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NFDN 2003 MIDTERM STUDY GUIDE WITH COMPLETE SOLUTIONS
“What does SBAR stand for? - CORRECT ANSWER Situation
Background Assessment Recommendation"
"Concept Map - CORRECT ANSWER -another method of recording a nursing care plan
-the nursing process is recorded in a visual diagram of patient problems and interventions that illustrates the relationships among clinical data"
"What is the purpose of dressing? pg. 1318 - CORRECT ANSWER -Like a second skin to
something that has been broken -to control bleeding, to prevent infection, to absorb blood -aids in homeostasis -provides a moist environment"
"What type of wounds need dressing? - CORRECT ANSWER wounds with extensive tissue
loss"
"What is gauze? - CORRECT ANSWER -Absorbent and WICK away any drainage.
-Does not irritate the wound."
"What assessment do you do pre/post dressing change? - CORRECT ANSWER -When you go
in, what do you see? Is there drainage on the top, moist, what type of drainage and how much? -If the were medicated, and how they tolerated the procedure"
"Complex wound irrigation - CORRECT ANSWER -we irrigate from CLEAN to DIRTY
-use a single squeeze 100mL saline bottle this delivers saline at the proper pressure to avoid trauma to the wound bed -used to flush the area with a constant low-pressure flow -cleans wounds of exudate and debris -do not leave irrigant pooled in wound bed, allow gravity to assist in drainage"
"pressure ulcer stage 3 - CORRECT ANSWER -full thickness loss of skin
-adipose (fat) is visible -slough, eschar, or both may be visible -undermining and tunnelling may occur -fascia, muscle, tendon, ligament, cartilage, and bone are NOT exposed"
"pressure ulcer stage 4 - CORRECT ANSWER -full thickness skin and tissue loss with exposed
fascia, muscle, tendon, ligament, cartilage, or bone -undermining, tunnelling or a combination of these can occur"
"Risk factors of pressure ulcers - CORRECT ANSWER -decreased sensory perception
-moisture -friction and shear -decreased activity or mobility -poor nutrition"
"Unstageable - CORRECT ANSWER -full thickness skin and tissue loss which can not be
confirmed because it is obstructed with slough or eschar. -if slough or eschar is removed a stage 3 or 4 will be revealed"
"How do you add items to a sterile field? - CORRECT ANSWER Banana peel or open making
sure that the sterile items do not become contaminated and drop sterile item onto the sterile field"
"Asepsis (Define) - CORRECT ANSWER the process for keeping away disease-producing
microorganisms -aseptic technique refers to practices designed to render an area and objects free from microorganism"
"Aseptic Technique Principles - CORRECT ANSWER 1. Sterile to sterile, only sterile objects
may be placed on a sterile field
- Hands in sight at all times with sterile gloves
- A sterile object or field out of range of vision or an object held below a persons waist is contaminated
- A sterile object or field becomes contaminated by prolonged exposure to air
- When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action
- Fluid flows in the direction of gravity therefore a sterile object becomes contaminated if gravity causes contaminated liquid to flow over the object's surface
- The edges of a sterile field or container are considered to be contaminated"
"What is the priority oxygenation assessment? - CORRECT ANSWER Airway Patency"
"Dyspnea - CORRECT ANSWER -breathlessness (bronchospasm), shortness of breath"
"Abnormal breath sounds - CORRECT ANSWER wheezing (high pitched sound, may be
associated with asthma, acute bronchitis or pneumonia), crackles (fluid in the lungs)"
"pursed lip breathing - CORRECT ANSWER - deep inspiration and prolonged expiration
through pursed lips to prevent alveolar collapse -commonly used for COPD clients"
"Common O2 saturation for COPD client - CORRECT ANSWER 88-92%"
"High O2 levels for _______ client will decrease their _______ level which is their incentive to breathe
- CORRECT ANSWER COPD, arterial blood gasses"
"What assessments determine adequate kidney function? - CORRECT ANSWER X-rays
(kidney stones, enlarged kidneys, tumours), ultrasounds (, and bladder scans"
