EXAM 1 Flashcards

Question

nose | hygiene

Answer 1

smell and taste. Very vascular mucous membrane. Mucous and cilia trap foreign matter to prevent it from entering the lungs. It is blown out or sneezed away

Answer 2

Wrinkles (decreased collagen) Thinning of skin layers Degeneration of elastin fibers Decreased sweat production Decreased oil production, drier skin More skin lesions Graying hair Increase in facial hair Dry brittle nails

Answer 3

Weakening of periodontal membrane so increased risk of infection, disease Dentures- pain, malnutrition- Ensure never thrown away or lost! Dry mouth due to decreased saliva, meds Malnutrition- due to socioeconomic status, limited ability to prepare healthy foods, dental problems

Answer 4

skin is loosely bound, easily damaged. Layers bind together as infant gets older.

Answer 5

sex hormones- sebaceous glands-oil, sweat glands- odor. Hygiene

Answer 6

Activity intolerance Self-care deficit: Impaired Ability to Bath Impaired mobility Impaired skin integrity Impaired oral mucous membranes Risk for infection r/t bathing, oral care, dressing, feeding, transfers, walking, turning in bed

Answer 7

Integrate nursing knowledge. Consider developmental and cultural influences. Think creatively. Be nonjudgmental and confident. Draw on your own experiences. Rely on professional standards. Use communication to promote the therapeutic relationship.

Answer 8

Who is involved in care? Community agencies needed? Amount of help required? Partner with the patient and family Measurable, achievable, individualized

Answer 9

Set priorities based on assistance required, extent of problems, nature of diagnoses Skin will be clean, dry, and intact with good turgor. No areas of inflammation will be noted Skin will have no pressure, tear, or sheared areas Skin will have no areas of infection Oral mucosa will be moist, pink, and intact

Answer 10

Provide privacy, professionalism, modesty, safety, warmth (water, room, bath blanket, mitt- loses less heat, prevents drag of washcloth across skin)

Answer 11

Primary reason-cleanse & reduce microbe count, remove dead skin, Secondary reasons- stimulate circulation, provide relaxation, enhance healing

Answer 12

Complete, Partial (unable to tolerate), Therapeutic (soothe itchy skin)

Answer 13

Wash with long, firm strokes from distal (away) to proximal (closest). Why? To promote venous circulation. (Light strokes if history of blood clots)

Answer 14

Apply lotion to all areas of skin- moisturizes (except in between toes- risk of skin irritation, maceration-softening)

Answer 15

increases the risk of HAI (Healthcare or Hospital Acquired Infections) (pneumonia), Oral moisturizers as needed. Tooth brushing twice daily, flossing once daily. Helps improve taste sensation & moisturizes

Answer 16

So Oral care twice a day OR Every 1-2 h for unconscious, ventilated, NPO- nothing by mouth (Toothbrushes most recommended for all oral care. Suction available for unconscious- risk of aspiration) (Check for gag reflex before care) Diabetes, artificial airways, unconscious, chemotherapy CHG oral rinse/paste is antimicrobial effective against dental plaque biofilms, decrease HAI

Answer 17

Don’t use near eyes, ears, Use in basins-stops bacterial growth, Leave on for more antibacterial effects, to rinse or not

Answer 18

allow the patient to do as much as they are able/willing anticipate needs

Answer 19

Keep dirty gown, linens away from uniform

Answer 20

Wash and dry areas breast, axillary, and abdominal folds well

Answer 21

to distribute oil. (Braid long hair to keep it from tangling.) Combing is more effective than use of pediculicidal shampoos in the case of head lice

Answer 22

in line with tip of finger as needed & cleanse dirt from nails- (short, clean nails are less likely to spread infection)

Answer 23

daily- (inspection prevents unnoticed injuries from worsening)

Answer 24

help with sleep, relaxation (Effleurage- long, slow, gliding strokes of massage)

Answer 25

relevant instruction, prevent injury/infection

Answer 26

independently or with assistance, risk of infection- uncircumcised males, urinary catheters, post-rectal or genital surgery or childbirth

Answer 27

burning during urination, soreness, excoriation (raw), pain, discharge- appearance, odor, amount. Risk for skin breakdown- incontinence, dressings, catheters, obesity.

