Foundations/Nursing Process
The final step of the nursing process, where the nurse determines the effectiveness of nursing care
What is Evaluation?
A nurse is preparing to leave the room of a client who is on contact and droplet precautions. In what order should the PPE be removed?
What is gloves, goggles, gown, then mask?
-Gloves are most contaminated, then followed by goggles, the gown then mask
Normal resting pulse for a healthy adult
What is 60-100 bpm?
Why is it dangerous to provide high-flow oxygen (6L/min) to a client with chronic CO2 retention like COPD?
A. It causes the blood pressure to spike
B. It can extinguish the client's physiological stimulus to breathe
C. It increases the risk of oxygen-induced hyperthermia
D. it causes immediate tooth decay
What is it can extinguish the client's physiological stimulus to breathe?
-COPD clients, high oxygen levels can supress the hypoxic drive to breathe (88-92%)
Which nurse responses are therapeutic?
A. “Tell me more about how you feel.”
B. “Everything will work out.”
C. “You shouldn’t worry about that.”
D. “It sounds like you’re feeling overwhelmed.”
E. “What concerns you most?”
A, D, E
Which action must the nurse prioritize before implementing any new intervention in the nursing process?
A. Document the intended action
B. Perform a focused assessment
C. Evaluating the previous shift's goal
D. Finalizing the discharge plan
What is perform a focused assessment?
-Assessment is the mandatory first step in the nursing process; interventions cannot be planned or performed without current data.
The nurse is reviewing the use of transmission based isolation precautions with a group of new nurses. Sort the following infectious diseases by the type of precautions required (Contact, Droplet Airborne)
A. Turbeculosis
B. SARS-CoV2 (COVID 19)
C.Influenza
D.C. Difficile
E. MRSA
Contact: C Diff, MRSA
Droplet: Influenza
Airborne: Tuberculosis, COVID 19
While auscultating the lungs, the nurse hears a high pitch, musical whistling sounds, especially during expiration.
*think of all the breath sounds from H2T*
What is wheezing?
A nurse is caring for a client with Pneumonia. Which assessment finding indicates the client’s condition is worsening?
A. Productive cough with sputum
B. Respiratory rate 30/min
C. Temperature 38.1°C (100.6°F)
D. Fatigue
What is the respiratory rate of 30/min
-Tachypnea indicates worsening respiratory compromise and possible respiratory distress.
A nurse is caring for a client who is newly admitted to the unit. Which action should the nurse take to establish a helping relationship with the client?
A. Make sure the communication is equally distributed between the nurses and client's desires.
B.Encourage the client to communicate their thoughts and feelings
C. Give the nurse-client communication no time limits
D. Allow communication to occur spontaneously throughout the nurse-client relationship.
B. encourage the client to communicate their thoughts and feelings
(think preventions)
What is primary prevention?
-Primary prevention includes education to prevent onset of a habit or disease.
While performing a sterile dressing change, the nurse accidentally touches the sterile field with an ungloved hand. What should the nurse do?
A. Continue procedure and monitor the client
B. Remove contaminated items and establish a new sterile field
C. Clean the area with antiseptic and continue
D. Ask the AP to complete the dressing change
What is remove the contaminated items and establish a new sterile field
-Any contamination requires re-establishing a new sterile field.
A nurse observes a client's breathing pattern: the depth of respirations gradually increases, then decreases followed by a 15 second period of apnea.
A. Tachypnea
B.Bradypnea
C.Cheyne-Stokes respiration
D. Hyperventilation
It is a repeating pattern of cresendo-decresendo breathing followed by apnea
Which finding indicates fluid overload in a client with Heart Failure?
A. Weight gain 2 kg in 2 days
B. Dry mucous membranes
C. Hypotension
D. Decreased edema
What is weight gain 2 kg in 2 days?
When a terminally ill client does not respond to medical treatment, which nursing action is most helpful in assisting the client in dealing with their impending death?
a.Providing literature on death and dying
b.Allowing the client privacy to think alone
c.Listening to the client talk about their feelings
d.Encouraging the client to get a second opinion
C. listening to the client talk about their feelings
This level of prevention focuses on early detection and prompt treatment of an existing asymptomatic disease
What is secondary prevention?
-Secondary prevention aims for early detection and prompt intervention to prevent disease progression.
Why is it important to maintain intact skin for infection prevention?
A. It acts as a barrier to pathogens.
B. It prevents dehydration.
C. It improves oxygen levels in the blood.
D. It eliminates sweat more effectively.
A. It acts as a barrier to pathogens.
-Maintaining skin integrity is crucial as it serves as the first line of defense against infection.
A nurse documents a "shell temperature" this refers to
A. the warmth at the skin surface
B. the temperature inside the esophagus
C. the temperature of the heart
D. the temperature of the urinary bladder
What is the warmth at the skin surface?
Why is it important to maintain intact skin for infection prevention?
A. It acts as a barrier to pathogens.
B. It prevents dehydration.
C. It improves oxygen levels in the blood.
D. It eliminates sweat more effectively.
A. It acts as a barrier to pathogens.
-Maintaining skin integrity is crucial as it serves as the first line of defense against infection.
What is the best nursing response when an 82-year-old client with Alzheimer disease says they are looking forward to a visit from their mother later today?
a.“Your mother has been deceased for years.”
b.“Tell me more about your mother.”
c.“Let me call and check on your mother.”
d.“When did you last see your mother?”
B." Tell me more about your mother"
-For a client with Alzheimer’s disease, reality orientation is not always helpful and can increase confusion or distress. Instead, therapeutic communication that validates feelings and encourages reminiscence is most effective. Asking the client to talk about their mother acknowledges their emotions and provides comfort.
A. Dependence on medical staff for all decisions
B. The need for specific training and education
C. Minimal theoretical instruction
D. Focusing on hospital administration over patient care
What is the need for specific training and education?
-Nightingale established nursing as a profession requiring specific training.
Which of the following are signs of systemic infection? Select all that apply.
Select all that apply
A. Fever
B. Localized redness at the infection site
C. Increased heart rate
D. Generalized fatigue
E. Purulent drainage from a wound
A, C, D
-Systemic infections affect the entire body and can manifest as fever, increased heart rate, and fatigue.
Phase V of the Korotkoff sound is defined as :
A. the second diastolic measurement where sounds disappear into silence
B. the systolic pressure measurement
C. a crisp knocking sound
D. swishing sound
What is the second diastolic measurement where sounds disappear into silence?
What is the first step in the Clinical Judgment Measurement Model (NCJMM)?
A. Recognize Cues
B. Analyze Cues
C. Prioritize Hypotheses
D. Generate Solutions
What is recognize cues?
-involves identifying and filtering relevant data from various information sources.
Which of the following techniques should the nurse avoid to maintain therapeutic communication?
A.using silence to allow the client to think
B. Asking "why" questions when the client refuses a treatment
C. Usiing active listening cues like nodding
D. asking open-ended questions to encourage sharing
B.Asking "why" questions when the client refuses a treatment
-Asking “why” questions can make the client feel defensive, judged, or anxious, which blocks therapeutic communication. Instead, the nurse should use open-ended questions, active listening, and validation to explore the client’s feelings and reasons in a non-threatening way.