NURS 175 midterm review QUESTIONS WITH 100% CORRECT ANSWERS, Exams of Nursing

Download NURS 175 midterm review QUESTIONS WITH 100% CORRECT ANSWERS and more Exams Nursing in PDF only on Docsity! NURS 175 midterm review QUESTIONS WITH 100% CORRECT ANSWERS Nursing process - CORRECT ANSWER_1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation Gordon's Functional Health Patterns - CORRECT ANSWER_Health perception-health management pattern Nutritional-metabolic pattern Elimination pattern Activity-exercise pattern Sleep-rest pattern Cognitive-perceptual pattern Self-perception-self-concept pattern Roles-relationships pattern Sexuality-reproductive pattern Coping-stress tolerance pattern Values-beliefs pattern Assessment - CORRECT ANSWER_-Collect data -Organize data -Validate data -Document data Nursing diagnosis - CORRECT ANSWER_-Analyze data -Identify health problems, risks, and strengths -Formulate diagnostic statements Planning - CORRECT ANSWER_-Prioritize problems and diagnoses -Formulate goals and designed health outcomes -Identify nursing interventions Implementation - CORRECT ANSWER_-Reassess the patient -Determine the nurse's need for assistance -Implement nursing interventions -Supervise delegated care -Document nursing activities Evaluation - CORRECT ANSWER_-Collect data related to outcomes -Complete data with outcomes -Relate nursing actions to patient goals/outcomes -Draw conclusions about problem status -Continue, modify, or end the patient's care plan Bradypnea - CORRECT ANSWER_-Abnormally slow breathing -Less than 10 breaths/minute Tachypnea - CORRECT ANSWER_-Rapid breathing -More than 24 breaths/minute, shallow Hyperpnea - CORRECT ANSWER_-Laboured breaths, increased in depth and rate -Normal during exercise -More than 20 breaths per minute Apnea - CORRECT ANSWER_-Breathing temporarily stops and then starts up again Hypoventilation - CORRECT ANSWER_-Slow and shallow respirations Kussmaul - CORRECT ANSWER_-Rapid deep respirations that are characteristic of an acid-base imbalance (frequently seen in uncontrolled diabetes) Cheyne-Stokes respiration - CORRECT ANSWER_-Alternating patterns of apnea and increasingly deep, rapid breathing Dyspnea - CORRECT ANSWER_-Difficult or labored breathing Orthopnea - CORRECT ANSWER_-Requiring a certain body position for comfortable breathing Sleep apnea - CORRECT ANSWER_-A disorder in which the person stops breathing for brief periods while asleep Considerations for assessing respirations - CORRECT ANSWER_-Consider patient status (active vs rest) -Asses rate, rhythm depth, and pattern -Assess breathing effort, flared nares, accessory muscles Oxygen status - CORRECT ANSWER_-Other names, pulse oximetry, pulse ox, oxygen saturation, O2 saturation, O2 sat -Expected findings 92-100% -Evaluates gas exchange and perfusion Arterial blood gas - CORRECT ANSWER_-A diagnostic test examining arterial blood; used to determine the pressure exerted by oxygen and carbon dioxide in the blood Hypoxia - CORRECT ANSWER_-Not enough oxygen in the blood Cyanosis - CORRECT ANSWER_-Objective evidence of decreased oxygen in the blood (below 85%) -Dusky color of skin around lips, nails, and eyes Abnormal pulse oximetry - CORRECT ANSWER_-Below 92% -Reposition patient -Assess position of saturation probe -Encourage deep breathing -Consider medical history (ex. lung disease) -Consider use of supplementary oxygen Pulse - CORRECT ANSWER_-Effect of the beating of the heart on the body's arteries -Cardiac output=heart rate x stroke volume Bradycardia - CORRECT ANSWER_-Abnormally slow heartbeat -Lower than 60bpm Tachycardia - CORRECT ANSWER_-Fast heart rate -Over 100bpm Pulse strength and amplitutde - CORRECT ANSWER_0-Not palpable 1-Diminished, weak, barely palpable 2-Strong, normal 3-Full, increased 4-Bounding Pulse points - CORRECT ANSWER_Common -Radial -Dorsalis pedis -Posterior tibialis -Carotid Less common -Temporal -Brachial 2. Determine the etiology (likely cause) of the problem 3. List the manifestations of the problem (not for risk diagnosis) Nanda