EXAM 1 Main Points Flashcards
1
Q
how do we get from tablespoon to mL
A
tablespoon amount x 3 (teaspoons) x 5 (mL)
2
Q
6 competencies of QSEN
A
patient centered care
teamwork and collaboration
evidence based practice
quality improvement
informatics
saftey
3
Q
informed consent 4 rights
A
right to not be harmed
right to full disclosure
right to self determination
right to privacy
4
Q
goals of EBP (RAPPA)
A
reduce variations
achieve clinical excellence
promote effective interventions and care
provide nurses with EBP
assist in clinical decision making
5
Q
3 points of EBP
A
individual clinical expertise
patients values and expectaions
best available clinical evidence
6
Q
QSEN
A
quality and safety of the education for nursing
7
Q
KSA
A
knowledge, skills, attitiude
8
Q
report vitals
A
T, P, R, BP + MAP, SpO2 + FiO2, Pain
9
Q
nursing process ADPIE
A
assessment
diagnosis
planning
inteplementation
evaluation
10
Q
elevated BP
A
120-129 AND 80-89
11
Q
stage 1 BP
A
130-139 OR 80-89
12
Q
stage 2 BP
A
> 140 OR >90
13
Q
hypertensive crisis
A
> 180 AND OR >120
14
Q
infection cycle
A
infectious agent
reservoir
portal of exit
means of transmission
portal of entry
Susceptible host
15
Q
means of transmission
A
direct, indirect, contact, droplet, airborne
16
Q
neutrophils
A
acute bacterial
17
Q
lymphocytes
A
chronic bacterial and viral
18
Q
eosinophils
A
parasitic infections, fungus, allergic reactions
19
Q
3 bloodborne pathogens
A
HBV
HCV
HIV
20
Q
top infections
A
UTI
surgical site infection
bloodstream infection
pneumonia
21
Q
hospitals will not be paid for
A
CAUTI
vascular catheter infection
surgical site infection
22
Q
contact viruses
A
C. Diff, MRSA
23
Q
droplet viruses
A
Pertusis
Influenza
Meningitis
pneumonia
24
Q
airborne
A
MMR
TB
Varicella
Covid
25
3 failures that decrease patient outcome
failure to recognize
failure to rescue
failure to plan
26
adequate _________ and ____________ of cells help to prevent skin injury
nutrition, hydration
27
adequate _________________ is needed to maintain skin cell life
circulaiton
28
yellow on wipe warmer
not warm yet
29
blinking green on wipe warmer
cloth is aging, use first
30
solid green on wipe warmer
cloth is ready
31
red on wipe warmer
cloth is expired, do not use and dispose
32
skin in elderly
thinning of subq and demerla layer
longer time for cell renewal
nail changes (thicker)
decrease activity of sebaceous glands
decrease collagen fiber
predisposed to skin breakdown
33
6 scores for braden
sensory
moisture
activity
mobility
nutrition
friction/shear
34
gold standard for patient care
brushing teeth
35
diabetic foot care
wash with lukewarm water and soap daily
dry feet and in between toes
applying moisturizing lotion but not between toes
check feet daily for blisters, cuts, redness
trim toenails (best to file)
change socks daily
never walk barefoot
examine shoes daily for cracks, stones, nails
36
one nurse assist
stand on weak side
37
how to walk with cane
hold cane on strong side
advance cane
advance weak leg
advance strong leg
38
second hand smoke
heart disease
39
oxygen + ventilation =
perfusion
40
ABG measures
oxygenation and ventilation
41
wheezes
high pitch
bronchoconstriction
Asthma, obstruction, tumor
asthma treatment is bronchodilator
ventilation issue
42
crackles
fine, course
discontinuous
collapsing alveloar sacs
pneumonia
treatment: diuretics, chest percusion
43
rhonchi
secretions in larger airway
Continuous
treatment: deep breath, cough 3 small times, deep breath, 1 big cough
if cannot cough then use suction
44
normal PaO2
60-80
45
if you have a SpO2 of 95% what's the PaO2
80%
46
if you have a SpO2 of 90% what's the PaO2
60%
47
if you have a SpO2 of 80% what's the PaO2
50%
48
if you have a SpO2 of 70% what's the PaO2
40%
49
we need a MAP of at least 60 mmHG to
perfuse vital organs
50
cough suppressants
give for nonproductive cough
