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NURS210C (Unit 2)
| Question | Answer |
|---|---|
| What are the five steps of the nursing process? | 1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation |
| In the nursing process, what does assessment include? | 1. The collection of subjective data, including client feelings and family observations 2. The collection of objective data, including vital signs and physical observations |
| Who can describe a client's symptoms, including perceptions, feelings, and descriptions of health status? | Only the client |
| A client telling a nurse. "My shoulder is sore," is an example of what kind of data source? | Primary subjective data source |
| A nurse writes, "Client grimaces when attempting to brush her hair with her left arm," is an example of what kind of data source? | Primary objective data source |
| A client's sister tells the nurse that the client is experiencing shoulder pain. This is an example of what kind of data source? | Secondary subjective data source |
| A nurse collects data from a client's medical records as well as other healthcare personnel working with the client. This is an example of what kind of data source? | Secondary objective data source |
| In the nursing process, what does diagnosis include? | Reviewing collected data, finding patterns, and comparing those patterns with standard reference ranges |
| In the nursing process, what does planning include? | Prioritizing patient care needs and setting a plan to promote, maintain, or restore patient health |
| What is ongoing planning? | Planning that happens throughout patient care and includes modifications and individualization |
| What is discharge planning? | Planning that anticipates client's needs after being discharged from the hospital |
| When planning client care, what should a nurse always do? | Discuss the plan with the client, making sure they understand their diagnosis, options for treatment, possible outcomes, and their right to autonomy |
| Repositioning a client every two hours is an example of what kind of intervention? | Nurse-initiated / independent intervention |
| A nurse taking blood administration procedures as a result of a provider's prescription is an example of what kind of intervention? | Provider-initiated / dependent intervention |
| In the nursing process, what is implementation? | Putting the client care plan into practice by performing nursing actions, delegating tasks, supervising other health care staff, and documenting client responses |
| In the nursing process, what is evaluation? | Evaluating client's responses to nursing interventions and deciding whether to stick with the plan, create a new plan, or modify the plan |
| Which of these factors can lead to a lack of client goal achievement? Incomplete database, specific client outcomes, delegation of tasks to assistive personnel, unrealistic client outcomes, nonspecific nursing interventions, and inadequate time | Incomplete database, unrealistic client outcomes, nonspecific nursing interventions, and inadequate time for the client to achieve the outcomes |
| By the second post-op day, a client has not received adequate pain relief. How should the nurse react? | She should reassess the client to determine the reasons for inadequate pain relief |
| A client tells his nurse that he is in pain. Before administering pain medication, what should the nurse do? | 1. Ask the client to label his pain on a 0-10 scale 2. Check his medical records to see if more pain medication can be administered |
| A client tells his nurse that he is experiencing pain. The nurse then checks his medical record, administers pain medication, and checks back with the patient half an hour later. What step of the nursing process did she miss? | Assessment, because she did not ask the patient to label his pain on a 0-10 scale |
| A nurse says, "I will determine the most important client problems that we should address." Which step of the nursing process is this? | Planning |
| A nurse says, "I will review past medical history on the client's record to get more information." Which step of the nursing process is this? | Assessment |
| A nurse says, "I will go carry our the new prescriptions from the provider." Which step of the nursing process is this? | Implementation |
| A nurse says, "I will ask the client if his nausea has resolved." Which step of the nursing process is this? | Evaluation |
| A post-op client is on a liquid-only diet and wants to eat solid food. The nurse gives a report to the client's surgeon and the surgeon prescribes a liquid-only diet still. Which level of critical thinking is this? | Basic critical thinking |
| A nurse realizes that her client is prescribed an antibiotic he's allergic to. The nurse calls his provider and requests a new prescription. Which type of critical thinking is this? | Responsibility / responsible critical thinking |
| Which level of critical thinking stems from a lack of critical experience and often includes a nurse who blindly trusts experts? | Basic critical thinking |
| Which level of critical thinking involves a more experiences nurse expressing autonomy by determining the best alternative through the study of data | Complex critical thinking |
| Which level of critical thinking involves a fully responsible and competent nurse showing an expert level of intuition, and a flexible attitude? | Commitment critical thinking |
| How does confidence fit into critical thinking? | A nurse should be confident in her training and know her abilities as well as limits |
