240 Exam 2

Question 1

7 medication rights

Answer 1

right patient
right drug
right route
right time
right dose
right reason
right documentation

Question 2

3 medication safety checks

Answer 2

When the nurse reaches for the container or unit dose package

After retrieval from the drawer and compared with the eMAR/MAR, or compared with the eMAR/MAR immediately before pouring from a multidose container

Before giving the unit dose medication to the patient or when replacing the multi-dose container in the drawer or shelf

Question 3

signs and symptoms of hypoglycemia

Question 4

signs and symptoms of hyperglycemia

Question 5

zofran nursing considerations

Question 6

nurse practice acts (ch 7)

Answer 6

law established to regulate nursing practice
protects the public by broadly defining the legal scope of nursing practice

Question 7

negligence (ch 7)

Answer 7

performing an act that a reasonably prudent person under similar circumstances would not do, or failing to perform an act that a reasonably prudent person under similar circumstances would do

Question 8

false imprisonment (ch 7)

Answer 8

Unjustified retention or prevention of the movement of another person without proper consent

The indiscriminate and thoughtless use of restraints on a patient can constitute false imprisonment

Question 9

standards of care (ch 7)

Answer 9

expectation of nurse role

Question 10

informed consent

Answer 10

informed and voluntary consent is needed for admission, for each specialized diagnostic or treatment procedure
consent must be written, designated for the procedure to be performed, and signed by the patient or person legally responsible for the patient
must be 18 or older
informed consent is not needed in an emergency

Question 11

scope of practice (ch 7)

Answer 11

legal boundaries of nursing care

Question 12

clinical reasoning model (ch 13)

Answer 12

use of inductive and deductive reasoning
Thought process that allows HC providers to arrive at a conclusion

Question 13

clinical judgment model (ch 13)

Answer 13

skill of recognizing cues regarding a clinical situation, generating and weighing hypotheses, taking action, and evaluating outcomes for a satisfactory clinical outcome

tanners clinical judgment model:
Noticing: initial grasp and perceptions of the situation that are impacted by context, the nurse’s practical experience, knowledge of expected versus unexpected data, ethical perspectives, and the nurse–patient relationship
Interpreting: attributing meaning to the data through multiple reasoning patterns
Responding: deciding on an action (or inaction) and monitoring outcomes
Reflecting: in-action and on-action

Question 14

nursing process (ch13)

Answer 14

ADPIE
used by the nurse to identify the patient’s health care needs and strengths, to establish and carry out a care plan to meet those needs, and to evaluate the effectiveness of the plan to meet established outcomes

Question 15

Nursing assessments focus on

Answer 15

the patient’s response to health problems

Focus on the person, physiological and psychological response to the illness. able to meet basic human needs? perform ADL’s

Question 16

SMART goals (ch 14)

Answer 16

S: specific
M: measurable
A: Achievable
R: realistic
T: timely

Question 17

ADPIE (ch 14)

Answer 17

A: assessment
D: diagnosis/ problem identification
P: planning
I: implementation
E: evaluation

Question 18

Maslows hierarchy (ch 15)

Answer 18

bottom to top:

physiological needs
safety
love/belonging
self esteem
self actualization

Question 19

ANA standard of practice 1 (ch 15)

Answer 19

Assessment
RN collects comprehensive data r/t the persons health or the situation

Question 20

Prioritization (ch 16)

Answer 20

ALWAYS THINK OF ABCs
Three helpful guides to determine priority in patient needs include Maslow’s hierarchy of human needs, patient preference, and anticipation of future problems.

High priority: greatest threat to patient well-being
Medium priority: nonthreatening diagnoses
Low priority: diagnoses not specifically related to current health problem

Question 21

ANA standard of practice 2 (ch 16)

Answer 21

population diagnosis and priorities
analyze assessment data to determine diagnosis

Question 22

ANA standards of practice 3 and 4 (ch 17)

Answer 22

outcome identification and planning

identify expected outcomes to make a plan
Develops a plan that reflects best practices by identifying strategies, action plans, and alternatives to attain expected outcomes.

