EXAM 1 Flashcards
1
Q
______ is the systemic collection of information about clients present health status
A
Assessment
2
Q
Nurses can collect data during what kind of assessments?
A
- Initial assessment (baseline)
- Focused assessment
- Ongoing assessment
3
Q
What are some methods of data collection?
A
- Client interviews
- Medical history
- Comprehensive/focused physical examination
- Diagnostic
- Lab reports
- Collaboration
4
Q
When should data be collected for an assessment?
A
Prior to interventions
5
Q
During the ______ phase of the nursing process, we identify the patients problems which provide direction for nursing care
A
Diagnose
6
Q
During this phase of the nursing process, we establish priorities, set goals/desired outcomes and plan our nursing interventions
A
Planning
7
Q
When does discharge planning begin?
A
During admission
8
Q
During this phase in the nursing process, we perform the nursing actions identified during the planning phase, delegate tasks, supervise and document care
A
Implementation
9
Q
During this phase, we determine if our goals and expected outcomes were achieved
A
Evaluation
10
Q
Before assessing a patient, what is the first thing you must do?
A
Build rapport
11
Q
What are the different types of assessment?
A
- Initial
- Focused
- Emergency
- Time lapsed
- Patient centered assessment method
12
Q
When does your initial assessment begin?
A
Upon first glance of the client
13
Q
What is a focused assessment?
A
Assessing specific body systems
14
Q
What is an emergency assessment?
A
Assessing the ABCs during an emergency procedure
15
Q
What is a time-lapsed assessment?
A
An assessment scheduled to compare a patient’s current status to baseline data obtained earlier
16
Q
What is the patient centered assessment method?
A
A tool nurses can use to assess how patients engage and respond in managing their health while others with similar health conditions do not experience the same outcomes
17
Q
During _____ we determine the risk factors that must be managed and identify resources, strengths and area for health promotion
A
Diagnosis
18
Q
_____ is never a priority, nurses must focus on actual conditions
A
Risks
19
Q
A ________ diagnosis identifies conditions, focuses on illness, injury or disease processes and remains constant until a cure is obtained
A
Medical
20
Q
A ________ diagnosis identifies situations, focuses on patient responses to health issues and changes with the patients response or health/life problems
A
Nursing
21
Q
What are the 3 types of a nursing diagnosis?
A
- Problem-focused
- Risk
- Health promotion
22
Q
Care plans include what 3 parts in a nursing diagnosis?
A
- Problem
- Etiology
- Defining characteristics
23
Q
A broken femur is an example of what type of diagnosis?
A
Medical diagnosis
24
Q
A lack of mobility is an example of what type of diagnosis?
A
Nursing
25
An alteration in urination is an example of what type of diagnosis?
Nursing
26
Chronic kidney failure is an example of what type of diagnosis?
Medical
27
What does an "at risk" patient mean?
They do not have it yet but have the potential to develop it
28
The etiology in a nurses plan of care is the ______ behind why something is occursing
Patho
29
A proper nursing diagnosis statement would look like:
Problem r/t Etiology as evidenced by Defining characteristics
30
Bathing self care deficit R/T fear of falling in the tub and obesity AEB strong body and urine odor, unclean hair: "I'm afraid ill fall in the tub and break something" (5 ft 4 in, 170 Ibs) is an example of a:
Nursing diagnosis statement
31
The defining characteristics in a nursing statement include _______ and ________ data
Objective and subjective
32
What NANDA component suggest the appropriate nursing measures?
Etiology
33
What NANDA component suggest the patient outcomes?
Problem
34
What NANDA component suggest evaluative criteria?
Defining characteristics
35
The physiological needs of the maslow hierarchy include:
Breathing, food, water, sex, sleep, homeostasis and excretion
36
SMART goals stands for:
- Specific
- Measurable
- Achievable
- Relevant
- Time-bound
37
Nursing action can be:
- Physician initiated
- Nurse initiated
- Collaborative
38
Who is legally responsible during physician initiated actions?
Doctors and nurses
39
A prescription of medication is a _________ action:
Physician initiated
40
The implementation of a catheter or oxygen is a _________ action
Nurse initiated
41
All nursing interventions must be appropriate to:
NANDA and SMART goals
42
________ is the process of transferring the performance of a task while retaining accountability for the outcome
Delegation
43
_________ is the process of directing, monitoring and evaluating the performance of tasks by other team members
Supervision
44
Who can RNs delegate tasks to?
- Other RNs
- PNs
- CNAs/PCTs
45
What are the 5 rights of delegation?
