D439 FOUNDATIONS EXAM QUESTIONS
WITH 100% CORRECT ANSWERS .
SBAR Format - Correct Answer --model for effective communication identifying Situation,
Background, Assessment, and Recommendation
-there are two types of ways that communication tools are used to communicate a patients change
in condition: CUS tool (Concerned, Uncomfortable, Safety) and SBAR
-note to always maintain pt privacy and confidentiality
SBAR EXAMPLE :
Case Study: You administered 1 tablet of oxycodone HCl 5 mg/ibuprofen 400 mg PO to a patient 30
minutes ago for postsurgical pain. You return to the patient's room to evaluate the effectiveness of
the medication 30 minutes later. The patient rates his pain as an 8 on a scale of 0-10. You use SBAR
to contact the patient's health care provider.
Situation: The patient is rating his pain as an 8 on a scale of 0-10. He had his pain medication 30
minutes ago.
Background: The patient had a knee replacement and returned from the postanesthesia care unit 6
hours ago. He has 1 tablet of oxycodone HCl 5 mg/ibuprofen 400 mg PO ordered every 6 hours. This
is the first pain medication he has taken since being admitted to the unit.
Assessment: His current medication order is not sufficiently managing the patient's pain. He does
not want to sit up or move because of the pain he is experiencing.
Recommendation: It might be helpful to change the pain medication order for the patient.
guided imagery - Correct Answer --mind/body intervention
-Concentrating on an image or series of images to treat pathological conditions
1
,Maslow's Hierarchy of Needs - Correct Answer --where (1) physiological needs are PRIORITY then (2)
safety and security, (3) love and belonging needs. (4) self esteem needs, and FINALLY (5) self
actualization needs
The nurse planning care for a client experiencing dystocia determines that the priority is which
action?
1. Position changes and providing comfort measures
2. Explanations to the client about what is happening
3. Monitoring for changes in the condition of the birthing parent and fetus
4. Encouraging the use of breathing techniques learned in childbirth preparatory classes
Answer: 3
Test-Taking Strategy: Note the strategic word, priority, and use Maslow's Hierarchy of Needs theory
to prioritize, remembering that physiological needs come first. The nurse needs to have knowledge
of the client's priority needs and generate solutions. All the options are correct and would be
implemented during the care of a client with dystocia. Also note that the correct option is the only
one that addresses both the birthing parent and the fetus. Remember to use Maslow's Hierarchy of
Needs theory to help prioritize and generate solutions!
EHR system and limitations - Correct Answer --EHR AND EMR are different from eachother
-A health care agency often relies on the nursing history model included in the electronic health
record (EHR) as the organizing framework for an assessment. However, EHR frameworks are often
medically driven. Frameworks developed from nursing theories are more holistic and patient-
centered, providing a more comprehensive patient review.
-When it comes to the EMR freezing it's best to notify IT or when the computer system shuts down
during data entry. The nurse should follow established protocols and prepare to re-enter data as a
late entry when the system is operational. Also never attempt to reboot or fix the EMR system which
may prolong the complication.
It's also not recommended to print EMR from a backup server without proper authorization and
ensuring data privacy and security.
-patient outcome data; and use clinical decision support systems. The electronic health record (EHR)
is an efficient method for documenting and managing patient health care information (see Chapter
26.) Computerized physician/provider order entry (CPOE), allowing health care providers to directly
enter medical orders, is a critical patient safety initiative especially in the area of medication
ordering and administration
2
, -Change-of-shift, hand-off reporting, and hourly bedside rounds are ways to keep all health care
providers and patients informed
Hand Hygeine - Correct Answer --hand washing does not kill microorganisms but reduces the
amount of them present
-four techniques: hand washing, antiseptic hand wash, antiseptic hand rub, surgical hand antisepsis
-4 elements of hand washing: water, friction, soap , and time
Dosage Calculation (ml, tbsp->ml) - Correct Answer -
VITAL SIGNS - Correct Answer --what to do if reassessment is needed
-know the pt usual range of vital signs (baseline)
-assess respiratory
Factors affecting vital signs of older adults:
MOBILITY: How do you use crutches? - Correct Answer -TYPES OF GAITS:
-2-point: 2 points (crutch or foot) on the ground: pt moves right crutch and left foot together, left
crutch and right foot together
-4 point gait:
-3 point gait: moving both crutches and the injured leg at the same time
-weight is on both hands
support weight at the hand grips, with elbow flexed at 30 degrees, position crutches on the
unaffected side when sitting or raising from the chair
-How to use crutches: Do Not Adjust Crutch Settings After Fitting (Should be 3 Finger Widths
Between Axilla and Top of Crutch) Support Body Weight on Hand Grips (Not Axilla), With Elbows
Flexed or bent at 30 Degrees
-an accurate measurement is important and the distance between the axillae and arm piece has to
be 2-3 finger widths in the axilla space and the arm bars
-all weight should be on the hand grips
-when ambulating pt, stand on their affected (weak) side
-never rest armpit on the axillary bars
3
WITH 100% CORRECT ANSWERS .
