RN-BC: Medical-Surgical Certification Review examinations with verified answers, Exams of Nursing

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RN-BC: Medical-Surgical Certification Review

examinations with verified answers

Nursing Code of Conduct - Correct Answer • Participating in intra-professional collaboration

• Avoiding conflicts of interests
• Maintaining respect for human dignity
• Integrating professional values with personal values The Code of Ethics from the American Nurses Association (ANA) states in point 5.3: "Nurses have both personal and professional identities that are neither entirely separate, nor entirely merged, but are integrated. In the process of becoming a professional, the nurse embraces the values of the profession, integrating them with personal values. Duties to self involve an authentic expression of one's own moral point-of-view in practice. Sound ethical decision-making requires the respectful and open exchange of views between and among all individuals with relevant interests." Nursing Ethics - Correct Answer Ethics: moral principles that govern behavior; ideal, standards Principles:
• Autonomy: duty to allow patient to make independent decisions
• Veracity: duty to tell the truth
• Fidelity: duty to keep promises and commitments
• Justice: duty to provide equal and fair distribution of resources
• Beneficence: duty to promote good and take positive actions

• Nonmaleficence: duty to do no harm and avoid negative actions
• Confidentiality: duty to keep some information from disclosure without consent
• Privacy: duty to protect physical body or information from unauthorized view Ethical Dilemmas - Correct Answer Issues surrounding quality-of-life, end-of life, and DNR orders most often trigger ethical dilemmas, when no clear course of action is apparent. Obtain a referral to ethics committee for disagreements about treatments:
• Between family members
• Among healthcare providers
• Between healthcare providers and the patient or family Advocacy - Correct Answer What it is: action or series of actions that argues for, speaks in favor of, recommends, or supports another person, place, or thing Nursing Advocacy:
• Integrates individuality, professionalism, and empowering
• Involves a process of analyzing, counseling, responding, and shielding An effective nursing advocate actively participates in supporting patients' wishes and needs through listening, educating, and collaborating. The ANA 2001 Code of Ethics includes:
• The nurse's primary commitment is to the patient, whether an individual, family, group, or community.
• The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. (ANA, 2001) Kubler-Ross Stages of Grief - Correct Answer Patients, families, and other caregivers can progress through these stages.
• Denial: avoiding the inevitable

• Anger: expressing emotions previously bottled-up
• Bargaining: trying to find a way out
• Depression: acknowledging the inevitable
• Acceptance: moving forward Leadership Styles - Correct Answer Autocratic: unilateral, dictatorial, works toward single goal; meets resistance from mature, experienced staff Democratic/participative: team approach, staff participation, retains responsibility for outcome Laissez-faire: little control; leaves decision to others; works well with committed, motivated staff who can analyze well Charismatic: trigger emotional response; eloquent communicator and persuader Transformational: connection between leader and follower increases motivation for problem - solving Transactional: compliance via reward/ punishment system Quantum: flexible, non-controlling, analytical, empathetic, visionary team player Situational/Contingency: match style to situation; high-stress situations are best handled by task-oriented leaders; moderate situations are best handled by relationship-oriented leader Shared Governance - Correct Answer What it is:
• A model of nursing practice designed to improve work environment, satisfaction, and nurse retention
• Champions staff as most important asset of organization
• Encourages autonomy, empowerment, involvement, and participation
• Teams and groups are designed to be self-led and self-managed Nursing Application: Bedside nurses are given equal footing with managers and leaders in the creation of policies, procedures, and other decision-making processes that

directly affect nursing practice within the organization. Adult Learning - Correct Answer The education process should reflect the nursing process (assess, plan, implement, evaluate)

• Multiple sensory avenues for learning increases learning and retention.
• Doing and saying (teach-back) is more effective than reading and hearing.
• Learning needs: patient goals met through instruction
• Non-learning needs: patient goals met through something other than instruction or in combination with instruction Basic Learning Styles:
• Visual: reading instructions or watching demonstration
• Hearing: listening to instructions while performing
• Tactile: hands-on Learning Barriers - Correct Answer Physical Impairments: inadequacies of the five senses; impaired mobility
• Cognitive: mental disability or impairment; dyslexia, phobias
• Language: aphasic; lack of fluency, reads at less than 8th grade level
• Emotional: fear/superstitions, anxiety, depression
• Religious/cultural: values differ, beliefs focus on healing from a higher power, dietary restrictions
• Financial: patient perception that they are unable financially to follow recommended plan of care Teaching Strategies—Adults - Correct Answer Assess: mental and physical capabilities, perception of the problem, preferred learning style Plan: establish mutual goals with patient that are specific, practical, attainable, relevant, and culturally sensitive Intervene: use multiple methods to enhance learning; ensure methods use vocabulary suited to learner's comprehension
• Oral, written, or electronic information via internet

