Block 1 Final Exam Flashcards
1
Q
What are the 5 phases of the nursing process?
A
- Assess
- Diagnose
- Plan
- Implement
- Evaluate
2
Q
Nursing diagnoses related to a pressure ulcer.
A
- Impaired bed Mobility
- Imbalanced Nutrition
- Acute Pain r/t tissue destruction, exposure of nerves
- Impaired Skin integrity
- Risk for Infection)
- Risk for Pressure ulcer
3
Q
Nursing diagnoses related to nutrition
A
- Readiness for enhanced nutrition
- Imbalanced Nutrition: less than body requirements
- Obesity
- Overweight
- Risk for Overweight
4
Q
Nursing diagnoses related to bowel function
A
- Bowel Incontinence
- Constipation r/t decreased motility
- Diarrhea r/t increased gastrointestinal motility
- Deficient Fluid volume r/t fluid loss in bowel
- Imbalanced Nutrition: less than body requirements r/t nausea, vomiting
- Acute Pain r/t pressure from distended abdomen
- Risk for dysfunctional Gastrointestinal motility
5
Q
Nursing diagnoses related to urinary function
A
- Impaired urinary elimination
- Urinary retention
- Acute Pain: dysuria r/t inflammatory process in bladder
- Toileting Self-Care deficit r/t cognitive impairment
- Situational low Self-Esteem r/t inability to control passage of urine
- Risk for impaired Skin integrity: Risk factor: presence of urine on perineal skin
6
Q
Nursing diagnoses related to immobility
A
- Constipation r/t immobility
- Impaired physical Mobility
- Ineffective peripheral Tissue Perfusion r/t interruption of venous flow
- Powerlessness r/t forced immobility from health care environment
- Impaired Walking r/t limited physical mobility, deconditioning of body
- Risk for impaired Skin integrity
- Risk for Overweight
7
Q
Nursing diagnoses related to perfusion
A
- Risk for ineffective Cerebral tissue perfusion
- Ineffective peripheral Tissue Perfusion
- Risk for ineffective peripheral Tissue Perfusion
- Risk for ineffective Gastrointestinal perfusion
- Risk for ineffective Renal perfusion
- Risk for decreased Cardiac tissue perfusion
8
Q
Nursing diagnoses related to oxygenation
A
- Activity intolerance r/t imbalance between oxygen supply and demand
- Ineffective Breathing pattern r/t compromised cardiac or pulmonary function, decreased lung expansion, neurological impairment affecting respiratory center, extreme anxiety
- Impaired Gas exchange r/t alveolar-capillary damage
- Ineffective Airway clearance r/t excess tracheobronchial secretions
- Ineffective Breathing pattern r/t inflamed bronchial passages, coughing
- Fear r/t oxygen deprivation, difficulty breathing
- Risk for Suffocation: Risk factors: inflammation of larynx, epiglottis
9
Q
Nursing diagnoses related to heart failure
A
- Decreased Cardiac output r/t impaired cardiac function, increased preload, decreased contractility, increased afterload
- Fatigue r/t disease process with decreased cardiac output
- Fear r/t threat to one’s own well-being
- Excess Fluid volume r/t impaired excretion of sodium and water
- Impaired Gas exchange r/t excessive fluid in interstitial space of lungs
- Risk for Shock (cardiogenic): Risk factors: decreased contractility of heart, increased afterload
10
Q
Nursing diagnoses related to fluid and electrolyte imbalance
A
- Deficient Fluid volume r/t active fluid loss, vomiting, diarrhea, failure of regulatory mechanisms
- Risk for Shock: Risk factors: hypovolemia, sepsis, systemic inflammatory response syndrome (SIRS)
- Excess Fluid volume r/t compromised regulatory mechanism, excess sodium intake
- Risk for imbalanced Fluid volume
- Risk for Electrolyte imbalance: Risk factors: renal dysfunction, diarrhea, treatment-related side effects (e.g., medications, drains)
11
Q
Nursing diagnoses related to diabetes
A
- Ineffective Health maintenance r/t complexity of therapeutic regimen
- Imbalanced Nutrition: less than body requirements r/t inability to use glucose (type 1 [insulin-dependent] diabetes)
- Ineffective peripheral Tissue perfusion r/t impaired arterial circulation
- Risk for unstable blood Glucose level (See Glucose level, blood, unstable, risk for, Section III)
- Risk for impaired Skin integrity: Risk factor: loss of pain perception in extremities
- Readiness for enhanced Knowledge: expresses an interest in learning
12
Q
Nursing diagnoses related to sleep
A
- Readiness for enhanced sleep
- Fatigue r/t lack of sleep
- Sleep deprivation
- Insomnia
- Ineffective Breathing pattern r/t obesity, substance abuse, enlarged tonsils, smoking, or neurological pathology such as a brain tumor
13
Q
Nursing diagnoses should be prioritized according to Maslow’s Hierarchy of Needs. List Maslow’s Hierarchy of Needs starting with the most important.
