Introduction to Nursing Exam Tested Questions with Correct Answers Score an A (Latest Version).

Introduction to Nursing Exam Tested Questions with Correct Answers Score an A (Latest Version). The foundation of the nursing profession; is the systematic approach to problem-solving and providing individualized care? The Nursing Process The phases of the nursing process? Assessment, Diagnosis, Planning (includes Outcome), Implementation, Evaluation What is Assessment? Collection of data to help establish a goal of making a clinical nursing judgment. Difference between subjective and objective data? Subjective, from the client; Objective, from the nurse's senses. Difference between primary, secondary and tertiary sources? Primary, can only be the patient; Secondary, info from families, medical records, or other health care professionals; Tertiary, info from textbooks, nurse's and other health care team responses to patient What must be done by the nurse on admission to a health care facility? And what does it identify? In depth nursing history and physical assessment must be done and it identifies the patient's strengths and weakness/health problems. When does data collection take place? Through observations, interviews, physical assessment, and interpreting lab and diagnostic results. What is diagnosis? The clinical act of identifying problems using the assessment data collected. This step identifies an individual, family or group response to an actual or potential health problem. What is the nursing diagnosis based on? The pathophysiology of the disease process. Who established the list of nursing diagnosis for classifying nursing problems, standardizing language and facilitating communication for nurses? North American Nursing Diagnosis Association (NANDA) What is included in Outcome? Development of patient focused goals...included in the planning phase. What are the guidelines on making goals? Must be patient-focused, specific to the nursing diagnosis or patient problem, measurable, realistic and have time frame. What is involved in the Planning phase? Preparing the nursing care plan with patient input in how to identify goals and interventions to help with the identified problems. What is included in the Planning phase? Patient goals/outcomes specific to the problem, assessment, specific treatments (independent and dependent), medications, teaching, and community care. What is a Joint Commission on Accreditation of Healthcare Organizations (JACHO) requirement? The care plan is a written summary of the care that a patient is to receive. What is the action phase? Implementatio/Intervention Why are nursing actions goal oriented? To help the patient reach maximum health potential What is crucial in the implementation phase? Documentation What is determined in the Evaluation phase? The patient's reactions to nursing interventions and judging whether the goals of the plan of care were achieved. What is ongoing and continuous process performed throughout the process? Evaluation..."revised or reassessed" Vital signs are a __________ mechanism? Homeostatic What is an important component of assessment? It yields info about underlying health status What is included in vital signs? Temperature, Pulse, Respiration, Blood Pressure, Pain, Pulse Oximetry What are normal vital ranges, in adults? Pulse: 60-100; Respirations: 12-20; Temp: 97-99; Systolic: 90-120; Diastolic: 60-80 When do you assess vital signs? Upon admission, physician order, facility policy; before and after- surgery, diagnostic procedure, medication administration, nursing interventions, patient becomes symptomatic What produces heat in the body? Basal metabolism, muscle activity, hormones and cells (fever) What causes loss of heat in body? Radiation, conduction/convection, evaporation... 40% of heat is lost through head. What is included in core body temperature? Temp of deep body tissue: abdominal, chest, pelvic cavities, and cranium What is included in surface body temperature? Temp of skin, subcutaneous tissue, and fat What factors affect temperature? Age, environment, time of day, exercise, stress and hormones. (temp is lowest in am) What are the temperature sites? What is most inaccurate and most dangerous? Mouth (frenulum), axilla, rectum, ear, forehead. Most inaccurate is the axilla, most dangerous is rectum. Elevated body temperature? Hyperthermia Fever? (exceeds 99.6F) Pyrexia Decreased body temperature? Hypothermia Fever or elevated body temperature? Febrile No fever, normal range temperature Afebrile What are critical signs of hypothermia? Decreased body temp, decreased bp and urinary output What are clinical signs of pyrexia? 3 stages: Onset (tachy-cardia & pnea, feeling cold, chills), Course (no chills, glassy-eyed, warm skin, drowsy, delirium, possible convulsions), Defervescence (warm, flushed skin, sweating, decreased shivering, watch for dehydration) How do you report the temperature? In Farenheit. What are pulse characteristics? Rate: # per min; Rhythm: regularity; Quality: strength of pulsation What can affect pulse rate? Age, gender, exercise, autonomic nervous system, fever, medications, hemorrhage (hypovolemia), stress, position changes Thickening, hardening or loss of elasticity of arterial walls? Arteriosclerosis Narrowing of the interior of the artery due to build-up of: lipids, complex carbs, fibrous tissues, blood issues Atherosclerosis What are risk factors associated with pulse? High blood pressure, high cholesterol, obesity, smoking, stress, family history What does elevated pulse pressure tell you? indicative of arteriosclerosis, decreased cardiac output. What is normal pulse pressure? 