• Visual/pictorial information such as DVDs and charts
• Demonstration and return demonstration
• Peer learning
• Group work Evaluate: observe the patient/family implement new skills, request a "teachback" from the patient; assess comments and conversations for misinformation or gaps in learning Maslow's Hierarchy of Needs - Correct Answer Physiological: basic needs such as air, water, food, shelter, and freedom from pain (comfort) Safety: free from harm or threat of harm; stability Love/Belonging: friendship, acceptance, affection; support system Esteem: self-respect, self-confidence, rewarding work/relationships Self-actualization: truth, justice, beauty, personal growth, "born to do" These drives (needs) are met in order from physiological to self-actualization. Illness can change a patient's focus to meeting basic needs as the priority. Nursing Diagnoses, Domains - Correct Answer NANDA-II taxonomy, 13 Domains ( Classes, 216 Diagnoses)
• Activity/Rest
• Comfort
• Coping/Stress Tolerance
• Elimination
• Growth/Development
• Health Promotion
• Life Principles
• Nutrition
• Perception/Cognition
• Role Relationships
• Safety/Protection

• Self-perception
• Sexuality Nursing Diagnoses, Format - Correct Answer Diagnosis: (example) Imbalanced nutrition: Less than body requirements Related to: (example) Insufficient caloric intake Evidenced by: (example) Weight loss Expected Outcomes: (example) The patient will achieve and maintain adequate weight (use NOC terminology) Nursing Interventions (independent/collaborative): Use words such as assess, monitor, teach, assist, provide, and record. For collaborative, use words such as obtain consult and administer medications, tube feedings, etc. (refer to NIC terminology) Evaluation: (example) The patient achieves and maintains optimal weight. Nursing Intervention Classification - Correct Answer What it is: A list of 554 interventions (in 2013 6th ed.) that nurses perform; includes direct, indirect, collaborative, and independent interventions that address both physiologic and psychosocial aspects of patient care. Interventions fall into three categories: illness prevention, illness treatment, and health promotion. Nursing Application: The standardized language of these interventions should be used when creating patient care plans. The interventions are sorted into 7 domains: Physiological: basic, Physiological: complex, Behavioral, Safety, Family, Health System, and Community. Nursing Outcomes Classification - Correct Answer What it is: A system which describes patient outcomes sensitive to nursing intervention; includes 490 outcomes in the 5th edition (2013); a means of standardizing nursing language used in the nursing process, similar to NANDA for diagnoses, and NIC for nursing interventions, NOC language is for outcomes

Nursing Application: The use of NOC outcomes provides a standardized, measurable terminology that all health care providers can understand and use. These outcomes are used when formulating care plans, and are individualized to each patient by the addition of "indicators." Each indicator is ranked from 1 (extremely compromised/severe) to 5 (not compromised/ none) based on patient presentation. Problem Prioritization - Correct Answer What it is: A means of focusing nursing interventions on the most important patient problems; usually follows Maslow's Hierarchy and the ABCDE mnemonic. Nursing Application: Once immediate ABC needs are met, the patient and family should participate in formulating the plan of care, including prioritization. What a nurse perceives as a priority may not be a priority in the patient's mind. Assess the patient's thought processes through therapeutic communication, and determine a course of action "with" the patient (not "for" or "to"). Collaboration with the primary practitioners and therapists will further support autonomy while promoting excellent patient care (as defined by the patient). Collaboration - Correct Answer What it is: A dynamic process that produces a synthesis of perspectives and shared responsibilities to address a problem set that cannot be handled by a single individual Nursing Application: The team approach is essential to patient care. Collaboration among patients, families, practitioners, nurses, therapists, technicians, and others leverages group thought and resources to manage complex patient care through all levels of health. Successful collaborators understand their own biases, know how to manage diversity, can resolve conflicts constructively, have interpersonal skills, understand values of other team members, and are able to maintain focus on meeting the patient's needs instead of exercising power plays to their own advantage.

