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N388 > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

Prioritization falls under what step of the nursing process?

A

planning

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2
Q

what is priority setting based on?

A

urgency
patient safety
patient needs

ABCs

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3
Q

what to think about when establishing priorities

A

“if left untreated, will result in harm”
threats to life and limb (ABCs, safety, acute pain)

high priority problems are not always physiologic problems

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4
Q

ABCs

A

airways
breathing
circulation

in this specific order

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5
Q

intermediate priority

A

non-emergent and non-life threatening

risk of infection

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6
Q

low-priority

A

future or long term health needs

education

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7
Q

HAIs require…

A

source
route
susceptible host

Healthcare Associated Infections

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8
Q

Tier 1

Standard Precautions

A

used for all patients

hand hygiene
gloves
environmental disinfection 
sharps safety
cough/respiratory etiquette
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9
Q

Second Tier

A

for patients who are infected or colonized with specific infections

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10
Q

what are the 3 most common modes of transmission?

A

contact
droplet
airborne

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11
Q

contact

A

most common
direct - sharps/needle
indirect - contaminated environment, c. diff

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12
Q

droplet

A

respiratory secretions; stay close, on surface; within 3 feet of patient; larger organisms

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13
Q

airborne

A

respiratory secretions; smaller, can be carried on air current, beyond 3 feet

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14
Q

Personal Protective Equipment (PPE)

A

refers to a variety of barriers and respirators used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents

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15
Q

What does PPE include?

A

Gloves – protect hands
Gowns/aprons – protect skin and/or clothing
Masks and respirators– protect mouth/nose
Respirators – protect respiratory tract from airborne infectious agents
Goggles – protect eyes
Face shields – protect face, mouth, nose, and eyes

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16
Q

Gowns are always worn with gloves? T or F

A

True

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17
Q

Contact precautions include what illnesses

A

c. diff, MRSA, herpes, scabies, varicella / shingles

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18
Q

PPE for contact precautions

A

Gown/gloves for all direct contact

Visitors may be asked to don PPE in a health care setting

OK for patients in contact precautions to leave room “if infectious material/location is contained or covered”, clean gown/clean hands

Disposable or dedicated medical equipment if possible (BP cuff for example)

If medical equipment must be shared, disinfect per institutional protocol (disinfectants may be specific for organisms)

Environmental cleaning/disinfecting important!

check hospital policy

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19
Q

droplet precautions illnesses

A

Diphtheria, rubella, streptococcal throat infection or pneumonia, meningoccal infections, pertussis, influenza

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20
Q

droplet precautions PPE

A

mask/goggles

Single patient room preferred in hospitals and long term care settings (if possible); clinics – patients should be placed in a separate area.

OK for patients to leave their room but patients need to wear a mask (if tolerated); respiratory hygiene

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21
Q

Airborne precaution illnesses

A

rubeola virus [measles], varicella virus [chickenpox], M. tuberculosis, and possibly SARS-CoV

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22
Q

airborne precaution PPE

A

N95 mask

Airborne infection isolation room (AIIR) single patient room (negative air flow). Room door remains closed.

HCWs wear an N 95 respirator (donned prior to room entry and removed after exiting patient room) (CDC)

Pt transport off unit? If allowed (medically necessary) , pt. wears surgical mask

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23
Q

what is a focused assessment?

A 
problem based - actual or at-risk problems
individualized 
may be conducted more frequently 
can extend to related systems 
can extend to psychosocial
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24
Q

when to do a focused assessment?

A 
clues from patient/family members
unexpected findings in standard assessment
policy (after an event)
presenting problem
nursing knowledge/expertise
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25
Q

OLDCARTS

A 
onset
location 
duration 
characteristics 
aggravating factors
relieving factors 
timing 
severity
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26
Q

breath sounds - crackles

A

Fine or coarse, crackling sound, most often heard on inspiration

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27
Q

breath sounds - rhonchi

A

Coarse, snoring sound inspiration, expiration, or both (larger airways)

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28
Q

breath sounds - wheezes

A

High pitched sounds heard on inspiration, expiration, or both (smaller airways)

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29
Q

what are nursing interventions to promote oxygenation?

A

positioning
ambulation
incentive spirometry
coughing & deep breathing

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30
Q

what are some reasons someone night need oxygen?

A

shortness of breath
hyperventilating
COPD
fatigue

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31
Q

signs for assessing oxygenation

A 
Respiratory rate
breath sounds
use of accessory muscles
color
patient complaints
mental state, alertness 
pulse oximeter
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32
Q

How much oxygen is person breathing room air receiving?

A

21%

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33
Q

when do you use humidity for oxygen

A

at 3/4 liters

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34
Q

when do you switch from a nasal cannula to a simple mask?

A

5/6 liters

35
Q

how much O2 does a simple face mask deliver?

A

40-60%

36
Q

what is so special about the Venturi face mask?

