Exam 1 Flashcards
What are the 5 HGTC Integrated Concepts?
- Safety 2. Profession Behavior 3. Clinical Decision Making 4. Patient Center Care 5. Teamwork & Collaboration
Give an Example of each Integrated Concepts
Safety: PPE, Med Safety, & Procedure Skills. Prof Beh: Pt. Come First, Good Attitube, Being on Time, Uniform, & Being Prepared. Clin Dec: Quick Decision. Pt. Center Care: All About Patient. Team & Collab: Communication Skills
What does the Nurse Practice Act do?
Regulates Nursing Practices in Each State
What is the Term for When One State Recognizes a License Granted in Another State?
Reciprocity
What are the 4 Aims of Nursing?
- Promote Health 2. Prevent Illness 3. Restore Health 4. Facillitate coping with Disability/Death
Give an Example of each Nursing Aim
Prom Health: Eat right, Exercise, No Smoking. Prevent Illness: Vaccination & Screening. Restore Health: Rehabilitation. Facil Coping: Helping Family & Pt Wishes
What Kind of Nursing License Works in Multiple States?
Comp License
What does ADPIE Stand for?
Assessment, Diagnosis, Planning, Interventions, Evaluation
An Exam that Must be Passed for Initial Licensure as a Practical Nurse.
NCLEX-PN
An Examination that Assesses the Knowledge and Skills Required for Nursing Practice.
NCLEX Exam
What are the Standards of Care in Nursing Practice?
What Nurses Can do
What are the Nurses Practice Acts?
How a Nurse Does Tasks
What is Compassion Fatigue?
Emotional Strain from Caring
What is Burnout?
Physical or Mental Collapse Caused by Overwork
What is Traditional Nursing Knowledge?
Passed Down Wisdom from Nurses
What is Secondary Traumatic Stress?
Stress Experienced From Exposure to Another’s Trauma
What is Authoritative Nursing Knowledge?
Knowledge from Experts
What is Scientific Nursing Knowledge?
Knowledge Gained from Research and Trials
What is Inductive Reasoning?
Using Multiple Concepts to Reach a Conclusion (2+2=4)
What is Deductive Reasoning?
Working Backwards to Identify a Cause (4=2+2)
What does the Nursing Theory Attempt to Describe?
Nursing and its Elements
What is Nursing Research?
Using Data to Inform Nursing Care
What is Qualitative Research?
Gains Insight into Patient Experience “Art of Nursing”
What is Quantitative Research?
Provides Data & Numbers “Science of Nursing”
What does PICOT stand for?
Population, Intervention, Comparison, Outcome, & Time
What is the Gold Standard of Nursing Practice?
Evidence-Based Practice
What is the Normal Adult Temp?
96.4-99.5F or 35.8-37.5C
What is the Normal Adult Pulse?
60-100
What is the Normal Adult Resperation Rate?
12-20
What is the Normal Adult Blood Pressure?
120/80
What is the Normal Older Adult Temp?
96.4-98.3F or 35.8-36.8C
What does Infection Control Encompass?
Everything We Do as a Nurse to Stop the Spread & Development of Infections. Ex: Stethoscope Hygiene and Hand Hygiene
What is the Infection Cycle?
Stages involved in the process of infection including infectious agent, reservoir, portal of exit, means of transmission, portals of entry, and susceptible host.
What is an Infectious Agent?
Pathogens like bacteria, viruses, and fungi that cause infection, such as avian influenza and swine flu Found Everywhere
What is a Reservoir in the Infectious Cycle?
Natural habitat where an infectious agent lives, typically found in animals like birds and pigs However, zoonotic human infection does occur (where the infectious agent lives/is at) (could be anything)
What is a Portal of Exit?
Method by which an infectious agent leaves its reservoir How the infectious agent is moved/released from where it lives. Once its out, it has to be transferred
What are Means of Transmission?
Ways in which an infectious agent is transmitted, including direct and indirect transmission Germs don’t move, people move germs
What is are Portals of Entry?
Site through which an infectious agent enters a new host (ex. mouth, nose, eyes, broken skin)
What are Susceptible Host?
An individual who is vulnerable to infection due to lack of immunity or vaccination We should encourage immunization, hand hygiene, cover wounds, and properly dispose of infectious/contaminated material
What is Direct Transmission of Infection?
