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NUR 352 > Exam 1 Blueprint > Flashcards

Exam 1 Blueprint Flashcards

1
Q

Assessment of Infection

A

Trending vitals increasing -> infection present;
Labs: Complete blood count (with WBC differential)
Culture and sensitivity
C-reactive protein (CRP)
Erythrocyte sedimentation rate (ESR)
Serological tests to detect specific antibodies or viruses
Radiology: X-rays
MRI
CAT
PET and indium scans

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2
Q

Hospital-Acquired Infection (risk factors)

A

Health care workers don’t hand hygiene properly, don’t wear PPE; common HAIs are Central Line Associated Bloodstream Infections, Catheter Associated Urinary Tract infections, Surgical Site Infections, Ventilator Assisted Pneumonias

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3
Q

Prevention Strategies: Weakening the chain of infection

A

Primary: vaccines, hygiene, good nutrition, exercise, socioeconomic status (ability to get care and preventative checks), good rest, educate the community

Secondary: early detection through screening and preventing it from getting worse (mammogram, pap smear, routine blood tests, screening for high risk populations)

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4
Q

Prevention Strategies: Education of health team members, patients, and community

A
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5
Q

Tier 1 Transmission Precautions

A

Standard Precautions

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6
Q

Tier 2 Transmission Precautions

A

Contact Precautions, Droplet Precautions, Airborne Precautions, Protective Environment

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7
Q

Evaluation of interventions (how do nurses know if interventions were successful)

A

Clients don’t get sick, are treated quickly, or vital signs/complete blood count go back to normal

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8
Q

Therapeutic communication approaches

A

“purposeful use of communication”; Plan and allow time to communicate, Active listening , Caring attitude, Honesty (open, direct, sincere), Trust, Empathy, Nonjudgmental attitude

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9
Q

Non-therapeutic communication approaches

A

passive, aggressive, passive-aggressive

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10
Q

Things that support effective communication

A

listening, planning, silence, good environment, privacy

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11
Q

Things that hinder effective communication

A

developmental/cognitive deficits, language barriers, poor/too bright lighting, excessive noise, extreme elements, strong emotions, cultural, what else can you think of?

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12
Q

Effective communication tools for health care team/nurses

A

ISBARR

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13
Q

ISBARR

A

introductions (identify self/title), situation (facility, patient, room number, briefly state the problem), background (brief and pertinent patient history, labs, meds), assessment (nurse’s assessment of situation, most recent vitals/changes), recommendation (make specific request), repeat (what other health care worker says)

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14
Q

Documentation: How to document patients own words

A

subjective

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15
Q

Documentation: Importance of documenting patient education

A

keeps other health care workers in the team up to date on what the patient has been informed, written history for the patient

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16
Q

Data Collection components of General Survey

A

appearance, behavior, body structure/mobility, height, weight, BMI, vital signs (including pain)

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17
Q

Data Collection components of Health History

A

P-past medical history/pertinent family history/childhood illnesses, hospitalizations, surgeries, immunizations, health maintenance screenings
L- last oral intake
E-events leading to illness or injury
A-allergies/reactions
S-symptoms of chief complaint
E-each medication (OTC, prescription, herbal, vitamins)
Health promotion behaviors
Review of systems (ROS) – information about the functioning of all body systems and health problems
Functional Health-questions regarding:
stress, occupation, sleep, substances, self-concept, relationships, abuse

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18
Q

Data Collection components of Physical Assessment

A

Inspection (vision, smell, hearing), Palpation (touch), Percussion (tapping body parts with fingers/small instruments), Auscultation (listening to sounds with stethoscope or doppler)

19
Q

Techniques used for physical assessment

  1. Skin is pink
  2. Skin is warm
  3. Hair is thinning
  4. Lung sounds clear
  5. No abdominal tenderness
A
  1. inspection
  2. Palpation
  3. Inspection
  4. Auscultation
  5. palpation
20
Q

Documentation of data collection

A

what limb used for data collection, time, date, who collected it, if for BG did patient just eat? if HR was patient sedentary?

