What should a nurse do with a pt with a hemovac drain

Maintain suction and measure output

Which are CMs of immobility on the respiratory system

Atelectasis, Pooling of secretions in lungs, Decreased cough effort, Hypostatic pneumonia

What is NREM sleep good for

Relaxing muscles, Deep/slow wave sleep, important for memory

What is the main purpose of negative pressure wound therapy (wound vac)

To help promote granulation and remove exudate by suction

Which are appropriate nursing actions for a pt with restraints

Remove restraints at least every 2 hours to check skin, Use the least restrictive device possible, Tie the restraints with a quick release knot, Perform neuromuscular checks regularly

What are signs for post op PE

Shortness of breath, Anxiety of restlessness, Low o2 sat, Sudden chest pain

What should you know about a the residue from hydrocolloid dressing

It may look like pus, but its not an infection

What precautions should you take with iodine based things

Ask about allergies to iodine, betadine, or shellfish

What does the Braden scale assess

A patient’s risk for pressure injury

Episodes of airflow cessation for 10 seconds or longer

Bronchospasms, GI ulcers from increase gastric acid, Dreams causing high HR creating angina or dysrhythmia, Cardiac

What is the purpose of time outs

To verify correct pt, procedure, and site

Which are pre op teachings a nurse should give a pt

Leg and ankle exercises, Pain management expectations, How and why to use an incentive spirometer, Deep breathing and coughing

Where do pt valuables go during surgery

With friends, family, or security

What is sleep hygiene

Having good habits and routine that helps encourage restful sleep

What is the best way to prevent orthostatic hypotension in an immobile patient

Dangle legs at the side of the bed before ambulating

What is the purpose of a trochanter roll

Prevent external rotation of the hips

Which are correct ways to use assistive devices

Use a quad cane for balance issues, Fit crutches with tops 2-3 inches below axilla, Use a straight cane on the stronger side, Up with the good, down with the bad for stairs

Which wound is healing from secondary intention

Wound is left open and heals bottom up

Which results would be normal

PT - 11 seconds INP - 1 aPTT 35 seconds

Which is the best nurse reaction to a pt wound evisceration

Place pt supine, cover with sterile towel soaked in saline, notify provider

How do you correctly assist a pt falling

Guide the pt down your body gently to the floor while protecting their head

Which group is a high risk for obstructive sleep apnea

Overweight males over 40 with a narrow upper airway

What is the best nursing action for a hospitalized patient with a poor sleep pattern