Answer 28

Cleanse from front to back to reduce chance of transmitting fecal organisms to urinary meatus. Use different sections of the washcloth for folds.

Answer 29

(Oxygen tubing- check what? …….) Cleaning ear gently with washcloth. Hearing aid maintenance

Answer 30

when to use electric razor

Answer 31

$, lens or soft cloth, cool water, no paper towels

Answer 32

clean hands, contact solution

Answer 33

warm normal saline (NS) to rinse eye, NS or water on soft gauze to rinse eye socket, Store in tap water or NS- labeled container. Observe for S& S of infection.

Answer 34

Inspect feet and between the toes daily-thoroughly (Use mirror if needed) Lukewarm water, thorough drying- do not soak feet due to risk of infection Lotion to feet but NOT between the toes b/c or risk of skin irritation & breakdown If can see and reach nails on their own, they should trim nails straight across, file edges smooth (HCW file but don’t cut- HCP order in healthcare facility)

Answer 35

Cotton socks, comfortable & sturdy shoes Do not apply heating pad to feet Elevate legs when sitting. Don’t cross legs for long periods. Avoid smoking. Wiggle toes and move ankles up & down for 5 minutes 2-3 times daily. Contact HCP (healthcare provider) if concerns

Answer 36

Through the patient’s eyes- Were the patient’s expectations met? Patient outcomes Evaluate after each hygiene intervention. Use teach back. If outcomes were not met, revise the care plan Bathed

Answer 37

Moisturized Teeth brushed twice a day; flossed once a day (ADA) Eyes, ears, nose without redness or drainage Nails clean and trimmed Feet have no areas of breakdown

Answer 38

Identify the patient with two identifiers. Move from the cleanest to less clean areas. Use clean gloves for contact with nonintact skin, mucous membranes, secretions, excretions, or blood.

Answer 39

Test the temperature of water or solutions. Use principles of body mechanics and safe patient handling. Give proper direction to UAP- unlicensed assistive personnel- when delegating.

Answer 40

A sequence of necessary pieces for an infection to occur. Includes an infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.

Answer 41

something that contains bacteria, fungi, virus, parasite, or prion.

Answer 42

the habitat of the infectious agent and is where it lives, grows, and reproduces itself or replicates.

Answer 43

can be any body orifice (for example, ears, nose, mouth) or can even be through the skin, and it provides a place for the infectious agent to replicate or for the toxin to act.

Answer 44

is the means by which the infectious agent can leave the reservoir

Answer 45

is required for the infectious agent to take hold and become a reservoir for infection. Not everyone who is exposed to an infectious agent gets sick.

Answer 46

contact droplet airborne

Answer 47

occurs when microorganisms move from an infected person to another person.

Answer 48

occurs when airborne droplets from the respiratory tract of a client travel through the air and into the mucosa of a host

Answer 49

occurs when small particulates move into the airspace of another person.

Answer 50

direct and indirect

Answer 51

occurs when microorganisms are directly moved from the infected person to another person without having a contaminated object or person between the two.

Answer 52

occurs when microorganisms are moved from the infected person to another person with a contaminated object or person between the two.

Answer 53

Nonspecific immunity refers to neutrophils and macrophages and their work as phagocytes.

Answer 54

eat and destroy microorganisms, thereby helping to protect the body from harm

Answer 55

during the inflammatory response.

Answer 56

refers to the work of antibodies (also called immunoglobulins) and lymphocytes. Antibodies bind to infectious agents and call to the white blood cells and complement to destroy them

Answer 57

1. Pattern receptors on the surface of cells recognize harmful stimuli. 2. Inflammatory pathways are activated. 3. Inflammatory markers are released. 4. Inflammatory cells are recruited.

