Exam 1 Review Flashcards
Which organization defines nursing with a framework that clarifies what nursing involves and the responsibilities of the nurse as a professional?
American Nursing Association (ANA)
a legal and regulatory body that is created by, and applicable in, each individual state. It establishes common definitions, rules, and regulations to guide the practice of a licensed nurse and thereby promote quality of care and safety when caring for a client?
A Nurse Practice Act
The _______ Scope of Nursing Practice provides the nurse with a clear definition of the complex and dynamic role of the nurse and the expectations of the nurse in that role
ANA’s
The _______ standards of Nursing Practice are explanatory statements that describe a competent level of care and professionalism that all nurses should achieve.
ANA’s
Which of the following are Florence Nightingale’s contributions that are still used today…
A. Documentation
B. Hand hygiene
C. Evidence-based practice
D. Data collection
E. American Red Cross
A, B, C, D
A patient has measles. Which type of precaution would they be on?
Airborne
A patient has varicella. Which type of precaution would they be on?
Airborne
A cancer patient has a CBC done which shows a very weak immune system. Which precaution would they be on?
Neutropenic
A patient has meningitis. Which precaution would they be on?
Droplet
A patient comes in feeling sick, has a temperature and we need to run tests, but none of the results are back yet. Which precaution would you use?
Standard
A patient tests positive for C. diff and you need to put a precaution sign on the door. Which precaution would you use?
Contact precautions
What PPE would you use for contact precaution patients?
Gloves and Gown
What PPE would you use for droplet precautions?
mask
What PPE would you use for airborne precautions?
gown, gloves, N95
For which adult client should the nurse make follow-up observations and monitor the vital signs closely?
A. Resting morning BP is 128/78mm Hg, whereas the afternoon BP is 122/76 mm Hg
B. Oral temp is 97.9 in AM and 99.8 in evening
C. Heart rate is 76 beats/min before eating and 88 bpm after eating
D. Respiratory rate is 16 breaths per min when standing and 18 breaths/min lying down
A. Because both blood pressures are higher and the resting rate was even higher than afternoon blood pressure.
If a test question refers to a nurse following up, which step of the nursing process is this?
Evaluation
If someone is eating it could make their HR go up or down?
Up
When a question asks what the ‘best action’ is what part of the nursing process is it referring to?
Intervention
What do we expect a temperature to do in the afternoon? Go up or down?
Go up
If a respiratory rate goes from 16 breaths/min when standing to 18 breaths/min when lying down is that an expected change or not?
Yes, it is an expected change
What is an antipyretic?
Medication used to reduce fever
A client’s vital signs 4 hours ago: oral temperature 101.4, HR 110 beats/min, RR 26 breaths/min, and BP 124/78 mm Hg. The temp is now 99.4 - based only on the expected relationship between temperature and respiratory rate, which respiratory rate would the nurse expect to find?
1. 16
2. 18
3. 20
4. 22
18 - for every degree the temperature falls the respiratory rate should fall 4 beats
For every degree a temperature drops, the respiration rates drop how many beats per minute?
4
The nurse is planning to initiate a research project that involves adult patients as participants. The nurse accepts moral and legal responsibility to protect research participants from physical or emotional harm. Which mechanism will the nurse utilize for participant protection?
IRB - The institutional review board at the research facility.
The nurse makes the following entry regarding the patient’s outcome, goal not met. “Patient’s pain remained the same after administering Acetaminophen.” What should the nurse do next?
Goal not met - create a new intervention
‘Goal not met’ in a question is referring to which part of the nursing process?
Evaluation
The nurse is using contact precautions to change the soiled bed sheets of a client with C. diff. In the process, the nurses right glove and skin on a finger are torn. After removing soiled gloves what action is priority?
A. Hold pressure to stop bleeding
B. Use bleach wipes to clean hands
C. Wash hands with soap and water
D. Cleanse hands using alcohol-based hand rub
C
With C. diff should you use soap and water or alcohol based cleanser for your hands after changing patient?
Soap and water
When heart rate increases does the respiratory rate increase or decrease?
Increase
What is diaphoresis?
Sweating
Would you expect temperature to decrease after diaphoresis? Y/N
Yes
A nurse is assisting a UAP about caring for a patient who has a low platelet count from chemo. Which of the instructions is the priority for measuring vital signs for this client?
A. Do not take the client’s temp rectal
B. Count the client’s radial pulse for 30 seconds and multiply by 2
C. Do not let the client know that you are counting their respirations
D. Let the client rest for 5 minutes before taking BP
A
If a patient has a low platelet count why wouldn’t you want to take rectal temperature?
The bowel could be easily perforated causing bleeding with an already low platelet (clotting) issue.
The nurse caring for a post surgical pt obtains an oral temp of 102F. The nurse contacts the surgeon, obtains an order, and administers acetaminophen 650 mg orally. Which clinical data should the nurse document? (Select all that apply)
A. Obtained oral temp of 102F
B. Called the surgeon to obtain the order
C. Administered acetaminophen 650mg orally
D. Administered aspirin 650 mg orally
E. Obtained rectal temp of 102F
A, B, C
TIP: For select all questions
-DON’T try to make the answer options make sense together
-DO ask if each option is true/false
:)
What is the first level of Maslow’s hierarchy of needs that must be met before you can move upward?
Physiologic Level
What is included in Maslow’s physiologic level that must be met?
Sex, food, water, air, shelter, sleep, air
What is one factor that will take over all other levels of Maslow’s hierarchy and won’t allow a person to climb the heirarchy?
Pain
What tasks can you delegate to a UAP?
bathe, hygiene, vital signs if not the first time, ambulate, feed (unless stroke pt)
