NUR1460 EXAM 1 | QUESTIONS AND ANSWERS | ss ss ss ss ss ss ss
SOLVED 100% CORRECT ss ss ss
FINAL EXAM Term 2 A7 – Review ss ss ss ss ss ss
1. Discuss the Nursing Process (ADPIE) ss ss ss ss
A - Assessment - Gather patient care data (objective and subjective) through observation,
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interviews, and physical assessments. Assessment data can be collected from a variety of
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sources, including patients, family members, friends, communities, health care professionals,
ss ss ss ss ss ss ss ss ss ss
medical records, and laboratory and diagnostic test results.
ss ss ss ss ss ss ss ss
D - Diagnosis -Analyze, validate, and cluster patient data to identify patient problems. 3-Step
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nursing diagnosis = problem, etiology (related to), defining characteristics (as evidenced by).
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P - Planning - Prioritize nursing diagnoses and identify short and long-term goals that are
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realistic, measurable and patient-focused, with specific outcome identification for evaluation
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purposes (SMART goals).
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I - Implementation - Initiate specific nursing interventions and treatments designed to help the
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patient achieve established goals or outcomes.
ss ss ss ss ss ss
E - Evaluation - Determine whether the patient’s goals have been met, examine the
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effectiveness of interventions, and decide whether the plan of care should be discontinued,
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continued, or revised.
ss ss ss
Yoost Ch. 5, pg. 71 ss ss ss ss
2. What can the RN delegate to unlicensed personnel? An RN can delegate bathing, dressing,
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feeding, ambulating, vital signs ( if patient is stable)
ss ss ss ss ss ss ss ss ss
What type of responsibilities can the RN not delegate? RN never delegates : Evaluation,
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Assessment, Teaching, New admits, unstable patients, what you can eat,
ss ss ss ss ss ss ss ss ss ss
3. Discuss the Process of Gas Exchange ss ss ss ss ss
Gas Exchange - the process by which oxygen is transported to cells and carbon dioxide is
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
transported from cells. This normal physiological process requires interaction among the
ss ss ss ss ss ss ss ss ss ss ss
neurologic, respiratory, and cardiovascular systems (Giddens Concept 19, pg. 178)
ss ss ss ss ss ss ss ss ss ss
Impairment of gas exchange occurs when the diffusion of gases (oxygen and carbon dioxide) is
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
impaired due to ineffective ventilation, reduced capacity for gas transportation (reduced
ss ss ss ss ss ss ss ss ss ss ss
hemoglobin and/or red blood cells), or inadequate perfusion.
ss ss ss ss ss ss ss ss
,4. Define and discuss Oxygenation Versus Perfusion
ss ss ss ss ss
Oxygenation - process by which oxygen is transported to cells and carbon dioxide is
ss ss ss ss ss ss ss ss ss ss ss ss ss
transported from cells.
ss ss ss
Perfusion - normal physiologic process that requires the heart to generate sufficient cardiac
ss ss ss ss ss ss ss ss ss ss ss ss
output to transport blood to patent blood vessels for distribution in the tissues throughout the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
body. (Giddens Concept 18, pg. 167)
ss ss ss ss ss ss
*Adequate oxygenation and perfusion of tissues depends on the cardiovascular and respiratory
ss ss ss ss ss ss ss ss ss ss ss
systems working together to oxygenate tissues.
ss ss ss ss ss ss
5. Define normal and abnormal findings of the Laboratory and diagnostic studies below
ss ss ss ss ss ss ss ss ss ss ss
a. RBC - determines the oxygen-carrying capacity of the blood. Normal range
ss ss ss ss ss ss ss ss ss ss
is 4.7 - 6.1 (men) and 4.2 - 5.4 (women). Patients who have anemia have
s s ss ss ss ss ss ss ss ss ss ss ss ss ss ss
decreased numbers of RBCs, which reduces the patient's oxygen-carrying
ss ss ss ss ss ss ss ss ss
ability.
