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Essentials of Nursing 2024 > Essentials Exam 1 > Flashcards

Essentials Exam 1 Flashcards

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1
Q

Medical diagnosis

A

the actual name of the condition
(ex: peripheral vascular disease)

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2
Q

nursing diagnosis

A

focus on care/symptoms rather than condition
(ex: risk for impaired skin integrity)

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3
Q

The way we provide care (KSA)
What does KSA stand for?

A

Knowledge: What we should do and why
Skill: How we do it
Attitude: What we think about what we are
doing

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4
Q

______ + ______ = critical thinking
(this is dumb but just in case yk)

A

specific knowledge + data and evidence

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5
Q

Clinical reasoning definition

A

The ability to integrate/apply
different types of knowledge and
evidence with a clinical
situation (The best action based on the
situation)

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6
Q

bloom’s taxonomy

A

thinking skills pyramid

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7
Q

bloom’s taxonomy (bottom to top)

A

remember, understand, apply, analyze, evaluate, create

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8
Q

ADPIE stands for

A

assessment/analysis diagnosis planning implementation evaluation

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9
Q

4 Cs of the nursing process

A

Consistent, Comprehensive and
Coordinated Care

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10
Q

infection definition

A

INVASION of a susceptible host by pathogens or microorganisms
- Results in disease

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11
Q

Colonization definition

A

The presence and growth of microorganisms within a
host WITHOUT INVASION or damage

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12
Q

Communicable disease

A

infectious process is transmitted from one person to another.

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13
Q

symptomatic definition

A

clinical signs and symptoms ARE present

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14
Q

asymptomatic

A

clinical signs and symptoms are NOT present

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15
Q

HAIs what are they

A

healthcare-associated infections

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16
Q

Exogenous plus 2 examples

A

from outside the individual (covid, MRSA)

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17
Q

endogenous

A

patient’s “normal” flora becomes altered = overgrowth (C. difficile)

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18
Q

Iatrogenic

A

resulting from a procedure (central line infection, surgical site infection, IUC infection)

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19
Q

infectious agent

A

bacteria, viruses, fungi, protozoa, parasite

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20
Q

reservoir

A

things/people that carry infectious agents (people, equipment, water/food, meds)

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21
Q

portal of exit

A

droplets, excretions, secretions

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22
Q

mode of transportation

A

contact, droplet, airborne, vectorborne

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23
Q

portal of entry

A

resp tract, GI tract, mucous membrane, skin

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24
Q

susceptible host

A

very young, very old, immunocompromised, people w/ chronic disease

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25
Q

Bacteria

A

single cell
named by shape
staining qualities
vary in size/shape/pattern as a means of replication

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26
Q

Viruses

A

Smallest microorganisms; not killed by antibiotics
Reproduce inside living host cells

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27
Q

fungi

A

Single-cell organisms, such as mold and yeast

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28
Q

parasites

A

live on or in other organisms

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29
Q

contact transmission define and examples?

A

Meeting of body surfaces with other bodies
or objects
-Direct: Contact with an infected person
-Indirect: Contact with contaminated
object
- examples: MRSA, VRE, C diff, drug-resistant
organisms

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30
Q

Airborne transmission define and examples?

A

Microorganisms dispersed by air, then
inhaled or deposited
examples: TB, Measles, Chicken Pox

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31
Q

droplet transmission define and examples?

A

Mucous membranes of resp tract are
exposed to secretions of infected
person
* Influenza, RSV

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32
Q

vectorborne transmission define and examples?

A

blood-feeding anthropods (insects,
ticks)
* Carry pathogens from one host to
another
* Lyme disease, West Nile Virus,
Rocky Mountain Spotted Fever

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33
Q

factors that lead to drug resistance

A
  • Prescribing antibiotics for nonbacterial
    infections
  • Use of inappropriate antibiotics
  • Incomplete courses of antibiotics
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34
Q

Wii method

A

wash introduce identify

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35
Q

Handwashing: why we do it

A

-Breaks the chain of infection
-Washing hands with soap removes germs much more effectively
- Soap molecules act as a mediator between water and oil molecules and bind them
- When you rinse off the soap the germs go with it!
- Handwashing can prevent about 30% of diarrhea-related sicknesses and about 20% of respiratory infections

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36
Q

what to do when hands are visibly soiled

A

soap and water
15-30s rubbing hands
C DIFF NEEDS SOAP AND WATER

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37
Q

what to do when hands are not visibly soiled

A

alcohol-based rub
rub until dry

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38
Q

contact precautions

A

private room, handwashing, gown, gloves

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39
Q

airborne precautions

A

private room with negative airflow, handwashing, N95 respirator

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40
Q

droplet precautions

A

private room, handwashing, gown, gloves, surgical mask, goggles

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41
Q

Airborne disease examples

A

Measles, tuberculosis,
SARS, MERS, COVID-19

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42
Q

protective isolation

A

filters, masks, handwashing, no live items, positive air pressure.

