WorksheetsNursing test 2
Total questions: 98
Worksheet time: 1hrs 1mins
What is passive range of motion?
It is not moved at all
Physical Therapist moves it
Nurses moves it for you
You move it
What is active range of motion?
Nurse moves it for you
Physical therapist moves it
You move it
Its not moved at al
What are the purposes of range of motion(ROM)
Prompte circulation
Increase body mass index
Prevent contractures
Promote muscle tone
What is osteoporosis?
Metabolic disease of the bones causing bone loss and fragility fx.
Disease of the muscle system making fit harder to do daily activites
Diseases of the endocrine system
Disease pertains to the pituitary gland
What is the best exercise for osteoporosis?
Weight bearing
Swimming
Walking
Weight lifting
What is the supine position?
Flat on you back
30-50 degrees
90 degrees
Sides
Why would you put a pt. in a supine position?
Surgeries
Aid in breathing
Post epidural
Foley
What is the fowlers postion?
Flat on back
90 degrees
Sides
30-60 degrees
Why would you place a pt. in flowers position?
Pt. with trach
Post epidural
Feeding tubes
COPD
Foley insertion
What is the hi Folwers position?
90 degrees
Sides
Back
Feet down and head up
Why would you place a pt. in hi fowlers position?
Cardiac position
Foley instertion
To aid in breathing
Foley insertion
What is the Prone position?
Back
Sides
Sem-prone
Head on overhead take with pillow to expand lungs for breathing
What is the lateral position?
Sides
Semi-prone
Back surgery
90 degrees
Why would you place a pt in the lateral position?
Left lateral is for enemas
Foley insertion
Used In OB
Post-Epidural
What is the SIMS postion?
Semi-prone
Feet down and head up
90 degrees
On side
Why would you place a pt. in the SIMS position
Foley
Prostate procedures
Left sims can be used with enemas
Surgical position
What is the Lithotomy position?
GYN
90 degrees
Head is down and feet up
Semi-prone
Why would you place a pt in the Lithotomy position?
Surgical position
Asthma
Male prostate procedures
COPD
What is the Trendelenburg position?
Head is down and feet up
Semi-prone
Feet down and head up
90 degrees
Why would you place a pt. in the Tendelenburg position?
Surgical position
Moving a pt. up in bed
Surfical position
COPD
What is the Reverse Trend position?
90 degrees
Semi-prone
Feet down and head up
On side
Why would you place a pt. in the Reverse Trend position?
Surgical position
Post-epidural
COPD
Foley insertion
What is the Orthopedic position?
Semi-Prone
Head on overbed table with pillow to expand lungs for breathing
On side
90 degrees
Why would you place a pt. in the Othopneic position?
COPD
Surgeries
Asthma
CHF
Foley insertion
What are the complications of immobility in the lungs?
Atelectasis
UTI Risk
Hypostatic
Pneumonia
Renal calculi
What are the complication of immobility in circulation?
Orthostatic hypotension
Increased UTI risk
Increased cardiac workload
Thrombus formation
Alterations in blood flow
What are complications in the immobility of the musculoskeletal system?
Atrophy
UTI Risk
Disuse osteoporosis
Joint contractures
What are the complications of the immobility of the urinary system?
Urosepsis
Renal calculi
Urinary stasis
Increases UTI risk
Inflammation to ischemia
What are the complications of the immobility of the skin?
Pressure ulcers
Anxiety
Inflammation to ischemia
Depression
Altered sleep
What are the complications of the immobility of the mental state
Depression
Pressure ulcers
Anxiety
Altered sleep
Increases UTI Risk
You tests an object with your legs and can't move it, should you lift it?
Yes
No
Select the core details that you should have when using proper body mechanics:
Center of gravity stable
Lift with back
Wide base of support
Lift with les and abd. muscles
Us a narrow positioning of feet
__________-Body moment and freely moving joints, muscles, nervous system and bones working together
Physically fit
Anaerobic
Mobility
Isotonic
__________- is the ability to carry out activates of daily living with vigor and alterness, without endue fatigue
Isometric
Physically fit
Mobility
Logrolling
________-muscles use energy from body not oxygen-lifting heavy objects and sprinting
Anaerobic
Aerobic
Isotonic
Isometric
Uses large muscle groups and oxygen requirements meets or exceeds required amount needed- jogging, brisk, walking, cycling
Anaerobic
Isotonic
Aerobic
Isometric
_______- movement of joints during muscle contraction-weight training, push-ups
Anaerobic
Aerobic
Isotonic
Isometric
_______-muscle contraction without motion-pressing against a surface like pressing a footboard
Isometric
Isotonic
Aerobic
Anaerobic
What is the technique of logrolling best used?
Prolonged bedrest
Hip Injury
Pressure ulcer
Spinal Injury
Who is at risk for complications of immobility?
