Exam 1 Flashcards
What should be done for feet and nails during basic patient care?
Do not trim nails as it can create wounds. Instead, clean under the nails.
How should hair be cared for in basic patient care?
Wash to remove dried blood, oils, dirt, and to get knots out.
What is the purpose of oral care in nursing?
To decrease bacteria and promote healthy gums by brushing teeth, cleaning dentures, and using a toothette to swab the mouth.
What assistance should be provided for toileting?
Offer a urinal, help on/off the bedpan, and assist to the bathroom.
What is important in dressing and grooming?
Provide a new gown.
What is the role of active listening in nursing?
Show interest in the patient’s day and pain instead of just performing tasks.
Why is rapport important in nursing?
Patients need to trust you; maintain eye contact and appropriate touching.
How can comfort measures decrease pain and anxiety?
By using distraction techniques like TV, books, music, guided imagery, and ensuring a restful environment.
What are some methods of comfort measures?
Massage, touch, heat for circulation, and cold for swelling and pain relief.
What are the bed positions in nursing?
Flat, Low Fowler’s (15-30 degrees), Semi Fowler’s (>30-45 degrees), High Fowler’s (80-90 degrees), Trendelenburg, and Reverse Trendelenburg.
What are the benefits of bathing?
Removes microorganisms, stimulates circulation, promotes relaxation, and prevents body odor.
What are the levels of bathing?
Self (independent), Partial (with assistance), and Complete (nurse does all).
What are the basics of bathing?
Identify the patient, have supplies ready, maintain proper bed height, and document.
What safety considerations are there when bathing infants/children?
Ensure supervision, check water temperature, and clean from clean to dirty.
What special considerations are there for bathing obese patients?
Ensure safety, assist with cleaning skin folds, and manage moisture effectively.
What are the considerations for bathing elderly patients?
Be cautious with dry skin, use lotion while skin is damp, and monitor water temperature.
What precautions should be taken when bathing unconscious patients?
Be aware of biting reflex, position carefully, and ensure communication.
What are the safety measures for diabetic patients?
Inspect feet daily, clean with mild soap, and wear sturdy shoes.
What are the isolation principles for contact precautions?
Wash hands before entering, don gown and gloves, and remove them before exiting.
What are the precautions for droplet infections?
Use hand hygiene, gown, gloves, eye protection, and a mask.
What are airborne precautions?
Use hand hygiene, gown, N-95 mask, and ensure the patient is in a negative pressure room.
What are the normal temperature ranges?
Normal temperature is 36.5-37.5 C or 97.6-99.6 F.
What are the normal pulse rates for adults and newborns?
Adult: 60-100 beats/min, Newborn: 130-160 bpm.
What are the normal respiration rates for adults and newborns?
Adult: 12-20 breaths/min, Newborn: 40-60 breaths/min.
What are the normal blood pressure parameters for adults?
Systolic BP < 120 mmHg and Diastolic BP < 80 mmHg.
How is pain defined in nursing?
Pain is what the experiencing person says it is and exists whenever they say it does.
What is the normal O2 saturation level?
Normal O2 saturation is above 94%.
What are the characteristics of pulse?
Rate, rhythm, and quality (strength).
What is a pulse deficit?
The difference between apical and peripheral pulse; normally, both should be equal.
What are the phases of Korotkoff sounds?
Phase I: Clear tapping sound (systolic), Phase IV: Muffled sound (diastolic in children), Phase V: Disappearance of sound (diastolic in adults).
What are non-pharmacological interventions for pain management?
Heat/cold therapy, massage, position changes, and ensuring a comfortable environment.
What are the effects of immobility on the respiratory system?
Decreased activity can lead to atelectasis and hypostatic pneumonia.
What cardiovascular complications can arise from immobility?
Orthostatic hypotension, increased workload on the heart, and risk for thrombus.
What musculoskeletal complications can arise from immobility?
Osteoporosis, atrophy, contractures, and decubitus ulcers.
What are the effects of surgery on the GU system?
Decreased urine output, urinary retention, and the need for monitoring I’s and O’s.
What are the effects of surgery on the GI system?
Ileus, nausea, vomiting, and constipation due to medications.
What are the effects of surgery on the respiratory system?
Risk of pulmonary embolism and atelectasis; interventions include encouraging deep breathing.
What neurological effects can surgery have?
Changes in level of consciousness and sensation; neuro checks may be required.
What cardiovascular effects can surgery have?
Shock due to decreased circulating volume and impaired tissue perfusion.
What should be ensured for patients to perform deep breathing exercises?
Pain is under control so they feel comfortable to do deep breathing exercises.
What is assessed in a respiratory assessment?
Respiratory assessment.
What are the effects of surgery on the neurological system?
LOC varies because of anesthesia but should get back to baseline, sensation, over-sedation.
What interventions are needed for neurological checks?
Neuro checks as ordered: Q2 or Q4 to check for A&O, re-orient as often as needed.
What are the effects of surgery on the cardiovascular system?
Shock, hemorrhage, DVT.
What is shock in the context of surgery?
Body’s response to decrease in circulating volume, impaired tissue perfusion, hypoxia, death.
What is hemorrhage and its effect post-surgery?
Not enough volume in the system so tissue perfusion is impaired.
What is DVT and its cause?
Occurs in pelvic vein or lower extremities from circulatory system slowing.
What interventions are needed for cardiovascular complications?
Fluids, blood transfusion, anticoagulants, CPR and code blue if necessary.
What are possible complications after surgery?
Infection, hemorrhage, compartment syndrome, dehiscence, evisceration.
What are the signs of infection post-surgery?
May see fever, drainage, pus.
What is compartment syndrome?
Severe pain, redness, swelling, pressure, decreased circulation.
What are the signs of dehiscence?
Rupture of surgical wounds, edges no longer approximated.
What are the risk factors for dehiscence?
Age, obesity, malnutrition, sudden increase in abdominal pressure.
What is evisceration?
Internal organs protrude through abdomen, a medical emergency.
What is the nursing care for patients in restraints?
Check in on patient 1 hr after the order started, then every 2 hrs.
What are examples of restraints?
Wrist, posey, mitt.
What are fall risks for patients?
Poor balance, history of fall, pain medications, urgency to go to the bathroom, tethered patients.
What are safety concerns with patient mobility?
Body mechanics, positioning, safe transfer techniques, assistive devices.
What are the Five Rights of delegation in nursing?
Right task, right circumstance, right person, right direction/communication, right supervision/evaluation.
What should not be delegated in nursing?
Evaluation, assessment, teaching, medication, unstable patients.
What are the types of surgery?
Inpatient and outpatient.
What is inpatient surgery?
Patient may be admitted to hospital unit before surgery, transferred to OR from unit, then to PACU, and back to original unit.
What is outpatient surgery?
Patient arrives for surgery, prepped in pre-op area, goes to OR, then to PACU/recovery area, and returns home the same day.
What is a major stressor after surgery?
Fearful of pain after surgery; always address it.
What interventions are used for pain management after surgery?
Pain medication, comfort measures, antiemetics.
What comfort measures can be used post-surgery?
Reposition, elevate, splint incision, hold pillow against incision when coughing or sneezing, ice/heat, massage.
What is important for discharge care of a patient?
Signs and symptoms of infection, activity level, diet, pain medication, use of braces, lifting limitations, driving restrictions, care of drains, follow-up appointments.
