NUR 215 REVISED FINAL EXAM 2025

How long do we perform hand hygiene? - -20-30 seconds Where should our hands be pointing as we are washing our hands? - -down below elbows Where should our hands be pointing as we are done washing our hands? - -up above elbows What kinds of vital signs will a pt that is relaxed demonstrate? - -- heart rate will slow down - BP lowers - RR lowers What is a common symptom an older pt with a UTI demonstrate? - -confusion What interventions can we promote for constipated pt's? - -- increase fiber foods: whole wheat, oatmeal, fruit - increase fluid intake: hydration - promote mobility: exercise What can make things worse for constipation? - -- opioids - immobility What can chronic use of laxatives cause? - -chronic constipation How do we transport a pt with measles in a hospital setting? - -surgical mask What does positive pressure do to a room? - -keeps air out of room, so air particles come in and make transplant patient's sick What does negative pressure do to a room? - -keeps air in room used for pt's with TB What are some contact precautions we can take for pt's with C. Diff? - -- keep door closed - .. Nur215 Nur215 Nur215 What is the term for a pt that snores @ night + wakes up with headaches + are exhausted? - -obstructed sleep apnea Caused by: atrial afib What are the type of meds you cannot administer thru an NG tube? - -- enteric coated - time release extended - extended release - sublingual What is the abbreviation for intramuscular? - -IM What is the abbreviation for intradermal? - -ID What is the abbreviation for subcutaneous? - -SC What are some precautions to take before we administer insulin? - -- use insulin needle ONLY - check blood glucose - double check with another licensed personnel to verify correct dosage What are some foods we should promote for pt's with osetoporosis? - -- calcium: milk, anything dairy What are the liters for a nasal cannula? - -1-6 L/min What are the liters for simple face mask? - -6-10 L/min What are the liters for non breather mask? - -12-15 L/min What are some risk factors to avoid for @ home oxygen? - -- wool blanket - clutter - petroleum jelly How should an oxygen tank be stored? - -upright What are S+S of early hypoxia? - -- restlessness Nur215 - tachycardia - tachypnea What are S+S of late hypoxia? - -- cyanosis - LOC - bradypnea What is a primary intervention with older adults with COPD? - -- pneumonia vaccine What is a secondary intervention with older adults with COPD? - -- screenings - tests What are tertiary interventions with older adults? - -- rehab - if pt has a cardiac infarction + get a stent, a stent is tertiary because it is after the events How can we thin out secretions? - - - no cigar use - increase hydration - utilize humidification What can you have a family do for their loved one that's a pt? - -have them participate in their loved one's care What are some things we consider safety wise to assist for a pt when it comes to ambulation? - -- body mechanics - gait belt - assistive devices - non-skid socks *you want them to dangle on bedside When administering a medication, what part of the nursing process is this considered? - -implementation When assessing a pt's pain level, vital signs such as: BP, RR and heart rate, what part of the nursing process is this? - -evaluation Nur215 Nur215 Nur215 What are some things we try to do for a pt who has hearing loss when we want to get a good assessment? - -- face them - turn dow background noises - talk lower - order an interpreter (if needed for ASL) What are examples of non-modifiable risk factors? - -- genetics - age - gender What are examples of modifiable risk factors? - -- hypertension - weight - high cholesterol Which side should a pt hold their cane on? - -stronger side: opposite side of injury As nurses, do we perform foot care for diabetic pt's? - -no, a podiatrist What type of pt's are appropriate for foleys? - -- pelvic fractures - stage 4 pressure ulcers - anything immobile - hematuria **ICU pt's DO NOT NEED A FOLEY What kinds of precautions should we take for MRSA + C. Diff pt's? - -contact precautions What kind of precaution should be taken with a pt with the flu? - -droplet precaution What kind of precaution is hand hygiene considered? - -standard precaution What are examples of airborne diseases? - -- TB - measles Nur215 Nur215 - chickenpox Fidelity: - -fulfillness of promises Nonmaleficence: - -do no harm Autonomy: - -independence that includes personal responsibility and decision making Beneficence: - -doing good What kinds of pt's are @ risk for hypovolemia? - -pt's with: nausea, vomiting, diarrhea What are S+S of hypervolemia? - -- weight gain - edema - ascites - crackles - high BP - bounding pulse - increased RR What position should we put a pt that is seizing? - -lateral position (so they don't aspirate) Orthopnea is a symptom of: - -fluid overload What body system should be prioritized for potassium? - -cardiac What position should we put our pt's receiving enemas? - -sims position The nurse is caring for an older adult pt in a long-term care facility, which action encourages autonomy? - -allowing pt to choose social activities A nurse is assessing a pregnant female pt. Which of the following spinal deformities should the nurse expect? - -lordosis Which pt is @ greatest risk for skin breakdown? - -an elderly pt who has a hip fracture Which of the following information is considered subjective during a health assessment? - -dizziness Nur215 Nur215 Which of the following pulse sites should the nurse assess in a unilateral fashion? - carotid Which of the following would the nurse need to assess the oculomotor nerve in a pt? - pen light Pt is experiencing RR of 32 + dyspnea with accessory muscle use. Which is the 1st priority action to take? - -raise head of the bed to high fowlers immediately. The nurse is assessing the skin using the ABCDE rule, what should be documented under "A"? - -the lesion is pear shaped Skin turner in an older adult is not a good indication of dehydration - -false When providing oral care for an unconscious pt, which action should be taken first? - turn the pt's head to the side Which of the following is the belief that one's culture is superior to others? - ethnocentrism During this step of the nursing process, the nurse determines the effectivenes