FUNDAMENTALS UNIT BOXES Terms in this set (157) Ethics: The registered nurse practices Education: The registered nurse attains knowledge and competency that reflects current nursing practice. Evidence-Based Practice and Research: The registere

FUNDAMENTALS UNIT BOXES Terms in this set (157) Ethics: The registered nurse practices Education: The registered nurse attains knowledge and competency that reflects current nursing practice. Evidence-Based Practice and Research: The registered nurse integrates evidence and research findings into practice. Quality of Practice: The registered nurse contributes to quality nursing practice. Communication: The registered nurse communicates effectively in all areas of practice. Leadership: The registered nurse demonstrates leadership in the professional practice setting and the profession. Collaboration: The registered nurse collaborates with health care consumer, family, and others in the conduct of nursing practice. Professional Practice Evaluation: The registered nurse evaluates her or his own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations. Resources: The registered nurse uses appropriate resources to plan and provide nursing services that are safe, effective, and financially responsible. Environmental Health: The registered nurse practices in an environmentally safe and healthy manner. Primary Care (Health Promotion) Prenatal and well-baby Nutrition counseling Family planning Exercise, yoga, and mediation classes Preventive Care Blood pressure and cancer screenings Immunizations Mental health counseling and crisis prevention Community legislation (e.g., seat belts, air bags, bike helmets, no texting while driving) Secondary Acute Care Emergency care • Acute medical-surgical care Radiological procedures for acute problems (e.g., x- rays, computed tomography [CT] scans) Tertiary Care Intensive care • Subacute care Restorative Care Cardiovascular and pulmonary rehabilitation, Orthopedic rehabilitation, Sports medicine, Spinal cord injury programs, and Home care Continuing Care • Assisted living • Psychiatric and older adult day care Temperature Range Average temperature range: 36° to 38° C (96.8° to 100.4° F) Average oral/tympanic: 37° C (98.6° Average rectal: 375°C (99.5° F) Axillary 36.5 C (97.7°F) Pulse 60 to 100 beats/min, strong and regular Pulse Oximetry (SpO,) Normal: Sp0, 95% Respirations Adult: 12 to 20 breaths/min, deep and regular Blood Pressure Systolic <120 mm Hg Diastolic <80 mm Hg Pulse pressure: 30 to 50 mm Hg Capnography (ELCO,) Normal: 35-45 mm Hg Exercise Exercise increases rate and depth to meet the need of the body for additional oxygen and to rid the body of CO2 Acute Pain Pain alters rate and rhythm of respirations; breathing becomes shallow. • Patient inhibits or splints chest wall movement when pain is in area of chest or abdomen. Anxiety increases respiration rate and depth as a result of sympathetic stimulation. Smoking Chronic changes pulmonary airways, resulting in increased rate of respirations at rest when not smoking. Body Position A straight, erect posture promotes full chest expansion Stooped or slumped position impairs ventilatory movement Lying flat prevents full chest expansion Medications Opioid analgesics, general anesthetics, and sedative hypnotics depress rate and depth. Amphetamines and cocaine sometimes increase rate and depth. • Bronchodilators slow rate by causing airway dilation. Neurological Injury Injury to brainstem impairs respiratory center and inhibits respiratory rate and rhythm. Hemoglobin Function Decreased levels (anemia) reduce oxygen- carrying capacity of the blood, which increases respiratory rate. • Increased altitude lowers amount of saturated hemoglobin, which increases respiratory rate and depth. Abnormal blood cell function (e.g., sickle cell disease) reduces ability of hemoglobin to carry oxygen, which increases respiratory rate and depth. Bradypnea. (remember it as b-low, (below) Rate of breathing is regular but abnormally slow (less than 12 breaths/min). Tachypnea Rate of breathing is regular but abnormally rapid (greater than 20 breaths/min). Нуperpnea Respirations are labored, increased in depth, and increased in rate (greater than 20 breaths/min) (occurs normally during exercise Apnea Respirations cease for several seconds. Persistent cessation results in respiratory arrest. Hyperventilation Respiratory rate is abnormally low, and depth of ventilation is depressed. Hypercarbia sometimes occurs. Cheyne-Stokes respiration Respiratory rate and depth are irregular, charactarite by uitemating periods of apnea and hyperventilation. begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses; and becomes shallow, concluding as apnea before respiration resumes. Kussmaul's respiration Respirations are abnormally deep, regular, and increased in rate. Biot's respiration Respirations are abnormally shallow for two to three breaths, followed by irregular period of apnea. Interference with Light Transmission Outside light sources interfere with ability of oximeter to process reflected light. • Carbon monoxide (caused by smoke inhalation or poisoning) artificially elevates Sp0, by absorbing light similar to oxygen. Patient motion, jaundice, black / brown nail polish, metal studs in nails, thickened nails, intravascular dyes, interferes with ability of oximeter to process reflected light. Interference with Arterial Pulsations Peripheral vascular disease (atherosclerosis) reduces pulse volume. • Hypothermia at assessment site decreases peripheral blood flow. Pharmacological vasoconstrictors (e.g., epinephrine) decrease peripheral pulse volume. • Low cardiac