Answer 58

incubation prodromal acute illness decline convalescence

Answer 59

An infection enters host and begins to multiply

Answer 60

The client begins having symptoms.

Answer 61

Manifestations of the specific infectious disease process are obvious and may become severe.

Answer 62

Manifestations begin to wane as the degree of infectious disease decreases.

Answer 63

The client returns to a normal or a “new normal” state of health.

Answer 64

are confined to one area of the body. Local infections can be treated with topical antibiotics and oral antibiotics

Answer 65

start as local infections and then spread to the bloodstream to infect the entire body

Answer 66

is systemic inflammatory response syndrome resulting from body’s response to a serious infection due to microorganisms (usually bacterial

Answer 67

broad term to cover any type of cleansing of hands

Answer 68

Handwashing- 15-20 sec. Soap and water for diarrheal disease (c-diff spore potential), Sanitizer >70% alcohol, lotion to prevent dermatitis- itchy, dry skin/ irritation

Answer 69

Hands are soiled, before & after pt contact, before sterile gloving, contact with body fluids, each time gloves removed

Answer 70

(clean technique) is a term used to define the elimination of and absence of disease-causing microorganisms

Answer 71

sterile technique

Answer 72

A sterile object is free of all microorganisms. All objects on a sterile field must be sterile. sterile items below the waist or out of the field of vision are not sterile avoid talking, laughing, sneezing, and prolonged air over sterile field

Answer 73

1st open flap or side furthest away from you using, 2nd & 3rd flaps on either side using closest hand, 4th side closest to you- Why?

Answer 74

Moisture contaminates a sterile field. Water-proof barriers are used. Wet objects become contaminated by capillary action. Pour from sterile solution into container. Make sure cap of bottle set face up on clean surface.

Answer 75

Outer 1 inch of a sterile field is considered unsterile b/c touches surfaces and can be touched by non-sterile hands. Outer edges of containers considered contaminated.

Answer 76

is a term used to describe the infection prevention practices applied to all clients, whether or not they are known to have an infectious agent

Answer 77

It is the nurse’s responsibility to know what type(s) of Personal Protective Equipment (PPE) are needed to care for clients and to don and doff PPE appropriately.

Answer 78

1. gown 2. mask/respirator 3. goggle/face shield 4. gloves

Answer 79

1. gloves 2. goggles/face shield 3. gown 4. mask/respirator 5. hand hygiene

Answer 80

for diseases that transmit via the air, either as molecules less than 5 microns or by riding on dust particles that small. Molecules remain suspended in the air. N95 particulate respirator-fit-testing, Negative pressure room (HEPA filtration) (TB, chicken pox, COVID, Ebola)

Answer 81

for pathogens that are transmitted by particles larger than 5 microns. And drop to the floor or fomites within 3 feet of the host (sick person). Mask required. (Influenza, pertussis)

Answer 82

for pathogens that are transmitted by direct or indirect contact with the host. All items and fomites (furniture) are contaminated within 24 hours of the host being place in the room. (Always gown, gloves, hand-washing, mask if risk of splashing) (MRSA)

Answer 83

same as contact but wipe down room surfaces routinely & thoroughly to kills spores- Clostridium difficilie/c.diff)

Answer 84

private room, positive airflow, high-efficiency particulate air (HEPA) filtration, mask when out of room, no live plants or flowers due to aspergillosis mold- can cause infection (Immunosuppressed/ Neutropenic) Limit patient movement outside of room, clean gown, mask (PPE) on patient for transport if needed, door closed Psychological implications, bagging of trash, patient care items, specimen collection

Answer 85

hand hygiene gown and gloves *if risk of splash/spray, wear face and eye protection