- Right task
- Right circumstance
- Right person
- Right direction and communication
- Right supervision and evaluation
46
Delegate an AP to assist Mr. Martin in room 312 with morning hygiene is an example of the:
Right direction and communication
47
Delegating an AP to assist with ambulating a client prior to the RN performing an admission assessment is an example of the:
Wrong supervision
48
What can RNs NOT delegate?
- The nursing process
- Client education
- Tasks requiring nursing judgement
49
What can APs do?
- ADLs
- Make beds
- Specimen collection
- I/O
- Vital signs
- Reapply condom catheter
50
_______ care should always be prioritized over _______ care
Acute; chronic
51
Actual losses are:
Tangible
52
What will help you better serve your patients when they are dealing with grief and death?
Understanding of your own feelings about grief and death
53
________ is the inner emotional response to loss and exhibited through thoughts, feelings and behaviors
Grief
54
________ includes both grief and mourning and is the outward display of loss
Bereavement
55
This type of care attempts to meet the clients physical, spiritual and psychosocial needs
Palliative or end of life care
56
This is a loss related to change that is part of the cycle of life and is anticipated but still intensely felt. It can be replaced by something different or better.
Necessary loss
57
This is the loss of a valued person, item, or status that others can recognize
Actual loss
58
This loss is anything the client defines as loss but is not obvious or verifiable to others
Perceived loss
59
This loss is normally expected due to the developmental processes of life and are associated with normal life transitions which aid in coping skills
Maturational or developmental loss
60
This loss is unanticipated and caused by an external event
Situational loss
61
This loss is experienced before the loss happens
Anticipatory loss
62
A child leaving home for college is an example of what kind of loss?
Maturational or developmental loss
63
A family loosing their home during a tornado is an example of what kind of loss?
Situational loss
64
A baby that died before birth or was born with an abnormality can be considered as what kind of loss?
Perceived loss
65
Perceived losses are:
Intangible
66
What factors increase a persons risks for dysfunctional grieving?
- Being dependent on the deceased
- Unexpected death at a young age through violence or socially unacceptable manner
- Inadequate coping skills
- Lack of hope or social support
- Preexisting mental health issues
67
This grief is uncomplicated, can be negative or positive, acceptance should be evident by 6 months after the loss and may result in chest pain, palpitations, headache, nausea, changes in sleep pattern and fatigue
Normal grief
68
This grief is chronic, exaggerated, masked and delayed which could result in depression or disorders and the person can become suicidal, have intense feelings of guilt or low self-esteem
Complicated grief
69
This grief implies letting go before the actual loss occurs and the person has the opportunity to start grieving before the actual loss
Anticipatory grief
70
This grief entails an experienced loss that cannot be publicly shared or is not socially acceptable
Disenfranchised grief
71
If a person says that a loss "should not have happened" what kind of grief are they experiencing?
Complicated grief
72
What is the Kubler Ross stages of Dying?
DABDA
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
73
T/F Clients might not experience DABDA in order and the length of each stage varies from person to person
True
74
This portion of Bowlbys attachment theory is when a person minimizes the impact of a loss and is protected from the full impact of loss
Numbing
75
This portion of Bowlbys attachment theory is when a person experiences outburst of tears, chest tightness, lethargy, insomnia, sobbing and acute distress
Yearning and seeking
76
This portion of Bowlbys attachment theory is when a person examines loss and expresses anger
Disorganization and despair
77
This portion of Bowlbys attachment theory is when a person accepts loss/change, new role or skills
Reorganization
78
What are the tasks in the Wordens grief tasks model?
- Task I: accept the reality of the loss
- Task II: experience the pain of grief
- Task III: adjust to a world in which the deceased is missing
- Task IV: emotionally relocate the deceased and move on with life
79
Grief as a series of processes instead of stages or tasks is which theory?
Rando's R process model
80
What are the 6 R's in the randos R process model?
- Recognize the loss
- React to the pain
- Reminisce
- Relinquish old attachments
- Readjust to life after loss
- Reminiscence again
81
What model moves back and forth between loss-oriented and restoration-oriented activities
Dual process model
82
What factors influence loss and grief?
- Human development
- Personal relationships
- Nature of loss
- Coping strategies
- Socioeconomic status
- Culture and ethnicity
- Spiritual and religious beliefs
- Hope
83
What do care plans for dying patients focus on?
- Comfort
- Dignity
- Emotional, social and spiritual support for family members
84
Federal and state law apply to which events after death?
- Documentation
- Organ and tissue donation
- Autopsy
- Postmortem care
85
_______ is the way people feel and view themselves
Self-concept
86
Is self concept subjective or objective?
Subjective
87
What stressors can affect self-concept?
