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LPN Fundamentals of Nursing Exam 1- 6
Final Exam
what is the final step in a complete assessment? (Ans- documentation S/S of hypostatic pneumonia (Ans- decreased lung expansion, generalized respiratory muscle weakness and secretions occur without immobility. (comes from inflammation of the lung from stasis or pooling of secretions. ) s/s of respiratory acidosis (Ans- increased PaCo2 and increased hydrogen ion concentration below 7.35. This reflects the excess carbonic acid in the blood (hypoventilation produces R. acidosis) what is the primary advantage of hydrogel dressing? (Ans- contains a high percentage of water for wounds that require moisture. Maintaining a moist wound environment needed for healing. Hydrogel facilitates debridement by softening dead tissue. A pt complains of chills, dizziness and feeling hot during a blood transfusion. What are the nurses most appropriate actions? (Ans- Stop transfusion immediately. Remove blood component and tubing containing and tubing contacting blood products replace with new primed tubing with 0.9% sodium chloride Maintain patent IV line with normal saline Stay with patient observe signs and symptoms and monitor every 5 min. Notify health care ream or response team notify bank prepare to do cpr and give emergency drugs save blood container, tube, labels and transfusion record
get blood and 1st urine document transfusion reaction, description, treatment and outcomes The nurse is providing preoperative teaching for a patient regarding pain control after surgery. Which of the following statements is/are true regarding the use of postoperative analgesia? (Ans-
- inform nurse as soon as pain becomes a persistent discomfort.
- takes time for a drug to act
- drugs rarely eliminates all discomfort.
- don't be fearful of dependency
- USE of PCA pump which leadership skills should a nursing student use when caring for patients? (Ans- clinical decisions making priority setting organizational skills use of resources time management evaluation team communication delegation a nurse wants to follow the American nurses association's social media policy. Which actions should the nurse take? (Ans- never name a patient never describe a patient never post an image of pt never disparage a fellow employee or employer report breaches of confidentiality and privacy. visual changes in older adults is caused by what? (Ans- glaucoma, Age Related MUACLAR DEGENERATION
perceived loss (Ans- loss that is uniquely experienced by a grieving person and often less obvious to others. p.l is very real to the person. situational loss (Ans- the result of an unpredictable life event ex. divorce and family n friends split up and they lose the house maturational loss (Ans- a lifetime of normal development processes. ex kid goes to school and mom feels loss, kid may also feel loss. They spend less time together. tort (Ans- assault, battery Intentional Negligence Unintentional tort (Ans- a civil wrong or injury for which remedy is in the form of money damages Negligence (Ans- conduct that falls below the standard of care living wills (Ans- documents, instructing physicians to withhold or with draw life sustaining procedures statuary law (Ans- a form of contemporary law created by elected legislative bodies good Samaritan law (Ans- limitation of liability for heath care professionals offering assistance at the scene of an accident
assault (tort) (Ans- any willful attempt of threat to harm another person common law (Ans- a form of contemporary law created by judicial decisions in court when cases are decided battery (Ans- any intentional touching or another persons body without consent incident report (Ans- completed when anything unusual happens that could potentially cause harm to a pt visitor or employee Felony (Ans- a crime of a serious nature that usually carries a penalty of imprisonment. Define Sinus Tachycardia (Ans- Regular Rhythm, rate 100-180 beats/min (higher in infants) When is the best time of the month to perform a self-breast examination? (Ans- 4th to 7th day during menstrual cycle or days after cycle has ended. Define total Patient Care (Ans- Rn is responsible for all aspects of care for one or more pts during a shift of care. Care is usually consistent, comprehensive, and holistic, care can be delegated. RN works directly with pt, family and health care team members. Define Primary nursing (Ans- 1 primary RN assumes responsibility for a caseload of patients, provides care for the same pts during their stay in health care facility. RN assesses
Autonomy (Ans- the right to make ones own personal decisions even when those decisions might not be in that persons own best interest beneficence (Ans- positive actions to help others Fidelity (Ans- agreements to keep promises Justice (Ans- fairness in care delivery and use of resources Nonmalefience (Ans- avoidance of harm or injury acid base imbalance (Ans- respiratory metabolic 4 types- R. Acidosis, R. Alkalosis, M. Acidosis, M. Alkalosis respiratory acidosis (Ans- increased PACO Increased Hydrogen ion Concentration Ph. below 7. Both reflect the excess carbonic acid (h2CO3) in blood. hypoventilation produces respiratory acidosis causes cerebrospinal fluid and brain cells to become acidic, thus decreasing the level of concisions. respiratory alkalosis (Ans- Decreased PACO Increased PH above 7.