output and hypotension decrease blood flow to peripheral arteries. Peripheral edema obscures arterial pulsation. Tight probe records venous pulsations in finger that compete with arterial pulsations. PULSE PRESSURE The difference between systolic and diastolic pressure is the _____ Ex: BP is 120/80 the pressure pulse is 40 Hypotension is present when the systolic BP fals to 90 mm Hg or below, Although some adults have low BP normally, for most people low BP is an abnormal finding associated with illness. Hypotension occurs because of the dilation of the arteries in the vascular bed, the loss of a substantial amount of blood volume (e.g. hemorrhage), or the failure of the heart muscle to pump adequately (e.g., myocardial infarction). Hypotension associated with pallor, skin mottling, clamminess, confusion, increased HR, or decreased urine output is life threatening reported to a health care provider SKO referred to as postural hypo- tension, occurs when person drops in systolic pressure by at least 20 mm Hg or a drop in diastolic pressure by at least 10 mm Hg within 3 minutes of rising to an upright position (Shibao et al., 2013). When a healthy individual changes from a lying-to sitting-to standing position, the peripheral blood vessels in the legs constrict. When standing, the lower-extremity vessels constrict, preventing the pooling of blood in the legs caused by gravity. Thus an individual normally does not feel any symptoms when standing. In contrast, when patients have a decreased blood volume, their blood vessels are already constricted. When a patient with volume depletion stands, there is a significant drop in BP with an increase in HR to compensate for the drop in cardiac output. A community center is presenting a nurse program on the PATIENT PROTECTION AND AFFORDABLE CARE ACT. Which statement by a participant indicates a need for further teaching? "As long as my son is a full-time student in college, I will be able to keep him on my health insurance until he is 26 years old." Which activity performed by a nurse is related to maintaining competency in nursing practice? Attending a review course in preparation for a certification examination patient tells a nurse that she is enrolled in a preferred provider organization (PPO) but does not understand what this is. What is the nurse's best explanation of a PPO? This health plan gives you a list of physicians and hospitals from which you can choose. Which of the following are examples of a nurse participating in primary care activities? 1) Providing prenatal teaching on nutrition to a pregnant woman during the first trimester 2) Assessing the nutritional status of older adults who come to the community center for lunch 3) Teaching a class to parents at the local grade school about the importance of immunizations Nurses on a nursing unit are discussing the processes that led up to a near-miss error on the clinical unit. They are outlining strategies that will prevent this in the future. This is an example of nurses working on what issue in the health care system? Patient safety Which of the following statements is true regarding Magnet status recognition for a hospital? Magnet is a special designation for hospitals that achieve excellence in nursing practice. A group of staff nurses notice an increased incidence of medication errors on their unit. After further investigation it is determined that the nurses are not consistently identifying the patient RAPID IMPROVEMENT EVENT (RIE) These are characteristics of managed care systems 1) provider receives a pre-determind amount for each patient in the program 2) system tries to reduce costs while keeping patients healthy 3) focus of care is on prevention and early intervention These are nursing activities provided in a secondary health care environment? Changing the postoperative dressing for a patient on a medical- surgical unit Doing endotracheal suctioning for a patient on a ventilator in the medical intensive care unit A nurse is using the Plan-Do-Study-Act (PDSA) strategy to do a quality improvement project to decrease patient falls on a nursing unit. Place the steps in the correct sequence for PDSA. 1) The nursing council develops a strategy for bedside change of shift report 2) bedside change of shift report is piloted on two medical surgical units. 3) patient satisfaction legels after implemention of the bedside report are compared to patient satisfaction levels before the change. 4) after modifications are made in the shift report elements bedside shift report is implemented on all nursing units. The nursing staff is developing a quality program. following are nursing-sensitive indicators from the National Database of Nursing Quality Indicators (NDNQI) that the nurses can use to measure patient safety and quality for the unit? Use of physical restraints Pain assessment, intervention, and reassessment Registered nurse (RN) education and certification A nurse is providing restorative care to a patient following an extended hospitalization for an acute illness. Which of the follow- ing is an appropriate goal for restorative care? Patient will be able to walk 200 feet without shortness of breath. nurse is presenting information to a management class of nursing students on the topic of financial reimbursement for achievement of established, measurable patient outcomes. The nurse is presenting information to the class on which topic? Pay for performance SPHYGMOMANOMETER tool for checking blood pressure FOWLERS POSITION a semi-sitting position; the head of the bed is raised between 45 and 60 degrees SUPINE POSITION lying on back, facing upward PRONE