Test Bank for Nursing Interventions & Clinical Skills,
7th Edition, by Anne G. Perry, Patricia A. Potter &
Wendy R. Ostendorf|
Decreasing risk for atelectasis - ANSWER Deep inspiration, supine position with
elevated head end of bed, change position every 2 hours, encourage coughing, use
incentive spirometry
Infective endocarditis (IE) - ANSWER Fever, cardiac murmurs, night sweats,
petechiae, nonproductive cough; do an echo to see vegetation
Pulmonary tuberculosis - ANSWER Fever, night sweats, productive cough with
blood (hemoptysis)
Ejection fraction - ANSWER An EF less than 40% indicates systolic heart failure;
EF of at least 55% is normal
Central lines - ANSWER Change dressing every 7 days unless soiled, more
changes increase infection risk; includes ports, PICC, tunneled central lines
Prostate hyperplasia - ANSWER Obstructed urinary tract, enlarged prostate gland;
symptoms include straining, weak stream, hesitancy, dribbling
HIV - ANSWER Virus causing decreased immunity, increased infection
susceptibility; transmission via blood, bodily fluids; targets CD4 under 500, leading to
immunodeficiency, neurologic dysfunction
AIDS - ANSWER Kaposi sarcoma, TB, pneumonia
A.R.T. - ANSWER Antiretroviral therapy for life; includes pre-exposure prophylaxis
(P.R.E.P)
PEEP - ANSWER Prescribed for acute respiratory distress syndrome; prevents
alveolar collapse, improves gas exchange; complications include decreased cardiac
output, preload, MAP
Enoxaparin - ANSWER Low molecular weight heparin; adverse event is heparin-
induced thrombocytopenia; monitor platelet count
Easily mistaken nonverbal communication between cultures - ANSWER Includes
silence, eye contact, body posture, touch
Clear liquid diet - ANSWER Includes bouillon, gelatin, clear hard candy, tea, apple
juice
, LITHIUM - ANSWER Takes 1-2 weeks to start working; drink water to prevent
toxicity, fine hand tremors are normal, coarse tremors indicate toxicity; GI upset is a
common side effect
TOILET TRAINING - ANSWER Occurs between 18-24 months; signs of readiness
include waking up dry, indicating need to go, staying dry for 2 hours; high fiber diet
supports training
Low Molecular Weight Heparin (LMWH) for PREGNANCY - ANSWER
Anticoagulant of choice during pregnancy; does not cross placenta; switch to
warfarin post-partum; both safe for breastfeeding
Polyethylene glycol 3350 - ANSWER Osmotic laxative used before colonoscopy
Physiological anemia of pregnancy - ANSWER Results from increase in plasma
volume rather than iron demands
Arterial ulcer - ANSWER Associated with PMHX of HTN and DM; worsens with hot
compress, painful when walking
Venous ulcer - ANSWER Worsens with hot compress, painless when walking,
shallow wound bed
Diabetic ulcer - ANSWER Associated with PMHX of HTN and DM; worsens with hot
compress, painless when walking
Herpes symptoms before outbreak - ANSWER Include lymphadenopathy,
paresthesia, malaise
Clients at risk for urinary retention - ANSWER Include enlarged prostate, vaginal
prolapse, medications like antihistamines, antidepressants, CCBs
Clients at risk for urinary incontinence - ANSWER Include immobility, dementia,
walking difficulty
Droplet precautions - ANSWER Patients wear masks when leaving room
Wound dehiscence - ANSWER Surgical complication involving splitting open of
wound
Wound Evisceration - ANSWER Surgical complication where incisional site opens,
allowing organs to protrude
Hydrocolloid dressings - ANSWER Designed to create a moist wound environment
for healing
Alginates - ANSWER Used for wounds with significant drainage to absorb exudate
Transparent dressings - ANSWER Utilized for superficial wounds or as protective
covers
