ABC's prioritize in this order: airways, breathing, circulation
Understand nursing clinical judgement model -recognize cues: identify and recognize relevant clinical data -analyze cues: be able to interpret, organize and recognize patterns in cues in order to link the patients clinical presentatio...
NUR 225 Final Exam Questions and
Solutions
ABC's ✅prioritize in this order: airways, breathing, circulation
Understand nursing clinical judgement model ✅-recognize cues: identify and recognize
relevant clinical data
-analyze cues: be able to interpret, organize and recognize patterns in cues in order to
link the patients clinical presentation to a problem
-prioritize hypothesis: narrow problems down to the most pressing problem
-generate solutions: determine desired outcomes and best solutions along with what
resources you may need
-take action: implement nursing interventions based on your plan
-evaluate outcomes: observed outcomes to the desired/expected outcomes
Understand nursing process ✅-assessment: gather information about patients
condition
-diagnosis: identify the patients problems
-planning: set goals of care and desired outcomes
-implement: perform the nursing actions identified in planning (assess, monitor,
collaborate, teach and psychosocial)
-evaluate: determine if goals and expected outcomes are achieved
How to work through goals and outcomes for our patients. ✅use ABC and specific time
frame when developing goals. Center them around patient behavior, make it singular
and focused, good goals/outcomes are observable
What are the precautions for C-diff? ✅contact precautions; gown and gloves. Wash
hands with soap and water NO HAND SANITIZER
What are the differences between alcohol vs soap/water for cleaning with patients with
c-diff? ✅alcohol based cleaners reduce the number of microbes but soap and water is
better at killing germs with spores such as c-diff
What is preload? ✅a volume (amount of stretch of ventricles at the end of diastole or
before contraction) also known as end-diastolic volume
What is afterload? ✅the pressure which the ventricles must push against to get blood
to lungs/body.
What is the equation for cardiac output? ✅HR x SV
, What do you want to do if a patient has high preload? ✅-give hypertension type of
medication to lower blood pressure
-alternate rest and activitiy
-high fowlers to semi-fowlers
-avoid valsalva maneuver
-avoid stimulants
-manage fluid balance
-O2 therapy
What do you want to do if a patient has low preload? ✅-administer more IV fluids to
increase fluid volume to venous
What types of HF are there? ✅right sided and left sided
What is left sided heart failure? ✅left sided heart failure is when the left side of heart
cannot pump blood out of the heart so blood starts to back up into the lungs.
-most common HF
-left sided usually leads to right sided HF
What are the manifestations of left-sided HF? ✅-Difficulty breathing
-Rales (crackles)
-Orthopnea (cant breathe laying down)
-Weakness
-Nocturnal Dyspnea
-Increased HR
-Nagging Cough
-Gaining Weight
What is right sided HF? ✅-right side of heart cannot pump used blood it receives from
body efficiently so blood cant get back to lungs to get replenished with oxygen causing
the blood to back up peripherally (legs, hands, feet, abdomen).
-increase in inferior vena cava pressure
-usually caused from left-sided HF because of increased fluid pressure backing up from
left side to right
What are the manifestations of right sided HF? ✅-Swelling of legs, hands, liver,
abdomen
-Weight gain
-Edema
-Large neck veins (jugular venous distention)
-Lethargic (weak and tired)
-Irregular heart rate (atrial fibrillation)
-Nocturia
-Girth of abdomen increases
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