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NFDN 2003 MIDTERM STUDY GUIDE
FINAL EXAM QUESTIONS AND ANSWERS 100% PASS
“What does SBAR stand for? - CORRECT ANSWER Situation
Background Assessment Recommendation"
"SBAR: Situation - CORRECT ANSWER a concise statement of the problem"
"SBAR: Background - CORRECT ANSWER pertinent and brief info related to the situation"
"SBAR:Assessment - CORRECT ANSWER Analysis and consideration of options (what you
found/think)"
"SBAR: Recommendation - CORRECT ANSWER action requested/recommended — what
you want"
"_______ can reverse decreased RR due to opioids - CORRECT ANSWER Narcan"
"Which best describes continuous bladder irrigation (CBi therapy) - CORRECT ANSWER
Removes clots after prostate or bladder surgery"
"What size is the NS bag used for continuous bladder irrigation? - CORRECT ANSWER 3L
(3000 ml)"
"Proper method of calculating urine output during continuous bladder irrigation? - CORRECT
ANSWER Calculate total output minus vol of irrigation fluid used"
"Can infection travel from foley bag to the bladder? - CORRECT ANSWER yes"
"A bronchoscopy permits visualization of what? - CORRECT ANSWER larynx, trachea,
bronchi"
"Blood accumulation in the pleural space - CORRECT ANSWER hemothorax"
"fluid in the pleural space is called - CORRECT ANSWER pleural effusion"
"Air that develops in the pleural space is termed - CORRECT ANSWER pneumothorax"
"What kind of pressure is found in pleural space - CORRECT ANSWER negative"
"Heavy sedation can cause a decrease in oxygen after surgery - CORRECT ANSWER true"
"Emphysema results in - CORRECT ANSWER alveolar destruction"
"Symptoms of COPD - CORRECT ANSWER History of progressive shortness of breath,
excessive cough, and sputum production. Patients with predominantly emphysematous COPD may have dry cough and weight loss"
"What is COPD? - CORRECT ANSWER chronic bronchitis, emphysema, and hyperactive
airway dz -doesn't tend to get better"
"Patients w COPD spo2 is usually between - CORRECT ANSWER 85-90"
"abbreviation to record oxygen saturation and pulse - CORRECT ANSWER SPO2%"
"Simple face mask - CORRECT ANSWER 6-8 L/min"
"Hypovolemic shock - CORRECT ANSWER shock resulting from blood or fluid loss"
"What isn't a nanda nursing diagnosis related to respiration - CORRECT ANSWER impaired
respiration pattern"
"Epidermis - CORRECT ANSWER several layers of epithelial cells"
"dermis - CORRECT ANSWER inner layer of skin that provides tensile, strength, mechanical
support, and protection to underlying muscles, bones, and organs)"
"subcutaneous fatty tissue - CORRECT ANSWER (fat, blood vessels, connective tissue)
regulates body and skin temperature and stores energy in the form of fat"
"wounds - CORRECT ANSWER type of lesion, disruption of normal anatomical structure turn
and function, classified by cause and descriptions"
"Wounds are classified as either - CORRECT ANSWER open or closed"
"Asthma - CORRECT ANSWER episodes of breathing difficulty due to narrowed or
obstructed airways"
"Emphysema - CORRECT ANSWER a condition in which the air sacs of the lungs are
damaged and enlarged, causing breathlessness."
