Fundamentals exam 1
Which information would the nurse provide to the client about the benefits of rehabilitation? Select all that apply. One, some, or all responses may be correct.
"Specialized rehabilitation services help clients and caregivers to adjust to lifestyle changes." "Rehabilitation helps prevent complications associated with illness or injury at the initial stages." "Clients who receive rehabilitation attain their fullest physical, mental, social, vocational, and economic potential." "These services enable the client to function with the limitations of their illness."
Parenteral vitamins are prescribed for the client with Crohn's disease. The client asks why the vitamins have to be given intravenously (IV) rather than by mouth. Which rationales will the nurse provide? Select the 4 findings that offer the correct rationale.
"They provide more rapid action results." " Oral vitamins are less effective." " Intestinal absorption may be inadequate." " It doesn't rely on liver absorption."
Components of critical thinking?
- Analyze the situation as it happens - Cognitive processes (thinking based on knowledge of client care) - Metacognitive processes (Reflective thinking and awareness of skills learned by a nurse in caring - Setting priorities (Will change and need to do what's needed first) (Be ready to explain the care to the patient) - Develop rationals ( How we react to a situation) - Reflect (look back at the day. Was it good or bad?)
Which action would the nurse take for a client whose right radial pulse is weak and thready? Select all that apply. One, some, or all responses may be correct.
- Assess all peripheral pulses - Assess and compare both radial pulses - Ask a second nurse to assess the client's pulses - Assess for edema or other issues that may be restricting peripheral blood flow - Observe for pallor/skin temperature differences distal to the weak pulse
What is he acronym of the nursing process? what does it stand for?
- Assessment - Diagnosing - Planning - Implementing - Evaluating
Which finding would the nurse identify as normal for a newborn? Select all that apply. One,some, or all responses may be correct.
- Baby's weight is 6 Ibs (2700 g) - Hands and feet appear cyanosed - Head circumference of 33 cm (13 inches)
A client who is positive for human immunodeficiency virus (HIV) is admitted to a surgical unit after an orthopedic procedure. Select the 2 possible routes of HIV transmission.
- Blood - Semen
What functions does bathing have?
- Cleans the skin - Stimulates circulation - Gives a sense of well-being
What are known to foster critical thinking?
- Independence- Feel more free to critically think - Insight to egocentricity- Whats normal to us is unfamiliar to others - Intellectual humility- Admit when wrong - Intellectual courage- Questions those you think are wrong - Perseverance- Never give up - Confidence- Be confident in youself - Curiosity- Ask lots of questions
What is important for skin care?
- Needs to be cleaned to avoid odors from the apocrine glands. - Can assess the skin while bathing the patient - plan for skin care after the hospital - Keep moisture off the skin; Know when to use lotions, moisturizers, and ointments - Make sure the patient is able to care for themselves after they leave the hospital
What is important in assessing feet for feet care?
- Normal foot care practices, self-care ability, risk factors, fissures and other issues such as ingrown nails
What are some things to keep in mind when doing hygiene care at the hospital?
- Try to keep clients early morning routine - Hours of sleep they require - as requested care
What is some need to know information for making a bed?
- Wash hands after handling linens - Hold soiled linens away from the body - Never place linens from one bed on another - Make a wrinkle free bed - Soiled go directly in the hamper - Do not shake the linens - One side of the bed at a time - Gather all linens before stripping the bed
What is important to know about bathing?
- Watching the patient bathe can help assess their functioning ability - Darker skinned patients give off darker skin cells on the white sheets. They are not dirty
What are some examples of people who may be a susceptible host?
- immunocompromised - age (Usually deal with elderly and young) - Immune deficiency (cancer, rheumatoid, diabetics asthma) - Heredity - Stressors (Suppresses the immune system) - Nutrition (Eating healthy is important) - Medical treatment (Chemo, radiation, and surgery) - Diabetics (sickness)
What are some people that definitely need mouth care?
- serious illness - confusion - Coma - Depression - dehydration - NG tube - On O2
client indicates a risk of breast cancer? Select all that apply. One, some, or all The nurse is performing a breast assessment. Which statement made by the responses may belcorrect.
-"My first child was born when I was 32." -"I noticed a slight discharge from a nipple." -"I consume two to four glasses of alcohol a day." - My provider prescribed hormone replacement therapy (HRT)" -"My new diet is not helping me with my obesity very much."
Which action would the nurse implement when a client is receiving total parenteral nutrition (TPN)? Select all that apply. One, some, or all responses may be correct.
-Assess hydration -Monitor weight daily -Infuse using an electric pump -Reassess vital signs every 4 hours -Discard any solution after 24 hours -Check the expiration date before administration
Which intervention would the nurse perform while caring for an actively dying client? Selelt all that apply. One, some, or all responses may be correct.
