Safety for Test 2

Question 1

What does RACE stand for?

Answer 1

• Rescue and remove all patients in immediate danger.
• Activate the alarm.
• Confine fire by closing doors and turning off any oxygen & electrical equipment.
• Extinguish the fire.

Question 2

Seizure precautions for nursing

Answer 2

• protect patients from traumatic injury
• positioning for adequate ventilation
• drainage of oral secretions
• providing privacy and support after event.

Question 3

Describe the auscultation site, cause, and character of: crackles

Answer 3

• Site = r/l lung bases
• Cause = disruptive passage of air through small airways
• Character = wet, popping sound not cleared w/coughing

Question 4

Describe the auscultation site, cause, and character of: wheezes

Answer 4

• SITE = all lung fields
• CAUSE = narrowed or obstructed airway
• CHARACTER = high-pitched whistling heard through inspiration/expiration, but louder on expiration

Question 5

Describe the auscultation site, cause, and character of: rhonchi

Answer 5

• SITE = trachea and bronchi
• CAUSE = muscular spasm, fluid/mucus in larger airways
• CHARACTER = loud, low-pitched rumbling/snoring. sometimes cleared w/coughing

Question 6

Describe the auscultation site, cause, and character of: pleural friction rub

Answer 6

• SITE = anterior lateral lung field
• CAUSE = inflammation
• CHARACTER = dry, rubbing, grating heard through inspiration/expiration

Question 7

Describe vesicular sounds.

Answer 7

soft, breezy, low-pitched. Air moving through small airway, inspiration longer than expiration

Question 8

Describe bronchovesicular sounds.

Answer 8

blowing sound, air moving through large airway.

Question 9

Describe bronchial sounds.

Answer 9

loud, high-pitched hollow quality, air moving through trachea.

Question 10

mitral/tricuspid valve closing = first heart sound

Answer 10

S1

Question 11

Aortic and pulmonic valve closure

Answer 11

S2

Question 12

Heart attempts to fill distended ventricle

Answer 12

S3

Question 13

Atria contracts and ventricular filling

Answer 13

S4

Question 14

Swelling by intestinal gas, tumor, or fluid in abdominal cavity

Answer 14

Distention

Question 15

Movement of contents through the intestines which is normal fx of small and large intestine.

Answer 15

Peristalsis

Question 16

Borborygmi

Answer 16

growling sounds, hyperactive bowel sounds

Question 17

Localized dilation of a vessel wall

Answer 17

Aneurysm

Question 18

Hunchback, exagerration of curvature of thoracic spine

Answer 18

Kyphosis

Question 19

Swayback, increased lumbar curvature

Answer 19

Lordosis

Question 20

Flexion

Answer 20

movement decreasing angle between 2 adjoining bones

Question 21

Extension

Answer 21

increasing angle between adjoining bones

Question 22

Abduction

Answer 22

away from midline

Question 23

Adduction

Answer 23

towards the midline

Question 24

Eversion

Answer 24

turning body part away from midline

Question 25

Inversion

Answer 25

turning body toward the midline

Question 26

Normal, good, unlabored breathing

Answer 26

Eupnea

Question 27

Absence of breathing

Answer 27

Apnea

Question 28

Distribution of RBC's to and from the pulmonary capillaries

Answer 28

Perfusion

Question 29

Diffusion

Answer 29

movement of oxygen and co2 between alveoli & RBC's

Question 30

Pulse Deficit

Answer 30

Apical pulse - radial pulse

Question 31

SaO2 (pulse oximetry)

Answer 31

percentage of hemoglobin bound w/oxygen in arteries

Question 32

Peak of max pressure when ejection occurs

Answer 32

SYSTOLIC PRESSURE

Question 33

When ventricles relax and blood remaining in arteries exerts minimum pressure

Answer 33

DIASTOLIC PRESSURE

Question 34

Pulse pressure

Answer 34

Systolic - diastolic

Question 35

2 steps of a nursing assessment

Answer 35

1. Data collection | 2. Interpretation and validation of data

Question 36

Subjective vs objective data

Answer 36

``` Subjective = pt verbal description Objective = observations/measurements of pt's health status ```

Question 37

Phases of patient-centered interviews

Answer 37

1. Orientation 2. Working Phase = assessment 3. Terminating an interview

Question 38

condition or etiology identified from patient's assessment data

Answer 38

Related Factor "related to"

Question 39

Define the 3 priorities in relation to importance and time when caring for multiple patients

Answer 39

1. HIGH = if untreated, could result in harm to pt or others. 2. Intermediate = nonemergent, nonthreatening needs of patient 3. Low = not always directly related to specific illness or prognosis.

Question 40

SMART related to outcome statement

Answer 40

``` Specific Measurable Attainable Realistic Time Frame ```

Question 41

NIC

Answer 41

Nursing Interventions Classification - level of standardization to enhance communication of nursing care across settings and to compare outcomes. - RELIABLE RESOURCE

Question 42

What are ADL's? Are they direct or indirect?

Answer 42

Activities of daily living: ambulation, eating, grooming, dressing, etc. Direct care

Question 43

Standards of documentation by TJC

Answer 43

All steps of nursing process, evidence of patient/family teaching, discharge planning.

Question 44

Multidisciplinary care plans that include patient problems, key interventions, expected outcomes.

Answer 44

Critical Pathways

Question 45

coordinated efforts of musculoskeletal and nervous system

Answer 45

Body Mechanics

Question 46

Actual/potential nursing diagnoses related to immobilized patient

Answer 46

1. Ineffective airway clearance 2. Ineffective coping 3. impaired phy

Question 47

Expected outcomes of goal "patient's skin will remain intact."

Answer 47

1. skin color/temp return to normal baseline within 20 min of position change. 2. changes position at least every 2 hours

Question 48

Fowler's

Answer 48

HOB elevated 45-60 degrees w/knees slightly bent

Question 49

Supine

Answer 49

Lay flat on back

Question 50

Prone

Answer 50

Lies on abdomen w/one head to the side

Question 51

Sims

Answer 51

Patient lies on left side w/right knee and hip partially bent forward

Question 52

What is POMR type of documentation?

Answer 52

Problem-oriented medical records - includes database, problem list, care plan, progress notes - DARP = POMR documentation

Question 53

PASS

Answer 53

Pull the pin Aim at base of fire Squeeze the handle Sweep side to side

Question 54

Cranial nerve associated with PERRLA

Answer 54

III: Oculomotor

Question 55

Romberg Test

Answer 55

used to test balance