Direct Contact or droplet spread
What is Indirect Transmission of Infection?
Contaminated object aka. Fomite
What is Bacteria?
Single-celled organisms that can either require oxygen or not, treated with antibiotics
What is Bacteria Culture and Sensitivity?
a lab test that helps identify the type of bacteria causing an infection and the best treatment for it Never give the first dose before this test is done
What is Fungus?
Organisms that can cause infection require warm, moist environments treated with antifungals. Found in lungs, skin, and GI, or any warm moist environment
What is a Virus?
Pathogen that requires entry into the human body to replicate, treated with antivirals (that help to prevent severe symptoms)
What are the 5 Moments for Hand Hygiene?
Guidelines for when to perform hand hygiene to reduce infection risk Moment 1: before touching a patient Moment 2: before a clean or aseptic procedure Moment 3: After a body fluid exposure risk Moment 4: After touching a patient Moment 5: After touching patient’s surroundings
What are the Stages of Infection?
Incubation, Prodromal, Full Illness, and Convalescence
Describe the Incubation Stage of Infection?
Infection has entered the body. Little to no symptoms.
Describe the Prodromal Stage of Infection?
Most contagious stage. Some symptoms Know you are sick but not with what
Describe the Full Illness Stage of Infection?
The disease is going to run its course. Sick role is taken on. Time varies
Cardinal signs of acute infection/inflammation (5)
Redness, heat, swelling, pain, and loss of function
Describe the Convalescene Stage of Infection?
When we get better. Time depends on many factors. Restored to highest ability of function
What does Rubor Mean?
Red
What does Erythema Mean?
Heat
What does Edema Mean?
Swelling
What are Resistant Organisms?
Pathogens that have adapted to resist treatment.
What are Hospital-Acquired Infections (HAI)
Infection acquired during hospital stay
Where is C.diff found and what causes it?
It is found in the gut, normal flora Becomes a problem when antibiotic for other infections kills flora, resulting in excess/overgrowth of it High recurrence rate
What are Standard Precautions?
Infection prevention practices used for all hospitalized patients regardless of infection status gloves, gowns, masks, and eyewear Tier 1 precautions The first line of defense This applies to all patient Used when a there is risk of contact with blood, mucus membrane, or body fluids (ex., Giving a shot)
What are Transmission-Based Precautions?
Additional precautions for patients suspected of having infections that can spread by airborne, droplet, or contact routes Tier 2 Protocol provided Standard precautions are still in place as need be Always hand wash, cough etiquette
What are Air Born Precautions?
Precautions used for diseases that spread through the air. M95 or higher mask are used. Goggles if actively coughing. Negative pressure (vented outside), isolation room. Door must be closed. Ex. Chickenpox, smallpox
What are Droplet Precautions?
Used for illness such as Flue, Mumps, COVID. Partials are heavier, if shot out, will hit the ground. Mask are used up close, but not far away. Gloves, goggles, and gown if needed
What are Contact Precautions?
Gloves and gowns. Ex: C.diff & Norovirus
What are Neutropenic Precautions?
Used for no immune system pt (like cancer pt.) You can’t give them something. Gowns, gloves, door close, & no fresh fruit or flowers
What is Medical Asepsis?
Clean Technique
What is Surgical Asepsis?
Sterile Technique Sterilize to the point is kills spores Can be done at bed side not just surgical room
What does a Safety Assessment intel?
Look at the person, monitor the environment, assess for risk factors
What are Some Common Safety Risk Factors?
Falls, Fires, Poisoning, Suffocation/Choking, & Firearms
What is the Biggest Future Indicator for a Fall?
A Past Fall
What are the Cues from an Assessment?
Mobility, Communication., Awareness/Orientation, Alteration Sensory Perception, Safety Hazards, & Domestic Violence/Neglect
What are Some Fall Prevention Strategies?
Methods to reduce the risk of falls, including proper use of side rails, bed and chair locks, bed and chair alarms, shower chair, and non-skid socks
What does R.A.C.E. P.A.S.S. Stand for and What is it Used For?
Rescue Activate Confine Evacuate/Extinguish Pull pin Aim Squeeze Handle Sweeping Motion. Used for Fire Safety
What are Special Age Group Safety Concerns?
Specific precautions needed for older adults due to risks associated with their age
What does PPE Stand for and What is it?
