Exam 1 Modules 1-3 Flashcards
NCLEX provides the __________ standard for knowledge of practice.
minimum
Nursing student graduate is minimally competent
National Nurses Association
ANA
American Nurses Association
National Nurses Association
NLN
National League for Nurses
National Nurses Association
AACN
American Association of Colleges of Nursing
National Nurses Association
NSNA
National Student Nurses Association
State Nurses Association
FNSA
Florida Nursing Student Association
Roles of Nurse
caregiver, educator, leader, advocate, researcher
Acute care nurses
practice inside hospital
Impatient vs outpatient
higher acuity and level of care
nonacute care nurses
practice outside the hospital
Maslows hierarchy of needs
Physiological (ABC’s)
Safety
Love/Belonging
Esteem
Self actualization
PICO(T)
Evidence based practice
Patient/Population
Intervention
Comparison
Outcome
Time (optional)
Decreased mobility = increased risk of
falling
Consequences of immobility
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
Transferring patient w/complete dependence:immobile
Use mechanical lift with sling
Crutches
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
Fall Causes
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
Guidelines for restraints
Never ordered as needed (PRN)
o Require order within 1 hour
o Must be re-ordered every 24 hours
o Assess and document frequently
What is the #1 way to stop the spread of infection?
HAND HYGIENE
Use friction
Stages of infection
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
2 Tiers of protection per CDC
Tier 1- Standard precautions and Tier 2- Transmission based precautions
Tier 1- Standard Precautions
▪ Apply to all patients
▪ Hand hygiene, surgical mask, proper sharp disposal, cover mouth and nose when sneezing/coughing
Tier 2- Transmission based precuations
▪ 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
Critical thinking
intellectual process
Clinical reasoning
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.
Clinical judgement
Contains thinking and reasoning
conclusion or outcome for patient scenario
outcomes of thinking, doing, and caring
NCSBN
creator of NCLEX
Layers of CJM
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)
Nursing process
ADPIE
ADPIE
Assessment
Collecting subjective and objective data
▪ Recognize cues
ADPIE
Diagnosis
Analyze cues and prioritize hypotheses
* Cues = unexpected findings (abnormal)
ADPIE
Plan
Prioritize hypotheses and generate solutions
ADPIE
Implementation
Take action
* Doing, delegating, and documenting
ADPIE
Evaluation
Evaluate outcomes
* Goal oriented
o Examples:
▪ Inability to walk → ambulate patient
▪ Risk for falls → make sure room is clear of clutter
subjective data
what the pt says/tells us
objective data
what we observe
factual data- vital signs, lab data
Nursing diagnosis- patient problems the nurse can treat independently
assessing and analyzing ques/data
Internal respiration
oxygen is exchanged to provide oxygen to the tissues (tissue perfusion)
External respiration
oxygen is diffused from the alveoli in the pulmonary circulation to the capillary system (CO2 is released from circulation into the alveoli)
Pulse oximetry
measures O2 saturation in hemoglobin
does not test for tissue perfusion
Nursing intervention to promote oxygenation
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
Oxygen delivery system: Non-breather
AKA mask w/ reservoir bag
delivers 100% oxygen to pt
do not use on copd pts
Minimum urine output
30mL/hr
Is urinary incontinence a normal part of aging?
no
UTI’s can cause __________ in elderly patients.
AMS
Before giving pt’s antibiotics for UTI, what diagnostic test should be completed?
Urine culture to determine which bacteria you are treating
Where do you collect urine specimen from when pt has a cath?
From specimen port
Not the collection bag
How do you prevent CAUTI?
asepsis technique, keep bag below bladder, no kinks in tubing
What macronutrient promotes healing?
protein
Metabolism
process by which the body converts food to energy
Nutrition is esp. important for post op patients, why?
promotes optimal healing
Constipation
increase fluid and fiber intake
Diabetic pts diet
low glycemic
First step after placing NG tube on pt, before giving any meds or food
radiographic (x-ray) verification is the most reliable
method for confirming tube placement and must be
performed before the first feeding is administered
Diets meant for short term use
NPO, clear liquid, full liquid
Surgery and diet progression
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
Valsalva maneuver
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
Vagal response
dizziness, ringing ears
Is increased GI motility (peristalsis) a healthy response to intestinal infection?
Yes
Best position for enema
left lateral Sim’s position
Florence Nightingale
founder of modern nursing
reduced death rates by improving hygiene
Benner’s models of novice to expert
novice
advanced beginner
competent
proficient
expert
Carbon monoxide poisoning
pt will be bright red in color
Ways to prevent pneumonia
early mobilization
upright position
turn, cough, deep breathe
incentive spirometer
Nosocomial infection
infection acquired during hospitalization
Hypoxia
deficiency in the amount of oxygen reaching the tissues
Hypoxemia
abnormally low concentrations of oxygen in the blood
Important w/ inhalers
ask pt to demonstrate inhaler technique, take as prescribed
Diagnostic testing for oxygenation status
ABG’s
peak flow monitoring
What type of finding is a cue?
abnormal
What does a nurse mean w/ a pt outcome
goals for the pt
Chain of infection - 6 components
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
Contact precautions
gloves and gown
First void after cath removal needs to be
measured
Macronutrients essential for
carbs- energy
fats- brain and nerve function
protein- healing
For IV contrast- its important to check for
iodine allergy
Responses to enema are governed by
height of solution container
speed of flow
concentration of the solution
resistance of the rectum
Hypertonic enema
fleet: sodium
maintain pressure on bottle until empty
What do you do if the pt you are administering an enema complains of abdominal cramping
slow the flow
Ostomy should be
red/pink and moist
NPO
nothing by mouth
Clear liquids
liquids that can be seen through clearly
clear juices, pops, jello, clear broth, tea
Full liquids
Pourable consistency
all liquids, milk, supplemental drinks, ice cream
ADPIE matches up with CJM Layer
3
