Nursing Final Exam Questions and Answers, Exams of Nursing

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Nursing 230: FINAL EXAM QUESTIONS

WUITH 100% CORRECT ANSWERS

Standard Precautions (universal) - CORRECT ANSWER -Applies to all body fluids (except sweat),

nonintact skin, and mucous membranes; is done to protect everyone (staff, patient, and other patients)

What practices should be implemented with standard precautions? - CORRECT ANSWER -Hand

hygiene; clean gloves when touching all body fluids, nonintact skin, and mucous membranes; mask/eye protection/face shield when splashing occurs; properly clean equipment; bag laundry; enable safety devices on equipment; properly dispose of sharps

Transmission Based Precautions (Tier Two) - CORRECT ANSWER -Used in addition to standard

precautions; is client specific because it is based on the pathogen; Requires a private room (can also be referred to as isolation precautions); three types- contact, droplet, and airborne.

Contact Precautions - CORRECT ANSWER -Used with patients who are infected by a multidrug

resistant organism (MDRO); limit movement of the patient out of the room; avoid sharing patient equipment; PPE: gown & gloves

Infections that require contact precautions - CORRECT ANSWER -MRSA, c-diff, VRE

Droplet Precautions - CORRECT ANSWER -Used for patients with an infection that is spread by large

droplet particles; transport patient out of the room only when necessary and use mask for patient; May have room to door open; PPE: gown, gloves, & surgical mask

Infections that require droplet precautions - CORRECT ANSWER -flu, whooping cough

Airborne precautions - CORRECT ANSWER -Used for patients who have an infection that spreads

through the air; patient is placed in neg pressure room- MUST keep door closed; PPE: gown, gloves & respirator mask (fit tested)

Infections that require airborne precautions - CORRECT ANSWER -TB, varicella, measles, SARS

Negative Pressure Room - CORRECT ANSWER -Outer door and inner door, pressure is lower on the

inside than outside, air flows into the room rather than out

Neutropenic Precautions (reverse isolation) - CORRECT ANSWER -Used for patients with low

neutrophil count; includes restricting visitors, private room preferred, prohibiting visitors with an infection, restricting exposure to live plants fruits and veggies, patient must wear a mask when out of room, and hand washing for patient and staff

Medical Asepsis - CORRECT ANSWER -The use of practices to reduce the number, growth, and

spread of microorganisms

What is done to promote medical asepsis? - CORRECT ANSWER -Hand hygiene (!!), cleaning rooms

and floors, changing linens, separating clean from contaminated materials, not holding linens on you + not shaking them + not placing on floor, biohazard bags, keep nails short + no artificial nails, clean from least soiled to most soiled

Surgical Asepsis - CORRECT ANSWER -The use of practices to ELIMINATE ALL microorganisms from

an object or area

Promoting & Maintaining Surgical Asepsis - CORRECT ANSWER -Avoiding coughing, sneezing, or

talking directly over sterile field; Touch only sterile materials with sterile gloves; Do not reach across,

above, or turn back on sterile field; Keep patient from moving suddenly, touching sterile field, or coughing/talking/sneezing over it

How large is the border around the sterile field that is considered non-sterile? - CORRECT

ANSWER -1 inch. Must discard any item that comes into contact with the border.

Chain of infection - CORRECT ANSWER -Infectious agent --> reservoir --> portal of exit --> method of

transmission --> portal of entry --> susceptible host

Infectious Agent - CORRECT ANSWER -Bacteria, virus, or fungi

Reservoir - CORRECT ANSWER -Place where the microorganism is comfortable. Can be other

humans, soil, water, animals, inanimate objects (ie equipment)

Portal of Exit - CORRECT ANSWER -Respiratory (coughing, sneezing, sometimes talking),

gastrointestinal (stool), urinary (urine), breaks in skin (exposure to blood, body fluids), blood & tissue

Method of Transmission - CORRECT ANSWER -Contact, vehicles (contaminated blood, food, water),

vectors (nonhuman carriers ie mosquitoes), droplet, airborne

Portal of Entry - CORRECT ANSWER -Same as portal of entry + invasive devices like caths and IVs

Susceptible Host - what factors impact susceptibility? - CORRECT ANSWER -Intact skin & mucous

membranes, normal pH levels, WBC count, age race sex and hereditary factors, immunization, fatigue climate nutritional and general health status, stress, invasive or indwelling devices.