ss
b. ABG - Normal pH range: 7.35 - 7.45 (if below 7.35, it is acidosis; if above
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
7.45, it is alkalosis)
ss ss ss ss
Normal Paco2 range: 35 - 45 mm Hg (if abnormal, it is respiratory) Normal
ss ss ss ss ss ss ss ss ss ss ss ss ss
ss HCO3 range: 22 - 26 mEq/L (if abnormal, it is metabolic)
ss ss ss ss ss ss ss ss ss ss
**Remember R.O.M.E. (Respiratory Opposite, Metabolic Equal) ss ss ss ss ss
c. Sputum - Can help in the diagnosis of respiratory disorders. Normal culturess ss ss ss ss ss ss ss ss ss ss
results are negative. Culture and sensitivity are performed on a single specimen
ss ss ss ss ss ss ss ss ss ss ss ss
to detect bacteria and determine which antibiotic is most effective. The most
ss ss ss ss ss ss ss ss ss ss ss ss
, common harmful bacteria found in sputum can cause bronchitis, pneumonia, or
ss ss ss ss ss ss ss ss ss ss
tuberculosis.
ss
6. Endoscopic Examination
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a. Bronchoscopy - an endoscopic examination in which a flexible fiber-optic
ss ss ss ss ss ss ss ss ss
bronchoscope is extended through the bronchi for the purpose of diagnosis,
ss ss ss ss ss ss ss ss ss ss ss
specimen collection, or tissue biopsy. Can be diagnostic or therapeutic (removing
ss ss ss ss ss ss ss ss ss ss ss
foreign objects).
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b. Thoracentesis - a procedure to relieve a pleural effusion by inserting a
ss ss ss ss ss ss ss ss ss ss ss
needle into the pleural space to remove fluid. Nurses assist physicians with this
ss ss ss ss ss ss ss ss ss ss ss ss ss
procedure and monitor the patient's vital signs, lung sounds, and pain level
ss ss ss ss ss ss ss ss ss ss ss ss
afterward.
ss
c. Lung Biopsy - a procedure in which samples of lung tissue are removed
ss ss ss ss ss ss ss ss ss ss ss ss
(with a special biopsy needle or during surgery) to determine if lung disease or
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
cancer is present.
ss ss ss
SOLVED 100% CORRECT ss ss ss
FINAL EXAM Term 2 A7 – Review ss ss ss ss ss ss
1. Discuss the Nursing Process (ADPIE) ss ss ss ss
A - Assessment - Gather patient care data (objective and subjective) through observation,
ss ss ss ss ss ss ss ss ss ss ss ss
interviews, and physical assessments. Assessment data can be collected from a variety of
ss ss ss ss ss ss ss ss ss ss ss ss ss
sources, including patients, family members, friends, communities, health care professionals,
ss ss ss ss ss ss ss ss ss ss
medical records, and laboratory and diagnostic test results.
ss ss ss ss ss ss ss ss
D - Diagnosis -Analyze, validate, and cluster patient data to identify patient problems. 3-Step
ss ss ss s ss ss ss ss ss ss ss ss ss ss
nursing diagnosis = problem, etiology (related to), defining characteristics (as evidenced by).
ss ss ss ss ss ss ss ss ss ss ss ss
P - Planning - Prioritize nursing diagnoses and identify short and long-term goals that are
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
realistic, measurable and patient-focused, with specific outcome identification for evaluation
ss ss ss ss ss ss ss ss ss ss
purposes (SMART goals).
ss ss ss
I - Implementation - Initiate specific nursing interventions and treatments designed to help the
ss ss ss ss ss ss ss ss ss ss ss ss ss
patient achieve established goals or outcomes.
ss ss ss ss ss ss
E - Evaluation - Determine whether the patient’s goals have been met, examine the
ss ss ss ss ss ss ss ss ss ss ss ss ss
effectiveness of interventions, and decide whether the plan of care should be discontinued,
ss ss ss ss ss ss ss ss ss ss ss ss ss
continued, or revised.
ss ss ss
Yoost Ch. 5, pg. 71 ss ss ss ss
2. What can the RN delegate to unlicensed personnel? An RN can delegate bathing, dressing,
ss ss ss ss ss ss ss ss ss ss ss ss ss
feeding, ambulating, vital signs ( if patient is stable)
ss ss ss ss ss ss ss ss ss
What type of responsibilities can the RN not delegate? RN never delegates : Evaluation,
ss ss ss ss ss ss ss ss s s ss ss ss ss
Assessment, Teaching, New admits, unstable patients, what you can eat,
ss ss ss ss ss ss ss ss ss ss
3. Discuss the Process of Gas Exchange ss ss ss ss ss
Gas Exchange - the process by which oxygen is transported to cells and carbon dioxide is
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
transported from cells. This normal physiological process requires interaction among the
ss ss ss ss ss ss ss ss ss ss ss
neurologic, respiratory, and cardiovascular systems (Giddens Concept 19, pg. 178)
ss ss ss ss ss ss ss ss ss ss
Impairment of gas exchange occurs when the diffusion of gases (oxygen and carbon dioxide) is
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
impaired due to ineffective ventilation, reduced capacity for gas transportation (reduced
ss ss ss ss ss ss ss ss ss ss ss
hemoglobin and/or red blood cells), or inadequate perfusion.
