NSG 212 Final Exam Review

What symptom is presented in mostly older adults that have a suspected UTI?

Delirium

What is the Z-track method?

Displace the subcutaneous tissue to get to muscle

What is a tool nurses can use to get a supervisor's attention when it is needed?

Concerned Uncomfortable Safety

What is the Health-Illness Continuum Model?

measures a persons level of health on graduated scale

What is the servant leadership style?

meet the needs of those they lead and help them grow

What is an unstageable pressure injury?

necrosis/escar/slough

How many mL of solution can be used in subq injections?

no more than 1 mL

What is a Stage 1 pressure injury?

non-blanchable erythema of intact skin

What is a chronic illness?

persists longer than 6 months; incurable but treatable in most cases

What is the function of antiembolytic stockings

prevent DVT by keeping the circulation with pressure

How is the Health Promotion Model used?

provides the nurse with interventions to promote health for people, families, and communities

What is an acute illness?

rapid onset of symptoms and lasts only a short time

How can nurses help a patient meet their self-esteem needs?

respecting their values and beliefs, encouraging patients to set attainable goals, and facilitating support from family/friends, or significant others.

What is intrapersonal communication?

self-talk

Why would you use the Health Belief Model?

teaching about health and illness, and assessing the patient's related beliefs and goals

What is a fecal occult blood test?

tests for blood in stool

Why should you always inquire if patient's are taking herbal supplements?

there are several drug interactions

What are the benefits of aroma therapy?

○ Calming ○ relieves pain ○ Sleep disorders ○ Anxiety ○ Nausea

How do you obtain a urine specimen from a Foley Catheter?

○ Clamp for no more than 30 minutes ○ 10 mL syringe (without needle) ○ Scrub the hub with alcohol pad ○ Draw from collection port ○ Unclamp the tube!! ○ Pt name, date, time

What can we do to make sure hard-of-hearing patients hear us?

○ Eye contact ○ Make sure they can see your lips ○ Quiet environment ○ Lower tone of voice to talk ○ Make sure hearing aids are in

What would a patient's lab look like if they had an infection?

○ Increased WBC ○ Sediment in urinalysis

What signs and symptoms would a patient present if they had an infection?

○ Increased temp ○ Increased heart rate ○ Decreased blood pressure ○ poor appetite

What are the benefits of yoga?

○ Relaxation ○ Decreased stress ○ Increased muscle tone

What is guided imagery?

○ Relaxation using images ○ Using 5 senses to picture themselves in that place

A patient is suspected of being incontinent. What actions should the nurse take first?

Try noninvasive interventions

What is the nurse's role in promoting health and preventing illness?

We can eliminate disparities in health care that improves the quality of life for all people; also taking care of their own health to be able to give effective nursing care to others

What is the transformation leadership style?

Whole team is a part of the change (input from whole team)

How is the Health-Illness Continuum Model used?

conceptualize a person's level of health

What is the impact of community in relation to individual health?

enables a person to maintain a high quality of life and productivity

What is an example of meeting a client's safety and security needs?

encouraging spiritual practices that provide strength and support

What is an example of meeting a client's love and belonging needs?

establishing a nurse-patient relationship based on mutual understanding and trust

How is the Agent-Host-Environment Model used?

explains how certain factors place some people at risk for an infectious disease

How can nurses help meet a patient's self-actualization needs?

focus on the person's strengths and possibilities rather than on their problems

What is the health belief model?

focuses on what people perceive or believe to be true about themselves in relation to their health

What is a Stage 4 pressure injury?

full thickness skin and tissue loss

What is the Health Promotion Model?

illustrates how people interact with their environments as they pursue health

What must we educate our patients to do when collecting a stool sample for a fecal occult blood test?

"Please make sure urine is not mixed with the sample"

What is the Laissez faire leadership style?

"Hands off" approach; can't tell who is in charge

. A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose (Round the answer to the nearest tenth) ?

0.2 mL

What indicates an upper G.I bleed?

Black tarry stool

What safety precautions should be taken to prevent poisoning in young children?

Call poison control, lock up cleaning supplies and meds.

What is the autocratic leadership style?

Leader completely controls direction and structure; limited group interactions

How should you turn patients that had a total hip replacement?

Log roll

What is continuity of care?

Process by which health care providers give appropriate, uninterrupted care and facilitate the patient's transition between different settings and levels of care

Why do we utilize Maslow's Hierarchy of Needs in nursing?

This can help a nurse identify unmet needs as they become health care needs

What is the Stages of Change Model and how is it used?

This is a model used to assess a patient's readiness to make a change

How do you educate a patient to collect a 24 hr urine collection?

Throw away first void, then complete.

What assessment finding would indicate a possible paralytic ileus after surgery?

absent bowl sounds in a 4 quadrants

What indicates a lower G.I bleed?

bright red blood in stool

What is interpersonal communication?

communication between two people

What is the Agent-Host-Environment Model?

views the interaction between an external agent, a susceptible host, and the environment as causes of disease in a person

What tasks can be delegated to a UAP?

○ Ambulation (not right after surgery or first time doing it) ○ Bed baths ○ Oral care ○ Vitals ○ Intake and output ○ No assessment or education

What is one thing to remember about spirituality?