21
Q

Collection components of vital signs including pain

A

temperature, BP, pulse, RR, pain, Pulse Ox

22
Q

Assessment and measurement of data for vital signs

A

measure vital signs as frequent as necessary, assess trends and your client, not individual measurements

23
Q

Documentation of vital signs including pain

A

document all vital signs in patient’s chart, vital signs flow sheets for routine, pulse ox: include if patient is on room air or oxygen (amount), note if there is a change in patients status

24
Q

Delegation of vital signs including pain

A

action of obtaining the vital signs may be delegated to unlicensed personnel, but interpretation of results remains in the nurse’s responsibility; if abnormal -> recheck data

25
Q

Unexpected findings and appropriate nursing actions for temperature (know normal ranges, and what abnormal is/looks like)

A

Hyperthermia – body temperature 40 C or 104.4 F
Nursing actions – obtain specimens; lab results; provide fluids, rest; antipyretics; provide comfort measures for chills, dry clothing and linens
Hypothermia – body temperature less than 35 C or 95 F
Nursing actions – warm environment, heated humidified oxygen, warming blanket, or warmed oral or IV fluids; head covered; continuous cardiac monitoring; emergency resuscitation equipment on standby

26
Q

Patient presentation with alterations of vital signs including pain: 1. Tachycardia

  1. Bradycardia
  2. Hypertension
  3. Hypotension
  4. Difficulty breathing
A

Pain: grimacing/they tell you; 1. sweaty, red, cant stay still, sometimes hyperventilating, constantly clutching at their chest

  1. Low energy, out of breath, tired, fatigued
  2. Red, sweaty, headache,
  3. Pale, dizzy, might pass out, tired
  4. Restlessness, clutching at their chest, increased resp rate, looking distressed/anxious, change in color of lips (bluish)
27
Q

Developmental considerations of vital signs including pain

A

Pain: developmental stage can alter how much a person can communicate; temp: kids run hot, older adults run colder; Pulse/respirations: gradually decreases with age; BP: gradually increases with age (decreasing elasticity of blood vessels);

28
Q

Ethical considerations of vital signs including pain

A
29
Q

Hepatitis A nursing considerations

A

Contact precautions; spread person-person (specifically through blood/waste) and through unclean food/water

30
Q

Hepatitis C nursing considerations

A

Contact precautions; spread person-person specifically through blood; CDC says Standard Precautions

31
Q

Respiratory Syncytial Virus nursing considerations

A

Contact Precautions

32
Q

Influenza nursing considerations

A

Droplet precautions

33
Q

Meningococcal meningitis nursing considerations

A

Droplet precautions

34
Q

MRSA nursing considerations

A

Contact precautions

35
Q

Mumps nursing considerations

A

Droplet precautions

36
Q

Norovirus nursing considerations

A

Contact Precaution

37
Q

C. Diff nursing considerations

A

Contact Precaution

38
Q

Varicella zoster nursing considerations

A

Airborne and Contact Precautions

39
Q

Pertussis (Whooping Cough) nursing considerations

A

Droplet precautions

40
Q

Unexpected findings and appropriate nursing actions for respiration (know normal ranges, and what abnormal is/looks like)

A

normal 12-20, if abnormal respirations find out source and correct the source

41
Q

Unexpected findings and appropriate nursing actions for Pulse Ox (know normal ranges, and what abnormal is/looks like)

A

normal range: 95-100 (COPD can be as low as 85%), if low put on oxygen

42
Q

Unexpected findings and appropriate nursing actions for BP (know normal ranges, and what abnormal is/looks like)

A

normal: systolic less than 120, diastolic less than 80; hypotension: systolic less than 90; hypertension: systolic above 140

43
Q

Unexpected findings and appropriate nursing actions for pulse (know normal ranges, and what abnormal is/looks like)

A

normal: 60-100 beats/min at rest, regular rhythm/strength/equal on both sides; pulse deficit = difference between apical and radial rate; dysrhythmia = irregular heart rhythm

NUR 352 (1 decks)

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