Answers
Define Sinus Tachycardia - correct answers>>Regular Rhythm, rate 100-180 beats/min (higher in infants)
When is the best time of the month to perform a self-breast examination? - correct answers>>4th to 7th
day during menstrual cycle or days after cycle has ended.
Define total Patient Care - correct answers>>Rn is responsible for all aspects of care for one or more pts
during a shift of care. Care is usually consistent, comprehensive, and holistic, care can be delegated. RN
works directly with pt, family and health care team members.
Define Primary nursing - correct answers>>1 primary RN assumes responsibility for a caseload of
patients, provides care for the same pts during their stay in health care facility. RN assesses pt, develops
plan of care and delivers appropriate nursing intervention. Communication is lateral from nurse to nurse
and caregiver to caregiver.
Define major surgery - correct answers>>Involves extensive reconstruction or alteration in body parts,
poses great risks to well being.
Describe a stage II pressure ulcer - correct answers>>Partial thickness loss of dermis presenting a shallow
ulcer red- pink wound bed without slough. May present an intact or open. ruptured serum filled blister.
Shiny dry shallow ulcer without slough or bruising.
Define Presbyscusis - correct answers>>Hearing loss associated with aging. Usually involves both a loss
of hearing sensitivity and a reduction in the clarity of speech.
Define Ventilation - correct answers>>movement of air in and out of the lungs. Afterload ejection of
blood from left ventricle
define contact precaution - correct answers>>Safeguards designed to reduce the risk of transmission of
epidemiologically important microorganisms by direct or indirect contact.
what sound do rhonchi make - correct answers>>sonorous wheeze-coarse, low pitched: may clear with
cough.
,describe head lice - correct answers>>attach their eggs to hair, eggs look like oval particles of dandruff.
Lice are difficult to see, observe for bites or pustule eruptions in the follicles and area where skin
surfaces meet behind the ears in the ears and in the groin.
describe diffusion - correct answers>>movement of gases between air spaces and blood stream
what is the final step in a complete assessment? - correct answers>>documentation
S/S of hypostatic pneumonia - correct answers>>decreased lung expansion, generalized respiratory
muscle weakness and secretions occur without immobility. (comes from inflammation of the lung from
stasis or pooling of secretions. )
s/s of respiratory acidosis - correct answers>>increased PaCo2 and increased hydrogen ion concentration
below 7.35. This reflects the excess carbonic acid in the blood (hypoventilation produces R. acidosis)
what is the primary advantage of hydrogel dressing ? - correct answers>>contains a high percentage of
water for wounds that require moisture. Maintaining a moist wound environment needed for healing.
Hydrogel facilitates debridement by softening dead tissue.
A pt complains of chills, dizziness and feeling hot during a blood transfusion. What are the nurses most
appropriate actions? - correct answers>>Stop transfusion immediately.
Remove blood component and tubing containing and tubing contacting blood products
replace with new primed tubing with 0.9% sodium chloride
Maintain patent IV line with normal saline
Stay with patient observe signs and symptoms and monitor every 5 min.
Notify health care ream or response team
notify bank
prepare to do cpr and give emergency drugs
save blood container, tube, labels and transfusion record
get blood and 1st urine
document transfusion reaction, description, treatment and outcomes
, The nurse is providing preoperative teaching for a patient regarding pain control after surgery. Which of
the following statements is/are true regarding the use of postoperative analgesia? - correct answers>>-
inform nurse as soon as pain becomes a persistent discomfort.
-takes time for a drug to act
-drugs rarely eliminates all discomfort.
-don't be fearful of dependency
- USE of PCA pump
which leadership skills should a nursing student use when caring for patients? - correct answers>>clinical
decisions making
priority setting
organizational skills
use of resources
time management evaluation
team communication
delegation
a nurse wants to follow the American nurses association's social media policy. Which actions should the
nurse take? - correct answers>>never name a patient
never describe a patient
never post an image of pt
never disparage a fellow employee or employer
report breaches of confidentiality and privacy.
visual changes in older adults is caused by what? - correct answers>>glaucoma, Age Related MUACLAR
DEGENERATION
Good Samaritan Law - correct answers>>provides immunity to nurse who does what's reasonable to
save life. follow through with care, hand off to emt or emergency personnel. Able to treat a minor
without parental consent.