4/4/25, 7:52 NR224 Final Exam |
PM
NR224 FINAL EXAM QUESTIONS AND ANSWERS WITH COMPLETE
SOLUTIONS VERIFIED GRADED A++
Terms in this set (93)
Bathing, hygiene, vitals What responsibilities can the nurse delegate to the AP?
Nurse should also obtain her own vitals
for accurate assessing
Medication use, one changing, sterile What responsibilities can a nurse not delegate to the AP?
procedures, gag reflex/aspiration
assessment.
What are the essential steps the nurse should do prior to performing any skill on
ADPIE
the patient?
Collecting data from health history, What is involved during the assessment stage of the nursing process?
clinical record, physical exam, functional
assessment
Compare clinical findings with normal and What is involved in the diagnosis stage of the nursing process?
abnormal variations in developmental
events. Interpret data to make a nursing
diagnosis
Establish priorities, set SMART What is involved in the planning stage of the nursing process?
goals, develop plan of care using
EBP
Implement any goals and document What is involved during the implementation stage of the nursing process?
modifications
See if goals were met and revise or set What is involved during the evaluation stage of the nursing process?
new goals
Procedures that help decrease the risk of What is medical asepsis/clean technique?
infection. Includes hand hygiene and
routine cleaning.
Isolates an operative or procedural area What is a sterile/surgical asepsis technique?
from an unsterile environment and
maintains a sterile field for surgery.
Includes gown, mask, sterile gloves, face
shield or goggles
Tracheostomy suctioning, indwelling Names and procedures that would be performed using a sterile technique
catheter insertion, wound
dressing change
Medication administration, NG tube Name procedures that would be performed using clean technique
insertion
Break the chain of infection How do you prevent the spread of infection?
Hand washing What is the number one way to prevent the spread of infection?
- Sterile objects remain sterile only What are principles associated with creating and maintaining a sterile field?
when touched by other sterile
objects.
- if you question sterility then it's unsterile.
- only sterile objects can be in the sterile
field
- if your hands drop below your waist
then it's unsterile.
- prolonged exposure means it's unsterile.
- wet surface and 1 inch border
is unsterile.
1/
7
, 4/4/25, 7:52 NR224 Final Exam |
PM
Airborne, droplet, contact, protective What are the different isolation procedures?
environment
Less than 5 nm. What are the precautions taken with an airborne infection?
Private room, negative pressure, surgical
mask on the patient, N95 on the
Nurse
Measles, varicella, herpes What are diseases that call for airborne isolation?
zoster, tuberculosis, rubella
Greater than 5 nm What are diseases that call for droplet isolation?
Flu, group a strep, pertussis, diphtheria,
pneumonia, rubella, mumps
Private room or cohort patient, surgical What are the precautions taken with droplet isolation?
mask
Private room or cohort patients, Gown, What are the precautions taken with contact isolation?
gloves
MRSA, scabies, C. Diff, shingles, major What diseases call for contact isolation?
wounds, HSV, RSV, varicella zoster
Private room, positive airflow, HEPA filter What are the precautions for a protective environment isolation?
for incoming air, mask, gown, gloves
Stem cell transplant or chemo patients What patients require protective environment isolation?
Respirations: 12-20 BMP What are the normal ranges for vital signs? respirations, pulse, oxygen saturation,
Pulse: 60-100 BMP temperature, blood pressure?
Oxygen Saturation: 95%+
Temperature: 36-38 C or 98.6-100.4 F
BP: 120/80 mmHg
If regular account for 30 seconds if your What is the technique for measuring pulse?
regular account for a full minute.
If the arm is above the heart or the cuff What gives a false low reading when taking blood pressure?
is too wide
If the arm is below the heart, cuff is too What causes a false high reading when taking blood pressure?
wide or loose
Has the person smoked in the last 10 What are the considerations when taking temperature?
minutes, hot or cold fluids in the last 30
minutes
Use on unaffected side. Move the How should a nurse teach a patient using a cane?
cane forward 6 to 10 inches while
keeping the body weight on both
legs, move cane then weak leg,
then strong leg.
Adjust 2 inches from the axilla. When How should a nurse instructed patient to use crutches?
walking up the stairs good leg goes first,
when walking downstairs bad leg goes
first.
Keep the elbows flex 15- 30°. How should a nurse instruct a patient to use a walker?