- Unrealistic expectations
- Surgery
- Chronic illness
- Changes in role
88
What stressors affect body image?
- Amputation
- Mastectomy
- Hysterectomy
- Loss of body function
- Unattainable body ideal
89
_______ is an inner sense of individuality that implies the persons uniqueness as compared with others
Identity
90
T/F Self-esteem is the same thing as self concept
False
91
When is the sense of self often negatively affected?
In older adulthood
92
How long is the development of self-concept?
Lifelong
93
This component of self-concept involves the internal sense of individuality, wholeness, and consistency of self
Identity
94
This component of self-concept involves attitudes related to physical appearance, structure or function
Body image
95
This component of self-concept is how people carry out their significant roles
Role performance
96
The adolescent self-concept includes:
- Identity confusion
- Disturbed body image
- Self-esteem
- Role conflict
97
Nursing interventions aimed at enhancing _______ and ______ in older adults are essential
Self-concept and self-esteem
98
What should a nurse always ask patients in order for them to gain a stronger sense of self?
What they think is important
99
When setting priorities, nurses should focus on:
Adaptations to stressors
100
What are some expected outcomes for a patient with a self-concept disturbance?
- Nonverbal behaviors showing positive self-concept
- Statements of self-acceptance
- Acceptance of change
101
Self-concept stems from:
Development
102
Self concept includes:
- Identity
- Body image
- Role performance
103
Role ______ is vaguely defined responsibility that creates confusion
Ambiguity
104
Role _____ is when a person takes on multiple roles with limited resources and cannot manage them all
Overload
105
Role ______ develops when a person assumes opposing roles with incompatible expectations; they require opposing actions
Conflict
106
Role ______ results in frustration and anxiety when a person feels inadequate for assuming the role
Strain
107
Caring for a parent with dementia can result in:
Role strain
108
Assuming the role of a student, employee and parent can result in:
Role overload
109
What are some factors that can cause stress?
- Sociocultural
- Substance abuse
- Lack of education
- Poverty
110
Stress is:
Developmental
111
_______ is the behavioral and cognitive efforts of a person to manage stress
Coping
112
What factors can influence a persons ability to cope?
- Number of stressors
- Duration of stress
- Intensity of stressors
- Past experiences
- Support system
- Resources
113
This mechanism assists a person during a stressful situation or crisis by regulating emotional distress
Ego defense mechanism
114
Symptoms of role strain include:
- Fatigue
- Difficulty sleeping
- Illness
115
______ is evaluating an event for its personal meaning
Primary appraisal
116
_______ focuses on possible coping strategies
Secondary appraisal
117
_______ is someones effort to manage psychological stress
Coping
118
Level of personal control, presence of social support system and feelings of competence are examples of:
Personal characteristics that influence response to a stressor
119
What are the three different types of stress?
- Chronic
- Acute
- PTSD
120
This stress occurs in stable conditions and results from stressful roles
Chronic stress
121
This stress is time-limited and threatens a person for a relatively brief period
Acute stress
122
What are the different types of crises?
- Developmental
- Situational
- Adventitious
123
This crisis occurs as a person moves through the stages of life
Developmental
124
This crisis comes from external sources such as a job change, car crash, death, illness, etc
Situational
125
This type of crisis results from a major natural or man-made disaster or a crime of violence effecting the public
Adventitious
126
This model is for prevention and is based on the concepts of stress and reaction to stress
Neuman systems model
127
The _______ phase of the neuman system model states prevention promotes patient wellness by stress prevention and reduction of risk factors
Primary
128
The _______ phase of the neuman system model states prevention occurs after symptoms appear
Secondary
129
The _______ phase of the neuman system model states prevention begins when the patients system becomes more stable and recovers
Tertiary
130
Having a patient screened for disease would be an example of:
Secondary prevention
131
When do situations become a crisis?
When stress overwhelms a persons usual coping mechanism and demands mobilization of all available resources
132
Grimacing, moaning, flinching and guarding are behavioral responses to what kind of pain?
Acute
133
Depression, fatigue and a decreased level of functioning is behavioral responses to what kind of pain?
Chronic
134
How can you relieve chronic pain?
Administering opioids and analgesics around the clock rather than PRN
135
This pain arises from a noxious stimuli that triggers nociceptors and causes pain
Nociceptive pain
136
This pain is throbbing, aching and localized, responding well to opioids and non-opioids
Nociceptive pain
137
What are the different types of Nociceptive pain?
- Somatic
- Visceral
- Cutaneous
138
This pain is in the bones, joints, muscles, skin or connective tissue
Somatic
139
This pain is in internal organs and can cause referred pain in other body locations
Visceral
140
This pain is in the skin or subcutaneous tissue
Cutaneous
141
This pain includes phantom limb pain, pain below the spinal cord, and is common in diabetics
Neuropathic pain
142
How does neuropathic pain feel?
