NUR 2090 FINAL EXAM CORRECT 100%
A CNA/LPN can ambulate a patient but should not if the nurse is ___________. -
ANSWER ASSESSING
do not delegate actions that require assessment
When prioritizing care for care for your patient, you will... - ANSWER address the
situation that is most dire to that patient at that time
subjective data - ANSWER -patients feelings and statements about their health
problems
-collected during the interview component of the health assessment
-data that cannot be directly observed by the nurse
Objective data - ANSWER -observable and measurable patient data
-collected during the physical assessment component of the health assessment
-data that can be directly observed through the senses of sight, hearing, touch, and
smell
empathy - ANSWER the ability to look at things from anothers perspective
THERAPEUTIC
positive regard - ANSWER Underlying assumption is that the person is worthwhile and
has value and dignity; avoids unnecessary labeling.
THERAPEUTIC
honesty - ANSWER open, direct, and sincere
THERAPEUTIC
trust - ANSWER demonstrate to patient, family, significant others that they can rely on
nurses without doubt, question, or judgement
THERAPEUTIC
self awareness or self reflection - ANSWER results in being aware of ones own
personality, values, cultural background, biases and style of communication; taking
responsibility for one's actions as a professional; and being seperate from but
connected to others
THERAPEUTIC
list nontherapeutic responses - ANSWER -rescue feelings (nurse is essential to patient
welfare)
-false reassurance (everything will be okay) must be based on fact
-changing the subject (anxiety by nurse) try to cheer up
-giving advice
-being moralistic (you should...)
,-nonprofessional involvement (establishes a social, economic, or personal relationship
with a patient )
offering self - ANSWER making oneself available to listen to the patient
open-ended questions - ANSWER asking neutral questions that encourage the patient
to express concerns
opening remarks - ANSWER using general statements based on observations
(you seem to be feeling better today)
restatement - ANSWER repeating to the patient the main content of his or her
communication
reflection - ANSWER identifying the main emotional themes contained in a
communication and directing these back to the patient
(you do not like how it tastes?)
focusing - ANSWER asking goal directed questions to help the patient focus on key
concerns
(tell me about your children)
encouraging elaboration - ANSWER helping the patient to describe more fully the
concerns or problems under discussion
(tell me about that)
airborne precautions - ANSWER private AIIR; respirator for healthcare personnel; mask
worn by the patient during transport out of the room
(tuberculosis, measles, varicella)
droplet precautions - ANSWER private room with the patient infected; mask required
when working within 3 feet of the patient
mask worn by the patient during transport
(flue, rubella, pertussis, respiratory virus)
contact precautions - ANSWER private room or cohabitation with patient infected with
dame organism; gloves at all time; change gloves when moving from soiled to clean;
hand hygiene ; gown and protective barriers during direct contact; patient dedicated
equipment
(c. diff, norovirus, herpes, conditions involving secretions)
review handwashing skill!!! - ANSWER
infiltration
s/s:
action:
, prevention: - ANSWER infiltration
s/s: swelling, coolness, and discomfort, slowed infusion rate, absence of blood return
action: discontinue IV and restart in another location; apply warm soaks to decrease
swelling
Prevention: select a site that is over long bones that act as splint
-avoid sites over joints
-consider using manufactured stabilization devices
Phlebitis
s/s:
action:
prevention: - ANSWER Phlebitis
s/s: pain, warmth, and redness at site; vein may feel hard, and cord like
action: discontinue IV and restart in another location; apply warm soaks, do not irrigate
prevention: change IV sites every 72 h; use large veins and large gauge needles; dilute
med/infuse slowly; use central line for very irritating solutions
INFECTION
s/s:
action:
prevention: - ANSWER INFECTION
s/s: redness, warmth, and purulent drainage, fever, chills, elevated WBCs
action: discontinue IV and restart, culture catheter tip and draw blood cultures; treat with
antibiotics
prevention: maintain asepsis, use good handwashing, change tubing and dressing q96
h
FLUID OVERLOAD
s/s:
action:
prevention: - ANSWER FLUID OVERLOAD
s/s: elevated bp, increased pulse and respirations, dyspnea, crackles, vein distention,
weight gain
action: slow iv to keep open rate and notify provider; place in semi or high fowlers,
administer o2 if needed
prevention: monitor rates carefully; use EID; dont catch up if IV gets behind
AIR EMBOLISM
s/s:
action:
prevention: - ANSWER AIR EMBOLISM
s/s: pain in chest, shoulder, or back; dyspnea; hypotension; thready pulse; cyanosis;
loss of consciousness
action: place on the left side in trendelenberg, notify the provider, monitor vital signs
A CNA/LPN can ambulate a patient but should not if the nurse is ___________. -
ANSWER ASSESSING
do not delegate actions that require assessment
When prioritizing care for care for your patient, you will... - ANSWER address the
situation that is most dire to that patient at that time
subjective data - ANSWER -patients feelings and statements about their health
problems
-collected during the interview component of the health assessment
-data that cannot be directly observed by the nurse
Objective data - ANSWER -observable and measurable patient data
-collected during the physical assessment component of the health assessment
-data that can be directly observed through the senses of sight, hearing, touch, and
smell
empathy - ANSWER the ability to look at things from anothers perspective
THERAPEUTIC
positive regard - ANSWER Underlying assumption is that the person is worthwhile and
has value and dignity; avoids unnecessary labeling.
