Exam 2015, questions - term 2 PDF

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Term 2...

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Examination Cover Page

Examination Period: Academic Institution: Academic Group: Academic Career: Examination Type:

AFFIX STUDENT ID STICKER HERE

2015 Term 2 Central Queensland University Higher Education Division Undergraduate Standard

I have read and understood the penalties involved if I do not abide by the rules outlined on the back of this examination paper. Student Signature: Student ID Number Course: Subject Area: Catalog Number: Paper Number: Component:

Foundations of Nursing Practice 1 NURS 11149 1 ALL Components

Duration: Perusal Time: First Contact: Second Contact:

120 minutes 15 minutes Kerry Reid-Searl Sandra Walker - walkers

Restrictions:

Closed Book

Contact Number: Contact Number:

0749309741 0749302176

Office Use: Release examination paper via the CQ University Past Exams website two weeks after the DE/SE examination period? Yes

Instructor Authorised/Allowed Materials Dictionary - non-electronic, concise, direct translation only (dictionary must not contain any notes or comments). No Calculators Permitted

Special Instructions to Students: Please see instruction sheet on first page of the examination paper.

Examination Office Supplied Materials 1 x Rough Paper

QUESTIONS ANSWERED

MARKS

QUESTIONS ANSWERED

MARKS

Number of examination answer booklets used: Number of separate sheets attached (Do not include rough paper):

This examination paper is not to be released to the student at the conclusion of the examination. Central Queensland University considers improper conduct in examinations to be a serious offence. Penalties for cheating are exclusion from the University and cancellation with academic penalty from the course concerned.

Term 2 Standard Examination 2015 Foundations of Nursing Practice 1 — NURS11149

Instructions Sheet

1.

The exam is worth a total of 50 marks.

2.

Write all answers in the spaces provided in this examination paper.

Page 1 of 15

Term 2 Standard Examination 2015 Foundations of Nursing Practice 1 — NURS11149

Question 1

2.5 Marks

Hand hygiene saves patients’ lives. A nurse should conduct hand hygiene on a regular basis. The World Health Organization recommends adherence to the ‘Five (5) Moments’. You are required to obtain a patient’s vital signs. State what each moment of hand hygiene is when undertaking a patient’s blood pressure: Moment 1. ________________________________________________________ Moment 2. ________________________________________________________ Moment 3. ________________________________________________________ Moment 4. ________________________________________________________ Moment 5. ________________________________________________________ Question 2

0.25 Mark

Hands should be visibly _________________prior to using ABHR. Question 3

0.25 Mark

If a nurse is in direct contact with excreta or secretions considered ‘dirty activities’, they should clean their hands with________________. Question 4

0.25 Mark

The most important nursing technique to prevent and control transmission of infection is ____________________________________. Question 5

2.5 Marks

Nurses use personal protective equipment (PPE) as part of standard and transmission based precautions. Once PPE is donned and care is provided, the nurse must then remove in a sequential order. If the nurse has gloves, mask, apron and goggles on, the order of removal is as follows: 1. _________________________________________________________________ 2. _________________________________________________________________ 3. _________________________________________________________________ 4. _________________________________________________________________ Page 2 of 15

Term 2 Standard Examination 2015 Foundations of Nursing Practice 1 — NURS11149 Question 6

1.0 Mark

The nurse is caring for a patient who requires transmission based airborne precautions. The single type of PPE absolutely required is: ______________________________. Question 7

1.5 Marks

Describe the following types of stools according to the Bristol stool chart. Type One:

________________________________________________

Type Five:

________________________________________________

Type Seven: ________________________________________________ Question 8

2.0 Marks

Vital signs are important indicators of a patient’s status. Nurses need to understand the terminology associated with vital signs. Define the following: Tachycardia _______________________________________________________ Hypotension _______________________________________________________ Bradypnoea _______________________________________________________ Febrile

_______________________________________________________

Question 9

0.25 Mark

In measuring an adult’s blood pressure, the systolic reading is best described as_______________________________________________________________. Question 10

0.25 Mark

In the process of auscultation of blood pressure, it is important that the nurse applies the cuff correctly. The position should be about ___________cm above the antecubital space.