Core Measures - Correct Answer Standards of care that improve patient care and outcomes

• Data is submitted to CMS (Medicaid/ Medicare) and TJC
• Includes reports on diseases/conditions seen, hospital-acquired conditions, Emergency Department (ED) care, and the Surgical Care Improvement Project (SCIP) Diseases:
• Acute MI
• Heart failure (HF)
• Pneumonia (PN)
• Venous thromboembolism (VTE)
• Stroke (STK)
• Children's Asthma Care (CAC) Core Measures: Reportable HospitalAcquired Conditions - Correct Answer Foreign object retained after surgery
• Air embolism
• Blood incompatibility
• Stage 3 and 4 pressure ulcers
• Falls and other traumas
• CAUTIs (urinary catheter infections)
• Vascular catheter-associated infections
• Manifestations of poor glycemic control
• Surgical site infections (CABG, ortho, bariatrics)
• DVT and PE after ortho procedures Core Measures: Prevention - Correct Answer Core Measures also address prevention. Sets of data collected are listed.
• Immunization (IMM): pneumococcal immunization rates for overall, age 65+, and high- risk groups ages 5 - 65; influenza immunization rates
• Tobacco Cessation (TOB): screening, treatment provided or offered, treatment, treatment provided or offered at discharge, treatment at

discharge, and assessing status after discharge

• Substance Abuse (SUB): alcohol screening, alcohol brief intervention provided or offered, alcohol brief intervention, alcohol and other drug use disorder treatment provided or offered at discharge, alcohol and other drug use disorder treatment at discharge, assessing status after discharge Health History Components - Correct Answer Biographical info (demographics): patient registration form, psychosocial data
• Chief complaint (CC): reason for visit; patient's exact words; include how long complaint has been going on (i.e., "belly's been hurting for two days")
• Health History (HPI, Hx): more details about chief complaint; progression of symptoms; include onset, duration
• Past Medical Hx: childhood to adult, meds, foods, habits (ETOH), herbal remedies, sexual hx
• Family Hx: notable medical conditions of parents, siblings, and grandparents
• Review of Systems: head to toe, identify health concerns that may not have already been discussed, any problems with ADLs HPI Details - Correct Answer Under HPI (history of present illness), include the following: Onset—"when" Duration—"how long" Location—"where" Quality—"what type" Quantity—"how many/much" Precipitating Factors—"what makes it worse" Alleviating Factors—"what makes it better" Can also use PQRST: Provocative/palliative, Quality/quantity, Region/radiation, Severity/pain, Timing Allergies/Sensitivities - Correct Answer Remember, any substance has the potential to cause a reaction. Ask about:
• Foods: eggs (vaccinations), shellfish (iodine), peanuts, lactose intolerance, meat (vaccinations and insulin)

• Medications: especially the ones used to TREAT allergic reactions (antihistamines, H blockers, steroids, etc.)
• Herbs and supplements: any reactions to OTC formulas
• Environmental: cleaning chemicals, soaps or detergents, pollen, perfumes, bees
• Family Hx: any medication or food allergies in immediate family; helps identify potential risks if the patient has yet to be exposed to certain medications in his lifetime
• Anything else that 1) causes a rash or itching, or 2) causes difficulty breathing Medication Allergies - Correct Answer Penicillins: MAY tolerate 2nd/3rd generation cephalosporins, use with caution; also use aminoglycosides, quinolones, macrolides, and tetracyclines
• Cephalosporins: Avoid any of the "Cef-" or "-ceph-" meds (ceftriaxone, cefixime)
• Sulfa: avoid any of the "sulfa-", "zulf-" meds, combination ABx (Septra, Bactrim), dapsone, and suspect other sulfonamides such as glyburide, glimepiride, celecoxib, sumatriptan, furosemide, and HCTZ; HIV patients may have increased sensitivity to sulfa meds
• Iodine: use caution with contrast dyes for those with iodine or shellfish allergies; can pretreat with steroids and/or antihistamines to reduce risk of reaction
• Morphine (rarely a true allergy): avoid opiates and semi-synthetic opiates (hydro- /oxycodone, hydromorphone, buprenorphine); treat with synthetic opiates (fentanyl, methadone, tramadol, meperidine) if possible •Benadryl: use an alternate histamine suppressor (H2 blocker, epi pen)
• Lidocaine: may be a contact or systemic allergen; avoid amide meds; instead use ester group meds (benzocaine, procaine, chlorprocaine, tetracaine) aromatic anticonvulsants is highly probable; try non-aromatics gabapentin and levetiracetam (Keppra)
• Insulin: May need to substitute a non-animal sourced insulin for patients who react to pork or other meats Common Age-Related Changes - Correct Answer • Brain: mild cognitive impairment, slower reflexes
• Bones/Joints: weaker bones, worn-down cartilage in joints
• Muscles: decreased strength and coordination, less elastic ligaments

