exam 1 Flashcards
To keep alignment of knees and hips because when laying for long period of time knees turn out and patients looses the ability to sit up
Trochanter Roll
A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? (Select all that apply.)
- It allows migration of organisms into the bladder.
- The insertion procedure is not done under sterile conditions
- It obstructs the normal flushing action of urine flow.
- It keeps an incontinent patient’s skin dry.
- The outer surface of the catheter is not considered sterile.
-It allows migration of organisms into the bladder.
It obstructs the normal flushing action of urine flow.
What is the normal respiratory range for toddler
: 25-32
Which of the following patients are at most risk for tachypnea? (Select all that apply.)
- Patient just admitted with four rib fractures
- Woman who is 9 months’ pregnant
- Adult who has consumed alcoholic beverages
- Adolescent waking from sleep
- Three-pack–per-day smoker with pneumonia
-Patient just admitted with four rib fractures
Woman who is 9 months’ pregnant
Three-pack–per-day smoker with pneumonia
What is the normal blood pressure range for adult
<120/80 B/P (mmHg)
An aspect of clinical decision making is knowing the patient. Which of the following is the most critical aspect of developing the ability to know the patient?
- Working in multiple health care settings
- Learning good communication skills Incorrect
- Spending time establishing relationships with patients
- Relying on evidence in practice
Spending time establishing relationships with patients
What 6 factors can influence temperature?
Age, exercise, hormonal levels, environment, Circadian rhythm, Temperature alterations
By using known criteria in conducting an assessment such as reviewing with a patient the typical characteristics of pain, a nurse is demonstrating which critical thinking attitude?
- Curiosity
- Adequacy
- Discipline
- Thinking independently
Discipline
You are caring for a patient who frequently tries to remove his intravenous catheter and feeding tube. You have an order from the health care provider to apply a wrist restraint. What is the correct order for applying a wrist restraint?
- Be sure that patient is comfortable with arm in anatomic alignment.
- Wrap wrist with soft part of restraint toward skin and secure snugly.
- Identify patient using two identifiers.
- Introduce self and ask patient about his feelings of being restrained.
- Assess condition of skin where restraint will be placed.
- 4, 3, 5, 1, 2
- 4, 3, 1, 5, 2
- 3, 4, 1, 5, 2
- 3, 4, 5, 1, 2
- 3, 4, 1, 5, 2
Killing or eliminating pathogen
Scrub (Surgical)
PPE Sterile handling
Sterile Asepsis
A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a slow but regular radial pulse of 44. What is your priority intervention?
- Request that the nursing assistant repeat the pulse check
- Call for a stat electrocardiogram (ECG)
- Assess the patient’s apical pulse and evidence of a pulse deficit
- Prepare to administer cardiac-stimulating medications
- Assess the patient’s apical pulse and evidence of a pulse deficit
If clinical signs and symptoms are not present, the illness is termed _________
asymptomatic.
the complete elimination or destruction of all microorganisms, including spores
Sterilization:
Drugs that increase pulse rate
Epinephrine
When should a nurse wear a mask? (Select all that apply).
- The patient’s dental hygiene is poor.
- The nurse is assisting with an aerosolizing respiratory procedure such as suctioning.
- The patient has acquired immunodeficiency syndrome (AIDS) and a congested cough.
- The patient is in droplet precautions.
- The nurse is assisting a health care provider in the insertion of a central line catheter.
- The nurse is assisting with an aerosolizing respiratory procedure such as suctioning.
- The patient is in droplet precautions.
The nurse is assisting a health care provider in the insertion of a central line catheter.
Two patient deaths have occurred on a medical unit in the last month. The staff notices that everyone feels pressured and team members are getting into more arguments. As a nurse on the unit, what will best help you manage this stress?
- Keep a journal
- Participate in a unit meeting to discuss feelings about the patient deaths
- Ask the nurse manager to assign you to less difficult patients
- Review the policy and procedure manual on proper care of patients after death
Participate in a unit meeting to discuss feelings about the patient deaths
3 levels of critical thinking starting with lowest to highest
basic
complex
commitment
Which of the following are physiological outcomes of immobility? A. Increased metabolism B. Reduced cardiac workload C. Decreased lung expansion D. Decreased oxygen demand
Decreased lung expansion
What is normal Pulse Oximetry Range?
