Final Exam: NR224 / NR 224 (Latest Update 2024/2025) Fundamentals: Skills Review| Complete Guide with Questions and Verified Answers| 100% Correct -Chamberlain
Final Exam: NR224 / NR 224 (Latest Update
2024/2025) Fundamentals: Skills Review|
Complete Guide with Questions and Verified
Answers| 100% Correct -Chamberlain
Q: what does PRN mean?
Answer:
as needed
Q: who is ultimately responsible for the med error?
Answer:
when you give the wrong med or dose, YOU are legally responsible for the error (not the
physician or phar- macy)
Q: how do we prevent medication errors?
Answer:
-important that during transitions in care we reconcile medications!
-follow seven rights of med administration
-only prepare one client’s meds at a time
-do the three med checks
-clarify orders as needed (illegible, unusually large/small doses, etc.)
-double check all calculations
-don’t allow other activities to interrupt med pass
-be vigilant when handling & administering high-risk medications
-use smart pumps when administering IV meds
Q: how many times do we check the rights and where do these checks occur?
Answer:
-1st check: in med room, while preparing medication check it against the MAR
-2nd check: after prep, re-check med against MAR ensuring right drug, right dose, right route, &
right time
-3rd check: at bedside, re-check med & compare to MAR at bedside ensuring right drug, right
dose, right route, right time, & right patient (with 2 patient identifiers)
Q: How do we verify the patient? How many identifiers do we need? What counts as patient
identifiers?
Answer:
verify patient with 2 identifiers by asking them for their name and DOB, and check that it
matches their wristband; never use room number as identifier
Q: what are the 7 rights of medication administration?
Answer:
-right patient
-right medication
-right dose
-right route
-right time
-right documentation
-right indication/reason
Q: can you crush an extended release or enteric coated pill?
Answer:
no
Q: if someone has no problem swallowing what position should the bed be in when giving
medications?
Answer:
at least 30 degrees, does not matter if they have no problem swallowing
Q: you crush a pill to administer through a feeding tube, what do you mix it with?
Answer:
sterile water
Q: you are checking the residual on a feeding tube prior to giving meds, and there is a lot of
gastric content. What does this mean and what do you do?
Answer:
this means that things are not being digested. You should call the provider and get the order
decreased for the dosage.
Q: what is a guaiac stool test?
Answer:
-measures microscopic amounts of blood in feces
-useful in colon cancer screening
-repeat test 3 times with 3 separate bowel movements
-blue color indicates positive test
Q: what test is used to look for blood in the stool?
Answer:
guaiac stool test
Q: serous
Answer:
clear, watery plasma
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Constipation Condition characterized by difficulty in passing stool or an infrequent passage of hard stool
diarrhea increase in the number of stools and the passage of liquid, unformed feces
flatulence the passage of gas out of the body through the rectum
fecal incontinence inability to control passage of feces and gas from the anus
What are some factors that affect bowel elimination? – age – diet – fluid intake – physical activity – psychological factors – personal habits – position during defecation – pain – pregnancy surgery and anesthesia – medications -diagnostic test
What should patients be educated on? (such as diet, fluids, exercise, etc.) Healthy food diet, adequate amount of fluids, and daily excercise (?)
What are some foods that promote bowel elimination? Leafy greens, whole grain, berries, avocados, and walnuts (?)
What type of diet should the patient be on to promote bowel regularity? foods that contain a lot of fiber
a. What are the different types of enemas? Cleansing enemas (tap water, normal saline, hypertonic solutions, soapsuds), oil retention, medicatated (carminative and kayexalate)
a. When/why do we use enemas? a prescribe bowel preparation (laxatives of enemas) to ensure that the bowel is empty; to promote defecation by stimulating peristalsis; volume of fluid instilled breaks up fecal mass, stretches rectal wall, and initiates defecation reflex
If the patient experiences complications during enema administration, what do we do?
You’re administering a tap water enema, the patient states he is having abdominal cramps, what should you do? Lower the bag to lower the rate
When does a patient need digital removal of stool? If the enemas fail to remove an impaction; last resort in managing severe constipation
a. How do you use a bedpan appropriately? What position should the patient be in? The proper position for the patient on a bed pan is with the head of the bed elevated 30 to 45 degrees; in a sitting position; roll patient onto bed pan if they cannot lift their hips
a. What does it mean to put a patient on a bowel training program? How does it work/what do we do? patient with chronic constipation or fecal incontinence; set up a daily routine and try to defecate at the same time each day to promote a regular pattern. measures microscopic amo
a. What is a guaiac stool test? What does it check for? measures microscopic amounts of blood in feces; useful for colon cancer screening; repeat 3 times with 3 separate bowel movements; blue color indicates positive test
a. How do we collect a stool sample? What do we do with it once it’s collected?
