Nurse 122 Final Exam 100%
Correct(GRADED A+)
Nursing Process + Next Gen terminology - ANSWERSA → Assessment → Recognizing
cues
D → Diagnosis → Prioritizing hypothesis + analyzing cues
P → Planning → Generating Solutions
I → Implementation → Taking action
E → Evaluation → Reflection
Communication - ANSWERSAssess
-Verbal communication →Speaking, phone calls, writing.
-Nonverbal communication → Facial expressions, body language, eye contact,
gestures.
-Effective → Active listening, open ended questions, empathy, cultural respect, finding
common ground, understanding one another, getting interpreter if needed.
-Noneffective → Asking yes/no questions, assuming, bad body language, rolling eyes,
monotone or careless voice.
Interventions → No judgment, listening to patient, asking open ended questions, using
effective communication.
Expected outcomes → better communication with pt/ pt family, decreased stress and
anxiety, understanding of education nurse gives.
Tissue Integrity - ANSWERSAssess → Physical exam, cap refill, ulcers, rashes,
healing, pulses, cap refill, turgor, pressure ulcer stages.
Interventions → Creams, lotions, antibiotics, dressings, wound vac, turn q2, cultures.
Expected outcomes → after tx, better skin function, warm + dry, healing improved, pulse
and cap refill normal.
Pain - ANSWERSAssess → PQRST, objective vs subjective data.
-Objective → Measurable data → vital signs, labs, physical assessments.
-Subjective → Unmeasurable data → experiences, feelings, symptoms.
Interventions → Analgesics, NSAIDs, Opiods + education (constipation) ,
distraction/comfort measures if nonpharmacological.
,Expected outcomes → decreased pain and happier or calmer pt.
Nutrition - ANSWERSAsses → physical exam (hair, nails skin), BMI
-Underweight ↓ 18.5 ↔ Overweight ↑25
-30 + → extreme obesity
-18.5 to 24.9 is a healthy weight
Interventions → TPN , more/less of certain foods depending on dx, add vitamins +
supplements, food pyramid teaching.
Expected outcomes → labs good, no deficits of hyper/hypo
HIPPA + Confidentiality - ANSWERS-Protects the privacy and security of patients'
health information.
-If discussing pt info make sure it is with a member of the healthcare team in a proper
setting.
-Nurses must be aware of HIPPA to protect patient info.
-Respect and support patients in exercising their privacy rights and provide information
about how their health information is used and disclosed.
-Patients will have access to their own healthcare.
-Nurses must get proper authorization to share health info.
Sleep - ANSWERSAssess
-Hx physical exam → obesity, enlarged tonsils, or nasal congestion?
-Meds
-Sleep study habits
-Stimulants
-Diet
S&S
-Difficulty falling asleep
-Insomnia
-Frequent awakenings
-Restless legs
-Snoring
-Apnea
-Excessive daytime sleepiness.
Interventions
-Medications → Melatonin
,-Comfort measures → Lavender, white noise, blackout curtains.
Expected outcomes → Better rest and no effect on ADL's.
Electrolyte Relationships - ANSWERSSodium/Potassium = Inverse
- ↑Na+ = ↓ K+
Calcium/Phosphate = Inverse
- ↑Ca = ↓ Phos
Calcium/Vitamin D = Vitamin D helps Ca absorb.
- ↑Ca = ↑Vitamin D
Magnesium/Calcium = Similar
-↑Mag = ↑Ca
Magnesium/Potassium = Similar
-↑Mag = ↑K+
Magnesium/Phosphate = Inverse
-↑Mag = ↓ Phos
Hyponatremia (↓ Na+ )
-Function →Na+ (Sodium) = Maintain BV + fluid balance - ANSWERSCauses → Loss
of Na+
-Diuretics
-GI fluid loss → V/D
-Renal disease
-Adrenal insufficiency
-Hypotonic solution overload →salt goes bye
-Extra H2O supplements
-SIADH → Antidiuretic hormone insufficiency
-Meds associated w/ water retention
-Hyperglycemia
-Heart Failure
-No Na+ in diet
Labs
- ↓ Electrolyte panel Na+
-↓ Urine specific gravity
-↓ Osmolity
S&S
-Mental Status → HA, lethargy, confused, stupor (ALOC's), seizures, coma.
-GI → Abdominal cramps, N/V
-Other → Orthostatic BP, muscle weakness, shallow breathing (late).
, Interventions
-Water restriction
-Encourage/Educate Na+ intake in moderation.
-Monitor I's + O's
-Daily weights
-Give Na+ PO/IV → Hypertonic Solution
-Safety precautions
-Monitor pt taking lithium
-Monitor neuro, GI, renal, vitals, and safety.
Diet
-Salty foods in moderation
-Canned foods
-Salty crackers
-Lunch meat
Hypernatremia (↑ Na +)
-Function → Na+ (Sodium) = Maintain BV + fluid balance - ANSWERSCauses → Gain
of Na+
-Dehydration
-Increase Na+ intake
-Aldosterone overload
-DM
-Heatstroke
-Burns
-Diaphoresis
Labs
-↑ Electrolyte panel Na+
-↑ Urine Specific Gravity
-↑ Osmolity
S&S
-Mental status → Confused, agitated.
-Skin/Other → Flushed, dry mucosa, edema (may be present), thirst, fever.
-GU → △'s in urine output.
Interventions
-Na+ restriction.
