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NSG 3100 Exam 1 202 5/
Questions & Verified Answers
What is the least effective decisionmaking process - establishing assumptions what does the trial-and-error method of problem solving lack - exactness The research process of problem solving is - most effective when used by experienced nurses why is the nursing process method used in nursing - it creates interaction between client and nurse, used to set healthcare needs and goals and plans, and works well in all environments what does critical thinking allow nurses to do during emergencies - recognize important cues child cannot grasp the mechanics behind a spirometer so the nurse uses balloons and jar of bubbles instead, what does this represent - creativity and critical thinking what does it mean when a nurse has a feeling of something going wrong or happening
- intuition a nurse observes a gsw patient and assumes the client is at an increased risk for hypovolemic shock after observing the blood spurting out of the wound. what is this an example of - inductive reasoning while attending a nursing educator conference a nursing instructor obtains information about the use of concept maps and pathways. the instructor returns to work and uses these techniques, what does this show? - creating an environment that supports critical thinking what is the definition of the nursing process - systematic rational method of planning and providing individualized nursing care
how are nursing cognitive skills learned - through reading and applying health related literature what nursing process phase identified the most current scope and standards of nursing practice thats not recognized by the NCLEX - outcomes identifications and diagnosis during the interview phase, what will the nurse consider may have a cultural implication? - physical distance between the nurse and client and seating arrangement what is an example of an open-ended question that the nurse may use in the interview process - how have you been feeling lately what is the name of the head to toe approach during a physical assessment - cephalocaudal what framework is based on 11 functional health patterns and collects data about dysfunctional and functional behavior - Gordons functional health patterns after health history and physical assessment, the nurse identifies discrepancies in the information. what is this process - validating the nurse takes the clients vital signs, the nurse is performing which phase of the nursing process - assessing the nurse reassesses a clients temperature 45 minutes after administering acetaminophen, this is an example of what type of assessment - ongoing the nurse is measuring the drainage from a Jackson-Pratt drain. what is considered objective data? - the drainage measurement is 25 ml what is the purpose of data collection and analysis - to identify actual or potential health concerns
the home health registered nurse needs to assign a person to insert a foley catheter on a client, who can she delegate this task - LPN or LVN that is licensed planning consists of which component - selecting nursing intervention the nurse admits a client in active labor to the LD floor, when does the planning for the client care start - during the initial meeting which component is part of the permanent client records - client care plan when a nurse turns a client q2h due to stage 4 ulcers on the coccyx, what nursing process is being carried out - implementation what are the benefits of a nursing intervention classification system - it helps demonstrate the impact that nurses have, assists educators to develop curricula for clinical nurses, standardizes and defines the knowledge base for nursing, facilitates the appropriate selection of a nursing intervention and communication of nursing treatments to other nurses taxonomy of nursing outcome statements is developed to describe measurable states, behaviors, or perceptions to respond to which part of the nursing process - nursing interventions evaluation of the clients healthcare while the client is still receiving care from the agency is called - concurrent audit basic nursing interventions are based on - scientific knowledge, nursing research, and evidenced based practice what is the 5th and last phase of the nursing process - evaluating nurse documents goal and desired outcome if it was met, what part is this - conclusion
when implementing plan of care the nurse should do what - supervise unlicensed support personnel and evaluate the clients reaction to the planned interventions which situation will the nurse need assistance with implementing in the nursing intervention - transferring a bilateral amputee from bed to chair what are the two nursing phases that overlap each other in the nursing process - evaluating/assessing what are the two parts in an evaluation nursing statement - conclusion and supporting data what means freedom from disease causing microorganisms - asepsis which consists of primarily nucleic acid and need a living host - viruses what is not a sign of inflammation - fatigue the most practical and inexpensive method for sterilizing at home - boiling water what demonstrates further need for teaching with types of infections - acute infections may occur slowly, over a long period of time and last months or years chain of infection, which is NOT one of the six links - hand hygiene an antigen is - substance that induces a state of sensitivity or immune responsiveness CDC recommends antimicrobial hand cleansing agents in all situations besides - when there are unknown multiple nonresistant bacteria a nurse planning a safety instruction class for parents of adolescents knows that the focus of the class should be on - teaching adolescents about driver safety