Question 23

ANA delegation of tasks: 5 rights of delegation (ch 18)

Answer 23

right task
right circumference
right person
right directions and communication
right supervision and evaluation

Question 24

ANA standards of practice 5 (ch 18)

Answer 24

implementation

Implements the identified plan by partnering with others

Question 25

holistic nursing and natural products (ch 29)

Answer 25

Healing the whole person is its goal. People have a mind, body, emotions, and spirit that are connected and function as a unified whole. A change in any part of the organism will be reflected in other parts natural products: nutritional and herbal remedies

Question 26

Functions of the integumentary system (ch 33)

Answer 26

protection, temperature regulation, psychosocial, sensation, vitamin D production, immunologic, absorption, and elimination

Question 27

risk factors for skin alterations (ch 33)

Question 28

types of wounds (ch 33)

Answer 28

intentional or unintentional open or closed acute or chronic partial thickness, full thickness, complex

Question 29

etiology of wounds and pressure injuries (ch 33)

Answer 29

surgical (intentional, controlled, sterile), traumatic (may require additional intervention such as fluid administration or a tetanus shot), neuropathic or vascular (related to an underlying neurologic and/or circulatory issue), or pressure related

Question 30

Prevention measures for skin (ch 33)

Question 31

wound and tissue repair/healing cascade (ch 33)

Answer 31

Hemostasis Inflammatory Proliferation Maturation

Question 32

staging of pressure injuries (ch 33)

Answer 32

Stage 1: nonblanchable erythema of intact skin Stage 2: partial-thickness skin loss with exposed dermis Stage 3: full-thickness skin loss; not involving underlying fascia Stage 4: full-thickness skin and tissue loss Unstageable: obscured full-thickness skin and tissue loss Deep tissue pressure injury: persistent nonblanchable deep red, maroon, or purple discoloration

Question 33

special population needs for skin care (ch 33)

Question 34

effects of nutrition on health/wellness/illness/injury (ch 37)

Answer 34

healing wounds require adequate proteins, carbohydrates, fats, vitamins, and minerals All phases of the wound healing process are slowed or inadequate in the patient with poor nutritional status and fluid imbalance.

Question 35

BMI- normal and healthy values (ch 37)

Answer 35

18.5-24.9 = healthy BMI below 18.5 is underweight BMI of 18.5 to 24.9 is a healthy weight BMI of 25 to 29.9= overweight person BMI of 30 to 39.9 indicates Obesity BMI of 40 or greater indicates extreme obesity.

Question 36

significance of waist circumference (ch 37)

Answer 36

Waist circumference is a good indicator of abdominal fat abdominal obesity poses greater risk for cardiovascular disease and diabetes

Question 37

digestive process (ch 37)

Answer 37

Digestion begins in the mouth where food is taken in, mixes with saliva pushed into the pharynx by the tongue continues into the esophagus Peristalsis moves the food through the esophagus and into the stomach stomach churns the ingested food, mixing it with substances to break down the food and convert it to a semiliquid mixture The food leaves the stomach and enters the small intestine The small intestine secrets enzymes, which, along with secretions from the liver and pancreas, digest the food. The digested nutrients are then transferred into the person’s circulation (absorption), to be transported throughout the body.

Question 38

clinical indicators of nutritional status (ch 37)

Question 39

PEG and J tube (ch 37)

Answer 39

A gastrostomy may be used for patients who have impaired chewing and swallowing related to neurologic diseases (stroke, multiple sclerosis) or obstruction of the upper respiratory and/or digestive tract, as in head and neck cancers; patients with oncologic health problems associated with malnutrition; and patients with other health issues that lead to malnutrition, such as chronic renal failure, cystic fibrosis, or Crohn disease

Question 40

Vitamin A: s/s of low values and how the patient would present

Answer 40

fat-soluble affects visual acuity, skin and mucous membranes and immune functions s/s: night blindness