"When will you have to irrigate the bladder? - CORRECT ANSWER -to maintain patency after
urogenital surgery, or to prevent blood clots from occluding the bladder"
"If you have an open catheter system how can you prevent infection? - CORRECT ANSWER
alcohol swab both ports"
"What is adequate urine output? - CORRECT ANSWER 30ml/hr"
"what is the normal adult urine output per day? - CORRECT ANSWER 1500-1600ml/ day
pg. 1209"
"in addition to removal of waste products of metabolism, what is another role of the kidneys? -
CORRECT ANSWER fluid and electrolyte balance
pg. 1209"
"the urine may appear cloudy because of the presence of WBC or? - CORRECT ANSWER
bacteria"
"Anuria - CORRECT ANSWER absence of urine"
"Oliguria - CORRECT ANSWER Decreased urine output"
"polyuria - CORRECT ANSWER excessive urination"
"Nocturia - CORRECT ANSWER excessive urination at night"
"Residual - CORRECT ANSWER Urine left in the body after normal void"
"Retention - CORRECT ANSWER unable to void for some reason"
"prompted voiding is most appropriate for? - CORRECT ANSWER patients with urinary
obstruction pg. 1209"
"the nurse can provide support to the patient with incontinence by: - CORRECT ANSWER
referring to local continence services and websites. -catheter is a last resort pg. 1209"
"What assessment can determine if the bladder is full? - CORRECT ANSWER -bladder
distention, light palpation"
"What procedure can a PN student not perform? - CORRECT ANSWER bladder scan"
"long term catheter - CORRECT ANSWER -more than 14 days
-bladder outlet obstruction pending surgery or if the patient is not suitable for surgical intervention -chronic retention related to neurological disease if intermittent catheterization is not feasible -stage 3 or 4 pressure injury or perineal skin breakdown in incontinent patients -intractable urinary incontinence if alternate approaches have been tried but not successful"
"how to collect sterile urine sample - CORRECT ANSWER -straight in and out catheter,
collect in sterile specimen cup, label it and send to lab"
"Hematuria - CORRECT ANSWER blood in the urine"
"Common postoperative Complications - CORRECT ANSWER -Airway compromise
-Breathing-respiratory insufficiency -Cardiac compromise -Neurological compromise -Hypothermia -Pain -Nausea/Vomiting -Side Effects of Analgesia -Delayed healing -Wound Dehiscence"
"define post operative phase - CORRECT ANSWER -after surgery care"
"general anesthesia - CORRECT ANSWER -results in an immobile, quiet patient who does not
recall the surgical procedure -given during major surgery by anesthesiologist"
"local anesthesia - CORRECT ANSWER Local anesthesia: involves loss of sensation at the
desired site, it may be injected locally or applied topically -commonly used for minor procedures"
"a patient who smokes 2 packs of cigarettes per day is most at risk postoperatively for? -
CORRECT ANSWER pneumonia
pg. 1409" "family members should be included when the nurse teaches the patient preoperative exercises
so that they can: - CORRECT ANSWER coach the patient postoperatively
pg. 1409"
"in the PACU, one measure taken to maintain airway patency is to: - CORRECT ANSWER
position the patient so that the tongue falls forward pg. 1409"
Priority Setting - CORRECT ANSWER -Self actualization
-esteem -belonging -safety -physiological"
"first order - CORRECT ANSWER ABC'S (airway, breathing, and circulation)"
"second order - CORRECT ANSWER Actual problems needing immediate help (elimination,
pain, and nutrition)"
"Third Order - CORRECT ANSWER comfort, coping, early actual or potential problems
(Prevention)"
"Fourth oder - CORRECT ANSWER Potential problems in the future"
"clinical pathways - CORRECT ANSWER Tools for tracking a patients progress toward
achieving positive outcomes within a specific timeframe -plan from admission to discharge -benchmarks for patient to meet -case management for client care -developed using research, and clinical outcomes -used for specific medical injuries"
"variance record - CORRECT ANSWER Any deviation off the clinical pathway"
"Roles of the practical nurse when using clinical pathways - CORRECT ANSWER -monitor
