What are the 4 established priorities of the nurse Priority 1: Life threatening illness Priority 2: Environment Safety (side rails, falls risk protocol, bed height, etc.) Priority 3: Client priorities (AM care, etc.) Priority 4: Nurse priorities
What does the ABCDE model stand for? A: airway B: br...
NURS 370 Midterm Exam Questions and
Solutions
What are the 4 established priorities of the nurse ✅Priority 1: Life threatening illness
Priority 2: Environment Safety (side rails, falls risk protocol, bed height, etc.)
Priority 3: Client priorities (AM care, etc.)
Priority 4: Nurse priorities
What does the ABCDE model stand for? ✅A: airway
B: breathing
C: circulation
D: disability
E: exposure
When assessing an airway: what 3 things are we looking for? ✅Patent airway
Voice sounds
Present breath sounds
What is seen during a partial airway obstruction? ✅Gasping actions
Anxiety
Adventitious sounds
Decreased LOC
Interventions used to open an airway? ✅Head tilt, chin lift → repositioning to open
airways
Check for foreign bodies. Look for obstruction (ie. choking on food)
Suction
CPR
Call code team
Why is nasopharyngeal suctioning commonly used on paediatric pt's? ✅In children,
part of the airway is the nasal cavity. This type of suctioning ensures airways are open
Chest physio is commonly done on which pt population? ✅Pediatric populations
tolerate this well
What is chest physio and why is it done? ✅Tapping forcefully on chest to clear
secretions, like mucous
,Can an oral airway be used on a pt who is conscious? ✅No. Patient must be
unconscious
How should the tongue be positioned before placing an oral airway ✅Ensure tongue is
out, before placing. Hence why oral airway is placed in "upside down" and then twisted
down - to avoid dragging tongue down airway.
Do Endotracheal tubes increase or decrease risk for pneumonia ✅Increase risk for
pneumonia. Allows secretions and bacteria entry into airway.
Best places to check for cyanosis? ✅Lips
Mucous membranes (mouth, universal for all skin tones)
Intercostal accessory muscle use is commonly seen in which pt population?
✅Paediatric population
It is more visible in children; because they are small and bony
What 3 areas are assessed for accessory muscle use during breathing ✅Intercostal
spaces
Under rib cage
Supraclavicular/ suprasternal spaces
Interventions used to maximize breathing ✅Reposition patient (To maximize breath
expansion, HOB at 45 degrees, with one pillow)
Increase oxygen (start ~2L then titrate up)
What is an expected cap refill time ✅Less than 3 seconds
Bounding pulses and high temp (flushed red skin) can indicate the early warning signs
of ________ ✅Sepsis
What does AVPU stand for? Which ABCDE priority does it fall under? ✅Alert
Voice responsive
Pain responsive
Unresponsive
Falls under D: disability
What is assessed under priority D: disability ✅LOC
AVPU
Blood glucose
PERRLA
,GCS
What is the recovery position and when is it used ✅Side lying position - head turned to
side
Used for unconscious pt's, to avoid choking on vomit/ secretions
What is assessed under priority E: exposure ✅Expose the skin and observe for any
signs of injuries:
-Bleeding
-Bruising
-Trauma
-Rashes → may indicate allergy (meningitis can cause rashes)
Temperature (hypothermia or fever)
Pain fits under which ABCDE priority ✅E: exposure
Define health literacy ✅The ability to access, comprehend, evaluate and communicate
information to promote, maintain and improve health in a variety of settings across the
life-span.
Signs of low health literacy ✅-Non-compliance (meds/ treatment)
-Difficulting recalling medication
-Missed appointments
-Difficulty or reluctance to fill out forms
-Difficulty navigating the healthcare environment (ie. finding rooms, following signs)
What are the 6 dimensions of health literacy ✅1. autonomous
2. interactive
3. cultural
4. informational
5. operational
6. contextual
Explain the autonomous competency ✅This competency considers Personal
empowerment
-Do they have the desire
-Self-awareness
Explain the interactive competency ✅Collaboration with others
-How do they respond to health care practitioners
Problem-solving (or lack of)
-Ex. waiting too long to access resources
, Explain the cultural competency ✅Interpret meaning of social practices
Is it of personal importance? Cultural/ social importance?
Ex. JW wont take blood transfusion
Explain the informational competency ✅Determine authority and currency of health
information
-The ability to sort through info and judge the credibility and accuracy
Ex. googling symptoms and self diagnosing
Explain the operational competency ✅Use of tools, procedures and techniques
Do they know how to use their meds/ treatments (ie. insulin pens)
Explain the contextual competency ✅Mastery of environment:
-Feeling overwhelmed/ fatigued that simple things don't make sense. They might have
high health literacy, but are not able to process the way they normally would due to the
context.
Ex. not giving patient teaching when patient is in pain. Give pain meds and then teach
once patient is ready to listen.
Define Pneumonia ✅Inflammation of the lung parenchyma (tissue and vascularity)
Pneumonia is the _____th leading cause of death in Canada ✅6th
What % of sepsis cases are due to pneumonia ✅40- 50%
T or F: Having pneumonia in the past, puts you at a higher risk for getting another type
of pneumonia. ✅True
What are the 4 causes of Pneumonia ✅Bacterial
Viral
Fungal
Parasitic
BVFP: bad violins fart poison
Bacterial pneumonia is most common in _________ patient's ✅Adult patients
Viral pneumonia is most common in _________ patient's ✅Paediatric patients
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