2024 NR 302 FINAL REVIEW EXAM
why is it important for patients to use incentive spirometry - CORRECT ANSWERS-prevent atelectasis and pneumonia
JVD indicates - CORRECT ANSWERS-right side heart failure
thrombophlebitis - CORRECT ANSWERS-inflammation of a vein
erythema - CORRECT ANSWERS-white skin is redness of the skin produced by
capillary congestion
objective data - CORRECT ANSWERS-measurable data, for example vital signs
after completing an initial assessment on a pt, the nurse charts, vital signs as temp of 100.1 oral, apical HR 98 irregular, RR 24 shallow, B/P 128/90, pulse ox of 90% on RA, what are you worried about - CORRECT ANSWERS-
oxygenation, infection, activity intolerance, capillary refill greater than 3 seconds
during assessment of the lower extremities of a male patient the nurse is unable to palpate the dorsalis pedis pulse, what action should the nurse take
first - CORRECT ANSWERS-reposition the fingers and assess again
what is a Doppler? - CORRECT ANSWERS-is a test that uses high frequency sound waves (ultrasound) to measure the amount of blood flow through your
arteries and veins, usually those that supply blood to your arms and legs
an example of objective data obtained during the physical assessment includes - CORRECT ANSWERS-audible and auscultated inspiratory wheeze, 2x2 cm stage 1 pressure ulcer on right ankle, crackles that clear with cough
audible vs. ausculated - CORRECT ANSWERS-auscultated is hearing through stethoscope while audible is heard within the room what does clears with cough mean - CORRECT ANSWERS-hear normal sounds
after patient coughs
level of consciousness - CORRECT ANSWERS-objective data, alert, lethargic, stuporons, and comatose
orientation x 4 - CORRECT ANSWERS-person, place, time, situation
a mother is at the clinic with her 2 year old son, "he wont go to sleep at night
and during the day he has several fits" I get so upset when this happens, the nurses best verbal response would be - CORRECT ANSWERS-to clarify and get more information, fits?, tell me what you mean by this
what are non-therapeutic communcation - CORRECT ANSWERS-asking closed
ended questions, medical jargon, talking too much, asking why questions
which of the following statements illustrates the use of open-ended questions - CORRECT ANSWERS-builds and enhances rapport, used when narrative information is needed
therapeutic communication techniques - CORRECT ANSWERS-assists the narrative, open-ended questions, repeating what patient says for clarification
a patients reason for seeking care is shortness of breath, when obtaining a health history, which of these questions by the nurse would obtain the most helpful information - CORRECT ANSWERS-will you please describe the activities that cause you to be short of breath
components of a health history - CORRECT ANSWERS-biographical data, review of systems, functional assessment, activities of daily living
the nurse is collecting data about a patients smoking history, the patient admits to smoking 1.5 packs/day for the last 10 years, the nurse documents the patient has a smoking history of how many pack-years - CORRECT ANSWERS-15 pack years
what is the relationship between sleep and smoking? - CORRECT ANSWERS-
decreases sleep by interrupting the latency cycle which is the time of complete wakefulness to the lightest REM (rapid eye movement) sleep
pack year formula - CORRECT ANSWERS-number of cigarettes times the years divided by 20
during an exam the nurse notices the patient has round, flat red lesions on the skin of the forearm, the nurse suspects - CORRECT ANSWERS-petechiae which is bleeds under the skin that confluence