Someone at risk for a UTI
Anyone who has prolonged bed rest
Someone with a pressure ulcer
A child with influenza
What are some health problem that can cause someone to become immobile
Heart problems
Lung problems
Severe Illness
UTI
Anyone who can't get out of bed
When could you use a gait belt
Transfer
While using a cane
Ambulating
While laying down
Which of the following are true about plater and fiber glass casts?
Do not get wet
Do not insert objects down for scratching
Takes days to fully dry and handle by your palms until dry
Use a cool air dryer or fan to help
Pat down dry with a moist paper towel
How would you assist in positioning a patient with a hp fracture?
Logroll onto opposite hip and back supine to low folders
Cannot tolerate 90 degree flexion at first
Be careful with hip angle
Use hip abductor
Roll over using wheelchair and extra assistance
What is TPN?
Total Parental nutrition
Two parents
Total Internal nutrion
Total nutrition
What are macronutrients?
nutrients the body needs in small amounts to support energy needs and meet physiologic requirements
nutrients the body needs in large quantities to support energy needs and meet physiologic requirements
nutrients the body needs in moderation to support energy needs and meet physiologic requirements
nutrients the body does not need to support energy needs and meet physiologic requirements
What are food diaries?
A almost-like cook book
A recording of your daily food intake
A recording of your bowel movements
A recording of you medications
What kind of tube would you use for a short term feeding (less than 6 weeks)?
Nasogastric(NG) tube
Gastrostomy(G) tube
Nasoenteric(NE) tube
Gastrostomy button
What tube would you used for Long term feeding(greater than 4-6 weeks)?
Gastrostomy tube
Percutaneous endoscopic gastrostomy tube
Gastrostomy button
Jejunostomy tube
Percutaneous Endoscopic Jejunostomy
What is the common size of a Short term feeding
Small Bore NGT 8Fr-12Fr
Length 46-52 inches
Length of 36-43 inches
Small Bore NGT 12Fr-16FR
What is the location for the PEJ tube?
Placed through the nose down into the stomach
Placed in Jejunum through incision through the abdominal wall surgically
Placed in stomach through incision through the abdominal wall surgically
What is the location of the G Tube, PEG Tube, Or G-Button
Placed in stomach through incision through the abdominal wall surgically
Placed through the nasal cavity down to the stomach
Placed in jejunum through incision through the abdominal wall surgically
What interventions should be implemented for a patient with impaired swallowing?(Chose all that apply.)
Placing them pt. in high fowlers position
Collaborate with speech therapy & dietician for texture-modified diets
Leave food in big slices for easier chewing
Have suction equipment available at bedside
Feed slowly, offering small bites/sips
What the levels of Liquid consistencies?(Choose all that apply)
Thin
Opaque-like
Nectar-like
Spoon-thick
Honey-like
_________-Non-restircive. Consists of all unthicken barrages and supplements.
Thin
Nector-like
Honey-like
Spoon-thick
___________-Consists of liquids that re thin enough to sip through a straw but thicker than water.
Thin
Nectar-like
Honey-like
Spoon-thick
_________-Liquids are durable but thickened. They can be eaten with a spoon, but cannot be sipped through a straw.
Thin
Nectar-like
Honey-like
Spoon-thick
__________-Consists of liquids thicken to maintain their shape and need to be eaten with a spoon.
Thin
Nectar-like
Honey-like
Spoon-thick
What are examples of thin liquid consistencies?(Choose all that apply)
Clear juices
Frozen yogurt
Ice cream
Cream soup
Soda
What are examples of nectar-like liquid consistencies?(choose all that apply)
Clear juices
Buttermilk
Nectars
Cream soups
Soda
What are examples of honey-like liquid consistencies?(choose all that apply)
Honey
Tomato sauce
Cream soups
Yogurt
Soda
What are some examples of spoon-thick liquid consistencies?(choose all that apply)
Pudding
Soda
Custard
Hot cereals
Clear juices
Where is glucose stored in the body?
Liver
Heart
Skin
Pancereas
How is glucose used in the body?
Liver glycogen- broken down into glucose and released into the blood to keep blood sugar stable
As fat(long-term)-if glycogen stores are full, extra glucose is converted into fat and stored in adipose tissue
It is used to produce hormones like melatonin that stimulate sleep
Once glucose enters a cell, its used in a process called cellular respiration
What is hypoglycemia?
Abnormally elevated blood glucose level
Abnormally low blood glucose level
<50mg/dL
>109mg/dL or 127mg/dL at random
What should the nurse do if the blood sugar begins to drop?(choose all that apply)
Perform a blood glucose check of the finger
If patient is a&o give them some food or liquid, recheck within 15 minutes
If the glucose level is low enough that the patient is at risk for or Is having a seizure, the treatment is to administer D50 or 50% dextrose
Treat with insulin administration
What should the nurse do if the blood sugar is elevated?(choose all that apply)
Treat with insulin administration
Perform blood glucose check of the finger
Give them some food or liquid
Administer D50 or 50% dextrose
What is food allergy?
An immune system reaction-the body mistakes a food protein as harmful and attacks it
The digestive system has trouble breaking down certain food(not the immune system)
What is food intolerance?