-Ensure the nurse talks to and not about the client. -Provide client and family reassurance. -Try to set a comfortable environment in the room. -Perform symptom management for the client. -Encourage family to talk to the client.
Which finding noted during assessment would lead the nurse to determine that a client is at an increased risk for infection? Select all that apply. One, some, or all responses may be correct.
-Surgical incision -Urinary catheter -Intravenous access -Antibiotic therapy
A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. Which physiologic change would the hurse expect with this client? Select the 3 findings that the nurse would expect.
-Temporal temperature of 101.2°F (38.4°C) -Radial pulse rate of 72 and irregular -Pain of 6 of 10 with coughing
What are the types of nursing diagnoses?
1. Actual 2. Health promotion 3. Risk nursing diagnoses
What do we look at to evaluate a patient and their ability?
1. Functional ability 2. client status 3. tissue integrity 4. Need for analgesics
What are the 3 types of care plans?
1. Informal 2. Formal 3. Standardized 4. Individualized
What are the phases of planning?
1. Initial 2. Ongoing 3. Discharge planning
What are the four types of nursing assessment?
1. Initial nursing assessment (When we can tell something based on looks) 2. Problem focused assessment (what needs to be taken care of first) 3. emergency 4. Time- lapsed
What is the 3 part statement of the actual nursing diagnoses?
1. NANDA list 2. etiology 3. Evidence by factors
What are the different types of data that can be collected?
1. Past history 2. Subjective 3. Objective 4. Primary 5. Secondary
What are the four steps to the planning process?
1. Set priorities 2. Establish client goals or desired outcomes 3. Selecting nursing interventions and activities 4. Write individualized nursing interventions
Techniques for critical thinking?
1. evaluating the credibility of information sources 2. Clarifying concepts 3. Recognizing assumptions
What is the risk nursing diagnoses?
A problem but is a risk present. A 2 part statement
What is a nursing diagnoses?
A statement of nursing judgment based on education and other skills to treat a patient. Don't need a doctors order to diagnose fever
what is the nursing process?
A systematic problem-solving process that guides all nursing actions
What is virulence?
Ability to produce disease; cause the chance of the disease to go up
What does selecting nursing interventions and activities in the planning process mean?
Actions performed by the nurse to achieve goals and treat S/S
What is the purpose of critical thinking?
Allows for and fuels creativity. Used to get the correct treatment for the patient in ways other then by the book
What is diagnoses for finger nails?
Altered self care or potential for infection
A cient with diarhea also has a primary care provider's order for a buk laxative daly. The nurse, not realizing that bulk laxatives can help solidity certain types of diarrhea, concludes, "The primary care provider does not know the client has diarrhea." What type of statement is this?
An inference
What is secondary data?
Another person outside the patient
What are parasitic infections treated with?
Antifungal
What is a acute a infection?
Appear suddenly and last a short period of time
A cient reports feeling hungry, but does not eat when food is served, Using clinical reasoning skills, the nurse should perform which of the folowing?
Assess why the client is not ingesting the food provided
What are the phases of the nursing process?
Assessment Diagnosis Planning Implementation Evaluation
What is important to know when bathing dementia patients?
Be patient, give choices, one section at a time, ensure privacy
What is the discharge planning phase?
Begins at admission
What is informal care plan?
Call lights and fall alarms. Informal care plans
What is a collaborative intervention?
Carried out in collaboration with other health care team members
Important info for finger nails?
Change with age; cut or file straight across; don't dig; file diabetics rather than cut
What are 3 sources of data?
Client, support people, and client records
client complains of shortness of breath. During assessment the nurse observes that the client has edema of the left leg only. The nurse reviews evidence-based practice literature and reflects on a previous client with the same clinical manifeestions. What do these actions represent?
Clinical reasoning
What is a resident flora?
Collective vegetation in an area; Normal to have in the body
What are individualized nursing interventions?
Conditions, modifiers, time element, Some tasks delegated. Rate/ access the needs of their patients
When the nurse considers that a client is from a developing country and may have a positive tuberculosis test due to a prior vaccination, which critical thinking attitude and skill is the nurse practicing?
Creating environments that support critical thinking
What is standardized care plan?
Day by day goals
What is a disease?
Detectable alteration in normal tissue function
What is assessment with finger nails?
Determine normal nail care practices and self care abilities and make sure to physically inspect
In the clincal reasoning process, the nurse sets and weighs the criteria, examines alternatives, and performs which of the folowing before implementing a plan?
Determine the logical course of action should intervening problems arise
What is the ongoing planning phase?
Done by all nurses, individualized. Done each day when looking at our patients
Why do we diagnose the toe nails on the patients feet?
Each person is different with what they can do and eat they can see on their feet
The nurse notes that the victim of an automobile crash may need cardiopulmonary resuscitation (CPR). Which factor would the nurse remember about performing CPR? Select all that apply. One, some, or all responses may be correct.