What are the 7 rights of medication administration? Right…patientmedicationdoseroutetimedocumentationindication/reason
How many times do we check the rights? Where do these checks occur? Check accuracy three times
Where do these medication checks occur? 1. in the med room, preparing medications against the mar2. after preparing the medication, against the mar (right drug, dose, route, right time)3. patient’s bedside, recheck medication compare to mar, with two identifiers (right drug, dose, route, right time)
a. How do we verify the patient? How many identifiers do we need? What counts as patient identifiers? two, pt name and DOB, match to wristband
a. How do we prevent medication errors? – reconcile medications- follow seven rights of med administration – only prepare one pt’s meds at a time – do three med checks- clarify orders as needed- double check all calculations- don’t allow other activities to interrupt med pass- be vigilant when handling and administering high risk medication- use smart pumps when administering IV meds
And who is ultimately responsible for the med error? when you give the wrong medication or wrong dose, YOU are legally responsible for the error (not the physician or pharmacy)
a. What are does PRN mean? Whenever there is a need
a. What steps do you need to take when getting a verbal or telephone order? – ensure prescription is complete and correct – read back- ensure correct spelling- remind provider to verify prescription and sign it to facility policy – write or enter prescription on medical record- if possible have 2nd nurse listen on the line.
a. What should the nurse do if they have a question about an order or can’t read the order? Who should the nurse clarify the order with? read/back or clarify with the provider
a. What is important to teach patients about self-administration? teach proper med administration, monitoring their side effect/ therapeutic effects, what meds to take, why, when, and how often to take them
a. How do we know teaching has been effective? What is the teach-back or return demonstration? have the patient do the actions with you, and using the teach back method
a. What happens if you drop medication on the floor or countertop? discard of the med properly; do not us it
Subcutaneous Injections Subcutaneous injections involve placing medications into the loose connective tissue under the dermis. injection sites include the outer posterior of the upper arms, the abdomen, and the anterior aspects of the thighs
intramuscular injection The intramuscular (IM) injection route deposits medication into deep muscle tissue, which has a rich blood supply, allowing medication to absorb faster than by the subcutaneous route. @ 90 degrees
How do we administer subcutaneous injections? What angles of injection are used for subcutaneous injections? 45 – 90 degrees; clean, pinch, inject, release, remove
How do we apply transdermal patches? – wash the skin with soap and water and dry it thoroughly- place the patch on a hairless area and rotate sites to prevent skin irritation – document location, application, and removal
Location of transdermal patches? where the patient prefers (idk)
What should we do to the skin prior to applying transdermal patches? clean the area
Know how to read a MAR and identify what medications you would give based on time, meds due, and patient assessment
Be aware of PRN meds (should we give?) We should give the medication as needed
Meds with parameters (should we give or hold)
i. How many tablets to administer to a patientii. How many mL/hr for an IViii. Given mg/kg and a patient’s weight, how many mgiv. If given a MAR and a patient’s blood glucose level, know how much insulin to give a patient given their blood glucose level, and a scheduled dose and a sliding scale
What are standard precautions? When should standard precautions be used? used to prevent and control infection and its spread- hand hygiene, hand antiseptic before and after, or washing hands when visibly soiled and scrubbing – clean gloves are worn when touching anything that has the potential to contaminate – mask, eye protection and face shield, when there may be splashing or spraying
Contact with bodily fluids what precaution Wearing gloves, eye protection, gown, and mask (?)
Airborne precautions and ppe small droplets: TB, COVID- a negative pressure room- respirator or mask, gown MTV (measles, TB, varicella) is on AIR
Droplet precautions and ppe large droplets that trave 3- 6 ft, influenza/ pneumonia- private room or a room with other clients who have the same infectious disease- mask -gown and gloves- face shield, goggles PIMP my ride is here to DROP off my car
contact precautions and ppe scabies, mrsa, wound infections-private room or room with other clients who have the same infection – gloves and gown
What type of room is the patient should patients with airborne precautions be placed in (ie. Negative or positive pressure – which one)? negative
correct order to remove ppe gloves > goggles or face shield gown > mask or respirator > hand hygiene
What is the biggest thing we can do to reduce the spread of microorganisms? (ie. What is our priority action?) hand hygiene
How long do you wash your hands? at least 20 secs
normal vs? temp: 96.8 to 100.4 FHR: 60-100 bpmRR: 12-20 bpmBP: <120/80 mmHgSpO2: > 95%
a. What do you do if you get abnormal vital signs? Or if the NA comes to you with abnormal vitals? Reassess (?)
