Exam 1: NR410 Flashcards
What is the mnemonic for jesuit values?
M-FM-CCU
What does the “M1” stand for in Jesuit Values
Magis= the more
What Does “F” stand for in Jesuit Values?
Finding God in all Things
What does “M2” stand for in Jesuit Values?
Men & Women for others in need
What Does “C1” stand for in Jesuit Values?
Cura Persona = Care for the person
What does “C2” stand for in Jesuit Values
Contemplatives in Action
What does “U” stand for in Jesuit Values?
unity of mind and heart
What is the primary purpose of hand hygiene?
to prevent or control the transmission of infection from any source.
When delegating patient care that requires nursing assistive personnel (NAP) to use personal protective equipment (PPE), it is necessary for the nurse to do what first?
Review the patient’s need for a specific isolation precaution
In which situation would it be appropriate for the nurse to use an antiseptic hand rub to perform hand hygiene?
The nurse’s hands are not visibly soiled.
What is the primary reason for performing perineal care on a male patient with incontinence?
To reduce the risk of skin breakdown in the patient’s genital and perineal area
A patient with difficulty breathing requests a back massage. In which position would the nurse instruct nursing assistive personnel (NAP) to place the patient during the massage?
Side-lying
As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, “I can do that myself.” Which action would be the priority?
Assess the patient’s ability to perform proper perineal care.
What temperature should the water be when bathing a patient?
Warm
The nurse is delegating a female patient’s perineal care to nursing assistive personnel (NAP). What instruction would the nurse give to ensure the NAP’s safety while performing this care?
wear clean gloves
The nurse is assisting a patient with a tub bath. After the patient has been safely positioned in the tub, he tells the nurse, “I’ll call you when I’m done.” What is the nurse’s best response?
check back in 5 min
The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care?
dorsal recumbent
A patient is being given a bed bath. The nurse realizes that another washcloth is needed to complete the bath. What is one way in which the nurse can ensure the patient’s safety?
Make sure the call light is within reach
As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, “I can do that myself.” Which action would be the priority?
Assess the patient’s ability to perform proper perineal care.
The nurse observes the nursing assistive personnel (NAP) providing perineal care to a male patient. Which observation of care requires the nurse’s follow-up?
Reserving the cleansing of the tip of the penis as the final step in perineal care
A patient with left-sided muscle weakness is prescribed a bath every other day. Which precaution would help the nurse reduce this patient’s risk of falling?
Decline the patient’s request to add scented oil to the bathwater.
A male patient receiving perineal care tells the nurse “It has started to hurt a little down there.” What is the nurse’s best response?
“When did you start experiencing the pain?”
What will the nurse do right after placing a clean top sheet on the patient?
Remove the bath blanket
The nurse is directing nursing assistive personnel (NAP) to make an occupied bed. What will the nurse say to minimize the risk of disease transmission to staff and patient during the bed change?
“You’ll need to apply Standard Precautions during this task.”
A nursing assistive personnel (NAP) has finished making a surgical bed for a patient in surgery. How would the nurse instruct the NAP to leave the bed to transfer the surgical patient safely?
Raise the height of the bed.
When making a surgical bed with no patient present, at which time is it unnecessary to perform hand hygiene?
After disposing of soiled linen that is not visibly soiled
Comparing the changes in vital signs as a person ages x3
- Respiratory rate remains fairly stable throughout a person’s life.
- Blood pressure increases; heart rate and respiratory rate decline
- Men have higher blood pressure than women until after menopause
What is your primary intervention
maintain, improve wellness, immunization, nutrition
Secondary intervention
diagnosis followed by prompt intervention
Tertiary Intervention
prevent complications, undue deterioration, & rehab
What does SMART stand for in the planning phase
Specific, Measurable, Attainable, Realistic, Timed
What is our bodies’ primary defense
skin
what is our bodies’ secondary defense
phagocytosis, fever
what is our bodies’ tertiary defense
b-cells, t-cells
What are examples of portal entry/exit
lines tubes, skin, mucous, respiratory tract, UTI, Reproductive tract, blood
Which is better to block portal exit or portal exit
Portal Exit, because blocking entry to others. Keeps it contained.
