Foundations Exam 1

Question 1

What is the nursing process?

Answer 1

Assess (history physical, subj, obj) GATHERING DATA, Diagnose, Plan, Implement, Evaluate

*(ADPIE)

Question 2

What is SBAR?

Answer 2

Communication tool between healthcare professionals: 1. Situation 2. Background 3. Assessment 4. Recommendation

Question 3

What is critical thinking?

Answer 3

Logical manner to take care of your patient, to reason what is going on with the patient and analyze.

Question 4

What is IPPA?

Answer 4

1. Inspect 2. Percuss 3. Palpate 4. Auscultate

Question 5

What are the physiological needs in Maslow’s Hierarchy?

Answer 5

1. Airway 2. Breathing 3. Circulation 4. Disability 5. Exposure 6. Transportation

Question 6

What is the nurse’s responsibility?

Answer 6

AAIPM: 1. Administer 2. Assess 3. Implement 4. Provide patient teaching 5. Monitor

Question 7

What is the most important thing when caring for patient hygiene?

Answer 7

Must be aware of patient’s beliefs, religion, and gender preferences.

Question 8

What are the guidelines for bathing a patient?

Answer 8

1. Privacy 2. Safety 3. Warmth 4. Independence 5. Needs

Question 9

What are the national patient safety goals?

Answer 9

1. Identify patients correctly - 2 factor
2. Improve staff communication - SBAR
3. Use medicines safely
4. Use alarms safely
5. Prevent infections
6. Identify patient safety risks
7. Prevent mistakes in surgery

Question 10

What must a statement like ‘ineffective airway clearance’ be related to?

Answer 10

Must be related to something, e.g., related to weak cough.

Question 11

What is the importance of body alignment?

Answer 11

Used for determining physical changes, deviations, posture, trauma, dysfunction, damage, incorrect alignment.

Question 12

What are 5 safety positions for patients?

Answer 12

1. Supported fowlers: angle 45-60 degrees with knees slightly bent and pillows for support 2. Supine: flat on back 3. Prone: flat on belly 4. Side-lying: lateral 5. Sims: legs and arms bent to side

Question 13

What are the 5 sleep disorders?

Answer 13

1. Insomnia; medical condition; trouble falling or staying asleep
2. Sleep apnea; medical condition; airway blocked during sleep
3. Narcolepsy; sleep paralysis
4. Sleep deprivation; emotional stress, meds, environmental
5. Parasomnias; sleep walking, night terrors, nocturnal enuresis (bedwetting), nightmares

Question 14

What is the #1 way to prevent infection?

Answer 14

Hand hygiene.

Question 15

What are the steps in the chain of infection?

Answer 15

1. Infectious agent or pathogen
2. Reservoir or source for growth (grow and multiply)
3. Portal of exit (blood or skin or mucous membranes or GI tract)
4. Mode of transmission
5. Portal of entry - to host
6. Susceptible host (age, nutritious, immunosuppressant, stress, trauma, smoking)

Question 16

What is a nosocomial infection?

Answer 16

Hospital acquired infection.

Question 17

What are the 4 steps of the infectious process?

Answer 17

1. Incubation period - entry of pathogen
2. Prodromal stage - vague, early symptoms 3. Illness stage - SXS manifest as type of infection
3. Convalescence - SXS start to disappear

Question 18

What are the modes of transmission?

Answer 18

Direct contact: person to person,
Indirect contact: surface to person,
Droplet: up to 3ft, cough and sneeze, Airborne: carried on dust, evaporated droplets.

Question 19

What is the importance of inflammation in infections?

Answer 19

WBCs diagnose infection, Purulent appearance.

Question 20

What do purulent, sanguinous, and serous mean?

Answer 20

Purulent - pus
Sanguinous - blood
Serous - clear.

Question 21

What are the types of healthcare associated infections?

Answer 21

1. Iatrogenic - from a procedure
2. Exogenous - from microorganisms outside the individual
3. Endogenous - patient’s flora becomes altered and overgrowth occurs.

Question 22

What is hemostasis?

Answer 22

Physiological process stopping bleeding after an injury

Hemostasis is a critical first step in the wound healing process.

Question 23

What are the steps in wound healing?

Answer 23

• Inflammatory Phase
• Proliferation Phase
• Remodeling (maturation) Phase

Each phase has specific processes vital for proper healing.

Question 24

What occurs during the inflammatory phase of wound healing?

Answer 24

• Homeostasis
• Histamine and vasodilation
• WBCs move to wound area to inject debris and promote healing
• Pain, swelling, heat

This phase is essential for starting the healing process.

Question 25

What is the role of albumin in wound healing?

Answer 25

Indicates how much protein is in the body; protein is needed to heal ## Footnote Adequate protein levels are crucial for effective healing.

