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Nursing Fundamentals > Exam 1-Skills > Flashcards

Exam 1-Skills Flashcards

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1
Q

Subjective Data

A

symptoms/ what patient is feeling

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2
Q

Objective Data

A

Nurse gathers/can see

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3
Q

A Patient is what source of data?

A

Primary source

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4
Q

Support People (family/ friends) is what source of data?

A

Secondary source

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5
Q

Other healthcare professionals are what source of data?

A

Secondary source

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6
Q

Observation is using what data collection method?

A

Senses

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7
Q

What are the 4 types of nursing assessment and what are examples of each?

A
  1. Initial
    (general doc visit)
  2. Focused-
    (focused on problem)
  3. Emergency-
    (wound treated 1st)
  4. Time lapsed-
    (issue happened months ago)
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8
Q

Ways problems can occur r/t data collection?

A

-co worker forgets to tell you
-duplicated data
-misinterpreted data
-no trust
-recording as data rather than observed behavior

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9
Q

Validating

A

double checking/ verifying

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10
Q

Inspection

A

purposeful observation

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11
Q

Palpation

A

the act of using the sense of touch

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12
Q

Percussion

A

the act of striking one object against another to produce a sound

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13
Q

Auscultation

A

the act of listening with a stethoscope to sounds within the body

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14
Q

When assessing the skin assess for:

A

-color
-moisture
-temperature
-texture
-turgor
-vascularity
-Edema/swelling
-Lesions

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15
Q

Pallor

A

reduction in tissue breakdown

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16
Q

Turgor

A

elasticity/measure of hydration

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17
Q

Pitting edema leaves indentation:

A

+1 = 2mm
+2 = 4mm
+3 = 6mm
+4 = 8mm

round up if in between

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18
Q

Inspect lesions for:

A

-color
-location
-texture
-size
-shape
-distribution
-exudate/drainage

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19
Q

When assessing hair inspect for:

A

-even distribution
-thickness
-texture

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20
Q

When assessing nails inspect for:

A

-nail bed color (pink)
-tissue around nails (intact)
-angle between nail and nail bed (160*)
-Texture
-capillary refill (<3 sec.)

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21
Q

Inspect skull for:

A

-size
-shape
-symmetry
-Nodules
-Masses
-lesions

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22
Q

Inspect nose for:

A

-position
-symmetry
-nasal flaring

Palpate for:
-Pain
-tenderness
-swelling

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23
Q

Inspect frontal & maxillary sinuses for:

A

-periorbital edema
-dark circles under eyes

Palpate with thumbs for:
Tenderness

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24
Q

Angioedema

A

a dermal, subcutaneous or submucosal swelling that is acute, painless and of short duration

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25
Q

Conjunctiva

A

Normal:
-shiny
-smooth
-pink/light red

Abnormal:
-extremely pale
-extremely red

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26
Q

Normal Pupil

A

-black
-equal 3-7mm in diameter

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27
Q

PERRLA

A

Pupils equally round and react to light and accommodation

*determines function of 3rd (oculomotor) & 4th (troclear) cranial nerves

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28
Q

Cataracts

A

-Opacity or clouding of lens
-blurry vision
-glare when driving
-double vision

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29
Q

Glaucoma

A

-increased intraocular pressure
-loss of peripheral vision
-halo’s around lights

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30
Q

20/40

A

20 top number is the distance from the chart; ALWAYS THE SAME

bottom number is the distance from which the normal eye can read the chart

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31
Q

Normal tympanic membrane

A

-shiny
-pearly gray
-intact

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32
Q

Cerumen

A

ear wax

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33
Q

Conductive hearing loss

A

-tear in the tympanic membrane
-obstruction
-swelling in the auditory canal

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34
Q

Sensorineural hearing loss

A

-damage to the inner ear
-damage to the auditory nerve
-damage to the hearing center in the brain

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35
Q

Weber Assessment

A

Evaluates bone conduction

+ = sound heard better in one ear
- = sound heard equally in both ears

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36
Q

Rinne Assessment

A

Compares air conduction with bone conduction

*patient should hear the air conducted tone for twice as long as the bone conducted tone

+ = AC>BC
- = BC >AC or BC = AC

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37
Q

Motor Function

A

-Muscle size
-tone
-strength
-movement

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38
Q

Cerebellar Function

A

-balance
-coordination

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39
Q

Gait

A

-walk

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40
Q

Grading Muscle strength

A

5/5= 100% Normal
4/5= 75% Good
3/5= 50% Fair
2/5= 25% Poor
1/5= 10% Trace
0/5= 0% Zero

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41
Q

Common Blood-borne Pathogens

A

Hepatitis B&C
HIV

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42
Q

Antiseptic Hand Rub

A

reduce # of microorganisms present

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43
Q

Alcohol based hand rub

A

decreases viable organisms

44
Q

Antimicrobial soap

A

decrease # of microbial flora

45
Q

Use soap and water when….