reflect the deficit of carbonic acid (h2CO3) in blood Hyperventilation produces respiratory alkalosis, which causes cerebrospinal fluid and brain cells to become alkolitic, decreasing the level of consciousness metabolic acidosis (Ans- metabolic acidosis results form condition's that increase metabolic acids in the body or decrease the amount of base( bicarbonate) bicarbonate level always is low because the bicarbonate system buffers metabolic acids. Diabetic ketoacidosis- causes metabolic acidosis. Calculation of ANION GAP cl- + bicarbonate = total Total - NA+ concentration= anion gap Anion gap reflects unmeasurable anion present in plasma. Metabolic Alkalosis (Ans- Increased Bicarbonate or excessive excretion of metabolic acid Common causes Vomiting and Gastric Suctioning Obtaining I and O on her Pt. What is considered intake? (Ans-
- all liquids eats, drinks
- nasogastric, jejunostomy feeding
- IV fluids and blood components
- Tube feeding and flush before and after should be counted as intake.
type of complicated grief (Ans- chronic grief delayed grief exaggerated grief masked grief importance of coughing, (Ans- coughing helps to remove retained mucus in the airway. A deep, productive cough is more beneficial than merely clearing the throat. A pt needs to anticipate postoperative discomfort and understand the importance of coughing, even when it is difficult. teaching pt to splint an abdominal or thoracic incision to minimize pain during coughing. Pain control is essential for effective deep breathing and coughing. educate a pt to ask for pain med as needed. kubler- ross 5 stages of grief. (Ans- denial - stage act as thought nothing has changed anger- individual postpones awareness of the loss and tries to prevent it from happening by making deals an promises. Bargaining- depression stage- person realizes the full significance of the loss during this stage. When depressed, the person feels overwhelming lonely or sad and w/ draws from interactions w/others. acceptance- the individual begins to accept the reality and inevitability of loss and looks to the future. randos r process model (Ans- specific to western society loss, reacting to the pain of separation, reminiscence, relinquishing old attachments and readjusting to life after loss. Reminiscence is an important activity in grief and mourings. In
reminiscence a person recollects and re-experiences the deceased and the relationship by mentally or verbally relieving and remembering the person and the past. incorrect order what should nurse do? (Ans- obtain further clarification from PCP inform nurse manager/supervisor do not carry out order if it risk of harm delegating guidelines (Ans- right task right circumstance right person right supervision right direction/communication leadership skills when caring for pt. (Ans- be responsible/accountable make a good clinical decisions learn form mistakes seek help collaborate with nurses strike to improve each interaction critical thinking Nurse practice acts (Ans- examples of statutes enacted by state legistures to regulate the practice of nursing. define the scope of nursing and expanded roles set education requirement's , distinguish between nursing and medical practice permits states boards to set rules, regulation's and guidelines that define the stranded of care In nursing practice.
