WGU D439: FOUNDATIONS EXAM SCORED
A+
SBAR Format Answer - -model for effective communication identifying
Situation, Background, Assessment, and Recommendation
-there are two types of ways that communication tools are used to
communicate a patients change in condition: CUS tool (Concerned,
Uncomfortable, Safety) and SBAR
-note to always maintain pt privacy and confidentiality
SBAR EXAMPLE :
Case Study: You administered 1 tablet of oxycodone HCl 5 mg/ibuprofen 400
mg PO to a patient 30 minutes ago for postsurgical pain. You return to the
patient's room to evaluate the effectiveness of the medication 30 minutes later.
The patient rates his pain as an 8 on a scale of 0-10. You use SBAR to contact
the patient's health care provider.
Situation: The patient is rating his pain as an 8 on a scale of 0-10. He had his
pain medication 30 minutes ago.
Background: The patient had a knee replacement and returned from the
postanesthesia care unit 6 hours ago. He has 1 tablet of oxycodone HCl 5
mg/ibuprofen 400 mg PO ordered every 6 hours. This is the first pain
medication he has taken since being admitted to the unit.
,Assessment: His current medication order is not sufficiently managing the
patient's pain. He does not want to sit up or move because of the pain he is
experiencing.
Recommendation: It might be helpful to change the pain medication order for
the patient.
guided imagery Answer - -mind/body intervention
-Concentrating on an image or series of images to treat pathological conditions
Maslow's Hierarchy of Needs Answer - -where (1) physiological needs are
PRIORITY then (2) safety and security, (3) love and belonging needs. (4) self
esteem needs, and FINALLY (5) self actualization needs
The nurse planning care for a client experiencing dystocia determines that the
priority is which action?
1. Position changes and providing comfort measures
2. Explanations to the client about what is happening
3. Monitoring for changes in the condition of the birthing parent and fetus
4. Encouraging the use of breathing techniques learned in childbirth
preparatory classes
Answer: 3
Test-Taking Strategy: Note the strategic word, priority, and use Maslow's
Hierarchy of Needs theory to prioritize, remembering that physiological needs
come first. The nurse needs to have knowledge of the client's priority needs
and generate solutions. All the options are correct and would be implemented
during the care of a client with dystocia. Also note that the correct option is the
only one that addresses both the birthing parent and the fetus. Remember to
,use Maslow's Hierarchy of Needs theory to help prioritize and generate
solutions!
EHR system and limitations Answer - -EHR AND EMR are different from
eachother
-A health care agency often relies on the nursing history model included in the
electronic health record (EHR) as the organizing framework for an assessment.
However, EHR frameworks are often medically driven. Frameworks developed
from nursing theories are more holistic and patient-centered, providing a more
comprehensive patient review.
-When it comes to the EMR freezing it's best to notify IT or when the computer
system shuts down during data entry. The nurse should follow established
protocols and prepare to re-enter data as a late entry when the system is
operational. Also never attempt to reboot or fix the EMR system which may
prolong the complication.
It's also not recommended to print EMR from a backup server without proper
authorization and ensuring data privacy and security.
-patient outcome data; and use clinical decision support systems. The
electronic health record (EHR) is an efficient method for documenting and
managing patient health care information (see Chapter 26.) Computerized
physician/provider order entry (CPOE), allowing health care providers to
directly enter medical orders, is a critical patient safety initiative especially in
the area of medication ordering and administration
-Change-of-shift, hand-off reporting, and hourly bedside rounds are ways to
keep all health care providers and patients informed
Hand Hygeine Answer - -hand washing does not kill microorganisms but
reduces the amount of them present
-four techniques: hand washing, antiseptic hand wash, antiseptic hand rub,
surgical hand antisepsis
-4 elements of hand washing: water, friction, soap , and time
, Dosage Calculation (ml, tbsp->ml) Answer -
VITAL SIGNS Answer - -what to do if reassessment is needed
-know the pt usual range of vital signs (baseline)
-assess respiratory
Factors affecting vital signs of older adults:
MOBILITY: How do you use crutches? Answer - TYPES OF GAITS:
-2-point: 2 points (crutch or foot) on the ground: pt moves right crutch and left
foot together, left crutch and right foot together
-4 point gait:
-3 point gait: moving both crutches and the injured leg at the same time
-weight is on both hands
support weight at the hand grips, with elbow flexed at 30 degrees, position
crutches on the unaffected side when sitting or raising from the chair
-How to use crutches: Do Not Adjust Crutch Settings After Fitting (Should be 3
Finger Widths Between Axilla and Top of Crutch) Support Body Weight on Hand
Grips (Not Axilla), With Elbows Flexed or bent at 30 Degrees
-an accurate measurement is important and the distance between the axillae
and arm piece has to be 2-3 finger widths in the axilla space and the arm bars
-all weight should be on the hand grips
-when ambulating pt, stand on their affected (weak) side
-never rest armpit on the axillary bars
Wound Care and skin integrity (ch 48) Answer - -levels of intention
A+
SBAR Format Answer - -model for effective communication identifying
Situation, Background, Assessment, and Recommendation
-there are two types of ways that communication tools are used to
communicate a patients change in condition: CUS tool (Concerned,
Uncomfortable, Safety) and SBAR
-note to always maintain pt privacy and confidentiality
SBAR EXAMPLE :
Case Study: You administered 1 tablet of oxycodone HCl 5 mg/ibuprofen 400
mg PO to a patient 30 minutes ago for postsurgical pain. You return to the
patient's room to evaluate the effectiveness of the medication 30 minutes later.