Page 3 of 15

Term 2 Standard Examination 2015 Foundations of Nursing Practice 1 — NURS11149 Question 11

0.5 Mark

When measuring a patient’s blood pressure, the correct size cuff is important. If the cuff is too large the nurse can expect the blood pressure to be _________________________________________________________________. Question 12

0.25 Mark

When assessing respirations, the nurse knows that an accurate measurement is gained by counting the respiratory rate for ____________________seconds. Question 13

2.0 Marks

State four (4) characteristics, specific to assessing a patient’s respirations, that the nurse should consider. 1. ________________________________________________________________ 2. ________________________________________________________________ 3. ________________________________________________________________ 4. ________________________________________________________________ Question 14

2.0 Marks

Correct documentation of vital signs is important as part of recognizing the deteriorating patient. When documenting vital signs on early warning tools (ADDS), the nurse should: 1. ________________________________________________________________ 2. ________________________________________________________________ 3. ________________________________________________________________ 4. ________________________________________________________________

Question 15

0.25 Mark

A nurse is caring for an elderly patient who is confined to bed. The nurse notices a broken area of skin on the patient’s sacrum. This is most likely to be a stage ________________pressure injury. Page 4 of 15

Term 2 Standard Examination 2015 Foundations of Nursing Practice 1 — NURS11149 Question 16

0.25 Mark

When calculating the overall intake and output for a patient on a fluid balance chart, the nurse notices that the patient has a less input than output. This means that the patient is in a _________________________ balance. Question 17

0.25 Mark

A patient who is able unable to weight bear and is required to be transferred with two or more persons would be mobility coded as __________________________. Question 18

1.0 Mark

Prior to transferring a person out of bed to a chair the nurse would complete the following 4 steps: 1.__________________________________________________________________ 2.__________________________________________________________________ 3.__________________________________________________________________ 4.__________________________________________________________________ Question 19

0.25 Mark

When undertaking a physical assessment the term used for tapping is: ________________________________________________________. Question 20

2.0 Marks

State eight (8) legal responsibilities required of the nurse when documenting in patient progress notes. 1. ________________________________________________________________ 2. ________________________________________________________________ 3. ________________________________________________________________ 4. ________________________________________________________________ 5. ________________________________________________________________ 6. ________________________________________________________________ 7. ________________________________________________________________ 8. ________________________________________________________________ Page 5 of 15

Term 2 Standard Examination 2015 Foundations of Nursing Practice 1 — NURS11149 Question 21

2.0 Marks

Nurses have a responsibility to prevent harm occurring to patients whilst in their care. Pressure Injury prevention is the responsibility of all nurses. Explain four (4) factors that may contribute to a person sustaining a pressure injury. 1. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 4. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Question 22

2.5 Marks

Consider the following scenario: Samantha Doby is a 75 year old female admitted to the surgical ward following an appendicectomy. Samantha has a medical history of diabetes mellitus Type II and no previous surgical history. Samantha is on a regular hypo glycaemic medication. It is now two days post operation. Samantha rings the call bell and tells you that she has been vomiting and feels dizzy. Samantha’s vital signs are: pulse 110 beats per minute, temperature 35.6 degrees Celsius, blood pressure 100/60mm Hg, Oxygen saturations of 98% in room air and respirations 16 breaths per minute. Her Blood glucose level is 1.0 mmol. You contact the Doctor using the ISBAR approach. The Doctor responds stating to give Samantha a sweet drink and that she will review Samantha in 15 minutes. What information in relation to the above scenario would be included under each of the headings of ISBAR? Question 22 continued over the page.

Page 6 of 15

Term 2 Standard Examination 2015 Foundations of Nursing Practice 1 — NURS11149 Question 22 (continued).

I -________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ S - ______________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ B - ______________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ A - ______________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ R - ______________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

Questions 23 and 24 relate to the following: Mrs James is a frail 85 year old visually impaired patient, who has recently experienced a cerebral vascular accident (stroke). She has weakness on her left side. Mrs James has hypertension. She is incontinent, wears glasses and is on antihypertensive medications. Mrs James is at risk of falls, pressure injuries and skin tears. Mrs James is alert, however does require the assistance of two persons with all patient transfers. Question 23

2.0 Marks

Describe four (4) strategies that you would implement to ensure that Mrs James does not sustain a skin tear.

