Exam 1 Review Flashcards
Ch 1,3,4,9,12,14,15,18,19,&20
1
Q
What does PICOT stand for?
A
Patients/population
Intervention
Comparison or comparison group
Outcome(s)
Time (as applicable)
2
Q
What are the 6 steps of the evidence-practice process?
A
- Ask the clinical question using the PICOT format
- Search for the best evidence based on the clinical question
- Critically appraise and synthesize the evidence
- Implement the evidence in practice
- Evaluate the practice decision or change
- Share the outcomes of the decision or change
3
Q
What does ADPIE stands for?
A
Assessment
Diagnosis
Planning
Implementation
Evaluation
4
Q
What does SBAR stand for?
A
Situation
Background
Assessment
Recommendation/request
5
Q
What type of information is included in the S step of SBAR?
A
- A brief description of the current situation.
- Identify who you are and your role.
- State the patient or issue clearly.
- Highlight the problem or concern that needs immediate attention.
6
Q
What type of information is included in the B step of SBAR?
A
- Relevant clinical history of the patient.
- Details of previous treatments or interventions.
- Any pertinent lab results or tests.
- Context that led up to the current situation.
- Most recent vitals
7
Q
What type of information is included in the A step of SBAR?
A
- Your clinical judgment or interpretation of the situation.
- Any changes in the patient’s condition.
- Patient condition unstable or worsening
8
Q
What type of information is included in the R step of SBAR?
A
- Your suggested course of action or what you need from the recipient.
- Any immediate interventions required (e.g., medications, specialist consults. test).
- Follow-up actions and timelines if applicable.
9
Q
What is the difference between assignment and delegation?
A
Assignment is part of the job. Delegation is a nursing job that another member of the team is permitted to do
10
Q
What is the definition of delegation?
A
the process of assigning authority or responsibility to another person to carry out specific activities
11
Q
‘Do not delegate what you can ____,’and what does it stand for?
A
E.A.T
Evaluate
Assess
Teach
12
Q
What are the 5 rights to delegation?
A
Right task
Right circumstances
Right person
Right directions & communication
Right supervision and evaluation
13
Q
What are the 7 goals of the National Patient Safety Goals?
A
- Identify patients correctly
- Improve communication among the health care team
- Use medicines safely
- Use alarm systems safely
- Prevent health care-associated infections
- Identify patient safety risks
- Prevent mistakes in surgery
14
Q
What is a sentinel event?
A
A patient safety event unrelated to the patient’s illness or underlying condition that results in death, permanent harm, or severe, temporary harm.
15
Q
What must one have in order to develop cultural competence (4)?
A
Cultural awareness, Cultural knowledge, Cultural skills, & Cultural encounters
16
Q
What is cultural awareness?
A
The ability to understand patient’s unique cultural needs
17
Q
What is cultural knowledge?
A
The process of learning key aspects of a group’s culture, especially as it relates to health and health care practices
- Patient’s are best source of information about their culture
18
Q
What is cultural skill?
A
The ability to collect relevant cultural data
Performance of a cultural assessment
19
Q
What is cultural encounter?
A
The direct cross-cultural interactions between people from culturally diverse backgrounds
Extended contact with a cultural group to enhance understanding of its values and beliefs
20
Q
When are emergency assessments done, and what does it involve?
A
In an emergency or life-threatening situation
Involves a rapid history and examination of a pt. while supporting vital functions
21
Q
What is a focused assessment?
A
An abbreviated health history and examination. Used to evaluate the status of previously identified problems and monitor for S/S of new problems
22
Q
When are comprehensive assessments done, and what does it involve?
A
Typically done on admission to the hospital or onset of care in a primary care setting.
Involves a detailed health history and physical examination of all body systems
23
Q
What is teaching?
A
The act of conveying information to facilitate learning
24
Q
What is learning?
A
The act of acquiring knowledge or skills that may produce a change in behavior
25
Who are caregivers?
People who care for those who cannot care for themselves
26
What are the 7 questions to ask during a caregiver needs assessment?
1. How are you coping with your caregiver role?
2. Do you have any problems performing your caregiver responsibilities?
3. How much support do you get from outside sources (e.g., other family members, friends)?
4. Are you aware of and do you use community resources (e.g., disease-specific professional organizations [such as Alzheimer’s Association, AHA, ACS], adult day care centers, religious/spiritual organizations)?
