Quiz 2 Nursing Ace Mastery Guide Flashcards

Comprehensive practice flashcards covering Nursing Process, Nutrition, Documentation, Oral Reporting, and Vital Signs.

What are the five cyclical steps of the Nursing Process represented by the acronym ADPIE?

Assessment, Diagnosis, Planning, Implementation, and Evaluation.

In the Nursing Process Assessment step, what is the key difference between subjective and objective data?

Subjective data is what the patient says, whereas objective data is what the nurse observes or measures.

How is an actual nursing diagnosis structured using the PES format?

Problem related to Etiology as evidenced by Signs and symptoms.

How does a risk nursing diagnosis differ from an actual nursing diagnosis in the PES format?

A risk diagnosis omits signs and symptoms because it is a potential problem, using only Problem related to Etiology.

What components are required for a SMART outcome in nursing care planning?

Specific, Measurable, Achievable, Relevant/realistic, and Time-bound, centered on the patient.

According to high-yield nursing priority rules, which needs take priority over higher-level psychosocial needs?

Airway, breathing, circulation (ABCs), fluid, and nutrition (physiological needs based on Maslow's hierarchy).

How many calories per gram are provided by carbohydrates, proteins, and fats?

Carbohydrates provide $4\,\text{cal/g}$, proteins provide $4\,\text{cal/g}$, and fats provide $9\,\text{cal/g}$.

What percentage of total daily calories is recommended for complex carbohydrates and adult protein intake?

Complex carbohydrates should comprise $45\text{ to }65\%$ of calories, and adult protein intake should be $10\text{ to }35\%$ of calories.

What is the clinical difference between prealbumin and albumin laboratory levels in assessing protein status?

Prealbumin reflects short-term protein malnutrition, whereas albumin reflects long-term protein status and malnutrition.

What are the adult Body Mass Index (BMI) ranges for underweight, healthy weight, overweight, and obesity?

Underweight is $<18.5$, healthy weight is $18.5\text{ to }24.9$, overweight is $25\text{ to }29.9$, and obesity is $30\text{ or more}$.

At what waist circumference measurements does disease risk increase for women and men?

More than $35\,\text{inches}$ for women or more than $40\,\text{inches}$ for men.

What dietary items are permitted on a clear liquid diet versus a full liquid diet?

Clear liquid includes clear fluids like apple juice, gelatin, coffee, and popsicles; full liquid includes clear liquids plus milk, pudding, custard, vegetable juice, cereal gruels, and pasteurized eggs.

What does NPO stand for, and when is it indicated?

NPO stands for nothing by mouth; it is used pre-operatively or to prevent aspiration when a patient has nausea and vomiting.

What signs during a meal indicate that a patient with dysphagia may be experiencing aspiration?

Throat clearing, coughing, or hoarseness while eating.

What head-of-bed position and duration are required to prevent aspiration during and after enteral feedings?

Keep the head of bed elevated $30\text{ to }45^\circ$ during feeding and for $1\,\text{hour}$ after.

How is initial enteral tube placement confirmed, and what ongoing checks are performed before each feed?

Initial placement is confirmed by x-ray; ongoing checks include tube length measurement, pH testing, comparing exposed tube length, and checking gastric residual volume.

How much water volume must be flushed through an enteral tube after feeds, during feeds, and after residual checks?

At least $30\,\text{mL}$ of water (using sterile water for immunocompromised or critically ill patients).

What are the intake volume conversions for $1\,\text{ounce}$ and $1\,\text{cup}$ in milliliters?

$1\,\text{oz} = 30\,\text{mL}$ and $1\,\text{cup} = 8\,\text{oz} = 240\,\text{mL}$.

What is the key nursing documentation rule regarding unrecorded patient care?

"If it was not charted, it was not done."

Which charting format incorporates the plan of care directly into progress notes rather than as a separate care plan?

PIE charting (Problem, Intervention, Evaluation).

What safety sequence must be followed when receiving a verbal order in an urgent situation?

Write the order as VO, read it back to verify accuracy, record the date, time, prescriber name, nurse name, and initials, and ensure the prescriber signs and dates it later.

What does the SBAR acronym stand for in oral handoff reporting?

Situation, Background, Assessment, Recommendation.

In which SBAR section does the nurse report current vital signs, mental status, and focused physical findings?

Assessment.

When should a nurse assess a patient's vital signs?

Upon admission, per facility policy, with any change in condition or loss of consciousness, before/after surgery or invasive testing, before/after risky activity, and before medications affecting cardiovascular or respiratory function.

What are the normal adult reference ranges for oral temperature, pulse, respirations, and blood pressure?

Oral temperature $96.4\text{ to }99.5^\circ\text{F}$ ($35.8\text{ to }37.5^\circ\text{C}$), pulse $60\text{ to }100/\text{min}$, respirations $12\text{ to }20/\text{min}$, and blood pressure below $120/80\,\text{mmHg}$.

What are the definitions of eupnea, tachypnea, bradypnea, apnea, dyspnea, and orthopnea?

Eupnea is normal unlabored breathing; tachypnea is increased rate; bradypnea is decreased rate; apnea is absent breathing; dyspnea is difficult/labored breathing; orthopnea is breathing difficulty affected by position.

What is the body's most powerful respiratory stimulant?

Increased level of carbon dioxide ($\text{CO}_2$).

How is pulse pressure calculated?

Pulse pressure equals systolic pressure minus diastolic pressure ($\text{Systolic} - \text{Diastolic}$).

What are the steps and sound recognitions for measuring manual blood pressure?

Estimate systolic by palpation, wait $1\text{ to }2\,\text{minutes}$, inflate $30\,\text{mmHg}$ above estimated point, deflate at $2\text{ to }3\,\text{mmHg/sec}$; first clear Korotkoff sound is systolic, and disappearance of sound is diastolic.

What characterizes orthostatic hypotension?

An inadequate blood pressure response to position change, particularly upon rising to an erect position.

What is an essential nutrient according to the course material?

A nutrient that the body cannot synthesize or makes in insufficient quantities, requiring intake through diet or supplements.

What is the difference between independent, dependent, and collaborative nursing interventions?

Independent interventions are nurse-initiated within scope (e.g., teaching, positioning); dependent require a provider order (e.g., medications, IV therapy); collaborative require coordination with other disciplines.