51
cough expectorants
give for productive cough
52
what does pressed lip breathing do
make exhalation time longer than inhalation by providing resistance
53
nasal cannula is measured in
liters/min
54
nasal cannula delivers how many liters
1-6
55
over how many liters of o2 should we humidify
2L
56
venturi mask delivers how much FiO2
24-40%
57
nonrebreather mask delivers how much FiO2
80-100%
58
nebulizer
fine particles of medications into deeper passages of the respiratory tract where absorption occur
59
bronchodilators can cause
tachycardia
60
after we give nebulizer we need to assess
heart rate
61
WHAT IS THE FIRST THING WE ALWAYS DO
ASSESS
62
if we go into a patients room and we notice change what do we need to do
ASSESS
63
room air FiO2
21%
64
1L FiO2
24%
65
2L FiO2
28%
66
3L FiO2
32%
67
4L FiO2
36%
68
5L FiO2
40%
69
6L FiO2
44%
70
10L FiO2
60%
71
15L FiO2
80%
72
20L FiO2
90%
73
30L FiO2
98%
74
why do we want adequate fluid intake (2-3L)
thins mucus and makes easier to cough up
75
calculate C
(F-32)/1.8
76
calculate F
(Cx1.8)+32
77
smoking is measured in
PACK YEAR
78
pulse ox
ARTERIAL hemoglobin saturation of oxygen
79
do not use SpO2 in
carbon monoxide posioning patients and arrest
80
SMILE incentive spirometry
sustained maximum inspiratory lung expander
81
things that interfere with light transmission on a pulse ox
outside light sources
carbon monoxide
patient motion
jaundice
dark skin = over estimation
82
things that interfere with arterial pulsations
peripheral vascular disease
hypothermia at assessment site
low cardiac output
hypotension
peripheral edema
tight probe
arrhythmias
edema
83
we use CHG baths on patients with
central IV lines
PICC lines
mid lines
hemodialysis catheters
84
foley care
cleaning perineal area
cleaning 6 inches down tube
tube must be secured to thigh
green clip is clamped
tubing is off floor and no dependent loops
85
do we put up 4 bed rails
NO
86
variables leading to back injury in health care workers
manual lifts
uncoordinated lifts
exceeding recommended lift weight limits
using out dated techniques
transferring/repositioning uncooperative or confused patients
87
will immobility cause a decrease or increase in cardiac workload
increase
88
will immobility cause a decrease or increase in endurance, stability, coordination
decrease
89
will immobility cause a decrease or increase in muscle size, tone, and strength
decrease
90
will immobility cause a decrease or increase in risk for venous thrombosis
increase
91
will immobility cause a decrease or increase in depth and rate of respiration
decrease
92
will immobility cause a decrease or increase in urinary statis
increase
93
will immobility cause a decrease or increase in risk for contractures
increase
94
will immobility cause a decrease or increase in bladder muscle tone
decrease
95
will immobility cause a decrease or increase in risk for skin breakdown
increase
96
will immobility cause a decrease or increase in sense of powerlessness
increase
97
will immobility cause a decrease or increase in sensory stimulation
decrease
98
will immobility cause a decrease or increase in bone loss
increase
99
will immobility cause a decrease or increase in work of breathing
increase
100
clinical site progressive exclusion criteria
Physiologically unstable patients
hypotensive
new EKG changes or elevated cardiac enzymes
INR >5 PTT> 100
patient who does not respond to verbal stimuli
suspected spinal trauma and unstable fractues
presence in femoral sheath
thrombolytic administration
101
fowlers degree
45-60
102
semi fowlers degree
30-45
103
high fowlers degree
90
104
low fowlers
15-30
105
foot drop is
plantar flexion
106
BP cuff length
75-100% pts arm circumference
107
BP cuff width
37-50% of patients arm circumference
108
cuff is too narrow
increased reading
109
cuff is too wide
decreased reading
