NR 226 Exam 3

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Chamberlain University

NR-226: Fundamentals – Patient Care

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Date

NR 226 Fundamentals of Nursing – Exam 3

Chapter 21: Managing Care

1. Prioritizing Patient Care

Why is prioritizing patient care important?
Prioritizing patient care is crucial because it enables nurses to identify the interrelationships between various patient problems, thus preventing delays in necessary interventions. This proactive approach helps avoid potential complications that could negatively affect patient outcomes. Nurses must act swiftly to stabilize conditions and always follow the ABC principle—airway, breathing, and circulation—when determining priority actions.

Levels of Priority
Patient needs are generally classified into three categories:

Priority Level	Description	Example
High	Life-threatening or safety-compromising situations requiring immediate intervention.	Obstructed airway, acute respiratory distress.
Intermediate	Urgent, but not immediately life-threatening; addresses actual or potential health needs.	Educating a patient about a new medication, managing post-operative pain.
Low	Needs not directly related to the illness; often long-term or developmental.	Preparing a new patient for discharge teaching.

2. Types of Nursing

What are the main nursing care delivery models and their characteristics?

1. Primary Nursing
   In this model, a single registered nurse (RN) assumes full responsibility for managing a patient’s care plan throughout their stay. It promotes direct nurse-to-nurse communication and fosters continuity of care. While it allows for a strong therapeutic relationship, it can be less cost-effective and requires approval from the primary nurse for care plan changes.
2. Total Patient Care
   The RN is responsible for all aspects of patient care during their shift. This method encourages holistic care but can be costly due to the need for a high RN-to-patient ratio. Communication lapses may disrupt continuity.
3. Functional Nursing
   Tasks are divided among the healthcare team, with each member assigned specific duties. While efficient for large patient loads, it can fragment care and reduce patient satisfaction.
4. Case Management
   This model focuses on coordinating and linking services to ensure quality while controlling costs. It is collaborative and goal-oriented but often involves less direct patient contact.
5. Team Nursing
   A team leader (usually an RN) directs a group that may include RNs, LPNs, and medical assistants. This approach allows for task delegation but requires strong leadership skills to maintain communication and patient connection.

3. Magnet Hospitals

What defines a Magnet Hospital?
Magnet Hospitals are recognized for nursing excellence, innovation, and high-quality patient outcomes. They foster autonomy, evidence-based practice, and collaborative relationships among staff. Nurses in these institutions have greater control over their practice environment, leading to improved job satisfaction and patient care.

4. Delegation (Including to Medical Assistants and LPNs)

How is delegation defined and what are the “Five Rights of Delegation”?
Delegation is the process of assigning responsibility for specific tasks while retaining overall accountability for patient outcomes. Before delegating, the nurse should assess the skill level of the individual, clearly communicate expectations, and provide supervision.

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Five Rights of Delegation

Right	Description
Right Task	Must be routine, non-invasive, and carry minimal risk.
Right Circumstance	Appropriate given patient condition and available resources.
Right Person	Assign to a person with the proper training and competence.
Right Direction/Communication	Provide clear, specific instructions and maintain open dialogue.
Right Supervision/Evaluation	Monitor performance, provide feedback, and intervene if necessary.

Chapter 24: Communication

1. Communication Techniques for Special Needs

What techniques should be used for patients with cognitive, hearing, or vision impairments, or those unable to speak?

Patient Condition	Communication Strategies
Cognitive Impairment	Speak in simple sentences, ask one question at a time, allow time for responses, and involve family members in discussions.
Hearing Impairment	Reduce background noise, gain the patient’s attention before speaking, face them so they can see your lips, speak clearly at a normal volume, and provide interpreters if necessary.
Visual Impairment	Use a normal tone, avoid glare with indirect lighting, and provide printed materials in large font (14-point or larger).
Unable to Speak	Listen attentively, be patient, ask yes/no questions, use visual cues or assistive communication devices.

2. Communication Techniques (Parroting, Clarifying, Focusing, Paraphrasing)

What are the differences between parroting, clarifying, focusing, and paraphrasing?

• Parroting – Simply repeating what the patient says; not the same as paraphrasing.
• Clarifying – Asking the patient to explain or rephrase to ensure understanding; can involve asking for examples.
• Focusing – Directing conversation toward important topics without interrupting the patient’s flow.
• Paraphrasing – Restating the patient’s message in your own words to confirm understanding and show active engagement.

