NR226 FUNDAMENTALS II EXAM 2 REVIEW QUESTIONS WITH
COMPLETE SOLUTION
Airborne Precautions (TB/Vaircella/Measles)
-Gloves
-Gown
-N-95 respirator
-Negative pressure room
-Private room
Droplet Precautions (Meningococcal pneumonia/Scarlet fever)
-Gloves
-Mask
-Eyewear if splashing is expected
Standard Precautions
Hand washing
(gloves if touching bodily fluids)
Contact Precautions (Scabies, MRSA, E.coli.)
-Gown
-Gloves
-Eyewear if splashing is expected
Protective Precautions (Cancer)
-Gown
-Gloves
-Masks
-Private room
-Client wears a mask when exiting the room
What are 3 occasions when a nurse would use standard precautions?
-When treating wounds or a break in the skin
-When coming into contact with contaminated equipment or bodily fluids
-When disposing of sharps
Clear Liquid Diet
-Chicken and beef broth
-Plain jello
-Clear juices like apple
-Popsicles
Full Liquid Diet
-Milk and milkshakes
-Strained creamy soups
-Ice cream
-Sherbet
-Pudding
-Cream of Wheat
Dysphagia Diet
,-(Same as full liquid diet)
-Pureed meats
-Vegetables
-Fruits
-Scrambled eggs
-Mashed potatoes
Mechanical Soft Diet
-Ground meats
-Flaked fish
-Cottage Cheese
-Rice
-Cooked/canned foods
Soft/Low Residue Diet
-Low fiber foods like pasta
-Moist tender meats
-Canned cooked fruits
-Desserts without nuts or coconut
High Fiber Diet
-Fresh uncooked fruits
-vegetables
-bran
-Oatmeal and dried fruits
Low Sodium Diet
-Low sodium food products that contain from 500 mg-4 gm sodium depending on the
provider's order
S in SBAR stands for?
Situation- Introduce yourself with your position, title, role, or relationship to the patient in
question. Include the location from which you are calling
• "Dr. Smith, this is Emily Boyce, from the Med-Surg floor at ABC Hospital, I'm the nurse
taking care of, Mr. Jones. Mr. Jones is complaining of shortness of breath and chest
pain."
B in SBAR stands for?
• Background- Date and reason for admission; Symptoms; Admitting diagnosis; Recent
vital signs; Laboratory status; Code status; Allergies; Medication that the patient is
currently taking.
• "Mr. Jones had a heart attack two weeks ago and was admitted yesterday for
observation due to new complaints of chest pain. His pulse is 124, and his blood
pressure is 100/58. He is restless and experiencing rapid, shallow breathing."
A in SBAR stands for?
• Assessment- Condition and the severity of the condition- New developments
concerning the condition
• "Given his history, I am concerned he may be experiencing a new cardiac event."
R in SBAR stands for?
, •Recommendation-Recommendation for treatment of the patient (e.g. surgery, physical
therapy, blood work, etc.)
• "I've initiated O2 per NC as per standing order and request an order for an EKG and
for you to assess him immediately. Do you agree?"
Circadian Rhythm
Hospital patients can have circadian rhythms disrupted by bright lights, sounds and
frequent contact by nursing personnel
Evaluation
• Reassess how your plan worked out
• State as met, partially met or unmet
• It's OK if your intervention didn't work, say "unmet" and rethink the plan (goal)
• Don't use the phrase "Patient will demonstrate...." This is a goal statement!
Direct Patient Care
• Activities of Daily Living
• Physical Care Techniques
• Lifesaving Measures
• Counseling
• Teaching
• Controlling Adverse Reaction
• Preventive Measures
Planning
• Establish priorities for care
• Establish priorities for intervention
• Set goals and expected outcomes
- SMART goals (specific, measurable, attainable, realistic, timed)
- Include patient in setting goals
.• Use critical thinking in planning nursing care
• Choose appropriate nursing interventions
Indirect Patient Care
• Communicating Nursing Interventions
- Charting
- Oral reporting
COMPLETE SOLUTION
Airborne Precautions (TB/Vaircella/Measles)
-Gloves
-Gown
-N-95 respirator
-Negative pressure room
-Private room
Droplet Precautions (Meningococcal pneumonia/Scarlet fever)
-Gloves
-Mask
-Eyewear if splashing is expected
Standard Precautions
Hand washing
(gloves if touching bodily fluids)
Contact Precautions (Scabies, MRSA, E.coli.)