a. What should you assess for before taking someone’s vital signs? (think what questions you asked during the check-off) Eat or drink or smoke in the past 30 mins, mastectomy, AV fistulas, nail polish
i. How long do we wait to take a temperature if someone had a hot or cold beverage? wait 15 minutes
how should the blood pressure cuff be on their arm and arm placement – Sit in a chair, with the feet flat on the floor, the back and arm supported and the arm at heart level- no use nicotine or drink any caffeine for 30 min. prior to measurement- Rest for 5 min before measurement
Pressure Ulcer Stage I: non-blanchable erythema of intact skin (not broken through skin)
Pressure Ulcer Stage II: partial-thickness skin loss exposing dermis (breaks the top 2 layers of skin)
Pressure Ulcer Stage III: full-thickness skin loss (2 layers and fatty tissue)
Pressure Ulcer Stage IV: full-thickness skin loss and tissue loss (deep wounds that impact bone and muscle)
Pressure Ulcer Unstageable: obscured full-thickness and skin loss. (covered in slough and eschar)
i. Which ulcer has partial thickness skin loss? Stage II
Which pressure ulcer has full thickness skin loss? Stage III, IV, and unstageable.
What is the treatment for evisceration? Evisceration: protrusion of visceral organs through a wound opening.Treatment: place sterile gauze soaked in sterile saline over the extruding tissues to reduce changes of bacterial invasion and drying of tissues.
What special care do we need to consider if patients are incontinent of bowel or urine?
How do we minimize risk for skin breakdown or pressure ulcer development? Regularly changing a person’s lying or sitting position.
serous drainage clear, watery plasma
sanguineous drainage thick, yellow, green, tan, or brown
serosanguineous drainage pale, pink, water; mix of clear and red fluid
purulent drainage bright red; indicates active bleeding
a. How to prevent infection in a patient with a catheter?
i. Should the catheter be switched out frequently?
i. What do you want to check the catheter tubing for? For intactness to make sure that it is not torn or bent which indicates that something occurred within the body that should be checked out.
i. How often should the perineal area be cleansed? At least twice a day
i. When inserting an indwelling catheter for a female client, what are you going to ask her to do as the catheter is inserted? To bear down.
a. How do you collect a urine sample from a foley catheter? – Clamp foley tubing after urine accumulates- Clean off the port with alcohol, attach a syringe and draw back to get the urine- NEVER get the specimen from the foley bag
a. Overflow incontinence: constant leakage of small amounts of urine from a full bladder. Bladder will feel extended and palpable.
a. Stress incontinence: loss of urine with physical exception: coughing, sneezing, laughing
a. Urge incontinence: strong desire to urinate but patient can’t get to toilet in time
a. Reflex incontinence: neurological dysfunction; no warning
a. What assessment findings do you see in each? Stress incontinence: dribbling.
a. How do we protect the skin from getting excoriated? Keeping the area clean and dry.
a. What types of interventions are useful in incontinence? Pelvic Floor Exercises (Kegel). Diet Changes: limit fluids and caffeine.
a. What does COCA mean when assessing urine? color: yellow, white or dark, odor: does it smell like ammonia, consistency: clear, cloudy, mucous tissue and amount
a. What urine characteristics/output would indicate an infection? Foul odor > infection, sometimes food.Bloody urine > hematuria. Usually caused by infections like UTIs.
a. How do you perform trach care? •Hyperoxygenate and suction•Set up sterile field•Remove old dressing with clean gloves, remove gloves, wash hands•Open trach care kit, pour solution•Don sterile gloves, arrange sterile field, drape, place inner cannula in cleaning solution•Clean inner cannula, rinse, dry & replace•Clean face plate & stoma, assess for stoma drainage & s/s of infection•Replace dressing utilizing appropriate precautions with trach ties•Provide oral care•Maintain sterile technique
What nursing interventions/patient teaching are needed for trach care?
i. What do should we not do when suctioning a patient’s trach (ie. Putting saline into the lungs)? the use of normal saline instillation into the airway before suctioning is not recommended
How often/how many passes/how long for each pass in suctioning? limit introduction of the suction catheter to 2 times with each suctioning procedure
a. How do we know suctioning is effective? auscultate lung sounds
a. What do you need to teach client/family about suctioning at home? sterile saline should be used prior to insertion of suction device, DO NOT SUCTION WHEN FIRST PLACING THE TUBE IN THE TRACH, suctioning upon withdrawing intermittently for no longer than 10-15 seconds
i. After educating the client and caregivers about suctioning, how do you know that they are comfortable with the procedure and are ready for discharge? Teach back
a. When would we perform chest physiotherapy? Used for clients who cannot expectorate pulmonary secretions such as CF clients.
