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Nurs 101 Lecture > Exam 1 > Flashcards

Exam 1 Flashcards

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1
Q

What is included in physical assessment

A

Subjective and objective data

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2
Q

Subjective data

A

Reported by patient, family, another member of health team

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3
Q

Objective data

A

What nurse observes, labs, xrays.

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4
Q

Vital signs

A

Temp
Pulse
Respiration
Blood presusre
Pain
Oxigenation

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5
Q

What does elevated temp mean

A

Infection

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6
Q

Is there an infection if body temp is normal

A

No

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7
Q

What does elevated temp do to immune system

A

Activates immune systsem

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8
Q

Hyperthermia

A

High body temp/fever

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9
Q

Hypothermia

A

Low body temp

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10
Q

Things that affect body temp

A

Food and fluid consumption, menstrual cycle, age, etc

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11
Q

Normal body temp

A

98-98.6 F

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12
Q

Pulse

A

60-100 BPM

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13
Q

Respiration

A

12-20 breaths per min

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14
Q

Blood pressure

A

Below 120/80

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15
Q

Elevated

A

120-129 systolic and below 80 diastolic(double check)

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16
Q

Hypertension 1

A

130-139 systolic or 80-89 dyastolic

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17
Q

Hypertension 2

A

140 or above systolic or 90 or above dyastolic

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18
Q

Hypertensive crisis

A

Above 180 systolic and or above 120 diastolic

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19
Q

MRSA

A

Surgical site contact staph infection

Caused by poor hand hygiene

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20
Q

CAUTI

A

Catheter acquired UTI-reportable to the CDC

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21
Q

Indwelling catheter effects

A

Loss of bladder muscle tone

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22
Q

What can catheters cause

A

UTI and urinary retention after removal

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23
Q

How log can a catheter stay in

A

72 hours

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24
Q

Five rights of delegation

A

Right person

Right task

Right direction

Right curcumstance

Right supervision

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25
Q

Right person

A

Has to be competent to complete task

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26
Q

Right task

A

Has to be within scope of practice, job description

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27
Q

Patient centered care

A

Foundation of nursing. Including patient and all members of treatment team

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28
Q

Should nurses always try to make sure patients are informed about care

A

Yes

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29
Q

Do nurses function as advocates

A

Yes

30
Q

Purpose of nursing process

A

Identify actual and potential problems

Perform interventions to address those problems

Protect nurses against legal liability

31
Q

ANA

A

Nursing organization

32
Q

Assess

A

Collect and analyze data

33
Q

Diagnose

A

Interpret data and draw conclusions.

34
Q

Plan

A

Care plan, goals, outcomes, interventions

35
Q

Intervention

A

Executing the care plan

36
Q

Evaluation

A

Did the care plan work

37
Q

Pneumonia

A

HAI caused by poor hand hygiene

38
Q

Should we take temp on someone who just drank or ate

A

No. Wait 15-30 mins.

39
Q

Radial pulse

A

On wrist

40
Q

Apical pulse

A

Point of Maximum impulse

Fifth intercostal space, midcloviculie

41
Q

What type of transmission is TB

A

Airborne and droplet

42
Q

Ppe for airborne

A

N95

43
Q

Ppe for contact

A

Gloves and gown

44
Q

Ppe for droplet

A

Gloves, mask, gown, goggles

45
Q

Temp routes

A

Axillary-underarm
Tempanic-in ear
Oral
Rectal
Skin

46
Q

What kind of patients receive oral and rectal temp

A

Stable

47
Q

Dangers of rectal temp

A

Vagal nerve is affected which can cause cardiac arrest

48
Q

What route do unstable patients use

A

Axillary and tympanic

49
Q

What is considered a fever

A

99.6 F and above

50
Q

Hypothermia temp

A

Below 95 F

51
Q

All pulses

A
52
Q

Instructions for clients before blood pressure

A

No smoking or drinking 30 mins prior
Record date, time, and pressure
Take multiple readings
Call provider if there are several high readings

53
Q

Chain of infection

A

Pathogen

Reservoir

Portal of exit from reservoir

Mode of transmission

Portal of entry

Susceptible host

54
Q

Types of infection

A

Local

Systemic

Bacteremia

Septicemia

55
Q

Local infection

A

Only one part of body

56
Q

Systemic infection

A

Throughout body

57
Q

Bacteremia

A

Blood culture shows bacteria/pathogen

58
Q

Septicemia

A

Systemic bacteremia

59
Q

Acute infection

A

Sudden and short term

60
Q

Chronic infection

A

Gradual and long lasting

61
Q

Nosocomial/HAI

A

UTI-improper catheter care

Surgery site- staph infections. Poor hand hygiene.

Bloodstream-poor IV care

Pneumonia-poor hand hygiene

62
Q

Specific defenses

A

Active
Passive

63
Q

Active immunity

A

You create your own antibodies naturally

64
Q

Passive

A

Body gets antibodies elsewhere. Vaccines and breast fewding.

65
Q

Should we investigate cultural preferences

A

Yes

66
Q

Durable power of attorney

A

When a competent individual gives someone else legal ability to make decisions if they are ever incompetent

67
Q

Duty

A

Obligation to do something

68
Q

Injury

A

Physical or mental harm or violation of a persons rights due to negligence

69
Q

Malpractice

A

Deviation from standard

70
Q

Negligence

A

Deviation from standard

71
Q

Example of staph

A

MRSR and pneumonia

72
Q

Is TB chronic or acute

A

Chronic

Nurs 101 Lecture (13 decks)

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