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PCC Lecture > Exam 1 Modules 1-3 > Flashcards

Exam 1 Modules 1-3 Flashcards

1
Q

NCLEX provides the __________ standard for knowledge of practice.

A

minimum

Nursing student graduate is minimally competent

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2
Q

National Nurses Association

ANA

A

American Nurses Association

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3
Q

National Nurses Association

NLN

A

National League for Nurses

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4
Q

National Nurses Association

AACN

A

American Association of Colleges of Nursing

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5
Q

National Nurses Association

NSNA

A

National Student Nurses Association

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6
Q

State Nurses Association

FNSA

A

Florida Nursing Student Association

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7
Q

Roles of Nurse

A

caregiver, educator, leader, advocate, researcher

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8
Q

Acute care nurses

A

practice inside hospital

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9
Q

Impatient vs outpatient

A

higher acuity and level of care

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10
Q

nonacute care nurses

A

practice outside the hospital

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11
Q

Maslows hierarchy of needs

A

Physiological (ABC’s)
Safety
Love/Belonging
Esteem
Self actualization

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12
Q

PICO(T)

Evidence based practice

A

Patient/Population
Intervention
Comparison
Outcome
Time (optional)

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13
Q

Decreased mobility = increased risk of

A

falling

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14
Q

Consequences of immobility

A

Orthostatic hypotension: sudden drop in BP > 10 at different positions (lying,
sitting, and standing)
o VTE: blood clots (can lead to pulmonary embolism)
o Atelectasis: collapse of lung
o Pneumonia: infection of lung
o Constipation/bowel obstruction
o Renal calculi: kidney stones
o Pressure ulcers
o Muscle atrophy: loss of muscle mass and tone
o Osteoporosis: decrease in bone density
o Contractures: shortening or hardening of muscles, tendons, and other tissues
o Psychosocial consequences: depression, sleep disturbances, disorientation

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15
Q

Transferring patient w/complete dependence:immobile

A

Use mechanical lift with sling

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16
Q

Crutches

A

Sizing:
* Axillary crutch pad should be 3 fingerbreadths below axilla
* Slight flexion of elbows
* Axilla should not rest on crutch pad

Teaching:
* Tripod position
* Lead with unaffected leg when going up stairs and to lead with affected leg coming down

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17
Q

Fall Causes

A

o Intrinsic:
▪ Orthostatic hypotension
▪ Meds: for new and dose changes
* Psychotropics
▪ Impaired gait or balance
▪ Neuropathy
▪ Incontinence/urgency
▪ Vision impairment
▪ UTI
▪ Confusion

o Extrinsic:
▪ Unsafe environment

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18
Q

Guidelines for restraints

A

Never ordered as needed (PRN)
o Require order within 1 hour
o Must be re-ordered every 24 hours
o Assess and document frequently

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19
Q

What is the #1 way to stop the spread of infection?

A

HAND HYGIENE

Use friction

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20
Q

Stages of infection

A

Incubation: period of time between invasion of the pathogen and the first signs or symptoms of infection
o Prodromal: most infectious, appear as vague symptoms
▪ Not all infections have a prodromal phase
o Illness: signs and symptoms present
o Decline: symptoms fade, # of pathogens decline
o Convalescence: tissue repair, return to health

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21
Q

2 Tiers of protection per CDC

A

Tier 1- Standard precautions and Tier 2- Transmission based precautions

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22
Q

Tier 1- Standard Precautions

A

▪ Apply to all patients
▪ Hand hygiene, surgical mask, proper sharp disposal, cover mouth and nose when sneezing/coughing

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23
Q

Tier 2- Transmission based precuations

A

▪ Patients with known or suspected infection or colonization with pathogens
* Contact precautions: gown and gloves
* Droplet precautions: gown, gloves, mask, eye protection
o COVID
* Airborne precautions: gown, gloves, N95 mask
o TB

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24
Q

Critical thinking

A

intellectual process

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25
Q

Clinical reasoning

A

the thinking process by which a nurse reaches a clinical judgement. enables you to synthesize, knowledge, experience, and information from various sources to develop an effective plan of care for a client.

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26
Q

Clinical judgement

Contains thinking and reasoning

A

conclusion or outcome for patient scenario

outcomes of thinking, doing, and caring

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27
Q

NCSBN

A

creator of NCLEX

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28
Q

Layers of CJM

A

o Layer 0: clinical decisions
o Layer 1: comprises the outcome = clinical judgement
o Layer 2: form, refine hypotheses; evaluation
o Layer 3: recognize cues, analyze cues, prioritize hypotheses, generate
solutions, take action, evaluate outcomes
▪ Not linear
o Layer 4: context (individual and environmental factors)

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29
Q

Nursing process

A

ADPIE

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30
Q

ADPIE

Assessment

A

Collecting subjective and objective data
▪ Recognize cues

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31
Q

ADPIE

Diagnosis

A

Analyze cues and prioritize hypotheses
* Cues = unexpected findings (abnormal)

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32
Q

ADPIE

Plan

A

Prioritize hypotheses and generate solutions

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33
Q

ADPIE

Implementation

A

Take action
* Doing, delegating, and documenting

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34
Q

ADPIE

Evaluation

A

Evaluate outcomes
* Goal oriented
o Examples:
▪ Inability to walk → ambulate patient
▪ Risk for falls → make sure room is clear of clutter

