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NSG 211 Final Exam| 380 Questions With
Complete Solutions
STUDY MEDTERM
The official do not use list: correct answer: - The symbols ">" and "<"
- All abbreviations for drug names
- Apothecary units
- The symbol "@"
- The abbreviation "cc
- "The abbreviation "μg 5 ethical principles correct answer: Autonomy, Beneficence, Fidelity, Justice, and Non-maleficence autonomy correct answer: Agreement to respect another right to self-determine a course of action; support of indolence decision making beneficence correct answer: Compassion; taking positive action to help others; desire to do good; core principle of our patient advocacy nonmaleficence correct answer: The ethical principle of doing no harm fidelity correct answer: Loyalty, fairness, truthfulness, advocacy, a dn decision to our patients. It involves an agreement
to keep our promises. Fidelity refers to the concept of keeping a commitment and is based upon the virtue of caring justice correct answer: individual people and groups with similar circumstances and conditions should be treated alike; fairness with equal distribution of goods and services confidentiality correct answer: trusting others with personal and private information veracity correct answer: truthfulness ANA correct answer: american nurses association; answer to board of the state for nursing ANA code of ethics: primary commitment Is to ___ correct answer: Patient (individual, family or community) ANA code of ethics the applies in course of professional practice: correct answer: - Primary commitment to patient -Demonstrates compassion and respect for all patients regardless of patient status
- Promotes the health and welfare of patients
- Accountable for individual practice.
- Maintains and increases own knowledge base
- Works to improve healthcare environment for providers and patients WV BON regulations & rules correct answer: - Regulates nursing practice in WV
- Ex: Pap smears, Communicable disease screening, Blood pressure screening, Early detection/treatment of DM, and Exercise program for frail older adults Tertiary prevention correct answer: Aims to prevent long-term consequences of chronic illness of disability and support optimal functioning (ex:)
- EX: Prevention of pressure ulcers after spinal cord injury and Promoting independence after traumatic brain injury NSG process correct answer: (ADPIE) Assessment, Diagnosis, Planning, Implementation, Evaluation critical thinking correct answer: think through analysis, develop alternatives, and implement the best interventions identify patterns and trends, consider missing or conflicting assessment information, and decide the type and frequency of future assessments Critical thinking entails ___ correct answer: Entails purposeful, outcome-directed (result-oriented) thinking Critical thinking is driven by: correct answer: patient, family, and community needs Critical thinking is based on what 3 things? correct answer: the nursing process, evidence-based thinking, and the scientific method
Critical thinking requires ___, ___, and __ correct answer: Requires specific knowledge, skills, and experience Critical thinking is guided by ___ correct answer: professional standards and codes of ethics Critical thinking is constantly doing what to improve? correct answer: reevaluating, self-correcting, and striving to improve Diagnostic reasoning is based on what? correct answer: based on nurse's critical thinking nurses draw inferences or ideas about what the issue is First step of diagnostic reasoning correct answer: gather assessment data How do you gather assessment data in diagnostic reasoning? correct answer: - Identify both abnormal findings and patient strengths
- Collect subjective and objective data
- Cluster data 3 main types of diagnoses: correct answer: wellness, at risk, and actual wellness diagnoses is what correct answer: focus on strengths and transition to a higher level of wellness
- patient quotes, i want to know more about etc
Priority issue assumes ___. ex: correct answer: Priority issue assumes the most importance among several issues
- Depends on acuity of setting
- Clinical experience, knowledge, expertise, and judgement