What are the 4 stages of infection
- Incubation (no symptoms yet)
- Prodromal (not feeling well)
- Illness (stay away)
- Convalescence (starting to feel better)
7 factors that influence hygiene and self care
- psychosocial
- personal pref
- culture/religion (male, female)
- Economic status
- development
- Knowledge
- phys health
What are common types of baths
- Assist- hard to reach areas
- Partial- necessary areas (perineum)
- Complete- head to toe
In a care plan what might you say for evaluation of ADLs?
how patient tolerated the procedure, give more.
When should you contact RRT (regional response team)
- if worriend about PT
- abnormal RR, BP, HR
- neuro
- acute urinary
What are the standards for taking vitals at a hosptial
every 4-8 hours
Why do some elders become malnourished or dehydrated
staffing issues, not enought time
What are common causes in changes in temperature
- fever
- hyperexia > 105.8
- hyperthermia
- hypothermia < 95F
1 degree celsius is equal to an increase in how many beats per min
10
Nursing Research
- examine phenomena important to nursing
- a guide to making clinical decisions
Steps to EBP x6
- Ask clinical question
- Collect evidence
- Critique evidence
- integrate
- evaluate
- share outcomes
What percent of hospitalized patients are malnourished
40-50%
What are nursing diagnoses for nutrion
- inadequate intake
- self-care deficit
- fluid volume deficite
- nutrition imbalances less/more than requirement
Restrictions for nutrition
- sodium
- fat
- calories
- protein
What does BRAT stand for
- Banana
- Rice
- Apple sauce
- Toast
What foods should be avoided for low residue diet?
- Fruits
- Vegetables
What are the standards for taking vitals for home health
ea. visit
Why do some elders become malnourished or dehydrated
staffing issues, not enought time
What are common causes in changes in temperature
- fever
- hyperexia > 105.8
- hyperthermia
- hypothermia < 95F
1 degree celsius is equal to an increase in how many beats per min
10
Kolvenbach
MEN and WOMEN FOR others. Respect no matter what background
Ignatius Tradition
value-centered choices. How we should live, Critical thinking Social responsibility
The main objected of the class x3
1) Service Learning 2) Didactus 3) Lab/Clinical
Gordon’s Functional Health Pattern
Health history//ADL’s
What are the 3 types of diagnosis
1) Actual 2) Risk for 3) wellness
PES stands for
Problem, Etiology, Signs & Symptoms
What is the ideal temp for most pathogens
68-109F or 20-43 C
What are the super bugs known in hospitals- or these you need to use soap and water
NORA virus, MRSA, C-Diff, VRE, TB
In what order do you put on your PPE
- Gown
- Mask
- Glasses
- Gloves
Ignatius Tradition
value-centered choices. How we should live, Critical thinking Social responsibility
What is enteral nutrition?
- nutrients through GI tract
- “tube feeding”
- know there is many diff types
Parenteral feeding means?
- short-term
- central venous line
Ventilation means..
gas in and out of lungs
What do we look for in the respiratory rate
rhtymn, rate, depth, quality, effectiveness
eupnea means
normal breathing
apnea
means temp not breathing
Cheyne Stokes
irregular shallow breathing, period of panea. Death approaching..
Immobility and ADL can cause risk for
pressure ulcers,
-Emia pertains to
blood flow
What can poor dental care cause?
- CV disease
- diabetes
- malnutrition
- stroke
- pneumonia
What can good oral care facilitate?
- improved appetite
UAP stands for
Unlicensed assisted personnel
“CNA”
Why would the nurse instruct nursing assistive personnel (NAP) to hand the patient a mirror before trimming his moustache and beard?
To allow him to point out which areas he would like to have trimmed
A patient with diabetes remarks during foot care that she has been letting her skin air-dry after bathing at home because her doctor told her to use plenty of moisturizer on her hands and feet. What should the nurse teach the patient?
towel dry thoroughly
What will the nurse do when a gown change is needed for a patient who is receiving intravenous fluids delivered by a pump?
pause the infusion by pressing the sensor on the pump
What would the nurse instruct nursing assistive personnel (NAP) to report when performing denture care for a patient?
any cracks
What is the purpose of parting the patient’s hair into sections?
to make brushing and combing more effective
Is it okay to have a CNA assess pain on a patient?
NO
What will the nurse instruct nursing assistive personnel (NAP) to do when measuring a patient’s rectal temperature using an electronic thermometer?
The patient should be placed in the side-lying Sims’ position.
What is pulse deficit
The difference btwn apical pulse and radial pulse
What is the major health problem resulting from a pulse deficit?
decreased cardiac output
Which instruction might the nurse give to nursing assistive personnel (NAP) that is applicable only to tympanic temperature assessment?