Answer 86

hand hygiene- not foam but requires soap and water gown gloves if risk of splash/spray, wear eye and face protection *twice daily cleaning of high touch surfaces

Answer 87

hand hygiene mask eye protection gown gloves

Answer 88

hand hygiene standar precautions but add mask

Answer 89

hand hygiene standard precautions n95 respirator Pt must be in negative pressure room with door closed

Answer 90

no one with an infection may visit hand hygiene Pt wears a surgical mask when out of room no live plants/flowers

Answer 91

Central Line-associated Bloodstream Infections (CLABSIs) Catheter-associated Urinary Tract Infections (CAUTIs) Surgical Site Infections (SSIs) Ventilator-assisted Pneumonias (VAPs)

Answer 92

Morbidity, mortality, cost------Not reimbursed

Answer 93

Iatrogenic—from a procedure Exogenous—from microorganisms outside the individual Endogenous—when the patient’s flora becomes altered and an overgrowth results

Answer 94

Invasive procedures, altered immune defenses, older adults, antibiotic administration, multi-drug resistant organisms (mdro) Gene mutations after surviving antibiotic therapy (mdro) Spread to sputum, bloodstream, urinary tract

Answer 95

MRSA (methicillin-resistant S. aureus) colonizes is nose, skin VRE (vancomycin-resistant Enterococcus) C-difficile (soap & water) to kill spores

Answer 96

to treat infection may eliminate or change normal flora, leading to a superinfection- overgrowth of harmful bacteria.

Answer 97

Microorganisms- found in skin, saliva, oral mucosa, and intestinal walls. Maintain sensitive balance with other microorganisms to prevent infection. Disruption of balance increases risk for acquiring of illness/disease.

Answer 98

Hand hygiene, conservative antibiotic use, universal precautions, transmission-based precautions, proper disposal of PPE, not sharing patient items, antimicrobial dressings, no artificial fingernails, limit urinary catheterizations, careful monitoring- Limit/Intervene/Break the chain of infection

Answer 99

Risk for Infection Imbalanced Nutrition: Deficient Food Intake Impaired Oral Mucous Membrane Impaired Skin Integrity Social Isolation Impaired Tissue Integrity Readiness for Enhanced Immunization Status

Answer 100

Separate personal care items Handling exudate Wound cleaning Cough etiquette Dirty linen- never on floor Maintain skin integrity Perineal care after toileting Urinary catheters and drainage sets Teach back

Answer 101

regulations to protect employees whose jobs put them at risk for exposure to blood/infectious agents

Answer 102

saliva, fluids contaminated with blood, semen, vaginal secretions, cerebrospinal fluids, synovial fluid, pericardial fluid, amniotic fluid, unfixed tissue or organs, cultures containing HIV/Hep B/Hep C, infected animals

Answer 103

providing care for all persons to reduce the risk of microbial transmission from one person to another- handwashing, safe disposal of Sharps- never recap used needle, PPE

Answer 104

Protect skin, mucous membranes, respiratory tract. Gloves, masks, gowns, shoe covers, goggles (not just eye glasses). Don’t touch face. Guidelines are to remove gloves, remove gown by only touching it on inside, remove mask, wash hands.

Answer 105

federal regulations instituting needless devices to promote needlestick safety and prevention- prevent puncture wounds

Answer 106

A diet with fresh fruits, vegetables, whole grains, nuts, & legumes; fewer processed foods; decrease allergies- early solid foods Adequate rest and Exercise at least three times a week for 30 minutes at a moderate or strenuous level Maintain a weight that is suitable for height so that Body Mass Index –Ideal BMI ranges from 18.5 – 24.9 Stress management and reduction by effective positive means

Answer 107

Use of alcohol, drugs, cigarettes, and unprotected sex increase the risk of a compromised immune system (triggers, stds) Immunizations are protective from communicable diseases by mounting an immune response (antigen-antibody) (active immunity- long-lasting) Treating ongoing disease whether related to infection or immune system

Answer 108

Hearing aids are often forced into the incorrect ears. Red is for right. Blue is for left.