Emergency treatment that is provided without a client's consent Not performed on adult clients who have already consented to a do-not- resuscitate order either verbally or in writing Performed on appropriate clients unless a do-not-resuscitate order has been signed and made part of the client's record Can be initiated and performed in the healthcare setting by personnel who hold a Basic Life Support (BLS) certification
The nurse is caring for an obese client with diabetes mellitus. Which nursing action satisfies the Quality and Safety Education for Nurses (QSEN) competency called teamwork and collaboration? Select all that apply. One, some, or all responses may be'correct.
Engaging the physical therapist in managing the client's condition Explaining the client's medication routine to the next shift nurse Consulting with the dietician to help manage the client's condition
What objective data?
Fact based data; can see the problem to fix
A client is diagnosed with hyperthyroidism and is treated with I-131. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which clinical manifestation would be included in the teaching? Select all that apply. One, some, or all responses may be correct.
Fatigue Dry skin Progressive weight gain Constipation
What is important to know for feet care for diabetic patients?
File don't clip them
The nurse is preparing to insert an intravenous (IV) catheter in a client who appears thin and emaciated and is scheduled to begin intravenous fluid therapy. Which interventions would the nurse follow to provide high-quality care? Select all that apply. One, some, or all responses may be correct.
Flush the IV line with normal saline Stop the insertion procedure when there is a break in technique Apply a tourniquet a few inches above the selected site After insertion assess for leaking and swelling
The nurse expects a client with an elevated temperature to exhibit which indicators of pyrexia? Select all that apply. One, some, or all responses may be correct.
Flushed face Increased pulse rate General lethargy Chills
What is asepsis?
Freedom from disease causing organisms
What is a standing order?
Gives nurse the authority to do a specific action under certain circumstances
What is infection?
Growth of microorganisms in body tissues where they aren't usually found. May cause disease
What is setting priorities in the planning process?
High priority are life threatening cases; Middle priority are health threatening cases; Low priority is for developmental needs cases
How would you assess infection?
History, Lab data, and physical assessment
What is a contagious disease?
How easily it can spread
What is a portal of exit for an infection?
How the bacteria escape the reservoir
What is problem solving?
Identify problem, clarify, learn from mistakes or past experience, trial and error, Intuition (sense something is wrong) research process
When is the client not allowed to give data for themselves?
If they are to young or confused from forms of dementia
What is a complete bath?
In the bed and the nurse does all of it
what is critical reasoning?
Integrates thinking and decision making in the clinical setting
The nurse is teaching a client about wound care during a follow up visit in the client's home. Which critical thinking attitude causes the nurse to reconsider the plan and supports evidencebased practice when the client states, "I just don't know how I can afford these dressings"?
Integrity
What is critical thinking?
Intentional higher level of thinking to define problems, examine evidence, and make delivery of care choices
What is the difference between interviewing and examining in collecting data?
Interviewing is from the mouth of the patient and examining is reviewing the patient after interviewing
What is a local infection?
Limited to specific body part; may spread
What is a medical diagnoses?
Made by a physician and refers to a disease process
What is an individualized care plan?
Made just for the patient being dealt with
What is a tub bath?
More rare as it can be dangerous for the patient due to fall risk
Information for ear care?
No q tips and treat hearing aids the same as dentures. Label and put them away
What is a independent intervention?
Not required to have a physicians approval
The nurse is concerned about a client who begins to breathe ery rapidy. Which action by the nurse reflects clinical reasonng?
Obtain vital signs and oxygen saturation
What is a chronic infection?
Occur lowly over a long period and last months or years
What is the acronym for a medical diagnoses and what does it mean?
PES; Problem (NANDA), Etiology (cause), S/S (AEB)
What is a self help bath?
Patient is helping with the bath
The nurse's advocate role for a victim of intimate partner violence (IPV) would include which important component? Select all that apply. One, some, or all responses may be correct.
Planning for future safety Validating the experiences Promoting access to community services
What is health promotion in nursing diagnoses?
Preparedness to change behavior to help health
What is the actual nursing diagnoses?
Problem has S/S associated. A 3 part statement
What is important to do with dentures?
Put them directly into a case and label where it went in the patients documents. Wash over a washcloth to avoid breaking if dropped
Which information would the nurse provide to a client diagnosed with chlamydia and prescribed doxycycline? Select all that apply. One, some, or all responses may be correct.
Report woksening symptoms. Refrain from sexual relations. Use barrier protection devices. Contact provider for continued infection. Contact partners to be tested. Take the entire course of antibiotics. Wear protective clothing when outside.