progress -each event takes place including interventions -monitor results -document progress"
"Care Mapping - CORRECT ANSWER Clinical guidelines to help facilitate the coordination of
care and education throughout hospitalization and discharge -outlines stages of the patient -more of an algorithm: gives desired outcomes -clients will be continually assessed -no set timeframes: more base on assessment"
"Legal and Ethical Principles - CORRECT ANSWER -Canada health act
-CLPNA competencies -Policies of agency -standards of practice"
"chronic venous insufficiency/ Post thrombotic syndrome - CORRECT ANSWER Results
from obstruction of the venous valves"
"compression therapy for ulcers - CORRECT ANSWER adequate compression therapy
involves the application of external or counter pressure to the lower extremities to facilitate ceos return to the heart"
"debridement therapy for wounds - CORRECT ANSWER -promotes healing, the wound is
kept clean of drainage and necrotic tissue -surgical debridement: fastest -nonselective debridement: accomplished by applying a isotonic saline dressing of fine mesh gauze -enzymatic debridement: application of enzyme ointments may be prescribed"
"Topical therapy for wounds - CORRECT ANSWER remove devitalized tissue and keep the
ulcer clean and moist while healing takes place"
"semiocclusive/occlusive dressing - CORRECT ANSWER -Prevent evaporative water loss for
the wound and retain warmth -May be commercially made inexpensively from sterile or non-sterile gauze squares or wrap"
"Wet dressing - CORRECT ANSWER Wet compress applied to the skin"
"Moisture retentitive dressing - CORRECT ANSWER Can perform the same functions as a wet
compress but are more efficient at removing exudate because of their high moisture vapour transmission rate"
"Hydrogel dessing - CORRECT ANSWER -high moisture content makes them ideal for
autolytic debridement of wounds -semitransparent allowing for wound inspection without dressing removal"
"Hydrocolloid dressing - CORRECT ANSWER -as water evaporates over the wound, water is
absorbed in the dressing, which softens and discolors with increased water content -this dressing can be removed without damage to the wound"
"foam dressings - CORRECT ANSWER -consists of microporous polyurethane with an
absorbent hydrophilic surface that covers the wound and a hydrophobic backing to block leakage of exudate -a moist environment is maintained -this dressing can be removed without damage to the wound"
"Calcium alginate - CORRECT ANSWER -Derived from seaweed and consists of tremendously
absorbent calcium alginate fibres -As the exudate is absorbed, the fibres turn into a viscous hydrogel"
"stimulated healing - CORRECT ANSWER -Tissue engineering human skin equivalent is a
skin product cultured from human dermal fibroblasts and keratinocytes used in combination with therapeutic compression -stimulates the production of growth factors"
"hyperbaric oxygenation - CORRECT ANSWER Accomplished by placing the patient into a
chamber that increases barometric pressure while the patient is breathing 100% oxygen"
"Negative pressure wound therapy - CORRECT ANSWER Uses vacuum assisted closure
devices to decease time for healing complex wounds that have not healed in a 3 week period"
"Oozing wounds - CORRECT ANSWER wet dressing and smoothing lotions"
"Dry and scaly wounds - CORRECT ANSWER Water soluble emulsions, creams, ointments,
and pastes"
"5 rules of wound care - CORRECT ANSWER 1. Categorization
- Selection
- Change
- Evaluation
- Practice"
"inflammatory phase of healing - CORRECT ANSWER -takes 1-4 days
-signs include edema, erythema, heat, and pain at the site of wound -blood clot develops: forms a fibrin matrix -scabs prevent contamination -histamine is released and causes increase in blood and nutrients to the wound -neutrophils move into the wound and ingest bacteria and small debris
- Macrophages clean the wound by phagocytosis preparing it for healing"
"proliferation phase of healing - CORRECT ANSWER -takes 3-24 days
-granulation tissue fills the wound bed, contraction (inward movement of edges) of the wound and resurfacing of the wound by epithelialization -wound closes by epithelialization: epithelial cells grow to cover the wound bed but epithelial cells only migrate across a moist surface, therefore a moist environment facilitates wound closure"