Answer 109

Don’t keep batteries by medications!!! -Battery doors should be open when the hearing aids are not being worn.

Answer 110

It is important that the hearing aids are cleaned as often as possible (ideally daily when removed).

Answer 111

Labeled nighttime storage containers. May be locked in secure spot.

Answer 112

9 times out of 10 when a patient reports hearing aids are not working, they are not clean. Inspect for wax. If possible, change wax guard or clean out tubing.

Answer 113

If the canal contains excessive cerumen, or is occluded the hearing aids will produce feedback. Referral for cerumen management.

Answer 114

Just because your patient has hearing aids, does not mean they have normal hearing. Volume VS. Clarity Presence of background noise. The aging brain.

Answer 115

Get their attention! Say their name. Alert them if the topic has changed. Be in an area with good lighting where they can access all visual cues Movements of the mouth, body language Eliminate noise sources.

Answer 116

Decrease your rate of speech. Talking loudly is not the answer. Complete your words. Slight pause between sentences. Rephrase. If they did not understand you the first time, do not repeat what you said. Rephrase and say it another way. Expand on what you are saying. Be patient! It can be frustrating for both parties. If worse comes to worse, write it down!

Answer 117

temp hr rr bp SaO2

Answer 118

pain is the 6th vs objective with pain scale

Answer 119

yes, but nurse is ultimately responsible and must follow up on values obtained

Answer 120

unstable/changing condition meds given that affect vs uncontrolled bleeding cold/clammy/pale skin suspected change/reaction such as shock, pe, stroke, mi, fall, injury

Answer 121

base line vs pmh normal/abnormal vs for age factors that influence vs appropriate interventions in collaboration with the dr minimizing environmental factors why, how, when, who

Answer 122

upon admission (initial assessment) check ups with dr with any change in status per facility policy as ordered by dr if Pt reports non specific symptoms

Answer 123

before/during/and after: surgical procedures receiving blood products receiving certain meds

Answer 124

when a fever breaks

Answer 125

fever from undetermined cause

Answer 126

cool juices/drinks cool room light/no covers (sheet only) antipyretics (tylenol, ibuprophen) antibiotics (once cultures obtained) cool them off

Answer 127

occurs when the body is exposed to subnormal temps

Answer 128

warming measures

Answer 129

shivering pale/cool/puffy decreased hr and rr irregular hr decreased sensation and bility to think --> confused

Answer 130

hyperthermia-hereditary condition of uncontrolled heat production (likely after anesthetics). MEDICAL EMERGENCY

Answer 131

cooling measures

Answer 132

Place thermometer to right or left of frenulum at the base of the tongue in the sublingual pocket.

Answer 133

Excessive talker Hx seizures Mouth breathers Uncooperative Unconscious Infant or small children Had oral surgery STOP! If client has been chewing gum, smoking, or eating hot/cold food or drinks.

Answer 134

closer to the accurate core temp

Answer 135

- Site can be embarrassing. - Can puncture GI mucosa. - Avoid if having diarrhea, has hemorrhoids, rectal surgery etc. -Avoid if patient has neutropenia or low platelet count.

Answer 136

preferred site for an infant and child Safer for adults with seizures or if oral is unsafe

Answer 137

a recent bath, rubbing of area, and poor circulation can affect results.

Answer 138

Place thermometer under arm and ensure it is in contact with skin and hold in place for duration of measurement.

Answer 139

temporal carotid brachial (antecubital space) radial femoral popliteal posterior tibialis dorsalis pedis

Answer 140

Carotid- Used during CPR/MI * Do not assess both carotids at same time- cuts off blood supply to the brain.

Answer 141

Brachial (antecubital space)- Used for B/P or to assess pulse in infants/children.