- Pulse ox vs coffee Issues that need immediate attention: correct answer: Risk for human violence Patient concerns correct answer: Often have to balance with what nurse identifies maslows hierarchy of needs correct answer: physiological, safety, love/belonging, esteem, self-actualization Frequency of assessment varies with correct answer: the patient's needs, purpose of data collection, and health care setting Frequency when assessing in long term care correct answer: once a month Frequency when assessing in Intensive care setting correct answer: hourly Frequency when assessing in acute care setting correct answer: once a shift Frequency when assessing in outpatient setting correct answer: focused assessments following treatments
Frequency when assessing in well visits correct answer: Periodic health assessment focuses on the most common screening and prevention services for four age groups how do you know how often you assess correct answer: kardex; if no orders it is hospital policy - typically once every shift Planning stage in Nursing process correct answer: patient outcomes/goals and nursing interventions Implement stage in the nursing process correct answer: planned nursing interventions Evaluate stage in the nursing process correct answer: patient outcome and then continue, revise, or discontinue plan the interview involves what correct answer: preorientation orientation working termination Characteristics of therapeutic communication correct answer: - The interview
- Active
- Nonverbal Cues
- Therapeutic Techniques & Non-therapeutic responses Critical process involved in gathering data: correct answer: - Pre-orientation
- Orientation
- Working
indirect contact correct answer: disease is carried from reservoir to host
- contaminated surfaces - formites PPE correct answer: Personal Protective Equipment and Supplies such as, Gloves, Gowns, Masks, and Protective eye gear What is the last piece of PPE you take off? correct answer: eye wear Dawning correct answer: putting on Dawfing correct answer: taking off when do you wash vs alcohol correct answer: wash - visibly soiled hands-bacterial diseases routes of transmission correct answer: contact droplet airborne Contact precautions correct answer: Measures taken to prevent the spread of diseases transmitted by the physical transfer of pathogens to a susceptible host's body surface
- gown and gloves, put on gown first and take off gloves first Droplet precautions wear: correct answer: Mask, gown, and gloves
Airborne precautions correct answer: Measures taken to prevent the spread of diseases transmitted from an infected person by pathogens propelled through the air on particles smaller than 5 μm in size to a susceptible person's eyes, nose, or mouth examples of droplets correct answer: diphtheria pertussis meningococcal meningitis Droplet precaution correct answer: Large droplets within ~ meter (3 feet) transmit infection via:
- Coughing, sneezing, talking
- Medical procedures Example of droplet: correct answer: - Diphtheria
- Pertussis (Whooping Cough)
- Meningococcal meningitis Airborne disease correct answer: Very small particles of evaporated droplets or dust with infectious agent may...
- Remain in air for a long time
- Travel farther than droplets
- Become aerosolized during procedures Airborne examples: correct answer: Tuberculosis and Measles (Rubeola) Techniques of physical exam correct answer: inspect auscultate palpate percuss
Temp: C = F = correct answer: C = 5/9 (F - 32) F = 9/5(C32) What influences temperature? correct answer: Age, Exercise, Hormones, Stress, Environment, Circadian Rhythm Rectal temp: correct answer: (99.5 ) (37.5 ) vagal stimulation,⁰ ⁰ core temp Axillary temp: correct answer: (97.7 ) (36.5 ) often inaccurate⁰ ⁰ Tympanic temp: correct answer: (99.5 ) (37.5 ) may be⁰ ⁰ inaccurate, core temp Forehead temp: correct answer: (94 ) (34.4 ) not in acute care⁰ ⁰ Changes for acute in general survey correct answer: Extreme anxiety, acute distress, pallor, cyanosis, and MS change
- behavior, mobility General survey correct answer: - Warm, comfortable, and relaxing room Begins immediately when meeting a patient (clinic or hospital)
- Make mental notes
- INTRO
- Shake hands (caring and assessment together)
- What is your first impression? Outstanding features?
- Does pt respond to name? Eye contact, smile, clear speech?
- Hand moist? Extend arm? Temp? Texture? Strength? Deformities?