95% to 100%
A continuous process characterized by open-mindedness, continual inquiry, and perseverance
critical thinking
A nurse has seen many cancer patients struggle with pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping patients focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of:
- Creativity.
- Fairness.
- Clinical reasoning.
- Applying ethical criteria
Applying ethical criteria
What is your role as a nurse during a fire? (Select all that apply.)
- Help to evacuate patients
- Shut off medical gases
- Use a fire extinguisher
- Single carry patients out
- Direct ambulatory patients
- Help to evacuate patients
- Shut off medical gases
- Use a fire extinguisher
- Direct ambulatory patients
A patient has been newly admitted to a medicine unit with a history of diabetes and advanced heart failure. The nurse is assessing the patient’s fall risks. Which of the following is the proper order of steps for the “Timed Get-up and Go Test” (TGUGT)?
- Have patient rise from straight-back chair without using arms for support.
- Begin timing.
- Tell patient to walk 10 feet as quickly and safely as possible to a line you marked on the floor, turn around, walk back, and sit down.
- Check time elapsed.
- Look for unsteadiness in patient’s gait.
- Have patient return to chair and sit down without using arms for support.
- 3, 1, 2, 5, 6, 4
- 2, 1, 3, 5, 6, 4
- 1, 2, 3, 6, 5, 4
- 1, 2, 3, 5, 6, 4
3, 1, 2, 5, 6, 4
A patient is experiencing some problems with joint stability. The doctor has prescribed crutches for the patient to use while still being allowed to bear weight on both legs. Which of the following gaits should the patient be taught to use?
- Four-point
- Three-point
- Two-point
- Swing-through
-Four-point
Which type of personal protective equipment are staff required to wear when caring for a pediatric patient who is placed into airborne precautions for confirmed chicken pox/herpes zoster? (Select all that apply.)
- Disposable gown
- N 95 respirator mask
- Face shield or goggles
- Surgical mask
- Gloves
Disposable gown
N 95 respirator mask
Gloves
In immobility
GI distended abdomen, _____ bowel sounds, _____ frequency of elimination
Decreased
In immobility
GU dysuria, _________ urinary output, cloudy/concentrated urine
Decreased
The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to:
Place a bed alarm device on the bed.
Place the patient in a belt restraint.
Provide one-on-one observation of the patient.
Apply wrist restraints.
Place a bed alarm device on the bed.
Any body action involving muscles and joints in natural directional movements
Range-of-Motion (ROM)
The_____ of a sterile field or container are considered to be contaminated.
edges
Modes of Transmission where
• Personal contact of susceptible host with contaminated inanimate object (e.g., needles or sharp objects, dressings, environment)
Indirect
Fire safety
R
A
C
E
- Rescue & remove those in immediate danger
- Activate the alarm
- Contain/confine the fire by closing doors/windows and turning off O2 and electrical equipment.
- Extinguish the fire.
6 parts to the chain of infection
infections agent or pathogen Reservoir or source for pathogen growth Portal of exit Mode of transmission Portal of entry Susceptible host
(the movement of oxygen and carbon dioxide between the alveoli and the red blood cells
diffusion
The nursing assessment of a 78-year-old woman reveals orthostatic hypotension, weakness on the left side, and fear of falling. On the basis of the patient’s data, which one of the following nursing diagnoses indicates an understanding of the assessment findings?
- Activity Intolerance
- Impaired Bed Mobility
- Acute Pain
- Risk for Falls
Risk for Falls
Modes of Transmission where
• Large particles that travel up to 3 feet during coughing, sneezing, or talking and come in contact with susceptible host
Droplet
The effects of immobility on the cardiac system include which of the following? (Select all that apply.)