• Eyes: presbyopia, cataracts, macular degeneration, dry eyes, yellowed lens
• Ears: presbycusis, tinnitus, altered spatial orientation and balance, problems hearing high-pitched voices or noises, thick wax and hair growth
• Digestive/Metabolic: diminished taste, weakened sphincters (GERD), lower production of insulin (Type II diabetes), weight gain, constipation, decreased liver and kidney function, decreased aldosterone production
• Urogenital: incontinence, prostatic hypertrophy (BPH)
• Dental: tooth decay, gingivitis, periodontitis
• Skin: wrinkles, dryness, damaged elastin proteins, thinner, age spots, loss of underlying fat, less insulating ability, decreased sweat glands and blood supply
• Hormones: menopause, decreased sex drive, decreased immune function, decreased or altered sleep patterns, decreased muscle mass Psychosocial Assessment - Correct Answer Observed/Visual components: appearance, demeanor, communication style, thought processes, overt behaviors, and reports from family or other practitioners Verbal components: name, birth order in family, adoption, past developmental history, international influences on health/diet, education, occupation, employment status, religious background and current practices, social/intimate relationships, legal concerns, current housing, leisure activities, motivation for health improvement, current resources, personal values. Use open-ended specific questions: "Tell me about...." Delegation - Correct Answer What it is: Process of assigning responsibility or activities to another; usually from a boss or superior to underlings Nursing application: A charge nurse will delegate the narcotics count to two other RNs. An RN will delegate oral medication administration to an LPN. Consider the FIVE RIGHTS of delegation:
• Right task: ensure task is within scope and practice of the person
• Right circumstances: ensure patient's current condition is appropriate

• Right person: ensure task does not exceed skills and knowledge of the person
• Right directions: ensure effective and thorough communication to all involved
• Right supervision/evaluation: ensure follow-up and compliance with policies Therapeutic Interviewing - Correct Answer • Focus on the present, not the past
• Identify alternatives and choices, instead of providing solutions
• Use broad statements or questions, "Is there something you would like to discuss?"
• Use general leads like "yes," "uh huh," "I see," nodding, attentive facial expressions
• Reflect patient statements back to them as a question; use selectively
• Share observations to allow patient to verify or elaborate the meaning of behaviors
• Acknowledge patient feelings; "It must be difficult to...."
• Use silence; used to slow conversation and allow patient time to reflect
• Give information and present reality (helpful with dementia)
• Clarify patient meaning; "I'm not sure I follow...."
• Verbalize implied feelings; "You feel this diet is not benefitting you?"
• Explore further; "Tell me more about...."
• Voice doubt when patient perceptions or expressions are distorted from reality; "Really? That's hard to believe."
• Collaborate with patient; doing things "with" patient instead of "to" or "for"
• Validate (evaluate) outcomes; "Are you feeling better now?" Therapeutic Interviewing Don'ts - Correct Answer DO NOT:
• Use clichés or stereotyped comments; "It will all work out"; "You'll be home in no time"
• Give advice; "You should..."
• Give approval; sets up a standard of acceptability; "You did the right thing."
• Ask "why"; encourages invention of answers on the spot
• Agree; "You must be right"; introduces the nurse's value system
• Disapprove; "Stop worrying"; introduces the nurse's judgment system
• Disagree or challenge; "That's not true"; conveys non-acceptance of patient

communication

• Belittle feelings; "I know how you feel"
• Defend staff; may reinforce patient belief that criticism is valid
• Change the subject; "That reminds me..." Suicide Screening - Correct Answer Look for: depressed mood (or sudden elevated mood after being depressed), unusually fast or slow movements, patient expressions of suicide or finality ("I won't be around to deal with that."), unusual expression of anger Ask about: changes in weight, sleep, or concentration Suspicious behavior: getting affairs in order, giving away personal belongings, obtaining a weapon, increased alcohol or drug use, telling a friend, family or healthcare professional about contemplating suicide, sudden violent behaviors What to do: practice therapeutic interviewing to gather more information about circumstances, suicide plan, and actions already taken; assess patient's ability to keep a meaningful contract; do not leave patient alone, involve the family if patient consents (contact family if under 16), admit for psych eval Tools: Beck Depression Inventory, Geriatric Depression Scale, Hopelessness Scale, Suicide Attempt Self-Injury Review, Suicidal Ideation Questionnaire (SIQ) for ages 13 - 18 or the Columbia-suicide Severity Rating Scale (C-SSRS) Abuse Screening - Correct Answer Look for: expression of fear, anxiety, depression, and/or anger; flat affect; loss of appetite; injuries inconsistent or improbable to story; chronic pelvic pain, headaches, vaginitis, IBS, guarding Ask about: activities or actions of others that make the patient feel uncomfortable, sad, or angry; direct language may also be appropriate Suspicious behavior: repeated visits, erratic attendance at appointments, increased substance abuse, suicidal attempts, heightened startle responses, abnormal distance placed between patient and staff; partner/caregiver hostility, talking for the patient, monitoring patient answers to questions, doesn't leave bedside What to do: ask questions in private; know state laws for reporting abuse (child, elder, disabled); competent adults can decide to report, not report, stay, or leave situation; collaborate for safe housing and support resources