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43
Q

transporting a patient in isolation

A

“yellow” gown on the patient (as a robe)
face mask if on droplet/resp precaution
an extra layer of sheets
notify personnel

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44
Q

medical asepsis

A

“clean”
REDUCE microorganisms
hand hygiene, etc.

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45
Q

surgical asepsis

A

“sterile”
ELIMINATE microorganisms

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46
Q

disinfection definition

A

REMOVAL of microorganisms

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47
Q

sterilization definition

A

DESTROY all microorganisms including spores

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48
Q

when can skin be sterile?

A

no, skin is never sterile

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49
Q

7 principles of surgical asepsis

A
  1. sterile can only touch sterile
  2. only sterile objects in a sterile field
  3. non-sterile = object below the waist, unattended objects, turning back on the field, DO NOT CROSS ARM OVER
  4. prolonged exposure contaminates the field
  5. moisture = contamination
  6. fluid flow in the direction of gravity
  7. 1” border around field = contaminated
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50
Q

pouring sterile fluid

A
  • contaminated = outside bottle, bottleneck
  • inside bottle top sterile = sterile
  • palm the container = hold the label to
    palm
  • lip liquid
  • pour from 1”-2” above the container
  • remainder of solution = date, time, and
    initial
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51
Q

examples of biohazard materials

A

bloody products, wound dressings, IV tubing, needles, scalpels, suction canisters, waste from patients with communicable disease

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52
Q

where to dispose of sharps

A

red sharps container

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53
Q

where to dispose of solid materials

A

red trash container lined with a red plastic liner

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54
Q

where to dispose of liquids

A

red “sealed” containers/bottles

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55
Q

functions of the skin

A

Protection, secretion, excretion, temperature regulation, and sensation

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56
Q

epidermis function

A

shields underlying tissues, protects from water loss, injury/integrity, and infection

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57
Q

dermis

A

Sweat glands, sebaceous glands, and hair
follicles
– Slows water loss, lubricates skin,
bactericidal
-Too frequent bathing or hot water can
interrupt the protective properties

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58
Q

normal oral mucose look

A

light pink, soft, moist, smooth

59
Q

xerostomia

A

dry mouth

60
Q

gingivitis

A

inflammation of the gums

61
Q

dental caries

A

tooth decay and tooth loss

62
Q

factors that can impact hair

A

Hormonal changes, nutrition,
emotional and/or physical stress,
aging, infection

63
Q

how to clean sensitive sensory tissues in a way that prevents injury and discomfort

A

– Do not use soap to clean eyes
– Examine ears for wax accumulation
- Dry outer ear
– Wipe outside of nares with warm, moist washcloth

64
Q

Hygiene care is routine: true or false

A

false: hygiene care is never routine

65
Q

4 ways to improve hygiene care

A

-check room temp
-administer meds before hygiene
-assist them to preform as INDEPENDENTLY
AS POSSIBLE
-NON-RUSHED atmosphere

66
Q

5 bath giving guidelines

A

privacy
safety
warmth
independence
anticipate needs

67
Q

besides soap and water, what is used for bathing hygiene

A

chlorhexidine gluconate (CHG) wipes

68
Q

3 musts for denture care

A
  • washcloth in sink
  • must be removed at night
  • must be covered in water when not worn
69
Q

