WGU D439 FOUNDATIONS FINAL EXAM UPDATED FOR 2025 WITH 100% VERIFIED SOLUTIONS
2023-2025
what can cause high blood pressure readings?
Anxiety, wrong cuff size, talking, legs crossed, arm not being level with heart, pain, dehydration,
fever/infection, hyponatremia, weight, alcohol/smoking, opioids, hypovolemia,
hyper/hypokalemia, hyper/hypocalcemia
no radial pulse at 90
PUMP TO 120
how much to pump cuff
at least 30 mm Hg above the point the radial pulse disappears
potassium levels involved
heart: helps the heart squeeze
high potassium levels
high apical pulse rate and rhythm
nursing charts by exception- lungs
LUNG SOUNDS DIMINISHED IN LEFT LUNG not normal
nasal cannula care: if patient has reddened areas around cheekbones
PLACE PADDING AROUND THE CANNULA TUBING
nasal cannula care: if patient's O2 readings improve with movement
place the nasal cannula in the nose securely
nasal cannula care: O2 levels low
VERIFY PLACEMENT OF PULSE OXIMETER
Oxygen chamber
store in a cool area
Fall Prevention "H"
Hourly rounds: check on patient HOURLY
Fall prevention "O"
,Organize belongings: use bed alarms
Fall Prevention "P"
Position changes slow: ensure slow position changes and keep everything needed within reach
Fall Prevention "E"
Ensure lighting is sufficient: For elderly patients keep a well lit room
patient has sleep apnea and given sedative
MAKE SURE AIRWAY PRESSURE DEVICE IS ON
restraint types
chemical & physical
restraint knot
slip knots
restraint tying area
BED FRAME ONLY
chemical restraints
meds such as benzos
first thing to assess after restraint
CAPILLARY REFILL
when to check capillary refill when restrained
immediately and every 15 mins
other checks when restrained
skin integrity, vital signs, ROM every 2 hours; offer bathroom every 2 hours
restraint documentation
reasoning, mental status, care offered, time in restraints
restraint order time
ONLY last 24 hours
urine specific gravity test use
, identify dehydration, kidney problems, conditions like diabetes insipidus
urine specific gravity test & range
concentration of particles in urine; 1.005- 1.030
high urine specific gravity test
HIGH = YOU'RE DRY/ DEHYDRATED = VOMITING/DIARRHEA
low urine specific gravity test
"overflow" kidney damage, kidney failure
pressure ulcers
"1 red, 2 broken, 3 deep, 4 bone"
red intact skin, break with blister, deep tissue, bone visible
pressure ulcers stage 1
red intact skin
pressure ulcers stage 2
skin breaks & blisters; 2 layers affected (epidermis, dermis)
pressure ulcers stage 3
full thickness skin loss; 3 layers affected (epi, dermis, sub-q tissue)
pressure ulcers stage 4
goes down into muscle and bone; 4 layers
pressure ulcers unstageable
eschar (black/brown dead tissue) and slough (yellow and stringy) make it impossible to see;
perform debridement
pressure ulcers deep tissue
purple and dead; over bony prominences; thirty degree lateral inclined position releases
pressure
scale used to measure risk of ulcers
braden scale; 1=high risk, 4=low to none
2023-2025
what can cause high blood pressure readings?
Anxiety, wrong cuff size, talking, legs crossed, arm not being level with heart, pain, dehydration,
fever/infection, hyponatremia, weight, alcohol/smoking, opioids, hypovolemia,
hyper/hypokalemia, hyper/hypocalcemia
no radial pulse at 90
PUMP TO 120
how much to pump cuff
at least 30 mm Hg above the point the radial pulse disappears
potassium levels involved
heart: helps the heart squeeze
high potassium levels
high apical pulse rate and rhythm
nursing charts by exception- lungs
LUNG SOUNDS DIMINISHED IN LEFT LUNG not normal
nasal cannula care: if patient has reddened areas around cheekbones
PLACE PADDING AROUND THE CANNULA TUBING
nasal cannula care: if patient's O2 readings improve with movement
place the nasal cannula in the nose securely
nasal cannula care: O2 levels low
VERIFY PLACEMENT OF PULSE OXIMETER
Oxygen chamber
store in a cool area
Fall Prevention "H"
Hourly rounds: check on patient HOURLY
Fall prevention "O"
,Organize belongings: use bed alarms
Fall Prevention "P"
Position changes slow: ensure slow position changes and keep everything needed within reach
Fall Prevention "E"
Ensure lighting is sufficient: For elderly patients keep a well lit room
patient has sleep apnea and given sedative
MAKE SURE AIRWAY PRESSURE DEVICE IS ON
restraint types
chemical & physical
restraint knot
slip knots
restraint tying area
BED FRAME ONLY
chemical restraints
meds such as benzos
first thing to assess after restraint
CAPILLARY REFILL
when to check capillary refill when restrained
immediately and every 15 mins
other checks when restrained
skin integrity, vital signs, ROM every 2 hours; offer bathroom every 2 hours
restraint documentation
reasoning, mental status, care offered, time in restraints
restraint order time
ONLY last 24 hours
urine specific gravity test use
, identify dehydration, kidney problems, conditions like diabetes insipidus
urine specific gravity test & range
concentration of particles in urine; 1.005- 1.030
high urine specific gravity test
HIGH = YOU'RE DRY/ DEHYDRATED = VOMITING/DIARRHEA
low urine specific gravity test
"overflow" kidney damage, kidney failure
pressure ulcers
"1 red, 2 broken, 3 deep, 4 bone"
red intact skin, break with blister, deep tissue, bone visible
pressure ulcers stage 1
red intact skin
pressure ulcers stage 2
skin breaks & blisters; 2 layers affected (epidermis, dermis)
pressure ulcers stage 3
full thickness skin loss; 3 layers affected (epi, dermis, sub-q tissue)
pressure ulcers stage 4
goes down into muscle and bone; 4 layers
pressure ulcers unstageable
eschar (black/brown dead tissue) and slough (yellow and stringy) make it impossible to see;
perform debridement
pressure ulcers deep tissue
purple and dead; over bony prominences; thirty degree lateral inclined position releases
pressure
scale used to measure risk of ulcers
braden scale; 1=high risk, 4=low to none
