NUR 240 Exam 1 Questions and Complete Solutions Graded A+

NUR 240 Exam 1 Questions and Complete Solutions Graded A+ Tanners model - Answer: Clinical reasoning leads to clinical judgment noticing interpreting responding reflecting Recognizing cues - Answer: assessment (noticing) health disparities - Answer: - minority groups, - those who are uninsured, -those who live in poverty or who are homeless, -those with chronic health problems and disabilities, -immigrants, refugees, those with limited English -, those who are incarcerated, -members of the LGBTQIA (lesbian, gay, bisexual, transgender, queer, intersex, asexual) community. Ethics - Answer: distinction between right and wrong on the basis of a body of knowledge, Morals - Answer: Behavior in accordance with customs or tradition, usually reecting personal or religious beliefs Ethical principles - Answer: Codes that direct or govern nurs- ing actions Values - Answer: Beliefs and attitudes that may inuence be- havior and the process of decision making Values clarification - Answer: Process of analyzing one's own values to understand oneself more completely re- garding what is truly important Autonomy - Answer: Respect for an individual's right to self- determination and making one's own decisions Nonmaleficence - Answer: The obligation to do or cause no harm to another; in providing care the nurse is obliged to refrain from acts that unnecessarily cause injury, harm, or suffer- ing beneficence - Answer: The duty to do good to others and to maintain a balance between benets and harms; paternalism is an un- desirable outcome of benecence, in which the health care provider decides what is best for the client and encourages the client to act against their own choices Justice - Answer: The equitable distribution of potential benets and tasks determining the order in which clients should be cared for Veracity - Answer: The obligation to tell the truth and communicate truthfully fidelity - Answer: The duty to do what one has promised, to maintain loyalty and commitment to the client, to be faithful to agreements and responsibilities one has undertaken, and to do no wrong to the client Ethical codes - Answer: nurse's obligation to the client, the role of the nurse, and duties of the nurse to the profession and to society. Ethical dilemma - Answer: conflict between two or more ethical principles. -result of differ- ences in cultural or religious beliefs. Ethical reasoning - Answer: thinking through what one should do in an orderly and systematic manner to provide justication for ac- tions based on principles Advocate - Answer: speaks up for or acts on the behalf of the client, protects the cli- ent's right to make their own decisions, and up- holds the principle of fidelity advocacy nursing alert - Answer: An important nursing responsibility is to act as a client advocate and protect the client's rights. Nurse practice act - Answer: series of statutes that have been enacted by a state legislature to regulate the practice of nursing -defines scope of nursing practice standards of care - Answer: guidelines that identify what the client can expect to receive in terms of nursing care. Negligence - Answer: conduct that falls below the standard of care. -acts of commission and acts of omission. Malpractice - Answer: the nurse owed a duty to the client and did not carry out the duty and the client was injured because the nurse failed to perform the duty. duty: what the nurse is expected to do breach of duty: Nurse did not perform duty proximate cause: was the breach of duty the cause of patients harm damage/injury: the actual sustained injury Assault - Answer: threat Battery - Answer: intentional touching of another's body without the other's consent. Invasion of privacy - Answer: violating confidential- ity, intruding on private client or family matters, and sharing client information with unauthoriz False imprisonment - Answer: a client is not allowed to leave a health care facility when there is no legal justification to detain the client. -restrain- ing devices are used without an appropriate clin- ical need. defamation - Answer: false communication that causes damage to someone's reputation, either in writing (libel) or verbally (slander) Fraud - Answer: a deliberate deception intended to produce unlawful gains. Examples of negligence - Answer: Failure to provide a safe environment for the client Failure to follow policy and procedures Failure to respond to or correctly implement new and ex- isting orders Medication errors that result in injury to the client Intravenous administration errors, such as incorrect flow rates or failure to monitor a flow rate, that result in injury to the client Failure to monitor for and take action in the event of inl- tration, phlebitis, circulatory overload, or other complica- tions following IV therapy Falls that occur as a result of failure to provide safety to the client Failure to use aseptic technique when indicated Failure to provide adequate care that results in altered skin integrity and pressure injuries Failure to check equipment for proper functioning Burns sustained by the client as a result of failure to moni- tor bath temperature or equipment, or to protect the client from spills of hot liquids or foods Errors in sponge, instrument, or needle counts in surgical cases, meaning that an item was left in a client Failure to properly delegate and supervise Failure to adequately monitor a client's condition Failure to report changes in