Nursing Final Exam Questions and Answers, Exams of Nursing

Download Nursing Final Exam Questions and Answers and more Exams Nursing in PDF only on Docsity!

NURSING Chapters 17, 22, 18, 20, 4, 21, 5, 26, 6,

28, 7, 27 FINAL EXAM Questions and Answers

How can you estimate a client's tidal volume? - answers> Tidal volume

can be estimated by observing the depth of the client's respirations.

What is the range of normal for an adult's respiratory rate? - answers> A

rate of 12 to 20 breaths per minute is normal for adults Besides the rate, what other characteristics of a client's respirations should

you observe? - answers> Depth, rhythm, effort, breath sounds, and chest

movement should be observed in addition to rate. What are some common clinical signs associated with poor oxygenation? -

answers> Pallor or cyanosis of the nails, lips, or skin; restlessness;

apprehension; confusion; dizziness; fatigue; changes in pulse and blood pressure; and decreased level of consciousness are associated with poor oxygenation. Which of the Korotkoff sounds would you record as the systolic pressure? -

answers> First

Which of the Korotkoff sounds would you record as the diastolic pressure?

• answers> Fifth A nurse is auscultating a BP. He hears the first sound at 170 mm Hg. The sound disappears immediately. At 150 mm Hg, the sound appears again and continues until there is silence at 80 mm Hg. The pressures were taken in the client's right arm while the client was lying down.

How should the nurse record these pressures? - answers> BP RA,

supine, 170/80 with an auscultatory gap from 170 to 150

How do you explain what happened? - answers> An auscultatory gap

occurred. A gap is most commonly heard in hypertensive clients, whose systolic blood pressure is higher than the adult normal limit of 140 mm Hg.

Which of the following patients has hypertension? One with a BP of: 150/80 on two separate occasions 180/100 on one occasion

138/88 on two occasions - answers> 150/80 on two separate occasions

Which of the following client(s) has/have primary hypertension? Client A, who is obese and has a high sodium intake Client B, who is in renal failure Client C, who has hypertension induced by pregnancy

Client D, who has a family history of hypertension - answers> Client D,

who has a family history of hypertension

What are five functions of the skin? - answers> The skin serves five

functions: protection, sensation, temperature regulation, secretion/excretion, and formation of vitamin D.

How does the skin help regulate body temperature? - answers> The skin

contains sensory organs or receptors for heat and cold. The skin regulates temperature through the process of dilating and constricting blood vessels and activating or inactivating sweat glands. The sweat glands found in the axillae and external genitalia secrete fatty acids and proteins and excrete perspiration, which produces a cooling effect as the moisture evaporates from the skin.

What changes take place in the skin as a person ages - answers> With

age, both layers of the skin become thinner and more fragile. As collagen and elastin fibers in the dermis deteriorate, the skin becomes wrinkled. Sebaceous and sweat gland activity decreases, causing the skin to become dry, scaly, and itchy, and temperature regulation in hot weather becomes more difficult. As the number and activity of hair follicles and pigment cells (melanocytes) diminishes, hair becomes thin, turns gray or white, and grows more slowly. Nails thicken and growth decreases. These changes increase the risk for skin problems. True or false: The professional nurse is responsible for making

assessments. - answers> True

True or false: Assisting with the bath is an excellent time to assess the

patient. - answers> True

To inspect for pallor in a dark-skinned person, which areas would you

assess for an ashen gray or yellow color? - answers> For dark-skinned

persons, the conjunctivae, buccal mucosa, tongue, lips, nail beds, palms, and soles should be assessed for pallor. What is the term that means "a bluish color of the skin"? -

answers> Cyanosis means a bluish discoloration of the skin.

Name two causes of erythema. - answers> Vasodilation and inflammation

are causes of erythema.

Where can you best see jaundice? - answers> The sclera of the eyes is

the best place to see jaundice True or false: Healthy nails are usually clean, smooth, and convexly curved

• answers> True

List at least three nail changes that occur with aging. - answers> As a

person ages, the nails thicken, become ridged, and may yellow or become concave in shape. List at least four things you should teach clients about self-care of their

nails. - answers> Answer:

Clients should be taught the following self-care of their nails: ● Inspect the nails daily. ● Trim nails with a nail clipper (people with diabetes or circulatory problems should file only, as cutting poses a risk for injury to the tissues). ● File the nails straight across, rounding the corners slightly to prevent scratching; do not cut deeply into the lateral corners, as this may cause ingrown nails. ● Remove hangnails by carefully cutting them off. ● Clean under the nails with an orangewood stick or other blunt instrument. ● Push back the cuticles gently. ● Use a moisturizing lotion to soften cuticles. ● Avoid biting nails. ● Consult a podiatrist for any ingrown toenails or other nail problems. ● Recommend to patients with diabetes, circulatory insufficiency, or nail problems that they seek nail care from a podiatrist.

