NURS 3330 Foundations Final Exam
questions well answered graded A+
Sleep Assessment - correct answer ✔✔ - sources of sleep assessment: patients are best
resource; bed partners; parents
- sleep history (any history of sleep problems) patterns, recent changes
- subjective measures of sleep: Epworth Sleepiness Scale; Pittsburgh Sleep Quality Index; 0-10
sleep rating
- assess usual bedtime, bedtime ritual, preferred environment for sleeping, preferred rising time
- if patient has a sleep problem, conduct a complete sleep history
- diagnosing sleep problems depends on identifying factors that impair sleep
Nursing Interventions to promote sleep - correct answer ✔✔ - environmental controls
- promoting bedtime routines
- promoting safety
- promoting comfort
- establishing periods of rest and sleep
- stress reduction
- bedtime snacks, avoidance of caffeine
- pharmacological approaches
What are the effects of long term sleeping pills use? - correct answer ✔✔ leads to difficulty
initiating and maintaining sleep
Pre-op Assessment - correct answer ✔✔ purpose:
- establish the patient's normal pre-op function and assist the nurse in preventing
,- recognizing possible post-op complications
accomplished by:
- healthy history-- include medications
- complete physical examination
What is one key assessment piece we can do that tells us about several of the body systems? -
correct answer ✔✔ Vital Signs
Why do we do Vital Signs pre-op? - correct answer ✔✔ provides us a baseline for assessment
Retrieving Health History - correct answer ✔✔ - best historian to collect data is the patient
- if patient is unable to provide this info, then the family members serve as the resource
- patient's medical record is a great source to retrieve data on past hospitalizations
Informed Consent - correct answer ✔✔ protect the individual, acility, staff, and physicians
- description of procedure
- risk and benefits
- probability of success
- consequences of non-surgical treatment or no treatment
- any and all info that will assist the pt reach and informed decision
Physcian's responsibilities with informed consent - correct answer ✔✔ responsible for obtaining
the pts consent in language the pt can understand --> get interpreter if needed
- responsible for obtaining informed consent
,Nurse's responsibilities with informed consent - correct answer ✔✔ - make sure the person
signing is in fact the correct person
- witness the signature
- ensure the signature was not forced or coerced
- ensure the pt understood what was signed
Who can provide informed consent? - correct answer ✔✔ - parent
- spouse
- sibling
- adult children
- guardian
- exception!!: emergency (physician must document)
Surgical Time Out - correct answer ✔✔ all members of surgical team stop what they are doing
just before the surgery starts and verifies pt identification, surgical procedure, and surgical site
Nursing Role in during Intra-operative phase - correct answer ✔✔ - surgical time out
- positioning the patient
- assisting anesthesia provider
- intra-operative medication prep (not anesthetics)
Discharge Instructions - correct answer ✔✔ - diet/any restrictions
- activity level (ambulating devices, driving)
- wound care/ supplies (s/s of infection)
- medications
- follow up (s/s to report, appointments)
- sign discharge instructions
, Preventing/Managing Post-Op complications - correct answer ✔✔ - atelectasis
- hypovolemic shock
- thrombus/embolus formation
- paralytic ileus
- wound infection/dehiscence/evisceration
- malignant hyperthermia
*refer to worksheet*
Physical Manifestations of End of Life - correct answer ✔✔ - BP lowers
- changes in HR
- fever
- breathing changes
- skin color changes
- surge of energy
- restlessness
-congestion -- "death rattle"
- eyes that no longer close or blink
- pinning of the earlobes (normally first thing you see)
- cognition changes/unresponsiveness
- dec. urinary output
- terminal fever
- slight dehydration (actually helps reduce pain)
- terminal restlessness
questions well answered graded A+
Sleep Assessment - correct answer ✔✔ - sources of sleep assessment: patients are best
resource; bed partners; parents
- sleep history (any history of sleep problems) patterns, recent changes
- subjective measures of sleep: Epworth Sleepiness Scale; Pittsburgh Sleep Quality Index; 0-10
sleep rating
- assess usual bedtime, bedtime ritual, preferred environment for sleeping, preferred rising time
- if patient has a sleep problem, conduct a complete sleep history
- diagnosing sleep problems depends on identifying factors that impair sleep
Nursing Interventions to promote sleep - correct answer ✔✔ - environmental controls
- promoting bedtime routines
- promoting safety
- promoting comfort
- establishing periods of rest and sleep
- stress reduction
- bedtime snacks, avoidance of caffeine
- pharmacological approaches
What are the effects of long term sleeping pills use? - correct answer ✔✔ leads to difficulty
initiating and maintaining sleep
Pre-op Assessment - correct answer ✔✔ purpose:
- establish the patient's normal pre-op function and assist the nurse in preventing
,- recognizing possible post-op complications
accomplished by:
- healthy history-- include medications
- complete physical examination
What is one key assessment piece we can do that tells us about several of the body systems? -
correct answer ✔✔ Vital Signs
Why do we do Vital Signs pre-op? - correct answer ✔✔ provides us a baseline for assessment
Retrieving Health History - correct answer ✔✔ - best historian to collect data is the patient
- if patient is unable to provide this info, then the family members serve as the resource
- patient's medical record is a great source to retrieve data on past hospitalizations
Informed Consent - correct answer ✔✔ protect the individual, acility, staff, and physicians
- description of procedure
- risk and benefits
- probability of success
- consequences of non-surgical treatment or no treatment
- any and all info that will assist the pt reach and informed decision
Physcian's responsibilities with informed consent - correct answer ✔✔ responsible for obtaining
the pts consent in language the pt can understand --> get interpreter if needed
- responsible for obtaining informed consent
,Nurse's responsibilities with informed consent - correct answer ✔✔ - make sure the person
signing is in fact the correct person
- witness the signature
- ensure the signature was not forced or coerced
- ensure the pt understood what was signed
Who can provide informed consent? - correct answer ✔✔ - parent
- spouse
- sibling
- adult children
- guardian
- exception!!: emergency (physician must document)
Surgical Time Out - correct answer ✔✔ all members of surgical team stop what they are doing
just before the surgery starts and verifies pt identification, surgical procedure, and surgical site
Nursing Role in during Intra-operative phase - correct answer ✔✔ - surgical time out
- positioning the patient
- assisting anesthesia provider
- intra-operative medication prep (not anesthetics)
Discharge Instructions - correct answer ✔✔ - diet/any restrictions
- activity level (ambulating devices, driving)
- wound care/ supplies (s/s of infection)
- medications
- follow up (s/s to report, appointments)
- sign discharge instructions
, Preventing/Managing Post-Op complications - correct answer ✔✔ - atelectasis
- hypovolemic shock
- thrombus/embolus formation
- paralytic ileus
- wound infection/dehiscence/evisceration
- malignant hyperthermia
*refer to worksheet*
Physical Manifestations of End of Life - correct answer ✔✔ - BP lowers
- changes in HR
- fever
- breathing changes
- skin color changes
- surge of energy
- restlessness
-congestion -- "death rattle"
- eyes that no longer close or blink
- pinning of the earlobes (normally first thing you see)
- cognition changes/unresponsiveness
- dec. urinary output
- terminal fever
- slight dehydration (actually helps reduce pain)
- terminal restlessness
