Fundamentals of Nursing Final Exam: Study Guide:Latest Updated: Questions & Answers, Exams of Nursing

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Fundamentals of Nursing Final Exam

What are direct interventions? (Ans- Anything that you do while physically with the patient e.g. administering medications, performing dressing changes What are indirect interventions? (Ans- Anything that you do outside of being with the patient on the patients behalf. e.g. restocking supplies, patient conferences, scheduling tests and treatments What are independent interventions? (Ans- They are nurse driven. Health promotion, teaching, basic comfort care, ADLs. The nurse doesn't need direction to do independent interventions. What are collaborative interventions? (Ans- Interventions carried out in collaboration with other members of the interdisciplinary healthcare team. e.g. physical therapy starting care and the RN continuing it. What are dependent interventions? (Ans- Interventions that are dependent on a prescription from someone with prescribing privileges. i.e. physician, NP, PA. These can include medications, diet, and some treatments. How will the nurse complete the implementation phase? (Ans- Documenting

What are some guidelines to help the nurse select appropriate interventions? (Ans-

1. Safe and appropriate based on age and gender.
2. Achievable with available resources.
3. Congruent with other therapies.
4. Based on current evidence-based practice.
5. Within established standards, policies, and laws.
6. Congruent with culture, values, and beliefs of the patient. What is happening during the evaluation phase of the nursing process? (Ans- Collect data related to outcomes Compare data with outcomes Relate nursing actions to patient goals/outcomes Draw conclusions about problem status Continue, modify, or terminate the patients care plan What does a written evaluation statement need to contain? (Ans-
7. Data and time
8. Conclusion statement, whether the goal was met, partially met, or not met.
9. Supporting statement e.g. 12/22/21 0900 goal met; patient consumed 75-100% of meal trays today. During the evaluation phase, the nurse needs to.... (Ans- Continue, modify, or terminate the plan of care. What do the nurse and patient determine together during the evaluation phase? (Ans-
10. The patients progress toward goals

What are some examples of things RN's can delegate to a UAP? (Ans- Vital signs ADL's Ambulation Bathing Weighing Post mortem care Suctioning CHRONIC trachs Gastrostomy feeds (CHRONIC) What tasks CANNOT be delegated? (Ans- Evaluation IV Meds Sterile procedures The nursing process

• Assessing
• Diagnosing
• Planning
• Evaluating Triaging Complex skills LPNs can do follow up education and assessments What is the difference between effectiveness and efficiency? (Ans- Effectiveness is doing the right things and efficiency is doing things right. What takes the lowest priority according to Maslow? (Ans- Self-actualization

What does ABCD stand for? (Ans- Airway, Breathing, Circulation, Disability What are low priority patient problems? (Ans- Problems that will resolve with minimum interventions. e.g. patient needs a snack What are medium priority patient problems? (Ans- Problems that may have unwanted consequences but are not life threatening. e.g. spiritual distress What are high priority patient problems? (Ans- Problems that are life threatening or health threatening. e.g. ABC's, change in VS, increased drainage. Describe priority 1 level of ranking activities. (Ans- Priority 1 is a must do task. Describe priority 2 level of ranking activities. (Ans- Priority 2 is a should do task. Describe priority 3 level of ranking activities. (Ans- Priority 3 is a nice to do task (probably can be delegated such as having a daily bath or washing hair) Describe Non-acute urgency level. (Ans- Low priority. e.g. teaching about self-care, medications Describe Acute urgency level. (Ans- Needs to be done, probably can be scheduled or planned. e.g. feeding a patient Describe Critical urgency level. (Ans- Needs to be done rapidly. e.g. administering oxygen

What types of skills are needed by nurses to fulfill the aims of nursing? (Ans-

1. Cognitive-Know and understand information. Be able to teach and analyze information.
2. Technical-Skills like taking BP, medication administration. Be able to demonstrate your skills.
3. Interpersonal-Get your patients, Dr., and coworkers to trust you in a short period of time. Come across as a compassionate, capable, and competent nurse.
4. Legal/Ethical-Be able to work ethically, legally, working within your scope of practice. What are nurses accountable for? (Ans- Nurses are accountable for their own actions and behaviors as well as the actions of others such as trainees and subordinates. What are nurses responsible for? (Ans- Nurses are responsible for performing their assigned tasks reliably, dependably, and to the best of their ability. Describe professional dress (Ans- No excessive jewelry, long fingernails or artificial nails, or chewing gum. Hair secured away from contact with the individual receiving care. Personal cleanliness, avoiding strong odors and perfumes. Clean uniform or clothing. No visible body modifications or unusual ear piercings. No tattoos visible on parts of the body not covered by scrubs. Describe professional demeanor (Ans-