-Fluids / meds → Hypotonic/isotonic solutions, diuretics
-I's + O's
-Daily weights
-Safety precautions
-Monitor labs + vitals → temp
Correct(GRADED A+)
Nursing Process + Next Gen terminology - ANSWERSA → Assessment → Recognizing
cues
D → Diagnosis → Prioritizing hypothesis + analyzing cues
P → Planning → Generating Solutions
I → Implementation → Taking action
E → Evaluation → Reflection
Communication - ANSWERSAssess
-Verbal communication →Speaking, phone calls, writing.
-Nonverbal communication → Facial expressions, body language, eye contact,
gestures.
-Effective → Active listening, open ended questions, empathy, cultural respect, finding
common ground, understanding one another, getting interpreter if needed.
-Noneffective → Asking yes/no questions, assuming, bad body language, rolling eyes,
monotone or careless voice.
Interventions → No judgment, listening to patient, asking open ended questions, using
effective communication.
Expected outcomes → better communication with pt/ pt family, decreased stress and
anxiety, understanding of education nurse gives.
Tissue Integrity - ANSWERSAssess → Physical exam, cap refill, ulcers, rashes,
healing, pulses, cap refill, turgor, pressure ulcer stages.
Interventions → Creams, lotions, antibiotics, dressings, wound vac, turn q2, cultures.
Expected outcomes → after tx, better skin function, warm + dry, healing improved, pulse
and cap refill normal.
Pain - ANSWERSAssess → PQRST, objective vs subjective data.
-Objective → Measurable data → vital signs, labs, physical assessments.
-Subjective → Unmeasurable data → experiences, feelings, symptoms.
Interventions → Analgesics, NSAIDs, Opiods + education (constipation) ,
distraction/comfort measures if nonpharmacological.
,Expected outcomes → decreased pain and happier or calmer pt.
Nutrition - ANSWERSAsses → physical exam (hair, nails skin), BMI
-Underweight ↓ 18.5 ↔ Overweight ↑25
-30 + → extreme obesity
-18.5 to 24.9 is a healthy weight
Interventions → TPN , more/less of certain foods depending on dx, add vitamins +
supplements, food pyramid teaching.
Expected outcomes → labs good, no deficits of hyper/hypo
HIPPA + Confidentiality - ANSWERS-Protects the privacy and security of patients'
health information.
-If discussing pt info make sure it is with a member of the healthcare team in a proper
setting.
-Nurses must be aware of HIPPA to protect patient info.
-Respect and support patients in exercising their privacy rights and provide information
about how their health information is used and disclosed.
-Patients will have access to their own healthcare.
-Nurses must get proper authorization to share health info.
Sleep - ANSWERSAssess
-Hx physical exam → obesity, enlarged tonsils, or nasal congestion?
-Meds
-Sleep study habits
-Stimulants
-Diet
S&S
-Difficulty falling asleep
-Insomnia
-Frequent awakenings
-Restless legs
-Snoring
-Apnea
-Excessive daytime sleepiness.
Interventions
-Medications → Melatonin
,-Comfort measures → Lavender, white noise, blackout curtains.
Expected outcomes → Better rest and no effect on ADL's.
Electrolyte Relationships - ANSWERSSodium/Potassium = Inverse
- ↑Na+ = ↓ K+
Calcium/Phosphate = Inverse
- ↑Ca = ↓ Phos
Calcium/Vitamin D = Vitamin D helps Ca absorb.
- ↑Ca = ↑Vitamin D
Magnesium/Calcium = Similar
-↑Mag = ↑Ca
Magnesium/Potassium = Similar
-↑Mag = ↑K+
Magnesium/Phosphate = Inverse
-↑Mag = ↓ Phos
Hyponatremia (↓ Na+ )
-Function →Na+ (Sodium) = Maintain BV + fluid balance - ANSWERSCauses → Loss
of Na+
-Diuretics
-GI fluid loss → V/D
-Renal disease
-Adrenal insufficiency
-Hypotonic solution overload →salt goes bye
-Extra H2O supplements
-SIADH → Antidiuretic hormone insufficiency
-Meds associated w/ water retention
-Hyperglycemia
-Heart Failure
-No Na+ in diet
Labs
- ↓ Electrolyte panel Na+
-↓ Urine specific gravity
-↓ Osmolity
S&S
-Mental Status → HA, lethargy, confused, stupor (ALOC's), seizures, coma.
-GI → Abdominal cramps, N/V
-Other → Orthostatic BP, muscle weakness, shallow breathing (late).
, Interventions
-Water restriction
-Encourage/Educate Na+ intake in moderation.
-Monitor I's + O's
-Daily weights
-Give Na+ PO/IV → Hypertonic Solution
-Safety precautions
-Monitor pt taking lithium
-Monitor neuro, GI, renal, vitals, and safety.
Diet
-Salty foods in moderation
-Canned foods
-Salty crackers
-Lunch meat
Hypernatremia (↑ Na +)
-Function → Na+ (Sodium) = Maintain BV + fluid balance - ANSWERSCauses → Gain
of Na+
-Dehydration
-Increase Na+ intake
-Aldosterone overload
-DM
-Heatstroke
-Burns
-Diaphoresis
Labs
-↑ Electrolyte panel Na+
-↑ Urine Specific Gravity
-↑ Osmolity
S&S
-Mental status → Confused, agitated.
-Skin/Other → Flushed, dry mucosa, edema (may be present), thirst, fever.
-GU → △'s in urine output.
Interventions
-Na+ restriction.
-Fluids / meds → Hypotonic/isotonic solutions, diuretics
-I's + O's
-Daily weights
-Safety precautions
-Monitor labs + vitals → temp