Answer 142

most common

Answer 143

used during cpr/mi

Answer 144

Popliteal- flex leg to palpate, Used if can’t use arms for B/P

Answer 145

Doppler (D)- is used if you can’t palpate a pulse—don’t document absent—document unable to palpate and get the doppler if available.

Answer 146

0- Absent 1+ weak and thready 2+ normal 3+ strong/bounding

Answer 147

Apical heart rate (Apical pulse) most accurate and is located left of the sternum, at or below the fifth rib, and midline with the clavicle.

Answer 148

Count for 1 minute. This is the point of maximum impulse. 60-100

Answer 149

Used if radial pulse irregular or weak Used if heart rate altering drugs being given (Digoxin).

Answer 150

S1- low pitched “lubb” (when tri and bi cuspid valves slam shut) S2-short sound-”dupp”(when pulmonary and aortic valves close) These two sounds represent one heartbeat

Answer 151

When assessing Respirations –count at least 30 seconds—one minute if irregular---you need to determine:

Answer 152

Rate per minute- includes one inspiration and one expiration. Watch rise and fall of chest or abdomen. Hold arm across chest.

Answer 153

Depth –chest expansion with each breath.

Answer 154

Rhythm- is it a consistent pattern. Regular or irregular?

Answer 155

Respiratory effort- how hard are they working to breathe? Should be effortless.

Answer 156

Always 2 parts! Ex. “Regular, Nonlabored, Rate 16”

Answer 157

ex: copd drive to breath

Answer 158

noninvasive technique to monitor the o2 sat of the blood

Answer 159

attach to finger, earlobe, toe, nose. make sure area is clean, dry, warm, and has good circulation. they need to remain still. remove nail polish and artificial nails

Answer 160

95-100% concern is less than 90%

Answer 161

site/location characteristics pain scale

Answer 162

Site or location- don’t assume; ALWAYS ask.

Answer 163

Characteristics- describe: is it sharp, dull, aching, cramping, tender, constant, intermittent, stabbing, burning? Ask When does it occur, what makes worse/better ?

Answer 164

Pain Scale (Severity)– 0- no pain to 10 worse pain ever. Scales vary for children and nonverbal patients. ex: numerical, faces

Answer 165

Acute pain is sudden onset, can be severe, lasts a short time.

Answer 166

Chronic pain- hangs around with little change; may be life long; does not affect VS as much as acute pain does.

Answer 167

Indicator of cardiovascular health

Answer 168

If taking manually must be documented in even numbers. If electronic can be uneven.

Answer 169

Usually obtained on the brachial artery but can use other sites. - Can use popliteal artery behind the knee. - Can use lower arm and radial artery. - Must document where B/P obtained.

Answer 170

- a mastectomy - bilateral upper extremity amputation - shunt/graft for dialysis - casts, braces, dressings, etc. - Vascular surgery or trauma - IV infusion site

Answer 171

Sphygmomanometer bladder width must cover at least 40% of patients upper arm, and the bladder length must wrap around 80-100% of the arm circumference. If the cuff does not fit appropriately, results will be inaccurate.

Answer 172

Review parts of Stethoscope ---ear tips are positioned downward and forward towards face. Ear pieces are cleaned with alcohol between users and the diaphragm cleaned between patients.

Answer 173

May also need to collect B/P in lying, sitting, and standing positions.

Answer 174

Less than 120/80

Answer 175

Quit smoking, weight management, medications.

Answer 176

assess- palpate brachial pulse, assess pt place- cuff 1-2 inches above antecubital area needle on manometer should be at 0, keep at eye level, inflate to 20 mmHg above palpated systolic pressure or up to 200 review factors affect bp

Answer 177

less than 90/x

Answer 178

change in patient position causes bp drop- lying, sitting, standing

EXAM 1 Flashcards

HYGIENE/PRECAUTIONS/INF CTRL/HEARING AIDS/ VS/ ROM/TRANSFERS WEEKS 1-3