Tools: Woman Abuse Screening Tool (WAST), Abuse Assessment Screen Complementary Therapies - Correct Answer • Cognitive behavioral therapy (CBT): alters perception, increases sense of control, and decreases maladaptive behaviors

• Biofeedback: teaches voluntary control over body physiology
• Relaxation: includes deep breathing, muscle relaxation exercises, and autogenics (use of mantras)
• Imagery: provides a competing cognitive focus that distracts from or controls the present experiences by using internal visualization techniques
• Meditation: Meditation has been shown to reduce stress levels, and regulate the responses of the sympathetic nervous system
• Hypnosis: facilitates modification of perception and memory; reduces cortical activation (pain sensors)
• Nerve stimulators: interfere with nocioceptive (non-nerve-injury-related) pain signals
• Massage: reduces muscle tension and promotes relaxation
• Acupuncture (and other TCM): focuses on balance and energy flow within the body; small needles are inserted along nerve meridians
• Chiropractic care: aims to correct musculoskeletal dysfunction; may parallel physical therapy interventions Herbs and Vitamins - Correct Answer The nurse should obtain the types and amounts of herbal substances used by the patient and inform the healthcare team of the patient's choice so adverse reactions can be avoided. May increase clotting times (stop 10 - 14 days prior to surgery): Ginger, Onion, Garlic (high doses), Ginseng, Gingko Biloba, Vit E (high doses), Feverfew, Red Clover, Willow bark, Arnica, Chamomile, Fenugreek, Papain, Omega- 3 fatty acids (high doses), Dong Quai (list is not exhaustive) May alter medication metabolism:

St. John's wort, milk thistle, ginseng, garlic, licorice, grapefruit juice (but not grapefruit seed extract), cruciferous vegetables, celery, carrots, and caffeine (list is not exhaustive) Homeopathy - Correct Answer What it is: Treatment of disease or symptomology by using very small doses of natural substances that, given in larger amounts, would cause disease symptoms in a healthy person; "like cures like"; assumes that the body has the ability to heal itself. Nursing application: Homeopathy is generally regarded as safe, but is considered by many practitioners to produce results based on the placebo effect. However, the placebo effect remains valuable in concert with conventional medical interventions, and should not be discounted if the patient appears to rely heavily on the tenets of homeopathy. The healthcare team should be made aware of the patient's use. Nutrition Assessment - Correct Answer Deficiency signs and symptoms: Vit A: dry eyes, slow growth rate, increased infections, infertility, VAD anemia Vit B: painful fissured tongue, greasy scaly facial skin, peripheral neuropathy, cognitive disturbances Vit C: nosebleeds, bleeding gums, plugged hair follicles, frequent colds Vit D: bone pain, muscle weakness, asthma, cancer, depression, sweaty head, rickets Vit E: myocardial arrhythmia or infarction, hyporeflexia or ataxia, blindness, dementia Vit K: hemorrhagic disease of the newborn, unusual bleeding, bruising, petechiae Iron: unusual food/substance cravings, pallor, fatigue, lightheaded, trouble breathing, fissured tongue, hair loss, spoon-shaped nails Magnesium: cold hands, soft/brittle nails, hyperactivity, irregular heart beat, high BP, tender

calf muscles, brisk knee reflexes, PMS Potassium: weakness, fatigue, dyspnea, constipation, exercise intolerance Calcium: coarse hair, brittle nails, psoriasis, cataracts, depression, muscle cramps Zinc: ridged or white-marked nails, stretch marks, hyperactivity, PMS, hair loss, miscarriage Folic acid: smooth painful tongue, gum disease Pain Assessment - Correct Answer Similar to the "History of Present Illness" interview:

