Rasmussen Fundamentals Final Questions with Complete Verified Solutions 2024/2025, Exams of Nursing

Download Rasmussen Fundamentals Final Questions with Complete Verified Solutions 2024/2025 and more Exams Nursing in PDF only on Docsity! Rasmussen Fundamentals Final Questions with Complete Verified Solutions 2024/2025 What are different tools to assess pain? 1-10 scale, face scale When is a patient's pain level tolerable? When they say it is How soon after giving a pain medication should you reassess a patient's pain level? IV - 30min or less, PO - 30min-1hr What are standard precautions used for? Every patient What is droplet precautions used for? Flu, RSV, Pertussis, R/O Meningitis A patient with pneumonia pneumonia is on which type of precaution? Standard - however is the patient is coughing everywhere use droplet as needed Which diseases are droplet precautions used for? Chicken pox, TB, Measles When must you use soap and water to wash hands instead of an alcohol gel/foam? When hands are visibly soiled What is a normal WBC? 4,500-12,000 What is a stage I pressure ulcer? Nonblanchable redness What is a stage II pressure ulcer? Partial thickness loss or a blister What is a stage III pressure ulcer? Full thickness loss, sub fat ay be visible What is a stage IV pressure ulcer? Full thickness loss, able to see tendon, muscle, or bone How is 0+ pitting edema classified? No edema How is 1+ pitting edema classified? Mild pitting edema, 2mm depression disappears rapidly. How is 2+ pitting edema classified? Moderate pitting edema, 4mm depression disappears 10-15sec How is 3+ pitting edema classified? Moderately severe pitting edema, 6mm depression, disappears in 1min. How is 4+ pitting edema classified? Severe pitting edema, 8mm of depression that can last up to 2min. What are s/s of dehydration? Delayed skin turgor, crack/peeling lips, flaking skin What is the difference when wound is infection vs. colonized? An infected wound shows signs and symptoms (redness/warm to touch), while a colonized wound does not show s/s, but has the bacteria present. What symptoms can occur if the circadian rhythm is interuppted? Memory loss, confusion, irritability, slow metabolism, weight gain, anxiety If the REM cycle is interrupted, what happens? It starts over When is TypeI Diabetes commonly diagnosed? Age 4-7 and 10-14 How does Type I Diabetes occur? Usually the child has a bad infection that causes the pancreas to stop producing insulin, making them diabetic When is Type II Diabetes commonly diagnosed? Middle age to older What are signs and symptoms of diabetes? 3 P's (polydipsia, polyuria, polyphagia) Which races are at a higher risk for diabetes? African american and hispanic What are some risks for diabetes? Obesity, a sedentary lifestyle, family history, history of gestational diabetes, carrying weight in the abdomen, poor diet What is an A1C? Average glucose for the past 3mo, should be less than 7%. What is necessary for diabetes to be diagnosed? A fasting glucose Absorption Elimination What are the phases of wound healing? Hemostasis (immediately after injury, blood vessels constrict, swelling occurs) Inflammatory (last 4-6days, WBCs move in, macrophages enter the wound) Proliferation (begins 2-3d post injury and lasts up to 3wks, new tissue is built) Maturation (3wk-6mo, collagen is remodeled and formed, scar is a thin, flat, white, line) What factors affect wound healing? Desiccation (dehydration) Maceration (overhydration) Trauma Edema Infection Excessive bleeding Necrosis (death of tissue) Presence of biofilm (thick grouping of microorganisms What are some wound complications? Infection Hemorrhage Dehiscence and evisceration Fistula formation What is the difference between wound dehiscence and evisceration? In wound dehiscence the muscle remains intact, but in evisceration the muscle opens and intestines can fall out of the body What are the QSEN core competencies? Patient-Centered Care Teamwork & Collaboration Evidence Based Practice Quality Improvement Safety Informatics What is client centered care? Care based on the patient's needs, values, and preferences What are treatments for diabetes? Insulin, medication (Metformin), diet, exercise, dialysis when kidneys fail, kidney AND pancreas transplant (must be together) What are complications of diabetes? Neuropathy, parathesia, renal failure, infection, poor wound healing, vision problems, cardiac issues A patient requests that all 4 side rails be raised at night, is this a form of restraint? No. Having 4 side rails up is only a restraint when not requested by the patient. What are some aspiration precautions? Feed small amounts of food. Seat patient fully upright Do not force feed Provide oral care before and after meals Never put food or fluids in the mouth of a patient who is not fully alert. Crush pills and put them in soft food such as pudding or applesauce What are some fall precautions? Decrease clutter in patient room Round regularly on patients Use chair/bed alarms Fall bands Educate patient on call light use What is therapeutic communication? The process of interacting that focuses on advancing the physical and emotional well-being of a patient What is interpersonal communication? Communication between 2 or more people What is intrapersonal communication? Self-talk What is group communication Communication within a small group What are some factors that can effect the urinary system? Food and fluid intake can affect urine amount, concentration, color and odor Psychological variables Activity and muscle tone can be lost with stress and use of urinary catheters Pathologic conditions (kidney disease, hypertension, diabetes, gout, etc., all affect the quantity and quality of urine produced How do you promote normal urination? Maintaining normal voiding habits Promoting fluid intake Strengthening muscle tone Assisting with toileting Who is at risk for a UTI? Sexually active women (migration of bacteria during intercourse) Women who use diaphragms for contraception (spermicide decreases normal protective flora) Postmenopausal women (urinary stasis, decreased estrogen contributes to loss of protective flora) Individuals with indwelling urinary catheter (80% of UTI's occur in individuals with catheters) Individuals with diabetes mellitus (glucose in urine is great medium for bacteria to reproduce) Older adults (aging, see previous) When can a catheter be used? Relieving urinary retention Obtaining a sterile urine specimen Obtaining a urine specimen when usual methods can't be used Emptying bladder before, during, or after surgery Monitoring critically ill patients Increasing comfort for terminally ill patients What does the small intestine do? Secretes enzymes that digest proteins and carbohydrates Responsible for digestion of food and absorption of nutrients into the bloodstream What are the different parts of the small intestine? Duodenum, jejunum, ileum What does the large intestine do? Absorption of water Formation of feces Expulsion of feces from the body What is peristalsis? A contraction that occurs every 3 to 12min that moves the stool through the intestines. What muscles are used in defecation? Muscles of abdominal wall Diaphragm Pelvic floor Thigh muscles When a patient bears down while having a bowel movement, what can happen? They can have a syncopal episode - bearing down can constrict the aorta and decrease blood flow What can effect normal bowel elimination? Developmental considerations Daily patterns Food and fluid Activity and muscle tone Lifestyle