WorksheetsFundamentals Exam #2: Part 1
Total questions: 92
Worksheet time: 46mins
State risk factors that contribute to pressure ulcer formation.
Immobility, poor nutrition, and decreased sensation
Frequent repositioning and good hydration
Regular exercise and balanced diet
High levels of physical activity
Impaired sensory perception (i.e. neuropathy) is a risk factor for what condition related to skin integrity?
Pressure ulcer formation
Psoriasis
Eczema
Acne
Alterations in LOC is a risk factor for what condition related to skin integrity?
Pressure ulcer formation
Eczema
Psoriasis
Acne
Shearing is a risk factor for what condition related to skin integrity?
Pressure ulcer formation
Eczema
Psoriasis
Cellulitis
The pressure ulcer staging system is used to:
Classify the severity of tissue damage in pressure ulcers
Measure blood pressure in patients with ulcers
Diagnose the cause of pressure ulcers
Determine the type of bacteria in ulcers
Stage 1 of pressure ulcer is characterized by ________.
intact skin with non-blanchable redness
open wound with exposed bone
blister with serous fluid
necrotic tissue with eschar
Stage 2 of pressure ulcer is characterized by ________.
partial thickness skin loss involving epidermis, dermis, or both
full thickness skin loss with damage to or necrosis of subcutaneous tissue
intact skin with non-blanchable redness
exposed bone, tendon, or muscle
Stage 3 of pressure ulcer is characterized by ________.
full thickness tissue loss with visible fat
non-blanchable erythema of intact skin
partial thickness loss of dermis presenting as a shallow open ulcer
exposed bone, tendon, or muscle
Stage 4 of pressure ulcer is characterized by ________.
full thickness tissue loss with exposed bone, muscle, or tendon
full thickness non-blanchable erythema of intact skin
partial thickness loss of dermis presenting as a shallow open ulcer
full-thickness tissue loss with localized area of non-blanchable deep red, maroon, or purple discoloration
An unstageable pressure ulcer is characterized by ________.
full thickness tissue loss in which the base of the ulcer is covered by eschar/necrosis in the wound bed
full thickness loss of dermis presenting as a shallow open ulcer
full thickness tissue loss in which the base of the ulcer is covered by erythema/petechiae in the wound bed
full thickness tissue loss with exposed bone, tendon, or muscle in the wound bed
The normal process of wound healing involves which of the following differences between partial thickness and full thickness healing?
Partial thickness wounds heal mainly by epithelialization, while full thickness wounds heal by granulation, contraction, and epithelialization.
Partial thickness wounds heal by granulation tissue formation only, while full thickness wounds heal by epithelialization only.
Both partial and full thickness wounds heal exclusively by contraction, granulation, and contraction.
Partial thickness wounds do not require any cellular activity, while full thickness wounds require only inflammation.
Wound healing by primary and secondary intention differ in which of the following aspects?
Primary intention involves minimal tissue loss and faster healing, while secondary intention involves significant tissue loss and slower healing.
Primary intention results in more scarring than secondary intention.
Secondary intention is used for clean, surgical wounds with edges that can be approximated.
Secondary intention involves minimal tissue loss and faster healing, while primary intention involves significant tissue loss and slower healing.
Which of the following is NOT a complication of wound healing?
Hematoma
Hemorrhage
Infection
Fracture
Factors that impede or promote wound healing include which of the following: moisture accumulation and nutrition?
Moisture accumulation and nutrition both affect wound healing.
Only moisture accumulation affects wound healing, not nutrition.
Only nutrition affects wound healing, not moisture accumulation.
Neither moisture accumulation nor nutrition affect wound healing.
State differences between nursing care of acute and chronic wounds.
Acute wounds are usually from surgical incisions or acute trauma, with the goal to have a complete heal if possible. Chronic wounds include pressure ulcers, cancers, major trauma, etc., with the goal to stave off infection and not allow the wound to get worse, keep wounds clean, dressings changed, and debride. Chronic wounds will likely never fully heal and require constant monitoring and attention.