Personal Protective Equipment. Gear worn to minimize exposure to hazards, including gloves, gowns, masks, and eyewear
What are the 6 Vital Signs?
Temperature, Pulse, Respiration, Blood Pressure, Pain, & Oxygen Saturation
What is the Normal Oxygen Saturation (O2 sat)?
> 95%
Do Most Facilities use Fahrenheit or Celsius?
Celsius
What Can Vital Signs Indicate?
When the Pt. is Taking a Turn for the Worst
Why are Vitals Taken Before Pt. Goes to Surgery?
To Check if the Pt. is Stable for Surgery
Why are Vitals Taken After Pt. Comes Back from Surgery?
To Determine the Impact of Sedation and to Check if Stable
Why Take Vitals Before Administering Medication?
To Determine if the Medication is Required/ Unsafe to Administer
What is the Primary Source of Heat in the Body?
Metabolism
What are Some Ways Metabolism is Increased?
Hormones, Muscle Movements, & Exercise
What is the Temperature Regulator of the Body?
Hypothalmus
What organ is the primary site of heat loss in the body?
Skin
What are Other Sources of Heat Loss?
Evaporation of Sweat, Warming & Humidifying Inspired Air, & Eliminating Urine & Feces
What is the Body’s Way of Cooling Off?
Sweating
What is the Normal Oral temperature for an Adult?
37.0C or 98.6F
What is the Normal Rectal Temperature for an Adult?
37.5C or 99.5F
What is the Normal Axillary Temperature for an Adult?
36.5C or 97.7F
What is the Normal Tympanic Temperature for an Adult?
37.4C or 99.5F
What is the Normal Forehead Temperature for an Adult?
34.4C or 94.0F
A nurse has an order to take the core temperature of a client. At which site would a core body temperature be measured?
Rectum/Rectal Temperature (invasive)
Where is the Tympanic temperature taken?
Ear
What temperature should you take for an intubated pt.?
Tympanic/ear
What are some of the factors that affect body temperature?
Circadian rhythms, age & gender, physical activity, state of health, & environmental temperature
In a digital thermometer, what do the blue and brown probes mean?
Blue= oral Brown= rectal
What is the medical term for fever?
Febrile or pyrexia
What is an intermittent fever?
Temperature returns to normal at least once every 24 hours
What is a remittent fever?
Temp does not return to normal and fluctuates a few degrees up and down
What is a sustained or continuous fever?
Temperature remains above normal with minimal variations
What is a relapsing or recurrent fever?
Temp returns to normal for 1+ days with 1+ episodes of fever, each as long as several days
What are some of the physical effects of fevers?
Muscle aches, fatigue, hr & rr increase, fluid & electrolyte imbalance, loss of appetite, headache, hot &/or dry skin thirst, & seizure &/or confusion
What do seizures and confusion?
Temperature is too High
At what temperature are medications given?
101-102F
What are some treatments of fevers?
Comfort, medications, cool baths, increase fluid intake, & simple carbs
What is the pacemaker of the heart?
The SA node (the autonomic nervous system)
What impact does parasympathetic stimulation have on the heart?
Decrease heart rate
What impact does sympathetic stimulation have on the heart?
Increase heart rate
What is the Pulse rate?
Number of contractions over a peripheral artery in 1 minute
What HR indicates Tachycardia?
> 100
What HR indicates Bradycardia?
<60
What happens to the blood volume when pulse increases?
Blood Volume Decrease
You check both pulse sight at the same time except?
Carotid
What is the name for the sounds heard durning BP?
Korotkoff
What arteries are commonly used to take blood pressure?
Brachial artery and poplitral artery
What are some factors that affect Blood Pressure?
Age, gender, race, circadian rhythm, food intake, exercise, weight, emotional state, body position, & drugs/medications
What numbers indicate hypertension?
> 130/90
What is primary hypertension?
Characterized by an increase above normal in both systolic & diastolic. No known case
What is secondary hypertension?
Caused by another disease conditions
What happens when the BP cuff is too big?
Decrease BP
What happens when the BP cuff is too small?
Increase BP
What is ventilation?
Movement of air in & out of lungs
What is diffusion?
Exchange of O & CO2 in alveoli
What is perfusion?
