NP1 FINAL EXAM QUESTIONS
• What are the stages of skin integrity break down?:
Stage 1: Non blanchableRedness
Stage 2: Partial Thickness Skin Loss
Stage 3: Full Thickness Skin Loss
Stage 4: Full Thickness Tissue LossUnstageable
• What defines stage 1 of break down?:
-in tact skin
-non-blanchable redness
• What defines Stage 2 of break down?:
- shallow, open ulcer
-red, pink wound bed without slough
• What defines Stage 3 of break down?:
-Subcutaneous fat visible (while bone,tendon, & muscle are not)
-Slough may be present but not enough to obscure the depth
-Tunneling & undermining may be present
• What defines Stage 4 of break down?:
-Bone, tendon, & muscle may be visible
-slough and eschar may also be visble, but not enough to obscure depth of wound
• What defines unstageable break down?: -full thickness tissue loss where depth is
unknown due to obscurity caused by slough (yellow, tan, gray, green, orbrown) and/or eschar
(tan, brown, or black) in the wound bed
• What foods are high in potassium?: fruits, potatoes, instant coffee, molasses,brazil nuts
• What ADLs can be delegated to NAPs?:
,-NAPs can do ADLs but only afterthe RN has taught the pt how to properly implement them
at home.
-Vitals and symptoms must be reported immediately to RN
• Should you use post operative baselines or pre?:
-Preoperative.
--Pain from procedure and medication administered afterwards can affect vitals andskew them
until regulated.
• What are the steps of the nursing process?: ADPIE A=assessment D=diag-nosis
P=planning I=implementation E=evaluation
• Nursing Process: Assessment: Systematic and continuous collection, analy-sis, validation,
and communication of patient data.
Data reflect how health functioning is enhanced by health promotion or compro-mised by
illness/injury.
A database includes all the pertinent patient information collected by the nurse andother health
care professionals.
The database enables the nurse to partner with patients to develop a comprehensiveand effective
plan of care.
• Nursing Process: Diagnosis:
Identify problem and etiology
Construct NANDA
Prioritize diagnosis based on what will harm the pt more
• Nursing process: Planning: Once you have found pt's weaknesses develop listof
interventions that would help pt reach their goal.
-Make them measurable, specific, and reasonable
• Nursing Process: Implementation: Determine patient readiness and involvepatient(s) in
health care process
Review planned interventions with interdisciplinary health care team members tofacilitate
, collaborative effort
Utilize principles of delegation, being mindful of supervision and evaluationCounsel person
and significant others
Refer for continuing careDocument care provided
• Nursing process: Evaluation: Through the patient's eyesPatient outcomes
Nurses and patients need to determine whether the plan of care has been success-ful.
Nursing interventions are evaluated to determine which strategies or interventionswere
effective.
If expected outcomes are not met, the plan of care needs to be modified.
• Stress Risk Factors: -Situational
-Maturational
-Sociocultural
• Stress Risk Factors: Situational: -Personal
-Job
-Family changes
-Chronic illness
• Stress Risk Factors: Maturational: -vary with life stage
-physical appearance
-families
-friends
-school
• Stress Risk factors: Sociocultural: -Environmental and social
-loss of parents
-parents divorce
-violence
-homelessness
-cultural variations
• What do you document in r/t HIPAA?: HIPAA: Health Insurance Portability and
Accountability Act
-Create pt right to consent to use and disclosure of PHI.
-inspect/copy medical record and amend mistaken/incomplete information
-due to this act, no PHI can be disclosed outside of health care setting.
• What are the stages of skin integrity break down?:
Stage 1: Non blanchableRedness
Stage 2: Partial Thickness Skin Loss
Stage 3: Full Thickness Skin Loss
Stage 4: Full Thickness Tissue LossUnstageable
• What defines stage 1 of break down?:
-in tact skin
-non-blanchable redness
• What defines Stage 2 of break down?:
- shallow, open ulcer
-red, pink wound bed without slough
• What defines Stage 3 of break down?:
-Subcutaneous fat visible (while bone,tendon, & muscle are not)
-Slough may be present but not enough to obscure the depth
-Tunneling & undermining may be present
• What defines Stage 4 of break down?:
-Bone, tendon, & muscle may be visible
-slough and eschar may also be visble, but not enough to obscure depth of wound
• What defines unstageable break down?: -full thickness tissue loss where depth is
unknown due to obscurity caused by slough (yellow, tan, gray, green, orbrown) and/or eschar
(tan, brown, or black) in the wound bed
• What foods are high in potassium?: fruits, potatoes, instant coffee, molasses,brazil nuts
• What ADLs can be delegated to NAPs?:
,-NAPs can do ADLs but only afterthe RN has taught the pt how to properly implement them
at home.
-Vitals and symptoms must be reported immediately to RN
• Should you use post operative baselines or pre?:
-Preoperative.
--Pain from procedure and medication administered afterwards can affect vitals andskew them
until regulated.
• What are the steps of the nursing process?: ADPIE A=assessment D=diag-nosis
P=planning I=implementation E=evaluation
• Nursing Process: Assessment: Systematic and continuous collection, analy-sis, validation,
and communication of patient data.
Data reflect how health functioning is enhanced by health promotion or compro-mised by
illness/injury.
A database includes all the pertinent patient information collected by the nurse andother health
care professionals.
The database enables the nurse to partner with patients to develop a comprehensiveand effective
plan of care.
• Nursing Process: Diagnosis:
Identify problem and etiology
Construct NANDA
Prioritize diagnosis based on what will harm the pt more
• Nursing process: Planning: Once you have found pt's weaknesses develop listof
interventions that would help pt reach their goal.
-Make them measurable, specific, and reasonable
• Nursing Process: Implementation: Determine patient readiness and involvepatient(s) in
health care process
Review planned interventions with interdisciplinary health care team members tofacilitate
, collaborative effort
Utilize principles of delegation, being mindful of supervision and evaluationCounsel person
and significant others
Refer for continuing careDocument care provided
• Nursing process: Evaluation: Through the patient's eyesPatient outcomes
Nurses and patients need to determine whether the plan of care has been success-ful.
Nursing interventions are evaluated to determine which strategies or interventionswere
effective.
If expected outcomes are not met, the plan of care needs to be modified.
• Stress Risk Factors: -Situational
-Maturational
-Sociocultural
• Stress Risk Factors: Situational: -Personal
-Job
-Family changes
-Chronic illness
• Stress Risk Factors: Maturational: -vary with life stage
-physical appearance
-families
-friends
-school
• Stress Risk factors: Sociocultural: -Environmental and social
-loss of parents
-parents divorce
-violence
-homelessness
-cultural variations
• What do you document in r/t HIPAA?: HIPAA: Health Insurance Portability and
Accountability Act
-Create pt right to consent to use and disclosure of PHI.
-inspect/copy medical record and amend mistaken/incomplete information
-due to this act, no PHI can be disclosed outside of health care setting.