How to stop an infectious agent - CORRECT ANSWER -Sterilization and antibiotics

How to stop a reservoir - CORRECT ANSWER -transmission based precautions, disposable supplies

How to stop portal of exit - CORRECT ANSWER -Gloves, covering mouth when coughing/sneezing,

intact dressing

How to stop mode of transmission - CORRECT ANSWER -Pesticides, adequate refrigeration, proper

precautions

How to stop portal of entry - CORRECT ANSWER -PPE, proper disposal of sharps

How to stop susceptible host - CORRECT ANSWER -Screenings and immunizations

Stages of an Infection - CORRECT ANSWER -Incubation period, Prodromal stage, Full stage of illness,

and Convalescent period

Incubation Period - CORRECT ANSWER -Organisms growing and multiplying

Prodromal Stage - CORRECT ANSWER -Vague and nonspecific signs of disease

Full Stage of Illness - CORRECT ANSWER -Presence of specific signs and symptoms of disease, the

class s/s

Convalescent Period - CORRECT ANSWER -Recovery from the infection

In what stage of illness is the person MOST infectious? - CORRECT ANSWER -Prodromal stage

Signs of Infection - CORRECT ANSWER -Elevated temp, chills, increased pulse, increased

respirations, redness/edema/warmth/drainage/pain, elevated WBC count, increase in specific types of WBCs, elevated erythrocyte sedimentation rate (inflammation), presence of pathogen in blood urine sputum or draining cultures

What is a normal WBC count? - CORRECT ANSWER -5,000 - 10,

What must be kept in mind with elderly and temp? - CORRECT ANSWER -Elderly generally run a

lower temp, so their norm isnt 98.6 F

Nosocomial Infections - CORRECT ANSWER -Infection acquired while in healthcare setting, also

called healthcare-associated infections (HAI). Very costly because they delay healing of patients creating more time in hospital - CDC estimates $30 billion/year in U.S.

Where are nosocomial infections most common to occur? - CORRECT ANSWER -ICU due to an

already compromised immune system and the most indwelling lines

Where is the most common site for a nosocomial infection? - CORRECT ANSWER -Urinary tract (due

to caths)

Latex allergies - CORRECT ANSWER -Before beginning any task or procedure, make sure to check for

latex allergy. If patient does have latex allergy, it must be clearly marked on chart and band and reported to other members of the health care team.

Latex Allergy Rxns - CORRECT ANSWER -Can range from contact dermatitis (superficial), delayed

hypersensitivity, to anaphylactic reaction

What products could contain latex that the nurse must be aware of? - CORRECT ANSWER -Gloves,

IV tubing, tourniquets, and BP cuffs

What foods are linked with latex allergies? - CORRECT ANSWER -Avocado, kiwi, bananas, and

passion fruit

What does HIPAA stand for? - CORRECT ANSWER -Healthcare Insurance Portability and

Accountability Act

What does HIPAA ensure? - CORRECT ANSWER -Confidentiality of patient. All info about patients

written on paper, spoken aloud, and saved on computer is confidential. Also name, address, phone, fax, SS#, demographic info, HPI, treatments, and PMH

Potential Breaches in HIPAA - CORRECT ANSWER -Sending confidential email messages, displaying

info on a public screen, sharing printers among units with differing functions, discarding copies of patient info in trash, holding conversations that can be overheard, faxing confidential info to unauthorized persons, sending confidential messages overheard on pagers.

5 Steps of the Nursing Process - CORRECT ANSWER -Assessment, diagnosing, planning,

implementing, evaluating

Assessing - CORRECT ANSWER -Identify assessment priorities determined by the purpose of the

assessment or the patient's condition. Organize or cluster data to ensure systematic collection. Establish the database: nursing hx, exam, review of patient record and literature, consultation with the patients support persons and healthcare professionals. Update, validate, and communicate data.

Diagnosing - CORRECT ANSWER -Interpret and analyze data, identify patient strengths and health

problems, formulate and validate nursing dx, detect and refer s/s that may indicate a problem beyond the nurse's experience

Outcome Identification & Planning - CORRECT ANSWER -Establish priorities, Identify expected

patient outcomes, Select evidence based nursing interventions, Communicate the plan of care.

Implementing - CORRECT ANSWER -Carry out the plan, Continue data collection and modify the

plan of care as needed, Document the plan.

Evaluating - CORRECT ANSWER -Measure how well the patient has achieved desired outcomes,

Identify factors contributing to success/failure, Modify plan of care as needed

Collecting a Stool Specimen - CORRECT ANSWER -Verify order, Standard precautions, Have patient

defecate into BSC, bedpan, or hat (no mixing with urine or toilet paper), and use specimen cup to collect

Administering an Enema and Suppository - CORRECT ANSWER -Verify order, prepare supplies, and

hand hygiene; ID patient; Assess patient, explain procedure, provide privacy; Don PPE and pad bed; Position patient in left lateral sims, insert tube for enema 3-4 inches, instruct patient to try and retain, control flow with clamp or by gravity, assist patient to commode; clean patient and bed; perform hand hygiene; Document.

