NSE 111 FINAL EXAM QUESTIONS
WITH COMPLETE SOLUTIONS
What are signs of constipation? - Answer-- Infrequent bowel movements (less than 3
per week)
- Hard, dry stools that are difficult to pass
- abdominal pain, fullness
what is diarrhea? - Answer-an increase in the number of stools and the passage of
liquid, unformed feces
how can you measure urine output? - Answer-from drainage bag or urine hats
how can you measure urine input? - Answer-measuring what fluids enter the body
during meals or through IV
abnormal urine output? - Answer-- less than 30ml per hour for 2 hours
- <2000-2500 daily
what are normal and abnormal urine colours? - Answer-normal = range from pale straw
to amber
abnormal = red, orange, dark amber
what are normal and abnormal urine clarity levels? - Answer-normal = transparent at
voiding, can become cloudy if left standing
abnormal = cloudy/foamy, thick
what are abnormal urine smells? - Answer-sweet = diabetes or starvation
ammonia = stagnant urine
what are interventions to promote normal micturition? - Answer-- patient education
- promote regular urinary habits (i.e. try not to void too frequently)
- promote complete bladder emptying
- using positions or stimulating the micturition reflex
what are interventions to promote normal bowel elimination? - Answer-- positioning
- ensuring comfort & safety
- address factors that can impact defecation
- ensure adequate fluid intake
- promote physical activity
- medications
,how do you collect a urine sample midstream? - Answer-clean the perineal area before
beginning to void, after stream has been initiated then collect sample
how do you collect a stool sample? - Answer-feces cannot be mixed with urine or water,
should defecate into a clean dry bedpan or special container
what factors can influence personal hygiene practices? - Answer-- social
practices/influences
- personal preferences
- body image
- socioeconomic status
- health beliefs / motivation
- culture
- physical condition
what considerations should be assessed when planning client hygiene needs? -
Answer-- patients ability to perform self-care
- usual hygiene practices
- preferences
- physical condition & abilities
what are risks to oral hygiene? - Answer-- mobility issues
- dehydration, PTO
- medications
- diabetes
- surgery / trauma
- etc
what are risks to skin related hygiene? - Answer-- immobilization
- reduced sensation
- limited nutrition / hydration
- external devices
- etc
what is a risk for foot hygiene? - Answer-inability to bend over / see clearly
what is a risk for eye care? - Answer-reduced dexterity / hand coordination
what is a complete bed bath? - Answer-bath administered to totally dependent patient in
bed
what is a partial bed bath? - Answer-only bathes body parts that would cause discomfort
or odour if not cleaned
what is a tub bath/shower? - Answer-helps promote independence & raises safety
concerns
, what is a bag bath? - Answer-10 washcloths in a bag w/ water/cleanser added - no
rinsing required
what is perineal care? - Answer-cleansing the genitalia and rectum
what are the benefits of back rubs? - Answer-promotes relaxation, relieves muscle
tension, stimulates circulation, improves sleep
what patients may require more frequent shampooing? - Answer-those who stay in bed,
perspirating excessively, are undergoing treatments (blood on scalp)
how often should oral hygiene be completed? - Answer-4 times a day - brushing
once a day - flossing
What does ADPIE stand for in the nursing process? - Answer-Assessment
Diagnosis
Planning
Implementation
Evaluation
what are the steps of the clinical judgement model? - Answer-Recognize cues
Analyze cues
Prioritize hypothesis
Generate solutions
Take action
Evaluate outcomes
what does DIPPS stand for? - Answer-Dignity
Independence
Preferences
Privacy
Safety
what is dignity? (DIPPS) - Answer-the state of feeling worthy, valued, respected
what is independence? (DIPPS) - Answer-encourage patients to do what they can
themselves, even if they may struggle
what is preferences? (DIPPS) - Answer-allow patients to make choices on how they
would like things done
what is privacy? (DIPPS) - Answer-ensure to provide privacy during care (also can refer