"Tuberculosis - CORRECT ANSWER chronic lung inflammation"
"Usually caused by trauma or rupture from an inflammatory process like pneumonia or TB -
CORRECT ANSWER pneuthorax"
"phases of wound healing - CORRECT ANSWER inflammatory
proliferative maturation (remodelling phase)"
"inflammatory phase of wound healing - CORRECT ANSWER edema, erythema, heat and
pain at wound sign (classic s&s of infection) - blood clot develops forms a fibrin matrix scab forms - prevents contamination histamine is released and causes increase in blood and nutrients to the wound neutrophils move into wound and ingest debris and bacteria macrophages clean there wound by phagocytosis and prepare it for healing"
"proliferative phase of wound healing - CORRECT ANSWER lasts 3-24 days
granulation tissue fills wound bed, contraction (inward movement of the edges) of the wound and resurfacing of the wound by epithelialization wound closes by epithelialization **EPITHELIAL CELLS CAN ONLY MIGRATE ACROSS A MOIST ENVIRONENT THEREFORE WOUND NEEDS TO BE MOIST TO FACILITATE WOUND CLOSURE"
"infection - CORRECT ANSWER watch for fever, drainage, swelling, tenderness, increased
WBC, general malaise"
"inflammation - CORRECT ANSWER edema, heat, pain"
"What factors affect skin integrity - CORRECT ANSWER LIFESTYLE FACTORS: Hygiene,
nutrition and fluid status, exercise, smoking substance abuse DEVELOPEMENTAL FACTORS: skin disease PHYSIOLOGICAL FACTORS: age, incontinence, hypoxemia, diabetes, infections, neurological impairment, medications"
"Incontinence with skin integrity - CORRECT ANSWER contamination of wound from
urine/stool. - bacteria"
"Hypoxemia with skin integrity - CORRECT ANSWER impaired blood flow and oxygen =
decreased nutrients to wound = decreased healing time"
"Diabetes and skin integrity - CORRECT ANSWER may have vascular disease
hyperglycaemia inhibits leucocyte activity and infection can set in - promotes growth of yeast and fungi"
"medications commonly affecting skin integrity - CORRECT ANSWER steroids,
antinflammatory meds, chemo"
"environment and skin integrity - CORRECT ANSWER dryness, mess, perspiration,
incontinence - skin becomes wet, macerated and softened can lead to breakdown"
"CBC - CORRECT ANSWER Complete Blood Count
hematocrit tells number of circulkating cells hemoglobin tells oxygen carrying capacity of the blood if hemoglobin is low = hematocrit is low WBC increase if infection present RBC carries Hgb"
"Pulmonary function diagnostic test - CORRECT ANSWER to assess respiratory function
(amount of air moving in and out of the lungs) - tests include: measurement of lung volumes, ventilatory function and mechanics of breathing, diffusion, gas exchange"
"ABGS diagnostic test - CORRECT ANSWER measures blood pH and arterial O2 and CO
levels"
"Pulse oximetry - CORRECT ANSWER oxygen saturation of hemoglobin should be above
"Sputum cultures - CORRECT ANSWER culture bugs too test for sensitivity could be TB"
"Interventions to clear the airways - CORRECT ANSWER DEEP BREATHING AND
COUGHING
INCENTIVE SPIROMETRY
POSITIONING
INHALED BRONCHODILATORS
"Jackson-pratt - CORRECT ANSWER closed bulb self-suction and collection of drainage -
secured w suture"
"drain care to promote healing - CORRECT ANSWER maintain patency
secure drain monitor drainage for color, consistency and quanitity empty fluid from drain- measure and record maintain dressing around drain"
"Non-pharmalogical interventions for wound healing - CORRECT ANSWER apply heat or
cold ice pack on for 20 min and off warm pack, warm blanket"
"factors that impair wound healing - CORRECT ANSWER infection
malnutrition age obesity impaired oxygenation smoking drugs vascular disease radiation wound stres"
"alginates - CORRECT ANSWER absorbs excessive moisture - used when large amounts of
drainage"
"foams - CORRECT ANSWER absorbs exudates and debris while maintaining mooisture"
"wound vac - CORRECT ANSWER assists in wound closure"
"Cleansing a surgical wound - CORRECT ANSWER cleanse least contaminated to moist
(wound to surface edge) gentle friction when irrigating allow solution to flow from least contamination to most clean to dirtty"
"restrictive respiratory disorder - CORRECT ANSWER restrictive to lung expansion or
obstructive to movement of air in/out of lungs reduced lung volume"
"obstructive respiratory disorder - CORRECT ANSWER decreased size of airway; increased
resistance, decreased ability to expand lungs"