diagnosis example - CORRECT ANSWER_Situation- Patient states he has pain, difficulty with movement observed, medical diagnosis of arthritis 1. NANDA-1 label: Acute pain 2.Etioloty- related to diagnosis of arthritis 3. Manifestation- as evidenced by patient's verbalization of pain and observed difficulty with turning self in bed Types of planning - CORRECT ANSWER_1. initial 2. ongoing 3. discharge Goals/outcomes - CORRECT ANSWER_-Broad statements about the patient's status written in relation to the chosen nursing diagnosis Ex. Diagnosis-Impaired physical mobility related to deconditioning as evidenced by need for walker when ambulating Outcome-Independent ambulation SMART goals - CORRECT ANSWER_Specific, Measurable, Attainable, Realistic, Timely -Can be short-term or long-term Nursing Interventions Classification (NIC) - CORRECT ANSWER_1. Independent (no order needed from a physician) 2. Dependent (initiated by the physician's orders) 3. Collaborative Evaluation - CORRECT ANSWER_ Avoiding precharting-guideline - CORRECT ANSWER_-Invites error -Is illegal and can count as falsification of the health record -Always document during or immediately after giving care Do not erase, apply correction fluid, or scratch out errors made while recording - CORRECT ANSWER_-Charting becomes illegible -May appear suspicious -Draw a single line through error and write error above it Do NOT leave blank spaces or lines in a written nurses' progress note. - CORRECT ANSWER_-Allows another person to add incorrect information in open space -Chart consecutively, line by line Record all entries legibly and in black ink - CORRECT ANSWER_-Do not use felt-tip pens or erasable ink -Never use pencil to document -Never erase entries or use correction fluid If an order is questioned, record that clarification was sought - CORRECT ANSWER_-Do not record that "physician made error) -Write Dr. Wong was called to clarify order for analgesic Document only for yourself - CORRECT ANSWER_-You are accountable for all information you enter in to the record -Never enter documentation for someone else Avoid using generalized, empty phrases such as "status unchanged" or "had good day". - CORRECT ANSWER_-This is subjective -Use complete, concise descriptions of assessments and care so that documentation is objective and factual Begin each entry with... - CORRECT ANSWER_-Date and time -End with signature and credentials -Document as closely to the event as possible Correct all errors promptly - CORRECT ANSWER_-Errors in recording can lead to errors in treatment -Avoid rushing to help prevent errors Narrative documentation - CORRECT ANSWER_-Records info as a sequence of events in a story like manner SOAP documentation - CORRECT ANSWER_S = subjective (what patient tells you, the story) O = objective (observational findings and verified information) A = assessment (identification of health issues and possible etiologies) P = plan (how to proceed from here) DAR documentation - CORRECT ANSWER_D-data Harmful incident - CORRECT ANSWER_-Resulted in patient harm Near miss - CORRECT ANSWER_-Incident that did not reach the patient but would have caused harm if it did No harm incident - CORRECT ANSWER_-Incident reached the patient but no discernible harm resulted Factors influencing safety - CORRECT ANSWER_-patient and provider factors -task factors -technology factors -environmental factors -organizational factors CPSI - CORRECT ANSWER_Canadian Patient Safety Institute -Takes a multidisciplinary approach to safe patient care 6 CPSI safety framework domains - CORRECT ANSWER_1. Contribute to a culture of patient safety 2. Work in teams for patient safety 3. Communicate effectively for patient safety 4.Manage safety risk 5. Optimize human and environmental factors 6. Recognize, respond to, and disclose adverse events Swiss Cheese Model of Accident Causation - CORRECT ANSWER_The model shows how errors occur when situational factors align, despite multiple layers of safeguards for the prevention of errors. Iceberg Model - CORRECT