hyperventilation (Ans- produces below 35mmHg. Increased rate and depth of respiration, more CO2 exhaled, there fore Decreased PaCO hypoventilation (Ans- Produces a PaCO2 above 45mmHg. Rate and depth decrease, less CO2 exhaled while cells continue to produce it, which increases the PaCo PaO2 (Ans- Partial pressure of oxygen in arterial blood. When Pa02 is with in normal range it has no primary role in acid base regulation. normal PaO2 (Ans- normal range 80 to 100mmhg. ( When Pa02 is with in normal range it has no primary role in acid base regulation. ) less than 60mmhg leads to anaerobic metabolism causing lactic acid production and metabolic acidosis. Hypoxemia- can cause hyperventilation leading to respiratory alkalosis. SaO2 (Ans- oxygen saturation is % of hemoglobin molecules that are carrying as much oxygen as is possible(saturated) SaO2 range (Ans- 95 - 100% pulse oximeter changes in tem. ph and paco2 affect SaO2 levels. Note finger nail polish will giber away wrong reading. base excess (Ans- base excess or deficit is the amount of blood buffer( hemoglobin and bicarbonate) Base normal range (Ans- 2 plus or minus mmol/L Increase positive= alkalosis Decreased Negative= acidosis bicarbonate HCO3 (3 has a line on top) (Ans- normal range in the ECF. extra cellular fluid
HCO3 22 to 26 Meq/L HCO3 is the principal buffer in the ECF. bicarbonate levels reflect the action the kidneys in managing metabolic acid. levels below 22 meq/L = metabolic acidosis Levels above 26 meq/L-= metabolic alkalosis vomiting (Ans- metabolic acidosis resp. acidosis (Ans- hyperventilation ( increasing H+ in blood) low ph= acidosis process of grandulation (Ans- temporary filling tissue. cont filling til wound is closed. primary intent (Ans- An example of wound healing by primary intention is a surgical incision. Second Intention Healing (Ans- A wound that is extensive and involves considerable tissue loss, and in which the edges cannot be brought together heals in this manner hypertonic- (Ans- water leaves cell. cell shrink hypotonic (Ans- water enters cell so full it erupts. Normal Saline (Ans- is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment. •It contains no antimicrobial agents. •The pH is 5.0 (4.5 to 7.0). • It contains 9 g/L Sodium Chloride with an osmolarity of 308 mOsmol/L. Osmosis is (Ans- the spontaneous net movement of solvent molecules through a semi-permeable membrane into a region of higher solute
undernutrition, poor perfusion, and co-morbidities known to impair wound healing). (Strength of Evidence = B) 2.3. Teach the individual and his/her family about the normal healing process and keep them informed about progress (or lack of progress) toward healing, including signs and symptoms that should be brought to the professi prevent pain with P. Ulcer (Ans- Prevent Pain
- Use a lift or transfer sheet to minimize friction and/or shear when repositioning an individual, keeping bed linens smooth and unwrinkled. (Strength of Evidence = C)
- Position the individual off of the pressure ulcer whenever possible (see Support Surface and Repositioning section). (Strength of Evidence = C)
- Avoid postures that increase pressure, such as Fowler's position greater than 30 or 90 side-lying position, or the semi-recumbent position. (Strength of Evidence = C)
- Minimize pressure ulcer pain by handling all wounds gently; flushing and not rubbing unnecessarily during cleansing; and protecting the periwound skin. P.U while in Bed (Ans- While in Bed
- Consider higher-specification foam or similar nonpowered pressure- redistribution support surfaces for Category/Stage I and II pressure ulcers. (Strength of Evidence = C)
- Avoid prolonged head-of-bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx. (Strength of Evidence = C) While in a Chair
- Use a pressure-redistribution cushion in the chair for individuals with Category/Stage I or II pressure ulcers. (Strength of Evidence = C)
- Minimize seating time and consult a seating specialist if pressure ulcers worsen on the seating surface selected. (Strength of Evidence = C)
- Ensure that the feet are properly supported either directly on the floor, on a footstool, or on footrests when sitting (upright) in a bedside chair or wheelchair. (Strength of Evidence = C)