Causes of Constipation - CORRECT ANSWER -Drug induced (Ca, Ca channel blockers, iron, narcotics,

anticholinergics); laxative abuse; neurological dysfunction; depression; bowel disease; lifestyle

Treatment of Constipation - CORRECT ANSWER -If an obstruction is suspected, do xray or other

diagnostic test; lifestyle changes (increase fiber and fluids, do not delay defecation, avoid laxative abuse); laxatives, suppositories, and enemas; digital disimpaction if stool is low enough

Causes of Diarrhea - CORRECT ANSWER -Laxatives, adverse drug effect, infection (c-diff, parasite,

viral , bacterial), malabsorption (ie. Celiac's disease), GI disease (crohns, UC, IBS)

Treatment of Diarrhea - CORRECT ANSWER -Stool for C+S, O+P, and c-diff toxin; Correct underlying

etiology; Replace fluids and electrolytes; Antibiotics for bacterial infection or c-diff; diet modification (clear liquid or BRAT); Anti-motility agent

What is the BRAT diet? - CORRECT ANSWER -Bananas, Rice, Applesauce, Toast. Meets nutritional

requirements without upsetting the stomach

Why should we use caution with anti-motility agents? - CORRECT ANSWER -We do not want to stop

diarrhea until we know whats occurring. We also do not want to cause constipation.

What meds are given as anti-motility drugs? - CORRECT ANSWER -Combination of

anticholinergic/narcotics. Loperamide (Imodium) and Dipheoxylate/atropine (lomotil)

Procedures to Visualize the Bowel - CORRECT ANSWER -EGD, colonoscopy, sigmoidoscopy, UGI,

barium enema

Types of Incontinence - CORRECT ANSWER -Transient, Stress, Urge, Overflow, Functional, Mixed,

Reflex, Total

Transient - CORRECT ANSWER -6 months or less

Stress - CORRECT ANSWER -Increase in intra-abdominal pressure. Sneezing, coughing, and laughing

Urge - CORRECT ANSWER -Urgent need; unable to suppress need to urinate.

Overflow - CORRECT ANSWER -Overdistension of bladder; Bladder cannot hold anymore

Functional - CORRECT ANSWER -Inability to reach toilet r/t environmental barriers

Mixed - CORRECT ANSWER -2 or more types of incontinence

Reflex - CORRECT ANSWER -Emptying of bladder w/o sensations to void

Total - CORRECT ANSWER -Total loss of ability to control urine

24 Hour Urine Collection - CORRECT ANSWER -Collection of all urine over 24 hours; Communicate

to entire team; Start time- have patient void and discard; End time- have patient void and add to collection; Refrigeration; Document

Signs & Symptoms of UTI - CORRECT ANSWER -Dysuria, hematuria, frequency, incontinence, fever,

flank pain. Weakness and confusion especially in older patients.

Foley Cath - CORRECT ANSWER -Aseptic technique for insertion; catheter care/cleansing every day;

Collection bag lower than bladder; Maintain patency/irrigate if blocked; Maintain generous fluid intake; Report drainage and keep I&O; Report s/s of infection

Kegel Exercises - CORRECT ANSWER -Used to treat urinary incontinence (especially helpful for

stress and urge incontinence); Very helpful in women because they have a shorter urethra and less muscular pelvic floor muscles; Contract pelvic floor muscles 3-5 seconds then relax, do this several times a day

IM Injections - CORRECT ANSWER -Used for antibiotics, hormones, and vaccines; Fast onset of

medication action; No more than 4 mL injected (except deltoid max is 1 mL); Site should be rotated with extended use

Sites for IM Injections - CORRECT ANSWER -Ventrogluteal (safest, recommended for adults and kids

over 7 months); Vastus lateralis (used in infants because gluteals arent developed); Deltoid (radial nerve and artery at risk, most frequent spot for adults)

What size needle should be used with IM injections? - CORRECT ANSWER -5/8 in to 1 1/2 in needle;

20-25 gauge

What degree angle should IM injections be given? - CORRECT ANSWER -72-90 degrees

SQ Injections - CORRECT ANSWER -Insulin, Heparin, Lovenox, and some immunizations. No more

than 1 mL given.

