NR 224 Week 8 Final Exam StudyGuide

NR224 Final Exam Nursing Process 200609958915▣Assessment- Gathering data How do we know if we have enough data? ▣Diagnosis Clustering data/finding patterns Diagnostic label (NANDA) related to etiology as evidenced by assessment data ▣Planning Prioritize, set up goals and outcomes, and plan what needs to occur ▣Implementation Putting the interventions into action. Doing. ▣Evaluation discontinued? goals me Were be t? How do you know? Does the client agree? Do items need to be modified? Can the plan of care or parts of the plan of care Mo dified? 569667277048 Question 1067112234190▣By the end of the 2nd postop day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? 43343283022673455928095Reassess the client to determine the reasons for inadequate pain relief Wait to see whether the pain lessens in the next 24 hours Change the plan of care to provide different pain relief interventions Teach the client about the plan of care for managing pain Infection Control ▣Stages of Infection ▣Types of isolation and the diseases ▣Standard precautions PPE on PPE off ▣Medical vs. surgical asepsis ▣Healthcare acquired infections Question 2709284189979▣A nurse is reviewing hand hygiene techniques with a group of assistive personnel. Which of the following instructions should the nurse include in this discussion? (Select All That Apply) 1074984123898Apply 3 to 5 mL of liquid soap to dry hands Wash the hands with soap and water for at least 20 seconds Rinse the hands with hot water Use a clean paper towel to turn off hand faucets Allow the hands to air dry after washing Vital Signs ▣Vital sign ranges What are the terms when they are not in range? What are the rationales, clinical judgements, and interventions if not in range? ▣Assessments to complete with each vital sign ▣How to perform the skill Question ▣A nurse is explaining to a group of nursing students the various factors that can affect a client’s heart rate. List 5 factors that can cause tachycardia and 5 factors that can cause bradycardia. Skin Integrity and Wound Care ▣Risk Factors for Pressure Ulcer Development ▣Friction and shear ▣Skin assessment and assessment tools ?? ▣Healing process primary and secondary intention ▣Stages of pressure injuries ▣Assessing a wound Tissue types Drainage types Measurements ▣Wound skill Question ▣A nurse educator is reviewing the wound healing process with a group of nurses. Which of the following should be included in the information regarding what wounds heal by secondary intention? (Select all that apply) 106416110917Stage III pressure ulcer Sutured surgical incision Casted bone fracture Laceration sealed with adhesive 10776443207Open burn area Immobility ▣Complications of Immobility What systems? How are they impacted? Question ▣A nurse is caring for a client who has been sitting in a chair for 2 hours. Which of the following complications is the greatest risk to the client? A.Muscle atrophy.B. Fecal impactionC. Pressure injury. D. Pneumonia 274878994702305095043524Mobility & Body Mechanics ▣Principles of body mechanics ▣Positioning ▣Cane Walking ▣Crutch walking Question ▣A nurse