3. SBAR (Situation–Background–Assessment–Recommendation)

How is SBAR used in nursing communication?
SBAR is a structured method for communicating patient information clearly and effectively, especially during handoffs or when reporting significant changes.

Component	Description
Situation	State the patient’s name, admitting diagnosis, and the immediate concern.
Background	Provide relevant medical history, treatments, allergies, and code status.
Assessment	Share current vital signs, assessment findings, recent labs, pain status, and ongoing treatments.
Recommendation	Suggest a course of action, further testing, or immediate interventions.

4. Communication Types

Type	Definition
Therapeutic Communication	Encourages expression of thoughts and feelings, shows respect, and supports patient well-being.
Non-Therapeutic Communication	Blocks or hinders communication, discourages expression, and may damage rapport.

5. Zones of Personal Space

Zone	Distance	Examples of Use
Intimate	0–18 in	Physical assessment, bathing, dressing changes.
Personal	18 in–4 ft	Bedside conversation, patient history-taking.
Social	4–12 ft	Teaching a class, family support group.
Public	12+ ft	Lectures, public speaking.

Chapter 50: Care of the Surgical Patient

1. Surgical Classifications

What are the main categories of surgical procedures and their purposes?

Classification	Definition	Examples
Urgent	Needed to preserve health or prevent further problems but not an immediate emergency.	Removal of gallbladder with stones, excision of cancerous tumor.
Elective	Performed by choice; not essential for health.	Hernia repair, breast reconstruction.
Emergency	Must be done immediately to save life or preserve function.	Repair of perforated appendix, control of internal bleeding.
Major	Extensive reconstruction or alteration of body parts; high risk.	Coronary artery bypass, colon resection.
Minor	Minimal alteration; low risk.	Tooth extraction, minor cosmetic surgery.
Diagnostic	Performed to confirm diagnosis.	Biopsy, exploratory laparotomy.
Ablative	Removal of diseased body part.	Amputation, cholecystectomy.
Palliative	Relieves symptoms without curing disease.	Colostomy, debridement.
Reconstructive/Restorative	Restores function or appearance.	Scar revision, fracture fixation.
Procurement for Transplant	Removal of organs from a donor.	Kidney transplant.
Constructive	Corrects congenital defects.	Cleft palate repair.
Cosmetic	Improves appearance.	Rhinoplasty, breast augmentation.

2. Malignant Hyperthermia

A rare but potentially fatal reaction to certain anesthetic agents, malignant hyperthermia is an inherited disorder. It results in increased CO₂ (hypercarbia), rapid breathing, fast heart rate, abnormal heart rhythms, unstable blood pressure, skin mottling, and muscle rigidity. The condition often occurs during anesthesia induction or with repeated exposures. Continuous temperature monitoring during surgery is vital.

3. Preoperative Care

Key actions before surgery include: explaining surgical steps, reviewing the pre-op checklist, assessing physical and mental readiness, reinforcing teaching, establishing IV access (usually 18-gauge), monitoring vital signs, and completing anesthesia assessment.

4. Post-Anesthesia Care

PACU nursing priorities include: monitoring vital signs, respiratory and cardiovascular status, peripheral circulation, pain, motor and sensory function, wound condition, temperature regulation, neurological orientation, IV patency, and skin integrity. Nausea, vomiting, and positioning needs are also assessed.

5. Types of Anesthesia

Type	Purpose	Complications	Nursing Implications
General	Produces complete unconsciousness and lack of sensation.	Cardiovascular/respiratory depression, liver/kidney damage.	Monitor airway, vital signs, and recovery closely.
Regional	Numbs a specific region without loss of consciousness.	Hypotension, respiratory compromise.	Monitor BP, respiratory rate, extremity positioning.
Local	Loss of sensation at targeted site.	Motor or autonomic loss.	Watch for allergic reactions; assess mobility after.
Conscious Sedation	Reduces anxiety and pain while keeping patient responsive.	Airway obstruction.	Monitor ability to maintain airway and respond.

6. Time-Out Procedure

Before incision, all surgical team members pause to confirm the patient’s identity, procedure, and surgical site. This safety step prevents wrong-site, wrong-procedure errors.

