NURS 211 Comprehensive Final Exam
235 A+ PASS!!!
NURS 211 Comprehensive Final Exam
235 A+ PASS!!!
ADPIE - Nursing Process - ANSWER-Assessment
Diagnosis
Planning
Implementation
Evaluation
purpose of a care plan - ANSWER-Care plans provide direction for individualized care
of the client
components of a care plan - ANSWER--nursing diagnosis (problem)
-related to... (cause of problem)
-manifestations (s/s or data supporting problem)
-outcome goal (broad)
-outcome criteria (SMART goals)
-nursing interventions (actions taken to accomplish goal)
-rationale and resource (evidence-based practice)
-evaluation (degree to which outcome goals were met)
-revision (edits based on desired outcomes and results)
what can UAP's (unlicensed personal) NOT do? - ANSWER-Assess
Teach (educate)
Evaluate
fowler's - ANSWER-semi-sitting position (head of bed is raised 45 degrees)
-used when patient is having difficulty breathing
semi-fowler's - ANSWER-head of the bed is raised 30 degrees
-takes pressure off of coccyx
trendelenburg - ANSWER-bed is flat but patient's feet and legs are higher than the head
-reduces leg swelling, inserting IV catheters
reverse trendelenburg - ANSWER-bed is flat but inclined so that the head is higher than
feet
-laparoscopic surgeries, lower central venous pressure without lowering blood pressure
kji
when shaving a client shave in the direction of... - ANSWER-hair growth
,NURS 211 Comprehensive Final Exam
235 A+ PASS!!!
complete bath - ANSWER-wash the patients entire body without assistance from the
patient
partial bath - ANSWER-bath that requires face, underarms, hands, and perineal area
sink bath - ANSWER-patients who are ambulatory may prefer to wash while standing or
sitting in front of a bath or sink
shower bath - ANSWER-- usually done for patients who only require minimal or no
assistance
- use of shower chair or stretcher
- may need lots of help washing the back, feet, or hair.
hair care - ANSWER-ask about preferences
-offer braiding for long hair
-check for lice
teeth care - ANSWER--brush away from gums
-brush 2x daily
-see dentist every 6 mos
denture care - ANSWER--inspect for damage
-remove starting from the top
-line sink with wash cloth
-use luke-warm water
-store in denture cup with solution
oral care for an unconscious patient - ANSWER-be careful to minimize any chance of
aspiration
-position patient on side with bed flat
-prepare suction device
-use airway
-CHD on intubated pt every two hours
oral care for cancer patient - ANSWER--rinse with saline
-can develop stomatitis & thrush
physical restraints require... - ANSWER-HCP order
physical restraints are... - ANSWER-LAST resort
when all four side rails are up, this is considered - ANSWER-physical restraint
, NURS 211 Comprehensive Final Exam
235 A+ PASS!!!
When applying restraints remember to... - ANSWER-Avoid bruising skin, cutting off
circulation, accidental entangling
after applying restraints, nurse should check that... - ANSWER-two fingers can
comfortable slip between restraint & patient to avoid cutting off circulation
safety with a confused patient - ANSWER-1. keep call light within reach and keep
reminding patient to call the nurse for assistance
2. keep frequently used items within close proximity
3. place patient in room close to nurse's station for better observation
4. place patient on a pressure-sensitive alarm to alert staff to patient's attempt to get out
of bed
5. toilet patient every two hours to prevent attempts by patient to get out of bed to use
the bathroom unassisted.
RACE - ANSWER-rescue: all patients in immediate danger, and move them to safe
areas
alarm: activate the fire alarm and have someone call 911
contain: the fire by closing doors, confining the fire, and preventing the spread of smoke
extinguish: the fire if possible after all patients are removed from the area
preventing complications of immobility - ANSWER-- graduated compression stockings
- pneumatic compression devices
- turning the patient in bed
- moving a patient up in bed
- safely transferring patients
- logrolling a patient
- assisting with ROM exercises
- helping patients ambulate
positioning a patient in bed - ANSWER-Supine Position
Side-Lying or Lateral Position
Prone Position
Sim's (Semi-Prone) Position
Log-rolling
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