Intense, shooting, burning, pins and needles
143
What medicines respond best to neuropathic pain?
- Antidepressants
- Antispasmodic agents
- Muscle relaxants
- Topical medications
144
What are the 4 phases of nociceptive pain?
- Transduction
- Transmission
- Perception
- Modulation
145
In this phase, conversion of painful stimuli to an electrical impulse are transferred via peripheral nerve fibers
Transduction
146
In this phase, electrical impulses travel along the nerve fibers where neurotransmitters regulate it
Transmission
147
The point at which a person feels pain is there:
Pain threshold
148
The amount of pain a person can bear is their:
Pain tolerance
149
At this phase, the brain is influenced by thoughts and emotional processes that register the pain
Perception
150
During this phase, muscles contract reflexively, moving the body away from a stimuli
Modulation
151
What substances increase pain tolerance and causes an inflammatory response?
- Substance P
- Prostaglandins
- Bradykinin’s
- Histamine
152
What substances decrease pain transmission and produce no pain?
- Serotonin
| - Endorphins
153
What effect does physical pain have on the body?
Increases BP, pulse, RR, etc.
154
What effect does emotional pain have on the body?
Fatigue and anxiety
155
What effect does cognitive pain have on the body?
Nonverbal cues
156
Pain is always:
Subjective and individualized
157
In the gate control theory of pain, pain impulses are blocked and an open gate means:
Pain is going to the brain
158
In the gate control theory of pain, pain impulses are blocked and a closed gate means:
No pain or pain is regulated and not going to the brain
159
How long does acute pain last?
Less than 3 months
160
This pain lacks identity of origin, can be persistent and non-cancer related, has psychological and physiological side effects
Chronic pain
161
This pain can be acute or chronic and adjunct therapies are used to manage the pain
Cancer pain
162
In a heart attack, pain can be felt in the left arm. This is an example of:
Referred pain
163
This pain is treatable, protective and a warning of damage. Once healed, the pain leaves
Acute
164
This pain serves no purpose, is treatable but long term there is no cure; treatment is from trial and error
Chronic
165
What allows us to understand the progression of cancer pain?
WHO cancer ladder
166
T/F We always want to start with opioids in the treatment of cancer pain
False
167
What factors influence pain?
- Attitudes/beliefs
- Age and gender
- Fatigue
- Genes
- Spiritual
- Anxiety
- Behavioral and coping
- Culture
- Religion
168
What is the ABCDE method of pain assessment and management?
```
A: Ask about pain level
B: Believe the rating
C: Choose appropriate therapies
D: Deliver 7 rights and 3 checks
E: Empower the patient
```
169
What is a major side effect of pain?
Insomnia
170
We always want to be ______ not _______ to pain
Proactive; reactive
171
What are some non-verbal pain cues?
- Vocalizations
- Facial expressions
- Body movements
- Social interactions
- Rhythmic/rubbing motions
172
What are some barriers to pain management?
- Physical dependence
- Addiction
- Drug tolerance
- Cultural
- Medication side effects and risks
- Non-compliance
- Bravery/stoic
- Financial limitations
173
What does it mean to have drug tolerance?
Reduced reaction to a drug following its repeated use
174
Why is medication side effects and risks important in the clinical setting?
Because the patient needs to be educated on what to expect when taking the drug so they know what to expect and what they need to report
175
What would be some reasons for non-compliance with patients?
- Forgetful
- Don’t like side effects
- Too expensive
176
Planning of care should be patient centered, meaning:
We are basing our plan off of the patients wants and needs
177
Before and after the administration of medication, nurses should:
Assess prior to ambulating
178
Nurses should always assess patients for what when analgesic administration?
- Allergies
- Medication response
- Side effects
179
Nurses should always have knowledge of patients what before analgesic administration?
- Current and past medical history
- Medication and selection
- Medication accuracy and dosage
180
What are the 3 types of analgesics?
- Non-opioids
- Opioids
- Adjuvants
181
What does SBAR stand for?
- Situation
- Background
- Assessment
- Recommendation
182
What is the purpose of epidural anesthesia?
To treat severe pain
183
Can epidural anesthesia be administered by a RN
No
184
Can someone who has received epidural anesthesia have mobility?
No, they cant feel anything below the administration site
185
T/F Patient who have been administered a epidural anesthesia will have a catheter
True
186
T/F The ANA supports aggressive treatment of pain and suffering even if it hastens a patients death
True
187
Who are pain centers good for?
