NUR1460 EXAM 1 QUESTIONS AND ANSWERS SOLVED 100- CORRECT.

NUR1460 EXAM 1 | QUESTIONS AND ANSWERS | ss ss ss ss ss ss ss




SOLVED 100% CORRECT ss ss ss




FINAL EXAM Term 2 A7 – Review ss ss ss ss ss ss




1. Discuss the Nursing Process (ADPIE) ss ss ss ss




A - Assessment - Gather patient care data (objective and subjective) through observation,
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interviews, and physical assessments. Assessment data can be collected from a variety of
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sources, including patients, family members, friends, communities, health care professionals,
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medical records, and laboratory and diagnostic test results.
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D - Diagnosis -Analyze, validate, and cluster patient data to identify patient problems. 3-Step
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nursing diagnosis = problem, etiology (related to), defining characteristics (as evidenced by).
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P - Planning - Prioritize nursing diagnoses and identify short and long-term goals that are
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realistic, measurable and patient-focused, with specific outcome identification for evaluation
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purposes (SMART goals).
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I - Implementation - Initiate specific nursing interventions and treatments designed to help the
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patient achieve established goals or outcomes.
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E - Evaluation - Determine whether the patient’s goals have been met, examine the
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effectiveness of interventions, and decide whether the plan of care should be discontinued,
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continued, or revised.
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Yoost Ch. 5, pg. 71 ss ss ss ss




2. What can the RN delegate to unlicensed personnel? An RN can delegate bathing, dressing,
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feeding, ambulating, vital signs ( if patient is stable)
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What type of responsibilities can the RN not delegate? RN never delegates : Evaluation,
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Assessment, Teaching, New admits, unstable patients, what you can eat,
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3. Discuss the Process of Gas Exchange ss ss ss ss ss




Gas Exchange - the process by which oxygen is transported to cells and carbon dioxide is
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transported from cells. This normal physiological process requires interaction among the
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neurologic, respiratory, and cardiovascular systems (Giddens Concept 19, pg. 178)
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Impairment of gas exchange occurs when the diffusion of gases (oxygen and carbon dioxide) is
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impaired due to ineffective ventilation, reduced capacity for gas transportation (reduced
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hemoglobin and/or red blood cells), or inadequate perfusion.
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,4. Define and discuss Oxygenation Versus Perfusion
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Oxygenation - process by which oxygen is transported to cells and carbon dioxide is
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transported from cells.
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Perfusion - normal physiologic process that requires the heart to generate sufficient cardiac
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output to transport blood to patent blood vessels for distribution in the tissues throughout the
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body. (Giddens Concept 18, pg. 167)
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*Adequate oxygenation and perfusion of tissues depends on the cardiovascular and respiratory
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systems working together to oxygenate tissues.
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5. Define normal and abnormal findings of the Laboratory and diagnostic studies below
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a. RBC - determines the oxygen-carrying capacity of the blood. Normal range
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is 4.7 - 6.1 (men) and 4.2 - 5.4 (women). Patients who have anemia have
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decreased numbers of RBCs, which reduces the patient's oxygen-carrying
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ability.
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b. ABG - Normal pH range: 7.35 - 7.45 (if below 7.35, it is acidosis; if above
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7.45, it is alkalosis)
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Normal Paco2 range: 35 - 45 mm Hg (if abnormal, it is respiratory) Normal
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ss HCO3 range: 22 - 26 mEq/L (if abnormal, it is metabolic)
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**Remember R.O.M.E. (Respiratory Opposite, Metabolic Equal) ss ss ss ss ss




c. Sputum - Can help in the diagnosis of respiratory disorders. Normal culturess ss ss ss ss ss ss ss ss ss ss



results are negative. Culture and sensitivity are performed on a single specimen
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to detect bacteria and determine which antibiotic is most effective. The most
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, common harmful bacteria found in sputum can cause bronchitis, pneumonia, or
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tuberculosis.
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6. Endoscopic Examination
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a. Bronchoscopy - an endoscopic examination in which a flexible fiber-optic
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bronchoscope is extended through the bronchi for the purpose of diagnosis,
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specimen collection, or tissue biopsy. Can be diagnostic or therapeutic (removing
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foreign objects).
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b. Thoracentesis - a procedure to relieve a pleural effusion by inserting a
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needle into the pleural space to remove fluid. Nurses assist physicians with this
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procedure and monitor the patient's vital signs, lung sounds, and pain level
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afterward.
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c. Lung Biopsy - a procedure in which samples of lung tissue are removed
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(with a special biopsy needle or during surgery) to determine if lung disease or
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cancer is present.
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