"hypoxemia - CORRECT ANSWER decrease in arterial oxygen in the blood - changes in
mental status, dyspnea, increase BP, changes in HR, dysthymia, central cyanosis (late sign)"
"hypoxia - CORRECT ANSWER decrease in oxygen supply to the tissues"
"inadequate ventilation - CORRECT ANSWER anxiety
restlessness or confusion use of accessory muscles for breahing change in cognition hypoxia hypoxemia"
"factors affecting respiration - CORRECT ANSWER lifestyle
environmental developemenmtal physiological any condition that might affect cardiovascular system directly affects bodies ability to meet oxygen demands"
"absent breath sounds - CORRECT ANSWER could mean consolidation in that area
(pneumonia or mass)"
"crackles - CORRECT ANSWER auscultated in right and left lung bases; caused by random
sudden re-inflatino of groups of alveoli"
"fine crackles - CORRECT ANSWER high pitched, fine, short, end of respiration not cleared
with coughing sounds like rubbing hair together"
"coarse crackles - CORRECT ANSWER loud, bubbly sounds during inspiration, not cleared
with coughing"
"wheezes - CORRECT ANSWER heard over all lung fields; high velocity air flow through
severely narrowed bronchus; high. pitched musical"
"pleural friction rub - CORRECT ANSWER heard over. anterior. lateral lung field; caused by
inflamed pleura"
"honcho - CORRECT ANSWER heard over trachea and bronchi"
"conduit - CORRECT ANSWER channel for the passage of fluid"
"ileal conduit - CORRECT ANSWER piece of ileum is resected and used to create a conduit or
passage for redirecting urine - bladder damaged or removed so alternative way is created for urine to drain outside of the body"
"indwelling catheter (retention/foley) - CORRECT ANSWER continuous bladder drainage,
gradual decompression of over distended bladder ballon 2 or 3 lumen"
"intermittent caheter - CORRECT ANSWER drains bladder for short periods of time
obtain sterile specimen single lumen no balloon"
"suprapubic catheter - CORRECT ANSWER continuous drainage
inserted above pubic area may or may not have ballooon"
"insertion of catheter - CORRECT ANSWER advance catheter additional 5 cm once urine
starts to drain"
"regional anesthesia - CORRECT ANSWER nerve blocked with local anaesthetic"
"spinal anesthesia - CORRECT ANSWER increased risk of headaches"
"general anaesthesia - CORRECT ANSWER patient put to sleep with drugs given either by
inhalation or IV"
What is the purpose of concept maps and clinical critical pathways? - CORRECT ANSWER
Care plans that use visualisation to organize the relationship between the interventions and issues involved."
"How do clinical pathways and concept maps support clinical decision making for nurses? -
CORRECT ANSWER By providing an organized way to provide evidence based nursing care
plans and daily interventions."
"What are the impacts of hospitalization on the med/surg client's determinants of health? -
CORRECT ANSWER loss of income, employment issues, ability to buy nutritional food,
stressful and unsafe employment, accessibility to social services, culture and gender Everyone could be struggling, do not assume."
"How does infection affect wound healing? - CORRECT ANSWER Prolongs inflammatory
phase. Change in volume, odor, viscosity, fever and pain. Purulent.. Never pus."
"How does malnutrition affect wound healing? - CORRECT ANSWER Impairs all phases of
healing. Protein, carbs, vitamins and minerals. Look at the client's diet."
"How does age affect wound healing? - CORRECT ANSWER Alters all phases of healing.
Reduce liver functions and slowed inflammatory responses."
"How does obesity affect wound healing? - CORRECT ANSWER Fatty tissue will have less
adequate blood supply. Observe wounds for infection. Dehiscent (characterized by splitting or bursting open) pops open."
"How does smoking affect wound healing? - CORRECT ANSWER Causes excessive clotting.
Necrosis/infection."
"How do vascular diseases affect wound healing? - CORRECT ANSWER Impaired
oxygenation. Prevent and instruct patients to avoid breaks in skin"
"What are some pharmacologic processes that promote wound healing? - CORRECT
ANSWER antibiotics, antihyperglycemics, vitamins, debridement agents ( silver),
antipyretics."
"What are some non-pharmacologic processes that can promote wound healing? - CORRECT
ANSWER turning patients, promoting ambulation, high protein diet, appropriate and
competent wound care, early detection of infection, compression and mobilization, elevation and wound irrigation."