Sites for SQ Injections - CORRECT ANSWER -Upper arms, abdomen, thighs, upper back, upper

buttocks

What size needle should be used for SQ injections? - CORRECT ANSWER -5/8 in needle at 45 or 1/

in needle at 90

Intradermal Injections - CORRECT ANSWER -Longest time to absorb, placed just below epidermis,

used for diagnostic purposes (TB test, allergy testing), dose is usually less than 0.5 mL

Sites for Intradermal Injections - CORRECT ANSWER -Inner aspect of forearm, dorsal aspect of

upper arm, upper back

What size needle is used for intradermal injections? - CORRECT ANSWER -Tuberculin syringe with

1/4 or 1/2 in needle

Drawing Meds out of an Ampule - CORRECT ANSWER -Break the neck, use filtered needle first

Insulin - CORRECT ANSWER -Rotate sites, no need to aspirate, do NOT massage (speeds up

absorption which isnt needed because insulin is already given to be absorbed at specific times

ASPART (Novolog/Humalog) - CORRECT ANSWER -Rapid acting, given with high blood sugars,

immediately prior to meal, can be given with NPH. Onset: 15 min Peak: 1-2 hours Duration: 4 hours

Regular (Novolin R/Humulin R) - CORRECT ANSWER -Short onset, given with high blood sugars, 15-

30 min prior to meal, can be mixed with NPH, sliding scale Onset: 30 min- 1 hour Peak: 2-4 hours Duration: 5-7 hours

NPH (Novolin R/Humulin R) - cloudy - CORRECT ANSWER -Intermediate acting, given prior to

breakfast and dinner, can be mixed with ASPART or reg Onset: 1-3 hours Peak: 6-14 hours Duration: 18-24 hours

Glargine (Lantus & Levemir) - CORRECT ANSWER -Long acting, no mixing (negates long duration),

cannot be given IV Duration: 24 hours

How is insulin given? - CORRECT ANSWER -Insulin syringe, pump, or pen

Insulin syringe - CORRECT ANSWER -In units (100 U = 1 mL), 3/8 in to 5/8 in needle, 28-30 gauge

Adminsitering ear drops - CORRECT ANSWER -Position ear based on patient's age and patient lies

on unaffected side Infants (0-3): down and back Children: straight back Adults: up and back

Administering inhalers - CORRECT ANSWER -Patient breaths in deeply. Rinse out mouth after

Administering Transdermal meds - CORRECT ANSWER -Disc or patch. Process: gloves, remove old

patch, fold & discard, cleanse old site, choose a new site, nurse name & date on patch, apply w/o touching med

Rights of med administration - CORRECT ANSWER -Right patient, med, dose, time, route,

documentation, assessment data, reason, response, right to education, right to refuse

3 Checks When Preparing Meds - CORRECT ANSWER -When retrieving from drawer, when

preparing and removing from dose package or multidose container, at the bedside before administering

3 Bedside As - CORRECT ANSWER -Armband (ID patient and scan), Allergies (check chart, MAR, and

confirm with patient), Assessment (any specific patient assessment data needed before or after administration of meds ie. apical HR)

Types of Pain - CORRECT ANSWER -Acute, chronic, referred, intractable, phantom

Acute Pain - CORRECT ANSWER -Comes on suddenly, typically doesn't last long, indicative of injury

or tissue problem

Chronic Pain - CORRECT ANSWER -Long lasting pain, 3-6 months of pain not being relieved, can

have periods of remission and exacerbation

Intractable Pain - CORRECT ANSWER -Pain that is not relieved by any measure

Phantom Pain - CORRECT ANSWER -Pain in a limb that was no longer there

Pain Assessment - CORRECT ANSWER -COLDSPA, ask them treatments tried, with cognitively

impaired - know baseline, observe facial expressions, behavior changes, groaning, movements

PCA - CORRECT ANSWER -Patient presses a button to get dose of pain meds, orders include drug,

bolus +/-, basal rate, lock out, PRN meds, can be epidural or IV, settings must be verified with 2 nurses

What to teach patient who has a PCA - CORRECT ANSWER -ONLY they should press button for dose

and that they should press when in pain

Advantages of PCA - CORRECT ANSWER -Better pain control, avoids dosing delays, less total dose

needed to control pain, increased sense of control for patient

Treating Pain Effectively - CORRECT ANSWER -Assess frequently, treat proactively, treat around the

clock, assess for and treat side effects, interdisciplinary team approach, involve patient in plan of care

Non-pharmacological methods for pain management - CORRECT ANSWER -Massage, heat, cold,

