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NURS 302 Assessment 1 Webinars & Potter
Questions With Complete Solutions
The Nursing Process is a systematic five step framework nurses use to... What are the steps? correct answer: plan and provide optimal patient care ADPIE Assessment Diagnosis/Analysis Planning Implementation Evaluation What is used to prioritize which patients should be seen first? correct answer: ABCDEP Airway Breathing Circulation Disability or change in level of consciousness Environment - concerns around patient's body Pain What are your first two actions for treating a patient in respiratory distress? correct answer: 1. First raise the head of the bed to allow the airway to open up
- Second intervention is to put on oxygen What question helps build critical thinking skills when thinking about what intervention to perform? correct answer: If I do "this" then "what" will happen? If I give IV fluids, what happens to a patients blood pressure? It increases If I give Oxygen to a patient, what should I see? An increase in oxygen saturation If patient has an infection, then what? They'll have a fever When making decisions, what four things should you do? correct answer: 1. Review the set of all possible nursing interventions for a patient's problem
- Review all possible consequences associated with each possible nursing action
- Determine the probability of all possible consequences
- Judge the value of the consequence to the patient Goals need to be SMART, which stands for? correct answer: Specific Measurable Achievable Realistic Time limit-framed Nurses must make accurate and appropriate clinical decisions or judgements. Clinical judgement is defined as correct answer: the outcome of critical thinking and clinical reasoning
Do incidence reports go in patient chart? correct answer: no, they go in hospital database What is the most important thing to do when taking a telephone/verbal order? correct answer: Repeat it back so the provider knows you heard everything because the nurse is the one entering the order Provider has to sign a telephone/verbal order within correct answer: 24 hours The standards for Evidence Based Practice (EBP) are (2) correct answer: -Problem-solving approach to clinical practice -Address clinical problems by using the best approach based on clinical evidence for managing the problem How can we determine if a patient understood what we just told them? correct answer: Best way is to have the patient demonstrate it back to you Second best is the make sure they tell you in their own words Patient education is always written at what grade level? Why? correct answer: 5th grade level So that every patient can understand what is going on with their care What can a UAP do? correct answer: Do tasks and gather data (e.g "patient had this much urine") Can help with turning or ambulation if it isn't the first time
What is QSEN? correct answer: Quality and Safety Education for Nurses Developed to help prepare future nurses who will be needed in their health care environments to improve patient safety. Patients over the age of ____ are at an increased risk of a fall correct answer: 65 What is the leading cause of fatal and nonfatal injuries for people over the age of 65? correct answer: falls Patients on prolonged bedrest usually develop (hint: not pressure ulcers) Why is this a problem when they begin to ambulate? correct answer: orthostatic hypotension -they get dizzy when they stand up They are at an increased risk of falling Most common means of transmission of pathogens is by correct answer: the hands How often should you sanitize your hands? correct answer: before and after every patient You only need to actually wash your hands (as opposed to sanitizer) when correct answer: hands are visibly dirty or treating a patient that has C.diff Do you need to wash your hands after treating a patient that has C.diff even if they are not visibly dirty? If so, why? correct answer: Yes
Have patients wear nonslip socks to prevent fall when getting out of bed For restraints applied for violent or self-destructive behavior, a health care provider must assess the patient within correct answer: 60 minutes What needs to be written in an order for restraints? correct answer: CTD Clinical indication, type and location, and duration Restraint orders may be renewed to the time limits for a maximum of correct answer: 24 consecutive hours After a restraint is applied, how often must a patient be monitored? correct answer: every 15 minutes for a violent patient and every 2 hours for a nonviolent patient Two categories of restraints? correct answer: Physical and chemical (ativan, haldol, benzo's) What are some complications associated with restraints? correct answer: Pressure ulcers Pneumonia Constipation Incontinence Instead of restraints, what are other options to stop a patient from injuring themselves? correct answer: Guard rails up (only 2!) Bed alarm
Sitter How do we measure if disuse atrophy is occurring? correct answer: Height, weight, and circumference of extremities What happens to a patient's metabolism when they are immobile? correct answer: Metabolism is decreased -alters metabolism of carbs, fats and proteins -fluid, electrolyte and calcium imbalances Decreased appetite and peristalsis -weight loss, decreased muscle mass, and weakness result from tissue breakdown -Constipation, fecal impaction Calcium loss from bones -fractures occur Important stuff about proteins correct answer: Muscle building and essential for healing Protein for blood panel is albumin -Poor albumin increases risk of wounds not healing Why is decreased peristalsis when a patient immobile such a huge concern? Why does decreased peristalsis even happen? correct answer: because the bowels are moving slowpoke slow so patient is at a higher risk of fecal impaction and obstruction Because of decreased blood flow. The heart is working regieleki hard and blood is shunted away from nonessential organs
DVT + lungs = pulmonary embolism which is UNFORTUNATELY pretty common Musculoskeletal changes due to immobility correct answer: muscle breakdown aka disuse atrophy Impaired calcium metabolism -bone resorption-bone becomes less dense and gets brittle-- increased risk for fracture Joint contracture -fixation of a joint from disuse, atrophy, and shortening of the muscle fibers -Cannot achieve full ROM What is a common joint contracture that occurs due to immobility? correct answer: Foot drop Foot is permanently fixed in plantar flexion and patient can't lift toes off of the ground If a patient can't move on their own, we help with correct answer: passive ROM exercises Someone actually moves the muscles for the patient. Bending legs, moving feet up and down, etc. etc. Aside from passive ROM exercises, what other intervention is used to prevent joint fixation? Issue with this intervention? correct answer: Splints Problem: Splints increase risk of skin breakdown