A 50-year-old client is diagnosed with chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 86 beats/min, a blood pressure of 142/82 mm Hg, a respiratory rate of 32 breaths/min, a tynipanic temperature 98.2°F (36.8°C), oxygen saturation of 88%, and general discomfort with pain 2 out of 10. Which vital signs obtained by the nurse indicate an improvement in condition? Select the 3 findings that indicate client improvement.
Respiratory rate: 14 breaths/min Blood pressure: 110/70 mm Hg Oxygen saturation: 92%
The nurse caring for a client postoperatively takes necessary steps to achieve quality client care. Which nursing action satisfies the Quality and Safety Education for Nurses (QSEN) competency called informatics? Select all that apply. One, some, or all responses may be correct.
Responding to generated alerts that cue necessary treatment procedures Documenting in the electronic health record (EHR) after performing wound care Locking the electronic health record (EHR) after every entrance of necessary information Using a computer-assisted instruction (CAI) program to provide better quality of care to the client
What is the acronym used for making goals?
SMART
What is a towel bath?
Same as a wash cloth bath just uses a towel
What are some ways to provide hair care?
Shower or sink but may be able to use a shower cap if can't move from the bed
What is a susceptible host?
Someone who lacks an effective resistance to a disease
what does the acronym SMART mean?
Specific, Measurable, Attainable, Relevant, Timely
What is a communicable disease?
Spreadable
What is a systemic infection?
Spreads to and damages different body parts; from bacteria
What are diagnostic labels?
Standardized NANDA name for the diagnoses; Give extra meaning to the cause of the disease
What is the 2 part statement of Risk nursing diagnoses?
Stem and etiology
What is primary data?
Straight from the patient
What is surgical asepsis?
Surgical Asepsis - Sterile - Eliminates all organisms, both pathogenic and non-pathogenic, including spores
What are characteristics in a nursing diagnoses?
The S/S noted in the chart to help find the problem
The client who is short of breath benefits from the head of the bed being elevated. Because this position can result in skin breakdown in the sacral area, the nurse decides to study the amount of sacral pressure occurring in other positions. What decision-making is the nurse engaging in?
The research method
What is etiology?
Treated by the nurse. Patho diagnoses not medical. The probable cause and give directions for fixing the issue
What is a bacterial infection treated with?
Treated with antibiotics
What does validation mean in nursing assessment?
Using signs to find what the patient has
The nurse is caring for a client who is terminally ill with cancer. The health care team meets and agrees to provide the client with information to help the client make decisions regarding treatment. Which ethical principle is applied in this situation? Select all that apply. One, some, or all responses may be correct.
Veracity Autonomy Justice Fidelity
What is a partial bath?
Washing all the dirtiest parts of the body
What is subjective data?
Whats being told to you
When bathing a patient when is it important to wear gloves?
When doing perineal- genital care
When do you use a short term goal?
When it is a short term recovery
What is past history data?
When the s/s started
What is the port of entry?
Where microorganisms find their way onto or into a new host, facilitating their relocation.
What is a reservoir in an infection?
Where they are located
What does establishing client goals or desired outcomes mean?
Write in patient responses; provide direction for care; motivate client and nurse
What is a nosocomial infection?
an infection acquired in a hospital; Would be considered the hospitals fault. They would, be charged for all services
What is critical analysis?
application of questions to a situation to get rid go unimportant ideas
What is formal care plans?
best for patient. Needs to be formally written up
What is hygiene?
care of skin, feet, nails, oral and nasal cavities, teeth, hair, eyes, ears, genitals
What is a dependent intervention?
carried out under doctors orders
What is a endogenous infection?
comes from the patient
What's initial planning phase?
develop initial plan of care after 1st assessment
What are supportive people with sources of data?
family, friends, caregivers all can have a say in the care of the patient if they are unconscious
What is the research process?
formalized, logical, systematic approach to problem solving
What is a exogenous infection?
from microorganisms outside the individual
What is inductive reasoning?
generalization formed from a set of facts and observations. Specific premises to general observations. Dry skin, sunken eyes, and dark urine are all examples. Use s/s to find this out.
What is the mode of transmission for an infection?
how it is transmitted. Direct, indirect, or airborne
What is the purpose of the nursing process?
identify the clients needs or problems clients needs or problems, make plans, deliver whats needed
What is a bacterium infection?
in the blood
What are the 3 types of interventions?
independent, dependent, collaborative
What is medical asepsis?
limit in the growth, number, and transmission of the organism.
What is planning for nail care?
maintain or restore health practices and establish schedule for nail care
What is socratic questioning?
posing questions in seek of answers to find the issue of the patient
What is deductive reasoning?
reasoning from general premise to specific conclusions. Does not use S/S for the premise.
What is viral infections treated with?
some may have antivirals such as tamiflu but may have to run its course
What is a diagnosis?
the problem
What is an etiology factor?
what causes the infection. Without one there is no issue