TENS, distraction, relaxation. spiritual care, acupuncture

Pharmacological methods - CORRECT ANSWER -Non-opioids, opioids, combo of opioids and non

opioids

Non-opioids - CORRECT ANSWER -Have a ceiling effect, ex are acetaminophen and NSAIDS

Opioids - CORRECT ANSWER -Can be oral (oxycontin, percocet, vicodin), parenteral (IM, IV-

morphine, dilaudid), epidural, transdermal (patch- Fentanyl)

Guidelines for Documenting Care - CORRECT ANSWER -Document according to policy, on the

correct chart, timely- AFTER something is completed, be objective & concise (avoid conjecture and vague terms, be factual), use correct terminology spelling and grammar, only use approved abbreviations, military time, date and time on each entry, document on consecutive lines, patient ID and name on each entry, signature

Correcting Errors in the Chart - CORRECT ANSWER -No white out, draw single line, write "mistaken

entry" or "error" with date, time, and initials

Incident Report - CORRECT ANSWER -NOT part of the chart and shouldnt be referenced in the

chart; used to report unusual occurrence, error, near miss, fall, etc; be factual when making report - avoid excuses or blame; purpose is tracking and quality improvement for the facility

Telephone Orders - CORRECT ANSWER -Cannot be taken by students, follow policy, read back,

record with date time and TORB, must be co-signed

Verbal Orders - CORRECT ANSWER -Increase risk of error, limited by policy to emergency, read

back, record with date time and VORB, must be cosigned by provider ASAP, not accepted by students

When a note should be entered into patient chart - CORRECT ANSWER -Admission, transfer,

discharge, ongoing care per policy, change in condition, communication

NPO - CORRECT ANSWER -Prior to/after surgery & medical tests. Inability to chew/swallow due to

risk of coming up during surgery. After surgery make sure swallowing/gag reflex are back before changing diet

Clear Liquid - CORRECT ANSWER -Diet contains only foods that are clear liquids at room temp,

many times a transitional diet (ex. going from GI surgery and working up to a full diet), includes jello, fat free broth, popsicles, clear juices, tea, and coffee

Full Liquid - CORRECT ANSWER -Includes all items on a clear liquid diet + liquids that can be poured

at room temp. Milk, pudding, eggs, vegetable juices

Fat Controlled - CORRECT ANSWER -Low fat diet. Used with patient experiencing gall bladder

issues, CV disease

Soft/Mechanical - CORRECT ANSWER -Modified to eliminate foods that are hard to digest and

chew. Excludes raw fruit and veggies, coarse bread. Mechanical soft = food is chopped, pureed, or ground to ease swallowing and digestion.

Low Residue - CORRECT ANSWER -low fiber

High fiber - CORRECT ANSWER -High on fruits and veggies

Bland diet - CORRECT ANSWER -Low in fiber, fat, and spices

Diabetic/NCS (no concentrated sweets) - CORRECT ANSWER -Carb counting, sometimes have a

specific number of cals

Low Sodium - CORRECT ANSWER -Someone who has fluid retention, heart failure, and high BP

Signs & Symptoms of Aspiration - CORRECT ANSWER -Sudden, severe coughing; choking; difficulty

breathing/cyanosis; voice change/gurgling after swallowing; frequent clearing of throat after meals

Prevention of Aspiration - CORRECT ANSWER -Provide rest prior to meals so swallowing abilities are

at peak, sit patient upright with chin down, avoid rushed/forced feeding, alternate solids and liquids- small amounts at a time

Bolus vs. Continuous - CORRECT ANSWER -Bolus = larger feeding at specific intervals

Gravity vs Pump - CORRECT ANSWER -Gravity = attach syringe or some type of device to allow food

in Pump = using a feeding bag

Confirming Placement of Feeding Tube - CORRECT ANSWER -X-ray, tube length, auscultation, pH (in

general the best way) the pH should be acidic

Administering a Tube Feeding - CORRECT ANSWER -Treat like medication (follow same checks,

write, and document), Medical asepsis (clean gloves, clean environment), Assess bowel sounds, residual, and tolerance (cramping/abd pain), flush tube, if giving meds, make sure to finely crush and flush, free water, change tubing and syringes Q 24 hrs or per policy

TPN & PPN - CORRECT ANSWER -Nutritional support administered through IV route; used in those

w/o a functional GI tract, comatose, and short-term recovery; temp need or temp solution until

something like PEG tube could be placed; contains nutrients we need to get by and some have lipids added

Nutrients that Regulate Body Processes - CORRECT ANSWER -Vitamins, minerals, and water