• Location
• Onset
• Quality
• Intensity (use appropriate Pain Scale)
• Duration
• Frequency
• Precipitating factors
• Alleviating factors
• Associated symptoms
• Changes to ADLs Pain - Correct Answer Acute Pain:
• Nerves warn of impending or actual tissue damage and place body systems on alert; increased blood pressure, heart rate, and respirations, diaphoresis, grimacing. Chronic Pain:
• Nervous system adapts, and acute symptoms may not appear.
• Patients may have both chronic and acute pain. Heart Sounds - Correct Answer • Best heard when patient is supine or lying on left side
• Valves shut in pairs: mitral and tricuspid; pulmonic and aortic
• S1 is the closure of the mitral and tricuspid valves (start of systole); best

heard over 5th intercostal, midclavicular line

• S2 is the closure of the pulmonic and aortic valves (end of systole); best heard over 2nd intercostal, right sternal border
• S3 comes after S2: lub-dub-by; from fluid overload, valve insufficiency
• S4 comes before S1: le-lub-dub; from acute MI, pulmonary HTN/embolus
• Murmur: extra noise(s) in between S-sounds; vibration, rumbling, woosh
• Rub: heard during systole and sometimes diastole; 3 rd intercostal space, lower left sternal border Circulation - Correct Answer Vena Cava > Right Atrium > Tricuspid Valve > Right Ventricle Pulmonic Valve > Pulmonary Arteries > Pulmonary Veins > Left Atrium Mitral Valve > Left Ventricle > Aortic Valve > Aorta Arteries, Arterioles > Capillaries > Venules, Veins > Vena Cav Lung Sounds - Correct Answer • Tracheal: high-pitched; heard over trachea
• Bronchial: high-pitched and loud; heard next to trachea
• Bronchovesicular: mid-pitch, med volume; heard next to sternum and between scapula
• Vesicular: low-pitched, soft; heard over lung fields
• Crackles (Rales): heard on inspiration when fluid-filled or collapsed alveoli pop open
• Wheezes: high-pitched on expiration, sometimes inspiration; asthma, infection
• Rhonchi: low-pitched, rattling; indicates partial block by fluid; clear by cough
• Stridor: high-pitched, on inspiration; indicates upper airway obstruction
• Pleural rub: low-pitched on both inspiration and expiration; indicates pleural inflammation, often accompanied by pain with breathing

Respiratory Patterns - Correct Answer • Cheyne-Stokes: apnea, crescendo/decrescendo rate and depth of breaths, then apnea; indicates damage to respiratory brain centers (stroke, TBI, metabolic encephalopathy), carbon monoxide poisoning, chronic heart failure, adjustments to altitude changes, and may also be seen after opioid administration

• Kussmaul: normal rate or fast deep gasping breaths; seen in DKA and other metabolic acidosis dx
• Biot's (cluster breathing): fast shallow breaths with abrupt apneic periods; indicates pons damage by stroke, trauma, brain herniation, or opioid use; sometimes considered equivalent to Cheyne-Stokes
• Central neurogenic hyperventilation: regular deep breaths that progress to irregular breaths; results from lesions on the brain stem that erroneously signal reduced CO2 levels in the blood, thus stimulating the respiratory center to over-breathe and cause respiratory alkalosis; very rare Ventilation Pathway - Correct Answer Nose/ Mouth (naso-/oropharynx) > Laryngopharynx, Epiglottis, Larynx, Trachea Carina > Lt and Rt Mainstem Bronchus > Lobar Bronchi > Tertiary Bronchi Terminal Bronchioles > Respiratory Bronchioles > Alveolar Ducts > Alveoli (300M) The right lung has 3 lobes; the left lung has two lobes. Bowel Sounds - Correct Answer Begin in LRQ and move clockwise; listen up to 5 minutes in each quadrant. Bowel sounds should be evaluated in light of other GI symptoms.
• Normal: more active prior to a meal
• Hypoactive: normal during sleep and after surgery or spinal anesthesia; may indicate constipation
• Hyperactive: increased frequency and/or volume; may indicate Crohn's,

diarrhea, food allergy, GI bleed, enteritis, ulcerative colitis

• Absent: paralytic ileus, mesenteric artery occlusion, mechanical blockage
• Very high-pitched: may indicate early bowel obstruction PERRLA - Correct Answer Pupils are:
• Equal: the size of both the pupils is the same; different sizes may indicate anisocoria, disorders of cranial nerve III or autonomic nervous system (Question to ask: does the larger or the smaller pupil represent the problem?)
• Round: shape of the pupils is symmetrical and round in shape; altered pupil shape may indicate syphilis, genetic variation, MS, or trauma, among others
• React to light: the diameter of the pupil changes in reaction to light (smaller with more light; larger with less light); fixed pupils indicate pharmacologic blockade, oculomotor nerve palsy, or brain herniation in an unconscious patient
• Accommodation: reflex action of the eye that automatically focuses on near and far objects (cranial nerve II) Level of Consciousness (LOC) - Correct Answer LOC can be evaluated using several tools such as Glasgow Coma Scale (GCS), FOUR, or AVPU. In general, these tools evaluate some or all of the following:
• Cognition/Orientation: is the patient aware of the correct date, time, and place?
• Ability to follow commands
• Ability to speak: is the patient understandable
• Ability to move: reflexes or to command
• Response to stimulus: verbal or physical
• Eye response
• Respiratory effort