Preserve their usual nighttime routine

studbud

FPCC Exam 3

92 termsStudBud Administration78 plays

Imported from external platform

Flashcards92 cardsFPractice quizPHost liveL

Questions 92

Answers

1
What should a nurse do with a pt with a hemovac drain
Maintain suction and measure output
Apply lotion to site
Remove drain daily
Irrigate the wound with hydrogen peroxide
2
Which are CMs of immobility on the respiratory system
Increased breath sounds
Atelectasis
Pooling of secretions in lungs
Decreased cough effort
Orthostatic hypotension
Hypostatic pneumonia
3
Granulation is yellow, stringy, necrotic tissue that must be removed
True
False
4
Which ulcer is a dry, circular punch out of skin found on lower legs and feet
Neuropathic ulcer
Arterial ulcer
Pressure injury
Venous stasis ulcer
5
Which is a common CM of sleep deprivation
Increased reflexes
Improved concentration
Excessive daytime sleepiness
Euphoria
6
Which dressing type is good for a wound with heavy exudate
Alginate
Hydrogel
Transparent film
Dry sterile dressing
7
Which type of wound healing happens when a surgeon closed a wound
Spontaneous closure
Primary
Secondary
Tertiary
8
What is NREM sleep good for
Brain is active, dreams and eye movements occur
Relaxing muscles, Deep/slow wave sleep, important for memory
Important for memory, learning, and emotional health
Helps with short term memory
9
What is the main purpose of negative pressure wound therapy (wound vac)
To deliver oxygen directly into wound
To help promote granulation and remove exudate by suction
To apply antibiotic ointment evenly
To keep the wound dry
10
Restraints should be used as a last resort after other alternatives have failed
True
False
11
Eschar and slough must be removed to accurately stage a wound
True
False
12
Which are appropriate nursing actions for a pt with restraints
Secure restraints to side rails
Obtain a providers orders after applying
Remove restraints at least every 2 hours to check skin
Use the least restrictive device possible
Tie the restraints with a quick release knot
Perform neuromuscular checks regularly
13
What is a common complication of spinal or epidural anesthesia
Decreased HR and BP
Respiratory depression
14
What are signs for post op PE
Shortness of breath
Anxiety of restlessness
Productive cough with green sputum
Bradycardia
Low o2 sat
Sudden chest pain
15
What should you know about a the residue from hydrocolloid dressing
It may look like pus, but its not an infection
It always indicates infection
It prevents reapplication of any dressing
It must be removed with alcohol
16
What precautions should you take with iodine based things
Never use on granulating wounds
Ask about allergies to iodine, betadine, or shellfish
Avoid using on surgical wounds
Cover with gauze and plastic wrap
17
Pt with sleep apnea have loud snoring, frequent waking, and high risk for cardiovascular complications
False
True
18
Restraints must have a providers orders that includes type, location, duration, and circumstances
True
False
19
Which wound drainage type is bright red blood and a sign of active bleeding
Purulent
Serosanguineous
Serous
Sanguineous
20
What wound has leathery black tissue
Granulation
Epibole
Eschar
Slough
21
What does the Braden scale assess
A patient’s risk for pressure injury
Type of dressing needed
The level of pain at the wound site
The severity of a wound
22
Which is sleep apnea
Episodes of airflow cessation for 10 seconds or longer
Repeated leg movements during sleep
Inability to fall asleep
Excessive REM sleep
23
Pt should be positioned flat after surgery to reduce risk of bleeding
False
True
24
Hydrogel is good for which wound type
Fresh surgical wound
Wound infected with purulent drainage
Wound with large amounts of drainage
Dry wound with eschar
25
What is the purpose of an diagnostic operation
Finding a problem
Always elective and for appearance
Removal or breaking something
Relieving symptoms
26
What is enuresis
Urinating frequently
Urinating in your sleep
Inability to urinate when waking up with a full bladder
Getting up in the night to urinate
27
Sleepwalking is a form of parasomnia
True
False
28
Risk during sleep
Bronchospasms
GI ulcers from increase gastric acid
Dreams causing high HR creating angina or dysrhythmia
CNS stimulus
Cardiac
Nocturia
29
What is the purpose of time outs
To give pt meds
To check pt insurance
To allow team to scrub in
To verify correct pt, procedure, and site
30
Which dressing type is best for autolyic debridement in a wound with slough
Alginate
Dry sterile dressing
Hydrocolloid
Transparent film
31
A post op pt is restless and has a distended abdomen with low be and high hr, what’s probably happening
Myocardial infarction
Infection