"What is an acute wound? - CORRECT ANSWER heal with the first line of treatment. Trauma
or surgical wounds."
"what is a chronic wound? - CORRECT ANSWER recurring wounds, wounds that are non-
healable, wounds that do not respond to the first line treatment, wounds that progress slowly in the healing process, wounds that happened due to underlying chronic disease."
"What are the 3 healing intentions? - CORRECT ANSWER Partial, Secondary, and tertiary
intention."
"What is the healing process for partial intention? - CORRECT ANSWER usually at the 24
hour mark it will clot."
"What is COCA? - CORRECT ANSWER Colour, odour, consistency and amount."
"What are the 7 principles of the sterile technique? - CORRECT ANSWER -A sterile object
remains sterile only when touched by another sterile object. -Only sterile objects may be placed on a sterile field. -A sterile object or field out of the range of vision or an object held below a person's waist is contaminated. -A sterile object or field becomes contaminated by prolonged exposure to air. -When a sterile surface meets/contacts a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action. -Fluid flows in the direction of gravity. -The edges of a sterile field or container are considered contaminated."
"What is the medical asepsis clean technique? - CORRECT ANSWER Clean gloves
Does not have to be "sterile to sterile" Objects may have one "contaminated/ dirty end" and one sterile end. Ex: subcutaneous infections, simple wound dressing."
"What is the surgical asepsis sterile technique? - CORRECT ANSWER Sterile Gloves
Following the 7 sterile principles Object are either sterile or containment end. Ex: surgical wound dressing, foley catheters, wound vacs."
"What is the principles and rationales for wound cleansing? - CORRECT ANSWER closed
wound: check physician orders, wipe clean to dirty, follow principles of sterile technique, one gauze per swipe, dry the wound and peri wound, same order you cleansed with a sterile dry gauze."
"What is the principles and rationales for wound irrigating? - CORRECT ANSWER used in
more complex wounds, but can also be used in closed wounds. Flush with consistent low pressure. Bottle of saline or 30 ml syringe. Fluid flows directly onto the wound, do not irrigate when base cannot be determined, and dry the periwound."
"What is the principles and rationale for wound dressings? - CORRECT ANSWER ordered by
doctor, nursing responsibility to assess appropriateness, maintain sterility while applying, wrinkles or folds provide a path of entry for microorganisms and should be avoided, use non- adhesive gauze wrap if patient at risk for skin tears due to adhesive, assess for allergies to adhesive."
"What is the principles and rationale for a non-adherent contact layer dressing? - CORRECT
ANSWER place overtop wound and periwound, can remain on skin while outer layer changed,
allows moisture to pass through it. Made with tulle, and infused with petrolatum or silicone."
"What is the principles and rationale for soft silicone dressings? - CORRECT ANSWER float
above the wound surface, does not interfere with wound healing, used on fungating wounds or wounds with fragile skin, requires an absorbent layer on top."
"What is the principles and rationale for hydrocolloid dressings? - CORRECT ANSWER used
on wounds with-minimal drainage, no evidence of infection, with slough on wound bed. Shallow deep wounds, autolytic debridement, "liquify slough", does not affect healthy skin, adhesive and occlusive, left on for 5-7 days."
"What is the principles and rationale for transparent film dressings? - CORRECT ANSWER
used to secure IV's, provides an occlusive barrier-does not allow fluid to escape and can lead to maceration, self adhesive- difficult to remove, do not use on fragile skin, utilize a lateral pull to remove."
"What is the principles and rationale for hydrogel dressings? - CORRECT ANSWER helps
provide a moist wound environment, promotes autolytic debridement."
"What is the principles and rationale for foam dressings? - CORRECT ANSWER non-adhesive
or adhesive, comes in a multitude of shapes and sizes, absorbs moderate to large amount of exudate. Left in place for up to 7 days, helps keep peri wound area healthy by wicking moisture away from healthy skin, very commonly used dressings for stage 2 or small 3 pressure ulcers."