5. Do you know about resources that are available for respite (someone caring for your loved one while you have time to yourself)?
6. What kind of help or services do you need now and in the near future?
7. How can I or other health care providers help you in your caregiving role?
27
What does the acronym SPEAK UP stand for?
Speak up if you have questions/concerns
Pay attention to the care you get
Educate yourself about your illness
Ask a trusted family member/friend to be your advocate
Know what medicines you take and why
Use a healthcare organization that has been carefully checked out
Participate in all decisions about your treatment
28
What are the 3 zones of the operating room?
Unrestricted, Semi-restricted, & Restricted
29
Who is allowed in the unrestricted area of the OR and what is typically included in this area?
People in street clothes interact with those in scrub attire.
These areas typically include the points of entry for patients, staff, & information
30
What is typically included in the semi-restricted area?
Who is allowed in this area of the OR and what are they supposed to wear?
Includes the surrounding support areas and corridors. Only authorized staff are allowed access to semi-restricted areas. All staff in the semi-restricted area should wear clean surgical attire. This includes scrub attire that was laundered in an accredited laundry facility, long-sleeved jacket, shoes dedicated for surgery use or shoe covers, surgical head cover that covers all head and facial hair, and any appropriate personal protective equipment (e.g., face shield).
31
Where is the restricted area located, and what does it include?
Found within the semi-restricted area. It includes the OR or surgical suite where the procedure takes place and the sterile core.
32
Who is part of the surgical team?
Perioperative nurse, Circulating nurse, Scrub nurse, LPN/VN, Surgical technologist, Surgeon and Assistants, Registered nurse first assistant, & Anesthesia care provider
33
What is the role of the scrub nurse?
Sterile
Follows the designated surgical hand antisepsis with sterile glove and gown attire. They prepare and manage the sterile field and instrumentation.
34
What is the role of the circulating nurse?
Unsterile
Stays in the unsterile field, facilitates the progress of the procedure, and keeps documentation.
35
What are the principles of aseptic technique in the OR?
* All materials that enter the sterile field must be sterile.
* If a sterile item comes in contact with an unsterile item, it is contaminated.
* Contaminated items are removed at once from the sterile field. If the unsterile item is small (e.g., unopened suture), once it is removed, the area is marked off (i.e., covered with a sterile drape). If the entire field is contaminated, it should be set up again with all new materials.
* The surgical team working in the operative field must wear sterile gowns and gloves. Once dressed for procedure, they must recognize that the only parts of the gown considered sterile are the front from chest to table level and sleeves to 2 inches above elbow.
* A wide margin of safety is maintained between sterile and unsterile fields.
* Tables are sterile only at tabletop level. Items extending beneath this level are contaminated.
* The edges of a sterile package are contaminated once the package has been opened. If a sterile package (e.g., package of sutures) is placed on the sterile field, that entire package stays sterile even when opened.
* Microorganisms travel on airborne particles and will enter the sterile field with excessive air movements and currents.
* Microorganisms travel by capillary action through moist fabrics, resulting in contamination.
* Microorganisms on the patient’s and team members’ hair, skin, and respiratory tracts must be confined by proper attire.
36
What effect does general anesthesia have on patients?
* Loss of sensation with loss of consciousness
* Combination of hypnosis, analgesia, and amnesia
* Usually involves use of inhalation agents
* Skeletal muscle relaxation
* Eliminates coughing, gagging, vomiting, and sympathetic nervous system responsiveness
* Requires advanced airway management
37
What effect does local anesthesia have on patients?
* Loss of sensation without loss of consciousness
* Induced topically or via infiltration, intracutaneously, or subcutaneously
* Topical applications may be aerosolized or nebulized
38
What effect does moderate sedation/analgesia have on patients?
* Sedative, anxiolytic, and/or analgesic drugs used
* Does not include use of inhalation agents
* Patient responsive and breathes without assistance
* Not expected to induce level of sedation that would impair patients’ ability to protect their airway
* Most often used for minor therapeutic procedures (e.g., fracture realignment in the emergency department)
39
What effect does monitored anesthesia care have on patients?
* Sedative, anxiolytic, and/or analgesic drugs used
* Does not usually involve inhalation agents
* Patient less responsive and may need airway management
* Gives greatest flexibility to match sedation level to patient needs and procedural requirements
* Often used in conjunction with regional or local anesthesia
* Often used for minor therapeutic and diagnostic procedures (e.g., eye surgery, colonoscopy)
40
What effect does regional anesthesia have on patients?
