Rasmussen Fundamentals Final Exam With Verified Correct Complete Solution 2024 Verified.

What are different tools to assess pain? - correct answer 1-10 scale, face scale When is a patient's pain level tolerable? - correct answer When they say it is How soon after giving a pain medication should you reassess a patient's pain level? - correct answer IV - 30min or less, PO - 30min-1hr What are standard precautions used for? - correct answer Every patient What is droplet precautions used for? - correct answer Flu, RSV, Pertussis, R/O Meningitis A patient with pneumonia pneumonia is on which type of precaution? - correct answer Standard - however is the patient is coughing everywhere use droplet as needed Which diseases are droplet precautions used for? - correct answer Chicken pox, TB, Measles When must you use soap and water to wash hands instead of an alcohol gel/foam? - correct answer When hands are visibly soiled What is a normal WBC? - correct answer 4,500-12,000 What is a stage I pressure ulcer? - correct answer Nonblanchable redness What is a stage II pressure ulcer? - correct answer Partial thickness loss or a blister What is a stage III pressure ulcer? - correct answer Full thickness loss, sub fat ay be visible What is a stage IV pressure ulcer? - correct answer Full thickness loss, able to see tendon, muscle, or bone How is 0+ pitting edema classified? - correct answer No edema How is 1+ pitting edema classified? - correct answer Mild pitting edema, 2mm depression disappears rapidly. How is 2+ pitting edema classified? - correct answer Moderate pitting edema, 4mm depression disappears 10-15sec How is 3+ pitting edema classified? - correct answer Moderately severe pitting edema, 6mm depression, disappears in 1min. How is 4+ pitting edema classified? - correct answer Severe pitting edema, 8mm of depression that can last up to 2min. What are s/s of dehydration? - correct answer Delayed skin turgor, crack/peeling lips, flaking skin What is the difference when wound is infection vs. colonized? - correct answer An infected wound shows signs and symptoms (redness/warm to touch), while a colonized wound does not show s/s, but has the bacteria present. What symptoms can occur if the circadian rhythm is interuppted? - correct answer Memory loss, confusion, irritability, slow metabolism, weight gain, anxiety If the REM cycle is interrupted, what happens? - correct answer It starts over When is TypeI Diabetes commonly diagnosed? - correct answer Age 4-7 and 10-14 How does Type I Diabetes occur? - correct answer Usually the child has a bad infection that causes the pancreas to stop producing insulin, making them diabetic When is Type II Diabetes commonly diagnosed? - correct answer Middle age to older What are signs and symptoms of diabetes? - correct answer 3 P's (polydipsia, polyuria, polyphagia) Which races are at a higher risk for diabetes? - correct answer African american and hispanic What are some risks for diabetes? - correct answer Obesity, a sedentary lifestyle, family history, history of gestational diabetes, carrying weight in the abdomen, poor diet What is an A1C? - correct answer Average glucose for the past 3mo, should be less than 7%. What is necessary for diabetes to be diagnosed? - correct answer A fasting glucose What lines the lungs and prevents the alveoli from collapsing? - correct answer Surfactant What is it called when the alveoli collapse? - correct answer Atelectasis Hypoxia - correct answer Inadequate amount of oxygen Hypoventilation - correct answer Decrease in the rate or depth of air movement into the lungs Dyspnea - correct answer Difficulty breathing What techniques/tools can be used to encourage proper breathing? - correct answer Deep breathing, pursed lip breathing, and incentive spirometer What are the different ways to deliver oxygen? - correct answer Nasal cannula : 1-6L/min (23-40%) Simple mask: 5-8L/min (40-60%) Partial rebreather mask: 8-11L/min (40-60%) - Bag remains 1/3 to 1/2 full Nonrebreather mask: 12L/min (80-100%) Venturi mask (color coded - amount of O2): 4-10L/min (24-40%) O2 Tent What does pulse oximetry measure? - correct answer The amount of oxyhemoglobin saturation in the arterial blood What is a normal SPO2 reading and when should the MD be notified? - correct answer Normal is 95%-100% Notify MD <90% Where does a decreased oxygen level fall of Maslow's Hierarchy of Needs? - correct answer Highest level What are the 5 parts of the nursing process? - correct answer Assess, Diagnose, Plan, Implement, Evaluate What are the 4 types of assessments? - correct answer Initial comprehensive, focused, emergent, and time-lapsed What is subjective date? - correct answer What the patient states What is objective data? - correct answer What you observe and measurable data What is a nursing diagnosis? - correct answer The recognition of a problem that the nurse can treat independently without a physician-prescribed intervention What occurs in the planning phase of the nursing process? - correct answer Identify expected patient outcomes. Establish priorities. Select evidence-based nursing interventions. Communicate the plan of care. What occurs in the implementation phase of the nursing process? - correct answer The interventions are put into place to help patients reach the set goals What happens in the evaluation stage of the nursing process? - correct answer The nurse evaluates the outcomes of the implementation and identifies any change sin the care plan that should be made What characteristics should the nurse's documentation have? - correct answer Should be clear, concise, accurate, legible, and done in a timely manor. What should the nurse use when planning patient care to ensure the patient is recieving the most helpful care possible? - correct answer Evidence based practice What are Erickson's stages of development? - correct answer Trust vs. mistrust (infancy) Autonomy vs. shame and doubt (toddler)