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Herzing
Medsurg exam1 Hesi
| Term | Definition |
|---|---|
| What are the key components of a thorough cardiopulmonary nursing assessment? | History of normal and present cardiopulmonary function , past impairments in cardiac/circulatory/respiratory functioning, methods the patient uses to optimize. Oxygenation, and review of allergies. |
| What is FiO2 and how does it relate to oxygen flow rate? ., | FiO2 is the fraction of inspired oxygen(percentage or concentration of oxygen delivered). Flow rates in L/min do not correlate directly with the percentage of oxygen delivered- amount depends on the type of devices used. |
| What knowledge base should guide clinical decision-making when caring for patients with impaired oxygen? | Cardiac and respiratory physiology, oxygen supply and demand, pathogenesis of cardiopulmonary diseases, and effects of underlying diseases on overall health and function. |
| What assessment cues support the nursing diagnosis of Impaired Airway Clearance? | Difficulty breathing and clearing respiratory secretions, decreased breath sounds, and crackles on auscultation. |
| What assessment cues support the nursing diagnosis of Impaired Gas Exchange? | Rapid respirations, difficulty with breathing, and reduced oxygen saturation. |
| How does clinical judgment help differentiate between similar nursing diagnoses like Impaired Gas Exchange and Impaired Breathing? | -By analyzing assessment findings and the patient's history to identify specific cues and clusters of data that distinguish one diagnosis from another, even when symptoms like dyspnea and nasal flaring overlap. |
| What standards guide nursing practice when caring for patients with cardiopulmonary alterations? | ANA standards and scope of practice, clinical practice guidelines, agency policies and procedures, and professional standards from organizations like the American Heart Association and American Association for Respiratory Care. |
| What device is used to set the prescribed rate of oxygen delivery? | An oxygen flowmeter |
| Why is experience important when assessing patients with cardiopulmonary conditions? | Experience caring for patients with cardiopulmonary conditions, observing patient responses to oxygen therapies, and personal experiences with alterations help nurses recognize patterns, anticipate complications, and make informed clinical decisions. |
| What attitudes should nurses display when assessing cardiopulmonary alterations? | Confidence when assessing the extent of alterations and creativity when assessing cultural factors influencing risk factors and care needs. |
| Which goal does the health care team use as the target for the patient experiencing pain? | Relieving pain The health care team collaborates to meet the goal: relief of pain. Assessing and evaluating pain are part of the nursing process and contribute to achieving the goal of pain relief |
| Which pain assessment tool would the nurse use for a patient who has cognitive impairment and pain related to an ankle fracture? | FLACC The FLACC scale is used for patients who are cognitively impaired. The nurse would assess the patient’s behavior in categories such as facial expression, limb movement, activity, crying, and consolability. |
| Which scale is the nurse using if the nurse asks the patient to select the number of paper straws that most accurately reflects the pain level? | Pieces of pain A pieces of pain scale uses five identical, plain objects that represent “pieces” of pain. The patient indicates the degree of pain by selecting the number of objects that equals the intensity of pain being experienced. |
| Which example of documentation is best for a patient who is reporting pain associated with a migraine headache? | States, “My pain is 8 out of 10, and it’s on my right forehead.” The documentation that includes the patient’s own words is the best way to record the patient’s subjective experience. |
| Which instrument would the nurse use to determine the amount of pain and to document the findings for a 6-year-old child experiencing pain? | FACES pain scale The FACES pain scale uses pictures of facial expressions to rate pain. This is typically the best pain scale to use with children. |
| Which score would the nurse give using the FLACC (Face, Legs, Activity, Cry, and Consolability) scale to assess a patient who has an occasional frown, legs drawn up, and rigid jerking movement; moans occasionally; and can be reassured by occasional touchi | 7 A score of 7 is the correct interpretation of the FLACC pain scale; occasional frown: +1, legs drawn up +2, rigid jerking movement +2, moans occasionally +1, can be reassured by occasional touching +1 = 7. |
| Which area would the nurse identify as the correct location for the stethoscope’s diaphragm to obtain the patient’s apical pulse? | At the apex of the heart The nurse would place the stethoscope at the apex of the heart to listen to the apical pulse. |
| Which finding would the licensed practical/vocational nurse (LPN/LVN) obtain through inspection of the patient? | The patient's hair is dirty. Inspection involves looking during data collection. By looking at the patient, the nurse would see that the patient's hair is dirty. |
| Which nursing intervention would the licensed practical/vocational nurse (LPN/LVN) complete after attending to the patient's physiologic needs? | Ensure the lighting and room temperature are comfortable. The second stage of Maslow's hierarchy of needs is security, and this is accomplished by creating a comfortable environment and meeting the patient's needs. |
| Which source would the licensed practical/vocational nurse (LPN/LVN) use to determine whether the patient’s prescribed medication is new to the patient? | The history and physical provide reasons for admission, home medications, past hospitalizations, and lab or radiology results, for example. The nurse could determine if a prescribed medication is new to the patient by reviewing this content. |
| Which comment demonstrates a nursing intervention for the patient whose primary problem is a urinary tract infection? | Encourage the patient to drink additional fluid during each shift. Encouraging the patient to drink additional fluid during each shift is a nursing intervention. |
| Which patient care skill is among the first priority level when the nurse uses Maslow’s hierarchy of needs, adapted by nursing, to prioritize nursing care? | Administering prescribed oxygen, Providing a patient with a bedpan, Administering medications for pain relief, _Providing food and water for a patient who is unable to self-feed |
| Which personal protective equipment (PPE) item is applied first when donning PPE? | Gown |
| Which priority action would the nurse take to prevent a respiratory tract health care–associated infection? | Encourage the patient to cough, deep-breathe, and use an incentive spirometer. To prevent a respiratory tract infection, the nurse should encourage the patient to cough, deep-breathe, use incentive spirometer, and move. Perform suctioning, tracheostomy c |
| Which information given by the nurse regarding hand hygiene indicates the need for further education? | “I only need to perform hand hygiene if I am not going to use gloves.” Hand hygiene must be performed regardless of whether gloves were used or not, otherwise the nurse can potentially transfer germs to the surface of the gloves.. |
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