7. Circulating Nurse vs. Scrub Nurse Roles

Role	Duties
Circulating Nurse	RN; manages environment, reviews assessments, assists as needed, verifies counts, documents procedure.
Scrub Nurse	RN, LPN, or surgical tech; maintains sterile field, passes instruments, assists with draping, verifies counts.

8. Surgical Risk Factors and Implications

Risk Factor	Implications
Age	Infants and older adults have higher risks due to immature or declining physiological reserves.
Nutrition	Poor nutrition delays healing; minimum 1500 kcal/day needed for recovery.
Obesity	Impairs ventilation and wound healing; higher infection and dehiscence risk.
Obstructive Sleep Apnea	Increases oxygen desaturation risk during and after anesthesia.
Immunocompromise	Higher infection risk.
Fluid/Electrolyte Imbalance	Risk of dysrhythmias and poor healing.
Pregnancy	Surgery only if urgent; risk to fetus.

9. Positioning During Surgery

Patients are positioned after anesthesia to optimize surgical site access, maintain circulation, protect skin integrity, and prevent nerve injury. Proper alignment is maintained to prevent complications.

NR 226 Exam 3

10. Aldrete Score

Used in PACU to assess readiness for discharge. Score is taken at set intervals, with 8–10 required for transfer. Criteria include activity, respiration, circulation, consciousness, and oxygen saturation.

11. Surgical Site Infection Prevention

Includes pre-op antibiotics, antiseptic bathing, hair clipping with clippers instead of razors, and surgical site skin prep.

Chapter 43: Pain Management

1. Gate Control Theory of Pain

This theory explains that pain signals can be blocked or allowed through “gates” in the spinal cord. Non-drug interventions such as massage or heat therapy help “close” these gates, reducing perceived pain.

2. Pain in Older Adults

Older adults metabolize drugs slower due to reduced liver and kidney function, increasing the risk for toxicity. They may also have altered absorption of topical medications.

3. Pain Management Interventions

Non-pharmacological methods: distraction, prayer, relaxation, guided imagery, massage, heat/cold therapy, and TENS.
Pharmacological methods: NSAIDs, opioids, adjuvant drugs.

4. Types of Pain

Type	Origin	Example
Visceral	Organs	Bowel obstruction.
Somatic	Musculoskeletal	Fracture pain.
Peripheral Neuropathic	Nerve injury	Diabetic neuropathy.
Central Neuropathic	CNS injury	Phantom limb pain.

5. Opioid Concerns

Term	Definition
Tolerance	Decreased drug effect with repeated use.
Physical Dependence	Withdrawal symptoms if abruptly stopped.
Addiction	Compulsive drug use despite harm.

Chapter 42: Sleep

1. Promoting Sleep

Strategies include creating a comfortable environment, establishing consistent routines, ensuring safety, reducing stress, and avoiding caffeine before bed.

2. Stages of Sleep

Stage	Features
NREM 1	Light sleep, easily awakened.
NREM 2	Sounder sleep, body functions slow.
NREM 3 & 4	Deepest sleep, restorative.
REM	Vivid dreaming, brain activity high, body immobile.

3. Sleep Disorders

Includes insomnia, sleep apnea, narcolepsy, parasomnias, cataplexy, and sleep deprivation.

Chapter 46: Bowel Elimination

1. Bristol Stool Scale

Type	Description
1	Hard lumps; difficult to pass.
4	Smooth, soft sausage-like stool (ideal).
7	Watery, no solid pieces.

2. Enemas

Type	Purpose	Notes
Cleansing	Removes feces before surgery/tests.	Tap water, saline, hypertonic, soapsuds.
Oil Retention	Softens stool for easier passage.	Retain for several hours.

3. Colon Cancer Screening

FOBT detects microscopic blood in stool, done at home or in clinical settings.

Medication Dosage & IV Flow Rate Calculations

Formulas

• Tablets (Have/Ordered): Amount to give = (Ordered ÷ Have)
• Liquids: (Ordered ÷ Have) × mL
• Drip Rate: (Volume × Drip Factor) ÷ Time in minutes
• Pump Rate: Total Volume ÷ Total Hours

References

American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). ANA.

Ignatavicius, D., & Workman, M. (2021). Medical-surgical nursing: Concepts for interprofessional collaborative care (10th ed.). Elsevier.

NR 226 Exam 3

Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2023). Fundamentals of nursing (11th ed.). Elsevier.

World Health Organization. (2020). WHO guidelines on hand hygiene in health care. WHO Press.