List at least four assessments you should make of a patient's hair. -

answers> The following assessments should be made on a patient's hair:

● Use of special products or medicated shampoos ● History of hair problems or current conditions necessitating treatment (e.g., pediculosis [head lice]) ● History or presence of disease or therapy that affect the hair (e.g., chemotherapy) ● Factors influencing the patient's ability to manage hair and scalp care (e.g., Impaired Mobility) ● Personal or cultural preferences for styling of the hair ● Condition, cleanliness, texture, and oiliness of the hair ● Inspection of the scalp for dandruff, pediculosis, alopecia (hair loss), secretions or lesions

What is pediculosis? - answers> Pediculosis is an infestation of head lice

What is alopecia? - answers> Alopecia is hair loss.

Identify the components of verbal and nonverbal communication. -

answers> Verbal communication. Vocabulary, denotative and connotative

meaning, pacing, intonation, clarity and brevity, timing and relevance, credibility, and humor are the components of verbal communication. ● Nonverbal communication. Facial expression, posture and gait, personal appearance, distance, gestures, and touch are the components of nonverbal communication. What action should you take when there is a discrepancy between the

client's spoken word and nonverbal body language? - answers> You must

discuss the communication discrepancy with the patient. Identify and describe the phases of the therapeutic relationship. -

answers> The therapeutic relationship has four phases: pre-interaction,

orientation, working, and termination. ● The pre-interaction phase occurs before you meet the client. In this phase you gather information about the client. ● The orientation phase begins when you meet the client. The goal of this phase is to establish rapport, trust, and a timeline.

● The working phase is the active part of the relationship. During this phase, caring is communicated, thoughts and feelings are expressed, mutual respect is maintained, and honest verbal and nonverbal expression occurs. ● The termination phase is the conclusion of the relationship. What are the five characteristics of therapeutic communication? -

answers> The five characteristics of therapeutic communication are

empathy, respect, genuineness, concreteness, and confrontation. Describe the difference between a task group and a self-help group. -

answers> A task group is developed to address a task or need. Members

are chosen based on ability to complete the task. ● A self-help group is a voluntary organization composed of individuals with a common need. The organization revolves around a belief that the experience of others who have resolved the need assists others with the need. Compare and contrast the role of a therapy group with a work-related

support group. - answers> ● A therapy group helps members cope with

issues, improve relationships, or address stress. It is a formal, organized group with a facilitator. ● A work-related support group helps members of a profession cope with the stress associated with their work. It may be a formal or informal group.

Identify at least five barriers to communication. - answers> Any five of the

following common barriers to communication would be an appropriate answer: ● Asking too many questions ● Asking why ● Changing the subject inappropriately ● Failing to listen ● Failing to probe ● Expressing approval or disapproval ● Offering advice ● Providing false reassurances ● Stereotyping ● Using patronizing language

What is a pathogen? - answers> Pathogens are bacteria, viruses, fungi,

and other organisms that cause disease.

What is the role of normal flora? - answers> Normal flora are

nonpathogenic microorganisms that help to control the growth of pathogenic microorganisms. Normal flora in the intestine also aid digestion and, when they die, release vitamins important to human health.

Identify at least five reservoirs of infection. - answers> Potential answers

include the following reservoirs of infection: ● Human body ● Animals ● Insects ● Food ● Floors in healthcare facilities ● Bathrooms ● Raw sewage ● Stagnant water ● Garbage ● Diapers ● Used wound dressings

Identify the six links in the chain of infection. - answers> The following six

links compose the chain of infection: ● Infectious agent ● Reservoir ● Portal of exit ● Mode of transmission ● Portal of entry ● Susceptible host What kinds of microbes favor the human body as a reservoir of infection? -

answers> The human body provides a warm, moist environment. The

microbes that are pathogenic to humans are so because they thrive at about the same temperature as the human body. To thrive in the human body, microbes also must be able to use the body's precise balance of moisture, nutrients, electrolytes, and pH to support their own reproduction.

Identify and describe the purpose of the body's three major lines of defense

against infection. - answers> ● The primary defense mechanisms prevent

entry of pathogens into the body. Primary defense mechanisms include intact skin, mucous membranes at body openings, normal flora, and a rich vascular supply at potential sites of entry for infection, including the mouth and vagina. They also include processes such as crying, salivating, vomiting, peristalsis, and diarrhea. ● The secondary defense mechanisms are activated if a pathogen gains entry into the body. Secondary defense mechanisms include phagocytosis, the complement cascade, inflammation, and fever. ● Specific immunity, a third line of defense, protects against specific pathogens and builds immune "memory" in the process. The humoral response produces antibodies that inactivate invading antigens. The cell- mediated response results in the production of T cells that destroy body cells infected with invaders. Mr. Jefferson has an acute infection. If lab work reveals that IgM, but not IgG, is present in his blood, what can you conclude about this infection? -

answers> IgM is present the first time an individual is exposed to a

particular pathogen. If IgG is not present, you can conclude that the exposure occurred less than 10 days ago.

