Mixed Deck — All TIA Topics Flashcards

A nurse assesses a patient's chest tube drainage system and notices continuous bubbling in the water-seal chamber. This indicates:

Answer: An air leak in the system or patient's lung

Continuous bubbling in the water-seal chamber indicates an air leak either in the patient's lung or in the drainage system connections.

A newborn has not passed meconium within 48 hours of birth. The nurse should assess for:

Answer: Hirschsprung's disease or imperforate anus

Failure to pass meconium within 24–48 hours suggests intestinal obstruction such as Hirschsprung's disease or imperforate anus.

A nurse witnesses a colleague make a medication error that caused patient harm. The nurse should first:

Answer: Assess the patient and notify the physician, then complete an incident report

Patient safety is the first priority — assess the patient, notify the provider, then complete the required incident report.

Which of these can be considered thinking critically?

Answer: Think actively and be aware of potential problems in the information you encounter.

Thinking critically involves actively engaging with information, questioning it, and being aware of any potential problems or biases. It requires analyzing and evaluating evidence, considering different perspectives, and making reasoned judgments. Thinking emotionally is not the same as thinking critically, as it involves being influenced by emotions rather than using rational and logical reasoning. Thinking logically is a component of critical thinking, but it is not the only aspect. Therefore, the option "Think actively and be aware of potential problems in the information you encounter" is the answer as it aligns with the principles of critical thinking.

Which strategy is most effective for improving HCAHPS (patient satisfaction) scores related to nurse communication?

Answer: Use hourly rounding to proactively address patient needs

Hourly rounding proactively addresses patient needs, reduces call lights, and improves communication scores on HCAHPS surveys.

A patient with anorexia nervosa is admitted weighing 82 lbs at 5'4". Which initial intervention is the priority?

Answer: Assess and stabilize vital signs and electrolytes

Physiologic stabilization — addressing electrolyte imbalances, hypotension, and cardiac dysrhythmias — is the priority in severe anorexia nervosa.

Which nursing action is the priority when a prolapsed umbilical cord is identified?

Answer: Place the patient in Trendelenburg or knee-chest position

The priority is relieving cord compression by positioning (Trendelenburg or knee-chest) while calling for emergency assistance.

When you encounter information, what should be kept in mind?

Answer: All of the above

When encountering information, it is important to keep in mind whether it is current, complete, and accurate. This is because outdated information may not be relevant or reliable, incomplete information may lead to incorrect conclusions, and inaccurate information can be misleading. Therefore, considering all three factors is crucial in evaluating the reliability and usefulness of the information.

A nurse is assessing a newborn at 1 minute after birth. The infant has a heart rate of 90 bpm, weak cry, some flexion, grimace to stimulation, and blue hands and feet. What is the APGAR score?

Answer: 6

HR <100 (1) + weak cry (1) + some flexion (1) + grimace (1) + acrocyanosis (1) = APGAR score of 6.

A patient is prescribed a monoamine oxidase inhibitor (MAOI). Which food must be strictly avoided?

Answer: Aged cheeses and cured meats

MAOIs combined with tyramine-rich foods (aged cheeses, cured meats) can cause a hypertensive crisis.

Which dietary instruction is most important for a patient with gout?

Answer: Avoid high-purine foods like red meat and organ meats

Purine-rich foods increase uric acid production, which precipitates gout attacks, so they must be limited.

A patient is diagnosed with post-traumatic stress disorder (PTSD). Which symptom cluster is unique to PTSD?

Answer: Intrusive symptoms such as flashbacks and nightmares related to the trauma

Intrusive re-experiencing symptoms (flashbacks, nightmares, intrusive memories of the trauma) are the hallmark of PTSD and distinguish it from other anxiety disorders.

Which maternal condition places the newborn at highest risk for hypoglycemia immediately after birth?

Answer: Poorly controlled gestational diabetes

Infants of diabetic mothers have high insulin levels at birth due to chronic maternal hyperglycemia, leading to hypoglycemia when the glucose source is cut off.

A nurse is assessing a child with a suspected head injury. Which finding indicates increased intracranial pressure (ICP) in a child?

Answer: Bradycardia, widening pulse pressure, and irregular respirations

Cushing's triad — bradycardia, widened pulse pressure, and irregular breathing — is the classic sign of dangerously elevated ICP.

What describes the action of a drug on the body?

Answer: Pharmacodynamics

Pharmacodynamics refers to the study of how a drug interacts with the body and produces its effects. It involves understanding the mechanisms of action, the biochemical and physiological effects, and the relationship between drug concentration and its effect on the body. This includes studying the drug-receptor interactions, signal transduction pathways, and the overall impact on the body's functions. Therefore, pharmacodynamics accurately describes the action of a drug on the body.

A client is following a low-sodium diet for hypertension. Which food item should the nurse advise the client to limit?

Answer: Canned soup

Canned soups are typically high in sodium, often containing 700–1000 mg per serving, making them inappropriate for a sodium-restricted diet.

A nurse is preparing to perform hand hygiene before a procedure. Which action is correct when using alcohol-based hand rub?

Answer: Apply to dry hands and rub for at least 15 seconds until dry

Alcohol-based hand rub should be applied to dry hands and rubbed together for at least 15 seconds until completely dry.

Which intervention is most important for a patient with a new diagnosis of deep vein thrombosis (DVT)?

Answer: Maintain bed rest and elevate the affected limb

Bed rest with limb elevation reduces venous pressure and minimizes risk of embolization in acute DVT.

A nurse is teaching a patient about signs of infection at a surgical wound. Which finding should be reported to the provider?

Answer: Purulent drainage with increasing redness

Purulent drainage and worsening redness are signs of wound infection requiring provider notification and possible antibiotic therapy.

A nurse delegates morning baths to an unlicensed assistive personnel (UAP). The nurse retains responsibility for:

Answer: Supervising the task and evaluating patient outcomes

Delegation transfers the task but not the accountability — the nurse is responsible for supervision and verifying patient outcomes.