Acute wounds are usually from surgical incisions or acute trauma, with the goal to have a incomplete heal if possible. Chronic wounds include pressure ulcers, cancers, major trauma, etc., with the goal to promote infection and not allow the wound to get worse, keep wounds clean, dressings changed, and debride. Chronic wounds will likely never fully heal and require constant monitoring and attention.
Nursing care for both acute and chronic wounds is identical, with no difference in approach or goals.
Acute wounds are usually from surgical incisions or acute trauma, with the goal to have a complete heal if possible. Chronic wounds include pressure ulcers, cancers, major trauma, etc., with the goal to stave off infection and not allow the wound to get better, keep wounds clean, dressings changed, and debride. Chronic wounds will likely fully heal and require constant monitoring and attention.
List appropriate nursing assessments for a patient with impaired skin integrity.
When inspecting a wound, the type of wound will guide assessment. For abrasions: superficial, little bleeding, plasma leakage, damaged capillaries. For lacerations: slice, may be heavy bleeding. For punctures: poke, deeper punctures have the potential to damage more structures than just the skin. For surgical wounds: wound made from procedure, should be tightly controlled and as small as possible. Describe the amount, color, consistency, and odor of wound drainage. Use REEDA for assessment.
When inspecting a wound, the type of wound will guide assessment. For abrasions: deep, heavy bleeding, plasma leakage, damaged capillaries. For lacerations: slice, may be heavy bleeding. For punctures: poke, deeper punctures have less potential to damage more structures than just the skin. For surgical wounds: wound made from procedure, should be tightly controlled and as small as possible. Describe the amount, color, consistency, and odor of wound drainage. Use REEDA for assessment.
When inspecting a wound, the type of wound will guide assessment. For abrasions: superficial, little bleeding, plasma leakage, damaged capillaries. For lacerations: chunk missing, may be heavy bleeding. For punctures: poke, deeper punctures have the potential to damage more structures than just the skin. For surgical wounds: wound made from procedure, should be tightly controlled and as large as possible. Describe the amount, color, consistency, and odor of wound drainage. Use REEDA for assessment.
When inspecting a wound, the type of wound will guide assessment. For abrasions: superficial, little bleeding, plasma leakage, damaged capillaries. For lacerations: slice, may be heavy bleeding. For punctures: poke, deeper punctures have the potential to damage more structures than just the skin. For surgical wounds: wound made from procedure, should be tightly controlled and as small as possible. Describe the amount, color, consistency, and taste of wound drainage. Use DIVA for assessment.
Identify different 'drainage' & significance of each type. What is serous drainage?
Serous drainage is clear (weeping, possible infection).
Serous drainage is thick and greenish-yellow in color.
Serous drainage contains large amounts of blood and clots.
Serous drainage is always foul-smelling and quite pussy.
Identify different 'drainage' & significance of each type. What is sanguineous drainage?
Sanguineous drainage is bright red bloody (active bleeding).
Sanguineous drainage is clear and watery.
Sanguineous drainage is thick and yellow-green.
Sanguineous drainage is pink and serous.
Identify different 'drainage' & significance of each type. What is serosanguineous drainage?
Serosanguineous drainage is clear and red combined (some active bleeding).
Serosanguineous drainage is thick, yellow, and foul-smelling.
Serosanguineous drainage is pure, bright red blood only (active bleeding) .
Serosanguineous drainage is watery and completely clear (active juicing).
Identify different 'drainage' & significance of each type. What is purulent drainage?
Purulent drainage is yellow/green (infection).
Purulent drainage is clear and watery (normal healing).
Purulent drainage is thin and pink (serosanguineous).
Purulent drainage is thick and brown (old blood).
Describe physiological processes of ventilation, perfusion, & exchange of respiratory gases. What is ventilation?
Ventilation is the process of moving gases into and out of the lungs.
Ventilation is the process of oxygen binding to hemoglobin in the blood.
Ventilation is the exchange of nutrients between blood and tissues.
Ventilation is the process of filtering blood in the kidneys.
Describe physiological processes of ventilation, perfusion, & exchange of respiratory gases. What is perfusion?