* Loss of sensation to a region of body without loss of consciousness
* Involves blocking a specific nerve or group of nerves by administering a local anesthetic
* Includes spinal, caudal, and epidural anesthesia and IV and peripheral nerve blocks (e.g., interscalene, axillary, infra-/supra-clavicular, popliteal, femoral, sciatic)
41
What drug class does methohexital belong to?
Barbiturates
- General anesthesia
- IV agents
42
What drug class does etomidate belong to?
Nonbarbiturate hypnotic
- General anesthesia
- IV agents
43
What drug class does propofol belong to?
Nonbarbiturate hypnotic
- General anesthesia
- IV agents
44
What kind of agent is nitrous oxide?
Gaseous agent
- General anesthesia
- Inhalation
45
What kind of drug is desflurane?
Volatile liquids
- General anesthesia
- Inhalation
- Risk of malignant hyperthermia
46
What kind of drug is isoflurane?
Volatile liquids
- General anesthesia
- Inhalation
- Risk of malignant hyperthermia
47
What kind of drug is sevoflurane?
Volatile liquids
- General anesthesia
- Inhalation
- Risk of malignant hyperthermia
48
What drug class does ondansetron belong to?
Antiemetic
- Adjunct to general anesthesia
49
What drug class does diazepam belong to?
Benzodiazepines
- Adjunct to general anesthesia
50
What drug class does lorazepam belong to?
Benzodiazepines
- Adjunct to general anesthesia
51
What drug class does midazolam belong to?
Benzodiazepines
- Adjunct to general anesthesia
52
What drug class does succinylcholine belong to?
Neuromuscular Blocking Agent
Depolarizing agent
- Adjunct to general anesthesia
53
What drug class does rocuronium belong to?
Neuromuscular Blocking Agent
nondepolarizing agent
- Adjunct to general anesthesia
54
What drug class does hydromorphone belong to?
Opioid
- Adjunct to general anesthesia
55
What type of information should be included in the preoperative pt & caregiver sensory information teaching?
* Preoperative holding area may be noisy
* Drugs and cleaning solutions may be odorous
* Operating room (OR) can be cold. Forced air warming devices may be used. Warm blankets are available
* Talking may be heard but may be distorted because of masks. Ask questions if something is not understood
* OR bed will be narrow. A safety strap will be applied over the thighs
* Lights in the OR may be bright
* Monitoring machines may be heard (e.g., beeping noises) when awake
56
What type of information should be included in the preoperative pt & caregiver procedural information teaching?
* What to bring and what type of clothing to wear to the surgery center
* Any changes in time of surgery
* Fluid and food restrictions
* Physical preparation needed (e.g., shower, bowel, or skin preparation)
* Purpose of frequent vital signs assessment
* Pain control and other comfort measures
* Why turning, deep breathing, and coughing after surgery are important. Do practice sessions
* Insertion of IV lines
* Procedure for anesthesia administration
* Surgical site may be marked with indelible ink or marker
57
What type of information should be included in the preoperative pt & caregiver process information about the general flow of surgery teaching?
* Admission area
* Preoperative holding area, OR, and postanesthesia care unit (PACU)
* Caregivers can usually stay in preoperative holding area until surgery
* Caregivers will be able to see patient after discharge from the PACU or possibly in PACU once the patient is awake
* Any technology that may be present on awakening, such as monitors, central lines, intermittent pneumatic compression devices
58
What type of information should be included in the preoperative pt & caregiver 'where caregivers can wait during surgery' teaching?
* Encourage caregivers to ask questions and express any concerns
* OR staff will update caregivers during surgery and when surgery is over
* Surgeon will usually talk with caregivers after surgery
59
What type of information is included in general surgery information teaching?
All patients should receive instruction about deep breathing, coughing, and early ambulation.
60
What is the time-out procedure?
A safety procedure in medical settings that ensures all team members confirm patient identity, procedure, and other critical factors before commencing surgery.
61
What is informed consent, and who can obtain it?
An active, shared decision-making process between the HCP and the recipient of care.
The surgeon
62
What 3 conditions must be met for consent to be valid?
