NUR 204/ NUR204 Exam 4 (NEW 2026/ 2027 Update) Leadership and Management VERSION 2| Questions & Answers| Grade A| 100% Correct (Verified Solutions)- Fortis

1 …..DLDD NUR 204/ NUR204 Exam 4 (NEW 2026/ 2027 Update) Leadership and Management VERSION 2| Questions & Answers| Grade A| 100% Correct (Verified Solutions)- Fortis Q. What should the nurse do before inserting the bed pan? Answer -make sure the top linens are pushed back far enough so they do not become soiled (make sure to cover the patient back up after bed pan is inserted) -place a water proof bad under the patient to ensure the linens do not become soiled -put the head of the bed down -if the patient is able, have them bend their knees and pull their bottom up so the bed pan can be placed underneath of them *make sure toilet paper and call bell are in reach* Q. Explain why often times toilet paper should not be dropped in the bed pan? Answer urine may need to be measured and the presence of toilet paper distorts the correct measurement 2 Q. When removing the bed pan, what do you want to be mindful of? Answer -make sure the water proof pad under the patient is dry -nurse may want to have a wash cloth/ towel handy -be very careful when separating their skin from the plastic to make sure the urine does not fall out Q. What do you do if a person is incontinent and they wear diapers? Answer count how many wet diapers & weigh the diaper before you put it on/ after you take it off Q. When providing post mortem care, where do you place the identification tag and what information should be put on it? Answer place the tag on the toe & the patient's name, doctor, and the hospital 3 Q. Where do the patients personal belongings go after they pass away? Answer there is a pouch in the body bag where they are placed Q. When informing a family of their loved ones passing, what should you do? Answer go out & speak with them, move them into a separate room Q. What are the legal responsibilities of a nurse after a patient passes away? Answer -sign & label death certificate -set up organ donations (call UNOS) -call time of death **each hospital/ health care setting has their own steps for this process 4 Q. What is the nurse responsible for doing when preparing the body? Answer -remove tubes -remove soiled linens -lay patient in anatomical position (prevents pooling of blood) Q. What does the patient need to do if the death of the patient was traumatic? Answer tubes & soiled linens still need to be removed/ patient laid in anatomical position -morgue will normally clean up the patient, but if there is a significant presence of blood, then clean the patient up before the funeral home & family get there so there is a good last view. 5 Q. What would a circumstance be when the tubes of a deceased patient wouldn't be removed? Answer -if patient had a communicable disease -if they are testing for sepsis Q. What do the nurses need to keep in mind if the patient has a certain religious background? Answer some religions do not allow washing of the body OR a certain family member will perform the washing Q. What does the nurse need to do with the tubes if an autopsy is being performed? Answer leave all of the tubes in place 6 Q. What do you need to be aware of when communicating with a blind patient? Answer -announce yourself -speak before touching -do touch, but thoroughly explain before performing action -make sure they know where the call light/ bell is -provide food hints (clock time placement) Q.What do you need to be aware of when communicating with a deaf patient? Answer -write questions -obtain ASL communicator -use correct terminology ("D" for born with deafness, "d" if they got it later on in life) -make them aware of your presence 7 Q. What do you need to be aware of when communicating with an autistic patient? Answer -they process things more slowly -ask concrete questions -engage them at their own level -speak calmly -know what triggers them -avoid harsh gestures Q. What do you need to be aware of when communicating with a non verbal patient? Answer -useful to have a whiteboard -ask yes or no questions -letter board -iPad type technology 8 Define infection the invasion & multiplication of microorganisms in body tissues, which may be clinically unapparent or result in local cellular injury due to competitive metabolism, toxins, intracellular replication, or antigen- antibody response What is the scope of infection? (infection categories) -bacterial -viral -protozoa -parasitic -fungal What are some of the common risk factors for infection? -population (age: infant, low socioeconomic system, geographical location) -individual (immunocompromised, environmental conditions) List the physical consequences of infection -vascular, renal, & nervous system compensation -respiratory compensation 9 -multisystem failure How do you assess for infection? HISTORY: risk for infections, symptoms associated with infection, incidence of injury, known exposure to pathogens, prior infections, etc EXAMINATION: fever, swelling, chills, malaise, redness, drainage, pain DIAGNOSTIC TESTS: CBC with differential (bacterial/ viral infection: elevated WBC, B & T lymphocytes, etc..... parasitic infection: elevated basophils & eosinphils), culture & sensitivity, C-reactive protein, erythrocyte sedimentation rate, radiographic test List some interventions for infection hand hygiene, PPE ( gloves, mask, protective eyewear, gown, & cap), isolation precautions, sterility, collecting specimens for culture, and medication administration List the major interrelated concepts of infection inflammation, nutrition, tissue integrity, immunity, & stress 