Grading Edema - Correct Answer + 1 - Barely detectable impression; ~2mm +2 - Slight indentation, ~4mm; 15 seconds to rebound +3 - Deeper indentation, ~6mm; 30 seconds to rebound +4 - Indentation takes >30 sec to rebound: ~8mm Pulse Oximeter - Correct Answer Used for: obtaining arterial oxygen saturation readings and pulse rates Oxygen saturation: the percentage of hemoglobin molecules that have all four spaces for oxygen molecules full; if all hemoglobin molecules are fully saturated, the reading is 100% Alternate Locations: earlobes, toes, forehead (with special sensor) False readings:

• Bad circulation
• Painted nails
• Carbon monoxide poisoning Contraindications: none; burn patients may need an invasive monitor Watch for: inaccurate readings caused by misplaced probes, compare pulse rate displayed to apical or ECG pulse waveform for validity Patient Safety - Correct Answer How to prevent:
• Diagnostic errors: obtain complete and accurate patient Hx, HPI, and headto-toe assessment; thoroughly document all findings
• Medication errors: question poorly written orders; use Five Rights without fail; look up meds that are unfamiliar; assess patient prior to administration
• Readmissions: fully assess available and reliable resources for post-discharge care; educate patient and family about S/S to report and options for care
• Falls: assess for risk; educate patients; place side rails up following opioid administration or other cognition or balance-altering medications
• HAIs: excellent handwashing and alcohol cleansing; follow guidelines for prevention of CAUTI, VAP/HAP and central-line infections; observe strict contact, droplet, and airborne precautions when indicated
• Wrong-site surgery: practice Universal Protocol (UP) behaviors without exception

Physical Therapy (PT) - Correct Answer What it is: Branch of rehabilitation science that focuses on improving physical function, movement, and flexibility of bones, muscles, and joints; may improve weakness, stiffness, low exercise tolerance, gait, posture, and ergonomics as well as relieve pain; focus is on gross motor skills. Nursing Application: PT may be able to delay surgical intervention for low back pain, osteoarthritis, meniscal tears, and other painful musculoskeletal conditions. Nurses should recognize when a PT consult may benefit the patient, administer pain medications before PT treatments, and encourage ongoing exercises as directed by PT. Occupational Therapy (OT) - Correct Answer What it is: Branch of rehabilitation science that focuses on improving patient's abilities with daily living activities and independence (e.g., using crutches, how to accommodate limitations caused by illness or injury, correcting delays in childhood development); addresses sensory, behavioral, and fine motor skills. Nursing Application: OT is useful when a patient has a life-altering medical event (e.g., stroke, amputation, paralysis) that diminishes or eliminates prior abilities, especially those related to ADLs. For children, OT helps them learn or expand these abilities. OT often works in tandem with PT. Respiratory Therapy (RT) - Correct Answer What it is: Branch of rehabilitation science that focuses on improving the health and strength of the respiratory system, including musculature, ventilation, oxygenation, and perfusion of the alveolar bed. Nursing Application: RT works closely with nursing staff on critical care units. Med-surg units may be staffed by a floating RT who covers several units. Nursing staff, depending on the unit policies and procedures, may handle several RT-related tasks such s incentive spirometry, inhaler administration and education, oxygen titration, arterial blood gases, tracheostomy care, suctioning, and chest physiotherapy. RTs usually intubate and extubate patients who require/have required ventilators.

Family Conference - Correct Answer What it is: A meeting with the patient, family, and health care team to exchange information, update the plan of care, review family goals and resources, and facilitate communication among all parties involved; a nursing intervention as defined by NIC terminology. Nursing Application: Prepare for conference by reviewing the chart, clarifying goals for the meeting, and obtaining reports or feedback regarding any recent family psychosocial issues. Conference should include introductions of everyone present, the patient/family statements of their understanding of the current status, and the statement of the goals for the conference, adding in other discussion topics brought up by patient/family. Be prepared for common questions ("how, why, when, how long, how certain are we, what do we do now?"). Care Conference - Correct Answer What it is: A gathering of multidisciplinary health professionals to plan and evaluate patient care; does not include patient or family. Nursing Application: A care conference is called instead of a family conference when some conflict or lack of direction in the healthcare team exists. Reasons to call a care conference include:

• Need for coordination among specialties
• Healthcare team disagreement
• Nursing inconsistencies or requests not to care for the patient
• Mental health condition complicating patient care; challenging family Community Resource - Correct Answer What it is: A person, agency, facility, company, or service separate from medical facilities that fills a need for persons who may have limited personal resources; these resources generally fill needs for housing, food, medical supplies or medications, legal assistance, safety, senior care, or support groups. Nursing Application:

