NU 311 SKILLS EXAM 2 QUESTIONS ANSWERED CORRECTLY LATEST UPDATE 2026

NU 311 SKILLS EXAM 2 QUESTIONS ANSWERED CORRECTLY LATEST UPDATE 2026 Know the steps of the Nursing Process - Answers Assessment Nursing Diagnosis Planning Implementation Evaluation Assessment - Answers Gathering the Data (medical history, physical assessment, vital signs), Sorting and organizing the collected data, and Documenting the data in a retrievable format Nursing Diagnosis - Answers A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes Ex. Impaired Skin Integrity R/T stool incontinence a.e.b. reddened and excorticated perineum (p.783) What are the parts of a nursing diagnosis? - Answers 1. Diagnostic Label (What is the problem; potential or actual?) Ex. Impaired Tissue Integrity (p. 870) Ex. Impaired Skin Integrity (p. 703) Found in the Nursing Pocket Guide 2. Etiology (What is the probable cause?) (Related to) AKA contributing factors Connected to the Diagnostic Label by "related to" or "R/T" What is the Causing problem? Ex. Risk for trauma R/T weakness, poor vision, and slippery floors 3. Defining Characteristics (What evidence leads you to 1 & 2?) (As evidenced by) Help select appropriate diagnosis Reflect causative or contributing factors Signs and symptoms Connected to Etiology by "as evidenced by" or "a.e.b" Ex. "I feel breathless" Ex. Dyspnea Clinical Thinking - Answers Thinking like a nurse Nursing Diagnosis - Answers is the response to an issue/problem/reason for coming in to then decide a plan of care Planning - Answers Establish Goals with your patient, Set Expected outcomes, Prescribe Specific Nursing Interventions (ex. ROM), Set Priorities, these actions are documented as your PLAN of CARE Implementation - Answers When the plan of care is put into action, When the nurse performs the interventions Evaluation - Answers addresses whether established goals are met, It is an ongoing process to determine effectiveness of the plan of care Four types of a Nursing Diagnosis. - Answers 1. Actual or Problem Focused Diagnosis Exists at present Ex. Acute pain or fluid volume deficit 2. Health Promotion Reflecting a desire to improve well being 3. Syndrome Cluster of NU DX Example: Relocation stress syndrome (p. 720) 4. Potential or Risk Diagnosis Exposure to factors increasing chance of developing certain conditions Ex. Risk for infection or Risk for falls A risk diagnosis is not evidenced by signs and symptoms because the problem has not yet occurred; rather, nursing interventions are aimed toward prevention (THIS IS PROACTIVE) What is different about a risk diagnosis? - Answers Exposure to factors increasing chance of developing certain conditions Risk for infection or Risk for falls A risk diagnosis is not evidenced by signs and symptoms because the problem has not yet occurred; rather, nursing interventions are aimed toward prevention It is proactive to a problem ex. just out of surgery and starts doing ROM to prevent PIs How is a risk diagnosis written? - Answers A Risk diagnosis is only 2 parts 1. NANDA Diagnostic Label: Risk for deficient fluid volume 2. Evidenced by risk factors of increased intestinal losses (vomiting and diarrhea) and decreased fluid intake 3. For example: Risk for deficient fluid volume as evidenced by risk factors of increased intestinal losses (vomiting and diarrhea) and decreased fluid intake How to prioritize nursing diagnoses - Answers A Nursing Diagnosis, if untreated, may cause harm to the patient Priorities are a moving target and change as the patient's condition changes Priorities -Safety -Airway -Breathing -Circulation -Pain Ex. of High risks Risk for other-directed violence (patients' safety) Impaired gas exchange (not breathing) Decreased cardiac output (circulation) Expected Outcomes - Answers measurable criteria used to evaluate goal achievement Know how to establish MEASURABLE PATIENT CENTERED outcomes - Answers they must be measurable and within a reasonable time frame Assessments MUST include a frequency of action: every 6 hours every AM before breakfast 30 minutes after pain medications nursing assessments - Answers the objective and subjective data that the nurse gathers from the patient initially nursing interventions - Answers the plans and goals the nurse creates because of the assessment of the patient. This is the change or actions that the patient should do to improve their situation The application of the steps of the Nursing Process - Answers Assessment- gather info about the patient's condition Nursing Diagnosis- identify the client's problems Planning- set goals of care and desired outcomes and identify the appropriate nursing actions Implementation- preform the nursing actions identified in planning Evaluations- determine if goals met and outcomes achieved The Application of Assessment - Answers Three Activities: Gathering the data Sorting and organizing the collected data Documenting the data in the retrievable format Sources of Data: Primary: patient Secondary: family, friends, HCP, medical records