the client's condition Failure to give a report or giving an incomplete report to the oncoming shift personnel Failure to convey discharge instructions to the client, the family, or providers who are assuming responsibility for the client Patient care partnership - Answer: Inform clients what to expect during care with regards to their rights and responsibilities (Client autonomy) -protects the client's ability to determine the level and type of care re- ceived -all health care agencies are required to have a Patient Care Partnership posted in a vis- ible area. Patient Self-Determination Act - Answer: law that requires clients be provided with information about their right to have written directions about the care that they wish to receive in the event that they become incapacitated and are unable to make health care decisions. advanced care directives admission - Answer: the client is asked about the existence of an advance directive, and if one exists, it must be documented and included as part of the medical record; -if the client signs an advance directive at the time of admission, it must be documented in the client's medical record. Assess staff/client knowledge of advance directives -integrate into care plan Instructional directive - Answer: Lists the medical treatment that a client chooses to omit or refuse if the client becomes unable to make decisions and is terminally ill. Durable power of attorney - Answer: Appoints a person (health care proxy) chosen by the client to make health care decisions on the client's behalf when the client can no longer make decisions. DNR - Answer: HCP writes a DNR prescription if the cli- ent and PHCP have made the decision that the client's health is deteriorating and the client chooses not to undergo cardiopulmonary resuscitation if needed. -client or legal representative must provide informed consent for the DNR status. -must know whether a client has a DNR prescription; if a client does not have a DNR prescription, HCPs need to make every effort to revive the client. -may need to be changed if the client's status changes. advanced directive nurses role - Answer: -discuss with the client -ensure client has been provided with information about the written decisions the client wishes to receive -admission nurse determines if one exists and ensures it is on medical record -nurse ensures HCP is aware of managed care - Answer: strategies used in the health care delivery system that reduce the costs of health care. case management - Answer: Inter professional (everyone is involved) Starts at admission through discharge -provides comprehensive client care throughout clients illness, using available resources to promote high quality cost effective care -includes assessment and de- velopment of a plan of care, coordination of all services, referral, and follow-up. (walkers, medications etc) -uses critical pathways/analysis case management core function - Answer: assessment, treatment planning, linking the client to resources, advocacy, and monitoring. nursing alert case management - Answer: Case management involves consultation and col- laboration with an interprofessional health care team. Time management - Answer: assist in completing tasks within a denite time period. -decides on prioritization and doing it correctly Delegation - Answer: -transfers responsibility to individual who is competent and has authority to perform specific task -nurse retains accountability throughout delegation -assess individuals knowledge and skills -communicate tasks to be completed and report concerns immediately * cannot delegate clinical judgement/ critical thinking 5 rights of delegation - Answer: 1. Right task 2. Right circumstance 3. Right person 4. Right direction/communication 5. Right supervision/evaluation (nurse still responsible to evaluate and supervise persons outcomes) Nurse practice act and institutional policies - Answer: defines delegation (scope of practice) -nurse must provide clear, concise, complete directions -validate delegates understanding -provide prompt feedback Assistive personnel delegation - Answer: NONINVASIVE -skin care -range of motion -ambulation -grooming/hygiene -can perform routine tasks LPN can delegation - Answer: perform certain invasive tasks -Dressing changes -suctioning -urinary catheterization -medication administration (IM, oral, sub-q, selected IVPB) -collect data -review client teaching plans (not initial teaching )] - Care for STABLE patients registered nurse - Answer: -assessment -planning care -initial teachings -IV medications -stable and unstable patients Prioritizing care - Answer: ABCS or CABS for CPR -use maslows -prioritize nursing interventions -apply knowledge of path -evaluate plan of care -revise as needed prioritizing patients - Answer: ABCs -acute -life threatening -new onset -unexpected symptoms -physiological -new admit -new diagnosis -post op less than 12 hours Bariatric surgery - Answer: option for person with extreme obesity to lose weight bariatric surgery criteria - Answer: BMI of 40 or greater or BMI of 35 with other significant co-morbidities (hypertension, diabetes, HF, sleep apnea) requirements of bariatric surgery - Answer: -extensive documentation -take part in supervised weight loss program for around 6 months -screened for psychological, physical, and behavioral conditions Bariatric surgery pre-operative care - Answer: -determine use of any assistive devices (cpap) or past current health information -coordinate care for