ss ss ss ss ss ss ss ss
,4. Define and discuss Oxygenation Versus Perfusion
ss ss ss ss ss
Oxygenation - process by which oxygen is transported to cells and carbon dioxide is
ss ss ss ss ss ss ss ss ss ss ss ss ss
transported from cells.
ss ss ss
Perfusion - normal physiologic process that requires the heart to generate sufficient cardiac
ss ss ss ss ss ss ss ss ss ss ss ss
output to transport blood to patent blood vessels for distribution in the tissues throughout the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
body. (Giddens Concept 18, pg. 167)
ss ss ss ss ss ss
*Adequate oxygenation and perfusion of tissues depends on the cardiovascular and respiratory
ss ss ss ss ss ss ss ss ss ss ss
systems working together to oxygenate tissues.
ss ss ss ss ss ss
5. Define normal and abnormal findings of the Laboratory and diagnostic studies below
ss ss ss ss ss ss ss ss ss ss ss
a. RBC - determines the oxygen-carrying capacity of the blood. Normal range
ss ss ss ss ss ss ss ss ss ss
is 4.7 - 6.1 (men) and 4.2 - 5.4 (women). Patients who have anemia have
s s ss ss ss ss ss ss ss ss ss ss ss ss ss ss
decreased numbers of RBCs, which reduces the patient's oxygen-carrying
ss ss ss ss ss ss ss ss ss
ability.
ss
b. ABG - Normal pH range: 7.35 - 7.45 (if below 7.35, it is acidosis; if above
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
7.45, it is alkalosis)
ss ss ss ss
Normal Paco2 range: 35 - 45 mm Hg (if abnormal, it is respiratory) Normal
ss ss ss ss ss ss ss ss ss ss ss ss ss
ss HCO3 range: 22 - 26 mEq/L (if abnormal, it is metabolic)
ss ss ss ss ss ss ss ss ss ss
**Remember R.O.M.E. (Respiratory Opposite, Metabolic Equal) ss ss ss ss ss
c. Sputum - Can help in the diagnosis of respiratory disorders. Normal culturess ss ss ss ss ss ss ss ss ss ss
results are negative. Culture and sensitivity are performed on a single specimen
ss ss ss ss ss ss ss ss ss ss ss ss
to detect bacteria and determine which antibiotic is most effective. The most
ss ss ss ss ss ss ss ss ss ss ss ss
, common harmful bacteria found in sputum can cause bronchitis, pneumonia, or
ss ss ss ss ss ss ss ss ss ss
tuberculosis.
ss
6. Endoscopic Examination
s s
a. Bronchoscopy - an endoscopic examination in which a flexible fiber-optic
ss ss ss ss ss ss ss ss ss
bronchoscope is extended through the bronchi for the purpose of diagnosis,
ss ss ss ss ss ss ss ss ss ss ss
specimen collection, or tissue biopsy. Can be diagnostic or therapeutic (removing
ss ss ss ss ss ss ss ss ss ss ss
foreign objects).
ss ss
b. Thoracentesis - a procedure to relieve a pleural effusion by inserting a
ss ss ss ss ss ss ss ss ss ss ss
needle into the pleural space to remove fluid. Nurses assist physicians with this
ss ss ss ss ss ss ss ss ss ss ss ss ss
procedure and monitor the patient's vital signs, lung sounds, and pain level
ss ss ss ss ss ss ss ss ss ss ss ss
afterward.
ss
c. Lung Biopsy - a procedure in which samples of lung tissue are removed
ss ss ss ss ss ss ss ss ss ss ss ss
(with a special biopsy needle or during surgery) to determine if lung disease or
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
cancer is present.
ss ss ss
