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Fundamentals of Nursing Final Exam
What principles does the Code of Nursing Ethics include? - Answer :advocacy, responsibility, accountability, & confidentiality primary prevention - Answer :Efforts to prevent an injury or illness from ever occurring. Ex. Health education programs, nutritional programs, and physical fitness activities. secondary prevention - Answer :focuses on preventing the spread of disease, illness, or infection once it occurs. Ex: screening techniques and treating early stages of disease to limit disability. teritiary prevention - Answer :occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration. Ex: a patient with a spinal cord injury undergoes rehabilitation to learn how to use a wheelchair and perform activities of daily living independently. How often should a bed bound patient be repositioned? - Answer :Every 2 hours All four side rails up at one time can be considered a - Answer :restraint
what type of precautions should you take with a patient who has C.difff? - Answer :Contact precautions and always wash your hands with soap and water. two components that are critical to the nursing process: - Answer :critical thinking and clinical judgement what are the 5 stages of Benner's Theory of nursing proficiency? - Answer :1. Novice
- Advanced beginner
- Competent
- Proficient
- Expert when did the ANA establish Center for Ethics & Human Rights - Answer : who regulates the scope of nursing practice? - Answer :the state board of nursing professional nursing organizations seek to: A. improve standards of practice. B. expand nursing roles. C. improve the welfare of nurses in specialty areas. D. all of the above. - Answer :D. all of the above. A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply.)
A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAs) can perform, which of the following client activities should the nurse include? (Select all that apply.) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs - Answer :A. Bathing B. Ambulating C. Toileting E. Measuring vital signs What is the definition of Health - Answer :A state of complete physical, mental, & social well-being, NOT merely the absence of disease or infirmity. A state of being that people define in relation to their own values, personality, & lifestyle under what category of Maslow's Hierarchy of Needs does oxygen, fluid, nutrition, and vital signs fall? - Answer :physiological (basic needs). health promotion - Answer :Helps individuals maintain or enhance their present health. (e.g., fitness instructor) illness prevention - Answer :Protects people from actual or potential threats to health (e.g. vaccines).
what are the three levels of prevention - Answer :primary, secondary, and tertiary You will use the concept of primary prevention when instructing a client to: A. get a flu shot every year. B. take a blood pressure reading every day. C. explore hiring a client with a known disability. D. undergo physical therapy following a cerebrovascular accident. - Answer :A. get a flu shot every year. What are risk factors? - Answer :•Variables that increase the vulnerability of an individual or a group to an illness or accident What are some examples of risk factors? - Answer :•Nonmodifiable risk factors (e.g. age) •Modifiable risk factors (e.g., smoking) •Environment (e.g., urban vs rural) illness - Answer :A state in which a person's physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired what is infection? - Answer :Results when a pathogen invades tissues & begins growing within a host colonization - Answer :Presence & growth of microorganisms within a host without tissue invasion or damage What kind of places do bacteria love to grow in? - Answer :warm, dark, and moist Chain of infection - Answer :1. Infectious agent
- reservoir
LOWER than normal WBC's indicate: - Answer :leukopenia: an autoimmune disorder that destroys white blood cells bone marrow problems cancer Nursing process in order: - Answer :assessment, nursing diagnosis, planning, implementation, evaluation reflection - Answer :Purposefully reviewing a situation to discover its purpose or meaning What does S.M.A.R.T stand for when relating to goals? - Answer :specific, measurable, attainable, realistic, time based. what is the #1 nursing injury? - Answer :back strain what is the normal range for potassium? - Answer :3.5-5.1 mEq/L what is the normal range for calcium? - Answer :8.2-10.2 mg/dL what is the normal range for hemoglobin? - Answer :12-16 g/dL in females 12-18 g/dL in males what is the normal range for albumin? - Answer :3.5-5.0 g/dL what is the normal range for hematocrit? - Answer :37-48% female 45-52% male How to calculate BMI: - Answer :▪weight (kg) ÷ height (m2) lab values to assess pertaining to nutrition - Answer :▪cholesterol, triglycerides, ▪ hemoglobin, ▪ electrolytes, ▪ Albumin (long term), prealbumin (short term),
▪ transferrin, lymphocyte count, nitrogen balance What does ISBAR stand for? - Answer :Introduction Situation Background Assessment Recommendation True or false. osteoporosis, a chronic condition, may cause a broken bone, an acute condition
- Answer :True. While conducting a survivor assessment of Ms. Williams, which question asked by Hanna is most appropriate? A."My grandmother died of cancer last year. It's a terrible disease, don't you think?" B."How long have you been sick?" C."What are the biggest concerns you face with regard to your cancer?" D."Would you like more pain medication?" - Answer :C."What are the biggest concerns you face with regard to your cancer?" the top layer of the skin is called: - Answer :epidermis the inner layer of the skin is called: - Answer :dermis open wound - Answer :an injury in which the skin is interrupted, exposing the tissue beneath
•Documented as it related to a clock (ex: at 5 o'clock) Wound margin (normal, macerated, erythema) Wound base (eschar, slough, exudate_ Document
- Consistency, color, odor or drainage Document in cm what should you limit the HOB to when trying to prevent pressure injuries in a bed bound patient? - Answer :Limit head elevation to 30 degrees how often should a wound vac dressing be changed? - Answer :every 24-72 hours depending on the amount of drainage. what is the preferred site to give an IM injection? - Answer :ventrogluteal muscle when inhaling what does the diaphragm do? - Answer :contract (moves down) When exhaling the diaphragm does what? - Answer :relaxes and moves up Where does gas exchange occur in the lungs? - Answer :alveoli 6 P's of Dyspnea - Answer :Possible foreign body Pulmonary bronchial constriction Pneumothorax Pulmonary embolus Pneumonia
PUMP (heart failure) early signs and symptoms of hypoxia include: - Answer :Restlessness Fatigue Agitated Confused Unable to lay down Vital sign changes Late signs of hypoxia - Answer :Declining level of consciousness Decreased activity level Hypotension Bradycardia Metabolic acidosis- increased CO •Cyanosis When auscultating the lungs of a patient who has been complaining of shortness of breath and fever/chills, you hear crackles or bubbling noises. This could indicate that the patient may have: - Answer :pneumonia what should you have in the room for a patient who has dysphagia as a precaution? - Answer :Suction pulmonary artery - Answer :Carries deoxygentated blood from the heart to the lungs pulmonary veins - Answer :carry the oxygenated blood from the lungs into the left atrium of the heart
D. Report any nausea or difficulty breathing. E. Post "No Smoking" signs in prominent locations. where is urine formed in the kidney? - Answer :nephron True or False. urinary problems are common in patients who have diabetes and in older adults
- Answer :True. urinary retention - Answer :An accumulation of urine due to the inability of the bladder to empty urinary incontinence - Answer :involuntary leakage of urine The HCP may suspect that a patient is experiencing urinary retention when the patient has: A. large amounts of voided cloudy urine. B. pain in the suprapubic region. C. spasms and difficulty during urination. D. small amounts of urine voided two to three times per hour. - Answer :D. small amounts of urine voided two to three times per hour. what should you look for when assessing urine for infection? - Answer :Color Clarity Odor what is Crede's method? - Answer :Credé's method involves putting pressure on the suprapubic area and is used for the relief of urinary retention.
