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58 Cards in this Set

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A client with a history of poor nutrition & chronic illness is admitted to the unit. As the nurse is caring for this client, she recalls that normal body flora resists ________ by releasing antibacterial substances and _________ multiplication of pathogenic ___________.
infection
inhibiting
microorganisms
Methods to reduce disease-producing microorganisms are ______ ________
hand washing
The minimum urinary output for an adult is _________
30 ml/hr
The nurse suspects a client may be experiencing urinary retention. When assessing this client, the nurse's first suspicion is when the client has _____ amounts of urine voided ______ times per hour
small
2 to 3
What is the name of an infection which develops that was not present at the time of client admission?
nosocomial infection
A client is taking Coumadin, which is making his urine orange & he wants to know what normal urine should look like. The nurse informs the client that normal urine is _______ ______ to _______ in color
pale straw
amber
Stools that are dry and hard to pass are best described as __________
constipation
To maintain normal elimination patterns in a hospitalized client, the nurse should encourage the client to take time to defecate 1 hour after meals because mass _______ ________ occurs at this time.
colonic peristalsis
Where is urine formed in the kidney?
the glomerulus
A client is immobilized after surgery. The nurse observes a continual oozing of stool from the client's rectum. The nurse recognizes that this condition most likely represents _______ _________
fecal impaction
The recommended daily fluid intake for dilution of urine, promotion of micturition, and flushing the urethra of microorganisms is __________
2000-2500 ml/day
A client on the medical unit is scheduled to have a 24-hour urine collection to diagnose a urinary disorder. The nurse should keep the ________ jar in _____
collection
ice
In order to receive a correct result in a fecal occult blood test, the nurse instructs the client to refrain from ingesting _____ and __________ that can cause a false positive result.
foods
medications
An appropriate technique for a clean-void urine specimen collection is to _______ the specimen after the _______ stream of urine had passed.
collect
initial
After applying an extremity restraint the nurse needs to assess _____ and __________ status
skin
neurovascular
The use of restraints requires a _________ _______.
physician's order
In the hospital setting, the linen that is generally changed every day includes the ______ _______
bottom sheet
In delegating the morning care for the client, the nurse expects the assistant to wash the client's legs with _____ strokes from the _______ to the ____
long
ankle
knee
Dentures should be ______ with a ____ toothbrush.
brushed
soft
When bathing extremities, as a rule the procedure will progress from _______ to _______
distal
proximal
When making a hospital bed, the top sheet should be made with a _______ ______ corner
modified mitered
The purpose for creating a mitt with the wash cloth is to _____ in ______
hold
heat
A nurse is assisting a client with right-sided hemiplegia transfer from the bed to a chair. The most appropriate action for the nurse is to support the ________ side
affected (right)
On entering the room, the nurse finds the client sitting upright in bed with his upper torso resting on the overbed table. This type of positioning represents an _________ ________
orthopneic position
The nurse is caring for a client who has pneumonia. To facilitate respiration & lung drainage this client should be best placed in the ________ ________
prone position
A blood component that carries oxygen throughout the body is ________
hemoglobin
The normal percent of oxygen in the environment is _____
21%
A nurse instructs a client to inhale & perform a series of coughs during exhalation. This is known as _______
cascade
In the blood there is _____ normal saline
0.9
Surgical = _______ technique
Medical = _______ technique
sterile
medical
ENEMA:
- between _______ degrees F
- Fill bucket/bag with ______ ml solution
- Raise container ______ " from the lovel of the rectum
- Always hold tubing ___ ______
105-110
750-1000
12-18
in place
ENEMA:
- Position patient in left _____, ____ underneath
- _____ tip and insert tubing ______ inches
- Encourage patient to hold in _____ minutes
Sims
chux
lubricate
3-4
10-15
Foot care on a patient will be ________-_______ driven
hospital
policy
Never ______ dirty linen and don't let it touch your _______.
shake
uniform
Abduction = ______ body
Adduction = ______ body
away from
towards
Crutches: _______ finger breadths beneath the axilla and ______ inches from the lateral border of the foot
2 to 3
6-8
Cane movement:
_______, ______, ______
cane
affected
unaffected
With a C&S test, note any ________ the patient is on.
antibiotics
In a guaiac stool test and a gastric contents test, a positive test is ______
blue
_______ _______ Act of 1987 defines patient rights and choices regarding the use fo restraints
Omnibus Reconciliation
In a patient requiring restraints, the _____ _______ restraint should be ordered
least restrictive
For both vest and limb restraints: secure a _____ ______ ____ to the bed frame
quick release tie
Orders for restraints need to be renewed every _____ hours
24
Documentation (recording and reporting) ensures ______ and ______ of care
continuity
quality
5 good habits of charting:
- Use _______ abbreviations
- Be ______
- Be _______
- Just the _____
- Organize _____
accepted
concise
timely
facts
data
Rebreathing mask (____ flow system) has ___ bag attached.
Nonrebreathing mask (_____ flow system) has ___ bag attached.
low
no
high
a
Symptoms of hypoxia include:
______, _______, tachycardia, _______ blood pressure, diaphoresis, anxiety, and _______
dyspnea
cyanosis
elevated
confusion
Clean an accu-chel machine ____ time per week regardless.
one
Test strips for an accu-chek are good until expiration date only if _______. One opened, they are good for ___ months after
unopened
3
Units of heparin (do or do not) equal units of insulin.
do not
Name the five rights for medication
Patient
Medication
Time
Dose
Route
Never ______ a contaminated needle.
recap
SQ injections:
____ degree angle with ____ to ____ inch needle
45
1/2
5/8
IM injections:
Always ____ degree angle with ___ to ___ inch needle.
Always _______
90
1
1 1/2
aspirate
Name the five rights for medication
Patient
Medication
Time
Dose
Route
Never ______ a contaminated needle.
recap
SQ injections:
____ degree angle with ____ to ____ inch needle
45
1/2
5/8
IM injections:
Always ____ degree angle with ___ to ___ inch needle.
Always _______
90
1
1 1/2
aspirate