POSITION lying on abdomen, facing downward (head may be turned to one side) LITHOTOMY POSITION lying on back with legs raised and feet in stirrups SIMS POSITION lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back LATERAL POSITION the person lies on one side or the other; side-lying position You are preparing a presentation for your classmates regarding the clinical care coordination conference for a patient with terminal cancer. As part of the preparation you have your classmates read the Nursing Code of Ethics for Professional Registered Nurses. Your instructor asks the class why this document is important. Which of the following statements best describes this code? Defines the principles of right and wrong to provide patient care. An 18-year-old woman is in the emergency department with fever and cough. The nurse obtains her vital signs, listens to her lung and heart sounds, determines her level of comfort, and collects blood and sputum samples for analysis. Which standard of prac- tice is performed? Assessment A patient in the emergency department has developed wheezing and shortness of breath. The nurse gives the ordered medicated nebulizer treatment now and in 4 hours. Which standard of practice is performed? Implementation A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patient's wishes with them. The nurse is acting as the patient's: Advocate. The nurse spends time with the patient and family reviewing the dressing change procedure for the patient's wound. The patient's spouse demonstrates how to change the dressing. The nurse is acting in which professional role? Educator The examination for registered nurse (RN) licensure is exactly the same in every state in the United States. This examination: Provides a minimal standard of knowledge for an RN in practice. Contemporary nursing requires that the nurse has knowledge and skills for variety of professional roles and responsibilities. Which of the following are examples? Caregiver Autonomy and accountability Patient advocate Health promotion Healthcare reform will ring changes in the emphasis of care. Which of the following models is expected from health care reform? Moving from an acute illness to a health promotion illness prevention model Nurses need to understand how beliefs and values are different. A nurse begins to offer information to a patient and the patient says, "I've already heard all of that before and I don't agree with any of it." How should the nurse proceed? b. Ask the patient to explain what he believes. Which nursing theory of care describes how the nurse's presence in the nurse-patient relationship transcends the physical and material world, facilitating the development of a higher sense of self by the patient? c. Watson's Theory of Human Science and Human Care Which statement best describes for new parents how and when children develop first-order beliefs? c. Throughout life from first-hand experiences and information provided by authority figures As the nurse explained the preoperative instructions to the patient, the patient's older brother suddenly stepped into the doorway and yelled, "People who go under the knife always die. Don't do it! They're going to kill you." What type of higher-order belief is the patient's older brother displaying? b. Stereotype After admitting a homeless patient to the floor, the nurse tells a colleague that "homeless people are too dumb to understand instructions." What action should the colleague take first? c. Ask the nurse about the patient's personal history assessment data The nurse in the emergency department is caring for an 8-year-old who has had a serious asthma attack. When the nurse attempts to explain the problem to the child's mother, she smells cigarette smoke on the mother's breath. The nurse asks the mother if she has been smoking and the mother responds, "Yes, and I know they've told me before I can't smoke around him." What should the nurse do next? b. Ask the patient's mother to explain what she believes about smoking and asthma. A nurse is working with a 35-year-old patient who needs to decide whether to donate a kidney to his brother who has been in renal failure for 5 years. The patient shares with the nurse that the decision is especially difficult because he would not be able to continue to work in his current profession and would be unable to support his three small children if he ever needed dialysis. Which intervention(s) would be most appropriate for the nurse to implement in this situation? (Select all that apply.) B Guide the patient through a values clarification process to help him make a decision based on his values. c. Provide information the patient needs to help him make an informed decision. d. Ask for his permission to contact the kidney donation team to answer any questions he may have. A 57-year-old male patient who was hospitalized with an admitting blood pressure of 240/120 asked the nurse if his family could bring in some meat and vegetable dishes from home. He explained that he cannot eat the foods on the hospital menu because it is summer and the hospital is only offering chicken and fish, which in his culture are "hot" foods that will interfere with his healing. Which response by the nurse would best demonstrate an application of Leininger's theory? Negotiate home-prepared food options with the patient and his family to ensure that treatment for the patient's blood pressure is supported. In Swanson's Caring Theory, the nurse demonstrates caring using several techniques. Which of the following is (are) included in the five caring processes? Ask the patient to identify the most important thing