10 What are the 2 goals of PPE? 1. protect ourselves & our families from the multitude of microorganisms that are in the healthcare environment 2. protect our clients from those same microorganisms by patient to patient and nurse to patient contamination What does PPE include? mask, face shield, shoe covers, gloves, cap, goggle/ glasses, & gown What is involved in a tier one standard precaution? (required for by the nurse when coming in contact with...) -mucous membranes -non intact skin -blood -body fluids -infectious materials (equipment or surfaces with potentially infectious material) Explain the transmission based precautions of tier two. -based on the mode of transmission of the microorganism 11 -known or suspected to be infected with microorganisms transmitted by contact, droplet, or airborne routs -precautions based on the diagnosis and used in addition to standard precautions (tier one) Explain contact precautions direct patient/ environmental contact -multi drug resistant organism (MRSA) -c diff -wound infections -immunocompromised adults (chemo, HHIV, suppressed immune system) -private room (or like infections together) (patients that have the same infections) -gowns & gloves minimum Explain droplet precautions droplets (coughing/ mucus): larger than 5 microns that can travel 3-6 ft of the patient -flu (could have other complications that could occur) -pertussis (whooping cough) -pneumonia/ scarlet fever in infants/ young children 12 -private room (or like infections together) -mask Explain airborne precautions droplet nuclei smaller than 5 microns (super tiny) & remain in the air longer because they are lightweight -chickenpox/ shingles -measles -tuberculosis (Tb) or suspected TB -private room with negative pressure with HEPA filter (often on an oncology floor) -N 95 mask required -A lot of times you don't know you have these things because there is an incubation period Explain Clostridum Difficile (c-diff) precautions -spore forming organism -commonly see in patients on antibiotics -suspect or confirmed cases on contact precautions -alcohol based hand rubs are ineffective against these spores -you must wash your hand with soap & water 13 What are the general guidelines for hand hygiene and PPE? -standard precautions DO NOT pertain to sweat -perform HH before, after, and between direct patient contact -perform HH when moving from a contaminated site to a clean site -visibility soiled/ contaminated hands required soap and water -know why your patient in on precautions and make sure the PPE is appropriate -be prepared for bedside care & organize your supplies that will be needed -assess the patient's emotional state (isolation, they may feel unclean, so be kind and friendly while you're in there) and educate patient & visitors on the precautions (keeping HIPAA in mind) What are some considerations to address with the elderly? keep reinforcing, they may not remember they are in that situation How can you make isolation less scary for children? 14 a parent may be with them, you could draw something on your mask, ped wards may have things to make it more kid friendly) What if your patient needs to leave the room to go for a diagnostic test or surgery? you perform PPE precautions & make sure everyone is aware Explain donning PPE (done OUTSIDE the door) 1. hand hygiene 2. gown- tie at the neck & waist 3. mask or N-95- top ties, bottom ties, pinch nose (take off after you exit the room and the door is closed behind you), eyewear, goggles, or face shield 4. gloves- cuffs pulled over the gown sleeves Explain doffing PPE (done INSIDE the room: except for airborne) 1. if gown is tied, untie it and let ties fall 2. gloves 3. gown- untie neck strings, allow to fall off shoulders, touch inside of gown only, withdraw arms, roll up snide out & dispose of in trash can 4. mask- remove elastic from ears or untie bottom string first, then drop into trash can 5. hand hygiene 15 Define the nursing process allows nurses to use critical thinking & clinical reasoning when providing care that is individualized & holistic and to define those areas of care that are within the domain of nursing What is the nursing process used to do? 1. identify the client's healthcare needs & strength 2. establish & carry out a plan to meet those needs 3. evaluate the effectiveness of the plan to meet the established outcome **ex: if patient has a fever you will evaluate it & record it What is the nursing process? Assessment Diagnosis Planning Implementation Evaluation 16 What do you do when assessing the patient? -assess the client to determine the need for nursing care -look at your client's current health situation What do you do when diagnosing? -determine nursing diagnoses for actual & potential health problems *what's wrong with my client that I can help with? Is my client at risk for something else? What do you need to keep in mind when planning and identifying the outcome? -keep patient/client & caregiver in mind at all times identify expected outcomes & plan care *what do you want to happen to/for your client? what can I do to make that happen? What is implementation? 