Avoid loud talking Maintain a positive attitude and instill hope Maintain a clean, uncluttered workstation Avoid taking personal calls at work Do not discuss personal problems with patients Never breach patient confidentiality Avoid gossiping with and bullying coworkers Do not complain to patients or family members Do not use illegal substances Describe professional electronic media use (Ans- Do not use personal cell phones to document patients Do not share patient information over social media What are the roles of the nurse? (Ans- Caregiver Manager Teacher Advocator Collaborator A professional nurse needs to be doing these things at all times What is nursing? (Ans- A profession focused on assisting individuals, families, and communities to attain, recover, and maintain optimum health and function from birth to old age. What are the phases of the nursing process? (Ans- Assessment Diagnosis Planning Implementation

Variable Data (Ans- information can change quickly, frequently, or rarely. e.g age, BP, pain level. What is an initial assessment? (Ans- made during first nurse-client encounter and is usually comprehensive, consisting of all subjective and objective data pertinent to client health status. Usually gathering information on all the body systems. (Head to toe assessment) What is a focused assessment? (Ans- Performed to assess a specific problem identified in an earlier assessment. (System specific) What is an emergency assessment? (Ans- A quick focused assessment in an emergency situation to identify life-threatening problems. Or to identify new or overlooked problems. What is an ongoing assessment? (Ans- performed as needed, after the initial database is completed, and after EVERY interaction with a patient. To compare patients current status to baseline data previously obtained. (Appropriate in long term care or home health) What is subjective data? (Ans- Data that only the subject or "patient" can feel and will tell you. Usually in a statement. e.g. pain, feelings of anxiety, nausea, itching, fear. What is objective data? (Ans- What you observe and can measure or test against acceptable standard. Can be seen, heard, smelled, or felt. e.g. BP reading, discoloration of the skin, temperature, incision measurement. What is the primary source of assessment data? (Ans- The Patient

What are secondary sources of assessment data? (Ans- Family or other support people Other healthcare professionals Records and reports Laboratory and diagnostic analysis Reports from other nurses All sources other than the patient are considered secondary sources of assessment data. What are the principle methods of collecting data? (Ans- Observing-noticing things about your patient and selecting, organizing and interpreting the data. Things you can observe using your 5 senses. Interviewing-planned communication with a purpose. asking about health history, a review of systems questions. Examining-using all your senses. doing a head to toe assessment, touching the patient. using inspection, percussion, palpation, and auscultation. What are the four primary techniques used during physical examination? (Ans-

1. Inspection
2. Palpation
3. Percussion
4. Auscultation Describe inspection (Ans- Inspection begins the moment you meet a client; overall appearance, clothing, demeanor, eye contact, interactions w/ health care workers and family. Skin color, hair, nail beds, skeletal deformities,

Prioritize nursing diagnoses What are the three components of a nursing diagnosis? (Ans-

1. Diagnostic label-Identify the focus or subject of the problem.
2. Etiology-The source or origin of the problem
3. Defining characteristics-what does it look like? what is the evidence that the patient has this problem? What are the types of nursing diagnoses? (Ans-

• Problem-focused
• Risk-for
• Health Promotion (Readiness for)
• Syndrome (cluster of individual nursing diagnoses) Example of a one-part diagnosis (Ans- Rape-trauma syndrome Example of a two-part diagnosis (Ans- Risk for infection related to indwelling lines (urinary catheter) Example of a three-part diagnosis (Ans- Constipation related to medication side effects (slow peristalsis) as evidenced by abdominal distention, report of feeling "full", report of no bowel movement x5 days, palpated stool mass What are some ways to avoid errors in diagnosing? (Ans-

1. Verify-verify assessment data, especially if it is out of the normal for the patient.
2. Building good knowledge and experience

3. Have a good working knowledge of normal-know what is typically normal for patients
4. Consult resources
5. Diagnose according to patterns, not one isolated incident
6. Improve critical thinking skills What is happening during the diagnosing phase of the nursing process? (Ans- Analyze data Identify health risks, problems, and strengths Formulate diagnostic statements What is a SMART goal? (Ans- S-Specific single action M-Measurable A-Attainable R-Relevant T-Time limited/time framed What is happening during the planning phase of the nursing process? (Ans- Prioritize problems/diagnoses Formulate goals/desired outcomes Select nursing interventions Write nursing interventions Written goals should always start with what two words? (Ans- Patient Will What does the nurse achieve when establishing goals with the patient? (Ans-
7. Provides direction in selecting interventions
8. Serves as criteria for evaluating progress
9. Closes the diagnosis phase
10. Helps motivate the client and the nurse