Question 41

Vitamin D

Answer 41

fat-soluble provides calcium and phosphorus metabolism and stimulates calcium absorption

Question 42

Vitamin E

Answer 42

fat soluble antioxidant that protects Vitamin A

Question 43

vitamin K

Answer 43

fat soluble helps the synthesis of certain proteins necessary for blood clotting

Question 44

urinary testing procedures (ch 38)

Answer 44

Routine urinalysis: checks for protein/blood/glucose/ketones, specific gravity- density of urine Clean-catch or midstream specimens Sterile specimens from indwelling catheter Urine specimen from a urinary diversion 24-hour urine specimens Point-of-care urine testing

Question 45

developmental changes in urinary function (ch 38)

Answer 45

children: toilet training 2-5 years old aging adults: Nocturia, Increased frequency, Urine retention and stasis, Voluntary control affected by physical problems

Question 46

bladder training (ch 38)

Answer 46

involves biofeedback and muscle training

Question 47

toileting self-care behaviors (ch 38)

Question 48

role of the pelvic floor in micturition (ch 38)

Answer 48

Detrusor muscle contracts, internal sphincter relaxes, urine enters posterior urethra Muscles of perineum and external sphincter relax Muscle of abdominal wall contracts slightly Diaphragm lowers, micturition occurs

Question 49

urinary diversions (ch 38)

Answer 49

Ileal conduit suprapubic catheter

Question 50

peristalsis (ch 39)

Answer 50

move waste products along the length of the intestine continuously

Question 51

laxatives (ch 39)

Answer 51

promote peristalsis laxatives makes pt go, stool softeners helps the patient go

Question 52

stool softeners (ch 39)

Answer 52

Agents with surfactant activity that decrease the tension between water and fat and lubricate the stool

Question 53

iron supplements (ch 39)

Question 54

chronic vs acute bleeding & s/s (ch 39)

Question 55

developmental changes in bowel function (ch 39)

Answer 55

constipation is often a chronic problem for older adults (constipation is not a normal part of aging) decreased peristalsis

Question 56

post-procedural changes in bowel function and aftercare (ch 39)

Answer 56

Direct manipulation of the bowel during abdominal surgery inhibits peristalsis, causing a condition termed postoperative Paralytic ileus temporary stoppage of peristalsis normally lasts 3 to 5 days.

Question 57

Flatus definition and etiology

Answer 57

gas caused by swallowing more air than usual or eating food that's difficult to digest

Question 58

ostomy types (ch 39)

Answer 58

colostomy urostomy Ileostomy

Question 59

empty and change ostomy appliance (ch 39)

Question 60

ISBAR

Answer 60

I: identify S: situation B: Background A: Assessment R: recommendation

Question 61

aim of nursing practice

Answer 61

To promote health To prevent illness To restore health To facilitate coping with disability or death

Question 62

Recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking actions, and evaluating outcomes are steps included in which model? A. Clinical Judgment Measurement Model B. Tanner’s Model C. The Nursing Process D. Developing Nurses’ Thinking Model

Answer 62

A. Clinical Judgment Measurement Model

Question 63

elements of a healthy work environment

Answer 63

Skilled communication True collaboration Effective decision making Appropriate staffing Meaningful recognition Authentic leadership

Question 64

types of nursing interventions

Answer 64

Nurse-initiated: actions performed by a nurse without a physician’s order Physician-initiated: actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders Collaborative: treatments initiated by other providers and carried out by a nurse

Question 65

open wound

Answer 65

inten/uninten= incision or abrasion- road rash

Question 66

closed wound

Answer 66

car accidents (air bag), fall, skin surface intact- but underlying tissue is damage- ecchymosis, hematoma

Question 67

acute wound

Answer 67

heal quickly- days to weeks. Edges approximate- go thru the healing cascade without delay/intruption…more on this

Question 68

chronic wound

Answer 68

4-6 weeks or longer…something has interrupted the healing cascade and has delayed the closure of the wound. Increasing risk for infection