to accomplish during the nurse's shift. A new nurse is about to insert a nasogastric tube for the first time but is not sure what equipment to gather or how to begin the procedure. The patient is an 80-year-old woman who is frightened and slightly confused. Which actions by the nurse would best demonstrate caring? Speak calmly while explaining the procedure to the patient beforehand. Ask another, more experienced nurse for assistance before initiating care. Mrs. Walters is a 43-year-old woman admitted to the psychiatric unit for major depressive disorder. She has voiced a suicidal plan in detail to her husband, which prompted Mr. Walters to seek help for her. Monica is the nursing student assigned to Mrs. Walters. Mrs. Walters tells Monica, “I’m so overwhelmed at home…three children and no help. My husband travels for work and is rarely around. I’m basically a single parent. I just can’t take it anymore. I want to go to sleep and never wake up again.” 1. Monica reflects on Mrs. Walters’ situation and what she can do to help. Which theoretical view on caring raises the nurse’s consciousness about what it means to be a nurse? Watson's Transpersonal Caring Rationale: Watson's theory describes a consciousness that allows nurses to raise new questions about what it means to be a nurse, to be ill, and to be caring and healing. To listen effectively, Monica must silence her mouth and her to provide Mrs. Walters with the best care possible. MIND Nurses must listen to patients with openness that includes silencing one's mouth and also the mind to concentrate fully on what the patient has to say. Monica explores Mrs. Walters’ spiritual health. Spiritual health occurs when a person finds a balance between his or her own self-actualization, needs, and priorities and those of others. A. True B. False False Spiritual health occurs when a person finds a balance between his or her own life values, goals, and belief systems and those of others, especially since research shows a link between spirit, mind, and body. Assessment begins at the moment the patient first interacts with the nurse. Redressing takes place at the end of the physical examination. Breathing during auscultation is part of the respiratory assessment, and sharing health history and demographic information takes place during the patient interview. Which action by a patient marks the beginning of the physical assessment process? Greeting the nurse in the examination room Which factors should be taken into consideration by the nurse before and during a patient interview? a. Distance between the chairs in which the nurse and patient are sitting b. Traditional treatments typically used by the patient to treat disease c. Gender preference for primary care providers d. Physical condition of the patient The first four factors are important for the nurse to consider when initiating or conducting a patient interview. The distance that is comfortable for personal interaction and gender preferences for care providers are affected by cultural and age norms. During the interview, it is an important aspect of assessment to ask patients about the treatments that they traditionally use in response to illness. Preferred treatments sometimes can be incorporated into care plans. The physical condition of patients affects their ability to answer questions during an interview. It may be necessary to break the interview process into short periods to accommodate the patient who is seriously ill. Music preference is irrelevant because there should not be music playing during the interview because it would be a distraction. Which action by the nurse is most appropriate during the orientation phase of the patient interview? Ask which name a patient prefers to be called during care to show respect and build trust. The nurse should provide a personal introduction and establish the name by which the patient wants to be called at the very beginning of the interview as part of the orientation phase. In most cases, the patient and the nurse should be seated at eye level during the interview portion of the assessment. Questions about intimacy and sexuality should be reserved for later in the interview to establish rapport before exploring potentially sensitive issues. A review of systems takes place during the working phase of the nurse-patient interview, just before initiation of the physical assessment. Which activity by the nurse best demonstrates part of the working phase of a patient interview? Including selected family members in care planning. Care planning takes place during the working phase of the nurse-patient interview. When a patient needs care assistance, it is important for family members who will be helping with the patient's care to be involved in the process. Verifying the name that a patient prefers to be called takes place during the orientation or introductory phase. Summarizing key topics covered in the interview and transferring care responsibilities take place in the termination phase. Which entry in a patient's electronic health record best indicates the need for a nurse to gather secondary rather than primary subjective data? Comatose Primary data are obtained from the patient directly. A patient who is comatose is unable to speak and therefore unable to share subjective, primary data. A patient complaining of chest pain has already shared primary, subjective data. A patient with an apical pulse of 110 who is alert or one who has difficulty swallowing may still be able to contribute subjective information to the data collection. Which line of questioning by the nurse best represents an appropriate approach to the