NUR 155 Exam 3 Review Questions with Complete Solutions

NUR 155 Exam 3 Review Questions with Complete Solutions Risk factors for pressure injuries - Answer ️️ -Immobility, Obesity/ Underweight, Mal- nutrition, Incontinent, Skin integrity, Age Abnormal vitals for oxygenation - Answer ️️ -SPO2 < 90%, Increased pulse, Increased RR, Clubbing of the fingers Priority intervention for patient having trouble breathing - Answer ️️ -Sit them up S/S of decreased tissue perfusion - Answer ️️ -Decreased capillary refill, Less or no hair around the area, Clubbing of the fingernails, Decreased peripheral pulses, cyanosis, edema, cold in the area Intervention for visual impaired pt. - Answer ️️ -Have things in close range, Clock diagram for food placement, Orient them to the place, Have room clear of clutter, Assistive devices Modifiable risk factors cardiovascular disease - Answer ️️ -Diabetes, Nutrition, Weight, Exercise, Stress, Smoking Non-modifiable risk for cardiovascular disease - Answer ️️ -Age, Gender, Genetics Intervention for promoting a healthy heart - Answer ️️ -Smoking cessation, Exercise, No alcohol, Reduce caffeine, Immunizations, Reduce stress Intervention for gustatory impairment (Taste) - Answer ️️ -Add spices, Strong smells, Ask patient about their preference, Oral hygiene How does a JP drain work? - Answer ️️ -A JP drain is a closed suction device, meaning that the fluids are collected within a closed system, without the need for an outside suction machine. Hearing impairment intervention - Answer ️️ -Use white boards, Enunciate, Face them, Interpreters, minimize background noises Delirium - Answer ️️ -Short term, too much stimuli, Reversible, Hallucinations, Not a mood disorder Normal physiological changes in the heart for elderly pt. - Answer ️️ -Valves start to harden and stiffen, Cardio output decreases S/S pulmonary edema - Answer ️️ -Hear crackles, SOB, Difficult breathing, Jugular distention, Pressed limb breathing, Retracting, Using accessory muscles What pt are at risk for sensory overload? - Answer ️️ -Pt in ICU, ER, Med surg Lab results to look at for patient with COPD or respiratory disorders - Answer ️️ -Arterial blood gases, CBC, Iron, Hematocrit, Hemoglobin Intervention for pt with contractors - Answer ️️ -Splints, ROM, Hand