People with chronic pain
188
What does palliative care promote?
Comfort and autonomy
189
What will happen to vital signs after prolonged acute pain?
They will stabilize despite the persistence of the pain
190
Are vital signs good indicators for the measurement of pain
No
191
Who is at an increased risk for under-treatment of pain and adverse events following analgesia administration
Older adults
192
What medication route is the best for immediate short term relief of acute pain?
Parental route
193
What route is the best for chronic, non-fluctuating pain?
Oral route
194
What is appropriate for treating mild to moderate pain?
Non-opioid analgesics
195
What is appropriate for treating moderate to severe pain?
Opioids
196
What is the typical order of adverse effects of opiods?
- Sedation
- Respiratory depression
- Orthostatic hypotension
- Urinary retention
- Nausea/vomiting
- Constipation
197
What enhances the effects of non-opioids and are useful in treating neuropathic pain?
Adjuvant analgesics
198
Clients self-administer safe doses of opioids in small frequent dosing, which ultimately decreases the amount of medication they need. What device is this?
PCA
199
A PCA pump holds what type of opioids?
- Morphine
- Hydromorphone
- Fentanyl
200
T/F The client is the only person who can push the PCA pump?
True
201
Additional pharmacological pain interventions include:
Local and regional anesthesia and topical analgesia
202
When should you administer naloxone?
When RR is below 8 and shallow or the client is difficult to arouse
203
During this phase of surgery, the patient and surgeon meet and agree on surgery, informed consent is signed and education is provided
Pre-op
204
During this phase the actual surgery is performed and the phase ends when the patient goes to the PACU
Inter-op
205
During this phase, the patient is discharged from the OR and it starts when they enter the PACU
Post-up
206
This type of surgery is considered as outpatient, requiring no hospital stay and option availability depends on severity of patient health history:
Ambulatory
207
What are some pros of ambulatory surgery?
- Huge cost savings
| - Decreased risk of HAI
208
What are some cons of ambulatory surgery?
- Home recovery
- Risk for non-compliance
- Risk for infection
- Risk for re-admittance
209
This type of surgery requires a hospital stay and major surgeries such as trauma, cardiac, brain, emergency
Inpatient
210
Inpatient surgery increases the risk for:
- HAIs
| - Hefty medical bill
211
Surgeries based on urgency are:
- Elective
- Urgent
- Emergent
212
______ surgery is based on patients choice and it being delayed will not cause harm to the patient
Elective
213
_____ surgery is not life threatening but you want to do it ASAP to preserve health
Urgent
214
_______ surgery needs to be done immediately to preserve life, limb or function
Emergent
215
This surgery can be elective, urgent or emergency
Major
216
This surgery is usually elective
Minor
217
What is the purpose of a diagnostic or explorative surgery?
To make or confirm a diagnosis
218
What is the purpose of a ablative surgery?
To remove diseased body part
219
What is the purpose of a palliative surgery?
Not a cure but reduces the intensity of illness
220
What is the purpose of a reconstructive surgery?
To restore function
221
What is the purpose of a organ procurement surgery?
To donate organs
222
What is the purpose of a transplant?
To transfer deceased or living persons organs to another person
223
What are the different classification of a patient before surgery?
P1: Healthy patient
P2: Mild systemic disease
P3: Non-controlled severe systemic disease
P4: Life threatening severe systemic disease
P5: Patient is terminal w/o surgery
P6: Brain dead patient - organ donation
224
For an assessment during an elective surgery, the nurse should cover:
- Allergies
- Lab values
- Patient knowledge
- Medication history
225
What happens if blood glucose is too high in a patient due for surgery?
Surgery is cancelled because patient will not heal
226
Why is coagulation lab values important before surgery?
Because we do not want abnormal bleeding
227
If a urinalysis shows a patient due for surgery has a UTI, what will happen?
Surgery will be cancelled
228
An assessment during an urgent/emergent surgery should be:
A focused assessment only because we want to rescue the patient from injuries that deprive them of their life
229
Patient with a latex allergy will always be:
The first surgery of the day
230
NPO status means:
Nothing by mouth, not even water because of aspiration risks
231
Garlic, Vitamin E and Girko can cause:
Bleeding
232
Vitamin K can cause:
Clotting
233
What should the nurse assess after surgery?