17 doing action/ care or education that you will provide implement the care What do you evaluate at the end of the nursing process? the results *was the plan effective? Falls are the leading cause of injury fatality among adults older than? 65 years of age What is the most common reason for hospital admissions in older adults? falls How many older adults fall at home each year? 1/3 18 What are the most common injuries that occur from a fall? hip or other fractures, head trauma, or soft- tissue injury What are the 4 types of falls? accidental, anticipated physiological, unanticipated physiologic, intentional What is an accidental fall? clutter or a spill caused a person to trip What is an anticipated physiological fall (limp, dragging of foot/ leg, dementia)? a direct consequence of gait imbalance, effect of medication, or dementia What is unanticipated physiologic fall? caused by unknown or unexpected medical issues such as a stroke or seizure What is an intentional fall? patients act out behaviorally with an intent to fall 19 Who is at a high risk for falls? -people older than 65 years -documented history of falls -impaired vision or balance -altered gait or posture -unfamiliar environment -etc Falls can be ____ if they can be ______. prevented, predicted How can I prevent a fall? -be diligent to monitor your patients and their rooms/ surroundings for situations that could put them at harm -complete fall risk assessment on every patient -indicate a risk for falling according to the facility policy -keep bed in low position -keep wheels on bed & wheel chair locked -leave call light within your patient's reach and instruct in its use -keep upper side rails up if at all possible 20 -answer call lights promptly -answer call lights promptly -leave a night light on -provide nonskid footwear -leave personal items within reach drug any substance that either positively or negatively alters physiologic function. medication •a drug specifically administered for its therapeutic effect on physiologic function. 4 designations of medications chemical name official name generic name brand name Every time a controlled substance is purchased or dispensed; 21 an accurate record must be documented. If a controlled drug should need to be wasted two licensed clinical staff members must witness the disposal of the substance and document the wasting of the drug in the appropriate manner. a lower schedule substance has higher potential for abuse Pharmokinetics the study of drugs within the body, absorption , distribution, metabolism, excretion Pharmodynamics the process in which a medication interacts with the bodys cell to produce a biologic response Therapeutic effect the desired result or action of a medication 22 medication action properties are dependent on absorption distribution metabolism excretion Absorption the passage of a drug from the administration site into the bloodstream. distribution is the process of delivering medication to tissues, organs, and the specific site of action. metabolism is the process by which a drug is altered to a less active form to prepare for excretion. excretion 23 process removes the less active drug or its metabolites. drugs half-life •the expected time it takes for the blood concentration to measure half of the original drug dose due to drug elimination. onset of action •the time the body takes to respond to a drug after administration. peak plasma level •indicates the highest serum (blood) concentration. trough the lowest serum level of the medication. side effects predictable but unwanted and sometimes unavoidable reactions to medications. 24 adverse effects severe, unintended, unwanted, and often unpredictable drug reactions. toxic effects result from a medication overdose or the buildup of medication in the blood due to impaired metabolism and excretion. A postoperative patient is receiving morphine sulfate via PCA. The nurse assesses that the patient's respirations are depressed. The effects of the morphine sulfate can be classified as? toxic allergic reactions unpredictable immune responses to medications idiosyncratic reaction an unpredictable patient response to medication. 25 medication interactions •occur when the drug action is modified by the presence of a certain food or herb or another medication. antagonism •when the drug effect is decreased by taking the drug with another substance. drug incompatibility Mixing medications in a solution that causes precipitation or combining a drug with another drug that causes an adverse chemical reaction Medication Order Components •Patient's name •Date and time •Drug name •Dosage •Drug route •Administration frequency •Signature 26 Medication Administration Record (MAR) includes •the patient name, full name of medication, administration time, dose, route, frequency, site of administration for parenteral medications, and the nurses' initials, signatures and (possibly) the prescribing health care provider. also with previous doses. Common routes of administration •oral, buccal, sublingual, parenteral, topical, by inhalation, and through a medical tube. topical medications applied to skin membrane absorption is affected by vascularity inhaled medications taken thru respiratory tract parenteral given thru needle 27 medication error any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer Six Rights of Medication Administration 1. Right medication 2. Right dose 3. Right patient 4. Right route 5. Right time 6. Right documentation If a nurse experiences a problem reading a physician's medication order, the most appropriate action will be to: call physician to verify order Nurses are legally required to document medications that are administered to patients. The nurse is mandated to document which of the following? Medication after administrating it 28 sites for topical medications eyes, ears, nose, rectum, vagina, and lungs, as well as skin. You are caring for a patient who has diabetes complicated by kidney disease. You need to make a detailed assessment when administering medications because this patient may experience problems with: Excretion