What factors increase a client's risk for infection? - answers> The

following factors increase a client's risk for infection: ● Very young children and older adults are at increased risk for infection. Young children have limited exposure to pathogens and little active immunity. Older adults have declining function of the immune system and limited physiological reserve. ● Any break in the skin also increases risk. ● Illness and injury, especially chronic disease, limit an individual's ability to fight infection. ● Smoking, substance abuse, and multiple sex partners increase the risk of infection. ● Some medications inhibit the immune response of the body. ● Environmental factors that increase exposure to pathogens increase risk for infection. ● Finally, nursing and medical treatments often provide portals of entry and exit or bypass natural defense mechanisms.

Under what circumstances are standard precautions used? -

answers> Standard precautions are used on all clients whenever there is

a possibility of coming in contact with blood, body fluids (except sweat), excretions and secretions, mucous membranes, and any break in the skin. When will you need to don sterile gloves using the closed method? -

answers> When you are performing an activity that requires you to wear a

sterile gown. The gloves must cover the gown cuffs. True or false: Some procedures require both standard precautions and

sterile technique - answers> Healthcare providers use sterile technique to

perform a variety of procedures. Some of the procedures require full surgical attire; others do not. The following procedures, for example, use both sterile technique and principles of medical asepsis: administering an injection, starting an IV line, and performing a sterile dressing change. To clarify, when administering an injection, you prepare the patient, cleanse the injection site, and remove the needle cap using standard precautions. You do not don sterile gloves, but for the rest of the procedure you observe sterile technique by taking care not to touch or otherwise contaminate the exposed needle.

What part(s) of a sterile field are considered to be unsterile? - answers> A

1-inch margin around the edges of the field and any material that hangs over the horizontal plane are considered unsterile. You may also recall that a field is no longer sterile if it becomes wet, if you turn your back on it, or if someone not wearing sterile garb comes within 1 foot of the field. State whether each of the following represents a nursing diagnosis, medical diagnosis, or collaborative problem.

1. All women after giving birth to a baby are at risk for developing postpartum hemorrhage
2. A patient has signs and symptoms of appendicitis, which must be treated with surgery and antibiotics. 3)A client is at risk for constipation because he postpones defecation and also does not get enough dietary fiber and fluids. The problem can be prevented by patient teaching, which the nurse is licensed to do. -

answers> 1)Collaborative problem (potential complication of childbirth:

postpartum hemorrhage)

Rationale: This is a potential problem that the nurse can help to prevent (e.g., by fundal massage); but if fundal massage is not effective, the physician must prescribe medication to prevent hemorrhage. This is a potential physiological complication associated with a medical diagnosis (childbirth). 2)Medical diagnosis: appendicitis (actual problem; nurse cannot treat independently; requires surgery and antibiotics) 3)Nursing diagnosis Rationale: The problem can usually be prevented by independent nursing interventions. Medication is sometimes prescribed, but not usually. What are the five types of nursing diagnoses that can be used? -

answers> 1. Actual nursing diagnosis

2. Risk (potential) nursing diagnosis
3. Possible nursing diagnosis
4. Syndrome nursing diagnosis
5. Wellness nursing diagnosis "Collaborative problems" is incorrect. Collaborative problems are a type of problem, but not a type of nursing diagnosis.

What kind of nursing diagnosis is each of the following? - answers> a.

Jane Thomas regularly engages in exercise but tells you she would like to increase her endurance. Answer: Wellness diagnosis b. Mrs. King has several of the signs and symptoms (defining characteristics) of the nursing diagnosis Ineffective Coping Answer: Actual diagnosis c. Alicia Hernandez seems anxious, but you are not sure. You would like to have more data in order to diagnose or rule out a diagnosis of Anxiety. Answer: Possible diagnosis d. Charles Oberfeldt has no symptoms of constipation, but he reports that he does not include many fiber-rich foods in his diet and drinks few liquids.

In addition, he is now fairly inactive because of a back injury. These are all risk factors for a diagnosis of Constipation. Answer:Risk diagnosis

What is a cue? - answers> Significant data (also called cues) are data

that influence your conclusions about the client's health status (or that influence your choice of nursing diagnoses). A cue should alert you to look for other cues that might form a cluster (pattern) representing a nursing diagnosis.

