Fundamentals FINAL Flashcards
influenced by culture, education and socioeconomic factors
The concept of health
Know idiopathic disease and what that means
cause is unknown
If someone has an abscess following a ruptured appendix, is it a primary or secondary illness
secondary illness
shows how an individual moves between peak wellness and transition of death in a constant process, the person moves back and forth in a dynamic state of change
dunn’s theory of a health continuum
A tendency of biologic systems toward stability of the internal environment by continuously adjusting to survive
homeostasis
(know) People of asian origin don’t want you being touchy feely, you have to ask permission before touching them
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its a defense mechanisms, I am not obese my entire family is large, is a defense mechanism
denial
Remember primary prevention, secondary prevention, and tertiary prevention
if you encourage a patient to patient in health maintenance in maintaining an ideal body weight that is primary prevention
(know) Prioritize the nursing problems according to Maslow’s hierarchy of needs
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If you made an error in the med record, a notation was made in the wrong chart, what do you do
you have to follow the agencies policy in correcting the agency
subjective: denies itching. Happy with improvement in skin. Objective: rash fading on face, chest m and back, no hive visible on skin. Skin warm, dry and intact. Assessment: skin integrity improving. Plan: check rash daily until discharge
Know Problem oriented medical record charting
Computer assisted charting, what are you responsible for
guarding the confidentiality of the patient record by not leaving the patients screen on when he leaves the terminal
to x-ray via wheelchair at 1030 IV to left arm
Source oriented format
(know)
Qsen = pre licensing informatics
quality and safety education for nurses
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Communication has best been understood by what
obtaining feedback from the patient that indicates accurate comprehension
(know) Obtain feedback using active listening techniques, use nonverbal techniques, nodding, leading slightly forward, looking at them
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A newly admitted patient you want to ask about pain management so you may first start out with an open ended question about this..
Tell me about the pain you have been having..
End of shift report that best conveys the patient’s status you want it to be very specific and its
abdominal dressing dry, ivs 800 ml left in number 6 ns running at 125 ml per hour urine output 8-0 ml this shift ,had morphine 1500ml for pain at 8 and at 1330 she is comfortable vital signs are stable no fever
(know) Someone who has a stroke and unable to speak clearly and has hemiplegia you want to design the approach as an assessment interview, speaking slowly and giving the patient time to respond
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Patient laughing at tv then stops when you come in
Laughter is the best medicine as it has a positive effect on the immune system
Recognize an open ended question
what was your daughters reaction to your desire for hospice
I tossed and turned last night the nurse responds to the patient you feel like you were awake all night
restatement
Someone had a mastectomy. The patient expresses concern that husband won’t find her attractive
you’re concerned your husband will find you unattractive because of your mastectomy?
A patient said she dislikes the served food and the nurse responds our cooks cook very hard
communication block,defensive response
Why in the world were you on the roof when you had been drinking
asking probing questions
Nurse caring for patient who is concerned about 10lb weight loss due to chemotherapy, nurse says lucky you every cloud has a silver lining, which communication block is this
using cliches
Diagnosis of lung cancer the nurse states if i were you i would have radiation therapy
giving advice
(know) Communicating with an adolescent the nurse should be very careful to avoid interrupting frequently
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(know) In order to safeguard patient information when using a computer you should log out of the computer when finished using it
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You are going to make an appropriate selection to be delegated to a UAP, pick out which one
toileting a patient on a bladder training regiment
You want to minimize a liability of a lawsuit against facility
demonstrating concern and attending to patients complaints
(know) A democratic approach in leadership always takes more time
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Team leader who is reviewing the list of assigned list would give priority to which patient
the one experiencing acute chest pain
Someone who has been diagnosed with pneumococcal pneumonia
bacterial and should respond with treatment with antibiotics
(know) The help personnel should wash their hands with soap and water for 20 seconds at the beginning of each shift
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84 year old patient recovering from a hip replacement, the elderly have:
Loss of elasticity and dont have as much lung capacity and have less cilia
(know) Droplet precautions, only wear a mask when working within 3 feet of the patient
