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2024 NS 500 FOUNDATIONS EXAM 1 WITH CORRECT ANSWERS
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2024 NS 500 FOUNDATIONS EXAM 1 WITH CORRECT ANSWERS
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2024 NS 500 FOUNDATIONS EXAM1 WITH CORRECT ANSWERS
What are the premises of Tanner's model of clinical judgement? - CORRECT-
ANSWERSNoticing, interpreting, responding, reflecting
How do we add JEDI into Tanner's model of clinical judgement? - CORRECT-
ANSWERSNotice intersectionality, interpret without bias, respond with
sensitivity
What are the two types of reflection and what are examples? - CORRECT-
ANSWERSReflection in action and reflection on action. Reflection in action
could be reflecting on past experiences and how to apply that experience
currently. Reflection on action is reflecting at the end of something about
how things went and what could be different.
How is climate change affecting infectious disease transmission? - CORRECT-
ANSWERSIncrease of mosquitos, higher water temps, human migration,
droughts
What are the four HAIs? - CORRECT-ANSWERSCAUTI: catheter-associated
urinary tract infection
SSI: surgical site infection
VAP: ventilator-associated pneumonia
CLABSI: central-line associated bloodstream infection
What are some ways to prevent a CAUTI? - CORRECT-ANSWERSAdvocate for
removal of Cath when it seems appropriate, or advocate for no cath at all if
you don't think your pt needs one
What are some common multi drug resistant organisms (MDROs) - CORRECT-
ANSWERSMRSA, VRE, ESBLs, MDRSP
How can MDROs best be prevented? - CORRECT-ANSWERSHand hygiene.
Contact precautions until a patient is culture negative, education, cleaning,
antibiotic stewardship.
A patient is admitted to the medical unit for a home-acquired pressure ulcer.
The patient has Alzheimer's disease and has been urine incontinent. The
nurse inserts a Foley catheter. What is the most significant risk for an HAI?
,a. restraints
b. poor dental hygiene
c. foley cath bag
d. improper positioning of patient - CORRECT-ANSWERSc. foley cath bag
What should we ask about in the subjective when it comes to infection
control? - CORRECT-ANSWERSFever, wounds, urinary symptoms, cough,
recent travel, stress, medications, recent sick contacts.
What medications are important to know about in regard to infection control?
- CORRECT-ANSWERSAntibiotics, chemotherapy, steroids.
What are important things to look for in the objective for infection control? -
CORRECT-ANSWERSVital signs, systemic and local symptoms. Labs.
What symptoms could indicate an infection? - CORRECT-ANSWERSLocal -
redness, warmth, purulent drainage, pain, swelling.
Systemic - fatigue, n/v, malaise, lymphadenopathy, fever.
What vital signs could indicate an infection? - CORRECT-ANSWERSFever,
tachycardia, tachypnea, hypotension
What do we worry about when our patient is hypotensive? - CORRECT-
ANSWERSPerfusion
What is a symptom of infection in older adults? - CORRECT-ANSWERSAltered
mental status, incontinence
What lab value would be elevated in an infection? - CORRECT-
ANSWERSWhite blood cell count with differential. Patient would have a
leukocytosis (elevated WBCs)
What is a normal WBC count? - CORRECT-ANSWERS5000-10,000/mm^3
Example of a nursing diagnosis statement for infection. - CORRECT-
ANSWERSRisk for infection related to long term urinary catheter use and
prescribed corticosteroid medications.
What is medical asepsis? - CORRECT-ANSWERS"CLEAN" - break the chain of
infection. Can do this by wearing gloves, hand washing, disinfecting, wearing
masks. Change linens. etc. Standard precautions should be used with all
patients.
What is surgical asepsis? - CORRECT-ANSWERS"STERILE" - the highest level
of aseptic technique that prevents contamination and isolates the operative
, or procedural area. This is used by the RN when inserting a catheter, trach
suctioning, sterile dressing change, central line dressing change.
What is the overall gist of the nursing process? - CORRECT-ANSWERSTo
diagnose and treat human responses to actual or potential health problem.
What are the components of the nursing process? - CORRECT-
ANSWERSAssessment, diagnosis, planning, implementation, evaluation
What comprises the assessment component? - CORRECT-
ANSWERSDetermines patient current and past health status with two steps:
collect information and interpret information. This is when you run through
an HPI, ROS, and exam.
What should you do prior to going in and assessing your patient? - CORRECT-
ANSWERSReview the EMR, review isolation precautions, and sanitize your
hands just prior to entering the room
What is a focused assessment? - CORRECT-ANSWERSThis assessment is
problem-oriented.
What are some interview techniques? - CORRECT-ANSWERSObservation,
open or closed ended questions, leading questions, back channeling, probing
What is a nursing diagnosis? - CORRECT-ANSWERSA clinical judgement made
by an RN to describe a patient response or vulnerability to health conditions
or life events that an RN is licensed and competent to treat.
What is a collaborative problem? - CORRECT-ANSWERSA problem that
requires both medical and nursing interventions to treat.
What are the three types of nursing diagnoses? - CORRECT-
ANSWERSProblem focused, risk, and health promotion
Write a PES statement for acute infection. - CORRECT-ANSWERSAcute
infection r/t wound from a ground level fall as evidenced by purulent
material, warmth, and erythema of the wound site.
What is wrong with this PES statement?
Risk for falls related to recent cerebrovascular accident. - CORRECT-
ANSWERSCVA is a medical diagnosis and should not be included. This could
be fixed by changing the statement to "Risk for falls related to impaired
balance."
What are the methods of prioritization? - CORRECT-ANSWERSConsider the
type of nursing diagnosis, as problem focused tend to be of higher
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