NR-226: CJE FUNDAMENTALS LATEST REVIEW 1
QUESTIONS WITH 100% CORRECT ANSWERS
ADPIE - ANSWER>>>assessment, diagnosis, plan, implementation, evaluation
SMART goals - ANSWER>>>specific, measurable, achievable, relevant, time bound
2017 National Patient Safety Goals - ANSWER>>>improve accuracy of patient identification, improve staff
communication, use medications safely, prevent infection, identify patient safety risks, prevent surgery
mistakes
Prioritizing Client Care - ANSWER>>>airway, breathing, circulation
Actual vs At Risk diagnosis - ANSWER>>>actual has current diagnosis, at risk doesn't
Chain of infection - ANSWER>>>pathogen, reservoir, portal of exit, transmission, portal of entry, host
High risk for infection - ANSWER>>>sick, immunocompromised, young and elderly
Adult Vital Sign Ranges: T, P, R, BP, SpO2 - ANSWER>>>96.8-100.4, 60-100, 12-20, 120/80, 95%
Surface temp - ANSWER>>>oral, axillary
Location for apical HR - ANSWER>>>5th intercoastal mid clavicular line
Stage 1 pressure ulcer - ANSWER>>>skin in tact, Nonblanchable erythema
stage 2 pressure ulcer - ANSWER>>>partial thickness skin loss, wound bed pink
stage 3 pressure ulcer - ANSWER>>>full thickness, tunneling, undermining
stage 4 pressure ulcer - ANSWER>>>full thickness, exposed bone, ligament
unstageable pressure ulcer - ANSWER>>>would bed covered in slough or eschar
Deep tissue injury - ANSWER>>>discolored intact skin, mushy
serous drainage - ANSWER>>>thing, clear, watery
serosanguineous drainage - ANSWER>>>thin, watery, pale red
sanguineous drainage - ANSWER>>>thin bright red
Primary intention healing - ANSWER>>>wound stapled or sutured
secondary intention healing - ANSWER>>>heals from ground up
hematoma - ANSWER>>>localized collection of blood under skin
Dehiscence - ANSWER>>>separation of wound
, evisceration - ANSWER>>>protrusion of visceral organs
fistula - ANSWER>>>opening between two or more organs
Braden scale - ANSWER>>>6-23 worse-best
Diet for wound healing - ANSWER>>>protein, vitamin c, zinc (meat, eggs, legumes, orange juice)
4 stages of full thickness wound healing - ANSWER>>>hemostasis, inflamation, proliferation, maturation
6 reasons to insert catheter - ANSWER>>>urinary retention, icu patient on strict intake and output,
periop, pressure ulcer, end of life care, patient immobilized due to trauma
Normal voiding output per 24 hrs - ANSWER>>>1,000-2,000 ml
Hyperventilation - ANSWER>>>increased ventilation, decreased C02 levels
Hypoventilation - ANSWER>>>decreased ventilation, increased C02
Hypoxia - ANSWER>>>inadequate tissue oxygenation at cellular level
cyanosis - ANSWER>>>blue discoloration of skin and mucous membrane
Humidification necessary for clients receiving ___ L/min - ANSWER>>>greater than 4
Nasal cannula - ANSWER>>>most common, at risk for skin break down on cheeks, nose and ears
Face tent - ANSWER>>>used when masks aren't tolerated, 4-8L/m
Simple face mask - ANSWER>>>most common midrange device
Venturi mask - ANSWER>>>Most accurate and consistent O2, must fit properly
Partial non-rebreather mask - ANSWER>>>allow patient to rebreath 1st 3rd of exhaled air, must keep bag
inflated
non rebreather mask - ANSWER>>>delivers highest oxygen concentration, one way valve only allows for
02 to be inhaled
Position allowing for maximal chest expansion - ANSWER>>>fowler's position
Orthopnea - ANSWER>>>shortness of breath when patient lays flat
Constipation - ANSWER>>>no stool for 3 days
Enema - ANSWER>>>helps stretch colon walls and soften stool
Diarrhea - ANSWER>>>unformed feces, caused by virus or bacteria, treated with antibiotics
Impaction - ANSWER>>>result of unrelieved constipation
Bowel diversions - ANSWER>>>Ileostomy, colostomy
Post-op stoma care - ANSWER>>>1st output within 2 days, keep skin dry and clean, educate