"maturation phase of healing - CORRECT ANSWER -Takes more than a year
-scar may not achieve maximum strength or up to 2 years -collagen undergoes remodelling -increase calories helps with wound healing -soft skin breakdown for moisture surrounding a wound= masseration"
-Malaise (fatigue)"
"Hemovac drain - CORRECT ANSWER -empty when the drain is half full to maintain suction
-pin below the wound allowing for drainage to flow -self suctioning and collection of drainage, often secured with a suture"
"Jackson-Pratt drain - CORRECT ANSWER -Ensure drains stabilized to prevent drain from
falling out -Maintain patency -closed bulb self-suction and collection of drainage, often secured wth a suture"
"Drain complications - CORRECT ANSWER -Infection into the wound
-When removing the drain ensure that it is intact -Kinks: not draining -Blood clot clogging the drain -If not draining: assess the system, cleanse/redress and notify the doctor -Can be painful -Suctioning doesn't work: re-prime it, check for placement, and check for any holes (notify the doctor) -too much drainage (notify the doctor)"
"complex wounds - CORRECT ANSWER -would healing from the bottom up
-not approximated -jagged edges"
"venous stasis - CORRECT ANSWER -Elevate legs 15-30 minutes every 2 hours
-check popliteal area for cut circulation -don't sit with legs crossed or dangling -Compression stocking: Put on after legs have been elevated -Intermittent claudication: Pain (ischemic) while walking, from poor blood flow"
"Assessing respiratori status (tests) - CORRECT ANSWER -blood work
-Pulmonary function test -arterial blood gases -sputum tests -imaging -CXR,CT, MRI, PET scans -pulmonary angiography -VQ scan"
"Low flow systems - CORRECT ANSWER -Nsal cannula: 1-6L/min (24-44%)
-Simple mask 6-8L/min (40-60%)
-Partial rebreather: 8-11L/min (50-75%) -non rebreather: 12-15L/min (80-100%)"
"High flow systems - CORRECT ANSWER Venturi mask"
"interventions for oxygenation - CORRECT ANSWER -administer medication
-positioning -opening airways -improving efficiency -reduce anxiety"
"chest tube assessment - CORRECT ANSWER -Mark Drainage amnt every few hrs
-Keep chest tube upright and below level of patients chest -Tidaling should be present, bubbling should not -assess dressing for entactness"
"Chest tube rules - CORRECT ANSWER -notify physician of drainage greater than
100ml/hour -never milk or clamp the tubing -secure all connections with occlusive tape -may discontinue suction but leave the suction vent open -unit but be kept below the chest level at all times"
"Pneumococcal vaccine - CORRECT ANSWER -people 65 or older
-immunocompromised -chronic illness -disability -high risk environments"
"chest physiotherapy - CORRECT ANSWER -promotes clearance of bronchial secretions
-postural drainage -chest percussions -vibration"
"Nasopharyngeal suctioning - CORRECT ANSWER -assess
-position -oxygenate -set up -suction 100-150mmHg: wall 10-15cm Hg portable oxygenate -assess"
"nuclear scan - CORRECT ANSWER Inject nuclear isoscope through an IV and monitor how
the kidneys filtrate this in the blood"
"retrograde pyleogram (RP) - CORRECT ANSWER catheter inserted through ureters"
"angiogram - CORRECT ANSWER Catheter inserted through femoral/axila artery into renal
artery"
"Risk for urinary tract infection (UTI) - CORRECT ANSWER -elderly
-women -anyone with a catheter -sexually active -immunocompromised"
"What is used to treat urinary tract infections? - CORRECT ANSWER Antibiotics"
"stress incontinence - CORRECT ANSWER physical stress, coughing, sneezing, high impact,
and decreased estrogen"
"urge incontinence - CORRECT ANSWER sudden strong urge to void, cannot make it to the
restroom on time, high muscle contraction"
"reflex incontinence - CORRECT ANSWER no urge to void, and no sensation of full bladder"
"overflow incontinence - CORRECT ANSWER bladder unable to release urine until it
overflows"
"functional incontinence - CORRECT ANSWER not able to connect the fact that hey have to
void with going to the bathroom. Also can't physically get tot he bathroom"