A. Thrombus formation B. Increased cardiac workload C. Weak peripheral pulses D. Irregular heartbeat E. Orthostatic hypotension
Thrombus formation
Increased cardiac workload
Orthostatic hypotension
Interval from onset of nonspecific signs and symptoms (malaise, low-grade fever, fatigue) to more specific symptoms. (During this time microorganisms grow and multiply, and patient may be capable of spreading disease to others.) For example, herpes simplex begins with itching and tingling at the site before the lesion appears
Prodromal Stage
An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility? A. Loss of appetite B. Gum soreness C. Difficulty swallowing D. Left-ankle joint stiffness
Left-ankle joint stiffness
The nurse recognizes that the older adult’s progressive loss of total bone mass and tendency to take smaller steps with feet kept closer together will most likely:
- Increase the patient’s risk for falls and injuries.
- Result in less stress on the patient’s joints.
- Decrease the amount of work required for patient movement.
- Allow for mobility in spite of the aging effects on the patient’s joints.
Increase the patient’s risk for falls and injuries.
A nurse just started working at a well-baby clinic. One of her recent experiences was to help a mother learn the steps of breastfeeding. During the first clinic visit the mother had difficulty positioning the baby during feeding. After the visit the nurse considers what affected the inability of the mother to breastfeed, including the mother’s obesity and inexperience. The nurse’s review of the situation is called:
- Reflection.
- Perseverance.
- Intuition.
- Problem solving.
Reflection.
thrive where little or no free oxygen is available.
Anaerobic bacteria
4 General rules of body mechanics
Assess the situation CAREFULLY before acting!
Use the large muscle groups whenever possible.
Work at appropriate height!
Use mechanical lifts
Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest?
A. Isometric exercises
B. Administration of low-dose heparin
C. Suctioning every 4 hours
D. Use of incentive spirometer every 2 hours while awake
Use of incentive spirometer every 2 hours while awake
A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant reports his admitting vital signs to the nurse. Which measurements should the nurse reassess? (Select all that apply.)
- Right arm BP: 118/72
- Radial pulse rate: 72 and irregular
- Temporal temperature: 37.4° C (99.3° F)
- Respiratory rate: 28
- Oxygen saturation: 99%
Radial pulse rate: 72 and irregular
Respiratory rate: 28
- Oxygen saturation: 99%
aspect of critical thinking where you must
Be orderly in collecting data about patients.
Apply reasoning while looking for patterns to emerge.
Categorize the data (e.g., nursing diagnoses.
Gather additional data or clarify any data about which you are uncertain.
Interpretation
Collapse of alveoli, preventing the normal respiratory exchange of oxygen and carbon dioxide.
atelectasis
using alignment, posture & balance in a purposeful and coordinated effort during activity
Body mechanics
Exercise influences pulse by
Increase in pulse rate from short term exercise
Decrease in pulse rate from athletes
Nursing intervention for
Musculoskeletal weakness, contractures, ↓ muscle tone and strength, ↓ROM
Mobilize patient, splint, PT, active and passive ROM, positioning, exercise program
A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility:
A. Decreased peristalsis
B. Decreased heart rate
C. Increased blood pressure
D. Increased urinary output
Decreased peristalsis
A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 lbs. Her vital signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8° C (98.2° F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy?
Temperature: 37° C (98.6° F)
Radial pulse: 112
Respiratory rate: 24
Oxygen saturation: 96%
Blood pressure: 134/78
Oxygen saturation: 96%
6 critical thinking skills
Interpretation Analysis Inference Evaluation Explanation Self-regulation
A patient who has been isolated for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. What is the most appropriate information to include in patient teaching? (Select all that apply.)
The organism is usually transmitted through the fecal-
oral route.
- Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer.
- Everyone coming into the room must be wearing a gown and gloves.
-While the patient is in contact precautions, he cannot
leave the room.
-C. difficile dies quickly once outside the body.
The organism is usually transmitted through the fecal-
oral route.
- Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer.
- Everyone coming into the room must be wearing a gown and gloves.
What is the normal blood pressure range for 6 years
105/65 B/P (mmHg)
A couple who is caring for their aging parents are concerned about factors that put them at risk for falls. Which factors are most likely to contribute to an increase in falls in the elderly? (Select all that apply.)