30-40...30 indicates decreased cardiac output. Low pulse pressure occurs with severe heart failure. Where are the pulse sites? From most common? Temporal, Carotid, Apical, Brachial, Radial, Femoral, Popliteal, Dorsalis pedis, Posterior tibial What is the most accurate site? Apical What are the processes of respiration? External-oxygen in, carbon dioxide out; Internal-use of oxygen, production of carbon dioxide, and cellular gas exchange What factors affect respiration? Age, gender, medications, stress, exercise, altitude Normal respiratory rate and rhythm? Eupnea Normal adult rate for respirations? 12-20 breaths/min Slower, but regular respirations? Bradypnea (can occur after certain meds or injury to the brain) Increased respiratory rate; rapid, shallow breaths? Tachypnea (not neurologic) Who should not get temperature taken via rectum? Patients with diarrhea, those that have had rectal surgery, rectal diseases, have cancer who are neutropenic Term meaning shortness of breath (SOB)? Dyspnea What is the condition where blood pressure is chronically elevated? What is the range? Hypertension; above 140/90 Blood pressure below 100/60 mm Hg? Hypotension When documenting vital signs you should: Watch for trends and report any abnormal findings to the physician. What are the phases of taking blood pressure? Phase 1 is the systolic pressure-first hear beating, Phase 2 and 3, Phase 4 is recorded as diastolic in children, Phase 5 is recorded as diastolic in adults...all part of the Korotkoff sounds Harsh inspiratory sound that may be compared to crowing; may indicate an upper airway obstruction Stridor High-pitched musical sound; partial obstruction of the bronchi or bronchioles, as in asthma Wheezing What equipment is used to monitor body temperature? Electronic thermometers, tympanic membrane thermometers, temporal artery thermometers, chemically treated paper thermometers. Glass mercury thermometers are no longer used. What causes pulsations? Heart contracts and ejects blood into the circulation, pulsations can be palpated at various arterial sites in the body What should you do if you detect an irregular pulse? Count it for the full minute, preferably at the apical site. When does a pulse deficit occur? When a cardiac contraction creates a pulse wave that is weak and not palpable at peripheral sites What factors affect blood pressure? Age, exercise, stress, race, gender, medications, obesity, diurnal variations, disease process Amount of air moving in and out with each breath tidal volume Increased carbon dioxide level? Hypercarbia What is systole? ventricular contraction What is diastole? ventricular relaxation The force that blood exerts against the walls of the blood vessels? Blood pressure The amount of blood each ventricle pumps with each heartbeat? Stoke volume What is equal to cardiac output? Blood flow What is the average cardiac output in a resting man? 5.5L per minute What increases as adults age? Blood pressure What influences heart rate, cardiac contractility, systemic vascular resistance, and blood volume? Autonomic nervous system What does systemic vascular resistance control? Blood volume and blood viscosity (thickness) Resistance in the pulmonary circulation? What does it affect? Peripheral Vascular Resistance; opposition to blood flow or impedance can increase b/p, diastolic b/p is usually affected Blood pressure when a patient sits or stands? Orthostatic hypotension What are medications based on? Blood pressure What are cyclic breathing patterns characterized by shallow breathing alternating with periods of apnea? Biot's Cyclic breathing pattern characterized by periods of respirations of increased rate and depth alternating with periods of apnea? Cheyne-Stokes Increased rate (above 20 beats/minute) and depth of respirations? Kussmaul What is important when taking bp? Use same location, same patient position and proper size cuff What are the phases of respiration? Phase 1/2- inspiration-thoracic cavity expands, pressure decreases and gases flow into chamber--volume increases 500ml/exhalation- inspiratory muscles relax and resume resting position, thoracic volume decreases and gases flow out of the cavity. Phase 3-External respiration-movement of respiratory gases from the lung to blood by diffusion across respiratory membrane-lung tissue/capillary membrane What is the process of respiration? Diffusion of O2 & CO2 cross between alveoli & pulmonary capillaries--Transport O2 & CO2 via blood to & from tissue cells--Diffusion of O2 & CO2 between capillaries & body cells What is a concentration of gases that is directly related to the concentration it has within the system? Partial pressure Amount of inhaled or exhaled from the lungs? Tidal volume Collapsed portion (alveoli) of the lung? Atelectasis A lipoprotein that reduces the surface tension, so that the alveoli in the lungs are able to expand? Surfactant How does blood transport the oxygen (2)? Small amounts are dissolved into plasma, but most is attached to hemoglobin (it carries it in molecular form--important for metabolism) How is carbon dioxide used in the body? Combined with water it dissociates into bicarbonate ions, forming bicarbonate buffer system, which is key in maintaining the body's acid-base balance How is ventilation regulated? Neural pathways; medulla oblongata and pons How do the chambers of the heart circulate? Right ventricle is pulmonary (lung); Left ventricle pushes blood to the the rest of the system (systemic) Stoke Volume X Heart Rate=Cardiac Output Stoke volume 70mL/beat What effects Cardiac Output? Heart rate, ventricles contraction/relaxation, stroke volume What is the difference between hypoxia and hypoxemia? Hypoxia-lack of O2 anywhere in the body; Hypoxemia- level of O2 in blood What is abnormally high levels of CO2 in blood? Hypercapnia What are early and late symptoms of Hypoxia? Early-patient sits up, 'can't breath', restless, BP, P, R...Late- BP, P, noisy respirations, cyanosis, retractions (ribs) Difference between hypoventilation and hyperventilation? Hypo-not enough O2 in blood; Hyper-too much O2 in the blood. Obstructed airways: Upper