NR 226 FINAL REVIEW Questions and Answers with complete solution
ADPIE - ANS assessment, diagnosis, plan, implementation, evaluation SMART goals - ANS specific, measurable, achievable, relevant, time bound 2017 National Patient Safety Goals - ANS improve accuracy of patient identification, improve staff communication, use medications safely, prevent infection, identify patient safety risks, prevent surgery mistakes Prioritizing Client Care - ANS airway, breathing, circulation Actual vs At Risk diagnosis - ANS actual has current diagnosis, at risk doesn't Chain of infection - ANS pathogen, reservoir, portal of exit, transmission, portal of entry, host High risk for infection - ANS sick, immunocompromised, young and elderly Adult Vital Sign Ranges: T, P, R, BP, SpO2 - ANS 96.8-100.4, 60-100, 12-20, 120/80, 95% Surface temp - ANS oral, axillary Location for apical HR - ANS 5th intercoastal mid clavicular line Stage 1 pressure ulcer - ANS skin in tact, Nonblanchable erythema stage 2 pressure ulcer - ANS partial thickness skin loss, wound bed pink stage 3 pressure ulcer - ANS full thickness, tunneling, underminingstage 4 pressure ulcer - ANS full thickness, exposed bone, ligament unstageable pressure ulcer - ANS would bed covered in slough or eschar Deep tissue injury - ANS discolored intact skin, mushy
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