Final Exam Review Flashcards
What is the patient describing when they say, “I am in so much pain I cannot sleep?”
perception
What will the nurse remove once they have removed their goggles?
gown
What precaution is used for a microorganism that is transmitted by small, evaporated particles suspended in the air?
airborne
What does delegate mean?
entrust a task to another person
What does pallor mean?
decreased hematocrit
What does 20/30 mean in terms of eyesight?
the 20/20 person sees the same at 30 feet
How do you straighten the ear canal of an adult?
pull up and back
How do you straighten the ear canal of a child?
pull down and back
What mechanism can be utilized to promote venous return?
ambulation
Where do you begin lung auscultation?
above the clavicle
How often should an artificial eye be cleaned?
as needed
What are the six QSEN competencies?
PCC, team work and collaboration, EBP, quality improvement, safety, and informatics
Which QSEN competency focuses on providing individualized care and restores an emphasis on personal relationships?
(respect client’s preferences, values, and needs)
patient centered care
The nurse provides a bed bath and asks the client how they feel. Which step of the nursing process is this?
evaluation
What do nurses evaluate in ADPIE?
client outcomes
Which clinical judgement skill causes the nurse to collect, categorize, and clarify data?
interpretation
What organization evaluates clinical judgement abilities of new graduate nurses?
NCSBN (national council of state boards of nursing) aka NCLEX
Are responsibility, discipline, creativity, and curiosity are key components of the attitudes of critical thinking?
yes
What is an emic worldview?
intercultural encounter from an insider perspective
What are the standards of professional performance?
EDUCATION, ethics, culturally congruent practice, communication, collaboration, leadership, EBP and research, quality of practice, professional practice evaluation, resource utilization, and environmental health
What are the 5 components of the transcultural care model?
awareness, knowledge, skill, encounter, and desire
What should be provided toa client who does not speak English to maintain linguistic competency?
medically licensed interpreter
what is the ability to obtain,
process, and understand basic health information and services needed to make
appropriate health decisions called?
health literacy
What is a client without health insurance at risk for?
health disparities
What should a nurse use to build a therapeutic relationship with a client?
open-ended question
What is client describing when they state “my chest feels really tight”?
quality/character
What describes where pain is, such as deep, superficial, and radiating?
location
What is described with “burning, sharp, dull, crushing, looks like…?”
character/quality
What is described with statements like “0/10 pain,” “soaked 5 sheets?”
quantity/ severity
What is described as onset, duration, or frequency?
timing
What is described as when/where symptoms started?
setting
What is described as factors that make something better or worse?
aggravating/ relieving factors
What is known as additional symptoms to the primary issue?
associated factors
What is being described when a client described the effect their condition has on their daily activities?
client’s perception
Which mode of transmission is person to person, object to person, or fecal to oral?
contact
Which mode of transmission is spread through sneezing and travels less than 6ft?
droplet
Which mode of transmission is spread through coughing and sneezing with small suspended particles that travel >6 ft?
airborne
What PPE is needed for contact precautions?
gown and gloves
What is required for droplet precautions?
surgical mask
What PPE is required for airborne infection isolation precautions?
particulate respirator (N95) and negative pressure isolation room
Which temperature alteration occur when pyrogens trigger the immune system, causing the hypothalamus to raise the set point?
pyrexia
What are some objective categories to assess during a skin assessment?
texture, thickness, edema, turgor, color
What should be washed first when giving a bath?
face (cleanest to dirtiest)
What can be used to assess head for lice?
tongue depressor
What is example of normal charting for a head?
normocephalic, no lumps, no lesions, no tenderness
How often should an artificial eye be cleaned, and what should you use to clean it?
as needed with soap and water or saline
What is clonus?
Very strong deep tendon reflex, +4
What is the grade for a weak deep tendon reflex?
1
What grade indicates a strong deep tendon reflex?
3
What is the graded muscle strength for a client who cannot resist gravity?
2
Muscle strength grade 5?
ROM full
The nurse is assessing range of motion in a client who is able to actively achieve full range of motion against full resistance. How will the nurse grade this client’s muscle strength?
grade 5
What is a full ROM against gravity with some resistance graded as?
4
What is the graded muscle strength for a client who cannot resist gravity?
2
What does a positive Romberg test indicate?
loss of balance
How should the nurse manage the effects of immobility on the respiratory system?
teach the client to use an IS (incentive spirometer)
How should the nurse manage the effects of immobility on blood flow to the skin?
turn the client every 2 hours
How may immobility impact the cardiac system? How will the patient present?
-activity intolerance
-light headed, dizzy, increased HR, decreased BP
Which interventions will the nurse implement to reduce the impact of immobility on a client’s integumentary system?
Turn the client every 1-2 hours, maintain a positive fluid balance, and teach the client to shift every 15 minutes
The nurse is caring got four clients with immobility from different conditions. Which client should the nurse place in the side-lying position?
client with pressure ulcers
How far should a client move a cane in front of them?
For maximum support when walking, the patient places the cane forward 6-10 inches
Which leg should step first when using a cane?
The client moves the weaker leg forward to the cane so the body weight is divided between the cane and the stronger leg
Which statement will the nurse include when teaching a client to use a walker?
” Your walker should be as tall as your wrist.”
How should a client move with a walker?
When walking the client should step with the affected side, then move the walker, then step with the affected or stronger side.
How will the nurse fit crutches to prevent nerve damage?
2-3 finger widths from axilla; 15-30 degree elbow angle
What kind of breaths are regular wax and wean sleep apnea sounds?
Cheyne-Stokes Respirations
What kind of breaths are irregular wax and wean sleep apnea sounds?
Biot Respirations
What kind of respirations are characterized with prolonged expirations with dyspneic episodes?
COPD respirations