- If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischia, limit sitting to three times a day in periods of 60 minutes or less. Consult a seating specialist to prescribe an appropriate seating surface and/or positioning techniques to avoid or minimize pressure on the ulcer. (Strength of Evidence = C)
- Avoid seating an individual with an ischial ulcer in a fully erect posture (in chair or bed). (Strength of Evidence = C)
- Modify sitting-time schedules and re-evaluate the seating surface and the individual's posture if the ulcer worsens or fails to improve. (Strength of Evidence = C) Category/Stage I and Hydrogel Dressings P. Ulcer (Ans- Hydrogel Dressings
- Consider the use of hydrogel dressings on shallow, minimally exudating pressure ulcers. (Strength of Evidence = B)
- Consider the use of hydrogel dressings for treatment of dry ulcer beds so that the gel can moisten the ulcer bed. (Strength of Evidence = C)
- Consider the use of hydrogel dressings for painful pressure ulcers. (Strength of Evidence = C)
- Consider the use of hydrogel sheet dressings for pressure ulcers without depth and contours and/or on body areas that are at risk for dressing migration. (Strength of Evidence = C)
- Consider the use of amorphous hydrogel for pressure ulcers with depth and contours and/or on body areas that are at risk for dressing migration. (Strength of Evidence = C)
- Consider the use of amorphous hydrogel for pressure ulcers that are not infected and are granulating. (Strength of Evidence = B) wound healing (Ans- Primary intention- minimal tissue loss, edges are approximated. No granulation, minimal scarring and infection risk is low. Secondary intention- wounds with full thickness tissue loss (deep lacerations, burns, pressure ulcers). Granulation present, and epithelial cells migrate across the granulation base (see picture). scarring, and can easily be infected.
Anger stage 2 k-R (Ans- Individual postpones awareness of the loss and tries to prevent it from happening by making deals and promises Stages of kubler-Ross (Ans- D, A, B, D, A Denial Anger Bargaining Depression Acceptance Depression stage 4 kubler-Ross (Ans- Person realized the full significance of the loss during this stage. When depressed the person feels overwhelming lonely or sad and with draws from interactions with others Acceptance stage 5 (Ans- The individual begins to accept the reality and inevitability of loss and looks to the future Bowlbys four phases Of mourning Phases 1 Numbing (Ans- A person has periods of extremely intense emotions and reports feeling "stunned" or "unreal" Last from several hours to a week Bowlbys four phases of mourning phase 2 yearning and searching (Ans- Phase evokes emotional outbursts tearful sobbing and a cute distress. To move forward people need to experience this painful phase of grief, include tightness of chest and throat, shortness of breath, feeling of weakness and lethargy, insomnia and loss of appetite. Last for months or intermittently to years Bowlbys four phases of mourning Phase 3 Disorganization and despair (Ans- Individuals spend much time thinking about how and why the loss occurred. Person often expressed anger at
anyone he or she believes to be responsible. Gradually this phase gives way to an acceptance that the loss is permanent. Bowlbys four stages of mourning Stage 4 Reorganization (Ans- Which usually requires a year or more. The person accepts unaccustomed roles, acquires new skills and builds new relationship. Nonblanchable (Ans- Persisting redness after palpating indicative of tissue damage. 1st stage of pressure ulcer development Undermining (Ans- Is deep tissue (subq fat and muscle) damage around the would margin. Wider area of wounding that lies beneath the wound opening. The wound is larger than hole. Ex would be like a basement leads down to a bigger room Blanch able (Ans- Reddened warm area of skin turns lighter in color following fingertip palpation Reactive hyperemia (Ans- Is the transient increase in organ blood flow that occurs following a brief period of ischemia Tissue ischemia (Ans- Inadequate blood supply to an organ or part of the body Informed consent requires (Ans- The pt to understand the options and risks of the care provided. Has opportunity to ask questions. Provides convent voluntarily. Is a competent adult Nurse responsible (Ans- For witnessing the patients signature on the consent form and sling if they understand or suspect they don't understand. Then the physician or health care provider and nurse supervisors should be notified