review of systems aspect of the assessment process? "Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?" During a review of systems, the patient is asked questions about each body system to determine the level of functioning. Asking about work-related information, family history, and immunizations is accomplished during the collection of health history data before initiating the review of systems. Which cue by a patient can be validated by laboratory and diagnostic test results? Deeply sighing with fatigue A cue is a behavioral hint of a potential disease process or concern. In this case, the only cue is a deep sigh indicating fatigue. The level of fatigue can be verified by evaluating the patient's hemoglobin and hematocrit levels for anemia. Crackles, oxygen saturation, and pitting edema are all physical assessment findings, not cues. Mr. When Chang is being admitted to the medical-surgical unit for management of a stage 4 decubitus ulcer on his left hip. Mr. Chang, a 37-year-old engineer, was in a near-fatal motor vehicle accident 3 months ago that precipitated a series of spine surgeries to help correct damage to his spine. He has been bedridden in a long-term care facility since his last surgery 7 weeks ago, and he has developed a stage 4 decubitus ulcer on his left hip. The wound is being treated with a wound vacuum and antibiotic therapy. Bettina is the nursing student who is assigned to Mr. Chang. Bettina enters his room, introduces herself, and explains that she is going to perform an admission health history and physical assessment. 1. Bettina asks Mr. Chang many questions to determine his health patterns. Which of the following are examples of Gordon’s model of 11 functional health patterns that Bettina may address in her assessment? Sleep-rest Role-relationship Sexuality-reproductive Elimination Bettina’s experience as a nursing student is a valid source of data that provides information about Mr. Chang’s illness. A. True B. False True: Nurses obtain data from a variety of sources, including their own nursing experience, that provide information about the patient's current level of wellness and functional status, anticipated prognosis, risk factors, health practices and goals, responses to previous treatment, and patterns of health and illness. Which of the following are examples of back channeling techniques that Bettina may use during the patient interview with Mr. Chang? "Go on." "I see." "All right." Back channeling techniques such as "go on," "I see," and "all right" reinforce the nurse's interest in what the patient has to say and encourage the patient to give more details. "Where does it hurt?" and "Why are you here?" are examples of open-ended questions. If the nurse discovers that a patient's right elbow is swollen and painful during a physical examination, which action should the nurse take next? Inspect the patient's left elbow to compare its appearance A major aspect of assessment is checking for symmetry. If an abnormality is observed on one side of a patient's body, the next step in the assessment is to compare that area with the other side. Applying ice is premature until the assessment is complete and an underlying cause of the swelling and pain is understood. Percussion is not indicated for assessment of a swollen elbow. Performing passive range of motion is not appropriate before identifying an injury or disease and determining its extent. A patient discusses his job stress and family relationships with the nurse during his health history interview. In which organizational framework is this type of data likely to be recorded most extensively? Functional health patterns model Job stress and family relationships data will only be recorded extensively when using the Functional health patterns model. The functional health patterns model is holistic in its approach. The body systems model and head-to-toe assessment model focus on physical rather than psychological or emotional concerns. All three models listed are ways to organize physical assessment findings. When initiating a physical examination, which action should the nurse take first? Assess the patient's vital signs Assessment of the patient's vital signs begins the physical examination aspect of the assessment process. This provides the nurse with baseline information about cardiac and respiratory function, pain level, and temperature. The nurse should review the patient's prior medical records before the interview or after the patient interaction to fill in gaps. Admission health history forms need to be gathered before initiating the interview, and abdominal palpation takes place about halfway through the head-to-toe physical examination. What is the purpose of the nursing process? Organizing the ways nurses think about patient care. The nursing process is the methodology used to "think like a nurse." Providing patient- centered care and enhancing communication among health team members is facilitated through the use of care plans. Collaborating with rather than identifying members of the health care team is part of many plans of care. A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first? Severity and duration of the nausea and vomiting In an emergent situation, the nurse initially focuses on the patient's chief complaint to determine its cause. Before initiating care, the nurse gathers information on the other topics. An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient? Patient The nurse collects primary data directly from patients who are alert and oriented. Family members and other members of the health care team may provide secondary data on patients.