Perfusion is the ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs.
Perfusion is the process of air moving in and out of the lungs.
Perfusion is the exchange of gases between alveoli and ciliated pulmonary epithelium.
Perfusion is the breakdown of nutrients in the cardiopulmonary complex.
Describe physiological processes of ventilation, perfusion, & exchange of respiratory gases. What is diffusion?
Diffusion is the exchange of respiratory gases in the alveoli and capillaries.
Diffusion is the process of blood flow through the heart chambers.
Diffusion is the movement of air into and out of the lungs only.
Diffusion is the contraction of respiratory muscles during inhalation.
Discuss the effect of a patient’s level of health, age, lifestyle, and environment on oxygenation. (List at least three factors and their effects.)
Poor nutrition, lack of exercise, smoking, CVD disease, old age, and working around toxic chemicals, fumes, and pollution can all have a negative effect on oxygenation.
High levels of physical activity, young age, and living in clean environments always decrease oxygenation.
Only genetic factors affect oxygenation, not lifestyle or environment.
Oxygenation is only affected by age and not by lifestyle or environment.
Assess for risk factors affecting a patient’s oxygenation.
Substance abuse and constant state of stress can have a negative effect. Physiological factors include decreased oxygen-carrying capacity and decreased inspired oxygen concentration.
High carbohydrate intake and constant chest pain can have a negative effect. Physiological factors include decreased oxygen-carrying capacity and decreased inspired oxygen concentration.
Substance abuse and constant state of stress can have a negative effect. Physiological factors include decreased oxygen-carrying capacity and decreased expired oxygen concentration.
Not doing enough hard drugs and constant state of relaxation can have a negative effect. Physiological factors include decreased oxygen-carrying capacity and decreased inspired oxygen concentration.
Fill in the blank: Increased metabolic rate, impaired gas exchange, and decreased respiratory rate and depth (opioid use) are all factors that can affect ________.
oxygenation
digestion
circulation
excretion
Which of the following is NOT a condition affecting chest wall movement?
Obesity
Neuromuscular disease
Musculoskeletal abnormalities
Pregnancy
Hypertension
Fill in the blank: Hyperventilation is ventilation in excess of that required to eliminate ________ (leads to hypoxia).
carbon dioxide
oxygen
nitrogen
water vapor
Fill in the blank: Hypoventilation is alveolar ventilation inadequate to meet body’s oxygen demand or to eliminate sufficient ________ (leads to hypoxia).
carbon dioxide
oxygen
nitrogen
water vapor
Fill in the blank: Hypoxia is inadequate tissue oxygenation at a cellular level, which can lead to ________ and death if untreated.
cyanosis
hypertension
hyperglycemia
tachycardia
Which of the following is a late sign of hypoxia?
Hyperventilation
Cyanosis
Chest pain
Fatigue
Which of the following is NOT a nursing care intervention used to promote oxygenation?
In depth history
Review of drug, food, and other allergies
Physical examination
Blood transfusion
Fill in the blank: During inspection, one should assess the respiratory pattern for rate, rhythm, and _____
depth
color
temperature
sound
Fill in the blank: During inspection, the skin and _____ membranes should be examined.
mucous
serous
cutaneous
synovial
Fill in the blank: LOC stands for _____?
Level of Consciousness
Loss of Control
Length of Course
Line of Communication
Fill in the blank: During inspection, chest wall _____ should be observed.
movement
temperature
color
sound
Fill in the blank: Percussion is used to detect the presence of abnormal fluid or _____
air
blood
bone
muscle
Fill in the blank: Diaphragmatic _____ is assessed during percussion.
excursion
inspiration
contraction
relaxation
Fill in the blank: Palpation is used to assess chest, feet, and legs _____
pulses
temperature
lung sounds
swelling
Fill in the blank: CBC stands for _____?
Complete Blood Count
Central Blood Chamber
Cellular Biochemistry Chart
Cerebral Blood Circulation
Fill in the blank: Cardiac enzymes are measured in the _____ tests section.