What are five ways you can recognize a cue? - answers> A cue is

recognized by the presence of data representing (1) a deviation from population norms, (2) a change in usual health patterns that is not explained by developmental or situational changes, (3) an indication of delayed growth and development, (4) a change in usual behaviors in roles or relationships, or (5) a nonproductive or dysfunctional behavior. What are the possible conclusions you can draw about a client's health

status (e.g., that no problem exists)? - answers> You might conclude that

there is a patient strength, no problem, a wellness diagnosis, a possible problem, an actual nursing diagnosis, a risk (potential) nursing diagnosis s, a collaborative problem, or a medical diagnosis.

What is the difference between a cue and an inference? - answers> A cue

is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. You can observe a cue directly, but not an inference. You cannot directly check the accuracy of an inference. How can you be satisfied that you have made a valid inference? -

answers> The more data and theoretical knowledge you have to support

an inference, the more sure you can be that it is valid/accurate.

List the steps in the diagnostic process. - answers> 1. Analyzing and

interpreting data (this includes identifying significant data, clustering cues, and identifying data gaps and inconsistencies)

2. Drawing conclusions about health status (this includes making inferences and identifying problem etiologies)

3. Verifying problems with the patient
4. Prioritizing the problems
5. Recording the diagnostic statements (it could be argued that this is not really a "part of" the diagnostic process)

What is a typical cause of fire in healthcare facilities - answers> Fire in

healthcare facilities is typically related to anesthesia or electrical causes. Which assessment tool would you use for a slightly confused home care client to assess her ability to safely live alone and perform activities of daily

living? - answers> The Safety Assessment Scale (SAS) primarily

evaluates whether the cognitively impaired person is capable of cooking, taking her own medicines, shopping, and performing other activities of daily living. ● List the six risk factors that are assessed on the Morse Fall Scale. -

answers> The following six risk factors are assessed on the Morse Fall

Scale:

1. Whether the patient has a history of falling
2. Whether the person has more than one medical diagnosis
3. Whether the person uses ambulatory aids, such as crutches or a walker
4. Whether the person has an IV or a heparin lock
5. Whether the person's gait is normal, stooped, or otherwise impaired
6. The person's mental status How should you screen older adults to see if they need a comprehensive

falls evaluation? - answers> Use the Get Up and Go test, and possibly the

Timed Up and Go test if indicated. What does the nurse do in the planning phases of the nursing process? -

answers> In the planning phases, the nurse chooses outcomes/goals

based on assessments and nursing diagnoses, chooses nursing interventions, and writes the plan of care. What is the purpose of initial planning? Ongoing planning? Discharge

planning? - answers> ● Initial planning is done for the purpose of

identifying patient problems and creating the care plan.

● Ongoing planning allows you to revise and individualize the patient's care plan as new data are obtained. ● Discharge planning is done to evaluate the patient's health status on leaving the institution, to prepare the patient for self-care, to prepare family members for caregiving, and to coordinate services that will be needed after the patient leaves the hospital or other healthcare agency. In addition to care related to the patient's basic needs, what other types of

information does a comprehensive care plan contain? - answers> The

comprehensive care plan also contains information about the medical/multidisciplinary plan of care, information about care related to nursing diagnoses and collaborative problems, and information regarding special teaching and/or discharge planning needs. How are critical pathways different from other standardized care plans? -

answers> Critical pathways focus on care for a particular medical

diagnosis or DRG; they are organized on a timeline to meet recommended lengths of stay; instructions for nursing interventions are usually less specific/detailed. What is the main disadvantage of computerized and standardized care

plans? - answers> Computerized and standardized care plans may cause

you to lose some creativity, intuition, insight, or caring because it is tempting, when you are busy, to accept the "easy answer" provided by the computer and not go further to think about the unique needs of this particular patient. Figure 5-4 in Volume 1, a patient plan of care for Acute Pain, uses NOC language.

● What outcomes did the nurse choose for this patient? - answers> ●

Pain Control Behavior ● Pain Level

List two indicators for each of the outcomes. - answers> ● Pain Control

Behavior ● Recognizes causal factors ● Uses non-analgesic relief measures ● Uses analgesics appropriately

● Reports pain controlled ● Pain Level ● Oral/facial expressions of pain ● Change in respiratory rate, heart rate, blood pressure ● Restlessness For which outcome does the nurse expect the highest level of functioning to occur after interventions? (Note that in this care plan the measuring scale has been applied to the outcomes rather than to the indicators.) -

answers> Pain Control Behavior

Rationale: It has higher numbers than Pain Level. List at least eight questions you could use to critically evaluate the quality

of your goal/outcome statements. - answers> Questions to ask include

the following: ● For each nursing diagnosis: Is there at least one goal that, when met, would demonstrate problem resolution? That is, does at least one goal flow from the problem clause? ● For each nursing diagnosis: Are the predicted outcomes adequate to completely address the nursing diagnosis? ● For each expected outcome: ● Is the outcome appropriate for the nursing diagnosis? ● Is each outcome derived from only one nursing diagnosis? ● Does each outcome describe only one patient response or behavior? ● Is the outcome stated as a patient behavior, not a nurse activity? ● Is the outcome stated in positive, rather than negative, terms? ● Is the outcome measurable or observable? ● Are the performance criteria specific and concrete? Avoid words like normal, sufficient, enough, more, less, adequate, increased. ● Does each goal include all the necessary parts? ● Is the expected outcome realistic and achievable by this patient, given the available resources? ● Does the outcome conflict with the medical or other collaborative treatment plan? ● Does the patient, family, or community value the outcome? ● Does the goal conflict with any religious or cultural values?