What is a pulse deficit? (Ans- difference between apical and radial pulse How do you determine if there is a pulse deficit? (Ans- Have the nurse and the UAP take the apical pulse and the radial pulse at the same time. What is maceration? (Ans- the softening and breaking down of skin resulting from prolonged exposure to moisture What is Skin Turgor? (Ans- Elasticity of the skin What is necrosis? (Ans- death of tissue What is ulceration? (Ans- Discontinuity of the skin showing complete loss of the epidermis revealing dermis or subcutis Pressure ulcer stages: Stage 4 (Ans- Stage IV: Extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures, with or without full-thickness skin loss. Undermining and tunneling may develop. Pressure Ulcer Stage 3 (Ans- Stage III: Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Slough may be present; may include undermining and tunneling. Pressure Ulcer Stage 2 (Ans- Stage II: Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister. Pressure Ulcer Stage 1 (Ans- Stage I: Epidermis is intact. Non-branch able erythema of intact skin. Discoloration of the skin, warmth, edema, induration or hardness may also be used as indicators, particularly on individuals with darker skin.

Pressure Ulcer-New Stage (Ans- Deep tissue injury (new stage): Purple or maroon localized area of intact skin or blood-filled blister resulting from pressure damage of underlying soft tissue. Pressure Ulcer-Unstageable (Ans- Unstageable: Full-thickness tissue loss in which actual depth of ulcer is completely obstructed by slough or eschar in the wound bed. describe the bristol stool chart (Ans- 1 - 7 (hard lumps- liquid); 3-5 is normal What is a colonoscopy? (Ans- A visual exam of the lining of the entire large intestine with a lighted, flexible fiber optic video endoscope. Nursing implications are to make sure the patient is prepared and possibly give a laxative. What is a upper GI study? (Ans- Diagnostic test of structural problem. (Usually patient will have to do a barium swallow before hand) What is a lower GI study? (Ans- Patient receives a barium enema and this will reveal highlights of structural problems. What sounds will be auscultated at the onset of a bowel obstruction? (Ans- High pitched tinkling, rushing, or growl sounds. What sounds will be auscultated for a late bowel obstruction? (Ans- Absence of sounds. What order should you assess the abdomen in? (Ans- Inspect, Auscultate, Percuss, Palpate How does the nurse assess balance? (Ans- You can assess balance using the Romberg test by having the patient stand with feet together, eyes closed for 30 seconds without falling over or losing balance.

Describe the brain lobe functions. (Ans- Frontal-Reasoning, planning, speech, movement, emotions, problem solving. Temporal-Auditory, perception, memory, speech. Parietal-Movement, orientation, recognition, and perception. Occipital-Visual processing. Describe reflex responses. (Ans- 0=no response 1=hypo-response 2=normal 3=hyper response 4=exaggerated response. always compare the left to the right. There is a wide variation in normal but the presence of a reflex is normal. Reflexes are measured 0-4+. 2+ is usually considered normal. What is impaired skin integrity? (Ans- Disruption or damage to the epidermal and/or dermal layers of skin as a result of a cut, scrape, burn, or other injury What nutrient is especially important for patients with impaired tissue integrity? (Ans- Protein What is erythema? (Ans- redness of the skin causes can be rash, inflammation, or irritation. What is jaundice? (Ans- yellow discoloration of the skin. causes can be liver disease What is cyanosis? (Ans- a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood. What is pallor? (Ans- paleness or whiteness of the skin. causes can be hypovolemia or anemia. What is vitiligo? (Ans- Pigmentation disease characterized by white patches on the skin. causes could be from an autoimmune disease.

What does a tan/brown appearance of the skin indicate? (Ans- This can indicate Addison's disease or just an overall darkening of the skin. What is a skin biopsy? (Ans- used to differentiate a benign skin lesion from a skin cancer. Skin biopsies can be obtained by a punch technique, incision, excision, or shaving. the nurse can make sure the dressing is C/D/I and that there are no infections following the biopsy. What is the Woods Lamp used for? (Ans- To Illuminate FUNGI, BACTERIA ,PIGMENTATION and other skin problems. the nurse can find a completely darkened room to complete the test in. What does PROM stand for? (Ans- passive range of motion What does AROM stand for? (Ans- active range of motion Ataxia (Ans- ______ describes a lack of coordination while performing voluntary movements. It may appear as clumsiness, inaccuracy, or instability. What is a stridor? (Ans- A narrowing of the upper airway, that causes a shrill sound on inhalation. (high pitched like a seal barking) What are crackles (rales)? (Ans- Short low pitched sounds consisting of discontinuous bubbling caused by air passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of mucosa. (Bronchitis, CHF, fibrosis, pneumonia) What are rhonchi? (Ans- Continuous rubbing, snoring or rattling sounds from obstruction of large airways with secretions. Can sometimes be cleared by coughing.