This serves as a form of communication within the health care team and providing information for other professionals, primarily for individuals and and groups involved with accreditation, credentialing, legal, regulatory, and legislative, research, etc. What purpose does patient records serve?
Ide...
NSG 321 Final Exam Questions and
Solutions
This serves as a form of communication within the health care team and providing
information for other professionals, primarily for individuals and and groups involved
with accreditation, credentialing, legal, regulatory, and legislative, research, etc.
✅What purpose does patient records serve?
Identify/ Introduce
Situation
Background
Assessment
Recommendation
Read- back ✅what does ISBARR stand for?
Assessment
Diagnosis
Plan
Implement
Evaluation ✅what are the steps to the nursing proccess?
Incident report ✅tool used by healthcare facilities to document unexpected events that
result in, or have the potential to result in harm to a patient or person.
Used to prevent the development of venous stasis, thrombophlebitis, and the the
development of venous thrombosis ✅what are graduated compression stocking used
for?
Rescue- rescue anyone in immediate danger
Activate- activate the fire code system and notify the appropriate person
Confine- confine the fire by closing doors and windows
Evacuate- evacuate patients and other people to a safe area ✅fire safety:
What does RACE stand for?
Crutch walking ✅with crutches, weight should rest on the hands, not on the underarms
for supports. Prevent crutches from getting closer than 12 inches to the feet
Active exercise ✅when the patient independently moves joints
Passive exercise ✅the patient is unable to move independently, the nurse moves each
joint through its range of motion
, Isotonic exercise ✅involves muscle shortening and active movement
Isometric exercise ✅involves muscle contraction without shortening
Isokinetic exercise ✅involves muscle contraction with resistance
Cutaneous pain ✅superficial pain usually involving the skin or subcutaneous tissue
Somatic pain ✅diffuse or scattered and originates in tendons, ligaments, bones, blood
vessels, and nerves
Visceral pain ✅pain originating in the internal organs in the thorax, cranium, or
abdomen
Referred pain ✅pain that is felt in a location other than where the pain originates
Opioid analgesics side effects ✅sedation- monitor levels of consciousness
Respiratory depression- monitor respiratory rate before and after administration of
opioid
Orthostatic hypotension- try to avoid sudden changes in position
Urinary retention- monitor I&O
Nausea/vomiting
Constipation
Numeric rating ✅pain scale used for adults and children >9 years old in all patient care
setting who are able to use numbers to rate the intensity of their pain
Critical care pain observation tool (CPOT) ✅pain scale used for adults who are
sedated and non-responsive
FLACC faces, legs, activity, cry, consolability ✅pain scale used to help rate pain for
ages 2 months to 7 years for those who are unable to validate the presence of or
quantify the severity of pain
Wong baker faces ✅pain scale used for adults and children (>3 years old) in all patient
care settings
PAINAD ✅pain scale used in patients whose dementia is so advanced that they
cannot verbally communicate
Moving away from a painful stimuli
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