1. There must be adequate disclosure of the (1) diagnosis; (2) nature and purpose of the proposed treatment; (3) risks and consequences of the proposed treatment; (4) probability of a successful outcome; (5) availability, benefits, and risks of alternative treatments; and (6) prognosis if treatment is not instituted.
2. The patient must show a clear understanding of the information before receiving sedating preoperative drugs. If a patient is sedated prior to signing the consent, surgery may be canceled or delayed.
3. The patient must give consent voluntarily. The patient must not be persuaded or coerced in any way by anyone to undergo the procedure.
63
What are the overall goals of preoperative assessments?
- Establish baseline
- Determine pt psychologic status
- Determine physiologic factors
- Participate in identification & documentation of surgical site
- Identify prescription drugs, OTC, & herbs taken
- Review results of preoperative diagnostic studies
- Identify cultural and ethnic factors
- Determine if pt. received adequate information from the surgeon to make informed decision
64
What are some common preoperative agents?
Antibiotics, Anticholinergics (atropine & scopolamine), Antidiabetics, Antiemetics, Benzodiazepines, Beta Blockers, H2 Antagonists, & Opioids
65
What are some Gerontologic Considerations for preoperative nursing care?
Medical history: often have multiple chronic conditions
Medication: often on multiple medications
Functional status: assess pt ability to perform ADLs to id potential needs for assistance
Cognitive function: Impairment can affect pt's ability to understand instruction
Nutritional status: Malnutrition can increase complication risk
66
What are some Gerontologic Considerations for postoperative nursing care?
Increased risk for complications (pneumonia, delirium, & cardiac event) so encourage early ambulation to decrease risk
May have altered pain perception & metabolism
Implement fall precautions
Have thinner skin, which increases risk for pressure injury
67
What is included in a nurse's PACU assessment? What should be assessed first?
Airway, Breathing, Circulation, Neurologic, Surgical site, Genitourinary, Gastrointestinal, Pain, & Pt. safety needs
Airway should be assessed first
68
What should be included in pt. & caregiver surgical discharge teaching?
* Symptoms to report (e.g., discomfort in other parts of the body, fever, increased incisional pain, swelling, redness, bleeding, drainage)
* When and how to take prescribed drugs and possible side effects (reinforce education regarding multimodal pain control)
* Care of wound, incision, drain (e.g., dressing change)
* Personal hygiene and showering recommendations
* Activities allowed and prohibited, when various activities can be resumed safely (e.g., driving, return to work, sexual intercourse, leisure activities, lifting restrictions)
* Diet restrictions or modifications
* Where and when to return for follow-up appointment
* Answers to any questions or concerns
* Who and what phone number to call to report symptoms, ask additional questions, and address concerns after discharge
69
What is the only solution that blood products can be mixed with?
Normal saline (0.9% sodium chloride)
70
What is the goal of the nursing pain assessment? (2)
The goals of a nursing pain assessment are to (1) describe the patient’s pain experience in order to implement appropriate pain management techniques and (2) identify the patient’s goal for therapy and resources for self-management.
71
What do most components of a pain assessment involve?
Direct interview or patient observation.
72
What does the pain scale FLACC look at and what type of pt. is it used on?
Facial expression Leg movement Activity Crying Consolability; Young children.
73
What type of pt. is the PAINAD pain scale used on?
Those with advanced dementia (scale similar to FLACC)
74
What type of pt. is the CPOT pain scale used on?
Pt. in the critical care unit (scale similar to FLACC)
75
Which condition would the nurse suspect when the postoperative patient exhibits muscle rigidity, blood pressure of 170/90, and temperature 104.5°F immediately after surgery?
Malignant hyperthermia
76
What drug is used to treat malignant hyperthermia?
Dantrolene
77
Which instruction would the nurse include in the discharge plan for a patient who experienced malignant hyperthermia during surgery?
Consider genetic testing
78
Which assessment finding would the nurse expect to document in the chart if a patient exhibits signs of malignant hyperthermia?
Muscle contracture
79
What is malignant hyperthermia?
A life-threatening condition triggered by certain anesthetics, characterized by a rapid increase in body temperature and severe muscle contractions.
80
What are some symptoms of malignant hyperthermia?
Include a rise in body temperature, muscle rigidity, tachycardia, and metabolic acidosis.
81
What are some preventative measures for malignant hyperthermia?