A
- Physiologicial
- Safety
- Love/Belonging
- Esteem
- Self Actualization
14
Q
Levels of priority setting
A
- High (Life threatening),
- Intermediate (Health threatening)
- Low (non-emergency)
15
Q
What are high priority needs?
A
Life-threatening. Left untreated, will result in harm to the patient or others.
- Airway, breathing, circulation, vitals
- Mental status changes.
- Homeostasis (Temperature, Fluid, pH)
- Safety
- Pain
16
Q
What are intermediate priority needs?
A
Non-emergent, non-life threatening needs. E.g. “Risk for…”
17
Q
What are low priority needs?
A
Affect the client’s future well-being. Focus is on a patient’s long term health needs.
18
Q
What phase of the nursing process do interventions fall under?
A
Implementation
19
Q
What should nursing interventions be based on?
A
Evidence
20
Q
What allows you to consider the complexity of interventions, changing priorities, alternative approaches, and the amount of time available to act?
A
Critical thinking
21
Q
What is Florence Nightingale’s Environmental Theory of Nursing?
A
The belief that nursing could improve a patient’s environment to facilitate recovery and prevent complications.
22
Q
What are the Five Rights of Delegation?
A
- Right Task
- Right Circumstance
- Right Person
- Right Direction/Communication
- Right Supervision/Evaluation
23
Q
What must the RN ensure when delegating?
A
That the delegated action was completed correctly, documented, and evaluated.
24
Q
What sort of tasks may be delegated to UAP/NAPs?
A
Noninvasive and frequently repetitive interventions such as skin care, ambulation, vital signs on stable patients, and hygiene measures.
25
Define "standard of care".
Minimum level of care accepted to ensure high-quality care to patients. Standards of care define the types of therapies typically administered to patients with defined problems or needs.
26
Define "negligence".
Careless act of omission or commission that results in injury to another.
27
Define "liability".
Something one is obligated to do or an obligation required to be fulfilled by law, usually financial in nature.
28
Define "privacy".
Seclusion, freedom from disturbance or interference. Privacy has two intertwined components in the context of healthcare:
(1) The patient’s rights and expectations that personal health information is shared only between professionals who need it to manage the patient; in the UK access to such information is monitored by the provider’s Caldicott Guardian; and
(2) The physical space, clothing and other measures taken to ensure that the private conversations remain so, and that patients’ dignity is preserved and embarrassment minimised by providing appropriate clothing.
29
Define "confidentiality".
Act of keeping information private or secret; in health care the nurse only shares information about a patient with other nurses or health care providers who need to know private information about a patient to provide care for him or her; information can only be shared with the patient's consent.
30
Define "credibility".
The extent to which a researcher’s findings are compatible with data and conclusions extant in the scientific community. Credibility is a criterion for determining the “quality” or “trustworthiness” of qualitative research.
31
Define "veracity".
Legal principle that states that a health professional should be honest and give full disclosure to the patient, abstain from misrepresentation or deceit, and report known lapses of the standards of care to the proper agencies.
32
Define "fidelity".