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A healthcare acquired infection is also known as a :
nosocomial
If someone has an infected stasis ulcer on ankle you are aware the patient is at risk for a HAI because
patients defenses are already engaged with previous infection
(know) Cleanse patient from rectum to meatus is WRONG so that cna needs more teaching
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With Pertesis what kind of precaution are they going to be on
droplet
Correct body alignment for a physical immobile patient in bed
supine position, keep them from having plantar flexion, you want them to be dorsiflexion
Correct body alignment for a physical immobile patient in bed
supine position, keep them from having plantar flexion, you want them to be dorsiflexion
Post stroke complains i don’t see why you’re wasting your time doing PROM on my legs the nurses most informative response is
that the exercises prevents contracture of hips
85 yr old man is ambulating and complains he feels he has lost all of his strength and cannot do the same things he could do before what is the nurse’s best response going to be
as we age our muscle cells are lost and are replaced by fat
Nursing interventions related to hygiene that is appr for patient with recent stroke that has right sided paralysis and inability to speak
be independent, encourage patient to use non dom hand to wash his hands and brush his teeth and other ADLs as necessary
(know) Providing oral care to patients who have dentures, remove clean and store in labeled containers at bedtime. Container needs to have solution or water in it
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(know) Usual routine for providing nail care to a patient includes soaking nails in warm soapy water to loosen
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Teach a nursing student regarding pressure ulcer prevention, you would know further instruction is needed if they
position patient directly on trochanter
African american hair should only be washed every:
7 to 10 days
(know) d/c after hip surgery, it needs to be a safe d/c so there is a home evaluation done so install grab bars for toilet and bathtub
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Someone might have accidentally ingested gasoline what do you do?
call poison control center and describe the situation, do not induce vomiting
Health care provider orders wrist protective device
check circulation to make sure its not impaired by checking the distal end
Resident is confused and teary and threatening to leave and go home what do you do
stay with patient to determine cause of the problem
alarm fatigue can be prevented by:
responding promptly to the alarms
Pulse ox measures arterial oxygen by :
measuring the oxygenated hemoglobin through a capillary bed
An older adult has a tympanic temp of 96.2 what nursing intervention would best fit this patients need
increase the room temp to 72 and add blankets to the bed
Accuracy in measuring apical pulse is enhanced when :
listening for a full minute with the diaphragm
Nurse educates pts with prehypertension to implement lifestyle changes to increase systolic from .. to 120
reduce rates of heart attacks, systolic rates above 120
Responsibility of the nurse is to perform a :
focused assessment on patient upon the beginning of each shift
Nurse weighing an infant in an outpatient clinic should:
keep one hand hovering over the infant during the weighing procedure
Caring for a bed rest patient with history of problems,
listen to their lungs beginning of shift
Best practice listening to heart sounds
diaphragm and bell, do not do over clothing
We pick up abnormal heart sounds with the :
bell directly on the patient’s skin
Someone with head injury we are doing a neurocheck you want to hear a statement from the nursing student to know they understand the concept of pupil checks what should happen if a light is shined into eye :
eye should constrict
The nurse monitoring patients eating in the dining room of a skilled nursing facility notes that a patient begins choking. As the nurse prepares to deliver the Heimlich maneuver, the fist should be positioned:
halfway between the xiphoid process and the umbilicus.
A patient requires a precise concentration of 40% oxygen. Which of the following devices would best allow for this?
venturi mask
A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by:
auscultate breath sounds
To help reduce a patient’s risk of recurrent cystitis, the nurse teaches the patient to:
wear cotton underwear and avoid nylon or constrictive clothing
A patient has been ordered to have a 24-hour urine collection as part of a diagnostic workup. The action taken to perform this procedure correctly is to:
have the patient void at the beginning of the collection and throw it away
The nurse is admitting a patient with suspected urolithiasis. An appropriate nursing intervention in the care of such a patient would be to:
Place a sieve over the commode
When the patient who has an order to be out of bed complains of feeling too weak to walk to the bathroom, the nurse assists the patient with urination elimination by:
Placing a commode at the bedside
An elderly male patient needs to have a condom catheter applied. An appropriate technique is to:
Leave 1 to 2 inches between the tip of the penis and the drainage part of the catheter
A nurse irrigating a patients indwelling urinary catheter should instill normal saline as ordered, and then:
unclamp the tubing and lower the collection bag.
