FINAL EXAM NUR 101 COMPLETE QUESTIONS AND VERIFIED ACCURATE SOLUTION (DETAILED & ELABORATED) |100% ACCURATE!! TEST!!

FINAL EXAM NUR 101 COMPLETE QUESTIONS AND VERIFIED ACCURATE SOLUTION (DETAILED & ELABORATED) |100% ACCURATE!! TEST!! ABC's Answer airway, breathing, circulation Used for prioritizing Activity Intolerance Answer is a state in which a patient has insufficient physiological or psychological energy to endure or complete required or desired activities. This is characterized by fatigue, weakness, discomfort on exertion, dyspnea, and verbalization of no interest in activity. Adequate tissue perfusion Answer -Tested with cap refill, HR, BP. mucous membrane color, peripheral pulses -Are the tissues getting their required amount of blood needed to function? -Needed for healing ADL's Answer Activities of Daily Living such as eating, dressing, bathing. ADPIE Answer -Assessment: data collection and recording -Diagnosis: statement of problem/ ND's -Planning: making goals to identify/treat/prevent (begins with first contact) -Implementation: implementing care/ goals -Evaluation: were the goals met? Assessing pulses Answer - document rate, rhythm, symmetry, strength (+1,+2, +3) -assese bilaterally Bladder Training Answer - technique for urinary incontinence that Involves placing a patient on a toileting schedule. -intervention for stress incontinence Body mechanics Answer the proper use of the body to facilitate lifting and moving and prevent injury -Wide base of support, pull towards center of gravity -No bending or twisting the spine -Sliding, rolling and pushing require less energy than lifting Caring for other cultures Answer - Be respectful -Use a hospital interpreter if available -Avoid being bias, believing your culture in better (ethnocentrism), cultural stereotyping, negative attitude (prejudice), or discrimination/ racism - Use therapeutic communication Caring for unresponsive client Answer -Never stick your hands in their mouth while performing oral care. Have a yankauer readily available. -Maintain airway ( - prevent injury -reposition every 2 hours Colostomy Answer More solid than ileostomy - changed every 3-5 days -Skin around must be clean and dry - Stoma should be red/pink and moist (cyanotic or dark colored is bad) -wafer fits snuggly - warm water and mild soap to clean -Stoma should only bleed when its new Death and dying interventions Answer - Palliative care - minimize loneliness, fear, depression - maintain client's security, self-confidence, dignity, and self- worth - help client accept losses - provide physical comfort - hygiene -controlling pain -relieving respiratory difficulties -assist with movement, nutrition, hydration and elimination -provide spiritual support -support the family Dehydration interventions Answer -Push fluids (IV or PO) - water soluble foods Dehydration S&S Answer -Xerostomia (dry mouth) - Skin tenting - Dark urine - vomiting/ diarrhea - headache -confusion -dizziness - cramps - increased HR -Decreased BP -Increased RR -constipation -weak, thready pulse DNR Answer (Do Not Resuscitate) An order that tells medical professionals not to perform CPR. Fear r/t procedures Answer -therapeutic communication and educate (open-ended questions) fecal occult blood test Answer -Test for blood in the stool -can detect colorectal polyps -false positives: red meat, vitamin c, pain relievers, menestruating