Atelectasis
Hemorrhage
32
Immobility increases the risk for pressure injuries, constipation, and pneumonia
False
True
33
Which are pre op teachings a nurse should give a pt
Leg and ankle exercises
Diet preferences for post op meals
Pain management expectations
How and why to use an incentive spirometer
Deep breathing and coughing
Details of how the surgery will be preformed
34
Which anesthesia causes total loss of consciousness and needs airway support
Moderate
Regional
General
Local
35
Where do pt valuables go during surgery
It stays with them
With friends, family, or security
In a locked safe
In a pt locker
36
What is sleep hygiene
Showering before bed
Sleep apnea
Making your bed before going to sleep
Having good habits and routine that helps encourage restful sleep
37
What is the best way to prevent orthostatic hypotension in an immobile patient
Keep the patient flat in bed as much as possible
Encourage deep breathing exercises
Leave pt in high Fowler position
Dangle legs at the side of the bed before ambulating
38
Which wound drainage type is clear, watery, and a sign of healing
Purulent
Serous
Sanguineous
Serosanguineous
39
What is the purpose of a trochanter roll
Support the neck during movement
Prevent wrist contractures
Prevent foot drop
Prevent external rotation of the hips
40
Which are correct ways to use assistive devices
Use a quad cane for balance issues
Walkers are ideal for stairs
Teach the 3 point gait to pt who can fully bear weight
Fit crutches with tops 2-3 inches below axilla
Use a straight cane on the stronger side
Up with the good, down with the bad for stairs
41
Which wound is healing from secondary intention
Edges are approximated with minimal scar
Wound is covered with a transparent dressing
Edges are sutured together immediately
Wound is left open and heals bottom up
42
Which results would be normal
PT - 40 seconds INP - 10 aPTT 10 seconds
PT - 1 seconds INP - 10 aPTT 60 seconds
PT - 2 seconds INR - 5 aPTT - 50 seconds
PT - 11 seconds INP - 1 aPTT 35 seconds
43
Generals anesthesia allows pt to be semi conscious and follow basic commands
False
True
44
Which is the best nurse reaction to a pt wound evisceration
Cover with sterile dry gauze, place pt prone, and contact provider
Apply pressure and call surgeon
Begin CPR
Place pt supine, cover with sterile towel soaked in saline, notify provider
45
Extra sleep on weekends helps restore the sleep-wake cycle
True
False
46
Which ulcer is a irregular, beefy, messy, with lots of drainage, found on lower legs and feet
Neuropathic ulcer
Arterial ulcer
Pressure injury
Venous stasis ulcer
47
Which wound drainage type is thick, yellow-green, may have a foul odor, and a sign of infection
Serosanguineous
Purulent
Sanguineous
Serous
48
How do you correctly assist a pt falling
Guide the pt down your body gently to the floor while protecting their head
Pull the pt into the nearest chair
Try to catch the pt
Step away and get help to pick them up
49
Which group is a high risk for obstructive sleep apnea
Children with ADHD
Overweight males over 40 with a narrow upper airway
Underweight adolescent females
Healthy older adult with no family history
50
The circulating nurse is part of the sterile surgical team
False
True
51
What is the best nursing action for a hospitalized patient with a poor sleep pattern
Encourage screen time to help tire them out
Administer sleep meds early before they feel sleepy
Wake them up every 2 hours for routine vitals
Preserve their usual nighttime routine
52
What is bruxism
Teeth grinding
Sleep walking
Eating in your sleep
Snoring
53
Which dressings are antimicrobial and must be prescribed
Foam and gauze
Transparent and hydrogel
Silver and iodine
Alginate and hydrocolloid
54
A wound with slough and undermining is healing with which intention
Delayed
Secondary
Primary
Closed
55
What is the nurses responsibility during informed consent
Explaining the procedure
Give the anesthesia
Verify the consent form is signed and the pt understands
Signing the consent for the pt if they need help
56
Cardiac, steroids, and anticoagulants meds increase surgical risk for a pt
False
True
57
Which should a nurse report with a post op wound
Approximated wound edges
Pink granulation tissue at incision site
Sanguineous drainage soaking dressing
Serosanguineous drainage
58
Which med is the most concerning pre op
Anticoagulants
Acetaminophen
Multivitamin
Beat blocker
59
Which is from chronic inadequate sleep
Decreased risk of chronic illness
Improved coordination
Decreased sensitivity to pain
Increased insulin resistance
60
Which of the following defines activity intolerance
Refusal to get out of bed
Pain that limits range of motion
Lack of motivation to preform daily activities
