Download NUR 155 exam 1 (165 questions) with precise detailed solutions and more Exams Nursing in PDF only on Docsity!
NUR |! 155 |! exam |! 1 |! with |! precise |!
detailed |! solutions
C-Diff |! specifics |! - |! Correct |! answer |! ✔- |! not |! killed |! by |! alcohol |!
- |! wash |! hands |! (soap |! & |! water) |!
- |! contact |! PPE |!
- |! endospores |! -patient |! in |! contact |! isolation -private |! room septesemia |! - |! Correct |! answer |! ✔When |! bacteremia |! results |! in |! a |! systemic |! infection Bacteremia |! - |! Correct |! answer |! ✔presence |! of |! bacteria |! in |! the |! blood |! / |! reveals |! microorganisms When |! transferring/moving |! a |! patient, |! you |! will |! need |! a |! second |! person |! when |! they |! are |! over |! __________ |! lbs. |! - |! Correct |! answer |! ✔ 35 What |! movement/transfer |! is |! used |! for |! a |! spinal |! cord |! injury |! patient? |! - |! Correct |! answer |! ✔log |! roll
Transferring |! a |! patient |! bed |! to |! wheelchair |! & |! vise |! versa |! you |! must: |! - |! Correct |! answer |! ✔- |! lock |! bed |! & |! wheelchair |! - |! bend |! and |! lift |! with |! knees |! - |! do |! not |! use |! back |! - |! use |! gait |! belt |! when |! appropriate/needed |! - shoulder |! width |! stance Infection |! control- N95 |! masks |! used |! for: |! - |! Correct |! answer |! ✔Airborne: |! Measles, |! TB, |! Varicella |! & |! Coronavirus it |! AIRS |! on |! MTV |! in |! '95 |! - |! Correct |! answer |! ✔airborne |! ; |! Measles, |! TB, |! Varicella |! ; |! N95 |! masks Infection |! Control- surgical |! masks |! used |! for: |! - |! Correct |! answer |! ✔Droplet: |! Pneumonia |! Mumps, |! Pertussis Droplets |! STick, |! Moms |! SCrub |! PErfectly |! Round |! PPs |! PNeriodically |! - |! Correct |! answer |! ✔Diphtheria, |! STrep, |! Mumps, |! SCarlet |! fever, |! PErtussis, |! Rubella, |! Pnuemonic |! Plague, |! PNeumonia Hands |! Can |! Stay |! Clean |! Even |! My |! Vagina |! - |! Correct |! answer |! ✔CONTACT: |!
Implementation Evaluation Assess: |! - |! Correct |! answer |! ✔collect |! data, |! collect |! patient's |! chief |! complaint Diagnosis: |! - |! Correct |! answer |! ✔identifying |! the |! problem/risk/strength, |! analyze |! data, |! formulate |! Dx |! statement Planning: |! - |! Correct |! answer |! ✔formulate |! goals |! & |! interventions, |! what |! you're |! going |! to |! do Implementation: |! - |! Correct |! answer |! ✔putting |! it |! all |! to |! practice/ |! action Evaluation: |! - |! Correct |! answer |! ✔evaluate |! in |! the |! goal |! was |! met? |! unmet? |! progress? Diagnosis |! formulated: |! P |! E |! D |! - |! Correct |! answer |! ✔Problem |! ; |! Etiology |! ; |! Defining |! Characteristics Goals |! Formulated:
S |! M |! A |! R |! T |! - |! Correct |! answer |! ✔Specific, |! Measurable, |! Attainable, |! Realistic, |! Timely What |! do |! you |! do |! if |! you |! are |! stabbed/ |! cut |! while |! working: |! - |! Correct |! answer |! ✔push/ |! milk |! out |! until |! fresh |! blood |! surfaces What |! do |! you |! do |! if |! poop/unknown |! substance |! splashes |! in |! eye/s: |! - |! Correct |! answer |! ✔-clean/flush |! out |! extensively |! with |! water/eye |! station |! -tell |! supervisor -fill |! out |! incident |! report |! -follow |! up |! w/ |! PCP S |! O |! A |! P |! - |! Correct |! answer |! ✔subjective, |! objective, |! assessment, |! plan Safety |! measures |! in |! room |! for |! patient: |! - |! Correct |! answer |! ✔-clear |! floor |! of |! debris, |! wires, |! rugs |! -bed |! wheels |! locked |! -ambulatory |! aids |! within |! reach |! (walker/cane) -eye |! glasses, |! water, |! call |! light, |! etc |! w/in |! reach |! -bed |! rails |! up |! but |! not |! restraining
