©SIRJOEL EXAM SOLUTIONS
10/10/2024 11:44 AM
NUR 233 Final Exam Questions With
Correct Answers.
Rights of delegation - answer✔person, task, circumstance, communication, evaluation
components of cultural assessment - answer✔communication, space, time, orientation, social,
organization, environmental control, biological variations
nursing process steps - answer✔A(ssessment)
D(iagnosis)
P(lanning)
I(nterventions)
E(valuation)
components of nursing diagnosis - answer✔P(roblem) --> dx
E(tiology) --> r/t
S(ymptoms) --> AEB
components of risk diagnosis - answer✔nursing dx... r/t
, ©SIRJOEL EXAM SOLUTIONS
10/10/2024 11:44 AM
components of condition dx - answer✔nursing dx... r/t... AEB
S(ituation)
B(ackground)
A(ssessment)
R(ecommendation) - answer✔used to provide a framework for communication between
members of the healthcare team in regards to pt care + their current condition
rights of medication administration - answer✔drug, dose, pt, route, time, documentation
stage 1 pressure ulcer - answer✔localized area of intact skin w/ nonblanchable redness; area can
be painful, soft, firm, or warm
stage 2 pressure ulcer - answer✔partial thickness loss of dermis; open, shallow w/ reddish-pink
wound bed; no slough; skin not intact
stage 3 pressure ulcer - answer✔deep crater characterized by full thickness skin loss w/ damage
or necrosis of subQ; adipose visible; may extend to but not through fascia; undermining may be
present; skin not intact
stage 4 pressure ulcer - answer✔full thickness skin loss w/ tissue necrosis/damage to muscle,
bone, or support structure; exposed bone/tendon is visible/palpable; possible presence of slough
+ eschar; ebole, undermining, + tunneling may be present
, ©SIRJOEL EXAM SOLUTIONS
10/10/2024 11:44 AM
unstageable pressure ulcer - answer✔full thickness skin loss; base of wound is obscured by
slough or eschar
purpose of Braden Scale - answer✔assesses the pt's risk for impaired skin integrity + skin
breakdown; total score < 18 = risk
components of Braden Scale - answer✔sensory perception, moisture, activity, mobility,
nutrition, friction/shear
COPD s+s - answer✔accessory muscle use, dyspnea, SOB, tripod position, barrel chest, cough,
inc sputum, pursed lip breathing, skin color changes, anxiety, O2 <90, crackles, wheezes,
clubbing of fingers
pneumonia s+s - answer✔fever, tachycardia, dyspnea, chills, productive/nonproductive cough,
pleuritic chest pain, fatigue, purulent/blood-streaked sputum, hypotension, dysrhythmias, dec O2
sat, body aches, SOB upon exertion
hyponatremia s+s - answer✔lethargy, headache, confusion, gate disorders, N/V, seizure, coma,
weakness, fatigue, muscle cramps, orthostatic hypotension
care for pts w/ hyponatremia - answer✔replacement of sodium, fluid restrictions, diuretics,
monitor sodium + fluid levels, daily weight, monitor I+O, monitor neuro changes, seizure
precautions