- Inadequate lighting
- Throw rugs
- Multiple medications
- Doorway thresholds
- Cords covered by carpets
- Staircases with handrails
- Inadequate lighting Correct
- Throw rugs Correct
- Multiple medications Correct
- Doorway thresholds Correct
- Cords covered by carpets Correct
What is the normal pulse range for school aged child
School aged child: 75-100 HR/minute
________ ROM is what is being done to patient
Passive
A nurse enters a 72-year-old patient’s home and begins to observe her behaviors and examine her physical condition. The nurse learns that the patient lives alone and notices bruising on the patient’s leg. When watching the patient walk, the nurse notes that she has an unsteady gait and leans to one side. The patient admits to having fallen in the past. The nurse identifies the patient as having the nursing diagnosis of Risk for Falls. This scenario is an example of:
- Inference.
- Basic critical thinking.
- Evaluation.
- Diagnostic reasoning
Diagnostic reasoning
patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention?
- Provide a dark, quiet room to calm the patient.
- Reduce the level of precautions to keep the patient from becoming angry
- Explain the reasons for isolation procedures and provide meaningful stimulation.
- Limit family and other caregiver visits to reduce the risk of spreading the infection
-Explain the reasons for isolation procedures and provide meaningful stimulation.
nursing diagnosis
K
E
S
A
knowledge
experience
standards
attiudes
What is the normal blood pressure range for 1 year
95/65 B/P (mmHg)
(the distribution of red blood cells to and from the pulmonary capillaries
PERFUSION
As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. What is the best response?
- Nail polish attracts microorganisms and contaminates the finger sensor.
- Nail polish increases oxygen saturation.
- Nail polish interferes with sensor function.
- Nail polish creates excessive heat in sensor probe.
- Nail polish interferes with sensor function.
_________ disease is the infectious disease transmitted from one person to another.
Communicable
High-level disinfection, which is required for some items such as endoscopes: ________
autoclave
5 signs and symptoms of fever
Hot, dry, flushed skin •Headache •Thirst •Loss of appetite (anorexia) •Malaise
is the act of washing hands with soap and water, followed by rinsing under a stream of water for 15 seconds.
Hand washing
aspect of critical thinking where you must
Be open-minded as you look at information about a patient.
Do not make careless assumptions.
Does the data reveal a problem or trend that you believe is true, or are there other options?
Analysis
Only to be used after less restrictive interventions have been determined to be ineffective
restraints
In immobility
Cardiovascular orthostatic hypotension, ________ HR, weak peripheral pulses, ______ monitor for edema, DVT
Increased
aspect of critical thinking where you must
Look at the meaning and significance of findings.
Are there relationships among findings? Does the data about the patient help you see that a problem exists?
Inference
infection that Results from delivery of health services in a health care facility
Health Care–Associated Infection (Nosocomial)
____ flows in the direction of gravity.
Fluid
(the movement of gases in and out of the lungs)
VENTILATION
What is the normal pulse range for adult
Adolescents: 60-100 HR/minute
Which is the correct gait when a patient is ascending stairs on crutches?
- A modified two-point gait (The affected leg is advanced between the crutches to the stairs.)
- A modified three-point gait (The unaffected leg is advanced between the crutches to the stairs.)
- A swing-through gait
- A modified four-point gait. (Both legs advance between the crutches to the stairs.)
A modified three-point gait (The unaffected leg is advanced between the crutches to the stairs.)
The nurse evaluates that the NAP has applied a patient’s sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply.)
A. Initial patient measurement is made around the calves
B. Inflation pressure averages 40 mm Hg
C. Patient’s leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve.
D. Stockings are removed every 2 hours during application.
E. Yellow light indicates SCD device is functioning.
Patient’s leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve.
Inflation pressure averages 40 mm Hg
- May be prevented by arising slowly, or “dangling” for a few minutes( raising head of bed (HOB) first then assisting the client to sit on the side of bed
- Assess for dizziness or faintness prior to standing
- If dizzy or lightheaded, return to supine position to restore cerebral perfusion
Orthostatic Hypotension
The nurse observes a nursing student taking a blood pressure (BP) on a patient. The nurse notes that the student very slowly deflates the cuff in an attempt to hear the sounds. The patient’s BP range over the past 24 hours is 132/64 to 126/72 mm Hg. Which of the following BP readings made by the student is most likely caused by an incorrect technique?