Question 69

classification of pressure injuries

Answer 69

(1) partial thickness where all or a portion of the dermis is intact (2) full thickness where the entire dermis, sweat glands, and hair follicles are severed, which can expose bone, tendon, or muscle (3) unstageable, a full-thickness loss where the true depth cannot be determined (4) deep pressure-induced tissue damage

Question 70

hemostasis phase

Answer 70

happens very quickly (minutes) involved blood vessels constrict and clotting begins (fibrin/scab) exudate (wound drainage) is formed causing swelling and pain increased perfusion results in heat and redness

Question 71

inflammatory phase

Answer 71

duration: 2-3 days leukocytes and macrophages, move to the wound 24 hr mark- macrophages enter the wound fibroblasts fill the wound increase in body temp and WBC patient feels generalized body response (malaise)

Question 72

proliferation phase

Answer 72

lasts for several weeks New tissue is built to fill the wound space through the action of fibroblasts. new filler tissue is highly vascular thin layer of epithelial cells forms across the wound

Question 73

maturation phase

Answer 73

Final stage of healing; begins about 3 weeks after the injury, possibly continuing for months or years collagen is remodeled

Question 74

Vitamins A and C are essential for

Answer 74

epithelialization and collagen synthesis.

Question 75

Zinc plays a role in

Answer 75

proliferation of cells.

Question 76

Fluids are necessary for

Answer 76

optimal function of cells

Question 77

waist to hip ratio

Answer 77

screening tool to identify central obesity WHR is calculated by dividing the patient’s waist circumference by the hip circumference men= > 40 inches, women= >35 inches

Question 78

folic acid

Answer 78

supplementation prior to conception and during pregnancy reduces the risk of neural tube defects

Question 79

QSEN competencies

Answer 79

Patient-centered care Teamwork and collaboration Evidence-based practice Quality improvement Safety Informatics

Question 80

Avulsion

Answer 80

tearing of a structure from normal anatomic position

Question 81

Keloid

Answer 81

excitable tissue formation (when extra tissue is formed)

Question 82

Atelectacis

Answer 82

complete or partial collapse of the entire lung or area (lobe) of the lung

Question 83

different types of enemas

Answer 83

Cleansing Retention: Oil: lubricate the stool and intestinal mucosa, easing defecation Carminative: help expel flatus from the rectum Medicated: provide medications absorbed through the rectal mucosa Anthelmintic: destroy intestinal parasites Large volume Small volume

Question 84

combination of allopathic and complementary and alternative modalities

Answer 84

integrative health care

Question 85

to evaluate for hypoxia which test should be ordered

Answer 85

Arterial blood gas (ABG)

Question 86

saturated vs unsaturated fats

Answer 86

saturated: raise cholesterol levels most animal fats solid at room temp unsaturated: lower cholesterol levels vegetable fats

Question 87

which type of fat raises cholesterol levels

Answer 87

saturated fats

Question 88

what vitamin is found only in food made from animals

Answer 88

vitamin B12

Question 89

a nurse is managing a continuous tube feeding via NG tube. how often should the nurse check for residual

Answer 89

every 4-6 hours

Question 90

most absorption occurs in the

Answer 90

small intestine

Question 91

a client on warfarin would be educated to have caution about eating foods containing which nutrient

Answer 91

vitamin k

Question 92

dehiscence

Answer 92

"I feel like something just popped" separation of wound layers

Question 93

function of large intestine and colon

Answer 93

absorption of water formation of feces expulsion of feces from the body

Question 94

black stools caused by

Answer 94

iron salts, pepto

Question 95

upper GI bleeds have which characteristics

Answer 95

black, tarry, coffee ground emesis

Question 96

when administering an enema lay the patient on which side

Answer 96

left side

Question 97

Acupunture

Answer 97

Acupuncture either increases or decreases the flow of qi along the meridian, restoring the balance of yin and yang

Question 98

1st stool passed is the start of the collection period

Question 99

nasogastric (NG) tube

Answer 99

tube is inserted and used to decompress or drain the stomach of fluid or unwanted stomach contents

