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NUR 233 Final Exam Questions and
Answers 100% Solved | Latest Update
rights of delegation - ✔✔person, task, circumstance, communication,
evaluation
components of cultural assessment - ✔✔communication, space, time,
orientation, social, organization, environmental control, biological variations
nursing process steps - ✔✔A(ssessment)
D(iagnosis)
P(lanning)
I(nterventions)
E(valuation)
components of nursing diagnosis - ✔✔P(roblem) --> dx
E(tiology) --> r/t
S(ymptoms) --> AEB
components of risk diagnosis - ✔✔nursing dx... r/t
components of condition dx - ✔✔nursing dx... r/t... AEB
S(ituation)
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B(ackground)
A(ssessment)
R(ecommendation) - ✔✔used to provide a framework for communication
between members of the healthcare team in regards to pt care + their
current condition
rights of medication administration - ✔✔drug, dose, pt, route, time,
documentation
stage 1 pressure ulcer - ✔✔localized area of intact skin w/ nonblanchable
redness; area can be painful, soft, firm, or warm
stage 2 pressure ulcer - ✔✔partial thickness loss of dermis; open, shallow
w/ reddish-pink wound bed; no slough; skin not intact
stage 3 pressure ulcer - ✔✔deep crater characterized by full thickness skin
loss w/ damage or necrosis of subQ; adipose visible; may extend to but not
through fascia; undermining may be present; skin not intact
stage 4 pressure ulcer - ✔✔full thickness skin loss w/ tissue
necrosis/damage to muscle, bone, or support structure; exposed
bone/tendon is visible/palpable; possible presence of slough + eschar;
ebole, undermining, + tunneling may be present
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unstageable pressure ulcer - ✔✔full thickness skin loss; base of wound is
obscured by slough or eschar
purpose of Braden Scale - ✔✔assesses the pt's risk for impaired skin
integrity + skin breakdown; total score < 18 = risk
components of Braden Scale - ✔✔sensory perception, moisture, activity,
mobility, nutrition, friction/shear
COPD s+s - ✔✔accessory muscle use, dyspnea, SOB, tripod position,
barrel chest, cough, inc sputum, pursed lip breathing, skin color changes,
anxiety, O2 <90, crackles, wheezes, clubbing of fingers
pneumonia s+s - ✔✔fever, tachycardia, dyspnea, chills,
productive/nonproductive cough, pleuritic chest pain, fatigue,
purulent/blood-streaked sputum, hypotension, dysrhythmias, dec O2 sat,
body aches, SOB upon exertion
hyponatremia s+s - ✔✔lethargy, headache, confusion, gate disorders, N/V,
seizure, coma, weakness, fatigue, muscle cramps, orthostatic hypotension
care for pts w/ hyponatremia - ✔✔replacement of sodium, fluid restrictions,
diuretics, monitor sodium + fluid levels, daily weight, monitor I+O, monitor
neuro changes, seizure precautions