Involves screening patients for family history and genetic testing, and using alternative anesthetic techniques when necessary.
82
What are the 9 principles of pain assessment?
1. Patients have the right to appropriate assessment and management of pain
2. Pain is always subjective
3. Physiologic and behavior signs of pain are not reliable or specific for pain
4. Pain is an unpleasant sensory and emotional experience
5. Assessment approaches, including tools, must be appropriate for the patient population
6. Pain can exist even when no physical cause can be found
7. Different patients have different levels of pain in response to comparable stimuli
8. Patients with chronic pain may be more sensitive to pain and other stimuli
9. Unrelieved pain has adverse consequences. Acute pain that is not adequately controlled can result in physiologic changes that increase the chances of developing persistent pain
83
What type of drug therapy is acetaminophen?
Nonopioid analgesics
Nonsalicylates
84
What type of drug therapy is celecoxib?
Nonopioid analgesics
NSAID
85
What type of drug therapy is ibuprofen?
Nonopioid analgesics
NSAID
86
What type of drug therapy is naproxen?
Nonopioid analgesics
NSAID
87
What type of drug therapy is oxycodone?
Opioid analgesics
Mu Agonists
88
What is patient-controlled analgesia?
A method that allows the patient to self-administer preset doses of an analgesic within a prescribed time period by activating an infusion pump.
89
What are the 3 functions of the immune system?
1. Defense: The body protects against invasions by microorganisms and prevents the development of infection by attacking foreign antigens and pathogens.
2. Homeostasis: Damaged cellular substances are digested and removed. Through this mechanism, the body’s different cell types stay uniform and unchanged.
3. Surveillance: Mutations continually arise. They are recognized as foreign cells and destroyed.
90
What are the 2 types of immunity?
Innate/natural immunity
Acquired immunity
- Active acquired immunity
- Passive acquired immunity
91
What is active natural immunity?
Natural contact with antigen through actual infection (e.g., chickenpox, measles, mumps)
92
What is passive natural immunity?
Transplacental and colostrum transfer from mother to child (e.g., maternal immunoglobulins passed to baby)
93
What is active artificial immunity?
Immunization with antigen (e.g., vaccines for chickenpox, measles, mumps)
94
What is passive artificial immunity?
Injection of serum with antibodies from 1 person (e.g., injection of hepatitis B immune globulin) to another person who does not have antibodies
95
What is immunocompetence?
Exists when the body’s immune system can identify and inactivate or destroy foreign substances.
96
What is autoimmune disease?
A type of hypersensitivity response occurs when the body does not recognize self-proteins and reacts against self-antigens.
97
What are hypersensitivity reactions?
Immune response is overreactive against foreign antigens or reacts against its own tissue, resulting in tissue damage.
98
What is anaphylaxis?
Occur when mediators are released systemically. The reaction occurs within minutes. It can be life-threatening because of bronchial constriction and subsequent airway obstruction and vascular collapse
99
What is inflammatory response?
A sequential reaction to cell injury.
Some use the term inflammation incorrectly as a synonym for infection
Inflammation is always present with infection, but infection is not always present with inflammation.
100
What are standard precautions?
Precautions used for care of all patients, regardless of diagnosis or presumed infection status
Includes the use of hand washing and appropriate PPE
101
What are transmission-based precautions?
Precautions designed for specific diseases
- Airborne
- Droplet
- Contact
102
What are airborne precautions?
Used for infections spread in small particles in the air, such as chickenpox (varicella), measles, TB
- Gown, N95 mask, Goggles, Gloves, & Negative pressure room
103
What are droplet precautions?
Used for infections spread in large droplets by coughing, talking, or sneezing, such as influenza and bacterial meningitis
- Gown, Mask, Goggles, & Gloves
104
What are contact precautions?
Used for infections spread by skin-to-skin contact or contact with other surfaces, such as C. difficile, MRSA, and VRE
- Gown & Gloves
105
What are health care-associated infections (HAIs)?
Infections that are acquired because of exposure to microorganisms in a health care setting.
106
What are the 4 types of hypersensitivity reactions?
Type I: IgE-Mediated
Type II: Cytotoxic
Type III: Immune-Complex
Type IV: Delayed Hypersensitivity
107
What are the antigens, rate of development, & mediators of injury for Type I hypersensitivity reactions?