opposition |! - |! Correct |! answer |! ✔Movement |! of |! the |! thumb |! to |! touch |! the |! fingertips Abduction |! - |! Correct |! answer |! ✔Movement |! away |! from |! the |! midline |! of |! the |! body: |! legs, |! arms, |! fingers Aduction |! - |! Correct |! answer |! ✔movement |! toward |! the |! midline: |! legs, |! arms, |! fingers Inversion |! - |! Correct |! answer |! ✔turning |! inward, |! i.e., |! of |! a |! foot Eversion |! - |! Correct |! answer |! ✔moving |! the |! sole |! of |! the |! foot |! outward |! at |! the |! ankle skin |! disorders |! - |! Correct |! answer |! ✔Abnormal, |! primary, |! secondary Abnormal |! skin |! disorder: |! - |! Correct |! answer |! ✔Jaundice, |! Cyanosis, |! Erythema, |! vitiligo, |! edema, |! etc. Primary |! Skin |! disorder: |! - |! Correct |! answer |! ✔skin |! lesion |! response |! to |! change |! in |! external/ |! internal |! environment |! of |! skin |! (Ex: |! blister)
Secondary |! skin |! disorder: |! - |! Correct |! answer |! ✔Not |! initial; |! result |! from |! modification |! such |! as |! a |! chronicity, |! trauma, |! or |! infection |! of |! primary |! (Ex: |! erosion |! from |! blister) Secondary |! skin |! lesions: |! - |! Correct |! answer |! ✔Atrophy Erosion Lichenification Scales Crust Ulcer Fissure Scar Keloid Atrophy |! - |! Correct |! answer |! ✔wrinkles erosion |! - |! Correct |! answer |! ✔scratching Lichenification |! - |! Correct |! answer |! ✔thick |! skin ulcer |! - |! Correct |! answer |! ✔pressure
(Lung |! sounds) |! rhonchi |! are |! - |! Correct |! answer |! ✔low/ |! deep |! pitched, |! snoring |! sounds (Lung |! sounds) |! wheezes |! are |! - |! Correct |! answer |! ✔high |! pitched, |! 'squeaky' |! sounds (Lung |! sounds) |! Rales |! are |! - |! Correct |! answer |! ✔short |! 'crackly' |! sounds/ |! high |! pitched bronchial |! - |! Correct |! answer |! ✔Anterior |! over |! trachea, |! minimal |! sound Broncho-vesicular |! - |! Correct |! answer |! ✔At |! 1st/2nd |! Intercostal |! space, |! moderate |! sound, |! normal |! breath |! sounds |! heard |! over |! the |! upper |! anterior |! chest |! and |! intercostal |! area Vesicular |! - |! Correct |! answer |! ✔the |! soft, |! low-pitched, |! normal |! breath |! sounds |! heard |! over |! peripheral |! lung |! fields Base |! of |! lungs, |! loudest |! sound Stridor |! happens |! at |! the: |! - |! Correct |! answer |! ✔Upper |! airway |! over |! trachea |! noisy/high |! pitched |! due |! to |! partial |! block |! from |! foreign |! airway |! obstruction
Rhonchi |! sounds |! are |! caused |! by |! - |! Correct |! answer |! ✔passage |! of |! air |! through |! an |! airway |! obstructed |! by |! thick |! secretions, |! muscular |! spasm, |! new |! growth, |! or |! external |! pressure. Rhonchi: |! - |! Correct |! answer |! ✔located |! at |! the |! top |! of |! lungs |! bilaterally Rhonchi |! happens |! at |! the: |! - |! Correct |! answer |! ✔larger |! airways low |! pitched- |! gurgling obstruction |! or |! fluid |! accumulation |! in |! larger |! airways |! *COPD; |! Pneumonia Wheezing |! happens |! at |! the: |! - |! Correct |! answer |! ✔Effects |! bronchi high |! pitched |! constriction |! airway |! trying |! to |! pass |! through |! bronchioles |! *Asthma; |! Bronchitis Rales |! happens |! at |! the: |! - |! Correct |! answer |! ✔smaller |! airways crackles; |! high |! pitched; |! popping fluids |! in |! lungs |! (Aveoli) *CHF; |! Pneumonia
What |! are |! we |! assessing |! hair |! for |! & |! why: |! - |! Correct |! answer |! ✔distribution: |! circulation, |! malnutrition, |! hormonal |! imbalance What |! are |! we |! assessing |! nails |! for |! & |! why: |! - |! Correct |! answer |! ✔cyanosis |! & |! capillary |! refill: |! circulation What |! are |! we |! assessing |! toes |! for |! & |! why: |! - |! Correct |! answer |! ✔cyanosis, |! capillary |! refill: |! circulation clubbed |! nail: |! lung |! issues What |! are |! we |! assessing |! heart |! for |! & |! why: |! - |! Correct |! answer |! ✔S1 |! & |! S2, |! Systolic, |! Diastolic: |! lub/dub, |! valves |! opening/ |! closing |! correctly, |! no |! abnormalities/arrhythmia |! in |! sounds What |! are |! we |! assessing |! lungs |! for |! & |! why: |! - |! Correct |! answer |! ✔breath |! sounds abnormalities: |! crackling, |! wheezing, |! stridor What |! are |! we |! assessing |! skin |! for |! & |! why: |! - |! Correct |! answer |! ✔turbot: |! moisture/elasticity