- Maintain respiratory function
- Prevent circulatory complications
- Achieve rest and comfort
- Temperate regulation
- Maintain neurological function
- Maintain fluid and electrolyte balance
- Promote normal bowel elimination and nutrition
- Promote urinary elimination and wound healing
- Maintain/enhance self-concept
234
Respiratory function includes:
- Patency
- Rate, rhythm and symmetry
- Breath sounds
- Color of mucous membranes
- POX
235
Circulatory complications include:
- HR, rhythm
- BP
- Capillary refill
- Nail beds
- Peripheral pulses
- Vitals
236
Temperature regulation monitors for:
- Malignant hyperthermia
- Hypothermia
- Shivering
237
Neurological function includes:
- LOC
| - Gag and pupil reflexes
238
Fluid and electrolyte influence includes:
- IV
- I/O
- Blood loss
239
How soon does urinary function return after surgery? What is the expected amount to void?
6-8 hours later; 30mL
240
The nursing diagnosis may alter after:
Each phase of the preoperative care
241
What does the planning phase of the nursing process require?
Acquired assessment data
242
What is the aldrete score?
A screening tool used in the PACU that determines the stability of a patient before transfer or discharge
243
When do you assess a patient using the aldrete score?
At 5, 15, 30, 45 and 60 minutes
244
What criteria is evaluated using the aldrete score (max. 2 points/ea.)?
- Activity
- Respiratory
- Circulation
- Consciousness
- Oxygen saturation
245
How many points are required for a passing aldrete score?
8 points to get discharged from PACU because anything lower increases risks for infection
246
What are the pressure ulcer stages?
Stage I: Intact skin-non blanchable redness
Stage II: Partial thickness and skin loss (epi, dermis or both)
Stage III: Full thickness and skin loss with visible fat and tunneling may be present
Stage IV: Full thickness and skin loss with exposed bone, tendon and muscle
Unstageable: Full thickness with skin loss, slough and eschar
247
T/F Anesthesia requires consent
True
248
What is Anesthesia dependent on?
- Surgery type
- Length of surgery
- Positioning during surgery
- Patient comorbidities
249
What are the 3 phases of Anesthesia?
- Induction (chemical agents)
- Maintenance (begins with positioning and throughout case)
- Emergence (awaken from agents)
250
This anesthesia causes loss of consciousness, relaxes skeletal muscles, results in full immobility with no reflexes and airway management is required
General anesthesia
251
This anesthesia does not put the patient totally under and they can respond to verbal commands and should be easy to wake. It is short term for minimally invasive procedures; the patient can keep their airway open
Conscious sedation
252
This anesthesia blocks transmission of sensory stimuli to CNS receptors and reflexes may also be lost but no loss of consciousness
Regional anesthesia
253
This anesthesia requires the numbing of an area for minor procedures
Local anesthesia
254
What happens when a time out is called?
It is a patient safety step to check that all materials are available, everyone on the team is on the same page and is one of the last steps before an incision is made
255
What happens when a bug out is called?
We are making sure that all safety mechanisms occurred and all ordered antibiotics have been given to the patient before incision is made
256
Someone with this life threatening genetic condition cannot process anesthesia and has symptoms such as muscle rigidity and hyperthermia
Malignant Hyperthermia
257
What is the treatment for Malignant Hyperthermia?
- 2.5 mg/kg of Dantrolene initially with 50 ml of sterile H2O
- Cool patient with ice
- Administer diuretics
- Correct acid base and electrolyte imbalances
258
Atelectasis is:
Partial or complete collapse of the lung as a result of airways obstruction caused by accumulation of secretions; may occur 1-2 days post-op
259
Pneumonia is:
An infection that inflames the air sacs in one or both lungs; may occur 3-5 days post-op
260
Pulmonary embolism:
Occurs when a blood clot gets lodged in an artery in the lung, blocking blood flow to part of the lung
261
Pulmonary edema is caused by:
Excess fluid in the lungs
262
Laryngospasm is:
A spasm of the vocal cords that temporarily makes it difficult to speak or breathe
263
Laryngeal edema is:
A frequent complication of intubation and is caused by trauma to the larynx
264
Thrombus is:
A blood clot formed in situ within the vascular system of the body and impeding blood flow
265
An emboli is:
A blood clot, air bubble, piece of fatty deposit, or other object which has been carried in the bloodstream to lodge in a vessel and cause an embolism.
266
Paralytic ileus is the condition where:
The motor activity of the bowel is impaired
267
Hemorrhage is:
Loss of a large amount of blood externally or internally in a short time period
268
Hypovolemic shock is an emergency condition in which:
Severe blood or other fluid loss makes the heart unable to pump enough blood to the body
269
______ is an example of uncontrolled prescription medications
Antibiotics
270
These orders are on a regular schedule w/o a termination date:
Routine or standing order
271
This order is once at a specific time or ASAP
Single or one time oder
272
This prescription is only for administration once and immediately (ex: IV bolus)
Stat order
273
This prescription is only for administration once but up to 30 minutes from when the nurse received the order
Now order
274
This prescription specifies at what dosage, frequency, and conditions a nurse can administer the medication
PRN order
275
What information should you collect during an OTP order?
