Exam 1 Main Points Flashcards
QSEN competencies?
patient centered care
teamwork and collaboration
EBP
quality improvement
safety
informatics
4 rights of informed consent?
right to:
not be harmed
full disclosure
self determination
privacy
EBP goals? “RAPPA”
Reduce variations
Achieve clinical experience
Promote effective interventions/care
Provide nurses with EBP
Assist in clinical decision making
3 main EBP points? “IBP”
Individual clinical experience
best available clinical evidence
Patient values and expectations
QSEN & KSA?
Quality and Safety of Education for Nursing
Knowledge, Skills, Attitude
in what order do you report vitals?
T
P
R
BP
SpO2 & FiO2
Pain
nursing process?
ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
elevated BP?
120-129 AND 80-89
(increase normal by 9)
stage 1 BP?
130-139 OR 80-89
(increase elevated by 9)
stage 2 BP?
> 140 OR >90
hypertensive crisis?
> 180 AND/OR >120
what is the infection cycle?
infectious agent
reservoir
portal of exit
means of transmission
portal of entry
susceptible host
different means of transmission?
direct
indirect
contact
droplet
airborne
what are neutrophils for?
ACUTE bacterial
what are lymphocytes for?
CHRONIC bacterial and viral
what are eosinophils?
parasitic, fungal, allergic reactions
what are the 3 bloodborne pathogens?
HIV
HBV
HCV
top infections?
UTI
surgical site infections
bloodstream infections
pneumonia
what will hospitals NOT pay for?
CAUTI
vascular catheter infection
surgical site infection
which viruses require CONTACT precautions?
C. Diff
MRSA
which viruses require DROPLET precautions?
Pertussis
Influenza
Meningitis
Pneumonia
which viruses require AIRBORNE precautions?
MMR
TB
Varicella
Covid
3 main failures that decrease patient outcomes?
failure to:
recognize
rescue
plan
adequate ____ and _____ of cells help to prevent skin injuries
nutrition and hydration
adequate ____ needed to maintain skin cell life
circulation
yellow light on CHG warmer?
not warm yet
blinking green light on CHG warmer?
USE FIRST, cloth is aging
solid green on CHG warmer?
cloth is ready
red on CHG warmer?
DO NOT use, cloth expired
specifics of skin in elderly?
-thinning of SUBQ and dermal layer
-longer time for cell renewal
-thicker nails growing upward
-decrease sebaceous gland activity
-decreased collagen fibers
-predisposed to skin breakdown
included in braden scale?
sensory perception
moisture
activity
mobility
nutrition
friction/shear
braden scale levels?
6 - lowest, not good
23 - highest, good
gold standard for patient hygiene?
brush teeth
diabetic footcare?
-wash with lukewarm water (decreased temp sensitivity) daily, in btwn toes
-dry feet
-lotion but NOT btwn toes
-check for blisters/cuts/etc
-trim toenails (better to file)
-change socks daily
-never walk barefoot
-examine shoes daily
when assisting a pt?
stand on their WEAK side
steps to walking with cane?
-stand on stronger side
-advance cane
-advance weak leg
-advance strong leg
second hand smoke can lead to?
heart disease
number one cause of lung disease?
smoking
oxygenation + ventilation = ?
perfusion
ABG measures?
oxy and vent
wheezes sound?
-continuous high pitch
-squeak or musical
what causes a wheezing sound?
air moving through narrow or partially obstructed airway passages (ventilation issue)
*treated with bronchodilator
crackles sound?
-can be fine OR coarse
-DISCONTINUOUS popping/crackling sound
what causes crackles sound?
air moving through wet secretions
*causes alveolar collapse
rhonchi sound?
-continuous low pitch
-snoring like quality
what causes rhonchi sound?
secretions in the larger airways
*need to cough (or use suction) to clear
normal PaO2?
60-80
SpO2 of 95%?
PaO2 of 80%
SpO2 of 90%?
PaO2 of 60%
SpO2 of 80%?
PaO2 of 50%
SpO2 of 70%?
PaO2 of 40%
MAP of at least 60 mmHG to _____?
perfuse vital organs
give cough suppressants for?
non productive cough
give cough expectorants for?
productive cough
what does purse lipped breathing do?
make exhalation time longer than inhalation by providing resistance
(inhale 2, exhale 4- common for COPD)
how many liters can be delivered by nasal cannula?
1-6
how much FiO2 does a venturi mask deliver?
24-40%
how much FiO2 does a nonrebreather mask deliver?
80-100%
nebulizer?
fine particles of meds released into deeper passages of respiratory tract (where absorptions occur)
*need to asses heart rate
room air FiO2?
21%
1L - FiO2?
24%
2L - FiO2?
28%
3L - FiO2?
32%
4L - FiO2?
36%
5L -FiO2?
40%
6L - FiO2?
44%
10L - FiO2?
60%
15L - FiO2?
80%
20L - FiO2?
90%
30L - FiO2?
98%
smoking is measured in?
PACK YEARS
pulse ox measures?
ARTERIAL hemoglobin saturation of oxygen
do NOT use SpO2 in?
carbon monoxide poisoning or arrest/code
what leads to back injuries in healthcare workers?
manual/uncoordinated lifts
exceeding recommended weight limit (35)
out dated techniques
transfer/reposition uncooperative or confused pt
immobility _____ cardiac workload?
increases
immobility _____ endurance, stability, coordination?
decreases
immobility ______ muscle size/tone/strength?
decreases
immobility _____ risk for venous thrombosis?
increases
immobility _____ respiration depth and rate?
decreases
immobility _____ urinary stasis?
increases
immobility _____ contracture risk?
increases
immobility _____ bladder muscle tone?
decreases
immobility _____ skin breakdown risk?
increases
immobility _____ sense of powerlessness?
increases
immobility _____ sensory stimulation?
decreases
immobility _____ bone loss?
increases
immobility _____ work of breathing?
increases
fowler’s degree?
45-60
semi fowlers?
30-45
high fowlers?
90+
low fowlers?
15-30
BP cuff length?
70/75-100% arm circumference
BP cuff width
37-50% arm circumference
cuff too narrow causes?
increased reading
cuff too wide causes?
decreased reading