35
Q

subjective data

A

what the pt says/tells us

36
Q

objective data

A

what we observe
factual data- vital signs, lab data

37
Q

Nursing diagnosis- patient problems the nurse can treat independently

A

assessing and analyzing ques/data

38
Q

Internal respiration

A

oxygen is exchanged to provide oxygen to the tissues (tissue perfusion)

39
Q

External respiration

A

oxygen is diffused from the alveoli in the pulmonary circulation to the capillary system (CO2 is released from circulation into the alveoli)

40
Q

Pulse oximetry

A

measures O2 saturation in hemoglobin

does not test for tissue perfusion

41
Q

Nursing intervention to promote oxygenation

A

o Positioning for maximum lung excursion:
▪ High fowlers → best position for patients who have difficulty
breathing

o Pursed lip breathing: exhalation is twice as long as inhalation
▪ COPD patients

42
Q

Oxygen delivery system: Non-breather

A

AKA mask w/ reservoir bag

delivers 100% oxygen to pt

do not use on copd pts

43
Q

Minimum urine output

A

30mL/hr

44
Q

Is urinary incontinence a normal part of aging?

A

no

45
Q

UTI’s can cause __________ in elderly patients.

A

AMS

46
Q

Before giving pt’s antibiotics for UTI, what diagnostic test should be completed?

A

Urine culture to determine which bacteria you are treating

47
Q

Where do you collect urine specimen from when pt has a cath?

A

From specimen port

Not the collection bag

48
Q

How do you prevent CAUTI?

A

asepsis technique, keep bag below bladder, no kinks in tubing

49
Q

What macronutrient promotes healing?

A

protein

50
Q

Metabolism

A

process by which the body converts food to energy

51
Q

Nutrition is esp. important for post op patients, why?

A

promotes optimal healing

52
Q

Constipation

A

increase fluid and fiber intake

53
Q

Diabetic pts diet

A

low glycemic

54
Q

First step after placing NG tube on pt, before giving any meds or food

A

radiographic (x-ray) verification is the most reliable
method for confirming tube placement and must be
performed before the first feeding is administered

55
Q

Diets meant for short term use

A

NPO, clear liquid, full liquid

56
Q

Surgery and diet progression

A

NPO → clear liquid → full liquid → surgical soft → regular diet
o NPO used prior to surgery to prevent aspiration
o Progression used to prevent vomiting —> can cause
incision to open

57
Q

Valsalva maneuver

A

act of bearing down to defecate

Do not perform on clients with heart disease, glaucoma, increased ICP, or a new surgical wound
▪ Increases risk for cardiac arrythmias

58
Q

Vagal response

A

dizziness, ringing ears

59
Q

Is increased GI motility (peristalsis) a healthy response to intestinal infection?

A

Yes

60
Q

Best position for enema

A

left lateral Sim’s position

61
Q

Florence Nightingale

A

founder of modern nursing

reduced death rates by improving hygiene

62
Q

Benner’s models of novice to expert

A

novice
advanced beginner
competent
proficient
expert

63
Q

Carbon monoxide poisoning

A

pt will be bright red in color

64
Q

Ways to prevent pneumonia

A

early mobilization
upright position
turn, cough, deep breathe
incentive spirometer

65
Q

Nosocomial infection

A

infection acquired during hospitalization

66
Q

Hypoxia

A

deficiency in the amount of oxygen reaching the tissues

67
Q

Hypoxemia

A

abnormally low concentrations of oxygen in the blood

68
Q

Important w/ inhalers

A

ask pt to demonstrate inhaler technique, take as prescribed

69
Q

Diagnostic testing for oxygenation status

A

ABG’s
peak flow monitoring

70
Q

What type of finding is a cue?

A

abnormal

71
Q

What does a nurse mean w/ a pt outcome

A

goals for the pt

72
Q

Chain of infection - 6 components

A

Infectious agent- pathogen such as bacteria, virus, fungi, parasite.

Reservoir- source of infection

Portal of Exit- most frequent= bodily fluids

mode of transmission ( direct/indirect)

Portal of entry - body openings

Susceptible host- person at risk of infections

73
Q

Contact precautions

A

gloves and gown

74
Q

First void after cath removal needs to be

A

measured

75
Q

Macronutrients essential for

A

carbs- energy
fats- brain and nerve function
protein- healing

76
Q

For IV contrast- its important to check for

A

iodine allergy

77
Q

Responses to enema are governed by

A

height of solution container

speed of flow

concentration of the solution

resistance of the rectum

78
Q

Hypertonic enema

A

fleet: sodium

maintain pressure on bottle until empty

79
Q

What do you do if the pt you are administering an enema complains of abdominal cramping

A

slow the flow

80
Q

Ostomy should be

A

red/pink and moist

81
Q

NPO

A

nothing by mouth

82
Q

Clear liquids

A

liquids that can be seen through clearly

clear juices, pops, jello, clear broth, tea

83
Q

Full liquids

A

Pourable consistency

all liquids, milk, supplemental drinks, ice cream

84
Q

ADPIE matches up with CJM Layer

A

3

PCC Lecture (3 decks)

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