Someone has been to mexico and they got diarrhea what should the nurse do for them
give ammonium
Constant diarrhea for 3 days showing signs of dehydration, what do you do :
offer small amounts of gatorade frequently or pedialyte
You are administering a cleansing enema, the nurse will fill the enema bag with :
500 to 1000 ml
A nurse is reinforcing a patient on bowel training and intervention, this program does not include :
enemas
(know) Face plate to a colostomy allow a quarter inch ¼ around the stoma
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Patient who had colostomy 2 days ago assess slight bleeding around the stoma, pale, and reddened under adhesive assessment that should be reported immediately is the
pale stoma
A patient is receiving an ice massage for relief of muscle spasms in the neck. The patient complains that the ice is making the pain worse. The most helpful response from the nurse would be:
I will stop these cold applications. Not everyone is helped by them.
The nurse is aware that the new order for indomethacin (Indocin) involves the administration of a:
nonsteroidal anti-inflammatory drug.
A nurse caring for a patient with a Fentanyl patch assesses that the patient is abnormally sleepy, is slurring words and is unsteady when ambulating. The nurse should
remove the patch and wipe off the skin.
A nurse is assessing the status of a patient who is sleeping. Which assessment data indicate that the patient is most likely in stage 3 of nonrapid eye movement (NREM) sleep?
Decreased respirations, slow heart rate
The nurse recommends that normal sleep patterns can best be acquired by suggesting to the patient that they:
exercise in the mornings.
A natural supplement that can enhance sleep for many people is:
melatonin
A relative complains that an elderly patient takes frequent naps during the day and awakens frequently during the night, and wants to know if this is normal. The nurse explains that an older adult:
will awaken more often during the night, but may nap more often during the day.
A nurse explains that endorphins are capable of reducing pain:
by attaching to opioid receptors.
The circulating nurse notes the patient has tensed muscles and irregular respirations the patient has reached what stage of analgesia :
stage 2 and surgical environment should be kept quite
(know) If an illiterate person needs to sign surgical consent form they can write an X if it is witnessed by another staff member
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(know) Preoperative surgical skin prep you may be required to instruct the patient in the use of antimicrobial soap use in the shower
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The circulating nurse is responsible for :
pointing out contamination immediately to the person involved
Post op surgical patient asked how compression boots can help
alternately compress and release blood flow through vessels
The patient had surgery early in the day and asked if he can eat, before he can eat, what do you do?
check for bowel sounds
You are preparing to get a patient out of bed for the first time, what do you do?
allow patient to sit with head of bed to high fowler’s position first
Pooling of blood under unbroken skin
hematoma
Someone who has left arm cast and changes to synthetic fiberglass cast, how long would you tell them it would be before it’s dry?
30 mins
The nurse assess a patient as having delayed cap refill
5 sec
With the general adaptation syndrome the alarm stage
slight increase in body temperature, decreased appetite, hormones released for mobilization for defense
(know) Self actualized is having met all other need levels and being certain in their belief and values
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An expected outcome should be :
realistic, obtainable, within a defined time, included after patient collaboration
A nurse is caring for a patient with impaired physical immobility related to nuero impairment and muscle weakness appropriate
assist with ROM exercises, instruct patient to call for assistance when needing out of bed, teach about exercises that will strengthen muscles while laying in bed, physical therapy assistance at least 3 times a day
Characteristics of delegation
use of effective communication, direction for desired result and time, tactful feedback, informing patient delegated tasks be performed by a UAP
(know) Adequate feedback is essential between nurse and patient to accomplish effective communication
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Ask questions that require more than a one word questions
open ended
Patient had abdominal surgery, temp 101.2 and reports feeling malaise nurse asses and observes edema and purulent drainage what stage of infection
illness
Frequent wet skin leads to :
maceration, softening of tissue
In order to prevent the cast from chaffing, instruct the patient to :
Petal the rough edges