co-morbidities -appropriate BP cuff, hospital gown size, -teach proper cough and deep breathing techniques -teach methods of turning and positioning to prevent pulmonary complications - teach spirometer use -obtain longer IV catheter -Transfer with specially trained personnel Post-operative care - Answer: -stabilize airway -manage pain -elevate head of bed 45 degrees (increase lung expansion) -assess for resedation -intermittine pneumatic compressive devices/ compression stockings -Range of movement exercises -keep skin folds clean and dry -asses skin -ambulation and turning -clear liquids are introduced slowly in 1-ounce (30 mL) cups for each serving once bowel sounds have returned and the client passes flatus. -clear fluids are followed by puréed foods, juices, thin soups, and milk 24 to 48 hours after clear fluids are tolerated (the diet is usually limited to liquids or puréed foods for 6 weeks); then the diet is progressed to nutrient- dense regular food. -monitor anastomosis leaks - assess for abdominal pain, restlessness, unex- plained tachycardia, and oliguria. -Advise the client not to recline for 1 hour after meal eating. -Avoid anticholinergics, which delay stomach emptying. bariatric surgery diet - Answer: -Avoid alcohol, high-protein foods, and foods high in sugar and fat. -Eat slowly and chew food well. -Progress food types and amounts as prescribed. -Take nutritional supplements as prescribed, which may include calcium, iron, multivitamins, and vitamin B12. -Monitor and report signs and symptoms of complications, such as dehydration and gastric leak (persistent abdomi- nal pain, nausea, vomiting). Dumping syndrome - Answer: rapid emptying of the gastric contents into the small intestine that occurs fol- lowing gastric resection Dehydration risk dumping syndroms sx - Answer: -nausea vomiting -dizziness -sweating -palpitations -diarrhea -abdominal fullness/cramping -weakness -borborygmi patient education dumping syndrome - Answer: -Eliminate caffeine containing products. -Eat a high-protein and complex carbohydrate diet, include foods such as oatmeal and other whole-grain foods high in fiber; increase fiber intake as tolerated. -Limit high-sugar foods, such as candy, table sugar, syrup,sodas and juices. -Eat small meals, five or six small meals a day rather than three larger ones. -Avoid consuming fluids with meals; drink most daily fluids between meals. -Eliminate dairy products if they are causing a problem; lac-tose may worsen symptoms. -Lie down for 20 to 30 minutes after meals to prevent rapid gastric emptying. -Take vitamin B12 injections as prescribed. -Take antispasmodic medications as prescribed to delay gastric emptying. -Consult with the primary health care provider about drink-ing alcohol. pulmonary embolism complication assessment - Answer: -Sudden dyspnea -Sudden sharp chest or upper abdominal pain -Cyanosis -Tachycardia - A drop in blood pressure pulmonary embolism interventions - Answer: -Notify the surgeon immediately, because pul- monary embolism may be life-threatening and requires emergency action. -Monitor vital signs. -Administer oxygen, medications, and treatments as prescribed. pneumonia and atelectasis assessment - Answer: -Dyspnea and increased respiratory rate -Crackles over involved lung area -Elevated temperature -Productive cough and chest pain pneumonia (3-5 days post-op) atelectasis (1-2 days post-op) pneumonia and atelectasis interventions - Answer: -Assess lung sounds. -Reposition the client every 1 to 2 hours. -Encourage the client to deep-breathe, cough, and -use the incentive spirometer as prescribed. -Provide chest physiotherapy and postural drain-age as prescribed. -Encourage fluid intake and early ambulation. -Use suction to clear secretions if the client is un- able to cough. -Encourage use of incentive spirometry. Hypoxemia assessment - Answer: Restlessness Dyspnea Diaphoresis Tachycardia Hypertension Cyanosis Low pulse oximetry readings hypoxemia interventions - Answer: -Monitor for signs of hypoxemia. -Notify the surgeon. -Monitor lung sounds and pulse oximetry. -Administer oxygen as prescribed. -Encourage deep breathing and coughing and use of the incentive spirometer. -Turn and reposition the client frequently; en- courage ambulation. Hemorrhage assessment - Answer: Restlessness Weak and rapid pulse Hypotension Tachypnea Cool, clammy skin Reduced urine output hemorrhage interventions - Answer: -Provide pressure to the site of bleeding. -Notify the surgeon. -Administer oxygen as prescribed. -Administer IV fluids and blood as prescribed. -Prepare the client for a surgical procedure if nec- essary. shock assessment - Answer: Similar to assessment findings in hem- orrhage shock interventions - Answer: -If shock develops, elevate the legs. -Notify the surgeon. -Determine and treat the cause of shock. -Administer oxygen as prescribed. -Monitor level of consciousness. -Monitor vital signs for increased pulse or de- creased blood pressure. -Monitor intake and output. -Assess color, temperature, turgor, and moisture of the skin and mucous membranes. -Administer IV fluids, blood, and colloid solu- tions as prescribed. thrombophlebitis assessment - Answer: Vein inflammation Aching or cramping pain Vein feels hard and cordlike and is tender to touch. Elevated temperature thrombophlebitis interventions - Answer: -Monitor legs for swelling, inflammation, pain, tenderness, venous distention, and cyanosis; -notify the surgeon if any of these signs are present. -Elevate the extremity 