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NSG 241 Exam 1 Marian ABSN Questions With Complete Solutions 5 ways that critical thinking components are demonstrated Correct Answers knowledge review - baseline & info gathering reasoning - inductive/deductive inferences - intuition/interpretation validation - validity attitudes - of thinker, positive an immobile patient should be moved how often Correct Answers every two hours describe actual nursing process Correct Answers describes human responses to health condition or life processes describe acute would healing Correct Answers progresses through the healing stages normally with no issues describe assessment phase of nursing process Correct Answers gather patient care data through observation, interviews, and physical assessment describe chronic wound healing Correct Answers fails to progress/heal in a timely manner describe diagnosis phase of nursing process Correct Answers analyze, validate, and cluster patient data to identify patient problems
describe dorsal recumbent position and what is it used for Correct Answers used for: fully insertion patient is supine with legs bent describe fowler position Correct Answers patient in sitting with pillow under knees for support, head at 45 degrees describe health promotion nursing diagnosis Correct Answers clinical judgement of motivation, desire, and readiness to enhance well-being and actualize human health potential describe lithotomy position - dorsal sickle - and what is the position used for Correct Answers used for: vaginal exams patient lying prone, heels in the holders Describe perineal care for females Correct Answers front to back each side then center Describe perineal care for males Correct Answers circular motion start from urethra & work way down penis describe planning phase of nursing process Correct Answers prioritize nursing diagnosis/identify short and long term goals describe risk nursing diagnosis Correct Answers describes human responses to health conditions/life process that may develop
11-15 is moderate 10 or below is high risk EHR Correct Answers electronic health record - shows collection of visits - longitudinal care EMR Correct Answers electronic medical record - shows one episode of care Hendrich II fall risk model Correct Answers uses 7 sections + Get up & go test how are the roles of the nurse demonstrated - 3 Correct Answers advocate delegator collaborator how do acute wound heal & what intention Correct Answers primary intention with little to no scarring how do chronic wounds heal & what types of intention Correct Answers secondary and is open for longer period of time, creates some new scar tissue how many times and hour should the spirometer be done Correct Answers 10x according to Profs, then cough 2x every hour how many times should a joint be moved through ROM and how many times a day and what to do with joints Correct Answers 5x per joint
2x per day support joints never do to the point of pain or stress How often to do rounds for fall patients? Correct Answers every hour If aspiration is suspected, what do you do Correct Answers Notify nutritional therapist or speech therapist to do a swallow study if patient is NPO or on oxygen, how often should oral care be done Correct Answers every two hours with a toothette also can use mouth lube to moisten mucosa if the patient is incontinent, what type of bath is done Correct Answers partial bath John Hopkins Hospital fall assessment scores mean what: 0- 6-
13 Correct Answers 0-5 low risk 6-13 moderate risk 13 high fall risk John Hopkins Hospital fall assessment tool Correct Answers uses 7 sections to assess + a high/low initial fall risk Morse Fall Scale Correct Answers uses 6 sections to assess Morse Fall Scale scores mean what:
Educator Researcher Delegator score of 5+ means what on the Hendrich II fall risk model Correct Answers patient is at high risk of fall stage I pressure wound Correct Answers non-blanchable redness of intact skin stage II pressure wound Correct Answers partial thickness skin loss or blister stage III pressure wound Correct Answers full-thickness skin loss - visible fat stage IV pressure wound Correct Answers full-thickness tissue loss - muscle/bone visible two types of inferences Correct Answers intuition interpretation two types of reasoning Correct Answers inductive deductive types of attitudes related to critical thinking - 4 Correct Answers confidence fairness risk taking thinking independently
what always happens with a face tent Correct Answers air is humidified What are charting steps following 5 steps of nursing process Correct Answers expected documentation: nursing assessment care plan interventions outcomes assessment discharge what are Maslow's hierarchy of needs - which help a nurse prioritize - 5 Steps Correct Answers physiological/safety/social/esteem/self actualization - this this order what are pediculicidal shampoos used for Correct Answers head lice what are the 3 types of 'beds' in regards to bed making Correct Answers occupied unoccupied surgical what are the 5 steps of the nursing process - ADPIE Correct Answers assessment diagnosis planning implementation evaluation
off 20 mins what are the two tests for skin integrity Correct Answers braden scale norton pressure ulcer scale what are the two types of bed pans Correct Answers 1. fracture
- regular bed pan - bigger, rounder what are the types of oxygen masks - 7 Correct Answers nasal cannula non rebreather trach mask and collar venturi mask simple face mask face tent venturi mask jet what are the types of ROM and describe them Correct Answers active - or isotonic - patient does it all active assistive - minimal assist passive - caregiver does it all what are three types of nursing diagnosis Correct Answers actual nursing diagnosis risk nursing diagnosis health promotion nursing diagnosis what comes first with instant clinical reasoning Correct Answers ABC's comes first!
MAKE SURE THEY'RE BREATHING
A: Airway B: Breathing C: Circulation what conditions can cause aspirations - 8 Correct Answers seizures cerebrovascular accidents dementia GERD conditions affecting mobility endoscopy meds feeding too fast what does a simple face mask not have Correct Answers no reservoir bag what does a ventrui mask ensure Correct Answers accuracy of oxygen concentration is delivered and is considered for use with CO2 retaining patient What does each patient need with charting & documentation - 5 Correct Answers physical psychosocial environmental self-care discharge needs what does moving a patient help prevent - 3 Correct Answers fragile skin/skin integrity
what is required with charting/documenting - 5 Correct Answers black ink date time signature no blank spaces what is sanguineous drainage Correct Answers bloody drainage
- from fresh bleeding seen in deep partial-thickness & full-thickness wounds what is serosanguinous drainage Correct Answers thin, watery, pale red to pink plasma with red blood cells What is serous drainage Correct Answers clear, thin, watery plasma - usually found in inflammatory stage of wound healing what is the American recover and reinvestment act of ' Correct Answers mandated that everyone have a electronic health record by 2014 what is the goal of charting/documentation Correct Answers to describe facts clearly and concisely to improve communication what is the ideal fluid intake for kidney function Correct Answers 1,500-2000mL what is the purpose of charting/documentation Correct Answers facilitation of info flow to support continuity, quality and safety of care
what makes a non rebreather a non rebreather Correct Answers there is no exhaled air that re-enters the reservoir bag, i.e. the patient does not inhale any expired air What never to do with thermal applications Correct Answers never apply directly to skin, always have a thin barrier what PPE and precautions are used for protective isolation - neutropenic patient Correct Answers No fresh food/ plants allowed in room wear mask, gown and gloves what PPE is the 'standard' Correct Answers hands washed gloves what PPE is used for airborne isolation Correct Answers neg. pressure room N-95 respirator mask, eye protection, gown, gloves what PPE is used for contact isolation Correct Answers gloves and gowns what PPE is used for droplet isolation Correct Answers eye protection gown gloves what should you keep in mind for principles of safety Correct Answers make sure it applies to all places where they receive care i.e. home/hospital/school
- length of treatment
- frequency of treatment
- part of body being treated follow the doctor guidelines for these Who is perineal care important for Correct Answers those who are: dependent incontinent have a urinary catheter wounds are classified by what Correct Answers the underlying cause