Many community resources are geared toward specific population or disease-process groups (poor, homeless, jobless, breast cancer, heart failure, rare diseases, mental health, children). To take best advantage of these resources, nurses should collaborate with knowledgeable staff such as social work, patient advocates, and home health to provide access for the patient. Diversity - Correct Answer What it is: The variations among the population; can refer to age, sexual preference, languages, ethnicity, religious and spiritual beliefs and practices, cultural practices, gender roles, communication patterns, views on afterlife, work ethics, ethics in general, and others. Nursing Application: Respect is the key word. Diversity does not define "bad" or "good," it simply defines difference. Each nurse brings his/her own diversity to the mix. Being "culturally competent" includes aligning care to these differences as much as possible without passing judgment or providing a lower standard of care. Thorough patient histories that include in-depth psychosocial assessments are most likely to reveal areas of diversity that will directly affect patient care plans. Family Dynamics - Correct Answer What they are: Patterns of interactions among family members; forces within the family that produce certain behaviors and symptoms. Usually these dynamics relate in some part to the goals and desires of each individual family member. Nursing Application: Responsibility, flexibility, and respect are key factors in a functional family unit. If these do not exist, stressful medical situations will exaggerate the dysfunction(s). Methods to handle family dysfunction or diversity:

• Determine who has legal authority to make decisions
• Have the family "elect" a family representative to receive updates and relay them to the rest of the family (if possible)
• Collaborate with other healthcare professionals who are trained in negotiation, conflict resolution, family dynamics, and legal issues Quality Improvement (QI) - Correct Answer What it is:

The process of analyzing data about performance and outcomes, and initiating efforts to improve both performance and outcomes. Nursing Application: High-quality patient care is largely dependent on the effective use of nursing resources within a facility. Nurses are most engaged in QI when given significant input into the process instead of just being told what to do (see Shared Governance). Quality Assurance (QA) - Correct Answer What it is: Monitoring and evaluating the processes and outcomes initiated by QI to ensure that the desired level of quality is consistently produced. Nursing Application: QA is at the heart of the phrase "Don't blame the person; blame the process."QA assumes that staff are not willfully failing to perform correctly. In very basic terms, if the quality of patient care declines, the QA team will send the QI team back to the drawing board to analyze and redesign policy and procedure to correct the decline. QA then reevaluates the outcomes of the new processes. Staff bedside nurses are best suited to evaluating and undertaking QI/QA processes, because they are most familiar with the detailed aspects of patient care. Coping Strategy - Correct Answer What it is: A conscious or unconscious response to negative life experiences such as stress, grief, loss, injury, loneliness, or invasion of privacy; positive and negative coping strategies exist and may become barriers to health promotion. Nursing Application: Through therapeutic communication, assist the patient and/or family to identify negative coping behaviors and assess for potential substitute behaviors. Education may be needed to adjust patient expectations about plan of care and outcomes. Part of planning interventions for negative coping behaviors may include the recommendation for mental health consultation and/or medications. The nurse should allow patient to express and explore emotions and feelings without judgment.

Management Terms - Correct Answer Utilization review: the detailed evaluation of health- care services provided to patients for necessity and cost-effectiveness; also monitors quality of care Risk management: the process of identifying, assessing, and prioritizing risks; goal is to prevent accidents and injuries, and control liability Performance improvement: the measurement of current performance and the implementation of methods to focus and improve performance to better meet the goals of the organization Case management: provides cost-effective continuity of care by linking people across clinical settings best suited to meet the patient needs Managed care: provides continuity of care by linking tasks and department functions within an organization Trend Data Analysis (TDA) - Correct Answer What it is: The use of past and/or present data to predict future problems, outcomes, costs, and more by identifying and monitoring trends. Nursing Application: TDA is used heavily in the nursing field. Everything from error trends related to length of nursing shifts to predicting the likelihood that DVTs will result in to increase the minimum education level of staff RNs. Healthcare facilities use TDA to proactively alter treatment protocols, staffing ratios, and provision of specialized services based on costs, community disease trends, and insurance reimbursements. Conflict Resolution - Correct Answer What it is: The process of facilitating a peaceful end to conflict and retribution; closely connected with the concept of negotiation. Nursing Application: Conflict usually results from deep personal needs, known or unknown. These needs can be correlated to a part of Maslow's Hierarchy. Good conflict resolution skills include 4 abilities:

• To remain alert and calm while managing stress quickly
• To control emotions and behavior (personal non-verbal communication) to avoid creating fear or a threat to others