THERAPEUTIC
honesty - ANSWER open, direct, and sincere
THERAPEUTIC
trust - ANSWER demonstrate to patient, family, significant others that they can rely on
nurses without doubt, question, or judgement
THERAPEUTIC
self awareness or self reflection - ANSWER results in being aware of ones own
personality, values, cultural background, biases and style of communication; taking
responsibility for one's actions as a professional; and being seperate from but
connected to others
THERAPEUTIC
list nontherapeutic responses - ANSWER -rescue feelings (nurse is essential to patient
welfare)
-false reassurance (everything will be okay) must be based on fact
-changing the subject (anxiety by nurse) try to cheer up
-giving advice
-being moralistic (you should...)
,-nonprofessional involvement (establishes a social, economic, or personal relationship
with a patient )
offering self - ANSWER making oneself available to listen to the patient
open-ended questions - ANSWER asking neutral questions that encourage the patient
to express concerns
opening remarks - ANSWER using general statements based on observations
(you seem to be feeling better today)
restatement - ANSWER repeating to the patient the main content of his or her
communication
reflection - ANSWER identifying the main emotional themes contained in a
communication and directing these back to the patient
(you do not like how it tastes?)
focusing - ANSWER asking goal directed questions to help the patient focus on key
concerns
(tell me about your children)
encouraging elaboration - ANSWER helping the patient to describe more fully the
concerns or problems under discussion
(tell me about that)
airborne precautions - ANSWER private AIIR; respirator for healthcare personnel; mask
worn by the patient during transport out of the room
(tuberculosis, measles, varicella)
droplet precautions - ANSWER private room with the patient infected; mask required
when working within 3 feet of the patient
mask worn by the patient during transport
(flue, rubella, pertussis, respiratory virus)
contact precautions - ANSWER private room or cohabitation with patient infected with
dame organism; gloves at all time; change gloves when moving from soiled to clean;
hand hygiene ; gown and protective barriers during direct contact; patient dedicated
equipment
(c. diff, norovirus, herpes, conditions involving secretions)
review handwashing skill!!! - ANSWER
infiltration
s/s:
action:
, prevention: - ANSWER infiltration
s/s: swelling, coolness, and discomfort, slowed infusion rate, absence of blood return
action: discontinue IV and restart in another location; apply warm soaks to decrease
swelling
Prevention: select a site that is over long bones that act as splint
-avoid sites over joints
-consider using manufactured stabilization devices
Phlebitis
s/s:
action:
prevention: - ANSWER Phlebitis
s/s: pain, warmth, and redness at site; vein may feel hard, and cord like
action: discontinue IV and restart in another location; apply warm soaks, do not irrigate
prevention: change IV sites every 72 h; use large veins and large gauge needles; dilute
med/infuse slowly; use central line for very irritating solutions
INFECTION
s/s:
action:
prevention: - ANSWER INFECTION
s/s: redness, warmth, and purulent drainage, fever, chills, elevated WBCs
action: discontinue IV and restart, culture catheter tip and draw blood cultures; treat with
antibiotics
prevention: maintain asepsis, use good handwashing, change tubing and dressing q96
h
FLUID OVERLOAD
s/s:
action:
prevention: - ANSWER FLUID OVERLOAD
s/s: elevated bp, increased pulse and respirations, dyspnea, crackles, vein distention,
weight gain
action: slow iv to keep open rate and notify provider; place in semi or high fowlers,
administer o2 if needed
prevention: monitor rates carefully; use EID; dont catch up if IV gets behind
AIR EMBOLISM
s/s:
action:
prevention: - ANSWER AIR EMBOLISM
s/s: pain in chest, shoulder, or back; dyspnea; hypotension; thready pulse; cyanosis;
loss of consciousness
action: place on the left side in trendelenberg, notify the provider, monitor vital signs