A

you can be specific with the amount of oxygen delivered

37
Q

true or false - the bag needs to be inflated for a partial rebreathing face mask

A

true

38
Q

how much O2 does a partial rebreather deliver?

A

40-60%

39
Q

what is the flow rate for a partial rebreather?

A

6-10 L

40
Q

how much O2 does a non-rebreather deliver?

A

60-100%

41
Q

what is the flow rate for a non-rebreather?

A

10-15 L

42
Q

how much O2 does a face tent/shield deliver?

A

30-40%

43
Q

what is the flow rate for a face tent/shield?

A

4-8 L

44
Q

what systems are affected by nutritional status?

A 
neurological
gastrointestinal
musculoskeletal 
cardiovascular 
HEENT
integumentary
45
Q

what are some factors influencing nutrition?

A 
environment
developmental
cultural/religious 
personal preferences 
abilities 
social factors 
age
46
Q

what is the typical progression for ‘advance as tolerated’ diet

A

clear liquid - fill liquid - regular diet

47
Q

what is dysphagia?

A

difficulty swallowing

48
Q

how long is the urethra in females

A

approx. 1.5 inches

49
Q

how long is the urethra in males

A

approx. 7-9 inches

50
Q

urinary retention

A

a person’s inability to empty the bladder

51
Q

true or false: a urinary catheter requires an order

A

true

52
Q

reasons for an indwelling catheter

A 
acute urinary retention or obstruction
a need for accurate urinary measurements
heal open wounds
prolonged immobilization 
long surgery
53
Q

what is the highest risk factor for a CAUTI

A

prolonged use

54
Q

causes of CAUTI

A 
female (shorter urethra)
duration 
older adults
bacterial colonization in the collection bag
non-sterile environment
diabetes
55
Q

when using a sterile environment when would you have to start over?

A

sterile to non-sterile

56
Q

you advance the catheter until….

A

you see urine

57
Q

after you see urine you advance the catheter…..

A

1 to 2 more inches

58
Q

signs of a UTI

A

increased temp, HR, RR
blood in urine, cloudiness, sediment, odor
increase in WBC count

59
Q

hematuria

A

presence of blood in urine

60
Q

dysuria

A

pain or discomfort when urinating

61
Q

factors that contribute to skin integrity

A 
age
mobility 
continence 
nutrition 
edema 
sensory deficites 
altered mental status
62
Q

abrasion

A

scrape, friction against skin, scratching

63
Q

laceration

A

clean cut

64
Q

ulceration

A

eroding skin, lower extremities, think when you bite the inside of your mouth

65
Q

fissure

A

crack or small tear, cracks on the side of your mouth

66
Q

incision

A

surgical

67
Q

skin tear

A

caused by shearing

68
Q

therapeutic diets

A

Nutrient Modifications (Sodium, Fiber, Fat, Cholesterol, Protein, Sugar)
Texture Modifications (Mechanical Soft, Puree, Dysphagia)
Allergy or Intolerance Modifications (Nut, Dairy, Gluten)
Mode of Delivery (Oral, Enteral, Parenteral)

69
Q

advanced as tolerated

A

clear liquid - full liquid - regular diet

70
Q

dysphagia diet

A

level 1 - pureed (pudding like)
level 2 - mechanically altered
level 3 - advanced - nearly all textures except hard, sticky or crunchy
level 4 - regular

71
Q

safety measures for diet

A 
position 
limit distractions
alertness
allow adequate time 
small bites of food 
foster independence
72
Q

why do people take medications?

A 
Treat, cure, manage an illness
Preventative 
Reduce symptoms 
Quality of life 
Help diagnose an illness
73
Q

rights of medication administration

A 
medication
patient
dose
time 
route
documentation
education
assessment
evaluation
right to refuse
74
Q

non-parenteral routes of administration

A 
Oral  (PO)
Sublingual 
Buccal 
Otic 
Ophthalmic
Nasal 
Vaginal  
Rectal
Topical (transdermal) 
Inhalation
75
Q

parenteral routes of administration

A

Intramuscular
Subcutaneous
Intradermal
Intravenous

76
Q

how many checks when administering medication?

A

3

77
Q

necrotic slough

A

yellow, tan, white

78
Q

necrotic eschar

A

black

79
Q

granulation tissue

A

red, healing tissue

80
Q

focused assessment wounds: objective

A 
Site (wound base)
Peri-wound area (around wound)
Size (measure)
Drainage
Dressing (type, status, date)
81
Q

focused assessment wounds: subjective

A 
How did you get this wound? 
How often does this happen or has this ever happened before? 
How long as it been there? 
What products have you tried?
Rate pain and describe it?
82
Q

blanchable

A

turns white when pressed

83
Q

non-blanchable

A

does not turn white when pressed

84
Q

signs and symptoms: wound infection

A 
Redness (erythema)
Swelling (induration)
Warmth 
Drainage (purulent)
Pain
Odor

N388 (2 decks)

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