"What is the principles and rationale for alignate and hydrofiber dressings? - CORRECT
ANSWER alginate-manufactured from seaweed, absorbs moderate to large amount of exudate,
for partial and full thickness wounds or infected wounds, CAN NOT be used on dry wounds, can be infused with antimicrobial medications such as silver, placed underneath other dressing materials such as gauze, can be packed into wounds."
"What is the principles and rationale for wound packing? - CORRECT ANSWER Completed
AFTER size, depth, shape and assessment has been completed, packing not required if less than 5cm needed,physician will order what type of material is used to pack the wound. Material must be moistened prior to packing(normal saline or physician ordered solution), entire wound surface to touch part of moist packing, periwound/surrounding skin kept dry, loosely pack undermining and tunneling, do not over pack/tightly pack, amount placed in wound needs to be documented."
"What is an endotracheal airway? - CORRECT ANSWER Not in the LPN scope. Requires
manual ventilation. Forcing them to breathe in and out. High risk for infection and airway injury."
"WHat is an oxymyzer? - CORRECT ANSWER Specialized nasal cannula. Consist of O
reserve. Can eat with mask on.. More comfortable, cheaper, reduces anxiety, humidification not required."
"what is a CPAP and BPAP machine? - CORRECT ANSWER CPAP for life sustaining measures;
hard decision, respect wishes, family has the right to remove it."
"what is mechanical ventilation? - CORRECT ANSWER Supported by a machine. Invasive
(trach/ endotracheal). Non invasive ( face or nasal mask)."
"What is end-tital? - CORRECT ANSWER Amount of CO2 in body after expiration 35-45. If it is
too high, ventilation is to low.... Ventilating too fast." "What is the PN responsibility when caring for a client with an oraltracheal and nasotracheal
suctioning? - CORRECT ANSWER Completed over max of 15 sec. Nose is preferred. Have O
ready and allow rest between passes."
"What is the PN responsibility when caring for a client with - CORRECT ANSWER "
"What is the PN responsibility when caring for a client with tracheal suctioning? - CORRECT
ANSWER Rotate the catheter while removing. 100-120 pressure. Check facility standards. High
risk for bodily fluid contact, creating droplets ( wear PPE)"
"What is the PN responsibility when caring for a client with a tracheostomy? - CORRECT
ANSWER Use sterile technique for caring and maintaining airway. O2 to be given before
suctioning. 10 sec suctioning rule. When changing dressing or ties make sure you have a buddy. Clean skin around the trach site to prevent build up of dried secretions and skin breakdown. Assess and clean the stoma under the face plate."
"What is the PN responsibility when caring for a client with chest drainage systems? -
CORRECT ANSWER nsure no kinks or clots in tubing. Make sure all tubing is plugged in.
Make sure the machine and also suction is turned on. Mark hourly or at the beginning of shift what level the chamber is at. Intermediate bubbling is ok, but do not want continuous. Check dressing to be dry and intact. Keep machine lower than patient (do not attach to bedrail), water rises with inhalation."
"What is the nursing process and proper diagnosis when caring for clients with a UTI? -
CORRECT ANSWER Confirm a possible UTI by testing a C&S. Second most common bacterial
disease. Most commonly found in women. Due to poor hygiene, increasing catheter use"
"What are the risk factors for the development of altered skin integrity? - CORRECT ANSWER
aging skin, dehydration, poor nutrition, prolonged use of corticosteroids, impaired sensory perception, cognitive impairment, and adhesive dressings."
"What are some interpreted assessment findings common to clients with altered oxygenation? -
CORRECT ANSWER -SPO2 will be increased, decreased then normal
-BP will be altered -difficulty with inspiration/expiration -hypoxemia -hypercapnia"
"What are some pharmacologic therapies commonly used for clients with altered oxygenation? -
CORRECT ANSWER Inhalers, oxygen masks, corticosteroids,"
"What are some NON-pharmacologic therapies commonly used for clients with altered
oxygenation? - CORRECT ANSWER Sitting upright, deep slow breaths, relaxing"
"What is the importance of collab with client, family, and interdesciplincary tesm to optimize
client outcomes? - CORRECT ANSWER -increase the pts well being
-provides link to personal life to enable more holistic care -POA -can help decrease risk factors/triggers -traditional healing practices consideration -encouraging family presence during invasive proced."