Question 26

What happens during the proliferation phase of wound healing?

Answer 26

New blood cells and capillaries grow; a thin layer of granulation tissue forms ## Footnote This phase is focused on tissue formation.

Question 27

What occurs during the remodeling (maturation) phase of wound healing?

Answer 27

Collagen is remodeled and deposited; scar tissue becomes a thin white line ## Footnote This phase improves the strength and appearance of the healed wound.

Question 28

What is primary intention in wound healing?

Answer 28

Surgical wound where edges are approximated ## Footnote This method typically results in minimal scarring.

Question 29

What is secondary intention in wound healing?

Answer 29

Loss of tissue, such as in burns, pressure ulcers, or lacerations ## Footnote Healing occurs from the edges inward and may result in more scarring.

Question 30

What are some complications of wound healing?

Answer 30

* Hemorrhage * Infection * Hematoma * Dehiscence * Evisceration ## Footnote Each of these complications can delay healing and worsen outcomes.

Question 31

What is dehiscence?

Answer 31

Partial or total separation of wound layers ## Footnote Common in obese patients or after abdominal surgeries.

Question 32

What is evisceration?

Answer 32

Complete opening of a wound with organs protruding ## Footnote Requires immediate medical attention.

Question 33

What defines a fistula?

Answer 33

Abnormal passage from an internal organ to the outside of the body or between organs ## Footnote Fistulas can complicate healing and require specific management.

Question 34

What are pressure ulcers?

Answer 34

Found on bony areas of the body; also known as pressure sores, decubitus ulcers, or bed sores ## Footnote They result from prolonged pressure on the skin.

Question 35

What does blanchable skin indicate?

Answer 35

Skin turns white and then back to original color when pressure is released ## Footnote This is a sign of stage 1 pressure ulcer.

Question 36

What characterizes non-blanchable skin?

Answer 36

If it does not turn back to red, it is a stage 1 pressure ulcer ## Footnote Non-blanchable redness indicates more severe skin damage.

Question 37

What factors influence the pathogenesis of pressure ulcers?

Answer 37

* Intensity * Duration * Tolerance ## Footnote Understanding these factors can help prevent pressure ulcers.

Question 38

What is the Braden Scale used for?

Answer 38

Assessing risk for pressure ulcers; scores range from 6 to 23 ## Footnote It evaluates factors like moisture, friction, sensory perception, activity, mobility, and nutrition.

Question 39

What does sloughing refer to in wound care?

Answer 39

Unviable tissue that appears yellow, white, or grey ## Footnote This tissue must be removed for proper healing.

Question 40

What are the classifications of pressure ulcers?

Answer 40

* Intact skin with non-blanchable redness * Partial-thickness skin loss involving epidermis, dermis, or both * Full-thickness tissue loss with visible fat * Full-thickness tissue loss with exposed bone, muscle, or tendon * Unstageable; cannot get depth measure ## Footnote These classifications help guide treatment.

Question 41

What distinguishes partial thickness wounds?

Answer 41

Shallow in depth, moist, painful, and appears red ## Footnote These wounds involve the epidermis and part of the dermis.

Question 42

What distinguishes full thickness wounds?

Answer 42

Extend into the subcutaneous tissue ## Footnote These wounds require more complex treatment and care.

Question 43

What factors influence pressure ulcer formation?

Answer 43

* Infection * Age * Nutrition * Tissue perfusion ## Footnote These factors must be managed to prevent ulcers.

Question 44

What are the colors associated with wounds?

Answer 44

* Black * Yellow * Red * Mixed ## Footnote Each color indicates a different stage or type of healing tissue.

Question 45

What are the nursing implementations for wound care?

Answer 45

* Continuous skin assessment * Check wounds * Assess Braden Scale ## Footnote Ongoing assessment is crucial for preventing complications.

Question 46

What diagnoses might a patient at risk for wound complications receive?

Answer 46

* Risk for infection * Imbalanced nutrition * Acute or chronic pain related to surgical incisions * Impaired mobility, integrity, perfusion ## Footnote These diagnoses guide nursing care and interventions.

Question 47

What are some goals and outcomes for wound care planning?

Answer 47

* Prevent ulcers * Promote wound healing ## Footnote Setting clear goals helps measure the effectiveness of interventions.

Question 48

What interventions might be implemented for wound care?

Answer 48

* Topical skin care * Changing positioning * Supportive positions and devices * Wound cleaning * Cleaning dressings ## Footnote These interventions are essential for effective wound management.

Question 49

What is the importance of evaluating wound care?

Answer 49

Ongoing assessment and evaluation are necessary to ensure effective treatment ## Footnote Regular evaluation helps adjust care plans as needed.