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NSG 3100 Exam 1 -with 100% verified solutions-2024- 2025.docx, Exams of Nursing

NSG 3100 Exam 1 -with 100% verified solutions-2024- 2025.docx

Typology: Exams

2023/2024

Available from 06/14/2024

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NSG 3100 Exam 1 -with 100% verified

solutions-2024- 2025

Rules for hand washing

  • 15-20 seconds -hands lower than elbows -firm rubbing circular motion -remove jewelry rules for baths -long firm strokes -inspect skin
  • persuasion -stop if distress -use distraction -ask for help complete bath sponge bath self help bath patients confined to bed;can help with back/feet partial bath client washes everything;nurse washes back bag bath Commercially prepared washcloths that are moistened with a no-rinse-required cleaning product. towel bath Nurse uses a single large towel to cover and wash a client tub bath A bath given in a tub.

independent no bathing assistance needed Semi-dependent requires help from another person moderately dependent help from another person and/or device totally dependent not able to participate at all foot care basics -nails cut straight across

  • diabetics -no lotion between toes, may cause fissures and cracks in skin Oral care basics
  • no lemon glycerin swabs (erodes enamel) -mouth swab in water -suction available critical thinking-independence think for yourself critical thinking-fair minedness consider all points of view critical thinking-insight into egocentricity be aware of own biases critical thinking-intellectual humility admitting you dont know critical thinking-challenge status quo and rituals ask why

critical thinking-integrity admit when wrong critical thinking-perseverance keep pushing forward and making progress critical thinking-confidence confident in words and actions critical thinking-curiosity gain new knowledge clinical reasoning process used by practitioners to plan, direct, perform, and reflect on client care applying critical thinking in practice -prioritize mult patients -cultural impacts on care outcomes -logical reasoning -review current evidence based research preventing falls -familiarize with environment -teach call light -personal items in reach

  • handrails -bed locked and low -nonslip footwear
  • nightlight -clean, dry floor Fall Risk Factors -Poor Vision -Cognitive dysfunction (confusion, disorientation, impaired memory/judgement) -mobility restrictions -Orthostatic hypotension -Urinary incontinence
  • Weakness

-sedatives, hypnotics, tranquilizers, narcotic analgesics, and diuretics Seizure precautions -padded side rails -suction working and available -clear area -lower to ground -check mouth -observe movements & time -turn on side -anti-seizure medications Poisoining -proper labels -no poisonous plants -poison control number restraints -only if needed:last resort -every 24 hours -lowest level restraint first -continuous monitoring -do not impede circulation -quick release knot -never to handrails belt restraint seatbelt jacket restraint jacket used to restrain pt - last resort mitt restraint -restrict finger movement -prevents the person from grasping tubes or catheters -allows for more freedom of arm movement than a wrist restraint wrist or ankle restraint -pad bony promineces -movable portion of bedframe

-2 fingers Moving patients -Safety is first priority -Ask patient to help as much as possible -Determine if patient comprehends what is expected -Determine patient's comfort level -Determine if you need assistance in moving the patient -bed to center of gravity -prevent spinal twisting-pivot technique -wide stance log roll -the method used to turn a patient with a spinal injury, in which the patient is moved to the side in one motion -arms across chest -blanket underneath slide to edge of bed -staff on both sides of the bed -supportive devices -pillow placed for side rolling (head) -leg pillows mechanical lift -provides a safe transfer for patients/residents from a supine to seated position or seated to seated transfer -hoyer lift. Patient positioning -firm mattress -no bone on bone -locked wheels -no wrinkles or wet sheets -turn every 2 hours -2 siderails up cane guidelines -rubber tips -length=permit elbow to be flexed -strong side of body -6 in tomside 6 inches in front of near foot

moving using a cane -cane forward 1 foot -move weak leg -move strong leg

  • repeat measuring crutch height Axillary (stading): -2" below axilla -handgrip should be @ styloid process w/ arms and shoulders relaxed: 20-30 degrees flexion Laying: -measure from anterior fold of axilla to heel of foot and add 1 inch Crutch Stance (Tripod position) -crutches 6 in out and 6 in fwd crutch stance (4pt alternate gait) -bear weight both legs
  • safest -right crutch-left foot left crutch-right foot repeat Crutches (3 pt gait) -bear whole weight good leg -both crutches-weak leg forward good leg fwd repeat Crutches (two pt alt gait) -left crutch-right foot together right crutch-left foot together repeat swing to gait -hip paralysis -Crutches moved forward simultaneously swing both feet together up to the crutches repeat

swing through gait both crutches are advanced then the legs swing past the crutches Fowler's position a semi-sitting position; the head of the bed is raised between 45 and 60 degrees Semi-Fowler's Position 15- degrees High Fowler's Position -sitting up almost straight -60 to 90 degrees -never long for elderly due to skin breakdown orthopedic bed position respiratory patients Sims position -a side-lying position with the lowermost arm behind the body and the uppermost leg flexed -pregnant women -halfway between lateral and prone dorsal recumbent position -lying on the back with the knees flexed -elevate head with pillow supine lying on the back lateral position side lying position prone position lying on abdomen, facing downward (head may be turned to one side) nursing labels (diagnosis terms)

-impaired skin integrity -impaired gas exchange -risk for fall -risk for infection Masiows hierarchy of needs -physiological needs -safety or security needs -love & belonging needs -self-esteem -self-actualization physiological needs the most basic human needs to be satisfied- water, food, shelter, and clothing safety needs A person's needs for security and protection from physical and emotional harm love and belonging needs friendship, family, sexual intimacy self-esteem needs The need for a person to feel good about oneself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments. self-actualization needs the need to be the best one can be; at the top of Maslow's hierarchy Phases of the nursing process Assessment Diagnosis Planning Implementation Evaluation Assessing collecting, validating, and communicating patient data

diagnosis analyzing and synthesizing data Planning determining how to prevent client problems to develop an individualized care plan with client goals stated Implementation carrying out the plan of care Evaluation measuring the degree to which goals have been achieved to determine how to modify care plans Safety Hazards

  • lifestyle -cognitive awareness -ability to communicate -mobility health status -emotional state -environmental factors -sensory perception altered -safety aweareness
  • feeding