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N320 Quiz 1 exam with complete solutions.
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N320 Quiz 1 exam with complete solutions.
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N320 Quiz 1 exam with complete solutionsNursing care prioritization - ANSWER- nurse-identified priorities are based on the
overall picture, the patient as a whole person, and availability of time and
resources
Maslow's Hierarchy of Needs - ANSWER- 1) air, water, food (bottom of pyramid)
2) safety and security needs (eg. risk for falls or skin breakdown, risk for suicide)
3) love and belonging, friendship, love, social relationships (ie. need to spend
time with lonely patients)
4) self-confidence, achievement, self-worth (ie. take time to help patient develop
self-care skills)
5) self-actualization
ABC's - ANSWER- Airway, Breathing, Circulation (in this order of importance)
Indication of Airway issues - ANSWER- 1) choking
2) cyanotic
3) pulse ox indicates if patient is getting adequate oxygen
4) retraction of respiratory muscles
5) tachypnea, stridor, wheezing
Indication of Breathing issues - ANSWER- 1) retractions
2) tachypnea
3) adventitious breath sounds (eg. rales, rhonchi, wheezing)
4) low pulse ox
Indication of Circulation issues - ANSWER- 1) cyanosis/pallor
2) capillary refill
3) edema
4) vital signs (BP and pulse)
5) disorientation/confusion,
6) assess for stroke (hand grasp, smile, sudden change in vision)
7) heart attack (diaphoresis, chest pain radiating to left arm, clammy skin, sense
of doom)
, Emergent - ANSWER- 1) clients with needs that have the highest priority
2) life-threatening cases, if you don't treat them very soon their life could be in
danger
3) basic survival needs
Urgent - ANSWER- 1) patient definitely needs medical care but these patients can
sit in the waiting room for a few hours
2) problems that do not impede medical treatment but require early resolution
and have potential to impair functioning of normal growth and development
3) eg. fractures, concussion, appendicitis, suturing
4) NB. change in mental status would bump patient up to EMERGENT status
Non-urgent - ANSWER- 1) client's problem does not need immediate attention
2) eg. upper respiratory infections, flu, headaches, pink eye
Acute - ANSWER- an illness with an abrupt onset and usually a short course
Chronic - ANSWER- 1) an illness that persists for a long period of time
(continuing disease process)
2) someone with a chronic illness can develop an acute problem (eg. patient with
asthma who comes in with an acute episode)
Delegation - ANSWER- the distribution of work that each staff member is
responsible for during a given work period
Assigning tasks - ANSWER- 1) assign staff members who have the appropriate
level of expertise that is necessary to deliver the patient care and perform the
activities
2) the RN may NOT assign an individual to perform a task that is outside the
individual's job description or scope of practice
5 Rights of Delegation - ANSWER- 1) Right Task = one that can be delegated for a
specific patient
2) Right Circumstance = appropriate patient setting, available resources,
considering patient safety
3) Right person = right person is delegating the right task to the right person to
be performed on the right patient
4) Right direction/communication = clear, concise description of task
5) Right supervision/evaluation = appropriate monitoring, evaluation, and
feedback
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