Question 23 continued over the page. Page 7 of 15

Term 2 Standard Examination 2015 Foundations of Nursing Practice 1 — NURS11149 Question 23 (continued). 1.

_______________________________________________________________ ______________________________________________________________

2.

_______________________________________________________________ ______________________________________________________________

3.

_______________________________________________________________ _______________________________________________________________

4.

_______________________________________________________________ ______________________________________________________________

Question 24

3.5 Marks

Identify seven (7) risk factors that exist for Mrs James in regards to sustaining a fall and the relevant strategy (specific to the risk) to prevent a fall. 1.

_______________________________________________________________ _______________________________________________________________ _______________________________________________________________

2.

_______________________________________________________________ _______________________________________________________________ _______________________________________________________________

3.

_______________________________________________________________ _______________________________________________________________ _______________________________________________________________

4.

_______________________________________________________________ _______________________________________________________________ _______________________________________________________________

5.

_______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Question 24 continued over the page. Page 8 of 15

Term 2 Standard Examination 2015 Foundations of Nursing Practice 1 — NURS11149 Question 24 (continued). 6.

_______________________________________________________________ _______________________________________________________________ _______________________________________________________________

7.

_______________________________________________________________ _______________________________________________________________ _______________________________________________________________

Question 25 and 26 relate to the following scenario. Jill Smith is patient admitted to hospital with cardiac failure. Jill’s date of birth is the 21/02/56. Her UR is 30447. Jill has been commenced on a fluid balance chart. You are the nurse who has been caring for Jill for the afternoon shift commencing at 1530hrs and finishing at 2300 hrs. Question 25

2.5 Marks

State five strategies that the nurse would implement in order to maintain an accurate daily fluid balance chart. 1. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 4. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Question 25 continued over the page.

Page 9 of 15

Term 2 Standard Examination 2015 Foundations of Nursing Practice 1 — NURS11149

Question 25 (continued).

5. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

Question 26

3.5 Marks

Using the chart below, please enter all relevant records of Jill’s fluid input and output based on the information below. Input

Output

Afternoon tea 1500 hrs: 1 piece of bread, 250 mls coffee, yoghurt 225mls. Dinner 1800 hrs. Soup 160 mls, potatoe, peas, fish, carrots, water 225 mls, tea 300 mls.

1600 hrs. 150 mls urine 1800 hrs. 200mls urine 1900 hrs. 300 mls vomit 2000 hrs. 200 mls urine 2000 hrs. Feaces Type 4

Question 26 continued over next page.

Page 10 of 15

Term 2 Standard Examination 2015 Foundations of Nursing Practice 1 — NURS11149 Question 26 (continued).

DATE Time

Family Name: Given Names: Address: Date of Birth: Sex: □M □F

CQUNIVERSITY HOSPITAL 24 HOUR FLUID BALANCE CHART INTAKE Oral Intake NGT

Vol.

Intravenous Fluid

OUTPUT Vol.

Urine

NGT Aspirate

Vomitus

Drain

Drain

Faeces

0100 0200 0300 0400 0500 0600 0700 SUB TOTAL 0800 0900 1000 1100 1200 1300 1400 1500 SUB TOTAL 1600 1700 1800 1900 2000 2100 2200 2300 2400 SUB TOTAL Carry forward remaining fluid to next day TOTAL TOTAL INTAKE:

mls

TOTAL OUTPUT:

Transfer totals to DAILY FLUID SUMMARY

Page 11 of 15

mls

Comments

Term 2 Standard Examination 2015 Foundations of Nursing Practice 1 — NURS11149 Question 27 and 28 relate to the following Joe Mills is a 58 year old man who has experienced a cerebral vascular accident (stroke) and has now been commenced on solid foods. Joe has a good swallowing reflex but he still has weakness on his left side including his arm. Question 27

2.0 Marks

It is meal time. As the nurse, you are conscious of the need to protect meals times for patients. In caring for Joe, identify four (4) strategies that you would implement to assist Joe with his meal. 1.

_______________________________________________________________ _______________________________________________________________ _______________________________________________________________

2.

_______________________________________________________________ _______________________________________________________________ _______________________________________________________________

3.