Clients name, medication, dosage, time to give, frequency, route
276
What do you do after collecting an OTP order?
Verify the provider will sign order and enter prescription in clients medical record
277
When should you give non-time critical medications prescribed once daily, weekly or monthly?
Within 2 hours of the prescribed time
278
When should you give non time critical medication prescribed more than once daily?
Within 1 hour of the prescribed time
279
When do you document administration of medication?
After giving it
280
Where is medicine metabolized?
In the liver
281
Medications are metabolized into a:
Less potent or an inactive form
282
When does biotransformation occur?
Under the influence of enzymes that detoxify, break down and remove active chemicals. Most occur in the liver
283
Where do medications exit the body?
- Kidneys
- Liver
- Bowel
- Lungs
- Exocrine glands
284
What determines the organ of excretion for medication?
The chemical make up of the medicine
285
______ are predictable, unavoidable secondary effects
Side effects
286
_____ is the accumulation of medication in the bloodstream
Toxic effects
287
______ is an overreaction or under-reaction or different reaction from normal
Idiosyncratic reaction
288
______ occurs when one medication modifies the action of another
Medication interaction
289
During this phase, medication has no effect at all
Trough
290
During this phase, medication concentration is highest
Peak
291
What are the 7 patient rights nurses must check before giving meds?
- Right patient
- Right medication
- Right dose
- Right route
- Right time
- Right documentation
- Right indication
292
What are the 3 checks for medication?
- Pyxis
- MAR
- Bedside
293
A patient has the right to:
- Refuse meds
- Have medication history
- Not receive unnecessary meds
294
Who can prescribe medicine?
- Physician
- NP
- PA
295
What are the components of an accurate medication order?
- Name
- Date/time
- Dose
- Route
- Frequency/time
- Provider signature
- Pain scale is applicable
296
What are the different medication routes?
- Oral
- Topical
- Inhalation
- Irrigation
- Parenteral
- Injection
297
Sublingual medication is placed where?
Under the tongue
298
Buccal medication is placed where?
Between the cheek and gum
299
How long does it take to absorb oral medication?
1 hour
300
These meds are easy, fast but take longer to work and are effected by food. They also increase risk for other drug interactions
Oral medications
301
This type of medication is placed on the skin, eyes and ears
Topical
302
This type of medication can be given via IV, is fast working, hard to reverse and can be painful
Parenteral
303
Higher the number, smaller the _____
Needle
304
What precautions should we take when giving topical medications?
- Wear gloves
- Place on smooth skin surface with no hair
- Use sterile technique for open womb
305
How do you instill eye medications?
- Avoid the cornea and eyelids
| - Instill into lower conjunctival sac
306
How do you instill ear medication?
- At room temperature with sterile solutions
| - Pull pinna up and back and check ear for rupture or drainage
307
What is the most important thing to do when administering medications by inhalation?
- Use a spacer to make sure full effect on medication is feasible
308
Why do we pump air into a vile?
To create pressure which helps the medication draw back
309
For an ampule, what type of needle is used?
Red filter needle that must be used to drawback meds and then discarded
310
What type of meds is the Z-track method used for?
Iron
311
Intradermal injections are used for:
- TB skin test
| - Allergy skin test
312
Angle insertion for intradermal injections are?
5 - 15 degrees with bevel up
313
This is unrelieved pressure over bony prominences that results in ischemia and damage to tissue
Pressure injury
314
When assessing the skin, you want to consider:
- Health history
- Color
- Texture/turgor
- Moisture
- Temperature
- Lesions
- Braden scale
315
What are the risk factors on the Braden scale?
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and shear
316
On a Braden scale, the lower the score:
The higher the risk
317
A severe risk for sore on a Braden scale would be a score of:
Less than or equal to 9
318
A high risk for sore on a Braden scale would be a score of:
Total score 10-12
319
A moderate risk for sore on a Braden scale would be a score of:
Total score of 13-14
320
A mild risk for sore on a Braden scale would be a score of:
Total score of 15-18
321
What is debridement?
Removal of nonviable, necrotic tissue
322
Mechanical debridement is:
wet to dry dressing changes (large syringe with needle on the end)
323
Autolytic debridement is:
A synthetic dressing
324
Chemical debridement is:
Dressing or topical enzyme that breaks down tissue exudate and absorbs bacteria
325
Surgical debridement is:
Removal of eschar
326
What is the purpose of a wound dressing?