This principle requires loyalty, fairness, truthfulness, advocacy, and dedication to our patients. It involves an agreement to keep our promises. Fidelity refers to the concept of keeping a commitment and is based upon the virtue of caring.
33
Define "beneficence".
Doing good or actively promoting doing good
34
Define "non-maleficence".
Fundamental ethical agreement to do no harm. Closely related to the ethical standard of beneficence.
35
Define "accreditation"
Process whereby a professional association or nongovernmental agency grants recognition to a school or institution for demonstrated ability to meet predetermined criteria.
36
What is the TJC Survey?
Joint Commission surveyors visit accredited health care organizations a minimum of once every 39 months (two years for laboratories) to evaluate standards compliance. This visit is called a survey. All regular Joint Commission accreditation surveys are unannounced.
37
Name 5 common malpractice claims made against nurses.
1. Failure to follow standards of care
2. Failure to communicate
3. Failure to document
4. Failure to assess and monitor
5. Failure to delegate appropriately
38
When can restraints be used?
1. Only to ensure the physical safety of the patient or other patients.
2. When less restrictive interventions are not successful
3. Only on the written order of a health care provider
39
What are complications associated with the use of restraints?
Pressure ulcers, pneumonia, constipation, incontinence, and in some cases death has resulted because of restricted breathing and circulation. Emotionally, loss of self-esteem, humiliation, and agitation.
40
After applying restraints, what should be evaluated every 15 minutes?
Signs of injury, e.g., circulation, vital signs, range of motion, physical and psychological status, and readiness for discontinuation. Perform visual checks if patient is too agitated to approach.
41
After applying restraints, what should be evaluated every 2 hours?
The patient's need for toileting, nutrition and fluids, hygiene, and elimination and release restraint.
42
Rule of thumb with side rails.
A patient needs to have a route to exit a bed safely and move freely within the bed. Raising only the top two side rails of a four rail system gives a patient room to exit a bed safely.
43
What position should the bed be in when using side rails?
The lowest position possible.
44
Define "incident report".
Confidential document that describes any patient accident while the person is on the premises of a health care agency.
45
Define "medical asepsis".
Procedures used to reduce the number of microorganisms and prevent their spread.
46
Define "surgical asepsis".
Procedures used to eliminate any microorganisms from an area. Also called sterile technique.
47
What are the 3 modes of pathogen transmission?
1. Contact
2. Vehicle
3. Vector
48
What the 4 methods of contact transmission?
1. Direct
2. Indirect
3. Droplet
4. Airborne
49
6 examples of vehicles of pathogen transmission.
1. Contaminated items
2. Water
3. Drugs
4. Solutions
5. Blood
6. Food
50
2 types of vector transmission and examples.
1. External mechanical transmission (e.g. flies)
| 2. Internal transmission between vector and host (e.g. mosquito, louse, flea, tick)
51
Items that enter sterile tissue or the vascular system present a high risk of infection if they are contaminated with microorganisms, especially bacterial spores. These are "critical items" and must be sterile. These items include:
* Surgical instruments
* Cardiac or intravascular catheters
* Urinary catheters
* Implants
52
Items that come in contact with mucous membranes or nonintact skin also present a risk. These objects must be free of all microorganisms (except bacterial spores). These are "Semicritical items" and must be high-level disinfected (HLD) or sterilized. These items include:
* Respiratory and anesthesia equipment
* Endoscopes
* Endotracheal tubes
* GI endoscopes
* Diaphragm fitting rings
53
Items that come in contact with intact skin but not mucous membranes must be clean. These are "Noncritical items" and must be disinfected. These items include:
* Bedpans
* Blood pressure cuffs
* Bedrails
* Linens
* Stethoscopes
* Bedside trays and patient furniture
* Food utensils
54
What are standard precautions?
* Standard precautions apply to blood, blood products, all body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes.
* Perform hand hygiene before, after, and between direct contact with patients.
* Wear gloves when touching blood, body fluids, secretions, excretions, nonintact skin, mucous membranes, or contaminated items or surfaces is likely.
* Wear personal protective equipment (PPE) when the anticipated patient interaction indicates that contact with blood or body fluids may occur.