Nutrients that Supply Energy - CORRECT ANSWER -Carbs, proteins, and fats

Carbs - CORRECT ANSWER -Sugars & starches; organic compounds composed of C, H, and O; most

abundant and least expensive source of calories in the world; classified as simple or complex; converted to glucose for transport through the body; cells oxidize glucose to provide energy, CO2, and water

Proteins - CORRECT ANSWER -Need for the formation of all body structures, can be complete (high

quality- meat, poultry, fish, dairy, eggs) or incomplete (low quality- veggies, beans, nuts, legumes, soy), protein tissues are in a constant state of flux, RDA for adults is 0.8g/kg of body weight 10-20% of total calorie intake

Fats - CORRECT ANSWER -Insoluble in water and blood, composed of C H and O, contains mixtures

of saturated (raise cholesterol) and unsaturated (lower cholesterol) fatty acids, digestion mainly occurs in small intestines, most concentrated source of energy in diet, and RDA not established but fats shouldn't be more than 20-35% of total calorie intake

Vitamins - CORRECT ANSWER -Organic compounds needed by body in small amounts, typical able

to be obtained in norm diet, needed for metabolism of carbs fat and protein, classified as fat or water soluble, absorbed through intestinal wall directly into bloodstream

Minerals - CORRECT ANSWER -Organic elements found in all body fluids and tissues, some function

to provide structures in body while others regulate body processes, either macrominerals or microminerals, difference is that macro is needed in larger quantities than micro

Water - CORRECT ANSWER -Account for 50-60% of adult's total weight, 2/3 is contained within cells

(ICF), remainder is ECF, needed for all chemical rxns in the body, acts as solvent and aids in digestion absorption circulation and excretion

Malnutrition - CORRECT ANSWER -Can be overnutrition, undernutrition, or protein calorie

malutrition

Over-nutrition - CORRECT ANSWER -Intake exceeds energy expenditure, leads to obesity and

diabetes associated with obesity, even if someone is obese it does not necessarily mean they are well- nourished (could still not be getting enough of certain vitamins, minerals, etc)

Under-nutrition - CORRECT ANSWER -Inadequate intake or absorption of key nutrient;, results in

weakness, immunocompromised, poor wound healing, and muscle wasting

Protein-calorie malnutrition - CORRECT ANSWER -Long-term deficiency in protein and/or calorie

intake

Body Mass Index (BMI) - CORRECT ANSWER -<18.5 = underweight

18.5-24.9 = normal 25-25.9 = overweight

30 = obese 40 = extremely obese

Advantages of Nasal Cannula - CORRECT ANSWER -Safe, simple, and easy to apply; comfortable and

well-tolerated; client is able to eat, talk, and ambulate

Disadvantages of Nasal Cannula - CORRECT ANSWER -The FiO2 varies with the flow rate & rate and

depth of client's breathing; Extended use can lead to skin breakdown and dry mucous membranes; tubing is easily dislodged

Nursing Actions with Nasal Cannula - CORRECT ANSWER -Assess the patency of the nares, ensure

that the prongs fit in the nares properly, use water soluble gel to prevent dry nares, tubing is easily dislodged

Advantages of Simple Mask - CORRECT ANSWER -Easy to apply, can be more comfortable than a

nasal cannula, and provides humidified oxygen

Disadvantages of simple mask - CORRECT ANSWER -Flow rates less than 5 L/min can result in

rebreathing CO2; clients who have claustrophobia or anxiety do not tolerate it well; eating, drinking, and talking are impaired; moisture & pressure can collect under mask and cause skin breakdown

Nursing Actions with Simple Mask - CORRECT ANSWER -Assess proper fit to ensure a secure seal

over the nose and mouth; Make sure the client wears a nasal cannula during meals; Monitor for skin breakdown

Advantages of Venturi Mask - CORRECT ANSWER -Delivers the most precise oxygen concentration,

humidification is not required, and best for clients who have COPD

Disadvantages of Venturi Mask - CORRECT ANSWER -Use is expensive; eating, drinking, and talking

are impaired

Nursing Actions with Venturi Mask - CORRECT ANSWER -Assess frequently to ensure an accurate

flow rate, assess proper fit to ensure a secure seal over the nose and mouth; assess for skin breakdown beneath edges of the mask particularly on the nares; make sure tubing is free of kinks; ensure that the clients wear cannula during meals

Advantages of Non-Rebreather Mask - CORRECT ANSWER -Delivers the highest o2 concentration

(except for intubation)

Disadvantages of Non-Rebreather Mask - CORRECT ANSWER -The valve and flap on the mask must

be intact and functional during each breath; poorly tolerated by clients who have anxiety or claustrophobia