- 96/40 mm Hg
- 110/66 mm Hg
- 130/90 mm Hg
- 156/82 mm Hg
130/90 mm Hg
A nurse changed a patient’s surgical wound dressing the day before and now prepares for another dressing change. The nurse had difficulty removing the gauze from the wound bed yesterday, causing the patient discomfort. Today he gives the patient an analgesic 30 minutes before the dressing change. Then he adds some sterile saline to loosen the gauze for a few minutes before removing it. The patient reports that the procedure was much more comfortable. Which of the following describes the nurse’s approach to the dressing change? (Select all that apply.)
- Clinical inference
- Basic critical thinking
- Complex critical thinking
- Experience
- Reflection
- Basic critical thinking
- Experience
Fire safety
P
A
S
S
- Pull pin
- Aim at base of fire
- Squeeze handles
- Sweep from side to side to coat area evenly
concept for a critical thinker that
Anticipate how a patient might respond to a treatment.
Analyticity
Modes of Transmission where
• Person-to-person (fecal, oral) physical contact between source and susceptible host (e.g., touching patient feces and then touching your inner mouth or consuming contaminated food)
Direct
A nursing assistive personnel asks for help to transfer a patient who is 125 lbs (56.8 kg) from the bed to a wheelchair. The patient is unable to help. What is the nurse’s best response?
- “As long as we use proper body mechanics, no one will get hurt.”
- “The patient only weighs 125 lbs. You don’t need my assistance.”
- “Call the lift team for additional assistance.”
- “The two of us can lift the patient easily.”
- “Call the lift team for additional assistance.”
Emotions influence decreased pulse rate by
Severe pain, relaxation
How can tempature be measured
Tympanic, oral, rectal, Axillary, Temporal artery, Esophageal, Pulmonary artery, Urinary bladder
What is the normal blood pressure range for 10-13
110/65 B/P (mmHg)
Which of the following actions by the nurse comply with core principles of surgical asepsis? (Select all that apply.)
- Set up sterile field before patient and other staff come to the operating suite.
- Keep the sterile field in view at all times.
- Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated.
- Only health care personnel within the sterile field must wear personal protective equipment.
- The sterile gown must be put on before the surgical scrub is performed.
- Keep the sterile field in view at all times.
- Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated.
A nurse on a busy medicine unit is assigned to four patients. It is 10 am. Two patients have medications due and one of those has a specimen of urine to be collected. One patient is having complications from surgery and is being prepared to return to the operating room. The fourth patient requires instructions about activity restrictions before going home this afternoon. Which of the following should the nurse use in making clinical decisions appropriate for the patient group? (Select all that apply.)
- Consider availability of assistive personnel to obtain the specimen
- Combine activities to resolve more than one patient problem
- Analyze the diagnoses/problems and decide which are most urgent based on patients’ needs
- Plan a family conference for tomorrow to make decisions about resources the patient will need to go home
- Identify the nursing diagnoses for the patient going home
Combine activities to resolve more than one patient problem
Consider availability of assistive personnel to obtain the specimen
Analyze the diagnoses/problems and decide which are most urgent based on patients’ needs
The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.)
- Contact the nursing supervisor.
- Restrict the family’s visiting privileges.
- Ask the family to stay with the patient if possible.
- Inform the family of the risks associated with side-rail use.
Thank the family for being conscientious and put the four rails up.
- Discuss alternatives that are appropriate for this patient with the family.
- Ask the family to stay with the patient if possible.
Inform the family of the risks associated with side-rail use
- Discuss alternatives that are appropriate for this patient with the family.
Most common fall injury is ______ fracture: of those who fracture a _____ due to fall, 24% die within one year, and 50% never return to their former level of functioning
hip
- Drop in BP and dizziness with position change
- Due to peripheral vasodilation accompanied by no increase in cardiac output
- Occurs: in the elderly; with bedrest; post-operatively; with dehydration, blood loss; with cardiac, BP, sedative or narcotic medications.
Orthostatic Hypotension
aspect of critical thinking where you must
Support your findings and conclusions
Use knowledge and experience to choose strategies to use in the care of patients.
Explanation