What is the body's most usable energy source - answers> Carbohydrates,

especially glucose, provide the most usable energy. Which nutrient's primary function is growth and repair of tissue? -

answers> The primary function of dietary protein is the growth and repair

of body tissues. Secondarily, proteins attract water in the bloodstream and contribute to regulating fluid-balance in the body. They function as buffers for regulating acid-base balance. Proteins are a secondary energy source. They are also involved in immune defense.

Identify five functions of adipose tissue (body fat). - answers> Answers

may include any of the following functions of body fat: ● Energy supply ● Thermal insulation ● Vital organ protection ● Nerve impulse transmission ● Tissue membrane structure ● Cell metabolism ● Essential precursor substances ● Which type of vitamin requires daily consumption to maintain appropriate

levels? - answers> Water-soluble vitamins require daily intake because

they are eliminated in the urine with little storage in the body. ● What distinguishes a major mineral from a trace mineral? -

answers> Major minerals are those needed in amounts of 100 mg or

greater per day. Trace minerals are essential, but needed in lower amounts.

● Identify at least four functions of water. - answers> Water has the

following functions: ● Solvent. Water is the basic solvent for the body's chemical processes, assisting in the regulation of nerve impulses and muscle contractions. ● Transport. Circulating as blood, water serves a medium for transporting oxygen, nutrients, and metabolic wastes. ● Body structure and form. Water "fills in the spaces" in body tissues (e.g., in muscle) providing structure and form to the body.

● Temperature. Water helps maintain body temperature and creates the necessary environment and temperature for cellular metabolism to occur. When body temperature rises, evaporation of sweat helps cool the body. ● List at least three nutrients that may be more difficult to supply with a

vegetarian diet. - answers> Nutrients more difficult to supply with a

vegetarian diet are vitamin B12, protein, calcium, iron, zinc, and vitamin D. Vegans must supplement these nutrients and calcium or consume foods fortified with them. ● When selecting a program for weight loss, what factors should a person

consider? - answers> One should consider whether a diet is nutritionally

and scientifically sound. For example, is it recommended by a respected organization, or is it a fad diet? Moderate calorie-restriction diets such as the American Heart Association diet describe food selection and preparation tips and other behavior modifications that can lead to slow, sustained weight loss, promote a diet that includes a variety of food choices and a balance of nutrients, and encourage physical activity as a cornerstone of weight loss. In contrast, fad diets often promise quick and dramatic weight loss, limit the range of foods from which the dieter can select, often recommend consuming supplements and/or specialized packaged meals, or include no practical strategies that help dieters permanently change eating and activity patterns. ● Why should you encourage clients from various cultures to follow their

traditional diets? - answers> Traditional diets of many cultures are healthy

and honor and respect family or cultural traditions. Adaptations made to these diets have compromised the nutritional quality. ● Describe the effects on nutrition of (a) smoking and (b) heavy alcohol

use. - answers> The effects on nutrition are as follows:

● Smoking. Smokers use Vitamin C faster than nonsmokers. Even children exposed to secondhand smoke tend to have lower plasma levels of ascorbate than unexposed children (Aghdassi, Royall, & Allard, 1999; Preston, 2003). If the person cannot quit smoking, a vitamin C supplement may help compensate. ● Alcohol. A 12-oz beer contains 150 kcal; a juice-based cocktail contains about 160 kcal. Such drinks can add many unnecessary calories to the regular diet. In addition, alcohol significantly decreases the rate of fat

metabolism, contributing to obesity. Excessive alcohol use interferes with adequate nutrition by (a) replacing the food in the person's diet, (b) depressing the appetite, (c) decreasing the absorption of nutrients by its toxic effects on intestinal mucosa, and (d) impairing the storage of nutrients. People who use alcohol heavily will need multivitamin supplements, especially rich in B vitamins and folic acid. ● Identify at least 10 physical examination findings that would lead you to