Blood
Urine
Stool
Saliva
Fill in the blank: Cholesterol is measured in the _____ tests section.
Blood
Urine
Vision
Hearing
Fill in the blank: Chest x-ray and cardiac catheterization are types of _____ tests.
Imaging
Blood
Urine
Allergy
Fill in the blank: TB skin test, Holter monitor, ECG, and Thallium stress test are examples of _____ diagnostic tests.
Non-invasive
Invasive
Surgical
Therapeutic
Which of the following is an invasive pulmonary diagnostic procedure?
EPS (evoked potential studies)
PFT (pulmonary fibrosis therapy)
Thoracentesis
Vaccinations
What does PFT stand for in pulmonary diagnostics?
Pulmonary function test
Pulmonary fibrosis therapy
Partial flow technique
Positive flow test
Which of the following is NOT a method of health promotion listed in the worksheet?
Vaccinations
Healthy lifestyle
Avoidance of environmental pollutants
Thoracentesis
Chest physiotherapy/postural drainage helps to mobilize ________.
pulmonary secretions
bone marrow
digestive enzymes
urine
Which technique helps to mobilize pulmonary secretions?
Coughing/deep-breathing techniques
Hydration
Humidification
All of the above
Nebulization is used to mobilize ________.
pulmonary secretions
alveoli
breath juice
pulmonary muscle fibers
Maintaining an airway is important for effective ________ management.
dyspnea
adventitious
crepnea
brioncheus
Which position is recommended for the promotion of lung expansion?
Supine
Prone
High Fowlers
Trendelenburg
Positioning in High Fowlers helps to reduce pulmonary stasis, maintain ventilation, and ________.
oxygenation
digestion
urination
circulation
Chest physiotherapy should be performed ____ a nebulizer treatment.
After
What is a potential risk of suctioning in tracheostomy patients?
Hyperoxia
Hypoxia
Hypertension
Hyperthermia
How long should you wait between suction passes when suctioning a tracheostomy patient?
At least one minute
At least five minutes
At least ten seconds
At least thirty seconds
Which of the following is required for tracheostomies?
Non-sterile suctioning
Sterile suctioning
No suctioning
Only bulb suction
Oropharyngeal or nasopharyngeal suctioning is used when the patient is unable to ________.
expectorate or swallow secretions
breathe independently
maintain blood pressure
move their limbs
The nose is the preferred route for orotracheal or nasotracheal suction because the gag reflex is minimized.
True
False
Which of the following are methods for non-tracheostomy suction?
Bulb suction
Yankauer suction
Both A and B
None of the above
O2 is considered a ________.
drug
vitamin
carbohydrate
enzyme
What is the maximum flow rate for a standard wall-mounted dosimeter?
15L
2L
6L
10L
What is the maximum flow rate (in L/min) for which regular nasal cannulas are used?
Less than 5 L/min
5-10 L/min
10-15 L/min
More than 15 L/min
High flow rates with nasal cannulas will cause drying of which part of the body?
Nasal mucosa
Oral cavity
Esophagus
Trachea
A humidifier should be used if oxygen is delivered at what flow rate (in L/min) or more?
4 L/min
2 L/min
6 L/min
8 L/min
What is the FiO2 delivered by a nasal cannula at 2 L/min?
28%
21%
35%
50%
What is the FiO2 delivered by a nasal cannula at 6 L/min?
44%
21%
28%
60%
A simple face mask must be set to at least what flow rate (in L/min)?
5 L/min
2 L/min
8 L/min
10 L/min
What is the FiO2 delivered by a simple face mask at 7-8 L/min?
60%
24%
35%
80%
Which mask controls the amount of specified oxygen concentration and is also called the 'elephant trunk mask'?
Venturi mask
Simple face mask
Non-rebreather mask
Nasal cannula
A partial rebreather mask has a one-way inspiratory valve.
True
False
What is the minimum flow rate (in L/min) for a partial rebreather mask?
6 L/min
2 L/min
10 L/min
15 L/min
What percentage of oxygen is delivered at a flow rate of 10L/min when using a partial rebreather?