Question 100

Anuria

Answer 100

less than 50 mL in 24 hours

Question 101

24 urine collection is started

Answer 101

after the patient urinates and that sample is discarded

Question 102

stress incontinence

Answer 102

involuntary loss of urine elated to increased intra-abdominal pressure

Question 103

medications that affect urine production

Answer 103

Diuretics: prevent reabsorption of water and certain electrolytes in tubules Lasix- HCTZ-common in txmt of htn, HF Cholinergic medications: stimulate contraction of detrusor muscle, producing urination Analgesics and tranquilizers: suppress CNS, diminish effectiveness of neural reflex

Question 104

furosemide

Answer 104

diuretics lasix increase urine production and common in the treatment of hypertension and heart failure

Question 105

Transient incontinence

Answer 105

appears suddenly and is usually caused by an illness or temporary problem that is short-lived or treatable It is usually caused by treatable factors, such as confusion secondary to acute illness or infection or as a result of medical treatment, such as the use of diuretics or intravenous fluid administration

Question 106

Ileal Conduit

Answer 106

attaches ureters to the bowel

Question 107

suprapubic catheter

Answer 107

Long term continuous drainage- spinal cord injury, prostate /obstruction/ cancer Less risk for contamination

Question 108

trans fats

Answer 108

Trans fats are a form of dietary fat that raise LDL (“bad”) cholesterol and lower HDL (“good”) cholesterol Naturally occurring trans fats are produced by some animals and small amounts of these trans fats are present in some meat (e.g., beef, lamb) and dairy products (e.g., milk)

Question 109

water percent of total weight

Answer 109

Accounts for between 50% and 60% of adult’s total weight

Question 110

Anticoagulants may cause Hematuria (blood in the urine), leading to a pink or red color. Diuretics can lighten the color of urine to pale yellow. Phenazopyridine, a urinary tract analgesic, can cause orange or orange-red urine. The antidepressant amitriptyline or B-complex vitamins can turn urine green or blue-green. Levodopa (L-dopa), an antiparkinson drug, and injectable iron compounds can lead to brown or black urine.

Question 111

Irritable bowel disease (IBD)

Answer 111

crohns and ulcerative colitis

Question 112

irritable bowel syndrome (IBS)

Question 113

malpractice is a _____ law

Answer 113

common law

Question 114

nurse practice acts fall under which laws

Answer 114

statutory laws The state nurse practice act is the most important law affecting nursing practice. Each nurse practice act protects the public by broadly defining the legal scope of nursing practice.

Question 115

four components of a diagnosis

Answer 115

Label Definition Defining characteristics Related factor

Question 116

implementation step involves

Answer 116

1. Determining how to implement the planned interventions 2. Delegating 3. Communicating 4. Teaching others

Question 117

Cholinergic medications on urine production

Answer 117

stimulate contraction of detrusor muscle, producing urination

Question 118

diagnosis step involves

Answer 118

how an individual, group, or community responds to actual or potential health and life processes etiology strengths and weaknesses

Question 119

planning step involves

Answer 119

Establish priorities. Identify and write expected patient outcomes. ("the pt will...") Select evidence-based nursing interventions. Communicate the care plan.

Question 120

types of urinary incontinence

Answer 120

Transient: appears suddenly and lasts 6 months or less Overflow/chronic retention: overdistention and overflow of bladder Functional: caused by factors outside the urinary tract Reflex: emptying of the bladder without sensation of need to void, spinal cord injuries- no urge to void Stress: involuntary loss of urine related to an increase in intra-abdominal pressure (laughing, sneezing, coughing) Mixed: urine loss with features of two or more types of incontinence Total: continuous, unpredictable loss of urine

Question 121

what two things must be present for pressure injuries to occur

Answer 121

unrelieved pressure mobility limitation

Question 122

scheduling diagnostic tests for stool

Answer 122

1: fecal occult blood test 2: barium studies (should precede UGI) 3: endoscopic examinations