NUR NUR215 Foundations Exam Study Guide Updated.

 IS THE PATIENT’S AIRWAY CLEAR?  IS THE PATIENT ABLE TO BREATHE?  IS THE PATIENT HEART RATE/BLOOD PRESSURE WITHIN RANGE? 1. IN THIS FRAMEWORK THE MOST IMPORTANT PATIENT IS THE ONE WHOSE AIRWAY IS BLOCKED. 2. THE SECOND WOULD BE THE PATIENT WHOSE BREATHING IS COMPROMISED AND CANNOT GET OXYGEN TO THE BODY. 3. THE THIRD WOULD BE THE PATIENT WHOSE BLOOD PRESSURE AND HEART RATE ARE COMPROMISED. 4. THE LAST WOULD BE A PATIENT WHO IS NOT SAFE OR WHOSE SAFETY IS AT RISK. S = SAFETY. PRACTICE QUESTION 1. A NURSE IS WORKING THE 7-7 SHIFT ON THE PEDIATRIC UNIT AND HAS RECEIVED REPORT ON FOUR POSTOPERATIVE PATIENTS. WHICH OF THE FOLLOWING REQUIRES IMMEDIATE INTERVENTION? a) AN ADOLESCENT WHO IS POSTOPERATIVE FOLLOWING AN APPENDECTOMY AND HAS REFUSED TO AMBULATE FOR THE PAST 8 HOURS b) A SCHOOL-AGED CHILD WHO IS POSTOPERATIVE FOLLOWING A HERNIORRHAPHY WITH AN INFILTRATED PERIPHERAL IV THAT HAS BEEN CLAMPED c) A PRESCHOOLER WHO IS POSTOPERATIVE FOLLOWING A TONSILLECTOMY AND IS EXPERIENCING FREQUENT SWALLOWING d) AN INFANT WHO IS POSTOPERATIVE FOLLOWING A CLEF PALATE REPAIR WITH A HEART RATE OF 146/MIN A RESPIRATORY RATE OF 28/MIN 2. A NURSE IS CARING FOR A PATIENT WHO WAS ADMITTED TO THE UNIT 3 HOURS AGO FOLLOWING A TOTAL HIP ARTHROPLASTY. WHICH OF THE FOLLOWING FINDINGS SHOULD BE THE NURSE’S PRIORITY CONCERN? a. URINARY OUTPUT OF 75ML OVER THE PAST 3 HOURS b. 8 POINT ELEVATION IN THE PRE-SURGERY DIASTOLIC BLOOD PRESSURE c. OXYGEN SATURATION OF 70% d. CORE BODY TEMP OF 97.2 F LEAST RESTRICTIVE/ LEAST INVASIVE  WHEN IMPLEMENTING INTERVENTIONS, THE MAIN GOAL IS TO BE AS MINIMALLY RESTRICTIVE AND INVASIVE TO THE PATIENT AS POSSIBLE  ALWAYS CHOOSE THE LEAST INVASIVE PROCEDURE POSSIBLE FIRST  ALWAYS CHOOSE THE LEAST RESTRICTIVE PROCEDURE POSSIBLE FIRST