NSG100 Final Exam

What skills are required to develop critical thinking?

Reasoning, Intellect, Creativity, Inquiry, Reflection, Intuition

Describe the features of clinical judgment

Clinical judgment combines: critical thinking abilities, evaluative decision making, and nursing experience

Understand the different parts that create a nursing diagnosis

Diagnostic label, etiology, defining characteristics

What is the priority nursing intervention for a post-op patient?

Pain control, protein intake for healing process, watching for complications.

Understand how to prioritize nursing care.

- ABC (Airway, Breathing, Circulation)
- Maslows hierarchy

What is the most important infection control measure in preventing
infection?

Hand washing

What diagnostic tests would be ordered for a wound infection?

Bacterial wound culture

Define healthcare-associated infection

Infections people get receiving health care for other condition. Most common, CAUTI (catheter associated UTI)

Review treatment/interventions for cellulitis

- Cellulitis treatment usually includes a prescription oral antibiotic (clindamycin or penicillin)
- Elevate area, warm compress, monitor complications, clean the area, wound care.

Identify S/S of UTI in adult/ child, older adult

Adult: Pain, burning, frequent urination, feeling the need to urinate , bloody or cloudy, pressure in abdomen/groin.

Child: Fever, abdominal/groin pain or fullness, foul-smelling urine, weight loss, vomiting and diarrhea, exhaustion, jaundice.

Older adults: Frequent falls, confusion, dizziness, agitation or aggression, fatigue and lethargy, decreased appetite.

Review nursing interventions for wound infection treatment

Apply appropriate wound dressings, keep area clean.

Identify fall risks

- unstable or abnormal gait
- a history of falling
- frequent toileting needs
- altered mental status
- certain medications.
- Scatter rugs, socks, no grab bars in bathroom

What are standard precautions?

Minimum infection prevention practices that apply to all patient care. Example: wearing gloves, washing hands, etc.

What is stress incontience and what are treatments for this?

- Stress incontinence is the most common type of urinary incontinence.
- It causes you to leak urine during physical exertion.
-It can happen during exercise, coughing, laughing, and sneezing.
- Pelvic floor exercises (Kegel) can strengthen muscles and reduce symptoms.

What is a cystoscopy?

- A procedure to look inside the bladder using a thin camera called a cystoscope.
- It is inserted into the urethra and passed into the bladder for inspection.

What are risk factors for Benign Prostatic Hyperplasia (BPH)?

- Age 40 years and older,
- Family history
- medical conditions such as obesity, heart and circulatory disease, type 2 diabetes, and urinary retention.

What is functional incontinence?

When a patient is not able to get to a toilet before having to expel urine or feces.

What are tasks a nurse can delegate to a UAP

Routine tasks such as:
- making unoccupied beds
- supervising patient ambulation
- assisting with hygiene
- vital signs
- feeding meals

What is furosemide used for?

diuretic that can treat fluid retention, swelling, etc.

What is loperamide used for?

Diarrhea medication, can also decrease the amount of drainage in patients with ostomies

What is spironolactone used for?

Spironolactone is a diuretic that can treat high blood pressure, it can also treat fluid retention, and high levels of the hormone aldosterone.

What is oxybutynin used for?

Bladder relaxant, it can treat overactive bladder

What type of diet helps with constipation?

- (outdated method) BRAT diet (bananas, rice, applesauce, and toast)
- high fiber diet.

What are nursing interventions for fecal incontinence?

- Diet changes
- bowel retraining
- pelvic floor exercises
- add fiber to the diet
- surgery

What are the anticipated assessment findings for a patient with impacted stool?

- Abdominal pain that comes and goes.
- Loss of appetite. Constipation. Vomiting.
- Inability to have a bowel movement or pass gas.
- Swelling of the abdomen.

What are the assessment findings for a patient with imbalanced nutrition?

- Fatigue
- brittle and dry hair
- ridged or spoon-shaped nails
- difficulty swallowing
- diarrhea
- lack of appetite.

What is xerostomia?

Dry mouth

What factors would affect an older client with imbalanced nutrition?

Older adults are more likely to have chronic conditions that put them at risk for malnutrition.

What foods can Muslim people eat?

Ovo-vegetarian

What foods promote satiety?

What type of diet is recommended for a patient with celiacs disease

Gluten Free

What is enteral nutrition used for?

It is Tube feeding, when one is not able to properly take food orally

What are modifiable risk factors for nutrition?

Cessation of smoking and alcohol, increase exercise and diet

What would the nurse include in a patient’s diet to promote wound healing?

Protein-rich foods:
- lean meats
- seafood,
Also:
- skinless poultry
- eggs
- tofu
- Vitamin C as well for because of its role in collagen formation.

What patient would you use the FACES pain rating scale for?

Persons 3-18, usually children but not limited to.

How is Ibuprofen effective for pain relief?

It reduces the ability of your body to make prostaglandins by blocking COX1 + COX22

Identify the following types of pain: chronic, breakthrough, visceral, central.

Chronic pain: long standing pain that has not been healed
Breakthrough pain: Sudden increase of pain
Visceral pain: A dull ache that stems from the internal organs.
Central pain: Neurological related pain

What is the WHO 3-step approach?

World health organization, 1. non-opioid analgesic, 2. mild opioid + non-opioid analgesic 3. strong opioid + non-opioid analgesic

What is sleep-rest disorders?

- Sleep disorders are problems with sleeping.
- These include trouble falling or staying asleep, falling asleep at the wrong times.
- Insomnia being unable to fall asleep and stay asleep. This is the most common sleep disorder.

What is contact dermatitis?

When a substance might irritate the skin or trigger an allergic reaction.

Identify patients at risk for pressure ulcers

- older age
-decreased mobility (bedrest) paralysis
-obesity
-lack of protein intake.

Identify stages of pressure ulcers

1 - Intact skin with blanch-able redness of a localized area usually over a bony prominence.
2 - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ ruptured serum-filled blister.
3 - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.
4 - Full thickness tissue loss with exposed bone, tendon or muscle.
Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.