Antigen: pollen, food, drugs, & dust
Rate: Immediate
Mediators: Histamine, Leukotrienes, Mast cells, & Prostaglandins
108
What are the antigens, rate of development, & mediators of injury for Type II hypersensitivity reactions?
Antigen: Cell surface of RBCs & Cell basement membrane
Rate: Minutes to hours
Mediators: Complement lysis & Macrophages in tissues
109
What are the antigens, rate of development, & mediators of injury for Type III hypersensitivity reactions?
Antigen: Extracellular fungal, viral, & bacterial
Rate: Hours to days
Mediators: Complement lysis, Lysosomal enzymes, Monocytes, macrophages, & Neutrophils
110
What are the antigens, rate of development, & mediators of injury for Type IV hypersensitivity reactions?
Antigen: Intracellular or Extracellular
Rate: Several days
Mediators: Cytokines & T cytotoxic cells
111
What is transplant rejection?
A reaction that occurs as a normal immune response to foreign tissue. Immunosuppression therapy, performing ABO and HLA matching, and ensuring that the crossmatch is negative reduces the risk of rejection.
112
When does hyperacute rejection occur?
Within 24 hours after transplantation
113
When does acute rejection occur?
In the first 6 months after transplantation
114
What is chronic rejection?
A process that occurs over months or years and is irreversible.
Can occur for unknown reasons or from repeated episodes of acute rejection.
115
What are some kinds of neurological post-op complications?
Emergence delirium, delayed emergence, postoperative cognitive dysfunction (POCD), & alcohol withdrawal delirium
116
What are some kinds of respiratory post-op complications?
Airway obstruction (tongue falls backward against the soft palate & block pharynx), aspiration, atelectasis, hypoxemia, pneumonia, & pulmonary embolus
117
What is an atelectasis?
A collapsed lung(s)
118
What is one of the best ways to avoid post-op complications?
Closely monitoring the pt.
119
What are some kinds of gastrointestinal post-op complications?
N/V, paralytic ileus, electrolyte imbalance, constipation (d/t opioid), gas, & nasogastric tube
120
What is hypovolemic shock?
a condition that occurs when the body loses a significant amount of blood or fluid, leading to decreased perfusion and oxygen delivery to tissues. (the plasma/fluid is too low)
121
What is the best way to prevent post-op GI complications?
Get the pt. up and moving early
122
What are some kinds of urinary post-op complications?
Urinary retention, Acute kidney injury, & catheter-associated urinary tract infection (CAUTI)
123
What are some kinds of cardiovascular post-op complications?
Hypotension, Hypertension, dysrhythmias, hypovolemic shock, & venous thromboembolism
124
What kind of labs need to be monitored to prevent post-op cardiovascular complications?
Potassium, BUN/creatinine, Magnesium, & Hgb/Hct
125
What are some kinds of integumentary post-op complications?
Infection, dehiscence, & evisceration
126
Which benefit would the nurse describe to a postoperative patient as the most important reason for early ambulation in the postoperative period?
"It is the best way to prevent complications"
127
List three complications of wound healing.
* Adhesions
* Contractions
* Dehiscence
## Footnote
These complications can affect recovery and may require additional interventions.
128
What is evisceration in the context of wound healing?
Evisceration refers to the protrusion of internal organs through a wound.
129
What is dehiscence in the context of wound healing?
The rupture or splitting open of a wound, incision, or surgical site.
130
A surgical unit’s quality improvement committee notes the number of new catheter-associated urinary tract infections (CAUTIs) increased over the past 6 months. The nurse understands that this means:
a. There is CAUTI pandemic on the unit.
b. There is a need to review unit practices.
c. Droplet precautions are needed to prevent CAUTIs.
d. The prevalence of antibiotic resistant CAUTI infections is decreasing.
b. There is a need to review unit practices.
131
Factors associated with an increase in reemerging infections include (select all that apply)
a. international travel.
b. poor immunization rates.
c. poor sanitation standards.
d. not completing a full course of antibiotics.
e. correct use of personal protective equipment.
a. international travel.
b. poor immunization rates.
c. poor sanitation standards.
d. not completing a full course of antibiotics.
132
Interventions to prevent health care–associated infections include (select all that apply)
a. following hand-washing protocols.
b. limiting visitors to persons over age 18.
c. giving all patients prophylactic antibiotics.
d. placing all patients on contact precautions.
e. decontaminating equipment used for patient care.
a. following hand-washing protocols.
e. decontaminating equipment used for patient care.