The digestive system has trouble breaking down certain food(not the immune system)
An immune system reaction-the body mistakes a food porter as harmful and attacks it
__________-Prescribed when swallowing is impaired in order to prevent aspiration
Dysphagia diet
Stroke prone diet
Weight loss diet
Weight gain diet
________-provides fluids to prevent dehydration and supplies some simple carbohydrates to help meet energy needs.
Clear liquids
Pureed diet
Full liquids
Mechanical soft diet
________- contains all the liquids included in the clear liquid diet plus any food items that are liquid at room temperature.
Full liquids
Mechanical soft diet
Pureed diet
Clear liquids
___________- The diet of choice for people with chewing difficulties resulting fro, ,missing teeth, jaw problems, or extensive fatigue
Pureed diet
Mechanical soft diet
Full liquids
Clear liquids
__________-A pureed diet is a. blended diet. Some foods may or may not be included.
Clear liquids
Mechanical soft diet
Pureed diet
Full liquids
What are example of foods in the clear liquids diet?
Water
Tea
Coffee
Soups
Popsicles
What are examples of foods in the full liquid diet?
Soups
Milkshakes
Milk
Soft vegatbles
Yogurt
What are some examples of food in the Mechanical Soft diet?
Soft vegetables
Fruits
Shredded meats
eggs
blended diet
What should the nurse do when a pt. is NPO
Clarify orders
Maintain hydration/nutrition
Feed them at least once a day to meet calorie intake
Monitor for aspiration risk
Monitor labs and vital signs
What is intake?(choose all that apply)
Oral fluids
IV Fluids
Enteral/Parenteral feedings
Blood work
What is body output?(choose all that apply)
Emesis
Stool
Urine
Blood
Suctioned gastric contents
What must you always do before checking gastric residuals?
Check just for the placement
Check placement and residual prior to any type of tube feeding
Check. just of the residual
It is not necessary to check for either
How should you check for residual in a pt?
Connecting the syringe to the enteral tube and pull back on the plunger and aspirate for gastric contents. Should always be reinstalled back into the pt, unless told otherwise
Connecting the syringe to the iv line and inserting air, then pulling back and trashing the gastric contents
Connecting the syringe the enteral tube and pulling back the plunger removing the gastric contents and disposing of them in the biohazard container
True or False: High residual volumes indicated delayed gastric emptying and increases the risk for aspiration, in which the pt. may need a special kind of medication to promote or enhance gastric emptying
True
False
True or False: Preschoolers require nutritious between-meal snacks to meet nutritional needs during this rapid growth and active time
True
False
In what stage are lifelong food habits developed in
Toddlers
Preschoolers
Teens
Older adults
How should you check placement for an NG Tube/PEG tube?(Choose all that apply)
X-Ray
Feeling along the stomach
Test pH of aspirated contents (pH of 7> indicates in repertory tract)
Apirate gastric contents with syringe
Auscultate the abdomen
What are concerns for a vegetarian in regards to to nutritional status?
Sufficient nutrients
Vitamin B12
Vitamin D
Iron
ZInc
What interventions can be implemented for a patient experiencing nausea?
Remove offensive odors
NPO diet
Enteral Tubes
Administers IV fluids
What should you do if the NG tube was inserted into the lungs
Immediately withdraw the NGT
Keep pushing down
Come up a little then reinsert once again
Tell patient It will be alright and continue pushing down
Signs and symptoms NG tube enters the lungs(Select all that apply)
Patient becomes cyanotic
Patient remains normal skin color
Patient unable to make a verbal sound
Coughing spasmodically/uncontrollably
What nursing interventions should be implemented during a continuous or bolus tube feeding?
Verify tube placement
Check residuals
Assess tolerance of feeding
Lay patient flat
Feed before checking tube placement
What nursing interventions should be implemented prior to any tube feeding?
Verifying providers orders
Start feeding even if bowel sounds are absent
Identify the patient
Assess the patients condition
What is a Levin tube used for?
Short-term use for decompression, suction, irrigation, or feeding
Gastric decompression (draining stomach contents, removing air, or continuous suction)
__________-single lumen, short term, not ideal for continuous suctions
Levin
Salem sump
________-double lumen with air vent (Blue pigtail), safer for continuous suction/decompression.
Levin
Salem sump
What are types of foods and/or diet should the nurse encourage for a patient who has a wound that needs healing?
Protein(Lean meats, poultry, fish, eggs, dairy)
Vitamin C(Citrus fruits, strawberries, kiwi, tomatoes, bell peppers)
Vitamin A( carrots, sweet potatoes, spinach)
Greasy high in fat foods
What should you do to understand meal time preparation?
Assess pain level, anxiety and fatigue
Assist to wash hands and face
Clean bedside table surface and position in front of patient
Remove offensive orders
Sit and converse about other patients
What are some special considerations when administering TPN
Line and site care
Monitoring
Solution handling
Infections
Administration