suspect nutritional problems. - answers> Answers may include any of the

following examination findings: ● An increase in temperature ● An elevated BP may be related to fluid volume excess; a low BP may be a sign of dehydration. Heart rate usually responds in an inverse fashion. ● A BMI less than18 or greater than ● An appearance of illness ● Poor skin turgor ● Poor wound healing ● Constipation ● Any areas of warmth or erythema require investigation ● Red, swollen skin lesions, excessive bleeding and xerosis ● Abnormal nail findings ● Hair that grows slowly, is thin, or easily breaks ● Irritation of the mouth, teeth, and gums ● Facial paralysis or drooping of one side of the face ● An enlarged thyroid gland ● Bounding pulses or a weak, thready pulse ● Edema ● An abdomen that is scaphoid or concave, round to protuberant, or generally enlarged ● Hyperactive or hypoactive bowel sounds ● Thin extremities with excess skinfolds ● Enlarged skinfold measurements ● Joint swelling, deformities, or limitation in range of motion ● Joint pain on palpation or with movement ● Cognitive deficits or severe psychiatric disorders ● Motor or sensory deficits ● Confusion, weakness, or diminished reflexes

● What factors would lead to poor wound healing? - answers> Factors

contributing to diminished healing are insufficient intake of protein, vitamin C, and zinc. ● When is enteral nutrition the preferred alternative feeding? -

answers> Enteral nutrition is the preferred method of feeding for a patient

with a functioning intestinal tract who is unable to meet his nutritional needs through oral intake.

● Identify and describe the types of enteral nutrition tubes. - answers> ● A

nasogastric (NG) tube terminates in the stomach. ● A nasoenteric (NE) tube terminates in the small intestine. ● A gastrostomy tube (G-tube), percutaneous gastrostomy tube (PEG) tube, jejunostomy tube, or G-button is inserted into the stomach or jejunum, respectively, through the skin and abdominal wall. ● A percutaneous jejunostomy (PEJ) tube is inserted into the stomach through the abdominal wall and advanced into the jejunum.

● List four tube placement verification techniques. - answers> Tube

placement can be verified by the following techniques: ● Radiography, which is the most reliable method ● Aspiration of contents and inspection for color ● Measuring the pH of the aspirate ● Injecting air into the tube while auscultating the stomach ("whoosh test") ● Serial observations and assessments. These include observing for respiratory distress, inspecting aspirate for color and consistency, measuring the residual volume of the aspirate, and measuring the tube that extends outside of the body. ● When observing for respiratory distress you might note difficulty breathing, coughing, choking, or cyanosis. Absence of these symptoms is not a reliable indicator of correct placement, but the presence of these symptoms is a strong indicator that the tube is in the respiratory tract. ● Inspecting the aspirate may help distinguish placement through observation of a brown, white, or greenish color and curdled consistency for gastric contents and a more yellow (bile) color with no curdling for intestinal contents. ● When evaluating residual volumes, note that gastric volumes will generally be larger than intestinal or esophageal volumes.

● If the tube is not well secured, it may migrate either up or down, and so a consistent measurement of the external tube may also help verify tube placement (Peter & Gill, 2009). ● Other bedside verification methods. Capnometry and additional tests of gastric juices may also serve as measures to ensure that the tube is correctly placed. ● Capnometry tests for carbon dioxide (CO2). The presence of CO2 with the placement of an NG or NE tube would indicate that the tube has been placed in the respiratory tract. This method is best used at the time of tube placement. For a photo of a CO2 detector Go to Chapter 26, Figure 26-12 , in Volume 1. ● Measuring biliru Review problem status (actual, potential, or possible nursing diagnosis; collaborative problem; or wellness diagnosis) in Chapter 4. For which

type(s) of problem would you write: - answers> ● Nursing orders for

observation/assessments? Answer: All problems ● Nursing orders for treatments? Answer: Primarily for actual nursing diagnoses and collaborative problems ● Nursing orders for health promotion interventions? Answer: Wellness diagnoses ● Preventive nursing orders? Answer: Actual and potential nursing diagnoses and collaborative problems Describe a five-step process for generating and choosing nursing

interventions. - answers> 1. Review the nursing diagnosis. Nursing orders

should flow from the etiology and sometimes from the problem side of the diagnosis.

2. Review the desired patient outcomes. Outcomes suggest nursing strategies that are specific to the individual patient.
3. Identify several interventions/actions that might achieve the desired outcomes for the nursing diagnosis.
4. Choose the best interventions for this patient—those expected to be most effective in helping to achieve client goals.
5. Individualize the standardized interventions to meet the unique needs of the patient.

List the five components of a nursing order. - answers> Date, subject,

action verb, times and limits, signature

● What is a normal defecation pattern? - answers> There is a wide range

of "normal." The frequency of BMs may range from several times per day to once per week. Bowel function may be regarded as normal as long as stools are passed without excessive urgency (needing to rush to the toilet), with minimal effort and no straining, without blood loss, and without the use of laxatives.