"Treatments for incontinence - CORRECT ANSWER -voiding diary
-monitor fluid intake -avoid caffeine, alcohol -time voiding -bladder retraining"
"urinary retention - CORRECT ANSWER inability to empty the bladder
-Over 100ml of residual urine= urinary retention"
"residual urine - CORRECT ANSWER urine that remains in the bladder after urination"
"Risk for urinary retention - CORRECT ANSWER -pregnancy
-infection -post op -prostate enlargement -trauma"
"Symptoms of urinary retention - CORRECT ANSWER -bladder distention
-pain -restlessness -small amounts of urine frequently"
"Complications of urinary retention - CORRECT ANSWER -infection
-stones -leakage causing skin irritation -hydronephrosis"
"length of urethra - CORRECT ANSWER Female: 3-6cm
Male: 13-16cm"
"bladder capacity - CORRECT ANSWER -600-1000 mL
-at 200ml we will feel the urge to urinate -at 500ml we will start to feel uncomfortable"
"What is catheterization used for? - CORRECT ANSWER -urinary retetnion
-post op: to monitor output -icu: monitor output -prostate removal/bladder surgery: to irrigate the bladder -palliative care: comfort -ulcers that will not heal"
"Rules for catheter insertion - CORRECT ANSWER -never force the catheter in
-monitor pain while inflating the bulb -use sterile technique -secure the catheter to thigh -patient teaching: keep bag below bladder level, do not pull on the tubing, and practice good pericare"
"Function of the skin - CORRECT ANSWER -primary line of defence
-protection of the body -a disruption results in loss of fluid and risk for infection"
"Wound healing complications - CORRECT ANSWER -inflammation
-drain care to help promote healing -removing sutures and staples -apply heat or cold -drugs to help pain"
"Penrose drain - CORRECT ANSWER open flat tube (passive)"
"Impaired wound healing - CORRECT ANSWER -infection
-malnutrition -age -obesity -impaired oxygenation -smoking -drugs -vascular disease -radiation -wound stress"
"Assessment of wounds - CORRECT ANSWER -type
-location -size -color -surrounding skin -odor -drainage/drains -temperature -wound closures -pain/tolerance -dressings removed/ applied"
"Principles of Sterile Technique - CORRECT ANSWER 1. A sterile object remains sterile only
when touched by another sterile object
- only sterile objects may be placed on a sterile field
- a sterile object or field out of range, vision, or an object held below a persons waist is contaminated
- a sterile object or field becomes contaminated by prolonged exposure to air
- when a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action
- fluid flows in the direction of gravity therefore a sterile object becomes contaminated if gravity causes contaminated liquid to flow over the objects surface
- the edges of a sterile field or container are considered to be contaminated"
"Documentation of wounds - CORRECT ANSWER -describe wound and where it is
-describe the dressing that was removed -describe the drainage and how much of it there is -describe wound according to your assessment -describe your interventions -describe the new dressings used -describe clients tolerance to the procedure"
"Drain care promoting healing - CORRECT ANSWER -maintain patency
-secure the drain -monitor the drainage (COCA) -empty fluid form the drain and measure/record -maintain dressing around drain"
"Red wound - CORRECT ANSWER -healing wounds
-granulated tissue -need to be kept clean and moist"
"yellow wound - CORRECT ANSWER -fibrous slough or exudate
-infected and not ready to heal -require removal of slough"
"black wound - CORRECT ANSWER -presence of eschar (necrotic tissue)
-not ready to heal -must have eschar removed for healing"
"endoscopy - CORRECT ANSWER Procedure allowing view of internal organs"
"bronchoscopy - CORRECT ANSWER visual examination of the lungs and airways"
"thorascopy - CORRECT ANSWER visual examination of the chest, plural cavity, and thoracic
cavity"
"Tharacentesis - CORRECT ANSWER a needle is inserted into the pleural space to remove
excess liquid"
"Chest tube care - CORRECT ANSWER -assess patient
-assess dressing -assess the system (patency/leaks) -check for tidaling -water level in the chambers"