i. Nasal Cannula: Low Flow.
ii. Venturi: Used for COPD. High Flow.
iii. Non-rebreather: Low Flow.
iv. Simple Face Mask: Low Flow.
i. Nasal Cannula vs. Simple Face Mask Nasal Cannula: for 1-6 L of O2Simple Face Mask: for 6-12 L of O2. For patients who just had surgery, or just extubated.
i. What type of sign would be restlessness? Early sign of hypoxia
i. What type of sign is cyanosis? Late sign of hypoxia
A. What would be a priority nursing diagnosis for someone who has tachypnea?
Clear liquid diet: – It is made up of clear liquids and foods that are liquid at room temperature.- anything you can see through- Juice; cranberry, grape, apple; broth, jello, popsicles
full liquid diet orange juice, pudding, yogurt, ice cream, milk, tomato juice. Smoothie without fruit chunks. Protein shake; ensure boost.
Dysphagia diets: Mechanical soft; easy to chew. Ground or pureed. Thickened liquids; nectar or honey thick. No straws or ice.
a. What is milk considered? Full liquid diet.
a. What is orange juice considered? Full liquid diet.
a. What is cranberry or grape juice considered? Clear liquid diet.
a. What is vanilla ice cream considered? Full liquid diet.
a. What are some examples of lean proteins including skinless white turkey meat? Beans, peas, white-fleshed fish, low fat cottage cheese, lentils.
a. What are some examples of foods that contain caffeine including chocolate Chocolate, tea leaves, coffee beans
What are the steps to insert an NG tube -patient in high-fowler position-tube is measured from tip of nose to tip of earlobe to tip of xiphoid process-lubricate first 4 inches of tube-insert down & back towards patients’ ear-instruct patient to touch chin to chest, advancing as they swallow-hold tube until secured to the nose with tape-withdraw gastric content, test with pH paper
a. What are the ways to evaluate placement of the NG? What is the gold standard? Abdominal X-ray.
a. How do we administer feedings through an NG tube (what are the steps from bowel elimination lecture)?
a. When using an NG tube for nutrition, what patient safety considerations do we need to consider? What position should the patient be in?
What are the steps to removing an NG tube? How do you know when you can remove one?
a. What position should the patient be in when they are receiving enteral feeding via a tube? position client upright or elevate HOB minimum of 30 degrees (preferably 45 degrees)
a. Out of these four, who would need the most help?i. A young adult who is being discharged with a sprained ankle from the urgent care?ii. A middle-aged adult who is on antihypertensive medications?iii. An older adult who is getting up for the first time after surgery and has a history of falling?iv. An older adult who has chronic bronchitis and had their knee replaced 2 years ago? An older adult who is getting up for the first time after surgery and has a history of falling?
A. If a patient is confined to a bed, what intervention should be included in their care to prevent pressure injuries? Rotate the patient’s position regularly. Ambulation.
A. How do we keep patients safe during ambulation? Keep their path clear of any obstacles or clutter.
A. What happens if a patient falls while they are ambulating? What do you do if you are walking with them? You break their fall. Stand with feet apart to provide broad base of support. Extend 1 leg and let client slide against it to the floor. Bend knees to lower body as the client slides to the floor.
a. How do we measure crutches? Proper fit is adjusted based on patients’ height. 1-1.5 inch gap between axillae and rest pad of crutch. Hand grip even with top of their hip line, elbow needs to be slightly bent at 20-30 degrees
a. Where should the patient’s weight be resting? 4 point: patient will bear weight on both legs3 point: patient bear all weight on one foot while using both crutches2 point: partial weight bearing on both feetNO weight on the axillae, rest weight on hand grips
a. How does a patient walk using crutches when they have a three-point crutch gait? -client can bear weight on one leg/foot while using both crutches-affected leg doesn’t bear weight or touch the ground-move both crutches and injured leg together then move non-injured leg
A. Immobility/Prolonged bedrest what are some complications to watch for? i. Pressure Ulcer Formationii. Blood clot (thrombus) formationiii. Constipationiv. Respiratory Complicationsv. Decreased muscle mass
a. What are our priority nursing assessments? Priority nursing actions?
A. If a client is using a cane, what side of the body should it be on, strong or weak? Strong side.