Exam 1 study guide+ results you need to know

Question 1

Understand the nursing process- be able to identify the 5 phases of the nursing process and the actions of the nurse during each phase.

Answer 1

Assess-gather info about patient problem

Diagnose-identify patients problem

Planning-set goals of care and desired outcomes of care

implement-perform nursing actions

Evaluate -determine if goals were achieved

Question 2

Be able to identify the role of the RN, LPN and UAP in developing and implementing a nursing plan of care

Answer 2

UAP-Assist patients with activities of daily living (ADL’s), including: Eating. Bathing. Toiletin
Assess stable patients
report changes to nurse

LPN-assist in data collection and planning and then have an RN review the data
Suggest data and watch UAP
Can reinforce teaching

RN-makes the plan.Can do all stuff LPN and UAP. Rn makes and signs off on plan
makes plan-evaluates plan
teaches client

Question 3

Be able to critique how a nursing diagnosis and outcome/goals are written.

Answer 3

watch nurse rn video

Question 4

Review different types of body defenses against infection

Answer 4

Physical, –skin sweat tears- block from coming in

chemical, -Acids and good bacteria in your stomach, chemicals in your saliva

inflammation–Second line of defense-body sends wbc to kill infection

,immune system–Produces weapons for each pathogen that in counters with

Question 5

Review methods of transmission of disease and steps nurses can do to stop the spread of infection

Answer 5

Airborne transmission. Airborne transmission occurs when infectious agents are carried by dust suspended in the air.

Respiratory (droplet) transmission.-espiratory droplets can land on hands, objects, or surfaces around the person when they cough or talk

Contact transimmion-occurs when microorganisms are transferred from an infected person to another person.

Question 6

Understand different types of immunity

Answer 6

Innate- immunity you are born with- t and B cells crap

Active natural: Body produces antibodies in response to exposure to a live pathogen.

Active artificial: Body produces antibodies in response to a vaccine.

Passive natural: Antibodies are passed from the mom to her baby through the placenta and breastmilk.

passive artificial : when a person receives antibodies in the form of an injection

Question 7

Identify manifestations of inflammation and infection

Answer 7

loss of function, heat, pain, redness, and swelling

Fever.
Chills.
Headache.
Fatigue.
Malaise.
Muscle aches.
Joint aches.
Swollen lymph nodes.

Question 8

Identify different stages of pressure ulcers and types of wound healing, including interventions for both.

Answer 8

Stage 1. The area looks red and feels warm to the touch.
Stage 2. The area looks more damaged and may have an open sore, scrape, or blister.
Stage 3. The area has a crater-like appearance due to damage below the skin’s surface.
Stage 4. The area is severely damaged and a large wound is present.-tissue may be present

Hemostasis- blood vessels constrict resulting in less blod flow to injured area. Ends with leaking exudate from injury site.
Inlafmattory – wbc(leokocytes and macrophages) move to wound to ingest bacteria..
Proliferation- tissues are built with fibrolblasts. Maturation phase—scar tissue is formed, this is where the bone starts to settle-

Question 9

Be able to identify different types of drainage and what they indicate.

Answer 9

(1) serous (clear and thin; may be present in a healthy, healing wound),

(2) serosanguineous (containing blood; may also be present in a healthy, healing wound),

(3) sanguineous (primarily blood), or

(4) purulent (thick, white, and pus-like; may be indicative of infection and should be cultured).

Question 10

Hgb (Hemoglobin)

Answer 10

• 12-18 g/dL

Question 11

Hct (Hematocrit)

Answer 11

– 40-50%

Question 12

Platelets-

Answer 12

150,000-400,000/mm3

Question 13

RBC- Red Blood Cell

Answer 13

• Female- 4.2-5.4
• Male- 4.7-6.1

Question 14

WBC (White Blood Cell)

Answer 14

5000-10,000/mm3

Question 15

• K- potassium

Answer 15

• 3.5-5.0 mEq/L

Question 15

Neutrophils

Answer 15

– 60-70%

Question 16

• Na- sodium-

Answer 16

135-145 mEq/L

Question 17

• Cl- chloride

Answer 17

• 98-101 mEq/L

Question 18

• Mg- magnesium

Answer 18

• 1.3-2.5 mEq/L

Question 19

• Ph-phosphorous-

Answer 19

2.5-4.5 mg/dL

Question 20

• Ca- calcium-

Answer 20

8.5-10.5 mg/dL

Question 21

Protein

Answer 21

• 6.4-8.3 g/dL

Question 22

Albumin-

Answer 22

3.5-5.5 mg/dL

Question 23

Lipase

Answer 23

• 0-160 units/L

Question 24

Ammonia-

Answer 24

10-80 mcg/dL

Question 25

aPTT- Activated partial thromboplastin-

Answer 25

30-40 seconds

Question 26

PT- Prothrombin Time-

Answer 26

11-12.5 seconds

Question 26

Therapeutic INR-

Answer 26

2-3

Question 27

ESR (erythrocyte sedimentation rate)

Answer 27

– Inflammation is present, nonspecific

Question 28

• Specific gravity

Answer 28

• 1.005-1.030

Question 29

• pH

Answer 29

• 4.6-8

Question 30

• WBC

Answer 30

• 0-4

Question 31

• Ketones-

Answer 31

none

Question 32

• Glucose

Answer 32

none

Question 32

BUN- Blood urea nitrogen

Answer 32

• 10-20 mg/dL

Question 33

Creatinine

Answer 33

• 0.4-1.5 mg/dL

Question 34

• Cholesterol Total-

Answer 34

< 200 mg/dL

Question 35

• HDL

Answer 35

• 30-70 mg/dL

Question 36

• LDL

Answer 36

< 130

Question 37

Triglycerides

Answer 37

• < 160

Question 38

Glucose

Answer 38

• 70-120 mg/dL

Question 39

Hemoglobin A1C

Answer 39

• Good DM control < 8%

Question 40

BMI

Answer 40

– 18.5-24.9