● Identify the factors that affect bowel elimination. - answers> The

following factors affect bowel elimination: ● Age ● Stress ● Dietary intake ● Fluid intake ● Activity ● Medications ● Surgery ● Anesthesia ● Pregnancy ● Pathological conditions (e.g., food allergies and intolerances, diverticulosis, diverticulitis) ● What changes in bowel elimination are associated with constipation?

With diarrhea? - answers> The following changes in bowel elimination are

associated with these conditions:

● Constipation is a decrease in frequency of BMs. As the length of time between BMs increases, more water is reabsorbed from the feces. As a result, constipation is also associated with passage of dry, hard stool that requires more effort to pass. ● Diarrhea is an increase in the frequency of BMs. As transit time through the colon decreases, less water is reabsorbed and stools are often watery.

● Why are bowel diversions performed? - answers> A bowel diversion is

a surgically created opening for elimination of digestive waste products from the bowel. This procedure is performed for clients with a variety of conditions, including cancer, ulcerations, trauma, or inadequate blood supply. Temporary diversions are performed to allow healing of the distal portion of the bowel; permanent diversions are performed in instances of severe disease or trauma when the bowel is necrotic or cannot be salvaged. ● What determines the nature of the effluent from a bowel diversion? -

answers> The effluent may range from liquid to solid depending on the

part of the bowel that is being diverted. The lower in the bowel the colostomy is placed (i.e., the closer to the rectum and anus), the more solid the effluent. Because the fecal matter stays in the bowel longer, more water can be absorbed from it, and it becomes more solid. ● What should you discuss with your client when performing a nursing

history focused on bowel elimination? - answers> The following items

should be part of a nursing history focused on bowel elimination: ● Normal bowel pattern ● Appearance of stool ● Changes in bowel habits or stool appearance ● History of elimination problems ● Use of bowel elimination aids, including diet, exercise, medications, and remedies For a list of questions that you may use to assess each of these areas, go to Chapter 28 of Volume 2, Assessment Guidelines and Tools, Focused Assessment: Bowel Elimination. ● Describe the physical assessment you would perform for a client with

constipation. - answers> Physical assessment for bowel elimination

includes examination of the abdomen, rectum, and anus.

● Recall that in abdominal assessment, the order of the exam is inspection, auscultation, percussion, and palpation. ● Observe the size, shape, and contour of the abdomen, and listen to bowel sounds. ● Percuss and palpate the abdomen for tenderness, presence of air or solid, and presence of masses. ● Inspect the anus for signs of hemorrhoids. ● Depending on the policies of your institution as well as your skill with assessment, you might also palpate the anus and rectum for the presence of stool or masses. ● How can you help a patient adapt psychologically to living with a bowel

diversion? - answers> The following nursing interventions help a patient

adapt psychologically to a bowel diversion (other answers are possible): ● Being willing to talk with a patient about his reaction to the stoma and concerns about living with an ostomy ● Taking a caring approach when providing stoma care ● Allowing adequate time for the patient to learn about self-care ● Coordinating a visit by a volunteer from the United Ostomy Association ● Providing information about a community support group of people living with an ostomy or other bowel diversion

● What does a healthy stoma look like? - answers> A healthy stoma is

colored from deep pink to brick red regardless of skin color and is shiny and moist at all times. The stoma will protrude above the level of the abdomen by approximately 0.5 to 1.0 inches.

● Why is skin care around a stoma so important? - answers> Skin care

around a stoma is essential to prevent skin breakdown, which may lead to infection, discomfort, and leakage of ostomy output from around the appliance. ● What are some reasons that a client may not follow a recommended

treatment regimen? - answers> A client may not follow a treatment

regimen because of the following reasons: ● The person might not understand the treatment. ● The person might not understand the reasons for/importance of the treatment. ● The person may have cultural objections to the treatment.

● The person's lifestyle may interfere; he may not be willing to change his lifestyle. ● Fear of failure. ● Reluctance to ask questions because of fear that the nurse/physician will think he should know the answers or of reluctance to bother a busy professional. ● Lack of resources (e.g., money to buy pills, transportation to a clinic). ● List at least four things you could do to promote client participation in care and/or adherence to recommendations for treatment. -

answers> The following actions promote client participation:

● Assess the client's knowledge about her illness and the treatments, and provide the necessary information ● Assess the client's supports and resources ● Be sensitive to the client's cultural, spiritual, and other needs and viewpoints. ● Realize and accept that some attitudes cannot be changed. ● Determine the client's main concerns. ● Determine the client's priorities. ● Help the client to set realistic goals.