* Discard all contaminated sharp instruments and needles in a puncture-resistant container.
55
Guidelines to hand hygiene
* When hands are not visibly soiled or contaminated with blood or body fluids, use an alcohol-based, waterless antiseptic agent to perform hand hygiene .
* When hands are visibly soiled or contaminated with blood or body fluids, wash them with either a nonantimicrobial or an antimicrobial soap and water.
* Wash hands with nonantimicrobial soap and water if contact with spores (e.g., Clostridium difficile) is likely to have occurred.
56
What are airborne precautions?
Standard precautions PLUS private room, negative-pressure airflow of at least 6 to 12 exchanges per hour via high-efficiency particulate air (HEPA) filtration; mask or respiratory protection device, N95 respirator.
57
With what conditions are airborne precautions necessary?
* measles
* chickenpox (varicella)
* disseminated varicella zoster
* pulmonary or laryngeal tuberculosis
58
What are droplet precautions?
Standard precautions PLUS private room or cohort patients; mask or respirator required.
59
With what conditions are droplet precautions necessary?
* diphtheria (pharyngeal)
* rubella
* streptococcal pharyngitis
* pneumonia or scarlet fever in infants & young children
* pertussis
* mumps
* Mycoplasma pneumonia
* meningococcal pneumonia or sepsis
* pneumonic plague
60
What are contact precautions?
Standard precautions PLUS private room or cohort patients, gloves, gowns (Patients may leave their room for procedures or therapy if infectious material is contained or covered, placed in a clean gown, and if hands are cleaned.)
61
With what conditions are contact precautions necessary?
* Colonization or infection with multidrug-resistant organisms such as VRE and MRSA, Clostridium difficile, shigella, and other enteric pathogens
* major wound infections
* herpes simplex
* scabies
* varicella zoster (disseminated)
* respiratory syncytial virus in infants, young children, or immunocompromised adults
62
What is a protective environment?
Standard precautions PLUS private room; positive airflow with 12 or more air exchanges per hour; HEPA filtration for incoming air; mask to be worn by patient when out of room during times of construction in area.
63
When is a protective environment necessary?
Allogeneic hematopoietic stem cell transplants
64
What is PPE?
Personal protective equipment. That is specialized clothing or equipment (e.g., gowns, masks or respirators, protective eyewear and gloves) that you wear for protection against exposure to infectious materials
65
7 principles of surgical asepsis.
1. A sterile object remains sterile only when touched by another sterile object.
2. Only sterile objects may be placed on a sterile field.
3. A sterile object or field becomes contaminated by prolonged exposure to air.
4. When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action.
5. Fluid flows in the direction of gravity.
6. The edges of a sterile field or container are considered to be contaminated.
66
What type of precautions should be used with MRSA?
Contact precautions
67
What type of precautions should taken with TB?
Airborne precautions
68
What is OSHA?
With the Occupational Safety and Health Act of 1970, Congress created the Occupational Safety and Health Administration (OSHA) to assure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance.
69
What is the CDC?
Center for Disease Control and Prevention. To prevent and control infectious and chronic diseases, injuries, workplace hazards, disabilities, and environmental health threats. CDC applies research and findings to improve people′s daily lives and responds to health emergencies.
70
What are intrinsic risk factors for falls in older adults?
* History of a previous fall
* Impaired vision
* Postural hypotension or syncope
* Conditions affecting mobility such as arthritis, lower extremity muscle weakness, peripheral neuropathy, foot problems
* Conditions affecting balance and gait
* Alterations in bladder function such as frequency or urge incontinence and nocturia
* Cognitive impairment, agitation, and confusion
* Adverse medication reactions (sedatives, hypnotics, anticonvulsants, opioids)
* Slowed reaction times
* Deconditioning
71
What are extrinsic risk factors for falls in older adults?