| How does independence fit into critical thinking? | A nurse needs to analyze ideas and reason logically by herself |
| How does fairness fit into critical thinking? | A nurse needs to be objective and nonjudgemental, providing care to everyone to the very best of her abilities regardless of sexual orientation, ethnicity, etc. |
| How does responsibility fit into critical thinking? | A nurse should adhere to the standards of practice and always do what she can to right irresponsible actions |
| How does risk-taking fit into critical thinking? | A nurse should be able to think outside the box to provide the absolute best standard of care in difficult cases |
| How does discipline fit into critical thinking? | A nurse should develop a systematic approach to thinking |
| How does perseverance fit into critical thinking? | Even if all evidence-based practice seems to be failing, a nurse should not give up on finding a solution for her patient's needs |
| How does creativity fit into critical thinking? | A nurse should be able to find creative solutions for difficult client needs |
| How does curiosity fit into critical thinking? | A nurse should have a desire to find out all information about clients and their needs to give them the best possible help |
| How does integrity fit into critical thinking? | A nurse should practice truthfully and ethically |
| How does humility fit into critical thinking? | Just as a nurse knows her strengths, she also needs to know her weaknesses so that she can improve them |
| What is a normal oral temperature? | 96.8 degrees - 100.4 degrees |
| What is a normal rectal temperature? | 97.7 degrees to 101.3 degrees |
| What is a normal axillary and tympanic temperature? | 96.6 degrees to 98 degrees |
| How do you convert Fahrenheit to Celsius? | Subtract 32 and them multiply by 5/9 |
| How do you convert Celsius to Fahrenheit? | Multiply by 9/5 and add 32 |
| If a patient has just had something to eat or drink, how long should you wait to take an oral temperature? | 20 to 30 minutes |
| When are times to avoid taking oral temperatures? | 1. When the patient cannot keep their mouth closed around the thermometer probe 2. When the patient has mouth sores 3. When the patient has facial injuries |
| When can a rectal temperature be taken? | 1. For infants 2. Comatose patients 3. Patients who are critically ill or injured |
| What is the process for inserting a rectal thermometer? | 1. Cover the probe with a disposable plastic sheath 2. Lubricate the plastic sheath 3. Insert 1 to 1 1/2 inches in the direction of the umbilicus |
| What should you do if you feel resistance when inserting a rectal thermometer? | Remove it immediately to ensure the patient's rectal mucosa is not injured |
| Why is the axilla not often used for temperature measurement? | It is less accurate than the others |
| When should the axilla not be used to measure temperature? | When a patient has open sores or rashes |
| What is the process for using a tympanic thermometer? | 1. Cover the tip with a disposable sheath 2. Place the tip at the external opening of the ear canal 3. Wait 2-5 seconds after pressing the scan button |
| When should you not use the tympanic measurement for temperature? | When a patient has excessive earwax, drainage or pain in the ear, or sores in or around the ear |
| What should you always do when using an oral electronic thermometer probe? | Use a protective cover |
| What are the different pulse strengths? | Absent, weak, diminished, strong, bounding |
| What do you do if you cannot palpitate peripheral pulses during a physical examination? | Use a Doppler ultrasound stethoscope to confirm presence or absence of pulse |
| What is a normal adult pulse rate? | 60-100 beats per minute |
| What are some things that can affect pulse rate? | Gender, age, exercise routine, medications, blood loss, oxygen saturation, and body temperature |
| What is bradycardia? | A pulse rate that's slower than 60 beats per minute |
| What is tachycardia? | A pulse rate that's faster than 100 beats per minute |
| What is the easiest and most frequently checked pulse? | Radial |
| When should you count a radial pulse for 1 minute? | When the pulse is irregular |
| When should you count a radial pulse for 30 seconds? What other step do you need to take to get beats per minute? | When a pulse is regular. Multiply by 2 |
| In an apical pulse rate, what is S1? | The sound you hear when the tricuspid and mitral valves close as the end of ventricular filling |
| In an apical pulse rate, what is S2? | The sound you hear when the pulmonic and aortic valves close at the end of systolic contraction |
| What is a pulse deficit? | Occurs when the heart contracts inefficiently and does not transmit a pulse wave to a peripheral site; it is the difference between the peripheral and apical pulse rates in one minute |
| What should you do after finding a pulse deficit? | Assess the patient for signs of decreased cardiac output, such as dyspnea, fatigue, chest pain, and palpitations |
| If a patient has been active, how long should you wait before taking an apical pulse rate? | At least 5-10 minutes |
| What are the two phases of breathing? | Inspiration and expiration |
| What should you observe when assessing a patient's respiration? | The rate, depth, and rhythm of chest wall movement |
| What is a normal respiratory rate for a healthy adult? | 12-20 breaths per minute |
| What is tachypnea? | A breathing rate of over 20 breaths per minute |
| What is bradypnea? | A breathing rate of under 12 breaths per minute |