SBAR Format - Correct Answer --model for effective communication identifying Situation,
Background, Assessment, and Recommendation
-there are two types of ways that communication tools are used to communicate a patients change
in condition: CUS tool (Concerned, Uncomfortable, Safety) and SBAR
-note to always maintain pt privacy and confidentiality
SBAR EXAMPLE :
Case Study: You administered 1 tablet of oxycodone HCl 5 mg/ibuprofen 400 mg PO to a patient 30
minutes ago for postsurgical pain. You return to the patient's room to evaluate the effectiveness of
the medication 30 minutes later. The patient rates his pain as an 8 on a scale of 0-10. You use SBAR
to contact the patient's health care provider.
Situation: The patient is rating his pain as an 8 on a scale of 0-10. He had his pain medication 30
minutes ago.
Background: The patient had a knee replacement and returned from the postanesthesia care unit 6
hours ago. He has 1 tablet of oxycodone HCl 5 mg/ibuprofen 400 mg PO ordered every 6 hours. This
is the first pain medication he has taken since being admitted to the unit.
Assessment: His current medication order is not sufficiently managing the patient's pain. He does
not want to sit up or move because of the pain he is experiencing.
Recommendation: It might be helpful to change the pain medication order for the patient.
guided imagery - Correct Answer --mind/body intervention
-Concentrating on an image or series of images to treat pathological conditions
1
,Maslow's Hierarchy of Needs - Correct Answer --where (1) physiological needs are PRIORITY then (2)
safety and security, (3) love and belonging needs. (4) self esteem needs, and FINALLY (5) self
actualization needs
The nurse planning care for a client experiencing dystocia determines that the priority is which
action?
1. Position changes and providing comfort measures
2. Explanations to the client about what is happening
3. Monitoring for changes in the condition of the birthing parent and fetus
4. Encouraging the use of breathing techniques learned in childbirth preparatory classes
Answer: 3
Test-Taking Strategy: Note the strategic word, priority, and use Maslow's Hierarchy of Needs theory
to prioritize, remembering that physiological needs come first. The nurse needs to have knowledge
of the client's priority needs and generate solutions. All the options are correct and would be
implemented during the care of a client with dystocia. Also note that the correct option is the only
one that addresses both the birthing parent and the fetus. Remember to use Maslow's Hierarchy of
Needs theory to help prioritize and generate solutions!
EHR system and limitations - Correct Answer --EHR AND EMR are different from eachother
-A health care agency often relies on the nursing history model included in the electronic health
record (EHR) as the organizing framework for an assessment. However, EHR frameworks are often
medically driven. Frameworks developed from nursing theories are more holistic and patient-
centered, providing a more comprehensive patient review.
-When it comes to the EMR freezing it's best to notify IT or when the computer system shuts down
during data entry. The nurse should follow established protocols and prepare to re-enter data as a
late entry when the system is operational. Also never attempt to reboot or fix the EMR system which
may prolong the complication.
It's also not recommended to print EMR from a backup server without proper authorization and
ensuring data privacy and security.
-patient outcome data; and use clinical decision support systems. The electronic health record (EHR)
is an efficient method for documenting and managing patient health care information (see Chapter
26.) Computerized physician/provider order entry (CPOE), allowing health care providers to directly
enter medical orders, is a critical patient safety initiative especially in the area of medication
ordering and administration
2
, -Change-of-shift, hand-off reporting, and hourly bedside rounds are ways to keep all health care
providers and patients informed
Hand Hygeine - Correct Answer --hand washing does not kill microorganisms but reduces the
amount of them present
-four techniques: hand washing, antiseptic hand wash, antiseptic hand rub, surgical hand antisepsis
-4 elements of hand washing: water, friction, soap , and time
Dosage Calculation (ml, tbsp->ml) - Correct Answer -
VITAL SIGNS - Correct Answer --what to do if reassessment is needed
-know the pt usual range of vital signs (baseline)
-assess respiratory
Factors affecting vital signs of older adults:
MOBILITY: How do you use crutches? - Correct Answer -TYPES OF GAITS:
-2-point: 2 points (crutch or foot) on the ground: pt moves right crutch and left foot together, left
crutch and right foot together
-4 point gait:
-3 point gait: moving both crutches and the injured leg at the same time
-weight is on both hands
support weight at the hand grips, with elbow flexed at 30 degrees, position crutches on the
unaffected side when sitting or raising from the chair
-How to use crutches: Do Not Adjust Crutch Settings After Fitting (Should be 3 Finger Widths
Between Axilla and Top of Crutch) Support Body Weight on Hand Grips (Not Axilla), With Elbows
Flexed or bent at 30 Degrees
-an accurate measurement is important and the distance between the axillae and arm piece has to
be 2-3 finger widths in the axilla space and the arm bars
-all weight should be on the hand grips
-when ambulating pt, stand on their affected (weak) side
-never rest armpit on the axillary bars
3