What |! are |! we |! assessing |! abdomen |! for |! & |! why: |! - |! Correct |! answer |! ✔masses/ |! lesions/distention/ |! abnormalities/ |! listen |! for |! bowel |! sounds/ |! palpate |! for |! pain Correct |! way |! to |! assess |! abdomen: |! - |! Correct |! answer |! ✔Inspect |! (Look) Auscultate |! (Listen) Palpate |! (feel) |! RLQ |! then |! clockwise Steps |! of |! delegation |! - |! Correct |! answer |! ✔-Assessment: |! client/staff, |! situation |! -Communication: |! provide |! direction |! during |! task |! -Surveillance |! & |! Monitoring: |! ensure |! compliance -Evaluation: |! effectiveness |! of |! delegation |! & |! desired |! outcome eu- |! - |! Correct |! answer |! ✔normal |! or |! good a- |! - |! Correct |! answer |! ✔without/ |! missing
Who |! do |! restraint |! orders |! come |! from |! & |! when |! do |! they |! need |! to |! be |! renewed: |! - |! Correct |! answer |! ✔doctor/physician |! & |! every |! 24 |! hours How |! often |! do |! you |! check |! on |! a |! patient |! in |! restraints: |! - |! Correct |! answer |! ✔every |! 30 |! mins How |! often |! do |! you |! release/give |! break |! for |! a |! patient |! in |! restraints: |! - |! Correct |! answer |! ✔every |! 2 |! hours Where |! can |! you |! tie |! a |! restraint |! to |! & |! how: |! - |! Correct |! answer |! ✔bed |! frame |! & |! slipknot Communication |! Methods |! - |! Correct |! answer |! ✔Assertive, |! non |! assertive, |! & |! therapeutic Assertive |! communication: |! - |! Correct |! answer |! ✔-communication |! that |! takes |! a |! listener's |! feelings |! and |! rights |! into |! account -telling |! patient |! what |! you/they |! will |! be |! doing -"I" |! statements Non |! assertive |! communication |! - |! Correct |! answer |! ✔passive
Therapeutic: |! - |! Correct |! answer |! ✔-builds |! trust,rapport |! & |! understanding |! -giving |! choice -open |! ended |! questions Donning |! PPE: |! - |! Correct |! answer |! ✔1.Head |! cover 2.Gown 3.Mask 4.Shoe |! Covers |! 5.Goggles/eyewear 6.Gloves Doffing |! PPE: |! - |! Correct |! answer |! ✔1.Shoe |! Covers 2.Gloves 3.goggles/eyewear 4.Head |! cover 5.Gown 6.Mask Vitals: |! - |! Correct |! answer |! ✔BP/ |! Blood |! Pressure |! Ox/Oxygen Temp/temperature |!
pain |! range |! scale: |! - |! Correct |! answer |! ✔1- Hand |! washing |! steps: |! - |! Correct |! answer |! ✔Apply |! soap, |! scrub |! hands |! and |! arms |! (10-15 |! sec), |! rinse, |! dry |! arms |! and |! hands |! with |! single |! use |! paper |! towels |! or |! hand |! dryer. |! Use |! towel |! to |! turn |! off |! sink |! & |! open |! door. Subjective: |! - |! Correct |! answer |! ✔What |! the |! Subject |! SAYS. based |! on |! or |! influenced |! by |! personal |! feelings, |! tastes, |! or |! opinions. Ex: |! nausea, |! headaches, |! dizzy Objective: |! - |! Correct |! answer |! ✔What |! can |! be |! OBSERVED. Factual, |! related |! to |! reality |! or |! physical |! objects; |! not |! influenced |! by |! emotions, |! unbiased. Ex: |! Vitals, |! bloodwork, |! surgery, |! labs, |! x-rays, |! surgery What |! do |! you |! do |! if |! an |! Aid |! brings |! irregular |! vitals |! from |! patient? |! - |! Correct |! answer |! ✔Recheck |! them |! manually; |! by |! RN |! only What |! can |! not |! be |! delegated? |! - |! Correct |! answer |! ✔E- |! evaluate A- |! assessment |! (initial) T- |! Teach/ing
Maslow's |! Hierarchy |! of |! Needs |! - |! Correct |! answer |! ✔physiological |! (most |! need) safety love/belonging self- |! esteem self-actualization |! (least |! need) Please |! Say |! Less |! SExy |! SAyings |! - |! Correct |! answer |! ✔Physiological |! Safety |! Love/belonging Self-Esteem Self-Actualization |! (P |! S |! L |! SE |! SA |! ) physiological |! - |! Correct |! answer |! ✔breathing, |! food, |! water, |! sex, |! sleep, |! homeostasis, |! excretion Safety |! - |! Correct |! answer |! ✔security, |! employment, |! health Love/belonging |! - |! Correct |! answer |! ✔friendship, |! family, |! sexual |! intimacy
