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RASMUSSEN FUNDAMENTALS EXAM #2 QUESTIONS AND ANSWERS
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RASMUSSEN FUNDAMENTALS EXAM #2 QUESTIONS AND ANSWERS
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RASMUSSEN FUNDAMENTALS EXAM #2QUESTIONS AND ANSWERS
What conditions would warrant a chest tube - Answer-Hemothorax
Pleural Effusion
Pneumothorax
If you are caring for a patient who had a left knee replacement, if the client is
experiences tingling in their left toe, what would you as the nurse, assess first? -
Answer-*CHECK PEDAL PULSE
Capillary Refill
Stages of infection - Answer-Incubation period - initial entry of the pathogen into the
host
Prodromal stage - experience general signs and symptoms of illness ; most infectious
Full stage of illness - signs and symptoms of disease are most obvious and severe (full
blown)
Convalescent period - the patient generally returns to normal functions
Why do we use care plans? - Answer-Patient centered care
Pt in control
for the most part the heatlchare team is in control which includes the nurse, tech, etc.
MD is not included
What is care based on? - Answer-Continuous evidence based practice
What instructual strategy do we use to put key concepts together? and why do we use
it? - Answer-Concept mapping
Gather subjective and objective data and putting it all together instead of using the care
plan
If we have a pt 5 days post abdominal surgery that refuses to take a bath, what is a
nursing diagnosis for this patient? - Answer-Bathing Self-care deficit
What is the purpose of a nursing diagnosis? - Answer-Help identify the actual problem,
and potential problems
When planning care, what nursing outcome would you want for impaired gas
exchange? - Answer-Oxygen above 94%
Pt does not need to rely on oxygen
Pt has a decreased level of consciousness, what would be the appropriate nursing
intervention? - Answer-Position him closer to the nurses station to reduce the risk of a
fall
, If you have been working with the same patient for four days, and the plan of care is
showing no signs of improvement, what nursing intervention needs to be done? -
Answer-Re-Evaluate the patient, figure out why the plan of care is not working and
readjust
If a patient develops a cough with mucus, what would you ask about their mucous? -
Answer-How much do you spit up?
What color is the mucous?
Consistency?
Time of day the spitting up happens?
A patient falls and becomes bedridden for 3 days. When you auscultate their chest you
notice they have decreased breath sounds, but are showing no other symptoms; what
do you think is happening? - Answer-atelectasis - collapse of lung tissue with loss of
volume
if they develop this they are a risk for pneumonia, dyspnea, respiratory failure
A patient develops a pressure ulcer involving skin layers of the epidermis and the
dermis, surrounding the ulcer is redness - Answer-Stage two Erythema (redness)
stage one pressure ulcer - Answer-nonblanchable erythema of intact skin
stage two pressure ulcer - Answer-partial thickness skin loss involving epidermis,
dermis, or both
stage three pressure ulcer - Answer-full thickness tissue loss with visible fat
stage four pressure ulcer - Answer-Full-thickness tissue loss with exposed bone,
tendon, or muscle
unstageable pressure ulcer - Answer-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.
intentions of wound healing - Answer-1. primary intention - occurs in wounds with
dermal edges that are close together (incision, surgical wound)
2. secondary intention occurs when the sides of the wound are not opposed, therefore
healing must occur from the bottom of the wound upwards.
Stages of healing - Answer-1. Hemostasis 2. Inflammation 3. Proliferation (fibrosis scar,
granulation tissue) 4. Remodeling (contractile fibroblasts, wound strength).
A patient is comatose and overweight; They also have a stage two pressure ulcer. What
nursing intervention can be done to prevent friction and shear - Answer-Use a lift to
reposition every two hours
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