to information)
WITH COMPLETE SOLUTIONS
What are signs of constipation? - Answer-- Infrequent bowel movements (less than 3
per week)
- Hard, dry stools that are difficult to pass
- abdominal pain, fullness
what is diarrhea? - Answer-an increase in the number of stools and the passage of
liquid, unformed feces
how can you measure urine output? - Answer-from drainage bag or urine hats
how can you measure urine input? - Answer-measuring what fluids enter the body
during meals or through IV
abnormal urine output? - Answer-- less than 30ml per hour for 2 hours
- <2000-2500 daily
what are normal and abnormal urine colours? - Answer-normal = range from pale straw
to amber
abnormal = red, orange, dark amber
what are normal and abnormal urine clarity levels? - Answer-normal = transparent at
voiding, can become cloudy if left standing
abnormal = cloudy/foamy, thick
what are abnormal urine smells? - Answer-sweet = diabetes or starvation
ammonia = stagnant urine
what are interventions to promote normal micturition? - Answer-- patient education
- promote regular urinary habits (i.e. try not to void too frequently)
- promote complete bladder emptying
- using positions or stimulating the micturition reflex
what are interventions to promote normal bowel elimination? - Answer-- positioning
- ensuring comfort & safety
- address factors that can impact defecation
- ensure adequate fluid intake
- promote physical activity
- medications
,how do you collect a urine sample midstream? - Answer-clean the perineal area before
beginning to void, after stream has been initiated then collect sample
how do you collect a stool sample? - Answer-feces cannot be mixed with urine or water,
should defecate into a clean dry bedpan or special container
what factors can influence personal hygiene practices? - Answer-- social
practices/influences
- personal preferences
- body image
- socioeconomic status
- health beliefs / motivation
- culture
- physical condition
what considerations should be assessed when planning client hygiene needs? -
Answer-- patients ability to perform self-care
- usual hygiene practices
- preferences
- physical condition & abilities
what are risks to oral hygiene? - Answer-- mobility issues
- dehydration, PTO
- medications
- diabetes
- surgery / trauma
- etc
what are risks to skin related hygiene? - Answer-- immobilization
- reduced sensation
- limited nutrition / hydration
- external devices
- etc
what is a risk for foot hygiene? - Answer-inability to bend over / see clearly
what is a risk for eye care? - Answer-reduced dexterity / hand coordination
what is a complete bed bath? - Answer-bath administered to totally dependent patient in
bed
what is a partial bed bath? - Answer-only bathes body parts that would cause discomfort
or odour if not cleaned
what is a tub bath/shower? - Answer-helps promote independence & raises safety
concerns
, what is a bag bath? - Answer-10 washcloths in a bag w/ water/cleanser added - no
rinsing required
what is perineal care? - Answer-cleansing the genitalia and rectum
what are the benefits of back rubs? - Answer-promotes relaxation, relieves muscle
tension, stimulates circulation, improves sleep
what patients may require more frequent shampooing? - Answer-those who stay in bed,
perspirating excessively, are undergoing treatments (blood on scalp)
how often should oral hygiene be completed? - Answer-4 times a day - brushing
once a day - flossing
What does ADPIE stand for in the nursing process? - Answer-Assessment
Diagnosis
Planning
Implementation
Evaluation
what are the steps of the clinical judgement model? - Answer-Recognize cues
Analyze cues
Prioritize hypothesis
Generate solutions
Take action
Evaluate outcomes
what does DIPPS stand for? - Answer-Dignity
Independence
Preferences
Privacy
Safety
what is dignity? (DIPPS) - Answer-the state of feeling worthy, valued, respected
what is independence? (DIPPS) - Answer-encourage patients to do what they can
themselves, even if they may struggle
what is preferences? (DIPPS) - Answer-allow patients to make choices on how they
would like things done
what is privacy? (DIPPS) - Answer-ensure to provide privacy during care (also can refer
to information)