The patient rates his pain as an 8 on a scale of 0-10. You use SBAR to contact
the patient's health care provider.
Situation: The patient is rating his pain as an 8 on a scale of 0-10. He had his
pain medication 30 minutes ago.
Background: The patient had a knee replacement and returned from the
postanesthesia care unit 6 hours ago. He has 1 tablet of oxycodone HCl 5
mg/ibuprofen 400 mg PO ordered every 6 hours. This is the first pain
medication he has taken since being admitted to the unit.
,Assessment: His current medication order is not sufficiently managing the
patient's pain. He does not want to sit up or move because of the pain he is
experiencing.
Recommendation: It might be helpful to change the pain medication order for
the patient.
guided imagery Answer - -mind/body intervention
-Concentrating on an image or series of images to treat pathological conditions
Maslow's Hierarchy of Needs Answer - -where (1) physiological needs are
PRIORITY then (2) safety and security, (3) love and belonging needs. (4) self
esteem needs, and FINALLY (5) self actualization needs
The nurse planning care for a client experiencing dystocia determines that the
priority is which action?
1. Position changes and providing comfort measures
2. Explanations to the client about what is happening
3. Monitoring for changes in the condition of the birthing parent and fetus
4. Encouraging the use of breathing techniques learned in childbirth
preparatory classes
Answer: 3
Test-Taking Strategy: Note the strategic word, priority, and use Maslow's
Hierarchy of Needs theory to prioritize, remembering that physiological needs
come first. The nurse needs to have knowledge of the client's priority needs
and generate solutions. All the options are correct and would be implemented
during the care of a client with dystocia. Also note that the correct option is the
only one that addresses both the birthing parent and the fetus. Remember to
,use Maslow's Hierarchy of Needs theory to help prioritize and generate
solutions!
EHR system and limitations Answer - -EHR AND EMR are different from
eachother
-A health care agency often relies on the nursing history model included in the
electronic health record (EHR) as the organizing framework for an assessment.
However, EHR frameworks are often medically driven. Frameworks developed
from nursing theories are more holistic and patient-centered, providing a more
comprehensive patient review.
-When it comes to the EMR freezing it's best to notify IT or when the computer
system shuts down during data entry. The nurse should follow established
protocols and prepare to re-enter data as a late entry when the system is
operational. Also never attempt to reboot or fix the EMR system which may
prolong the complication.
It's also not recommended to print EMR from a backup server without proper
authorization and ensuring data privacy and security.
-patient outcome data; and use clinical decision support systems. The
electronic health record (EHR) is an efficient method for documenting and
managing patient health care information (see Chapter 26.) Computerized
physician/provider order entry (CPOE), allowing health care providers to
directly enter medical orders, is a critical patient safety initiative especially in
the area of medication ordering and administration
-Change-of-shift, hand-off reporting, and hourly bedside rounds are ways to
keep all health care providers and patients informed
Hand Hygeine Answer - -hand washing does not kill microorganisms but
reduces the amount of them present
-four techniques: hand washing, antiseptic hand wash, antiseptic hand rub,
surgical hand antisepsis
-4 elements of hand washing: water, friction, soap , and time
, Dosage Calculation (ml, tbsp->ml) Answer -
VITAL SIGNS Answer - -what to do if reassessment is needed
-know the pt usual range of vital signs (baseline)
-assess respiratory
Factors affecting vital signs of older adults:
MOBILITY: How do you use crutches? Answer - TYPES OF GAITS:
-2-point: 2 points (crutch or foot) on the ground: pt moves right crutch and left
foot together, left crutch and right foot together
-4 point gait:
-3 point gait: moving both crutches and the injured leg at the same time
-weight is on both hands
support weight at the hand grips, with elbow flexed at 30 degrees, position
crutches on the unaffected side when sitting or raising from the chair
-How to use crutches: Do Not Adjust Crutch Settings After Fitting (Should be 3
Finger Widths Between Axilla and Top of Crutch) Support Body Weight on Hand
Grips (Not Axilla), With Elbows Flexed or bent at 30 Degrees
-an accurate measurement is important and the distance between the axillae
and arm piece has to be 2-3 finger widths in the axilla space and the arm bars
-all weight should be on the hand grips
-when ambulating pt, stand on their affected (weak) side
-never rest armpit on the axillary bars
Wound Care and skin integrity (ch 48) Answer - -levels of intention