A

visibly soiled, before you eat and go home

46
Q

Standard Precautions

A

-guidelines recommend by the CDC
-used in the care of all patients regaurdless of their diagnosis

Use when:
-blood
-bodily fluids
-non intact skin
-mucous membranes

47
Q

Order of PPE on:

A

-gown
-mask
-eye protection
-gloves

48
Q

Order of PPE off:

A

-gloves
-eye protection
-gown
-mask

49
Q

PAPR

A

Powered Air Purifying Respirator

Used when:
-N95 does not fit
-facial hair

50
Q

Airborne Precautions

A

Respiator

51
Q

Droplet Precautions

A

Mask 3 ft of patient

52
Q

Contact Precautions

A

Gown, gloves, facial protection when appropriate

53
Q

Medical Asepsis

A

Clean technique

54
Q

Surgical Asepsis

A

Sterile Technique

55
Q

Medical Asepsis or Surgical Asepsis?

Rectal Temperature

A

Medical

56
Q

Medical Asepsis or Surgical Asepsis?

Foley Insertion in hospital

A

Surgical

57
Q

Medical Asepsis or Surgical Asepsis?

Foley Insertion at Home

A

Medical

58
Q

Medical Asepsis or Surgical Asepsis?

IV Insertion

A

Sterile

59
Q

Medical Asepsis or Surgical Asepsis?

Dressings

A

Depends on dressings

60
Q

Medical Asepsis or Surgical Asepsis?

IM injections

A

Sterile

61
Q

Medical Asepsis or Surgical Asepsis?

NG insertions

A

medical

(don’t sterilize the food we eat)

62
Q

What would you do if sterile technique has been broken?

A

Start over

63
Q

Sterile Field

A

a area free of microorganisms

64
Q

A person or animal that harbors a specific infectious agent and serves as a potential source of infection yet does not manifest any clinical signs of the disease is a ________.

A

-Carrier

65
Q

Fomites

A

non living objects

66
Q

Which precaution should be implemented when there are clients with wound infections?

A

Contact Precautions

67
Q

Erythema

A

Redness

68
Q

Ecchymosis/ ecchymotic

A

bruising

69
Q

Hematoma

A

collection of blood

70
Q

Exudate

A

Drainage

71
Q

Serous

A

clear/watery

72
Q

Sanguineous

A

blood/red

73
Q

Serosanguineous

A

Pink

74
Q

Purulent

A

Pus

75
Q

Approximated

A

closed tissue surfaces

76
Q

Dehiscence

A

splitting of wound

77
Q

Evisceration

A

Splitting of wound and can see organs coming out

78
Q

What to do if Dehiscence/evisceration happens?

A

-Sterile dressing soaked with saline
-Steri strips
-Call doctor

79
Q

Slough

A

Yellow, narcrotic

80
Q

Necrosis

A

black/dead

81
Q

Wound Debridement

A

Removal of necrotic, non-viable tissue, pressure ulcers, burns and other wounds

82
Q

4 Methods of Debridement

A

-Sharp or scalpel- surgical removal
-Mechanical- scrubbing force/wet to dry
-Chemical- enzymes & other compounds to dissolve necrotic tissue
-Autolytic-transparent dressing-body is able to dissolve dead tissue

83
Q

Granulation

A

red, bumpy tissue in the wound bed as the wound heals

84
Q

Ischemia

A

reduced blood flow

85
Q

Abrasion

A

a scrape

86
Q

Laceration

A

a deep cut or tear in skin

87
Q

Sepsis

A

the body responds improperly to an infection

88
Q

Asepsis

A

the absence of bacteria, viruses, and other microorganisms.

89
Q

Nosocomial Infection

A

infection(s) acquired during the process of receiving health care that was not present during the time of admission

90
Q

Vehicle

A

occurs when a substance, such as soil, water, or air, carries an infectious agent to a new host.

91
Q

Vector

A

mosquitoes and ticks

92
Q

Olfactory

A

smell

93
Q

Hypoglossal

A

nerve function is to control the muscles of the tongue

94
Q

Vagus Nerve

A

one of 12 cranial nerves in the body. It’s responsible for various bodily functions, including digestion, heart rate, and breathing

95
Q

Trochlear Nerve

A

controls the superior oblique muscle in your eye

96
Q

Accessory Nerve

A

essential for neck and shoulder movement

97
Q

Myopia

A

nearsightedness

98
Q

Astigmatism

A

front surface of the eye or the lens, inside the eye, is curved differently in one direction than the other

Blurry vision

99
Q

Normacephalic

A

a person whose head and all major organs of the head are in a normal condition and without significant abnormalities

100
Q

Glossitis

A

inflammation of the tongue

101
Q

Sims

A

lying on the left side, left hip and lower extremity straight, and right hip and knee bent.

102
Q

Fowlers

A

The bed angle is between 45 degrees and 60 degrees

sitting position

103
Q

Lithotomy

A

a supine position of the body with the legs separated, flexed, and supported in raised stirrups, originally used for lithotomy and later also for childbirth.

104
Q

Prone

A

person lies flat with the chest down and the back up

105
Q
A

Nursing Fundamentals (12 decks)

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