● List the "five rights" of delegation. - answers> These are the "five rights"

of delegation: ● Right task ● Right circumstance (patient) ● Right person (personnel) ● Right direction/communication ● Right supervision ● List at least four characteristics of a "right task"—that is, a task it would

be acceptable to delegate. - answers> Characteristics of a "right task" to

delegate include the following: ● Within the nurse's scope of practice to perform and delegate, as defined by the state nurse practice act ● Within the LVN/LPN or NAP's scope of practice ● In accordance with agency policies, if they exist ● Does not require complex observations or critical decisions ● Is performed according to a set procedure and requires little innovation ● Does not require repeated nursing assessments

● Occurs frequently in the daily care of patients on the unit ● Has reasonably predictable results ● Does not require independent, specialized nursing knowledge, skills, or judgment ● Is not health teaching or counseling ● As an RN, how could you establish that a NAP is competent to perform a

task? - answers> These actions would establish whether a NAP is

competent to perform a task: ● Check facility records for documented proof that the person has demonstrated competence. ● Find out how often the NAP has performed the task. ● Find out whether the NAP has worked with patients with similar diagnoses. ● Observe and evaluate the NAP's performance. ● List at least three ways to help assure that the NAP will understand

clearly when you delegate a task. - answers> These actions help assure

that the NAP will understand a task: ● Explain exactly what the task is, including what to do and what not to do. ● Include specific times and methods for reporting. ● Explain the purpose or objective of the task. ● Describe the expected results or potential complications to expect. ● Be specific in your instructions. ● List at least three things you should do when providing supervision to an

unlicensed caregiver. - answers> Supervisory activities should include the

following: ● Monitor the person's work to be sure it complies with agency policies and procedures and standards of practice. ● Intervene, if necessary. Perhaps demonstrate caregiving activities. ● Obtain and provide feedback from the worker. ● Give positive, as well as negative, feedback often. ● If the NAP's performance was not acceptable, communicate privately with the NAP. ● Evaluate client outcomes. ● Ask the client for input after the care is given. ● Ensure proper documentation.

Using the following outcomes and reassessment data, determine whether

each goal has been met, partially met, or not met. - answers> Goal: By

8/24, will walk, unassisted, to the end of the hall without pallor or shortness of breath. Reassessment Data: 8/24 Walked, unassisted, to end of hall; states no shortness of breath, but skin color was noticeably pale. Answer: Partially met. Two desired responses were seen, but one (no pallor) was not. Goal: By 8/24, will walk, unassisted, to the end of the hall without pallor or shortness of breath. Reassessment Data: 8/23 Walked, unassisted, to end of hall. Skin color pink, respirations 14/min, no dyspnea observed, states no shortness of breath. Answer: Met. All desired outcomes were seen. Goal: By 8/24, will walk, unassisted, to the end of the hall without pallor or shortness of breath. Reassessment Data: 8/25 Walked halfway to end of hall before becoming pale and short of breath. Answer: Not met. It is 1 day past the target time of 8/24, and the patient was unable to walk the desired distance; both pallor and shortness of breath occurred.

● Identify the major structures of the urinary system. - answers> The

urinary system comprises the following major structures: ● Two kidneys ● Two ureters ● Bladder ● Urethra

● What are the functions of the kidneys? - answers> Kidneys have the

following functions: Primary functions ● The kidneys filter metabolic wastes, toxins, excess ions, and water from the bloodstream and excrete them as urine.

● The kidneys also help to regulate blood volume, blood pressure, electrolyte levels, and acid-base balance by selectively reabsorbing water and other substances. Secondary functions ● Produce erythropoietin ● Secrete the enzyme rennin ● Activate vitamin D3 (calcitriol)

● Briefly describe how urine is formed. - answers> Urine is formed in the

nephrons. The renal arteries bring blood to the kidneys and into the glomeruli. Blood pressure forces plasma, dissolved substances, and small proteins out of the porous glomeruli into the Bowman's capsule to form a liquid called filtrate. The filtrate moves from Bowman's capsule into the tubular network of the nephrons where 99% of the fluid is reabsorbed. About 1% of filtrate returns, as urine, to the collecting tubule, which transports it into the ureters. ● What role do the ureters, bladder, and urethra play in urinary elimination?

• answers> The structures of the urinary system have the following roles: ● The ureters transport urine from the kidneys to the bladder. ● The bladder stores urine until it is excreted. ● The urethra transports urine from the urinary bladder to the body exterior. ● What quantity of urine in the bladder will stimulate the urge to void? -

answers> Approximately 200-450 mL of urine in adults (50-200 mL in

children) are sufficient to stimulate the urination reflex. Less may be required in older adults. ● Identify at least three methods for determining whether hydration is

adequate and urine output is within normal limits. - answers> Methods for

determining if hydration is adequate and urination is normal include the following: ● The person voids 1,500 mL in a 24-hour period in five to six voids. ● An infant has 8-10 wet diapers per day. ● For most adults, pale to clear urine indicates adequate hydration. ● What common medications increase the amount of urine voided? -

answers> Diuretics increase urine output.