Nursing Actions with Non-Breather - CORRECT ANSWER -Perform an hourly assessment of the valve

and flap; Assess proper fit to ensure a secure seal over the nose and mouth; assess for skin breakdown beneath the edge of the mask and bridge of the nose

Tracheal Suctioning - CORRECT ANSWER -When patient is unable to raise secretions from airways,

patient may appear irritable. Limit frequency, sterile technique, limit suction time 10-15 seconds, apply suction only when withdrawing catheter, pre/post oxygenate, assess

Pulse ox - CORRECT ANSWER -Non-invasive, measures the O2 sat of arterial blood, monitors those

needing assessment of respiratory functioning, normal range 95-100%

What does a pulse ox of less than 90% mean? - CORRECT ANSWER -They are not getting enough O

to tissues

Thoracentesis - CORRECT ANSWER -Aspiration of fluid from the pleural cavity, done at

bedside/tripod position, fluid has to be removed to ease breathing, sterile procedure, standard precautions also used, insert needle with catheter, remove needle, assessment after procedure to look for any bleeding or change in respiratory patterns because there is a risk of puncturing the lung, if patient complains of being SOB after take VS

Patients Experiencing SOB/Difficulty breathing - CORRECT ANSWER -Take VS, LOC, Color, Pulse ox,

COLDSPA, Semi-Fowlers/High-Fowlers

Pursed Lip Breathing - CORRECT ANSWER -Causes slowed/prolonged expiration - keeps airways

open longer so more oxygen can get it, helps to decrease airway monitoring, improves air exchange, used with COPD patient

Conscious States - CORRECT ANSWER -Normal consciousness, lethargy, confusion, dementia,

delirium

Lethargy - CORRECT ANSWER -Continued drowsiness, able to arouse but alertness is not

maintained

Confusion - CORRECT ANSWER -Reduced awareness, not aware of 1 or several factors r/t reality.

Easily distracted. NOT a normal part of aging.

Dementia - CORRECT ANSWER -Difficulties with spatial orientation, memory, language, changes in

personality. A gradual decline.

Delirium - CORRECT ANSWER -Sudden onset of confusion, may include disorientation, restlessness,

agitation, decline in perception and cognition

Unconscious States - CORRECT ANSWER -Asleep, stupor, coma, vegetative state

Stupor - CORRECT ANSWER -Can be aroused by extreme or repeated stimuli, very difficult to arouse

Coma - CORRECT ANSWER -Cannot be aroused and does not respond to stimuli

Vegetative State - CORRECT ANSWER -Cannot be aroused, may have sleep/wake cycles, postures of

withdraws to noxious stimuli, occasional non-purposeful movement, random smiling or grimacing

CT Scan - CORRECT ANSWER -Computerized axial tomography, with or without contrast medium

(check for allergies to shellfish), depending on area of scan may be NPO prior

MRI - CORRECT ANSWER -Magnetic resonance imaging, higher resolution, soft tissues, MRI

checklist (important to check for metal), med given prior if needed (anxiety due to tight space, loud noises, and long procedure. Ativan can mildly relax)

Glasgow Coma Scale - CORRECT ANSWER -Assessment scale for neurological function, tests eye

opening/motor/verbal responses, best score = 15, worst score= 3, 8 or less = comatose patient

Macular degeneration - CORRECT ANSWER -Breakdown of cells in macula, deposits of scar tissue

Diabetic retinopathy - CORRECT ANSWER -Vessels are permeable (edema/exudate)

Cataracts - CORRECT ANSWER -Clumping of proteins (clouding), allows less light in

Glaucoma - CORRECT ANSWER -Increase in IOP, optic nerve damage, blindness. Often first

experience a decrease in peripheral vision.

Nursing Interventions for Hearing Impaired - CORRECT ANSWER -Sit and face the client, avoid

covering the mouth while speaking, speak slowly and clearly, try lowering vocal pitch before increasing volume, use brief sentences with simple words, write down what clients don't understand, minimize background noise, ask for a sign language interpreter if necessary

Sensory Overload - CORRECT ANSWER -Excessive, sustained, and unmanageable multisensory

stimulation (ex ICU psychosis)

Sensory Deprivation - CORRECT ANSWER -Reduced sensory inout from the external or internal

environment. Can be the result of illness, trauma, or isolation (ex. loss of vision, loss of hearing)

Complications of Immobility - CORRECT ANSWER -Orthostatic HTN, VTE, atelectasis, constipation,

renal calculi, pressure ulcers, loss of muscle mass and tone, osteoporosis, contractures, psychosocial consequences

