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N3632 Foundations of Nursing Final Exam
__________ ensure that health care providers and agencies comply with state regulations. - Solution State licensing boards __________ sets quality standards for accreditation of health care facilities.
- Solution The Joint Commission QSEN - Solution Quality and Safety Education for Nurses - assists nursing programs in preparing nurses to provide safe, high-quality care. What are the six QSEN competencies? - Solution Safety Patient-Centered Care Evidence Based Practice Informatics Quality Improvement Teamwork and Collaboration __________ is the right to make one's own personal decisions, even when those decisions might not be in that person's own best interest. - Solution Autonomy __________ is the action that promotes good for others. - Solution Beneficence __________ is the fulfillment of promises. - Solution Fidelity __________ is fairness in care delivery and use of resources. - Solution Justice __________ is a commitment to do no harm. - Solution Nonmaleficence __________ is a commitment to tell the truth. - Solution Veracity What are the 2 types of unintentional torts? - Solution negligence and malpractice
An example of __________ is when a nurse fails to implement safety measures for a client at risk for falls. - Solution Negligence An example of __________ is when a nurse administers a large dose of medication due to a calculation error. The client has cardiac arrest and dies. - Solution Malpractice What are the 2 types of quasi-intentional torts? - Solution Breach of confidentiality and defamation of character An example of __________ is when a nurse releases a client's medical diagnosis to a member of the press. - Solution Breach of confidentiality An example of __________ is when a nurse tells a coworker that they believe the client has been unfaithful to their partner. - Solution Defamation of character What are the 3 types of intentional torts? - Solution assault, battery, false imprisonment __________ is when the conduct of one person makes another person fearful and apprehensive. - Solution Assault Ex: A nurse threatens to place an NG tube in a client who is refusing to eat. __________ is intentional and wrongful physical contact with a person that involves an injury or offensive contact. - Solution Battery Ex: A nurse restrains a client and administers an injection against their wishes. __________ is when a person is confined or restrained against their will. - Solution False imprisonment Ex: A nurse uses restraints on a competent client to prevent the leaving the health care facility. Negligence issues that prompt most malpractice suits include failure to: - Solution Follow professional and facility-established standards of care Use equipment in a reasonable and knowledgeable manner
__________ refers to the use of precise practices to reduce the number, growth, and spread of microorganisms. - Solution Medical asepsis Ex: administering oral medications (antibiotics, antivirals, antifungals), managing NG tubes, and providing personal hygiene __________ refers to the use of precise practices to eliminate all microorganism from an object or area and prevent contamination. - Solution Sterile technique Ex: parenteral medication administration, insertion of urinary catheters, surgical procedures, and sterile dressing changes True or False: Microbes can move by gravity from a non-sterile item to a sterile item. - Solution True True or False: Bottle caps from a sterile solution should be placed on the sterile field. - Solution False. Bottle caps from a sterile solution should be placed face up on a clean (non-sterile) surface. Sterile solutions expire __________ after opening and recapping in some facilities. - Solution 24 hours (other facilities' policies state that once a sterile solution container is opened, it can only be used once then thrown away). __________ is the interval between the pathogen entering the body and the presentation of the first finding. - Solution Incubation __________ is the interval from onset of general findings to more distinct findings; during this time, the pathogen multiplies. - Solution Prodromal stage __________ is the interval when findings specific to the infection occur. - Solution Illness stage __________ is the interval when acute findings disappear, total recovery taking days to months. - Solution Convalescence
__________ are infections that a client acquires while receiving care in a health care setting. - Solution Health-care associated infections (HAIs) An __________ is a type of HAI resulting from a diagnostic or therapeutic procedure. - Solution Iatrogenic infection True or False: HAIs are always preventable and always iatrogenic. - Solution False. What are some atypical findings that can indicate an infection in older adults? - Solution agitation, confusion, or incontinence What findings are expected in the first stage of the inflammatory response?