"what are the health education needs for a client with oxygenation? - CORRECT ANSWER
lifestyle behaviour changes (smoking, 2nd hand exposure, adequate nutrition and hydration, exercise, immunizations, reduce cold outdoor exposure, limiting caffeine and alcoholic bevies, use filtration masks around chemicals and pollutants, deep breath techniques.)" "What is pertinent information is required to accurate documentation and reporting regarding
the client with altered oxygenation? - CORRECT ANSWER exactly what is going on, any
interventions, assessments done, teachings done, evaluations, interventions,"
"What is the nursing process of pyelonephritis? - CORRECT ANSWER usually starts as a
lower UTI, or an obstruction of the lower GU tract from BPH or renal calculi."
(hydration, reduce caffeine), pelvic floor muscle rehabilitation (good for everyone), anti- incontinence devices, containment devices."
"What is a radiography used for? - CORRECT ANSWER Abdominal view used to show the
renal outline, shadow and a full bladder. Used to detect stones and foreign bodies, abscesses, tumors and cysts."
"what is a pyelogram used for? - CORRECT ANSWER Presence, position, size and shape of the
kidneys, the ureters and the bladder. Uses contrast medium. Assess for allergies and an allergic response to injection site and after affects of anaphylaxis."
"what is urodynamic testing? - CORRECT ANSWER combination of tests for urinairy
incontinence. Urine flow study and a cystometrography."
"What is bladder irrigation? - CORRECT ANSWER May require if catheter becomes occluded
by sediment and enrustation. Only used when deemed harmful to remove and reinsert. Two styles; intermittent bladder irrigation, continuous bladder irrigation."
"what is hemodialysis? - CORRECT ANSWER A machine acting as an artificial kidney to
remove waste from the blood."
5 Star solution - CORRECT ANSWER - do it yourself
- influence others
- assign someone
- do nothing
- combine knowledge"
"Qualities of Good Decision Makers - CORRECT ANSWER - Self confident
- Proactive
- Flexible
- Focused
- Always accountable for their actions
- Current knowledge
- Works w/ resources
- Competency"
"Mentorship - CORRECT ANSWER - To have a knowledgable/competent/ reliable person to
learn/understand from
- Informal/Formal relationship for the purpose of educating a jr. nurse"
"Mentorship -- Benefits - CORRECT ANSWER - support for new grad
- faster growth of future generation
- creates long term connections
- role models
- incluse on curriculum vitae
- feeling of empowerment"
"Mentorship -- Downfalls - CORRECT ANSWER - Personality conflict
- Imposing their style on you
- Social issues"
"Clinical Pathway - CORRECT ANSWER - Support team
- Client population
- Time frames
- Interventional categories of Rx plans
- Meet expected outcomes
- Variance record"
"SBAR - CORRECT ANSWER - S [situation] - report clearly the situation and give the facts
- B [background] - give background info about the client
- A [assessment] - give details of your assessment
- R [recommendations] - suggests recommendations that you would like to see done"
"Metaparadigm Concepts - CORRECT ANSWER - PERSON/CLIENT- centre of all nursing
process
- ENVIRONMENT - person is a part of and interacts w/ a complex environmental system
- HEALTH - more than the absence of disease, ideal health, optimal health or total wellbeing
- NURSING - see individual as a whole"
"Wound Care Nursing Roles - CORRECT ANSWER - proper assessment: gather history,
physical examination, determine priority ND"
"Skin - CORRECT ANSWER - Primary line of defence, protection of the body [alteration of
skin allows bacteria/pathogen can move in/further into the body], a disruption results in loss of body fluids and risks for infection"
"Wound classification - CORRECT ANSWER - Cause: intentional/unintentional
- Skin integrity: open, closed [hematoma], acute [cellilitis], chronic [bowel related]
- Depth: partial thickness, full thickness
- Cleanliness: clean, clean-contaminated, contaminated
- Duration: acute vs. chronic"
"Wound Color Classification - CORRECT ANSWER - Red: healing wound, granulation tissue,
inflammatory, proliferative, or maturation phase of healing, needs to be kept clean and moist*
