Chapter 28 & 29 Infection Prevention and Control & Vital signs Flashcards
Which statement describes why arterial blood gases are used in patient assessment?
To obtain baseline values
Which step should be performed first in a respiratory assessment?
Focused interview
When assessing the patients lung sounds the nurse should keep in mind that the right lung has how many lobes?
3
Where should the nurse auscultate for vesicular or alveolar breath sounds?
Posterior lower lobes
A nurse assessing a patient suspects moderate to severe hypoxia. Which oxygen saturation range would indicate this condition?
85% to 89%
Which nursing diagnoses are examples related to ventilation and oxygenation?
Anxiety
Acute pain
Activity intolerance
Impaired Gas Exchange
Which nursing diagnoses are appropriate initially for a patient in the emergency department who “can’t catch a breath?”
Impaired Gas exchange
Ineffective breathing pattern
Which goal is appropriate initially for a patient in the emergency department who “can’t catch a breath?”
Patient will exhibit regular breathing pattern with ambulation to the bathroom and back within 24 hours
Which example provides a realistic goal for a patient with altered ventilation and oxygenation?
The patient will develop and maintain an effective breathing pattern before discharge to home.
Which desired outcome is appropriate for a patient with altered ventilation and oxygenation?
Patient demonstrates normal rate and depth of respiration’s
Which value represents acceptable rate for a 15 year old patient
15
18
A frail older adult patient who is experiencing shortness of breath is only able to breath laying on the right side. The patient has a current respiratory rate of 28 bpm. Which terms describe the signs and symptoms the patient is exhibiting?
Dyspnea
Orthopnea
Tachypnea
The older adult patient has very poor perfusion on the fingers. Which location should the nurse use to measure oxygen saturation?
Toe
Nose
Earlobe
The nurse is assessing the patients ventilation status. Which feature will the nurse assess?
Chest rise
Respiratory rate
Lung compliance
The nurse is caring for the patient diagnosed with a head and brain injury. Which alterations in breathing pattern could possibly occur?
Hypoventilation
Biots breathing
Cheyne strokes respiration
What % reflects a normal value for SvO2?
70%
The nurse is in the emergency department where a patient presents as follows : 65 year old, shortness of breath, tripod position, pale skin, 42 bpm, blood pressure 152/95, history of chronic obstructive pulmonary disease. Which objective can the nurse obtain?
Pale skin
History of COPD
high blood pressure
Which is an initial nursing action for a patient having shortness of breath?
Assess pulse oximeter for O2 saturation levels
The cerebral cortex of the brain allows voluntary control of breathing. When a patient sings, to which aspect do receptors in the medulla react?
Changes in pH
High levels of Carbon Dioxide
Which statement describes ventilation
Movement of oxygen and carbon dioxide in and out of the lungs
(Inhale, exhale)
The student nurse is discussing arterial blood gases (ABG) which statement made by the nurse reflects the student needs further education?
Nurses do not draw ABG
During the respiratory assessment the nurse hears “wheezes” which type of sound is the nurse hearing?
Whistling
The nurse obtains an arterial blood gas on a patient and the pH is 7.33 and the PaO2 is 103. Which action should the nurse take?
Call the health care provider because these results are abnormal
The nurse has a patient who was admitted 24 hours ago for asthma. The patient is currently on 8 liters high flow oxygen with respiratory treatments every 2 hours. Which statement reflects a realistic goal?
The patient will demonstrate the ability to complete all activities of daily living with no increase in dyspnea before discharge.
Which aspects would the nurse measure to assess respiration and ventilation?
Respiratory rate, depth, rhythm
A student nurse is learning about altered oxygen saturation levels. Which statement indicates further teaching is needed?
Nose bleeds are caused by altered oxygen saturation levels.
What is an infection?
Results when a pathogen invades tissues and organs and begins growing within a host
What is colonization?
Presence and growth of a microorganism within a host but without tissue invasion or damage
Communicable disease
Infectious disease Transmitted directly from one person to another
Chain of Infection
Infectious agent or pathogens Reservoir or source for pathogen growth Port of exit from reservoir Mode of transmission Port of entry to a host Susceptible host
Resident organisms
Normal flora
Permanent resident on the skin and within the body
Survive without causing illness
Virulent
Ability to produce disease
Bronchitis
S. pneumoniae, H. influenzae, respiratory viruses
Device-related
Coagulase-negative staphylococci, Corynebacterium sp.
Empyema
S. aureus, streptococci, anaerobes
Endocarditis
S. viridans, S. aureus, enterococc
Gastroenteritis
Salmonella sp., Shigella sp., Campylobactersp.,
Meningitis
E. coli O157:H7, viruses
Which factor contributed to the development of health care acquired respiratory infection in a ambulatory diabetic patient receiving an intravenous antibiotic?
Current comorbidity
There is clear evidence to support the patients comorbidity of diabetes mellitus. It placed the patient at increased risk for development of a health care associated infection.
Prior to discharge what will the nurse teach patients about antibiotics to help prevent anti microbial resistance?
Take of of there medication for the full time prescribed.
This is important to help prevent anti microbial resistance.
A patient infected with which pathogen cannot be treated with antibiotics because the infectious agent has a protective envelope?
Virus
Which precautions will be implemented for a patient admitted for suspected West Nile virus?
Standard
Which patient is considered to be susceptible host in the chain of infection?
70 year old with diabetes learning about insulin therapy.
Diabetes is a chronic disease
Which infections are considered health care associated (HAI)?
Urinary tract infection related to in dwelling catheter
Pneumonia related to presence of ventilator
Wound infections related to surgical incision
A nurse recognizes which microorganisms as blood borne pathogens that can be transmitted by needle sticks?
Hep B virus
HIV
Antibiotic use in animals contributes to human anti microbial resistance through which effect?
Creates a reservoir of potentially resistant bacteria