-Gown
-Gloves
-Eyewear if splashing is expected
Protective Precautions (Cancer)
-Gown
-Gloves
-Masks
-Private room
-Client wears a mask when exiting the room
What are 3 occasions when a nurse would use standard precautions?
-When treating wounds or a break in the skin
-When coming into contact with contaminated equipment or bodily fluids
-When disposing of sharps
Clear Liquid Diet
-Chicken and beef broth
-Plain jello
-Clear juices like apple
-Popsicles
Full Liquid Diet
-Milk and milkshakes
-Strained creamy soups
-Ice cream
-Sherbet
-Pudding
-Cream of Wheat
Dysphagia Diet
,-(Same as full liquid diet)
-Pureed meats
-Vegetables
-Fruits
-Scrambled eggs
-Mashed potatoes
Mechanical Soft Diet
-Ground meats
-Flaked fish
-Cottage Cheese
-Rice
-Cooked/canned foods
Soft/Low Residue Diet
-Low fiber foods like pasta
-Moist tender meats
-Canned cooked fruits
-Desserts without nuts or coconut
High Fiber Diet
-Fresh uncooked fruits
-vegetables
-bran
-Oatmeal and dried fruits
Low Sodium Diet
-Low sodium food products that contain from 500 mg-4 gm sodium depending on the
provider's order
S in SBAR stands for?
Situation- Introduce yourself with your position, title, role, or relationship to the patient in
question. Include the location from which you are calling
• "Dr. Smith, this is Emily Boyce, from the Med-Surg floor at ABC Hospital, I'm the nurse
taking care of, Mr. Jones. Mr. Jones is complaining of shortness of breath and chest
pain."
B in SBAR stands for?
• Background- Date and reason for admission; Symptoms; Admitting diagnosis; Recent
vital signs; Laboratory status; Code status; Allergies; Medication that the patient is
currently taking.
• "Mr. Jones had a heart attack two weeks ago and was admitted yesterday for
observation due to new complaints of chest pain. His pulse is 124, and his blood
pressure is 100/58. He is restless and experiencing rapid, shallow breathing."
A in SBAR stands for?
• Assessment- Condition and the severity of the condition- New developments
concerning the condition
• "Given his history, I am concerned he may be experiencing a new cardiac event."
R in SBAR stands for?
, •Recommendation-Recommendation for treatment of the patient (e.g. surgery, physical
therapy, blood work, etc.)
• "I've initiated O2 per NC as per standing order and request an order for an EKG and
for you to assess him immediately. Do you agree?"
Circadian Rhythm
Hospital patients can have circadian rhythms disrupted by bright lights, sounds and
frequent contact by nursing personnel
Evaluation
• Reassess how your plan worked out
• State as met, partially met or unmet
• It's OK if your intervention didn't work, say "unmet" and rethink the plan (goal)
• Don't use the phrase "Patient will demonstrate...." This is a goal statement!
Direct Patient Care
• Activities of Daily Living
• Physical Care Techniques
• Lifesaving Measures
• Counseling
• Teaching
• Controlling Adverse Reaction
• Preventive Measures
Planning
• Establish priorities for care
• Establish priorities for intervention
• Set goals and expected outcomes
- SMART goals (specific, measurable, attainable, realistic, timed)
- Include patient in setting goals
.• Use critical thinking in planning nursing care
• Choose appropriate nursing interventions
Indirect Patient Care
• Communicating Nursing Interventions
- Charting
- Oral reporting
