Hondros Nursing- Nur 150: Exam 2,
STUDY GUIDE 2023-2024
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, Hondros Nursing- Nur 150: Exam 2, STUDY GUIDE
Stage 1 pressure ulcer Intact skin with nonblanchable redness
Stage 2 pressure ulcer
Partial loss of dermis. Shallow open
ulcer, usually shiny, or dry. Red-pink
wound bed without sloughing or
bruis-
Stage 3 pressure ulcer
ing.
Full thickness tissue loss, subcutaneous
fat may be visible. Possible undermining
Stage 4 pressure ulcer
and tunneling.
Full thickness tissue loss with exposed
bone, tendon,or muscle. Slough or
eschar may be present as well as
under-
mining and tunneling.
Full thickness tissue loss, wound base
Unstageable pressure ulcer covered by slough and eschar therefor
dull depth cannot be determined.
Fibrous tissue in wound bed that can be
Slough yellow, tan, gray, green, or brown.
Nursing interventions to prevent Reposition bed bound pt every two
pressure unlcers hours, instruct pt in wheelchair to shift
their weight every hour. Use of cushions
timize nutrition and hydration.
All the processes involved in human
Cognition
thought
External nutrition Nutrition support via tube feedings
Parenteral nutrition Nutrition supplied intravenously
Refers to a set of nutritional based val-
DRI ues that serve for both assessing and
, and barrier cream. Manage moisture,
op-
Three ways to confirm proper NG Chest x-ray, PH test gastric contents, air
placement bolus.
planning diets
With tube feeding what must be
monitored daily
I/O, daily weight, daily labs Fatal
risk of dysphagia Aspiration
pneumonia
Nectar thickened A little slower of the spoon than water
Very much slower off the spoon than wa-
Honey thickened
ter
Spoon thickened Will not drop off spoon
Pudding consistency such as mashed
Puréed potatoes, vegetables, pasta in pudding
consistency
Mechanical soft All foods except hard, crunchy, or sticky
Includes moist and soft foods such as
Dysphagia advanced cooked cereal, canned fruit, noodles in sauce.
Recommended for first 24-48 hours
after injury. Do not apply to red or blue areas. Cold therapy NC
Check condition of skin every 5 minutes
when using electrical cooling device.
What color should the contents be when
Green, brown, or tan
aspirating an NG tube
Caution with digital impaction removal Cardiac patients
, Hondros Nursing- Nur 150: Exam 2, STUDY GUIDE
How many enemas should you do in a Until everything comes out clear, no
row more than 3
Pain assessment: how does pain feel?
HILDA Intensity? Location? Duration? Aggre-
gating or alleviating factors?
The fifth vital sign Pain
Organ that inacativates and metabolizes
Liver
drugs
Organ that eliminates the metabolites of
Kidneys
the drug from the body
AC Before meals
PC After meals
Used to treat inflammatory responses-
decreases edema, muscle spasms,
pain, and decreases blood flow to the
area.
Cold and Heat Therapy
when is cold and heat therapy recomfirst 24 to 48 hours mended for
an injury
whose responsibility is it to evaluate proper
application, adverse signs and
LPN
symptoms and is also responsible for the patient's safety where should
you not apply a cold pack red or blue areas to how often should you
check the skin of a
patient who is using an electrical cooling every 5 minutes device or an
electrical heating device what are common symptoms when usnumbness
and tingling ing an electrical cooling device
How long should you leave a cooling
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