ANSWER_-Root cause analysis -Looks for contributing factors rather than direct cause to prevent additional adverse events in the future Staff safety risks - CORRECT ANSWER_-Environmental risks -Infection prevention and control -Violence Patient safety risks - CORRECT ANSWER_-Falls (90%) -Procedure-related accidents Most common types of errors in healthcare - CORRECT ANSWER_-Medication errors -Transfusion errors -Errors during surgery -Falls -Burns -Restraints -Pressure injuries -Wrong patient Nurse's role in patient's safety - CORRECT ANSWER_-Assess the client to meet basic needs -Reduce physical hazards -Reduce equipment-related and procedural harm -Maintain sanitation -Control pollution -Reduce transmission of pathogens Ideal fluid intake - CORRECT ANSWER_-1500-2000ml/day Typical urine output - CORRECT ANSWER_-500ml for infants 1500ml for adults Psychological factors that influence urination - CORRECT ANSWER_-Nervousness -Stress -Fear -Cold Medical factors that influence urination - CORRECT ANSWER_-Diabetes or diuretics -Bladder or kidney problems -Obstructions (kidney stones, prostate enlargement, tumours) -Dehydration from diarrhea or vomiting Surgical factors that influence urination - CORRECT ANSWER_-Pelvic surgeries causing swelling and pressure on the urethra -Bladder or kidney removal -Other complications to blood flow Neurological factors that affect urination - CORRECT ANSWER_-Impaired neuromuscular function -Damage at or below the sacral region of the spinal cord -E-coli infection Anal abnormalities - CORRECT ANSWER_-Hemorrhoids -Anal fissure -Excoriation Passing gas - CORRECT ANSWER_-Indicates a functioning GI tract -Inability to pass gas can become severe with decreased mobility, surgery, or anesthetics -Increasing mobility is ideal Bristol Stool Chart - CORRECT ANSWER_1-7 (hard lumps- liquid); 3-5 is normal Health promotion related to bowel health - CORRECT ANSWER_-Adequate hydration and fiber intake -Regular hand hygiene -Stool regularly -Proper perineal care -Kegel exercises can strengthen pelvic floor muscles Newborns hygiene concepts - CORRECT ANSWER_-Skin is thin and can dry out quickly -Susceptible for rashes and infection -Skin folds increase risk of infection -Oral care is important Older adults hygiene concepts - CORRECT ANSWER_-Skin loses resiliency and moisture with less active sweat glands -Skin is fragile with easy bruising and breaking -Practices depend on learned behaviour as a child, personal preference, expectations from others, ability to manage self-care, and degree of assistance required Mouth hygiene concerns-older adults - CORRECT ANSWER_-Decreased saliva -Risk for gum disease if oral care is not consistent -Risk for damage from dentures -Dentures may not fit well Ears, eyes, nose hygiene concerns-older adults - CORRECT ANSWER_-Watch for build up of wax, discharge Feet hygiene concerns-older adults - CORRECT ANSWER_-Possible deformity of toes, consider shoes -Nails thick, brittle, fungus is possible, keep feet clean and dry -Watch for sores Providing hygiene care general guidelines - CORRECT ANSWER_-Patient-centered -Timely, safe, and efficient -Maintaining dignity and autonomy -Considering the patient's ability -Respecting personal preferences -Six C's of caring The Six C's of Caring in Nursing - CORRECT ANSWER_1. Compassion 2. Competence 3. Confidence 4. Conscience 5. Commitment 6. Comportment Levels of care - CORRECT ANSWER_1. Independent 2. Assistive device to complete self-care activities 3. One person assistance 4. Dependent, requires complete care from care provider Skin assessment during hygiene care - CORRECT ANSWER_-Colour, moisture, bruises, tears, sores, pressure points -Moisture, rashes, breakdown Hair and nails assessment during hygiene care - CORRECT ANSWER_Hair-Moisture, distribution, smoothness, cleanliness Nails-Length, condition, cleanliness, abnormalities Bathtub safety considerations - CORRECT ANSWER_-Water temperature -Mobilizing in and out of tub -Slippery surface -Use of mechanical lift -Supervision in water