RNSG 1216 Midterm Exam Questions & Answers Solved 100%

Health-care Associated Infections (HAIs): - Answer infection acquired while patient is receiving health care services Most common HAIs include: - Answer Pneumonia GI Illnesses UTIs Bloodstream Infections Wound Infections Hand Hygiene is the single most important intervention to prevent ... - Answer HAIs in the health care setting. Alcohol-based hygiene products (more/less) effective than soap. - Answer more (reduce infections) When is hand washing with soap and water necessary? - Answer -For hands visibly soiled with organic material -After exposure to spore forming organisms such as Clostridium difficile or multidrug-resistant organisms (MDROs) -Before/After eating -After using the Restroom In & out rule: - Answer Wash In and Out of Rooms Wash In and Out of Gloves Wash In and Out of Sterile Tray/Field Wash In and Out of Procedures Hand washing key points: - Answer Warm water, not hot water Avoid splashing water, touching sink/faucet Apply 3-5 ml of soap Wash for at least 15-20 seconds Cover all surfaces Friction Hand and forearms LOWER than elbows Dry thoroughly Personal Protective Equipment (PPE): - Answer Gloves Mask Eye-wear Gown Cap Isolation Precautions: - Answer Standard/Universal Precautions (Tier 1) Transmission-Based Precautions (Tier 2) -Airborne -Droplet -Contact 3 H's of nursing practice - Answer Head Heart Hands National Patient Safety Goals - Answer Identify Patients Correctly with 2 identifiers Improve staff communications Uses medicines safely Use alarms safely Prevent Infections Identify patients safety risks Prevent mistakes in Surgery Patient Safety - Answer 2 Identifiers Communication/Documentation Six rights of Medication Administration Appropriate & Proper Techniques/Procedures -Medical Asepsis or Sterile Safe Medical Equipment/Supplies Safety Risk Assessments Safety Checks (Bed Locked/Lowest Position, Side Rails Up X2, Call Light within Reach/Alarms) _______________ are the most common type of inpatient accident. - Answer Patient falls CMS will not pay for ... - Answer "never events." Fall Prevention in a Health Care Facility - Answer Bedside safety -Call light -Side rails -Electronic alarms -Bedside devices Fall Recording and Reporting: - Answer -Record fall risk assessment findings and specific interventions -Report specific risks to patient's safety and measures taken to minimize risks If patient falls, document a description of the fall as given by patient or you as witness -Complete an agency's adverse event report Physical restraints require - Answer a licensed health care provider's order based on face-to-face patient assessment When are restraints used? - Answer Only as a last resort, try alternatives Restraint use is - Answer Only to ensure immediate safety A temporary measure. Discontinue asap Associated with serious/fatal complications Applied according to hospital policy A restraint-free environment is the ____ goal of care. - Answer 1st Restraint Recording and Reporting: - Answer -Record alternatives tried -The purpose for restraint, the type and location, the time applied, the time ending the restraints, and the routine observations made every 15 minutes -Record patients level of orientation and behavior after restraint application -Record times patient was evaluated, attempts to use alternatives, and patient's response when restraint was removed Legal Guidelines for Charting: - Answer -Chart only for yourself -Begin entry with Date/Time. Record in ink. -Do not erase/scratch out error/use white out -Do not make critical comments about pts. -Do not leave blank spaces-draw horizontal line -End entry with your signature and credentials. -If additional information is needed for existing entry, use first available line as Addendum/Late Entry with date and time of prior note. Guidelines for Quality Documentation and Reporting: - Answer Factual -Objective -Subjective Accurate -Exact measurements -No unnecessary words -Accepted abbreviations only Complete -Care given and patient response Current -At the time of occurrence Organized -Logical order Charting Systems: - Answer -Narrative -Problem oriented -SBAR -SOAP• -PIE -DAR -Charting by Exception -Critical Pathways -Electronic Documentation -Standardized Language -Classification Systems NANDA/NANDA-1 NIC NOC -Benefits Higher quality Etiology Specific interventions Nursing Specific Nursing outcomes Techniques of Assessment: - Answer Inspection Palpation Percussion Auscultation Head to toe physical assessment is - Answer systemic (includes all body systems). Focused physical assessments involve - Answer one are that may be your primary concern. Level of consciousness and general patient survey: - Answer -Assess orientation to person, place, time, and situation -Assess for pain -Assess allergy status -Assess fall risk using John Hopkins Scale Pain assessment: - Answer assess location and how much pain Assessing allergies: - Answer ask what they are and the type of reaction Eyes: - Answer PERLA Neurological/musculoskeletal Assessment: - Answer -Eyes -Observe gait and balance -Test muscle strength in upper and lower extremities -Test range of motion of head and upper and lower extremities -Check deep tendon reflexes (DTRs) bilaterally (triceps, biceps, patellar, Achilles, and plantar) Respiratory Assessment: - Answer -Ask about conditions that may affect respiration -Inspect size/symmetry of the chest -Inspect accessory muscle use -Palpate by checking for chest excursion -Auscultate in a ladder pattern What are we listening for while auscultating the lungs? - Answer Crackles Rhonchi Wheeze Pleural rub Cardiovascular Assessment: - Answer -Auscultate 5 valves and listen for abnormalities (murmurs) -Palpate radial and pedal pulses -Assess cap refill on hands and feet -Assess for pretibial edema -Assess for sacral edema Murmur: - Answer turbulent blood flow through the heart Bruit: - Answer turbulent blood flow through the vessels Gallop: - Answer 3rd and 4th heart sounds Abdominal Assessment: - Answer -Inspect contour, symmetry, movement/pulsations -Auscultate (gurgling, popping) - then palpate Listen to bowel sounds for _________ before you call them absent. - Answer 5 minutes in each quadrant Ileus: - Answer obstruction of the bowel occurring after surgery (distention, N/V, decreased or absent BS) Integumentary Assessment: - Answer -Inspect overall skin color, moisture, temperature -Check turgor at the clavicle -Inspect for bleeding, bruising, injuries, lesions, scars, body piercings, tattoos, varicosities, wounds -Note body hair distribution -Inspect nails (hands and feet) -Braden scale Vital Signs: - Answer HR (P) BP T RR O2 Sat Pain What may alter vital signs? - Answer Age Pain Stress Environmental temperature Exercise Adult VS: - Answer T: Afebrile 98.6-100.4 F P: 60-100 beats/min <60 bradycardia >100 tachycardia RR: 12-20 breath/min BP: <120/<80 mmHg Pain: Scale of 0-10 Pulse Oximetry: 95-100% SpO2 Thermometers: - Answer 1. Electronic Rectal probe Oral/axillary probe Tympanic Temporal 2. Disposable Chemical dot thermometer 3. Mercury Environmental hazard Not allowed in health care institutions Have pts dispose of these at hazardous waste disposal sites Temperature: - Answer Normal Range: 98.6-100.4 F Sustained Fever: constant fever > 104 F Intermittent Fever: fever spikes & falls but never reaching normal Relapsing: fever spikes & falls and at some point returns to normal Measurement of pulse: - Answer 4+ Bounding 3+ Strong 2+ Expected/Normal 1+ Barely palpable 0 Absent Radial pulse: - Answer Use first three fingers in groove on thumb side of wrist Regular pulse: - Answer count pulse for 30 seconds then multiple by 2 Irregular pulse: - Answer count for 60 seconds Apical pulse: - Answer Point of Maximal Impulse (PMI): Midclavicular line, 5th intercostal space (ICS), apex of the heart Pulse Sites: - Answer temporal carotid apical brachial radial ulnar femoral popliteal posterior tibial dorsalis pedis