Exam 2 review

oxygenation

100

• Normal SpO₂ range in a healthy adult?

95-100%

200

• High-pitched crackling breath sounds are known as?

Crackles

300

• Breathing pattern characterized by deep, rapid respirations often seen in metabolic acidosis?

Kussmaul breathing (like in DKA)

400

• Device delivering the highest concentration of O₂?

Non-rebreather mask

500

• The nurse notes accessory muscle use during breathing. This indicates?

Respiratory distress/ increased work of breathing

perfusion

100

• Normal adult systolic blood pressure range?

90-120mmHg

200

Pulse grade of 2+ is considered

Normal

300

• Which position promotes venous return in hypotension?

Trendelenburg

400

• Edema in ankles due to heart failure indicates impaired…

• venous return/right-sided heart function?

500

• Drug class often used to improve perfusion by decreasing afterload?

Vasodilators (ACE inhibitor)

Nursing process

100

What is the first step in the nursing process?

Assessment

200

Measurable patient outcome is created during which step of the nursing process?

Planning

300

• Implementation involves what?

Carrying out interventions

400

• The nurse rechecks a patient’s blood pressure after giving medication. Which step is this?

Evaluation

500

• Correct order of the nursing process (mnemonic ADPIE)?

Assessment, diagnosis, planning, implementation, evaluation. 

clinical judgement

100

• Interpreting data is part of which phase of Tanner’s model?

Interpereting

200

• A nurse identifies a patient with COPD at risk for hypoxemia. This demonstrates which aspect of judgment?

Recognizing cues

300

• Choosing the best nursing intervention represents what?

• What is prioritizing hypotheses/generating solutions?

400

• Reassessing after intervention demonstrates which step?

Evaluation/ reflection

500

• Using past experiences to guide care is part of which stage in Tanner’s model?

Reflecting

safety

100

• The most important method for infection control?

Hand hygiene 

200

• Side rails should not all be raised because…

It is considered a restraint

300

• Medication error prevention starts with verifying?

• the six rights of medication administration?

(Right patient, drug, dose, route, time, documentation)

400

• A nurse should identify fall risk using which scale?

The Morse fall scale

500

• Oxygen tanks must be kept away from what?

Heat, open flames