Inability to preform ADLs without excessive fatigue or SOB
61
Which is best for foot drop
Elevate HOB to 90 degrees
Use a trochanter roll
Encourage the pt to sleep in prone position
Apply a foot board or ankle splint
62
Which type of wound healing happens when a wound is intentionally left open and closed later
Secondary
Primary
Tertiary
Spontaneous closure
63
Which dressing type is best for a superficial wound that has minimal draining and needs visualization without opening it
Transparent film
Alginate
Hydrogel
Dry sterile dressing
64
When is pre op teaching done
Weeks to moments before, when pt is not in pain
Right before surgery
Weeks before
Anytime weeks to moments before pt goes into surgery
65
Which type of wound healing happens when a deep wound closes open and without a suture
Secondary
Tertiary
Primary
Spontaneous closure
66
What does TCDB mean
Time, comfort, diet, bed rest (pt rest and recover)
Talk, communicate, delegate, breathe (manage nurses stress)
Temperature, circulation, drainage, bandage (assess wound healing)
Turn, cough, deep breathe (prevent respiratory complications)
67
What is the purpose of a palliative operation
Relieving symptoms
Removal or breaking something
Finding a problem
Always elective and for appearance
68
Which are surgical risk factors
Age over 65
Obesity
High protein diet
Smoking
Diabetes
COPD
69
Which increase a clients fall risk
History of falls
Urinary urgency or incontinence
Intact vision and sensation
Use of assistive devices
70
Which of the following helps with the sleep
Chocolate
Alcohol
L-triptophan
Nicotine
71
Which pt are at a higher risk for pressure injury
Malnourished elderly pt
Pt with high protein diet
Pt with urinary incontinence
Pt with limited mobility
Diabetic pt with poor circulation
Post op pt with Braden of 22
72
What is the purpose of an ablative operation
Finding a problem
Always elective and for appearance
Removal or breaking something
Relieving symptoms
73
What should you do for a wound with dehiscence
Ignore unless its bleeding
Apply pressure and bandage tightly
Cover with sterile dressing and notify provider
Re-suture the wound
74
Liver disease increase surgical risk because of its effect on protein wound/fluid balance, clotting, and drug metabolism
True
False
75
What should a nurse do to help prevent skin break down
Reposition every 2 hours
Ensure adequate protein intake
Keep the pt NPO
Use specialty support surfaces
Use moisture barriers/protectants
Massage over body prominences
76
Which of the following are signs of wound infections
Purulent drainage
Redness around wound
Increased pain at site
Clear serous drainage
Approximated edges
Fever
77
What are the components of the Braden scale
Friction and shear
Sensory perception
Moisture
Mobility
Nutrition
Activity
78
Pressure injuries can reverse
False
True
79
What should you do for a pt with urinary stasis
Increased hydration
Lay pt supine
Catheterization
Increased movement
80
Which wound drainage type is pale, pink, and watery and a sign of healing
Serosanguineous
Sanguineous
Purulent
Serous
81
Alcohol improves sleep quality
True
False
82
Range of motion exercises are only necessary if the pt is completely immobile
False
True
83
Which wound drainage type is a sign of possible infection
Serosanguineous
Sanguineous
Purulent
Serous
84
What is cataplexy
Inability to move upon waking
Severe nightmares
Sudden loss of muscle control when your awake
Type of sleepwalking
85
Which type of wound dressings maintain a moist environment and autolytic debridement
Hydrocolloid
Alginate
Transparent film
Dry gauze
86
What should you be concerned about when removing a dressing that adheres to the wound
Applying betadine directly to wound
Ensuring it is completely dry before removal
Removing it quickly to reduce pain
Preventing removal of healthy granulation tissue
87
Which sleep disorder has uncontrollable episodes of falling asleep during the day
Bruxism
Narcolepsy
Insomnia
Sleep apnea
88
What is osteogenesis imperfecta
Excessive growth of bone tissue
Autoimmune disorder that causes cartilage and bones to separate and break
Vit D deficiency resulting in fragile bones
Genetic disorder that causes bones to break easily
89
Risks due to poor sleep
Chronic illness
Accidents
Epilepsy (sleep lowers seizure threshold)
Larger appetite
Poor work/performance
Myocardial infarction
90
Splinting the incision helps reduce pain and protects the wound when when coughing post op
True
False
91
Which devices use continuous suction to help heal wounds
Penrose
Hemovac
Jackson Pratt
Negative pressure wound therapy
92
What does red, beefy granulation tissue in a wound bed mean
Necrosis
Healing
Need for debridement
Infection

FPCC Exam 3 Flashcards | StudBud