Where are pressure ulcers most likely to occur? correct answer: over bony prominences The upright position promotes the flow of urine... correct answer: out of the renal pelvis and into the ureters and bladder due to gravity Urinary stasis occurs when laying flat for too long. What is urinary stasis? What does urinary stasis increase the risk of? correct answer: When laying flat the ureters cannot overcome gravity and the renal pelvis fills first Increased risk of UTI Increased risk of renal calculi (kidney stones if you ain't tryna be fancy) What causes pressure ulcers? correct answer: Where too much pressure is put on the skin causing the blood vessels in an area to collapse Pressure ulcers usually occur where Most common where and why? correct answer: over bony prominences (elbows, wrists, knees, toes, and sacrum) Most common on the sacrum on account of you kinda can't not lay on it
Bed position should be at waist height so you're not bending over If sliding patient then put them flat or inverted What should be considered during ambulation? Like, what should you assess/do before ambulating? (5) correct answer: non slip socks Strength assessment Bed in lowest setting Have patient sit up and dangle legs out of bed until you're sure they won't pass out from orthostatic hypotension Have equipment - gait belt, walker, extra people etc. etc. Wait until patient isn't dizzy What is the purpose of evidence based practice (EBP)? correct answer: it helps the patient's plan of care and it focuses on client's values What is the most important part of the planning phase? correct answer: setting priorities patients often have a metric butt-ton of problems so it's super important to prioritize what the main and most threatening problems are first What is the PICOT method? correct answer: It's a way to format your "foreground" (WTF) question when you're looking for research to treat a patient P - Patient population of interest I - Intervention C - Comparison
O - Outcome T - Time What is the purpose of performance improvement (PI) and quality improvement (QI)? correct answer: helps to reduce a nurse's legal risk for malpractice and negligence because they help you see potential hazards and eliminate them before harm occurs What is SOAP? (in healthcare. Not, like, to stop you from having BO and stuff) correct answer: A note taking method for charting. Like the order you should put info Subjective info Objective info Assessment Plan What is a normal WBC range? correct answer: 4,000-10, mm^ What is a normal hemoglobin range (Hgb) Men? Women? correct answer: Men: 13-18 g/dL Women: 12-15 g/dL What is a normal hematocrit range (Hct) Men? Women? correct answer: Men: 40-52%
What is it? correct answer: clear to pale yellow water plasma What is serosanguineous drainage? Looks like? correct answer: It's plasma mixed with blood (NOT pretty pink, like gross pink -- just google it, you'll get what I mean.) Thinner and more watery than blood What are the three types of health-care associated infections? (HAI) correct answer: Iatrogenic Exogenous Endogenous What is an iatrogenic infection? Related to...? Example? correct answer: occurs from diagnostic or therapeutic procedure related to use and implement proper cleaning protocols CAUTI and CLABSIssss What is an exogenous infection?
Example? correct answer: An infection that comes from outside the body salmonella from the cafeteria What is an endogenous infection? How does it happen? correct answer: When the infection is coming...FROM INSIDE THE HOUSE!!!! ...or part of the patient flora becomes altered and an overgrowth results, if you wanna be boring Happens from receiving broad-spectrum antibiotics What are the four specific sites for a HAI? correct answer: Urinary tract -bad technique when inserting foley -drainage bag too high or on flood -obstructed urine flow -repeated catheter irrigation Wounds -improper technique for wound cleaning, dressing change, or skin prep Respiratory tract -Contaminated respiratory equipment -Immobility -Failure to use aseptic technique while suctioning Bloodstream -Improperly accessed central line/port -Contaminated needles, IV tubing, or IV fluids
What ARE droplet precautions? correct answer: Diphtheria, pneumonia, scarlet fever, pertussis, mumps -Private room -Mask or respirator required -Isolated or cohort patients Disinfection eliminates many or all organisms except (BLANK) from (BLANK) correct answer: Disinfection eliminates many or all organisms (EXCEPT SPORES) from INANIMATE OBJECTS What is the tier list for aseptic techniques? correct answer: CDS Cleaning - worst one Disinfection - ehhh little bettah Sterilization - the big daddy Cleaning does what? ok like, stupid question, but definition wise it removes what? correct answer: removes soil from objects and surfaces Disinfection eliminates BLANK or BLANK organisms (except BLANK) from inanimate objects correct answer: Disinfection eliminates MANY or ALL organisms (except SPORES) from inanimate objects WOAH REMEMBER YOU CAN BOLD WORDS TOO THAT'S DOPE AF
What is asepsis? correct answer: The absence of all pathogenic microorganisms What is aseptic technique? correct answer: Any healthcare procedure in which added precautions are used to prevent contamination of a person, object, or area by microorganisms Surgical asepsis includes procedures used to eliminate... correct answer: ALL microorganisms (including spores!) PHILOSOPHY TIME: If you look away from a sterile field, is it still sterile? correct answer: NO What are the stages of pressure ulcers? correct answer: Stage 1 - Non-blanching erythema (redness) of intact skin (red intact) Stage 2 - Partial-thickness skin loss involving epidermis, dermis, or both Stage 3 - Adipose showing and granulation --full-thickness skin involving damage to or necrosis of subcutaneous tissue that may extend down to fascia Stage 4 - Extensive destruction, tissue necrosis, or damage to muscles, bones, or supporting structures with or without full- thickness skin loss Unstageable Why is an unstageable pressure ulcer not stageable? correct answer: Because it's too gross from too much slough or eschar so you can't see all the damage