* Environmental hazards outside and within the home such as poor lighting, slippery or wet flooring, items on floor that are easy to trip over, furniture placement and other obstacles to ambulation, and sidewalks and stairs in poor repair
* Inappropriate footwear
* Unfamiliar environment of a hospital room that contains barriers to movement (e.g., clutter, equipment, poor lighting at night)
* Improper use of assistive devices (e.g., canes, walkers, crutches)
72
10 actions to prevent a fall.
1. Assess patient with a fall risk assessment tool.
2. Bed locked in the lowest position
3. Use of properly fitted skid-proof footwear.
4. Orient patient to surroundings, call light, routines.
5. Safe use of side rails (does not restrain patient)
6. Make the patient's environment safe.
7. Prioritize call light to patient at risk.
8. Establish elimination schedule.
9. Use a gait belt when ambulating.
10. Safe transport using a wheelchair.
73
What is "C-Diff"?
A common causative agent of diarrhea is Clostridium difficile (C. difficile), which produces symptoms ranging from mild diarrhea to severe colitis.
74
How is C-Diff acquired?
* Patients acquire C. difficile infection in one of two ways: by antibiotic therapy that causes an overgrowth of C. difficile and by contact with the C. difficile organism.
* Patients are exposed to the organism from a health care worker's hands or direct contact with environmental surfaces contaminated with it.
75
What is appropriate hand hygiene after exposure to C-Diff?
Only hand hygiene with soap and water is effective to physically remove C. difficile spores from the hands.
76
What does a complete blood count (CBC) evaluate?
* Evaluation of white blood cells: WBC count; may or may not include a WBC differential
* Evaluation of red blood cells: RBC count, hemoglobin (Hb), hematocrit (Hct) and RBC indices, which includes mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), and red cell distribution width (RDW). The RBC evaluation may or may not include reticulocyte count.
* Evaluation of platelets: platelet count; may or may not include mean platelet volume (MPV) and/or platelet distribution width (PDW)
77
What does a WBC Differential evaluate?
A WBC differential totals the number of each of the different types of WBCs in a person's sample of blood and reveals if the cells are present in normal proportion to one another, if the number of one cell type is increased or decreased, or if abnormal and/or immature cells are present.
78
What does a WBC Differential include?
A WBC differential typically includes the following:
• absolute neutrophil count or % neutrophils
• absolute lymphocyte count or % lymphocytes
• absolute monocyte count or % monocytes
• absolute eosinophil count or % esosinophils
• absolute basophil count or % basophils
79
What is the focus of a musculoskeletal assessment?
The assessment of musculoskeletal function focuses on determining range of joint motion, muscle strength and tone, and joint and muscle condition.
80
What is "Buck's Traction"?
one of the most common orthopedic mechanisms by which pull is exerted on the lower extremity with a system of ropes, weights, and pulleys. Buck's traction, which may be unilateral or bilateral, is used to immobilize, position, and align the lower extremity in the treatment of contractures and diseases of the hip and knee. The mechanism commonly consists of a metal bar extending from a frame at the foot of the patient's bed, supporting traction weights connected by a rope passing through a pulley to a cast or a splint around the affected body structure.
81
What are the signs and symptoms of mild to moderate dehydration?
* Increased thirst
* Dry mouth
* Tired or sleepy
* Decreased urine output
* Urine is low volume and more yellowish than normal
* Headache
* Dry skin
* Dizziness
* Few or no tears
82
What are the signs and symptoms of severe dehydration?
* Severely decreased urine output or no urine output. The urine, if any, produced is concentrated and a deep yellow or amber color.
* Dizziness or lightheadedness that does not allow the person to stand or walk normally.
* Blood pressure drops when the person tries to stand after lying down (low blood pressure or orthostatic hypotension)
* Rapid heart rate
* Fever
* Poor skin elasticity (skin slowly sinks back to its normal position when pinched)
* Lethargy, confusion, or coma
* Seizure
* Shock
83
Signs and symptoms of hypervolemia.
Symptoms include weight gain, swelling, and shortness of breath.
84
Signs and symptoms of hyperkalemia.
* fatigue or weakness.
* a feeling of numbness or tingling.
* nausea or vomiting.
* problems breathing.
* chest pain.
* palpitations or skipped heartbeats.