When to obtain hair consent

A
  • braiding
  • cutting
  • shaving facial hair
70
Q

shaving techniques

A
  • go in the direction of hair growth
  • if a patient is on certain medications
    (anticoagulants) use an electric razor
71
Q

eye care technique

A
  • no soap
  • inner to outer canthus
72
Q

when changing linens what not to do to maintain medical asepsis

A

do NOT place soiled linen on the floor or next to your body/scrubs

73
Q

back/return demonstration

A

having patient repeat what you taught to show proficiency

74
Q

when entering a room what two things do you always do

A

2 pt identifiers
hand hygeine

75
Q

when bathing what direction do you clean

A

most clean to least clean

76
Q

order of bathing body parts

A
  1. face
  2. trunk and upper extremities
  3. legs
  4. perineal (front-back)
  5. back
  6. butt (front-back)
77
Q

client assessment during hygiene

A
  • skin assessment
  • ROM
  • strength
  • independence
  • comfort/ pain lvl
78
Q

culture of safety environment

A

blame-free environment

79
Q

wellness pyramid (bottom -> top)

A

physiological needs
safety/security
love/belonging
self-esteem
self-actualization

80
Q

RACE what does it stand for

A

fire safety: Remove Activate Contain Extinguish

81
Q

“speak up” campaign purpose and who created it

A

Encourages the patient/family to take an active role in preventing errors (created by The Joint Commission)

82
Q

Yellow wristband =

A

fall risk

82
Q

Red wristband =

A

allergies

83
Q

purple wristband =

A

DNR

84
Q

Inappropriate use of restraints =

A

violates both state and federal regulations.
– Use in this manner constitutes abuse

85
Q

medical protection devices

A

Temporary immobilization for the performance of or recovery from a medical procedure or surgical treatment
– Protects the patient from exacerbating underlying illness or injury
(ex: Splints, braces, casts)

86
Q

what are restraint medications and when to use

A

Sedatives and anti-anxiety medications
-Control disruptive behavior
–Confusion, agitation, wandering,
combativeness

86
Q

when are medications considered a “restraint”

A

– Not part of standard care for the condition
– Used intentionally or in excess to
specifically limit behavior

87
Q

why to NOT use restraints

A
  • convenience
  • family pressure
  • under-staffed
  • decrease legal liability
  • restraints do not reduce fall/injury
87
Q

spiraling mobility

A
  • Process where an older person is perceived to be at risk for
    falling and is restrained to prevent falling
  • Becomes unable to walk due to prolonged immobilization
88
Q

hypoxic encephalopathy

A
  • due to restraints
    Causing increased confusion and disorientation, altered mental status, restlessness
89
Q

psychological effects of restraints

A

Demoralization, humiliation, feelings of low self worth, depression, impaired social functioning, social isolation

90
Q

alternatives to restraints

A
  • re-evaluate medications
  • hourly nursing rounds
  • identify the cause
91
Q

how often must the provider complete a face-to-face patient assessment for restraints?

A
  • RN must assess a minimum of every 2
    hours
  • limited to 4hrs for adults; 2hrs children
  • time limit for restraints 24 hrs
  • know your facility policies and state laws
92
Q

ongoing care when using restraints for patient

A
  • restraint breaks
  • call light within reach
  • bed in lowest position, locked
  • delegation (assessment cannot be
    delegated)
93
Q

how to tie a restraint

A
  • quick-release knot
  • 2 fingers should fit between the body
    restraint
  • always tied to BED FRAME
94
Q

what is a seizure?

A

– Sudden, disorderly discharge of cerebral
neurons
– Characterized by sudden alteration in the
brain. function: motor, sensory and
autonomic function

95
Q

Who is at risk for a seizure?

A

– Neurologic or metabolic disturbance
– Head Injury
– Brain tumor

96
Q

generalized seizure

A
  • tonic-clonic
  • sustained involuntary muscle contractions
  • 2-5 minutes, cry, loss of consciousness,
    tonic-clonic movement, incontinence
    – During: shallow breathing, cyanosis,
    incontinence
    – Postictal phase: disoriented, no recall of
    event, deep sleep
97
Q

Grand mal (or tonic-clonic)

A

Tonic: rigid muscles
Clonic: muscular jerking
2-5 minutes

98
Q

Focal seizure

A
  • Motor: muscular jerking, smacking lips,
    clapping hands, blinking, chewing
  • Non-motor: lack of movement, staring,
    change in sensation, cognition
99
Q

absent seizure

A
  • Staring spells
  • Last usually less than15 seconds
100
Q

Status Epilepticus

A
  • a seizure lasting more than 5 minutes
  • 2 or more seizures within 5 minutes
101
Q