Exchange of O & CO2 bt circulating blood and tissue cells
What part of the body does CO2 stimulate?
Pons
What is the most powerful respiratory stimulant?
Carbon Dioxide
What controls rate & depth of breathing?
Medulla & Pons
What is the term for normal, unlabored respiration 1 resp to 4 heartbeats
Eupnea
What is the term for increased respiratory rate; may occur in response to an increased metabolic rate (>20)
Tachypnea
What is the term for decreased RR; occurs in some pathologic conditions (<12)
Bradypnea
What is the term for period when no breathing occurs?
Apnea
What is the term for difficult or labored breathing?
Dyspnea
What is the term for changes in breathing when sitting or standing?
Orthopnea
What are some factors that affect Respiratory Rate?
Age, gender, exercise, acid-base balance, brain lesions, increased altitude, anemia, anxiety, medication, pain
A client who is an avid runner has been monitoring her pulse at home. Recently, her pulse has been below the normal range of 60-100 bpm for adults. Today her pulse is 58 BPM. The client asks the nurse at her annual screening if she should be concerned what is the most appropriate response by the nurse?
Well-conditioned athletes can run lower pulse rates because of the greater efficiency and strength of the heart muscle from regular cardiovascular exercise.
What population is at greatest risk for hypertension?
African American
The nurse is preparing to assess the client’s vital signs, the client just had morning coffee. What explanation and action does the nurse take in this situation?
Wait 30 minutes, then assess the oral temp
A client, whose RR is 8, is experiencing what?
Bradypnea
A client, whose RR is 14, is experiencing what?
Eupnea
A client, whose RR is 26, is experiencing what?
Tachypnea
A client, whose RR is 20, is experiencing what?
Eupnea
A nurse is measuring the apical pulse of a client. Where should she place the diaphragm of her stethoscope in this assessment?
Over the space between the 5th and 6th ribs on the left midclavicular line
Which pulse site should the nurse recommend for home monitoring?
Radial
In a code situation, what pulse site(s) should you check?
Carotid or Femoral
The nurse assesses that a client is shivering. Which intervention is most appropriate to prevent further stress on the body?
Applying a blanket
What is the purpose of a health assessment?
Establish relationships, gather data, identify strengths, identify health problems, & establish a base
What is a comprehensive health assessment?
Conducted upon admission to health care facility. Must be done by a RN.
What is an ongoing partial health assessment?
Conducted at regular intervals. The 10 min assessment. Snapshot of comprehensive. Track progress. Frequency depends on facility. LPN can help, but RN at least every 24hr
What is a focused health assessment?
Conducted to assess a specific problem/complaint
What is an emergency health assessment?
Conducted to determine life-threatening or unstable conditions
What should you consider during a physical assessment?
Consider the physiologic and psychological needs of the patient
What three things should you explain during a physical assessment?
Explain the process to the patient, that the physical assessment will not be painful (Decrease patient fear and anxiety), and each procedure in detail as it is conducted.
What should you ask during a physical assessment?
Ask the patient to change into a gown and empty bladder
What should you answer during a physical assessment?
Answer patient questions directly and honestly. Talk in terms pt. will understand.
What are the 6 steps to preparing the environment for physical assessment?
Agree on time, Free of pain, Prepare table, Provide gown & drape, Gather supplies & instruments, & Provide a curtain or screen
What are the 6 pieces of equipment used during a physical examination?
Thermometer or sphygmomanometer, scale, flashlight or penlight, stethoscope, metric tape measure and rule, and eye chart
What does a standing assessment assess?
Posture, balance, and gait
What visualization does a Sitting assessment allow?
Allows visualization of upper body
What does a Supine assessment allow?
Allows relaxation of abdominal muscles
What type of patients are Dorsal recumbent assessments used for?
Used for patients having difficulty maintaining supine position
What does a Sim’s assessment assess?
Assessment of rectum or vagina
What does a Prone assessment assess?
Assessment of hip joint and posterior thorax
What does a Lithotomy assessment assess?
Assessment of female genitalia and rectum
What does a Knee-chest assessment assess?
Assessment of anus and rectum
What are the 6 components of a preventive health assessment?
Healthy history, risk for depression, functional ability, level of safety, physical examination, & patient education and counseling
What are the 4 considerations when performing health assessment?