- Conversation? Look ill or well
General survey physical appearance: correct answer: Overall appearance Hygiene and dress Skin color Body structure and development General survey Behavior: correct answer: Facial expressions LOC speech General survey Mobility: correct answer: Posture Range of motion Gait When does the assessment begin? correct answer: As soon as you get in the room The Joint Xommission established ___ correct answer: National patient safety goals National patient safety goals correct answer: - Identify patients correctly
- Use medications safely
- Prevent infection
- Check patient medications
- Improve staff communication
- Identify patient safety risks
- Adverse drug events
- Catheter associated UTI
- Central-line associated bloodstream infections
- lifts/repositioning of pt, etc. humidify o2 greater than __ L correct answer: 4 Nutritional Assessment Subjective Data Collection risk factors: correct answer: - Medical history
- Weight history
- Appetite and taste changes
- Gastrointestinal symptoms
- Food allergy or intolerance
Commonsymptoms of altered nutrition correct answer: Weight changes; changes in eating habits; skin, hair, nail changes; energy level decrease Comprehensive nutritional history correct answer: - Food records: 24-hour recall/3-day food diary Food-frequency questionnaires
- Direct observation: Percentage of meal eaten; calorie count Nutritional Assessment Objective Data Collection: Equipment needed: correct answer: Scale, measuring tape, growth chart Nutritional Assessment Objective Data Collection: Physical Assessment correct answer:
- Body type: Small, average, or large build
- General appearance
- Swallowing: dysphagia
- Elimination
- Body mass index (BMI)
- Weight calculations
- Percentage of ideal body weight
- Recent weight change (percent change)- Significant weight loss
- Percent usual body weight
- Waist circumference
- Waist-to-hip ratio
- Skinfold thickness
- Mid Upper arm muscle circumference: Accuracy important Percent usual body weight: correct answer: Current/usual x 100 waist circumference averages for men and women: correct answer: >40 men; > 35 women= increase in chronic dx risk 1 kg= ___ lb correct answer: 2. BMI categories: correct answer: - Below 18.5 is underweight
- 18.5 to 24.9 is healthy weight
- 25 to 29.9 is overweight
- 30 or higher is obese Ways to stimulate appetite correct answer: small frequent meals, solicit food preferences, encourage, schedule things around meal time, control pain, keep area free of odor, etc. How to assist with eating? correct answer: involve pt as much as possible, sit ata eye level, encourage, provide drinks, place napkin on pt, etc.
- commonly occurs during coughing, sneezing, laughing, or other physical activities Urge incontinence correct answer: The involuntary loss of urine that occurs soon after feeling an urgent need to void
- pt experiences loss of urine before getting to toilet and an inability to suppress the need to urinate Functional incontinence correct answer: Urine loss caused by the inability to reach the toilet b/c of environmental barrier, physical limitations, loss of memory, or disorientation Shift Assessment of hospitalized client POCT-delegation: correct answer: Shift/comprehensive assessment Delegation:
- The right task
- Under the right circumstances
- To the right person
- With the right directions and communication
- Under the right supervision and evaluation POCT safety interventions: correct answer: - Two-patient identifiers
- Written documentation, medical terminology, and SBAR
- Alarms
- Prevent infections
- Identify risks
- Prevent surgical mistakes
POCT characteristics to remember: correct answer: - Review Multistick, accucheck, pH testing, and Hematest
- "Waived" "POCT" terminology (qualitative vs. quantitative)
- Why and when to do quality controls on Accucheck and Hemacult
- Critical Accucheck results and what to do about them
- General process for performing FS, Hemaprompt and/or Multistick: Be able to read result Better to be hyper or hypo glycemic? correct answer: hyper, hypo kills faster Accucheck:
- Hypoglycemia level:
- Hyper glycemia level: correct answer: - less than 70
- greater than 130 pos gastricult correct answer: blue Documentation correct answer: - Purpose
- Parts of the Medical Record
- Confidential, accurate, organized, timely, concise
- Written Notes (progress, narrative [SOAP, PIE, Focused]) Interdisciplinary Communication correct answer: - Reporting errors
- Organized, complete, accurate, concise, and respectful
- SBAR - components, why
- Telephone communication