long term use of a catheter can result in what complication? - Answer :UTI what is the gateway to the rest of your body? - Answer :The mouth. providing oral care multiple times a day is essential in preventing serious complications. what does a cookie swallow assess? - Answer :dysphagia
- A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with: A. abnormal defecation. B. constipation. C. fecal impaction. D. fecal incontinence. - Answer :B. constipation what position should you put the patient in when giving an enema? - Answer :sims position What is an oil retention enema? - Answer :Lubricates the rectum & colon Must retain for a minimum of 30 mins to several hours to work Oils absorbed by feces making softer and easier passage when using a cane, what foot should be moved first when taking a step? - Answer :affected foot moves first cleansing enema - Answer :Stimulates Peristalsis through the infusion of a large volume of solution or through local irritation of the colon's mucosa (Include tap water, normal saline, soapsuds, and low-volume hypertonic saline enemas)
Sympathy A nurse has just admitted a client with a medical diagnosis of congestive heart failure. When completing the admission paperwork, the nurse needs to record: A. an interpretation of client behavior. B. objective data that are observed. C. lengthy entry using lay terminology. D. abbreviations familiar to the nurse. - Answer :B. objective data that are observed. If a nurse decides to withhold a medication because it might further lower the patient's blood pressure, the nurse will be practicing the principle of: A. responsibility. B. accountability. C. competency. D. moral behavior. - Answer :B. accountability True or False. incident reports should be charted in the patients chart - Answer :False. there is a separate form that needs to be filled out. When an incident like a fall occurs what is the first thing you want to do? - Answer :assess the patient. You can fill out the incident report at any point in your shift.
what are some teaching techniques when educating a client? - Answer :Verbal one-on-one discussion Group instruction Preparatory instruction Demonstrations Analogies Role-playing Simulation morals - Answer :what you believe is right-from parents, society, religion, & other sources values - Answer :guides choices & actions—right vs wrong Beneficence - Answer :Intent to DO GOOD Nonmaleficence - Answer :AVOID Harm fidelity - Answer :faithful to person, cause or belief Emergency Medical Treatment & Active Labor Act - Answer :When a patient presents to an emergency department, they must be treated True or False. It is often the RN who obtains client informed consent in the acute care setting - Answer :True Informed consent includes - Answer :-An explanation of the procedure or treatment -The names & qualifications of people performing & assisting in the procedure
D. posttraumatic. - Answer :B. situational. Factors that influence stress & coping: - Answer :-situational factors: personal, job, family changes, etc. -maturational factors: stressors vary with life stage, ex: identity or self esteem in in preadolescents -sociocultural factors: environmental and social stressors. Ex: poverty, divorce, handicap Oncotic pressure (colloid osmotic pressure) - Answer :a form of osmotic pressure exerted by proteins, notably albumin, in a blood vessel's plasma (blood/liquid) that usually tends to pull water into the circulatory system. hydrostatic pressure - Answer :pressure exerted by a fluid within a compartment such as blood within the vessels. Moves fluid from an area of greater pressure to an area of lesser pressure. Hydrostatic pressure within vessels of the body moves fluid from intravascular compartment interstitial compartment what is it called when the lungs are unable to excrete enough CO2 and the pH is out of range? - Answer :Uncompensated respiratory acidosis what is it called when the the lungs excrete too much carbonic acid? - Answer :respiratory alkalosis ◦Occurs from an increase of metabolic acid or a decrease of base - Answer :metabolic acidosis
Occurs from a direct increase of base (HCO_3^-) or a decrease of metabolic acid - Answer :metabolic alkalosis If a patient's albumin lab value is low, the patient may develop what? - Answer :edema - especially in the lower extremities the device used to prevent DVT's in immobile patients: - Answer :SCD ( sequential compression device) if a patient is going for a procedure tomorrow, when should they be made NPO? A. Two days prior B. The morning of the procedure C. At midnight D. two hours before the procedure - Answer :C. at midnight What does the STOP BANG acronym stand for? - Answer :Snoring Tiredness Observed apnea blood Pressure Bmi Age Neck circumference Gender-males are at a higher risk this is a risk assessment for reintubation What is a first priority task the nurse should perform on a patient who is post operative?
