NURS 1871: FUNDAMENTALS OF NURSING FINAL EXAM
REVIEW QUESTIONS AND ANSWERS WITH COMPLETE
SOLUTIONS VERIFIED
What is the nursing process?
ADPIE
Assess:
gather information about the patient’s condition
Diagnose:
identify the patient’s problems
Plan:
plan care and desired outcomes and identify appropriate nursing actions
Implement:
perform the nursing actions identified in planning
Evaluate:
determine if goals and expected outcomes are achieved
Subjective data
patients' verbal descriptions of their health problems
patient feelings, perceptions, and self-reported symptoms
Objective data
Findings resulting from direct
observation
,When you collect objective data, apply
critical thinking intellectual standards so that you can correctly interpret your findings.
PQRST
Palliative
Quality
Region
Severity
Time
SBAR
Situation
Background
Assessment
Recommendation
Wheal
,an irregularly shaped, superficial localized edema that varies and is caused by a hive or
mosquito bite
Papule
a palpable, solid elevation in the skin like an elevated nevus
Macule
a flat, nonpalpable change in skin color like freckles or petechiae
Petechiae
pinpoint, round spots that appear on the skin as a result of bleeding
Pustule
a circumscribed elevation on the skin that is filled with pus and may be caused by a
staphylococcal infection or acne
Papilla
small rounded protuberance on a part or
organ of the body
Factors that contribute to pressure injuries
- Impaired sensory perception
- Alteration in LOC
- Shear
- Friction
- Moisture
- Nutrition
- Impaired mobility
- Tissue perfusion
, - Infection
- Age
- Psychosocial impact of wounds
- Poor circulation
- Other disease processes
Stage 1: non-blanchable erythema of intact skin?
keep area dry, turn pt more frequently, transparent dressing
Stage 2: Partial-thickness skin loss with exposed dermis
no epidermis, mo drainage, blister, barrier cream, zinc oxide, moisture risk, hydrocolloid
Stage 3: Full-thickness skin loss
full-thickness but no slough or eschar, can see subcutaneous tissue
Stage 4: Pressure-injury that has full-thickness skin and tissue loss
clean wound, then get a culture, negative pressure to drain and increase perfusion
Unstageable: Eschar and/or slough present
in this stage you can't see the depth of the pressure ulcer
Deep tissue pressure injury: appears as a bruise, has potential to open, non-
blanchable
non blanchable, purple in color, starts at the subcutaneous level, cause of this is chronic
pressure
Intentional wound
created for therapy, i.e. surgical
Unintentional wound
resulting from trauma, i.e. fall
REVIEW QUESTIONS AND ANSWERS WITH COMPLETE
SOLUTIONS VERIFIED
What is the nursing process?
ADPIE
Assess:
gather information about the patient’s condition
Diagnose:
identify the patient’s problems
Plan:
plan care and desired outcomes and identify appropriate nursing actions
Implement:
perform the nursing actions identified in planning
Evaluate:
determine if goals and expected outcomes are achieved
Subjective data
patients' verbal descriptions of their health problems
patient feelings, perceptions, and self-reported symptoms
Objective data
Findings resulting from direct
observation
,When you collect objective data, apply
critical thinking intellectual standards so that you can correctly interpret your findings.
PQRST
Palliative
Quality
Region
Severity
Time
SBAR
Situation
Background
Assessment
Recommendation
Wheal
,an irregularly shaped, superficial localized edema that varies and is caused by a hive or
mosquito bite
Papule
a palpable, solid elevation in the skin like an elevated nevus
Macule
a flat, nonpalpable change in skin color like freckles or petechiae
Petechiae
pinpoint, round spots that appear on the skin as a result of bleeding
Pustule
a circumscribed elevation on the skin that is filled with pus and may be caused by a
staphylococcal infection or acne
Papilla
small rounded protuberance on a part or
organ of the body
Factors that contribute to pressure injuries
- Impaired sensory perception
- Alteration in LOC
- Shear
- Friction
- Moisture
- Nutrition
- Impaired mobility
- Tissue perfusion
, - Infection
- Age
- Psychosocial impact of wounds
- Poor circulation
- Other disease processes
Stage 1: non-blanchable erythema of intact skin?
keep area dry, turn pt more frequently, transparent dressing
Stage 2: Partial-thickness skin loss with exposed dermis
no epidermis, mo drainage, blister, barrier cream, zinc oxide, moisture risk, hydrocolloid
Stage 3: Full-thickness skin loss
full-thickness but no slough or eschar, can see subcutaneous tissue
Stage 4: Pressure-injury that has full-thickness skin and tissue loss
clean wound, then get a culture, negative pressure to drain and increase perfusion
Unstageable: Eschar and/or slough present
in this stage you can't see the depth of the pressure ulcer
Deep tissue pressure injury: appears as a bruise, has potential to open, non-
blanchable
non blanchable, purple in color, starts at the subcutaneous level, cause of this is chronic
pressure
Intentional wound
created for therapy, i.e. surgical
Unintentional wound
resulting from trauma, i.e. fall
