloration of a bruised nature is not the best way to differentiate phlebitis from infiltration. With phlebitis, the area is typically reddened. With infiltration, the area is typically pale.
    (this multiple choice question has been scrambled)
  69. For a client with a nursing diagnosis of excess fluid volume, the nurse is alert to which one of the following signs and symptoms?
    A. Flushed skin
    B. Dry mucous membranes
    C. Hypertension
    D. Weak, thready pulse
    C. ***KNOW*** Hypertension is a symptom of fluid volume excess. A weak, thready pulse is associated with fluid volume deficit. A bounding pulse is a symptom of fluid volume excess. Dry mucous membranes and flushed skin are both symptomatic of fluid volume deficit, not excess.
    (this multiple choice question has been scrambled)
  70. An IV solution of 125 mL is to be infused over a 1-hour period. A microdrip infusion set will be used. The nurse calculates the infusion rate as:
    a. 32 gtt/min
    b. 60 gtt/min
    c. 125 gtt/min
    d. 250 gtt/min
    ANS: 3(60 gtt/mL ÷ 60 min) x 125 mL = 125 gtt/min.
  71. A client is prescribed 0.9% sodium chloride (normal saline), which is an isotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to:
    A. Keep protein levels normal
    B. Pull fluid from the cells
    C. Expand the volume of fluid in the vascular system
    D. Move fluid into the cells
    C. Isotonic solutions such as normal saline, 0.9% sodium chloride, expand the body’s fluid volume without causing a fluid shift from one compartment to another. The remaining options describe the function of other types of fluids.
    (this multiple choice question has been scrambled)
  72. A client is prescribed 3% sodium chloride, which is a hypertonic solution. The nurse recognizes the primary goal of such intravenous therapy is to:
    A. Move fluid into the cells
    B. Expand the volume of fluid in the vascular system
    C. Pull fluid from the cells
    D. Keep protein levels normal
    C. A hypertonic solution (a solution of higher osmotic pressure), such as 3% sodium chloride, pulls fluid from cells, causing them to shrink. The remaining options describe the function of other types of fluids.
    (this multiple choice question has been scrambled)
  73. What are 5 complications of eneteral tube feeding?
    • Aspiration
    • Diarrhea
    • Constipation
    • Tube occlusion
    • Tube displacement
  74. Liquid nutritional supplements/feedings if unable to swallow food is _______
    enteral feeding
  75. Internall app of pressure through inflated balloon to prevent hemorrhage is _________
  76. irrigation of stomach for active bleeding, poisoning, gastric dilation is ________
  77. Levin tube
    • lumen
    • most commonly used
    • one lumen NG tube
    • useful in instilling material into/suctioning material out of stomach
  78. Salem-sump tube
    • two lumen
    • drainage lumen and secondary tube open to air
    • major advantage - can be used for continuous suction
    • white and blue ends
  79. Miller-Abbott tube
    • two lumen
    • rubber ballon, and tube with holes
    • one tube is used for suction, the other is used for doctor to inflate balloon
  80. Sengstaken-Blakemore tube
    • tripe lumen
    • inflatable esophagus ballon
    • stomach balloon
    • gastric suction lumen
    • used to treat bleeding ulcers and cirrhosis
  81. Dobhoff tube
    • used for long term feeding
    • placement must be verified by xray
    • takes 24 hours for tube to pass from stomach into small intestines
    • patient lays on RIGHT side to facilitate passage of tube
  82. What is the best way to verify placement of an NG tube?
    xray, then gastric pH
Card Set:
Foundations (Flash cards) Test 3
2012-04-14 19:59:32
Foundations test

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