- Solution redness, warmth, edema, pain or tenderness, loss of use of the affected part What findings are expected in the second stage of the inflammatory response? - Solution Exudate (serous, sanguineous, and/or purulent) What findings are expected in the third stage of the inflammatory response? - Solution Damaged tissue is replaced with scar tissue; gradually, the new cells take on characteristics that are similar in structure and function to the old cells __________ applies to all bodily fluids (except sweat), non-intact skin, and mucous membranes; should be implemented for all clients. - Solution Standard precautions True or False: hand washing is the most effective in removing microorganisms. - Solution False: Using alcohol-based products is more effective in removing microorganisms. Soap and water should be used instead of an alcohol-based product when a patient has __________ - Solution C. difficile For which infections should a nurse use airborne precautions? - Solution measles, varicella, and pulmonary or laryngeal tuberculosis __________ airflow exchange should be used for patients on airborne precautions. - Solution Negative pressure
Fires in health care facilities are usually due to __________. - Solution electrical or anesthetic equipment or from smoking RACE stands for __________. - Solution rescue, alarm, contain, extinguish __________ are at risk for injury due to a tendency to put objects in their mouth and from hazards encountered while exploring their environment. - Solution Infants and toddlers __________ often face injury from limited or underdeveloped motor coordinatino. - Solution Preschool- and school-aged children __________ risks for injury can stem from increased desire to make independent decisions and relying on peers for guidance rather than family.
- Solution Adolescents' __________ continue to be a major cause of death and injury for people of all ages. - Solution Home fires __________ is a major cause of illness in the United States. - Solution Food poisoning __________ position prevents regurgitation of enteral feedings and aspiration by clients who have difficulty swallowing. It also promotes lung expansion for clients who have dyspnea or are receiving mechanical ventilation. - Solution Semi-Fowlers: 15º - 45º, typically 30º __________ position is useful during procedures (nasogastric tube insertion and suctioning). It allows for better dependent drainage after abdominal surgeries. - Solution Fowler's: 45º - 60º __________ position promotes lung expansion by lowering the diaphragm and thus helps relieve severe dyspnea. It also helps prevent aspiration during meals. - Solution High Fowler's: 60º - 90º The client lies on their back with the head and shoulders elevated on a pillow and forearms on pillows at their sides. A foot support prevents foot drop and maintains proper alignment. - Solution Dorsal recumbent
Which position promotes drainage from the mouth after throat and oral surgery. - Solution Prone. Which triage category has the highest priority given to clients who have life- threatening injuries but also have a high possibility of survival once they are stabalized? - Solution Emergent or Immediate Category (Class I) Which triage category has the second-highest priority given to clients who have major injuries that are not yet life-threatening and can usually wait 30 min to 2 hr for treatment? - Solution Urgent or Delayed Category (Class II) Which triage category has priority given to clients who have minor injuries that are not life-threatening and do not need immediate attention? - Solution Nonurgent or Minimal Category (Class III) Which triage category is the lowest priority and given to clients who are not expected to life and are allowed to die naturally? - Solution Expectant Category (Class IV) Comfort measures can be provided, but restorative care is not. If evacuation of the unit is necessary, __________ is done first. - Solution horizontal (lateral) evacuation Vertical evacuation to other floors is done if client safety cannot be maintained. RACE stands for __________. - Solution Rescue, Alarm, Contain, and Extinguish At what age should a patient receive yearly visual acuity exams? - Solution 65 At what age should patients receive high-sensitivity fecal occult blood testing? And how often? - Solution 50 years old; yearly How often should patients between the ages of 50 and 75 receive a flexible sigmoidoscopy? - Solution Every 5 years
Infants should sit in a rear-facing car seat at least until age __________. - Solution 2 __________ is acute, temporary, and can have a physiological source or related to a change in surroundings. This is often the first manifestation of infection in older adults. - Solution Delirium __________ is chronic, progressive, and possibly with an unknown cause.