Patient holds the walker steps
forward then moves the walker
Nurse supports the beltat the patient How should a nurse instruct a patient to use a gait belt?
waist while walking
2/
7
PM
NR224 FINAL EXAM QUESTIONS AND ANSWERS WITH COMPLETE
SOLUTIONS VERIFIED GRADED A++
Terms in this set (93)
Bathing, hygiene, vitals What responsibilities can the nurse delegate to the AP?
Nurse should also obtain her own vitals
for accurate assessing
Medication use, one changing, sterile What responsibilities can a nurse not delegate to the AP?
procedures, gag reflex/aspiration
assessment.
What are the essential steps the nurse should do prior to performing any skill on
ADPIE
the patient?
Collecting data from health history, What is involved during the assessment stage of the nursing process?
clinical record, physical exam, functional
assessment
Compare clinical findings with normal and What is involved in the diagnosis stage of the nursing process?
abnormal variations in developmental
events. Interpret data to make a nursing
diagnosis
Establish priorities, set SMART What is involved in the planning stage of the nursing process?
goals, develop plan of care using
EBP
Implement any goals and document What is involved during the implementation stage of the nursing process?
modifications
See if goals were met and revise or set What is involved during the evaluation stage of the nursing process?
new goals
Procedures that help decrease the risk of What is medical asepsis/clean technique?
infection. Includes hand hygiene and
routine cleaning.
Isolates an operative or procedural area What is a sterile/surgical asepsis technique?
from an unsterile environment and
maintains a sterile field for surgery.
Includes gown, mask, sterile gloves, face
shield or goggles
Tracheostomy suctioning, indwelling Names and procedures that would be performed using a sterile technique
catheter insertion, wound
dressing change
Medication administration, NG tube Name procedures that would be performed using clean technique
insertion
Break the chain of infection How do you prevent the spread of infection?
Hand washing What is the number one way to prevent the spread of infection?
- Sterile objects remain sterile only What are principles associated with creating and maintaining a sterile field?
when touched by other sterile
objects.
- if you question sterility then it's unsterile.
- only sterile objects can be in the sterile
field
- if your hands drop below your waist
then it's unsterile.
- prolonged exposure means it's unsterile.
- wet surface and 1 inch border
is unsterile.
1/
7
, 4/4/25, 7:52 NR224 Final Exam |
PM
Airborne, droplet, contact, protective What are the different isolation procedures?
environment
Less than 5 nm. What are the precautions taken with an airborne infection?
Private room, negative pressure, surgical
mask on the patient, N95 on the
Nurse
Measles, varicella, herpes What are diseases that call for airborne isolation?
zoster, tuberculosis, rubella
Greater than 5 nm What are diseases that call for droplet isolation?
Flu, group a strep, pertussis, diphtheria,
pneumonia, rubella, mumps
Private room or cohort patient, surgical What are the precautions taken with droplet isolation?
mask
Private room or cohort patients, Gown, What are the precautions taken with contact isolation?
gloves
MRSA, scabies, C. Diff, shingles, major What diseases call for contact isolation?
wounds, HSV, RSV, varicella zoster
Private room, positive airflow, HEPA filter What are the precautions for a protective environment isolation?
for incoming air, mask, gown, gloves
Stem cell transplant or chemo patients What patients require protective environment isolation?
Respirations: 12-20 BMP What are the normal ranges for vital signs? respirations, pulse, oxygen saturation,
Pulse: 60-100 BMP temperature, blood pressure?
Oxygen Saturation: 95%+
Temperature: 36-38 C or 98.6-100.4 F
BP: 120/80 mmHg
If regular account for 30 seconds if your What is the technique for measuring pulse?
regular account for a full minute.
If the arm is above the heart or the cuff What gives a false low reading when taking blood pressure?
is too wide
If the arm is below the heart, cuff is too What causes a false high reading when taking blood pressure?
wide or loose
Has the person smoked in the last 10 What are the considerations when taking temperature?
minutes, hot or cold fluids in the last 30
minutes
Use on unaffected side. Move the How should a nurse teach a patient using a cane?
cane forward 6 to 10 inches while
keeping the body weight on both
legs, move cane then weak leg,
then strong leg.
Adjust 2 inches from the axilla. When How should a nurse instructed patient to use crutches?
walking up the stairs good leg goes first,
when walking downstairs bad leg goes
first.
Keep the elbows flex 15- 30°. How should a nurse instruct a patient to use a walker?
Patient holds the walker steps
forward then moves the walker
Nurse supports the beltat the patient How should a nurse instruct a patient to use a gait belt?
waist while walking
2/
7