30 degrees without allow- ing any pressure on the popliteal area. -Encourage the use of antiembolism stockings as prescribed; remove stockings twice a day to wash and inspect the legs. -Use a sequential compression device as pre- scribed (see Fig. 15.3). -Perform passive range-of-motion exercises every 2 hours if the client is confined to bed rest. -Encourage early ambulation, as prescribed. -Do not allow the client to dangle the legs. -Instruct the client not to sit in one position for an extended period of time. -Ultrasound may be ordered. -Administer anticoagulants such as heparin so- dium or enoxaparin as prescribed. constipation assessment - Answer: Bowel sounds Absence of bowel movements Abdominal distention Anorexia, headache, and nausea constipation interventions - Answer: -Encourage uid intake up to 3000 mL/day un- less contraindicated. -Encourage early ambulation. -Encourage consumption of fiber foods unless contraindicated. -Provide privacy and adequate time for bowel elimination. -Administer stool softeners and laxatives as pre- scribed. Urinary retention assessment - Answer: Inability to void Restlessness and diaphoresis Lower abdominal pain Distended bladder Hypertension On percussion, the bladder sounds like a drum. urinary retention interventions - Answer: -Monitor for voiding. -Assess for a distended bladder by palpation and bladder scanning if indicated. -Encourage ambulation when prescribed. -Encourage fluid intake unless contraindicated. -Assist the client to void by helping the client stand or ensuring proper positioning for voiding. -Provide privacy. -Pour warm water over the perineum, or allow the client to hear running water to promote voiding. -Contact the surgeon and catheterize the client as prescribed after all noninvasive techniques have been attempted. paralytic iléus assessment - Answer: Vomiting postoperatively Abdominal distention Absence of bowel sounds, bowel movement, or flatus paralytic illeus interventions - Answer: -Monitor intake and output. -Maintain NPO status until bowel sounds return. -Maintain patency of a nasogastric tube if in place; -assess patency and drainage per agency procedure. -Encourage ambulation. -Administer IV uids or parenteral nutrition as prescribed. -Administer medications as prescribed to increase gastrointestinal motility and secretions. -If ileus occurs, it is treated first nonsurgically with bowel decompression by insertion of a na- sogastric tube attached to intermittent or con- stant suction. wound infection assessment - Answer: Fever and chills Warm, tender, painful, and inamed incision site Edematous skin at the incision and tight skin su- tures Elevated white blood cell count wound infection interventions - Answer: -Monitor temperature. -Monitor incision site for approximation of su- ture line, edema, or bleeding and for signs of in-fection (REEDA: redness, erythema, ecchymosis, drainage, approximation of the wound edges); notify the surgeon if signs of wound infection are present. -Maintain patency of drains, and assess drainage amount, color, consistency, and odor. -Maintain asepsis, change the dressing, and per- form wound irrigation if prescribed (Box 15.6). -Anticipate prescriptions for wound culture and blood culture if infection is suspected. - Administer antibiotics as prescribed. Wound dehiscence and evisceration assessment - Answer: dehiscence -Increased drainage Opened wound edges Appearance of underlying tissues through the wound evisceration -Discharge of serosanguineous uid from a previ- ously dry wound The appearance of loops of bowel or other ab- dominal contents through the wound Client reports feeling a popping sensation after coughing or turning. wound dehiscence and evisceration interventions - Answer: Calls for help; asks that the surgeon be notied and that needed supplies be brought to the client's room. Stays with the client. Places the client in a low-Fowler's position with the knees bent. Covers the wound with a sterile normal saline dressing andkeepsthedressingmoist. Takes vital signs and monitors the client closely for signs of shock. Prepares the client for surgery as necessary. Documents the occurrence, actions taken, and the cli- ent's response. Recognizing cues - Answer: Assessment/noticing Getting the information -what is presenting -what is most significant -what needs follow up -what additional info is needed what questions should nurse ask Analyzing cues - Answer: Diagnosis/interpreting Making meaning of information -what findings did you expect -what patient problems are consistent with these findings -is data concerning Prioritize hypothesis - Answer: Diagnosis/planning and Interpreting Making meaning of information -what are possible explanations -what is priority -what are all possible patient problems Generate solutions - Answer: Planning/interpreting determine actions to take -what interventions are indicated what outcomes are most important -how will interventions promote the expected outcomes -what interventions should be avoided Take action - Answer: Implementation/ Responding Taking action -what interventions are appropriate -what interventions should be done first -what actions should be done now -what would you teach before discharge -what should be reported ASAP Evaluate outcomes - Answer: Evaluation/Reflection Evaluating outcomes and your thinking -what shows patient is improving -are interventions effective what observations would you make to see if the patient understands discharge instructions