airway ie and lower airway ie... upper-foreign object; lower-mucous What is stiffening/hardening or loss of elasticity of arteries? Arteriosclerosis What is condition where artery walls thicken? Atherosclerosis What is high blood pressure called? Hypertension What are risk factors associated with respiratory? Smoking, Occupational hazards, family history, sleep habits (apnea), allergies Where does sputum and serum come from? Sputum-lungs (mucous), Serum-blood (ABGs) What are used in pulmonary function studies? Spirometer (incentive) What is included in a CBC? WBC=increased, possible infection; RBC=decreased, possible O2 problems What is involved in a Bronchoscopy? It is invasive and requires a consent to be signed, sterile procedure done at bedside, after nurse needs to watch for breathing problems, wait for gag reflex to return before eating, hemoptysis (bleeding) What are some indirect (non-invasive) diagnostic procedures? Chest X-Ray, VQ (Ventilation Quotient) Scan, MRI What is involved in Thoracentesis? Invasive, consent required. Requires anesthesia, performed by physician at bedside. Long needle extracts fluid from thoracic cavity What are independent nursing interventions for respiratory? Adequate hydration, positioning, turn-cough-deep breath (after surgery), splinting (after surgery), pursed-lip breathing. What are dependent nursing interventions for respiratory? Oxygen therapy, incentive spirometry, breathing treatments & medications What is most important in O2 delivery? The concentration of O2 is more important than the liter flow/min. What is nasal cannula O2 concentration? 22-44% What is simple face mask O2 concentration? 40-60% What is the venturi mask O2 concentration? 24,28,30,35,40,50% (valves) What is the partial rebreather O2 concentration? 60-90% What is the non rebreather (reservoir mask) O2 concentration? 95-100% What is an artificial airway consisting of a plastic tube surgically implanted just below the larynx into the trachea. Tracheostomy How is nursing distinguished? specialized education, body of knowledge, ethics, autonomy, professional organizations What organization's purpose is to foster high standards of nursing practice and to promote educational and professional advancement; establish Standards of Nursing Practice, Code of Ethics, Credentialing? American Nurses Association (ANA) What organization's purpose is to foster development and improvement of all nursing services and nursing education; individuals, agencies, services? National League for Nursing (NLN) Branch of philosophy dealing with standards of conduct and moral judgement? Ethics Means doing good or promoting good? Beneficence, ie performing wound changes, administering pain meds, and providing emotional support. Means to avoid doing harm, to remove from harm, and to prevent harm? Nonmaleficence, g meds to prevent further suffering, protecting from chemically impaired practitioner, and reporting suspected child abuse to prevent further abuse Means creating the conditions where patients can make their own decisions? Autonomy (self governing) What is a person's mental or physical ability? Capacity What is the foundation for decisions about resource allocation for societies or groups? Justice Means telling the truth? Veracity Means being faithful to one's commitments or promises? Fidelity What involves appropriately using patient info? Privacy What requires that information about a patient be kept private? Confidentiality (professional duty and legal obligation) What directives specify what interventions patients would or would not want if they became terminally ill Advanced Directives What is a private wrong that the law provides a remedy, often including compensation for damage? Tort--defines and enforces duties and rights among private individuals We have an expert-written solution to this problem! What wrongs are considered unintentional? negligence-failure to exercise degree of care that a reasonable nurse would under the same circumstances, duty, breach of duty, proximate cause, damages Malpractice-negligence applied to the professional person--medication errors, burning a patient, falls, incorrectly identifying patients, safeguarding a patient's property What can be considered assault and batter? Not getting a consent for a procedure, giving a sedative that the patient specifically does not want, resuscitation What are the guidelines for standard of nursing care? State Nurse Practice Act, American Nurses Association, Joint Commission, Institutions and Facitities What does the Nurse Practice Act do? Only control nursing practice through licensing, State BON, Protects the Public Who writes the NCLEX? National Council for Licensing Examinees What is "standing the gap" for patients, being on the patient's side? Advocacy Means to impart information, exchange ideas, and express one's self? Communicate--process of giving and receiving information What are the 3 phases of the nurse-client relationship? Orientation-introduction and agreement on their mutual roles, Working-nurse and patient expore and develop solutions, Termination-is the closure of the relationship (discharge planning)...nurse/client is goal oriented What kind of relationship do the nurse and patient have? Contractual-informal and verbal and assumed by both parties What is circle of confidentiality? "Need to know"..only those that need to know are included in the circle (other healthcare, nurses) What facilitates interactions based on the patient and the patient's concerns? Therapeutic Communication What are the components of Therapeutic Communication? Empathy (other person's perspective) Positive Regard (giving value to that patient no matter what), Comfortable sense of self What are examples of non-therapeutic communication? Rescue feelings, false reassurance, giving advice, changing the subject, being moralistic, nonprofessional involvement