NURS 221 Final exam 2024, Exams of Nursing

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NURS 221: Final exam Concepts related hygiene, elimination, immobility - correct answer ✔- infection control - nutrition - development - functional ability - cognition - self care - fluids and electrolytes what to assess for before beginning with a patient's care - correct answer ✔- what can the patient do independently? - what will their medical/condition allow? - what are their preferences and normal practices? - what are their needs related to hygiene? - who usually assists with their hygiene? - what are their teaching needs? - what else would be important to do at thus time? what to do for early morning care - correct answer ✔- bathroom, urinal or assistance to the bathroom - washing hands and face - oral care - prepare for breakfast what to do for morning care (AM care) - correct answer ✔- bath, shower or bed bath - hair care and shaving - oral care - foot/nail care - dressing in clothes or changing gown - bed linen change afternoon care - correct answer ✔- washing hands and face (to refresh) - oral care - elimination needs - checking bed linens HS or evening - correct answer ✔- washing face and hands - oral care - elimination needs - changing into a new gown or bed clothes - back massage - straightening up area to reduce clutter safe bathing temperature - correct answer ✔- 38 degrees to 43 degrees Celsius safe bathing temperature policy is there because - correct answer ✔- standards are laid out to prevent harm to patients as a result of incorrect water temp - applies to all care settings/showers - habits - medication use - diet/fluid intake and output - exercise and mobility - family & medical/surgical history - psychosocial - environment and use of aids Physical assessment (urinary) - correct answer ✔- flank pain - bladder position - skin and mucosa integrity - perineum assessment of the urine - correct answer ✔- clarity - quantity (intake and output) - odour lab tests (urinary) - correct answer ✔- urine culture - urinalysis - specific gravity - blood work health history questions for bowel assessments - correct answer ✔- symptoms - normal pattern - bladder and bowel diary - habits - medication use - diet + fluid intake and output - exercise and mobility - family & medical/surgical history - psychosocial - environment and use of aids physical assessment (bowel) - correct answer ✔- oral cavity - abdominal assessment - skin integrity and rectal area assessment of stool - correct answer ✔- see Bristol Stool Chart - identify color - shape - odor - amount lab tests (bowel) - correct answer ✔- fecal specimen testing - blood work - serum electrolytes - CBC bristol stool chart - correct answer ✔- 1-7 (hard lumps- liquid) - 3 +4 is normal less than ____ ml of urine output over 2 hours is urgent - correct answer ✔- less than 30 ml or urine over 2 hours dysuria - correct answer ✔- painful or difficult urination oliguria - correct answer ✔- Decreased urine output polyuria - correct answer ✔- excessive urination hematuria - correct answer ✔- blood in the urine excoriation - correct answer ✔- injury to the surface of the skin (abrasion) melena - correct answer ✔- partially digested blood in the stool peristomal - correct answer ✔- Area around a stoma occult blood - correct answer ✔- hidden blood effluent - correct answer ✔- material discharge from a stoma steatorrhea - correct answer ✔- stool with abnormally high fat content types of ostomies - correct answer ✔colostomy ileostomy urostomy transverse loop colostomy is done for - correct answer ✔- two openings in the transverse colon - but one stoma - usually temporary descending colostomy is done for - correct answer ✔- left sided tumors sigmoid colostomy is done for - correct answer ✔- rectal tumors urostomy drainage and consistency and colour - correct answer ✔- frequent/continuously - urine - may have mucous threads ileostomy drainage and consistency and colour - correct answer ✔- frequent - fluid like-to mushy and dark green - usually not odorous colostomy (sigmoid) drainage and consistency and colour - correct answer ✔- semi to formed - semi-solid or formed with gas - less frequent 4 CRNA standards - correct answer ✔1. safety 2. authority 3. knowledge 4. ethics standard 1, CRNA - correct answer ✔- safety - Regulated members are responsible and accountable to provide safe medication management standard 2, CRNA - correct answer ✔- authority - Regulated members follow current legislation, standards, and policies re medication management standard 3: CRNA - correct answer ✔- knowledge - Regulated members are knowledgeable about the medications they administer and those that their clients are taking, whether prescribed, over the counter, or natural health products. standard 4: CRNA - correct answer ✔- ethics - Regulated members follow the Code of Ethics for Registered Nurses and ethical principles in all aspects of medication management. 3 checks of medication administration - correct answer ✔1. compare to the MAR as you remove the drug from the storage area 2. compare the drug to the MAR as you prepare the drug 3. compare the drug to the MAR at the patients bedside before giving the drug 10 medication rights - correct answer ✔Right drug Right dose Right time Right route Right patient Right reason Right documentation Right evaluation Right patient education Right to refuse 3 steps of medication reconciliation - correct answer ✔step 1: generate a best possible medication history (BPMH) step 2: reconcile the BPMH at care transitions step 3: document and communicate the medication information medication reconciliation - correct answer ✔A procedure to maintain an accurate and up-to-date list of medications for all patients between all phases of health care delivery. 5 types of medication orders - correct answer ✔- routine - PRN - one time only doses - STAT (immediately) - Now (has to be given as soon as possible, not as urgent as a STAT order) Independent double check - correct answer ✔a dble check is a process in which a second authorized individual conducts a verification. what 5 things need a co-signature - correct answer ✔- all IV medication - controlled substances