Lifespan consideration, cultural considerations and sensitivity, patient preparation, & environmental preparations
What are the 8 factors to assess during a health history?
Biographical data, reason for seeking health care, history of present illness, past health history, family history, functional health, psychosocial and lifestyle factors, & review of systems
What does inspections assess?
Assesses size, color, shape, position, and symmetry
What does palpation asses?
Assesses temperature, turgor, texture, moisture, vibrations, and shape
What does percussion assess?
Assesses location, shape, size, and density of tissues
What does auscultation assess?
Assesses the four characteristics of sound, that is pitch, loudness, quality, and duration
What are the 6 characteristics of masses determined by palpation?
Shape, Size, Consistency, Surface, Mobility & Tenderness
What are the 4 characteristics of sound heard during auscultation?
Pitch, Loudness, Quality, & Duration
What are the 4 aspects of a general survey?
General appearance, Vital signs, Height, weight, waist circumference, & Calculating BMI
What are the 4 common thorax & lung variations in older adults?
Increased anteroposterior chest diameter, Increase in the dorsal spinal curve (kyphosis), Decreased thoracic expansion, & Use of accessory muscles to exhale
What is integument a term for?
Skin
What are some risk factors for depression?
Death in family, illness, injury, job loss, loss pet, ect.
What are common cardiovascular & peripheral vascular variations in older adults?
Difficult-to-palpate apical pulse and distal arteries, Dilated proximal arteries, More prominent & tortous blood vessels (varicosities common), increased systolic & diastolic bp, & Widening pulse pressure
What is functional ability?
Ability to preform task of daily living
What is biographical data?
Age, gender, race, married, job
What is an abdominal variation commonly seen in older adults?
Decreased bowel sound & abdominal tone & Fat accumulation on the abdomen and hips
What does history of present illness encompass?
Chief complaint, when it started, has it occurred before, any changes, underlying health problems, what makes it better, & what makes it worse
What are psychosocial factors?
Mental health & outside factors that can impact health (like job)
What is a nurse’s best assessment tool?
Their eyes
What is the back of the hand called?
The dorsum of the hand
What is the term for something found under the skin?
Mass
How would you assess a pt. level of awareness to time?
Asking the date, year, last holiday, day of the week, etc.
How would you assess a pt. level of awareness to place?
Asking current location, city, state, etc.
How would you assess a pt. level of awareness to person?
Asking name, age, visitors, etc.
What are the 4 key points in documentation?
Identify, Make, Plan, & Evaluate
What does Prone position look like?
The person lies on the abdomen with head turned to the side, the bed is flat
What does Supine (dorsal recumbent) position look like?
The pt. lies flat on the back with head & shoulders slightly elevated w/pillow
What does Fowler’s position look like?
Head of the bed is elevated 45-60 degrees, semi-sitting position
What does Semi-Fowler’s position look like?
Head of the bed is elevated 15-45 degrees
What does Lateral position look like?
Pt. lies on the side with a pillow bt legs, weight on lateral aspect of lower scapula and lower ilium
What does Sims position look like?
Pt. lies on the side with a pillow bt legs, lower arm is behind pt and upper arm is flex at both the shoulder & elbow
What does Trendelenburg position look like?
Pt. is supine on the bed with head decline below their feet at an angle of roughly 16 degrees
What is the order for abdominal assessment?
- Inspect 2. Auscultate 3. Percuss 4. Palpation
During a head-to-toe assessment nurse palpates nails. Which is the best rationale?
To assess capillary refill and oxygenation
Erythema is a term for?
Red
Pallor is a term for?
Pale
Cyanosis is a term for?
Blue
What position should the pt be in for an abdominal assessment?
Supine
Why does BP increase in older adults?
Arteriosclerosis
What is arteriosclerosis?
Hardening of blood vessels
What is pulse pressure?
The difference between systolic & diastolic
Risk factors for altered health assessment in health history includes?
History of trauma, arthritis, neurologic disorder, pain, swelling, surgery, smoking, etc
What is the golden rule for documentation?
If it was not documented, it did not happen
What could Restraints cause?
Increased injury risk, skin injury, depression, anxiety/delirium, aspiration, & death
When should you assess vital signs (7)?
On admission, Based on policy and procedures, When there is a change, Loss of consciousness, Before and after surgical or invasive procedure, Before and after activity, & Before administering medications