Types of Data: Subjective: verbal description Objective: observation or measurement The Application of Nursing Diagnosis - Answers Clinical Judgement 250 choices Divided into Subjects: Individual Family Group Community Types of Diagnosis: Actual or problem Health Promotion Potential or Risk The Application of Planning - Answers Prescribe intervention Set priorities Documented as plan of care Types of intervention Independent: autonomous action; no med order required Dependent: require an order Collaborative: require knowledge and skill The Application of Implementation - Answers Occurs when: Plan of care is put into action Preforms the interventions The Application of Evaluation - Answers Addresses if goals are met Ongoing process to determine effectiveness of the plan of care Evaluation statement: Should directly address the goal statement and the outcomes expected If goal met: Either continue or establish a new goal If goal unmet: Modify goal or interventions Care Plan - Answers a written plan for each resident created by a nurse; outlines the steps taken by the staff to help the resident reach his or her goals Asepsis - Answers state of being free from disease-causing microorganisms Medical Asepsis - Answers "clean techniques" used in daily hygiene, medications, etc Surgical Asepsis - Answers "sterile technique" used in surgical procedures Principles of surgical asepsis - Answers To eliminate all pathogens Only sterile can touch sterile Never reach across a sterile field Open a sterile package with the edge away from you Avoid spilling or splashing onto the sterile field Sterile is above the waist Never turn your back on a sterile field A sterile barrier that has been permeated by punctures, tears or moisture must be considered contaminated. Once a sterile package is open, a 1-inch border around the edge is considered unsterile. Tables draped as part of a sterile field are considered sterile only at table level. Any question or doubt whether an item is sterile, the item is considered unsterile. A sterile object or field becomes contaminated by prolonged exposure to air; stay organized and complete any procedure as soon as possible. Cannot lean over sterile field Know the steps to prepare and maintain a sterile field for a sterile kit - Answers Open outermost flap away from body first, keeping arm outstretched and away from the sterile field. Open side flaps, one at a time keeping arms to side and not over sterile surface Grasp outer border of last flap and open towards your body last. Careful to stand away from the sterile package. Hold sterile field away from body Know the steps to prepare and maintain a sterile field for a sterile drape - Answers You may touch outer 2.5-cm (1-inch) border of drape without wearing gloves. Using fingertips of one hand, pick up folded top edge of drape along 2.5 cm (1-inch) border. Gently lift drape straight up from its container without touching any object. With other hand, grasp an adjacent corner of drape and hold it straight up and away from body. Allow drape to unfold, keeping it above waist and work surface and away from body Holding drape, position bottom half over top half of intended work surface (as in pictures) Proper positioning prevents nurse from reaching over sterile field. *Hands are on side of drape closest to body. Know the steps to prepare and maintain a sterile field for pouring a sterile solution - Answers Verify solution Check expiration Palm label Removed lid in upright position or discard if single use Pour without splashing Do not pour over sterile field Pour with nonsterile bottle outside of field Move your position or angle to avoid contamination Do not pour across or reach across sterile field Know the steps to maintain a sterile field for applying sterile gloves - Answers Preform hand hygiene Safe glove selection (Assess for latex allergy) Obtain proper size for hands Place on clean and dry surface at waist level. Open carefully not touching the inside of the wrapper or gloves. Avoid touching wrapper (inside too) after gloves are donned. Apply with hands up and away from the body Do not attempt to smooth down one-inch border with hands. Do not remove wrapper from surface after gloves applied! Individuals with a latex allergy - Answers Spina bifida Multiple surgeries or medical procedures High latex exposure (e.g., health care workers, housekeepers, food handlers, tire manufacturers, workers in industries that use gloves routinely) Rubber industry workers Personal or family history of allergies. There is a connection between an allergy to latex and an allergy to avocados, bananas, chestnuts, kiwis and passion fruits. These foods have some of the identical allergens that are found in latex. How to perform a wound assessment - Answers Location- note anatomical position of wound Type of wound (i.e., Surgical, Pressure, Trauma) Extent of tissue involvement (i.e., Full-thickness (dermis and epidermis) or Partial-thickness (only epidermal layer)) Type and percentage of tissue in the wound