Exam 3

Question 1

SBAR

Answer 1

situation, background, assessment, recommendation

Question 2

oxygenation assessment

Answer 2

usual pattern of respirations or recent changes, respiratory infection (sputum, coughing, fever), medications, smoking, pain, dyspnea, fatigue, allergies

Question 3

adventitious sounds

Answer 3

crackles, coarse, wheeze

Question 4

crackles

Answer 4

soft high-
pitched, heard on
inspiration (fluid)

Question 5

Coarse

Answer 5

low pitched,
secretions can clear
with coughing

Question 6

wheezing

Answer 6

Musical
sounds heard on
inspiration and/or
expiration
10

Question 7

Capnography

Answer 7

Measures ventilation and
indirectly blood flow through
the lungs. Exhaled air pases
through a sensor that
measures the amount of
carbon dioxide exhaled with
each breath.

Question 8

Deep Breathing

Answer 8

Semi-Fowlers position
* Ask patient to:
* Exhale completely
* Inhale through the nose
* Hold 3-5 seconds
* Exhale thru pursed lips
* Repeat
* Done every 1-2 hours

Question 9

Effective Coughing

Answer 9

• Semi-Fowlers position & a splint
  pillow
• Ask patient to:
• Inhale & exhale deeply
  slowly thru nose
• Take deep breath & hold
  3 secs.
• Cough deeply 1-2 times
• Done every 2 hours while awake

Question 10

Expectorants

Answer 10

• Facilitate removal of
  secretions by thinning
  secretions
• Guaifenesin (Robitussin)
• Humidified air &
  Adequate fluid intake

Question 11

Suppressants

Answer 11

• Used for dry, non-
  productive cough
• Depresses cough reflex
• Codeine, prescription
  required
• Usually at bedtime

Question 12

Nebulizers

Answer 12

disperse fine particles of
liquid medication into the deeper
passages of the respiratory tract

Question 13

Meter-dose inhalers

Answer 13

deliver a
controlled dose of medication with
each compression of the canister

Question 14

Dry powder inhalers

Answer 14

breath-
activated delivery of medications

Question 15

spices

Answer 15

 S – Sleep disorders
 P – Problems with eating or feeding
 I – Incontinence
 C – Confusion
 E – Evidence of falls
 S – Skin breakdown

Question 16

intentional torts

Answer 16

Assault (threat)
Battery (actual contact)
Defamation of character
Invasion of privacy
False imprisonment
Fraud

Question 17

unintentional torts

Answer 17

Negligence:
Below the standard of care,
“reasonably prudent person”
Malpractice
Failure to carry out duty 
caused injury

Question 18

Four Elements of Liability: Malpractice
Elements

Answer 18

duty, breach of duty, causation, damages

Question 19

Elements of Informed Consent

Answer 19

Disclosure
Comprehension
Competence
Voluntariness

Question 20

Cleansing Enemas

Answer 20

Tap water
Soap suds
Fleets most common

Question 21

retention enemas

Answer 21

oil, medicated

Question 22

TEACH

Answer 22

T: Tune into the patient
* E: Edit patient information
* A: Act on every teaching moment
* C: Clarify often
* H: Honor the patient as a partner in the
education process

Question 23

Ask Me 3

Answer 23

1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this>

Question 24

Three Learning
Domains

Answer 24

• Cognitive: storing and recalling
  of new knowledge in the brain
• Psychomotor: learning a
  physical skill
• Affective: changing attitudes,
  values, and feelings

Question 25

Critical-Care Pain Observation Tool (CPOT) and Adult Nonverbal Pain Scale (NVPS)

Answer 25

Adults who are sedated and nonresponsive

Question 26

Behavioral Pain Scale (BPS)

Answer 26

Useful with intubated, critically ill patients; measurement of bodily indicators of pain; and tolerance of intubation

Question 27

CRIES Instrument

Answer 27

Neonates (ages 0–6 months)