Prevention of VTE - CORRECT ANSWER -Early mobilization, leg exercises, SCDs/TEDs

DVT Teaching - CORRECT ANSWER -Don't cross legs, no pillows under knee, don't massage legs

Atelectasis prevention - CORRECT ANSWER -Early mobilization, upright position, turn cough deep

breath, incentive spirometer

Contracture prevention - CORRECT ANSWER -ROM exercises, braces/splints

Ambulation Equipment - CORRECT ANSWER -Cane: hold on strong side, advance cane, then weaker

leg, then stronger leg Walker: patient moves walker forward then steps into it Crutches: crutch pad 3 fingers below axilla, hand grips w/ 30 degree elbow flexion All fitted by PT

Types of gaits with Crutches - CORRECT ANSWER -2 point gait/4 point gait: weight bearing on both

legs 3 point gait: when 1 leg in injured/ nonweight bearing swing through gait: used for bilateral LE weakness

Body Mechanics - CORRECT ANSWER -Use strongest muscles, avoid use of back muscles, lift objects

close to body, push rather than pull, use broad base of support, lift from thighs, keep back straight

Restraints - CORRECT ANSWER -Ordered for shortest duration possible and only if other less

restrictive measures aren't sufficient, for physical protection of clients/staff, must tie with quick release knot, assess skin integrity every 2 hours, offer food and fluid, provide with means for hygiene and elimination, monitor vs, offer ROM exercises

Heat Therapy - CORRECT ANSWER -Increases blood flow, relaxes muscle, eases joint ,stiffness and

pain. Avoid over metal devices & patches. Closely monitor. Avoid long application. Do NOT place under someone who is immobile or has sensory impairment.

Ice Therapy - CORRECT ANSWER -Decreases inflammation, prevents swelling, reduces fever. Do not

use in patients with cold intolerance or vascular insufficiency. On/off periods. Do NOT place under someone who is immobile or with sensory impairments.

Shock & Denial (stage 1) - CORRECT ANSWER -Disbelief in what they have been told. Encourage

patient to share their feelings and concerns.

Anger (stage 2) - CORRECT ANSWER -Rage, hostility, and isolation. Anger feelings are directed

towards others. Treat the patient with respect and allow the patient to express feelings of angers.

Bargaining (stage 3) - CORRECT ANSWER -Tries to negotiate for more time. "If I can just make it..."

Be supportive of bargaining expressions and offer realistic hope.

Depression (stage 4) - CORRECT ANSWER -Grieve before death ("I don't know what my wife will do

when I'm gone" Provide normal responses that help the patient cope. Encourage expressions of sadness.

Acceptance - CORRECT ANSWER -Patient may withdraw from loved ones, patient may feel tranquil,

reality of death has been accepted, family may feel rejected, encourage family and loved ones to remain present.

Clinical Signs of Impending Death - CORRECT ANSWER -Difficulty talking or swallowing. Nausea,

flatus, and abdominal distension. Urinary and/or bowel incontinence or constipation. Loss of movement, sensation, and reflexes. Decreasing body temp with cold or clammy skin. Weak, slow, or irregular pulse. Decreasing BP. Noisy, irregular, or cheyne stokes respirations. Cooling, mottling, and cyanosis of the extremities.

Palliative Care - CORRECT ANSWER -Taking care of the whole person (body, mind, spirit, soul, and

heart). Dying is viewed as natural and personal. Goal = give patients with life-threatening illnesses quality of life through aggressive management of symptoms (has no time limit, no expecting them to die in a specific amount of time). Provided across the spectrum of disease and illness.

Hospice - CORRECT ANSWER -Provided to patients w/ limited life expectancy (usually 6 months or

less), can be provided at home or in a healthcare setting, focuses on the needs of the dying, philosophy is dying with comfort and dignity, provides care for family during illness and death, bereavement care for fam up to 1 year after the death of their loved.

Stage 1 Pressure Ulcer - CORRECT ANSWER -Skin intact- no opening, redness that does not blanch,

can be warm and tender to touch, darkly pigmented skin may not have visible blanching but its color may differ from the surrounding area.

Stage 2 Pressure Ulcer - CORRECT ANSWER -Skin is not intact. Partial thickness of dermis presenting

as a shallow open ulcer with a red, pink wound bed w/o slough. May present as an intact or open/ruptured serum-filled blister.

Stage 3 Pressure Ulcer - CORRECT ANSWER -Full thickness tissue loss. SQ fat may be visible but

bone, tendon, or muscle. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.