NURS 209 COMPREHENSIVE QUESTIONS AND VERIFIED DETAILED SOLUTIONS2025

Subjective Data - -What the subject says! Objective Data - -What YOU find out, whether that's through labs, assessing, or any other measure Caregiving - -Finding resources, providing personal care (bathing, feeding, or grooming), monitoring for complications or side effects of an illness or treatment, and providing instrumental activities of daily living (shopping or housekeeping) Autonomy - -An essential element of professional nursing that involves the initiation of independent nursing interventions without medical orders Accountability - -Means that you are responsible professionally and legally for the type and quality of nursing care provided Chest Tube Reasons - -Pneumothorax and Hemothorax ANA - -Develops, revises, and maintains the scope of practice statement and standards that apply to the practice of all professional nurses Preventive Care - -Adult screenings for blood pressure, cholesterol, tobacco use, and cancer; Pediatric screenings for hearing, vision, autism, and developmental disorders; HIV screening for adults at higher risk; Wellness visits; Immunizations; Diet counseling; Mental health counseling and crisis prevention; Community legislation Primary Care - -Diagnosis and treatment of common illnesses; Ongoing management of chronic health problems; Prenatal care; Family planning; Patient-centered medical home care Secondary Care - -Urgent care; emergency care; Acute medical-surgical care: ambulatory care, outpatient surgery, hospital; Radiological procedures Tertiary care - -Highly specialized: intensive care, inpatient psychiatric; Specialty care (neurology, cardiology, oncology, etc.) Maslow's Hierarchy of Needs - -Self Actualization; Self Esteem; Love and belonging needs; Safety and security: Physical and Psychological; Physiological: oxygen, fluids, nutrition, body temperature, elimination, shelter, sex Chain of Infection - -An infectious agent or pathogen; A reservoir or source for pathogen growth; A port of exit from the reservoir; A mode of transmission; A port of entry to a host; A susceptible host Direct Transmission - -Person-to-person (fecal, oral) physical contact between source and susceptible host. Indirect Transmission - -Personal contact of susceptible host with contaminated inanimate object (e.g., needles or sharp objects, soiled linen, dressings, environment). Droplet Transmission - -An infected person coughs or sneezes, creating droplets that carry germs short distances (within approximately 6 feet). Airborne Transmission - -Organisms are carried in droplet nuclei or residue or evaporated droplets suspended in air during coughing or sneezing. Providing Oral Hygiene - -The skill of oral hygiene (including toothbrushing, flossing, and rinsing) can be delegated to assistive personnel (AP). Gag Reflex Assessment - -The nurse is responsible for assessing the patient's gag reflex to determine whether the patient is at risk for aspiration. Oral Mucosa Changes - -Types of changes in oral mucosa to report to the nurse include ulcerations, lesions, open sores, or bleeding of oral mucosa or gums and patient report of pain. Aspiration Prevention - -Positioning the patient to avoid aspiration by keeping head of bed (HOB) raised 30-45 degrees. Reporting Oral Hygiene Issues - -The need to immediately report to the nurse excessive patient coughing, drooling, or choking during or after oral hygiene. Variables influencing health practices - -Individual beliefs, values, and self-efficacy. Assessment prior to ambulating a patient - -Assess strength, balance, coordination, vital signs, pain level, orthostatic hypotension risk, and need for assistance or devices (e.g., walker, gait belt). Complications of being bedridden - -Pressure injuries, pneumonia, deep vein thrombosis (DVT), muscle atrophy, joint contractures, constipation, urinary stasis. Home care safety measures for impaired mobility - -Remove throw rugs, ensure good lighting, install grab bars, use nonskid mats, encourage assistive devices, organize home environment. Sleep requirements for infants - -14-16 hrs/day. Sleep requirements for toddlers - -12 hrs/day. Sleep requirements for school-age children - -9-12 hrs/day. Sleep requirements for adolescents - -8-10 hrs/day. Sleep requirements for adults - -7-9 hrs/day. Sleep requirements for older adults - -7-8 hrs/day (lighter sleep). Types of sleep disorders - -Insomnia, sleep apnea, narcolepsy, parasomnias (e.g., sleepwalking, night terrors), restless leg syndrome. Planning activities for hospitalized patients - -Around periods of rest/sleep, treatments, diagnostic tests, and patient energy levels. Interventions for the hearing impaired - -Speak clearly without shouting, reduce background noise, face the patient, use written communication as needed, ensure hearing aids are functional. Donning PPE sequence - -Gown → Mask → Goggles/Face Shield → Gloves. Doffing PPE sequence - -Gloves → Goggles/Face Shield → Gown → Mask. Stage 1 pressure injury - -Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Stage 2 pressure injury - -Partial-thickness skin loss with exposed dermis; the wound bed is viable, pink or red, and moist. Stage 3 pressure injury - -Full-thickness skin loss; adipose tissue (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Stage 4 pressure injury - -Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Unstageable pressure injury - -Obscured full-thickness skin and tissue loss; Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Deep-tissue pressure injury - -Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Why we read a doctor's order - -To verify correct treatment, medication, dosages, timing, and ensure patient safety. Precautions when giving an enema - -Lubricate tip, insert gently to avoid mucosal trauma, monitor for vagal response (bradycardia). How to apply ostomy pouch - -Clean and dry skin, measure and cut opening to fit stoma, apply skin barrier, attach pouch without wrinkles or gaps. Precautions with a digital rectal exam - -Be gentle, monitor heart rate (especially if history of cardiac issues), use gloves and lubricant. How to calculate I & O for CBI - -Total output minus amount of irrigation fluid instilled = true urine output. Safety guidelines for tube feeds - -Elevate head of bed (30-45°), verify tube placement, check residual volumes, monitor for aspiration. How to assess/treat pain in different patient populations - -Use age-appropriate tools (e.g., FLACC for infants, numerical scale for adults), observe nonverbal cues, tailor interventions (nonpharmacologic and pharmacologic). Nasopharyngeal suctioning vs. oropharyngeal suctioning - -Nasopharyngeal: Deeper suctioning through nose to throat; sterile technique. Oropharyngeal: Mouth and upper throat; clean technique. How to troubleshoot an air leak in a chest tube - -check all tubing, examine drainage system for bubbling in seal chamber, clamp tube, notify provider Planning spiritual care for a patient - -Assess spiritual needs, respect beliefs, facilitate access to spiritual resources (chaplains, prayer materials).