133
When working with a patient who has suspected tuberculosis, the nurse would
a. wear a cloth mask.
b. only use standard precautions.
c. place the patient on airborne precautions.
d. wear a new gown each time they enter the room.
c. place the patient on airborne precautions.
134
Which factors place the patient at increased risk for severe COVID-19? (select all that apply)
a. Obesity
b. Thyroid disease
c. Cigarette smoking
d. Pernicious anemia
e. Chronic kidney disease
a. Obesity
c. Cigarette smoking
e. Chronic kidney disease
135
The patient asks the nurse why they need viral load testing. The nurse responds that an undetectable HIV viral load (select all that apply)
a. is the goal of HIV therapy.
b. occurs with drug resistance.
c. is a sign of disease progression.
d. means that person is cured of HIV.
e. means that someone is unable to sexually transmit HIV.
a. is the goal of HIV therapy.
e. means that someone is unable to sexually transmit HIV.
136
A basic principle to consider when planning treatment for HIV is
a. stimulating the immune system to increase viral load.
b. using a combination of drugs from more than one class.
c. suppressing the replication of virus by decreasing the CD4+ count.
d. encouraging patients to use natural supplements, such as St. John’s Wort.
b. using a combination of drugs from more than one class.
137
Opportunistic diseases in HIV infection
a. are usually benign.
b. are slow to develop and progress.
c. occur in the presence of immunosuppression.
d. are curable with appropriate drug interventions.
c. occur in the presence of immunosuppression.
138
The nurse caring for a patient with HIV who has been on ART for many years plans care with the knowledge that the patient
a. will inevitably develop drug resistance.
b. is less likely to develop problems such as hyperlipidemia.
c. is more likely to require treatment of opportunistic infections.
d. can develop other chronic conditions at an earlier age than someone without HIV.
d. can develop other chronic conditions at an earlier age than someone without HIV.
139
What is the most appropriate nursing intervention to help patients with HIV adhere to their treatment plan?
a. Set up a drug pillbox for the patient every week.
b. Give the patient a video and a brochure to view and read at home.
c. Tell the patient that side effects of ART are bad but that they go away.
d. Assess the patient’s routines and find adherence cues that fit into their life circumstances.
d. Assess the patient’s routines and find adherence cues that fit into their life circumstances.
140
When does Infection occur?
When a pathogen (a microorganism that causes disease) invades the body, multiplies, and causes disease, usually causing harm to the host. The signs and symptoms of infection are a result of specific pathogen activity, which triggers inflammation and other immune responses.
141
Which actions would the nurse prioritize when admitting a patient to the PACU?
a. Assess the surgical site, noting presence and character of drainage.
b. Assess the amount of urine output and the presence of bladder distention.
c. Assess for airway patency and quality of respirations and obtain vital signs.
d. Review results of intraoperative laboratory values and medications received.
c. Assess for airway patency and quality of respirations and obtain vital signs.
142
A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse, “I think I am going to throw up.” Which is the priority intervention?
a. Increase the rate of the IV fluids.
b. Give antiemetic medication as ordered.
c. Obtain vital signs, including O2 saturation.
d. Position patient in lateral recovery position.
d. Position patient in lateral recovery position.
143
After admitting a postoperative patient to the clinical unit, which assessment data require attention first?
a. O2 saturation of 85%
b. Respiratory rate of 13/min
c. Temperature of 100.4°F (38°C)
d. Blood pressure of 90/60 mm Hg
a. O2 saturation of 85%
144
A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. Which interventions would the nurse prioritize? (Select all that apply.)
a. Obtain a bladder ultrasound scan.
b. Perform a straight catheterization.
c. Continue to monitor this normal finding.
d. Evaluate the patient’s fluid volume status.
a. Obtain a bladder ultrasound scan.
d. Evaluate the patient’s fluid volume status.
145
Which factors would the nurse include in discharge criteria for a Phase II patient? (select all that apply)
a. Nausea and vomiting controlled.
b. Ability to drive themselves home.
c. No respiratory depression present.
d. Written discharge instructions understood.
e. Opioid pain medication given 45 minutes ago.
a. Nausea and vomiting controlled.
c. No respiratory depression present.
d. Written discharge instructions understood.
e. Opioid pain medication given 45 minutes ago.