- Protect womb from microorganisms
- Aid in homeostasis
- Promote healing
- Support/splint wound site
- Protect patients from seeing it
- Promote thermal insulation
327
This healing process has little or no tissue loss, edges are approximated, healing is rapid, theres a low risk for infection and no/minimal scarring
Primary intention
328
This healing process has loss of tissue, wound edges are widely separated and unapproximated, its a longer healing time with increase risk for infection, scarring and heals by granulation
Secondary intention
329
What is the preferred cleansing agents for wounds?
Isotonic solutions
330
This absorbs exudate from the wound
Woven gauze
331
This is a temporary second skin for small superficial wounds
Film dressing
332
This forms a seal at the wounds surface to prevent evaporation of moisture and surface contamination; it is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing?
Hydrocolloid
333
This is mostly water and maintains a moist surface to support healing; are best for partial or full-thickness wounds
Hydrogel
334
This is a negative pressure suction that speeds tissue generation, decreases swelling and enhances healing in a moist, protected environment
Wound vacuum
335
What are some complications that can occur with wounds?
- Infection
- Hemorrhage
- Hematoma
- Dehiscence
- Evisceration
336
This is a partial or total rupture of a sutured wound usually with separation of underlying skin layers
Dehiscence
337
This is a dehiscence that involves the protrusion of visceral organs through the wound opening
Evisceration
338
This is a collection of blood into a clot that appears as a red or blue bruise
Hematoma
339
What are the nursing interventions for evisceration and dehiscence?
- Cover wound and any organs with sterile towels or dressings soaked with sterile normal saline solution to decrease chance of bacteria invasion and drying of the tissues
- Position the client in supine position with knees and hips bent
- Observe for shock
- Maintain calm environment
- Keep client NPO
340
What labs are important to consider regarding wound care?
- Albumin levels
| - WBC
341
Examples of bacteria:
- C.Diff
- E. coli
- Staph
- TB
342
Examples of viruses:
- Hep. B
- Flu
- HIV
- Herpes zoster
- COVID
343
Examples of fungi:
Candida albicans
344
Examples of parasites:
Malaria
345
This is the ability of a pathogen to invade and injure a host
Virulence
346
Nonspecific innate is:
Temporary immunity (passive = antibodies from external source)
347
Nonspecific innate includes:
- Intact skin
- Mucous membrane
- Vascular response
- Cellular response
348
Specific adaptive immunity:
Permanent immunity. Allows the body to make antibodies in response to a foreign organism
349
Specific adaptive immunity includes:
- B and T cells
| - Immunoglobulins
350
Patient at greater risk for HAIs include:
- Immunocompromised
- Elderly/infants
- Poor nutrition
- Comorbidities
- Multiple drugs
351
How soon should a IV be removed?
After 72 hours
352
Major sites for HAIs include:
- Urinary tract
- Bloodstream
- Surgical site
- Trauma wounds
- Respiratory tract
353
Different types of HAIs:
- Iatrogenic
- Exogenous
- Endogenous
354
What are the modes of transmission?
- Droplet
- Airborne
- Contact
- Vector
355
What are the different types of precautions?
- Isolation
- Standard
- Transmission
356
What viruses fall under standard precautions?
- CMV
- HIV
- Hep. B and C
- Aspergillosis
357
What viruses fall under contact precautions?
- MRSA
- VRE
- Adenovirus
- Diarrhea
- C.Diff
- Rotavirus
- E. Coli/Enterovirus
- Salmonella
- Shigella
- Hep. A
- Herpes Zoster/Simplex
- Parainfluenza
- RSV
- Lice/Scabies/Chicken pox
358
What viruses fall under droplet precautions?
- Pertussis
- Neissera meningitides
- Coxsackie
- Bacterial meningitis
- Mumps
- Rubella
359
What viruses fall under airborne precautions?
- Disseminated herpes zoster
- Measles
- SARS
- Avian flu
360
How should you wash your hand after caring for someone on extended contact?
With soap and water
361
Droplet precautions include standard precautions plus a:
Surgical mask
362
Airborne precautions include standard precautions plus a:
- N95
| - Pressure negative room
363
What is the proper process to donn PPE
- Gown
- Mask
- Goggles
- Gloves
364
What is the proper process to doff PPE
- Gloves
- Goggles
- Gown
- Mask
365
Stridor, wheezing or a crowing sound indicates:
Partial obstruction, bronchospasm or laryngospasm
366
Crackles and rhonchi indicate:
Ateletasis, pneumonia or pulmonary edema
367
Vomiting post-op, abdominal distention and absence of bowel sounds may be signs of:
Paralytic ileus
