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NUR 150 Final Exam Study Guide: Questions & Answers
What are the three types of isolation? (Ans- Airborne, droplets and contact Rules of restraints (Ans- You need an MD order, check them every 15 mins but release in 2 hours, tie the knot to the non-movable part of the bed frame, always check for wrist bruises. Sometimes family will sign a release. privacy for patients (Ans- knock on the door first and ask to enter, close the door and pull the curtains What does "least restrictive environment" mean? (Ans- whatever allows the patient the most movement If you use a BP cuff that is too small? (Ans- May result in falsely high readings
If use a BP cuff that is too big? (Ans
- May result in falsely low readings Where should you not use BP for readings? (Ans- Never use the forearm Never take BP on the arm that has: (Ans-
- IV catheter
- AV shunt
- breast surgery on that side
- arm/hand that has been traumatized
- arm cast or bulky dressings What is the single most important technique to avoid infection in the healthcare? (Ans- washing your hands
What can nurses do to prevent complications of immobility? (Ans- turn PT every two hours, encourage fluids, move PT around and use white tight socks to help increase circulations. Donning PPE (Ans-
- gown
- mask
- goggles
- gloves Removing PPE (Ans-
- gloves
- goggles
- gown
- mask
Dorsal (Ans- (supine) lying flat on back. Dorsal (recumbent) (Ans- Lying flat on back, may place pillows under knees Fowler (Ans- head of bed raised 45-60 degrees. Place pillows under arms, hands and ankles Semi-Fowler's (Ans- Sitting at 90 degrees Sims (Ans- lying on one side with knee and thigh drown upward towards chest Prone (Ans- face down lithotomy
sitz bath (Ans- reduces inflammation in perineal/anal areas. Benefits patients who had rectal/genital surgery, hemorrhoids and postpartum patients Tepid bath (Ans- to reduce elevated body temp. water is at 98.6 degrees, cloths applied to groin and axillae areas to reduce fever medicated baths (Ans- using products like oatmeal, cornstarch etc to reduce tension and relieve itching back massages (Ans- relieve muscular tension and stimulate circulation Health care law (Ans- If a patient refuse hygiene, legally we cannot touch the patient but we can inform them the consequences for infections and such if care is not given Top 3 concerns when it comes to bed making (Ans- patient safety, comfort and privacy
Why is it necessary to perform oral hygiene on patients? (Ans- maintain healthy state of mouth, remove odors, stimulate appetite and prevent oral diseases Nail care (Ans- soak in warm water push back cuticles with washcloth clean under nails file and dry and use lotion if needed Foot care (Ans- soak in warm water, check between toes for poor circulations clean under toenails, file and dry always wear gloves Hair care (Ans- Shampooing can be done by bedside, comb and brush daily wear gloves Using electric razors (Ans- 1. patients with anticoagulants
- disoriented patients
Tunneling (Ans- full tissue loss including muscle tendon or bone; slough or eschar might be present How does a nurse assess wound? (Ans- size of it, touch/feel, stage of wound, depth, color, odor and pain interventions to prevent pressure ulcers? (Ans- 1. pressure relieving mattress
- chair cushions
- proper positioning
- lift to prevent friction Skin tears? (Ans- traumatic wounds in which the epidermis separates from the dermis Anaerobic specimen collection (Ans- collections found from deeper wounds Head to toe assessment (Ans- an assessment that organizes the collection of comprehensive physical data by proceeding through the entire body from head to toe
general survey (Ans- Patients appearance? Hygiene? Neurological survey (Ans- If PT awake, sleepy? Ask PT time and place and if they remember situation. asses pupils (Ans- PERRLA are they round, equal, reacting to light and accommodating? Intergumentary survey (Ans- Skin color normal for ethic group? Use turgor technique to monitor body temp. Tenting (Ans- skin stays raised up - pt is dehydrated respiratory survey (Ans- equal chest expansion, note rate, depth etc zig zag pattern (Ans- start at front of chest top left and move left from right down to bottom of lung, same with back breath sounds (Ans- crackles: excess fluid in alveoli wheezes (rhonchi) croup/stridor (barking)
Post OP risks? (Ans- death, urine/bowel, pain, pneumonia, mental status, falls, infections (high fever & HR) Benner's Theory (Ans- novice, advanced beginner, competent, proficient, expert When we graduated as nurses we are? (Ans- advanced beginners Experience nurses will pick up (Ans- subtle patterns In a clinical setting you always (Ans- prioritize care Assumptions (Ans- you never guess, always get evidence or proof ADLs (Ans- activities of daily living: feeding, grooming, dressing, bathroom etc critical thinking (Ans- collect info, help prioritize care, always think with a purpose, have evidence to support, provide safe patient care
Just culture (Ans- taking responsibilities for the wrongs you did at work so like wrong medication etc What are the 5 vitals signs? (Ans- Temp: 97-99. HR: 60- 100 Respiration: 12- 20 BP: 120/ Pain: 1-10 (always the 5th vital sign) Chronic illness (Ans- Lasts more than 6 months; does not go away usually Acute illness (Ans- New illness; something that can be taken care of Airborne (TB) (Ans- gloves, mask (N95), gown and goggles Droplets (flu) (Ans- gloves, regular mask, gown and goggles Contact (C-diff) (Ans- gown (most important), gown, gloves and goggles. C-diff (Ans- a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon.
As nurses we ask questions like? (Ans- Their sleep schedule, their diet, any daily practices, any issues etc S B A R (Ans- miscommunication between nurses and MD often lead to errors s- what is the situation? b-background of the patient a- assessment r- recommendation always give this info when talking to MD