Aura

A

the before of seizures
safe environment

102
Q

During seizure

A
  • positioning, no objects in the mouth, do
    not restrain, time seizure, privacy
103
Q

post-ictal

A

post seizure
- reorient
- assessment

104
Q

seizure precautions

A
  • padded side rails
  • bed at lowest
  • clutter-free environment
  • access to call bell
  • suction equipment at bedside
  • O2 and nasal cannula at the bedside
  • avoid the use of restraints
105
Q

how to document a seizure

A
  • the time it begins
  • duration
  • the time it ends
  • sequence and times
  • note an injuries
    -not pt report of ‘aura’
106
Q

morse fall scale

A

simple, quick assessment tool for fall risk
high risk: 45 or higher
moderate risk: 25-44
low risk: 0-24

107
Q

Hendrich II Fall Risk

A

looks at not only physical factors but medications as well
get up and go test: part of assessment
a score of 5 or greater = high risk

108
Q

how often should fall risk be evaluated

A

minimum once a day

109
Q

“if it wasn’t documented it wasn’t done” true or false

A

true (documentation)

110
Q

who sets the standards of documentation and why?

A

The Joint Commission (TJC)
evaluates quality and appropriateness of client care

111
Q

non-reimbursable events

A

‘never’ events
specific hospital-acquired/preventable conditions

112
Q

how to begin each documentation entry

A

date/time and end with your signature and title

113
Q

SOAP:

A

subjective, objective, assessment, plan

114
Q

SOAPIE:

A

subjective, objective, assessment, plan, intervention, evaluation

115
Q

PIE:

A

plan, intervention, evaluation

116
Q

DAR:

A

data, action, response

117
Q

hand-off report can be:

A

verbal, recorded, or written

118
Q

SACCIA: (documentation/handoff)

A

Sufficiency
Accuracy
Clarity
Context
Interpersonal Adaptation

119
Q

‘Read back’

A

method for verification
do not ‘repeat back’

120
Q

student nurses CANNOT take phone orders. true or false

A

true

121
Q

SBAR

A

situation background assessment recommendation

122
Q

Paperwork cannot be given to the patient. true or false

A

true

123
Q

why is immobility a critical nursing concern

A

increase hospital stays
increase fall risk

124
Q

effects of immobility

A

metabolic changes
GI motility decreases
respiratory changes
cardiovascular changes
urinary changes
musculoskeletal changes
pressure ulcers

125
Q

assessment of mobility

A

ROM
Gait
Activity Tolerance
Body alignment
body systems

126
Q

trochanter roll

A

maintains hip alignment
prevents external rotation

127
Q

supine position

A

laying on back

128
Q

prone position

A

laying on stomach

129
Q

semi-fowlers position

A

sitting at a 45-degree angle

130
Q

lateral position

A

fetal position

131
Q

sims position

A

fetal position with one leg up

132
Q

Trendelenburg position

A

supine position head lowered feet raised

133
Q

safe patient transfer of patient that can assist

A

wide base of support
lower center of gravity

134
Q

what position to sit the pt when helping the patient walk

A

DANGLE the client’s legs

135
Q

how a walker should be measured

A

top of the walker should line with the crease of the inside of the wrist
elbows flexed 15-30 degrees

136
Q

cane measurements

A

The cane length should equal the distance
between the greater trochanter and
the floor

137
Q

how to use a cane

A
  • Keep cane on stronger side of body
  • Place cane forward 6 to 10 inches,
    keeping body weight on both legs
  • Weaker leg is moved forward
  • Divide weight between cane and
    stronger leg
  • Stronger leg is advanced past cane
  • Divide weight between cane and
    weaker leg
137
Q

crutches measurement

A
  • Ensure the length of the crutch is 2-3 finger widths below the axilla
  • Position the tips (bottom) about 2 inches lateral
  • 4-6 inches anterior to the front of the patient’s shoes
    -Handgrips: Arms should flex 20-25 degrees when upright and supporting weight on handgrips
138
Q

Writing Learning Objectives MUST HAVE

A
  • Condition: What teaching strategy are you going to use
  • Audience: the client, the patient, the community
  • Behavior: domain, level, verb, product (topic)
  • Degree: 100%, correctly, consistently
139
Q

avoid phrases:

A

appreciate, have faith in, know, learn, understand, believe

Essentials of Nursing 2024 (3 decks)

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