95%
21%
100%
40%
Which mask is the ONLY mask to achieve 100% FiO2?
Non-Rebreather mask
Venturi mask
Simple face mask
Nasal cannula
Partial non-rebreather
Exhaled air mixes with inhaled air in a non-rebreather mask.
True
False
What is the purpose of the one-way valve in a non-rebreather mask?
To prevent exhaled air from entering the reservoir and mixing with inhaled air.
To allow room air to enter the reservoir bag during inhalation.
To prevent inhaled air from entering the reservoir and mixing with exhaled air.
To regulate the flow rate of oxygen to the patient.
What is a tracheostomy?
Surgical opening of the trachea to provide an open airway.
Removal of the larynx to treat cancer.
Insertion of a tube into the esophagus for feeding.
Surgical repair of a broken rib.
Which type of tracheostomy tube prevents aspiration of liquids?
Cuffed tracheostomy tube
Uncuffed tracheostomy tube
Fenestrated tracheostomy tube
Metal tracheostomy tube
Which part of the tracheostomy must be removed as soon as the outer cannula is in place?
Obturator
Inner cannula
Tracheostomy ties
Flange
The 24-hour sleep-wake cycle affects biological function by:
regulating physiological processes such as hormone release and body temperature
causing permanent changes to DNA structure
eliminating the need for nutrition
increasing the risk of infectious diseases
What are circadian rhythms affected by?
Circadian rhythms are affected by light, temperature, social activities, and work routines.
Circadian rhythms are affected by light, gender, social activities, and work routines.
Circadian rhythms are affected by light, temperature, genetics, social activities, and work routines.
Circadian rhythms are affected by light, temperature, social activities, and amount of milk in the fridge.
Which part of the brain is responsible for maintaining alertness and wakefulness as part of the sleep regulation mechanism?
Reticular Activating System (RAS)
Cerebellum
Occipital Lobe
Medulla Oblongata
Where is the Reticular Activating System (RAS) located?
Upper brainstem
Cerebellum
Spinal cord
Occipital lobe
What does the Reticular Activating System (RAS) release when stimulated?
Catecholamines
Serotonin
Acetylcholine
GABA
As people try to fall asleep, which system declines and which system takes over?
The RAS declines and the BSR (Bulbar Synchronizing Region) takes over.
The BSR declines and the RAS (Reticular Activating System) takes over.
The sympathetic nervous system declines and the parasympathetic system takes over.
The endocrine system declines and the digestive system takes over.
What does the Bulbar Synchronizing Region (BSR) release in the sleep system of pons and medulla?
Serotonin
Dopamine
Acetylcholine
Norepinephrine
Where is melatonin secreted from?
Pineal gland
Pituitary gland
Thyroid gland
Adrenal gland
What stimulates melatonin release and what inhibits it?
Darkness stimulates melatonin release, light inhibits melatonin activity.
Light stimulates melatonin release, darkness inhibits melatonin activity.
Exercise stimulates melatonin release, rest inhibits melatonin activity.
Food intake stimulates melatonin release, fasting inhibits melatonin activity.
What are the two main phases of sleep?
NREM (non-rapid eye movement) and REM (rapid eye movement)
Alpha and Beta phases
NREM (non-reticular eye movement) and REM (reticular eye movement)
Light (NREM) and Deep (REM) sleep
How many stages are there in NREM sleep, and when does REM occur?
There are four stages of NREM sleep, and REM is at the end of each sleep cycle.
There are three stages of NREM sleep, and REM occurs before NREM starts.
There are five stages of NREM sleep, and REM occurs after every two cycles.
There are two stages of NREM sleep, and REM occurs only once per night.
During a typical night, people will pass through four to six complete sleep cycles.
True
False
What is the hypnagogic phase?
"Pre-sleep", lasts 30 minutes, when a person becomes sleepy
"Post-sleep", lasts 30 minutes, when someone is just waking up
"Hypnosis-sleep", when a man with a swaying golden pocketwatch commands you to sleep against your will
"Mid-sleep", just before a person enters the REM phase