Gently tug the pinna backward, up, and out before inserting the probe.
What does the systolic measurement represent?
The pressure exerted against the arterial wall.
What is the nurse’s priority action if a patient’s radial pulse has an irregular rhythm?
Assess the patient for a pulse deficit.
For which patient would the nurse instruct nursing assistive personnel (NAP) to weigh a patient with a bed scale?
patient who has heart failure & inability to bear weight
This is a patient’s life experiences and patterns of living
Assessment
This is the basis for all nursing interventions and of which the nurse is accountable…
Nursing Diagnosis
What are the steps to formulate a nursing diagnosis? x3
- identify the problem
- diagnostic statement
- validate
Thi is a pattern of related cues and describes the prblem or wellness response
diagnostic label
What words should be used when describing an intervention
action words, frequency, amount
All nursing interventions directed at solving patient’s problems and meeting healthcare needs..
implementation
What types of transmission are transported via dust?
Airbone, Droplet
What are common types of airborne infections? x 3
- Varicella
- TB
- Measles
What PPE do you need for MRS precautions?
full gown, mask, gloves, hand hygiene
What are common infections considered to be droplet
Mumps, Flu
Which type of precaution do you need to wear a fitted mask (N95)?
Airborne
Ignatian Pedagogy Conceptual Model
- Context
- Experience
- Action
- Evaluation
What is service learning also, besides just a community service?
Academic Learning, purposeful civic learning
What are 3 components of evidence based practice?
- decisions based on most current research evidence
- clinical expertise
- needs/wants of the patient
Professional nursing promotes…X4
- Responsibility 2. Accountability 3. Confidentiality 4. Advocacy
What are the 4 components of NANDA
1)Planning 2)Outcome 3) Identity 4)Intervention
What does malaise mean & is this local or systemic?
Fatigue, systemic
What are the main purposes of hygiene care x 3
1) maintenance of personal hygiene 2)Protection 3)Improve circulation (blood clots, pressure ulcers)
Nurse’s Role for ADL’s x 4
1) assess self care abilities 2)provide assistance w self care/independence 3)promote 4)delegate
What should you inform the UAP of
- limitations
- amt assistance needed
- assisted devices
- presence and care of tubes
- observation to make during hygiene care
Other times to take vitals..
- admission
- change in condition
- symptms
- pre-post surgery
- pre-post medication (cv sys)
- pre-post nursing interventions
this is necessary in the OR and is a hereditary response to anasthetic agents
malignant hyperthermia
What was early research focused on
education
What is the focus of research now?
patient care
Who says we need to do research as a means of improving health and welfare of people?
international council of nursing
Dyarthria
- difficulty chewing
- signs-
- pocketing food, slurred speech
Dysphagia
- difficulty swallowing
- signs
- coughing
- Speech therapy
NPO stands for
- nothing by mouth
- Nil Per Os
Diet after a procedure
- clear liquid
- full liquid-milk shake
- pureed
- ground
- mechanical soft-mashed potatoes
- soft
- regular
In a care plan, an intervention looks a lot like..
a to do list of procedures
Diagnosis
Valid influences, compare “clusters”, identify related factors
Outcome
realistic, something that can be measured, TIME FRAME, unique to PT
Planning
establish priorities, refer back to outcomes, plan of care, interventions
Implementation
readiness, review interventions, collaborate team members, counseling, refer continuing care
What does PQRSTU Stand for
1) Provocative 2)Quality/Quantity 3)Region/Radiation 4) Severity 5) Timing 6)Understanding
When is surgical apses necessary?
- intentional perforation of the skin
- body cavity, not exposed to outside
Name 5 types where patient needs surgical asepsis technique
- Open Body Cavity
- Catheter
- Burns
- Central Line
Clean technique
- removes majority of microorganisms, not everything
- no autoclaving
How has the nursing field changed over time?
- NCLEX process
- Education
- Subj/Objective Data
- Evidence Based
- Research
- diversity
- responsibile for patient care + outcomes
What was the nurse’s identity originally?
- only a female job
- nursing for infants
- meant to “nourish”
- used to be spiritual only
- physical only
- now it is both
identifyi nursing actions that convey a negative image of nursing?
- abuse
- neglect
- sexual assault
- understaffing
- drug abuse
Steps to Removing PPE
- Gloves
- Eyewear
- Ties on Gown
- Gown
- Mask