- Solution Dementia __________ is chronic and can have an acute or gradual onset; This is often due to loss of a loved one, feelings of isolation, or chronic disease. - Solution Depression When palpating, the __________ is most sensitive to temperature. - Solution Dorsal surface When palpating, the __________ is sensitive to vibration. - Solution Palmar surface True or False: The average body temperature for older adults is 95.9º to 99.5º F. - Solution True __________ is the difference between the apical rate and the radial rate. - Solution Pulse deficit Which age group can have a slightly elevated systolic pressure due to decreased elasticity of blood vessels? - Solution Older adults Which ethnic group has a higher incidence of hypertension in general and at earlier ages? - Solution African Americans The width if the blood pressure cuff should be __________ of the arm circumference at the point where the cuff is wrapped. - Solution 40% The bladder if the blood pressure cuff should surround __________ of the arm circumference of an adult. - Solution 80% When taking blood pressure, the cuff should be inflated __________ above the palpated systolic pressure. - Solution 30 mmHg
True or False: In therapeutic communication, silence allows time for meaningful reflection. - Solution True __________ is when there are abusive words or actions of peers. - Solution Lateral violence This includes gossiping, exclusion of information, threats of harm, and actual harm. Adjusting to a chronic disease or stressful job change would be classified as __________ stress. - Solution Situational __________ stress varies with life stages. - Solution Developmental Adult stressors can include losing parents, having a baby, and getting married. True or False: Substance abuse, lack of education, and prolonged poverty can cause stress. - Solution True This is stress caused by sociocultural factors. True or False: The presence of stressors delays a client's return greater than the presence of a foreign body or infection delays the healing of a wound. - Solution False: Stress delays the body's return to health in the same way that a foreign body or infection would. What are the three stages of the stress reaction? - Solution Alarm stage, resistance stage, and exhaustion stage In this stage of stress, body functions are heightened to respond to stressors, also called fight-or-flight response. - Solution Alarm stage In this stage of stress, body functions normalize while responding to the stressor. - Solution Resistance stage
__________ means that nurses apply their knowledge of a client's culture to their care delivery. - Solution Cultural appropriateness __________ means that nurses understand and address the entire cultural context of each client within the realm of the care they deliver. - Solution Culturally competence __________ is similar to ethnocentrism and occurs when a nurse imposes the rules of their culture onto another person. - Solution Cultural imposition __________ is the belief that one's culture is superior to others. - Solution Ethnocentrism True or False: Many Asians use a soft tone of voice to convey respect. - Solution True True or False: Many Italian and Middle Easterners use a soft tone of voice.
- Solution False Many Italians and Middle Easterners use a loud tone of voice. A __________ consists of directive documents for medical treatment per the client's wishes. - Solution Living will A __________ appoints someone to make medical decisions when the client is no longer able to do so on their own behalf. - Solution Durable Power of Attorney for health care __________ is a loss related to a change that is part of the cycle of life and is anticipated but still can be intensely felt. - Solution Necessary loss This type of loss can be replaced by something different or better. __________ is any loss of a valued person, item, or status that others can recognize. - Solution Actual loss __________ is anything clients define as loss but that is not obvious or verifiable to others. - Solution Perceived loss
__________ is any loss normally expected due to the developmental processes of life. - Solution Maturational or developmental loss __________ is any unanticipated loss caused by an external event. - Solution Situational loss __________ is experienced before the loss happens. - Solution Anticipatory loss The Kübler-Ross Model of grief involves these 5 stages. - Solution Denial, anger, bargaining, depression, and acceptance True or False: Clients may not experience the 5 stages of grief in order and the length of each stage varies from person to person. - Solution True This type of grief is considered uncomplicated. - Solution Normal grief Emotions can be negative but should chance to acceptance with time. Some acceptance of loss should be evident by __________ after the loss. - Solution 6 months True or False: An individual experiencing normal grief can experience somatic complaints. - Solution True Ex: chest pain, palpitations, headaches, nausea, changes in sleep patterns, and fatigue This kind of grief implies the "letting go" of an object or person before the loss. - Solution Anticipatory grief This type of grief can be subcategorized as chronic, exaggerated, masked, and