Fundamentals: Hard

Question 1

Describe wound healing by secondary intention

Answer 1

The wound is left open to heal through granulation, contraction, and epithelization

Question 2

If a patient’s abdominal wound has eviscerated, what are two things the nurse should do?

Answer 2

Any two of the following:
- Place saline-moistened gauze over open area
- Lower head of the bed
- Notify provider
- Keep patient NPO in anticipation of surgical repair

Question 3

Fill in the blanks: The nurse should report a patient’s weight gain of ________lbs in 24 hours, or ________lbs in a week

Answer 3

• 1-2lbs in 24 hours
  -3lbs in a week

Question 4

Name the BMI ranges for underweight, healthy, overweight, and obese

Answer 4

Under: <18.5
Healthy: 18.5-24.9
Over: 25-29.9
Obese: >/= 30

Question 5

Describe the difference in the causes of nociceptive vs neuropathic pain

Answer 5

Nociceptive: Caused by injury to tissue
Neuropathic: Caused by injury to nerves

Question 6

What impact does acute vs chronic pain have on a patient’s vital signs:?

Answer 6

Acute: Cause alteration in vital signs (increased HR/BP)
Chronic: Vital signs may not be altered

Question 7

What is the difference between ADLs and iADLs?

Answer 7

ADLs = Basic tasks (Ambulating, bathing, dressing, eating, toileting)
iADLs = more complex tasks (Transporation, finances, shopping)

Question 8

What is the key difference between palliative care and hospice care?

Answer 8

Palliative: Can be provided along with interventions aimed at curing disease
Hospice: Care is not focused on curing disease

Question 9

If a patient with a DVT reports new onset chest pain and shortness of breath, what complication does the nurse suspect?

Answer 9

A pulmonary embolism

Question 10

Name two lab test that will be altered in a patient with a fluid volume deficit

Answer 10

Any two of the following:
- Increased hematocrit
- Blood osmolality
- BUN
- Urine specific gravity
- Urine osmolality

Question 11

What is the difference between sensible and insensible fluid loss?

Answer 11

Sensible: Losses are measurable (urination)
Unsensible: Losses are not measurable (Sweat)

Question 12

A patient’s urine is positive for leukocytes, esterase, and nitrates. What may these findings indicate?

Answer 12

The presence of a UTI

Question 13

Which type of incontinence is caused by an overactive detrusor muscle

Answer 13

Urge incontinence

Question 14

Describe the difference in the stool output of an ileostomy compared to a sigmoid colostomy

Answer 14

Ileostomy: Output will be loose/watery because it doesn’t go through the colon
Sigmoid: Stool will be formed because it goes through the colon

Question 15

When providing tube feeding to a patient, how does the nurse prevent aspiration?

Answer 15

Keep HOB elevated (30-45 degrees) during the feeding and for at least 1 hour after feeding

Question 16

Describe the difference in onset and duration of dementia vs delirium

Answer 16

Dementia: Gradual onset and is non-reversible
Delirium: Sudden onset and is typically reversible

Question 17

A patient is presenting with increased agitation, incontinence, and disorientation, and requires assistance with ADLs. Which stage of Alzheimer’s is this patient likely experiencing? Stage I, II, or III

Answer 17

Stage II

Question 18

In a mass casualty should the nurse prioritize a patient with a sucking chest wound or a Glasgow Coma Scale of 3?

Answer 18

Chest wound - They have a higher survivability potential over the patient with a GCS of 3

Question 19

Should the nurse prioritize a patient with pneumonia and a SpO2 of 90% or a patient with COPD and a SpO2 of 90%?

Answer 19

Patient with pneumonia - An SpO2 of 90% is an expected finding in a patient with COPD

Question 20

Which of the following is NOT a best practice for employee performance appraisals?
A) Collect data over time
B) Include peer evaluations
C) Compare nurse performance against peers
D) Allow for self-appraisal

Answer 20

C) Compare nurse performance against peers

Question 21

What is the priority intervention for a chemically-impaired employee?

Answer 21

Remove the employee from the work setting immediately

Question 22

Name two instances in which a minor can provide consent

Answer 22

Any two of the following:
- Emancipated
- Married
- In the military
- Requiring mental health/substance abuse/STI treatment

Question 23

On a written record, what should the nurse do after making an error?

Answer 23

Cross the error out with one line and add initials, date, and time

Question 24

List the five parts of Maslow’s hierarchy from the bottom to the top

Answer 24

1. Physiological needs (Food, water)
2. Safety (Shelter)
3. Love and belonging
4. Self-esteem
5. Self-actualization

Question 25

Name the four stages of Piaget’s theory of cognitive developmnt

Answer 25

1. Sensorimotor (Understands world through senses and actions)
   2.Preoperational (Understands world through language and mental images)
2. Concrete Operational (Logical thinking and categories)
3. Formal Operational (Hypothetical thinking and scientific reasoning)

Question 26

Name the six stages of the transtheoretical model

Answer 26

1. Precontemplation (No awareness/intention of behavior change)
2. Contemplation (Aware of needed behavior change)
3. Preparation (Planning to make behavior change)
4. Action (Implement intended behavior change)
5. Maintenance ( Maintaining behavior change)
6. Termination (Failure to maintain behavior change)

Question 27

What is the difference between acute and chronic illness in terms of onset and duration?

Answer 27

-Acute illness has a sudden onset and limited duration
- Chronic illness has a slower onset and persists >1 year