| When does respiration become shallow? | When a patient is in pain or has an injury to the chest or abdomen |
| When does respiration become deep? | After a patient exercises |
| What is blood pressure? | The force blood exerts against a vessel wall |
| What is systole? | The high point of blood pressure, which occurs when the ventricles of the heart contract and force blood into the aorta |
| What is diastole? | The low point of blood pressure, which occurs when the ventricles relax and minimal pressure is exerted against the vessel wall |
| What is a normal blood pressure for a healthy adult? | 90 to 119 mm Hg systolic and 60 to 79 mm Hg diastolic |
| For a healthy adult, how is blood pressure most often measured? | By using a sphygmomanometer and stethoscope or an electronic device |
| For a hemodynamically unstable patient, how is blood pressure most often measured? | By inserting a catheter into the brachial, radial, or femoral artery |
| How often should a sphygmomanometer be calibrated and why? | Every 6-12 months to ensure accurate blood readings |
| Which Korotkoff sound should you document for most adult patients? | The first, which is the patient's systolic blood pressure, and the fifth, which is the patient's diastolic blood pressure |
| What are the two types of pain? | Acute and chronic |
| What is acute pain? | Severe, sudden, and has a short duration |
| What is chronic pain? | Pain that continues past the point of healing |
| How do you measure a patient's oxygen saturation? | By using pulse oximetry |
| What is a normal oxygen saturation for a healthy adult? | 95-100% |
| Is pulse oximetry a part of a general examination? | No, it is normally just used for patients with unstable oxygen status or who are at risk for respiratory problems |
| When inserting an enema tube into the rectum of an adult how far should you insert it? | 3 to 4 inches |
| When inserting an enema tube into the rectum of an infant, how far should you insert it? | 1 to 1.5 inches |
| When inserting an enema tube, what direction should you always point it? | In the direction of the umbilicus |
| When inserting an enema tube into the rectum of a child, how far should you insert it? | 2 to 3 inches |
| What should you do if you feel resistance or a patient c/o pain while inserting an enema tube? | Stop, ask the patient to take a deep breath, and instill a small amount of fluid |
| What position should a patient be in for a nurse to insert an enema tube? | Left Sim's or Left Lateral positions |
| When performing a cleansing enema procedure, what solution reduces the risk of electrolyte imbalance and allows for a steady fluid volume? | 0.9% Sodium Chloride (Saline) |
| Other than saline, what solutions can be used for cleansing enemas? | Tap water and soapsuds solution |
| Which patients should never receive enemas made with a tap water solution and why? | Young infants and dehydrated patients, because tap water enemas cause water to move from the colon to the interstitial space |
| Which patients should only receive soapsud enema solutions if completely necessary, and why? | Pregnant women and older adults, because soapsud enemas can lead to electrolyte imbalance and damaged intestinal mucosa |
| A pre-op patient has an order for an enema to be administered until the patient is clear. After 3 enemas, the patient still passes fluid containing fecal matter. What should you do? | Do not administer another enema |
| What is a return-flow enema? | An enema administered to expel flatus (gas) |
| What should you do after instilling the solution of a return-flow enema? | Lower the container to allow the solution to flow back into the container, repeating the process until the patient expels flatus |
| What is an oil retention enema? | An enema administered to lubricate the rectum and colon |
| How does an oil retention enema work? | Oil is absorbed by feces, making them softer and easier to pass |
| How long should a patient retain an oil retention enema? | Long enough for it to work, which is about 1-3 hours in most cases |
| What is a medicated enema? | An enema given for the local effect they exert on the rectal mucosa, such as bacterial reduction or to treat patients with dangerously high serum potassium levels |
| A provider orders for his pre-op patient to receive a medicated enema before bowel surgery. Why? | Medicated enemas are often given to reduce bacteria in the colon |
| What are carminative enemas? | Enemas used to relieve flatus and abdominal distention |
| How do carminative enemas work? | They instill a small amount of fluid into the rectum to stimulate peristalsis (the involuntary constriction and relaxation of the intestinal muscles) |
| What are some ways to ensure patient comfort when inserting an enema tube? | Preheat the normal saline to lukewarm, lubricate the tip of the rectal tube, and point to tip of the enema tube towards the umbilicus during insertion |
| Why should a patient never bear down as you're inserting an enema tube? | A patient who's bearing down will often be unrelaxed and hold their breath, which could result in the solution being expelled immediately. |
| What signs show that an enema has had the desired effect? | A large amount of slightly discolored solution with no solid fecal matter |
| Is abdominal cramping normal when inputting an enema? How can discomfort be lessened? | Yes, but it can be lessened by warming the solution prior to insertion as well as lowering the enema to reduce the speed of flow |
| What quality of a nurse is central to the nursing process? | Critical thinking |
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