base -Granulation- red tissue (good) -Slough- dead tissue that is yellow and adherent to wound -Eschar- dead tissue that is black or brown Wound size (Length X Width X Depth in centimeters) Wound exudate (TACCO) -Amount: scant, moderate, copious Presence of odor Periwound (perimeter) area: (Color, temp, and integrity of skin around wound) Pain- Use a validated pain assessment scale to evaluate pain wound dehiscence - Answers separating or splitting open layers of a surgical wound wound evisceration - Answers extrusion of viscera or intestine through a surgical wound Primary intention - Answers when the edges of a clean surgical incision remain close together. The wound heals quickly, and tissue loss is minimal or absent. The skin cells regenerate quickly, and capillary walls stretch across under the suture line to form a smooth surface as they join. Secondary intention - Answers Wounds that are left open and allowed to heal by scar formation. There is tissue loss and open wound edges. Granulation tissue gradually fills in the area of the defect. This process is typical of severe laceration or massive surgical intervention with skin loss. Tertiary intention - Answers delayed primary intention-tissue loss, debris in wound, infection-clean out, stay open 3-5 days, surgeon will close up, usually need skin graft occurs when surgical wounds are not closed immediately but left open for 3 to 5 days to allow edema or infection to diminish. Then the wound edges are sutured or stapled closed describe different wound drainage - Answers Serous- clear, watery plasma Serosanguineous- pale red, pink, clearish Sanguineous- bright red drainage indicates fresh bleeding Purulent- thick yellow, pale green, or white (pus) describe the amount of drainage - Answers Copious- an excessive amount Moderate- a normal amount Scant- a little, insufficient Slough - Answers is a yellow/tan adherent moist rubbery-like tissue composed of fibrin, white blood cells, protein, and debris, necrotic tissue in the process of separating from living tissue Necrosis (eschar) - Answers the death of all or most of the cells in an organ or tissue, is a leathery black or brown dead tissue how to clean a wound - Answers Clean from "clean to dirty" Cleaning solution should be at room temperature Avoid using cotton balls or other products that shed fibers Sequence: -Top to bottom: or cleanest to dirtiest -Clean around wound Unpack the wound noting of the skin and tissue Then sterilize and moisten the 4x4 in NS and then fluff them Gently pack the wound loosely and being careful not to touch the periwound or the inside Do NOT pack the wound full Then place a dry 4x4 over the wound and then an ADB pad over that. Tape it down Assessment of wound - Answers 1. length 2. type 3. extent of tissue 4. type and percentage of tissue in the wound base 5. size 6. exudate (TACCO) 7. odor 8. periwound area 9. pain Maceration - Answers "pickling" softening and breaking down of skin resulting from prolonged exposure to moisture how to irrigate a wound - Answers in Sims position so that the irrigation will not sit in the wound but will roll out Directing solution from top to bottom of wound and from clean to contaminated area prevents further infection. Position patient during the planning stage, keeping in mind bed surfaces needed for later preparation of equipment. Position patient so wound is vertical to collection basin. Irrigate should be room temperature. Can be painful (premedicate 30 mins before procedure) Large syringes provide safe, effective pressure document care of a wound - Answers Record type of wound tissue present in injury, wound measurements, periwound skin condition, character of drainage or exudate, type of topical agent used, dressing applied, and patient's response Record patient's understanding through teach-back for reasons for frequent observation and measuring of wound Report any deterioration in wound appearance to nurse in charge or health care provider How to prepare to remove staples or stitches? - Answers Considerations: Location of incision, any patient allergies, agency policy, and HCP order Supplies needed: suture removal or staple removal kit, 4x4 gauze, antiseptic swabs per agency protocol, clean gloves, biohazard bag, Steri- Strips (adhesive strips), and sharps container Adequate lighting for visualization (proper assessment) & Hand Hygiene! Incision Assessment: Ensure safe to remove (site well-approximated and healed together without observable complication?) Plan to remove every other suture or staple if order does not specify and check agency policy Report any abnormal findings to HCP BEFORE removing how to remove staples - Answers Removed within 7 to 14 days Remove every other staple to assess incision is ready Process: place lower tips of staple extractor under first staple. As you close handles, upper tip of extractor depresses. Carefully control extractor. As soon as both ends are visible, move it away from skin surface and continue until staple is over refuse bag.