the nurse needs to insert a hearing aid, which is not appropriate - gently press the ear-mold into the ear while rotating it forward Rules for hand washing - - 15 - 20 seconds
- hands lower than elbows
- firm rubbing circular motion
- remove jewelry rules for baths - - long firm strokes
- inspect skin
- persuasion
- stop if distress
- use distraction
- ask for help complete bath - sponge bath self help bath - patients confined to bed;can help with back/feet partial bath - client washes everything;nurse washes back bag bath - Commercially prepared washcloths that are moistened with a no-rinse- required cleaning product. towel bath - Nurse uses a single large towel to cover and wash a client tub bath - A bath given in a tub. independent - no bathing assistance needed Semi-dependent - requires help from another person moderately dependent - help from another person and/or device totally dependent - not able to participate at all
foot care basics - - nails cut straight across
- diabetics
- no lotion between toes, may cause fissures and cracks in skin Oral care basics - - no lemon glycerin swabs (erodes enamel)
- mouth swab in water
- suction available critical thinking-independence - think for yourself critical thinking-fair minedness - consider all points of view critical thinking-insight into egocentricity - be aware of own biases critical thinking-intellectual humility - admitting you dont know critical thinking-challenge status quo and rituals - ask why critical thinking-integrity - admit when wrong critical thinking-perseverance - keep pushing forward and making progress critical thinking-confidence - confident in words and actions critical thinking-curiosity - gain new knowledge clinical reasoning - process used by practitioners to plan, direct, perform, and reflect on client care applying critical thinking in practice - - prioritize mult patients
- cultural impacts on care outcomes
- logical reasoning
- review current evidence based research
- lowest level restraint first
- continuous monitoring
- do not impede circulation
- quick release knot
- never to handrails belt restraint - seatbelt jacket restraint - jacket used to restrain pt - last resort mitt restraint - - restrict finger movement
- prevents the person from grasping tubes or catheters
- allows for more freedom of arm movement than a wrist restraint wrist or ankle restraint - - pad bony promineces
- movable portion of bedframe
- 2 fingers Moving patients - - Safety is first priority
- Ask patient to help as much as possible
- Determine if patient comprehends what is expected
- Determine patient's comfort level
- Determine if you need assistance in moving the patient
- bed to center of gravity
- prevent spinal twisting-pivot technique
- wide stance log roll - - the method used to turn a patient with a spinal injury, in which the patient is moved to the side in one motion
- arms across chest
- blanket underneath slide to edge of bed
- staff on both sides of the bed
- supportive devices
- pillow placed for side rolling (head)
- leg pillows mechanical lift - - provides a safe transfer for patients/residents from a supine to
- hoyer lift. Patient positioning - - firm mattress
- no bone on bone
- locked wheels
- no wrinkles or wet sheets
- turn every 2 hours
- 2 siderails up cane guidelines - - rubber tips
- length=permit elbow to be flexed
- strong side of body
- 6 in tomside 6 inches in front of near foot moving using a cane - - cane forward 1 foot
- move weak leg
- move strong leg
- repeat measuring crutch height - Axillary (stading):
- 2" below axilla
- handgrip should be @ styloid process w/ arms and shoulders relaxed: 20- 30 degrees flexion Laying:
- measure from anterior fold of axilla to heel of foot and add 1 inch Crutch Stance (Tripod position) - - crutches 6 in out and 6 in fwd crutch stance (4pt alternate gait) - - bear weight both legs
- safest
- right crutch-left foot left crutch-right foot repeat
Crutches (3 pt gait) - - bear whole weight good leg
- both crutches-weak leg forward good leg fwd repeat Crutches (two pt alt gait) - - left crutch-right foot together right crutch-left foot together repeat swing to gait - - hip paralysis
- Crutches moved forward simultaneously swing both feet together up to the crutches repeat swing through gait - both crutches are advanced then the legs swing past the crutches Fowler's position - a semi-sitting position; the head of the bed is raised between 45 and 60 degrees Semi-Fowler's Position - 15 - 45 degrees High Fowler's Position - - sitting up almost straight
- 60 to 90 degrees
- never long for elderly due to skin breakdown orthopedic bed position - respiratory patients Sims position - - a side-lying position with the lowermost arm behind the body and the uppermost leg flexed
- pregnant women
- halfway between lateral and prone dorsal recumbent position - - lying on the back with the knees flexed
- elevate head with pillow
Phases of the nursing process - Assessment
Diagnosis Planning Implementation Evaluation Assessing - collecting, validating, and communicating patient data diagnosis - analyzing and synthesizing data Planning - determining how to prevent client problems to develop an individualized care plan with client goals stated Implementation - carrying out the plan of care Evaluation - measuring the degree to which goals have been achieved to determine how to modify care plans Safety Hazards - - lifestyle
- cognitive awareness
- ability to communicate
- mobility health status
- emotional state
- environmental factors
- sensory perception altered
- safety aweareness
- feeding