A person can be spiritual without belonging to a certain religion

What position should a patient that has dysphagia be kept in?

High Fowler's

Where is Sensory overload the most common?

ICU

What is a revised approach to handoffs?

ISBARQ

What is the fastest and slowest absorption route?

IV and PO

Upon auscultation, would you be able to hear bowel sounds in a patient with a G.I obstruction?

If it is small enough, yes.

Do you collect a wound culture from inside or outside the wound?

Inside because the outward has different flora

What does ISBARQ stand for?

Introduction Situation Background Assessment Recommendation Question and Answer

What would cause Sensory deprivation the most?

Isolation

What is an example of meeting a client's physiological needs?

Oral care

What is the most essential physiological need?

Oxygen

What is a Stage 2 pressure injury?

Partial-thickness loss of skin with exposed dermis

What is the most popular approach to handoffs?

SBAR

What position should a patient that just had a total hip replacement be placed in for insertion of a foley catheter?

Sim's position

What defines the scope of legal nursing practices?

State Legislature

What is the most effective way to teach a client?

Teach-back method

What signs can a patient present if they are in the process of dying?

- Cheyne-Stokes sounds (death rattle) - cool skin temperature - unconsciousness - low urine output - muscle tone decreases - hunger decreases

What are the six health dimensions?

- Physical - Emotional - Sociocultural - Spiritual - Environmental - Intellectual

What are some examples of community factors affecting health?

- air and water pollution - food sanitation - number and availability of health care institutions an services - recreational opportunities - employment opportunities

What does the Achieving Recovery and Rehabilitation stage include?

- begin in the hospital and conclude at home or rehab center - person gives up dependent role and resumes normal activities/responsibilities - person MAY return at a higher level of functioning and health than before illness

What are the sites for IM injections in adults?

- deltoid - ventrogluteal

What are the length of needles used for IM injections in adults?

- deltoid (5/8"-1 1/2") - ventrogluteal (1'- 1 1/2")

What does the Experiencing Symptoms stage include?

- first indication of an illness - pain is the most common symptom

What can we do to prevent skin breakdown?

- moisture barrier cream - turn pt every 2 hours - do not leave sheets wrinkled - use warm water - use pressure-relieving devices

What are some examples of community-based nursing care?

- neighborhood clinics - patient's homes - long-term care facilities - schools - churches - prisons

What are the roles of a community-based nurse?

- patient advocate - coordinator of services -patient and family educator

What does the Assuming a Dependent Role stage include?

- patient's decision to accept the diagnosis and follow treatment plan - goal is both the caregivers and family is to get well and assume normal roles

What are the components involved int the Stages of Change Model?

- precontemplation - contemplation - commitment to action - implementing the plan - maintenance, relapse, and recycling

What does the Assuming the Sick Role stage include?

- seeks validation of this experience form others - gives up normal activities - the person may chose to do nothing, research symptoms, buy over the counter meds - try alternative remedies - seek out HCP for diagnosis and treatment

What are the sites for IM injections in children?

- vasa lateralis - deltoid

What are the qualities of a community-based nurse?

-Knowledgeable and skilled -Independent in making decisions -Accountable

How many mL of solution can be used in IM injections?

1 mL, but up to 2 mL can be administered

What are the 4 stages of illness behaviors?

1) Experiencing symptoms 2) Assuming the Sick Role 3) Assuming a Dependent Role 4) Achieving Recovery and Rehabilitation

What 3 components are included in the health belief model?

1) Perceived susceptibility 2) Perceived seriousness 3) Perceived benefits of action

What is the order of Maslow's hierarchy of needs from bottom to top?

1) Physiological needs 2) Safety needs 3) Love and belonging 4) esteem 5) self-actualization

What does community-based nursing care provide?

1) manage acute and chronic health problems 2) promote health 3) facilitate self-care

What gauges of needles are used in subcutaneous injections?

25-30

What length of needles are used in subcutaneous injections?

3/8"-1"

A nurse is preparing to infuse a 250-mL unit of packed RBCs over 2 hr. The drop factor of the manual IV tubing is 15 gtts/mL. The nurse should adjust the flow rate to deliver how many drops per minute (Round to the nearest whole number)?

31 gtts/min

What angle should you inject the needle for a subq injection?

45-90 degrees

What angle should you inject the needle for a intradermal injection?

5-15 degrees

What are the length of needles used for IM injections in children?

5/8"-1"

A nurse is caring for a client who is to receive liquid medications via a gastrostomy tube. The client is prescribed phenytoin 250 mg. The amount available is phenytoin oral solution 25 mg/5 mL. How many mL should the nurse administer per dose (Round the answer to the nearest whole number)?

50 mL

What angle should you inject the needle for an IM injection?

90 degrees

When you need a wound culture, do you clean the wound before collection or after?

Before; do not give meds before culture

What position would you normally put patients in for insertion of a foley catheter?

Dorsal Recumbent

T/F: Call the pharmacy to get a list of all medications

FALSE! Any herbal supplements a patient is taking will not be listed in their prescribed meds

What is a Stage 3 pressure injury?

Full-thickness skin loss Subcutaneous tissue and underlying fascia may be damaged