delayed grief. - Solution Complicated grief This type of grief entails an experienced loss that cannot be publicly shared or is not socially acceptable. - Solution Disenfranchised grief Ex: suicide and abortion
Each gram of protein produces __________ kcal. - Solution 4 A, D, E, and K are __________ -soluble vitamins - Solution fat C and B complex vitamins are __________ -soluble. - Solution Water Older adults require __________ calories. - Solution Fewer True or False: Older adults need more vitamins and minerals than younger adults. - Solution False Older adults need the same amount of most vitamins and minerals as younger adults. A BMI over 30 is considered __________ - Solution Obese A BMI of 26 is considered __________. - Solution Overweight 1 oz = __________ mL - Solution 30 To prevent aspiration, the client should be placed in __________ position. - Solution High-Fowler's True or False: Clients at risk of aspiration should tuck their chin when swallowing to help propel food down the esophagus. - Solution True True or False: Clients at risk of aspiration should drink liquids through a straw. - Solution False The use of a straw should be avoided in clients at risk for aspiration. Clients should be in semi-Fowler's for at least __________ hr(s) after meals. - Solution 1 Clear liquids, gelatin, and broths are part of a __________ diet. - Solution Clear liquid Clear liquids plus liquid dairy products, and all juices are a part of a __________ diet. - Solution Full liquid
Foods such as dairy products, eggs, and ripe bananas are a part of a __________ diet. - Solution Soft/low residue These are foods that are low in fiber and easy to digest. Whole grains, raw and dried fruits are part of a __________ diet. - Solution High-fiber A low sodium diet should have a maximum of __________ of sodium per day. - Solution 2 g A low cholesterol diet should have no more than __________ of dietary cholesterol per day. - Solution 300 mg A diabetic diet is limited to about __________ calories per day. - Solution 1, A client with dysphagia will likely be prescribed a diet comprising of __________. - Solution Pureed foods and thickened liquids Skin assessments should be conducted every __________ hour(s). - Solution 2 Clients should consume at least __________ mL fluid per day, unless intake is restricted. - Solution 2, Nurses should encourage active or provide passive ROM exercises __________ times per day. - Solution 2 or 3 When using a cane, a client should maintain __________ points of support on the ground at all times. - Solution 2 A cane should be placed on the __________ side of the body. - Solution Stronger When using crutches, the body weight should be supported at the hand grips with elbows flexed at __________. - Solution 20º to 30º
__________ pain occurs in internal organs and can cause referred pain in other body locations separate from the stimulus. - Solution Visceral __________ pain occurs in the skin or subcutaneous tissue. - Solution Cutaneous __________ pain arises from abnormal or damaged pain nerves. - Solution Neuropathic It is usually intense, shooting, burning, or described as "pins and needles". __________ pain includes phantom limb pain, pain below the level of a spinal cord injury, and diabetic neuropathy. - Solution Neuropathic __________ is the conversion of painful stimuli to an electrical impulse through peripheral nerve fibers (nociceptors). - Solution Transduction __________ occurs as the electrical impulse travels along the nerve fibers, where neurotransmitters regulate it. - Solution Transmission __________ is the point at which a person feels pain. - Solution Pain threshold __________ is the amount of pain a person is willing to bear. - Solution Pain tolerance __________ occurs in the spinal cord, causing muscles to contract reflexively, moving the body away from painful stimuli. - Solution Modulation __________ increase pain transmission and cause and inflammatory response. - Solution Substance P, prostaglandins, bradykinin, and histamines __________ decrease pain transmission and produce analgesia. - Solution Serotonin and endorphins __________ is the most reliable diagnostic measure of pain. - Solution The client's report of pain
True or False: Older adults are at an increased risk for undertreatment of pain. - Solution True Older adults are at an increased risk for undertreatment of pain, as well as increased risk for adverse events following analgesia administration. Therapeutic touch involves __________. - Solution Using hands to help bring energy fields into balance Aloe is used for __________. - Solution Wound healing Chamomile is used for __________. - Solution Anti-inflammatory, calming Echinacea is used to __________. - Solution Enhance immunity Garlic is used to __________. - Solution Inhibit platelet aggregation Ginger is used as an __________. - Solution Antiemetic Ginkgo biloba is used to __________. - Solution Improve memory Ginseng is used to __________. - Solution Increase physical endurance Valerian is used to __________. - Solution Promote sleep, reduce anxiety Clients should receive __________ g of fiber per day. - Solution 25 to 38 Foods that increase gas are __________. - Solution Cabbage, cauliflower, apples
