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Intro to Nursing Practice > Exam #2 > Flashcards

Exam #2 Flashcards

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1
Q

What is the purpose of the joint commission?

A

To accredit hospitals based on their safety performance, policy, procedures, practice, and outcomes.

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2
Q

What are the National Patient Safety Goals?

A
  1. Identify Patients with two identifiers
  2. Improve staff communication: get important test results to the right person on time
  3. Use medications safely: label any nonlabeled medication before surgery, take extra caution for patients who use meds to thin their blood, document the meds administered, etc.
  4. Use alarms safely: make improvements to make sure alarms on machines are responded to on time
  5. Prevent infections: use hand cleaning guidelines provided by the CDC
  6. Identify Patient Safety risks: reduce the risk of suicide
  7. Prevent mistakes in surgery: make sure surgery is being performed on the right person and in the right location
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3
Q

Discuss interventions to prevent injury in the clinical setting.

A

2 identifiers, staff communication, medication safety, bed alarms, infection prevention, breaks in surgery, prevent fatigue, reduce stress, and fall reduction

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4
Q

Discuss Latex allergy.

A

-hospital workers are likely to develop an allergy over time due to exposure

-handwashing reduces irritants

-less likely to occur in powder-free gloves

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5
Q

Patient-inherent accidents

A

physical or psychosocial attributes such as seizures

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6
Q

Procedure-related accidents

A

caused by a healthcare provider such as a medication error or improper technique

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7
Q

Equipment-related accident

A

faulty equipment, injury/death from equipment failure are reportable to the FDA

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8
Q

RACE

A

R- Rescue and remove all people who are in immediate danger

A- activate the fire alarm

C- confine the fire by closing the doors

E- Extinguish the fire if safe to do so

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9
Q

PASS

A

P- Pull

A- Aim

S-Squeeze

S-Sweep

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10
Q

ABC fire extinguishers put out…

A

A (trash, wood, paper)
B (liquids and gases)
C (energized electrical sources)

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11
Q

How is a fall risk assessed?

A

Age, fall history, elimination pattern, high-risk medication, mobility, and cognition. Complete fall risk scale, changes in balance, orthostasis or dizziness

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12
Q

How is a fall risk prevented?

A

HRF bracelet, bed or chair alarm, non-skid footwear, frequent rounding, having patient items in reach

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13
Q

What is the nursing care for a client in restraints and guidelines that must be followed?

A

-must use least restrictive measures first
-HCP must asses face to face
-can be chemical (sedative)
-Physical: limb, belt, ,mitt, and hand
-must reevaluate q24h (can not be used as needed)

asses: hydration, elimination, circulation, ROM, nutrition, VS, skin integrity, and cognitive function

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14
Q

What is the nursing care for a client with seizures?

A

-make sure the patient is placed on their side
-all 4 bed rails up and padded
-time each seizure and stay with patient at time of seizure
-have 02, suction, oral airway at bedside and loosen clothing

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15
Q

Describe Nursing Sensitivity Quality indicators in general.

A

Structure- Where it’s happening?
Process- What is happening?
Outcome- Results

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16
Q

Quality Improvement

A

advancing the practice of health care through the use of objective, measurable information

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17
Q

Quality Assurance

A

Ongoing efforts of organizations outside the hospital that evaluate outcomes to ensure safety

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18
Q

Alignment

A

Relationship of a body part to another along a horizontal or vertical line. The body should be symmetrical while standing, sitting, or lying

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19
Q

Balance

A

Center of gravity over a low and wide stable base of support.

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20
Q

Posture

A

Position of the body in relation to the surrounding space. Requires the least amount of muscular work and strain.

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21
Q

Scoliosis

A

S curve of the spine

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22
Q

Kyphosis

A

convex curvature (rounded upper back)

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23
Q

Lordosis

A

Concave curvature of the spine inward at the lower back (commonly seen in pregnancy)

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24
Q

Congenital hip dysplasia

A

ball is loose in hip and socket and dislocates easily

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25
Q

Isotonic movement

A

Active movement that can control the needed movement speed and direction of bones and joints

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26
Q

What does isotonic movement help accomplish?

A

Improves circulation, and respiratory function, increases muscle mass, tone, and strength, prevents osteoporosis (walking, running, swimming, and biking)

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27
Q

Isometric movement

A

stretching, tightening or tensing the muscles without joint movement

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28
Q

What does Isometric movement accomplish?

A

improves circulation, increases muscle mass, tone, and strength, promotes osteoblastic activity, and increases respiratory rate and HR

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29
Q

Health Promotion

A

BMI < 25, Physical activity to be performed in moderate intensity for 150 minutes a week (5x 30 minutes a day)

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30
Q

What is the rule of 30?

A

keeping the head of the bed at 30 degrees to prevent shear injury

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31
Q

Friction Prevention:

A

-have the patient cross arms to reduce surface area before moving

-have patients bend their knees as you help them up in bed

-move patients’ pillow and have them lift their head off the bed

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32
Q

Shear injury Prevention:

A

-Rule of 30

  • use transfer devices when moving patient
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33
Q

Examples of ADLs

A

bathing, brushing teeth, toileting, eating

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34
Q

Examples of Instrumental ADLs

A

driving, shopping, cooking

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35
Q

Flexion

A

bend, reduces the angle between the bones

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36
Q

extension

A

straighten the limb

37
Q

abduction

A

move away from the baseline

38
Q

adduction

A

bring closer to the baseline

39
Q

pronation

A

turning to face backwards

40
Q

supination

A

turning to face forward

41
Q

circumduction

A

circular motion

42
Q

rotation

A

side to side

43
Q

inversion

A

turn inward

44
Q

eversion

A

turn outward

45
Q

dorsiflexion

A

Draw toes upward toward the body

46
Q

plantarflexion

A

point toes downward away from the body

47
Q

How often should ROM exercises be performed daily

A

2-3x daily (q8h), and you should do 5 reps per joint

48
Q

Passive ROM

A

Use of a Continuous Passive Motion machine or motion preformed by a PT

49
Q

Active ROM

A

walking, running, etc

50
Q

Osteoporosis

A

reduction in bone density or mass (aging)

51
Q

How can you prevent osteoporosis?

A

-weight-bearing exercises

-smoking cessation

-Increased intake of Calcium

-Isotonic exercises help the best

52
Q

What are the adverse effects of the immobility of the respiratory system?

A

-poor lung expansion
-weak cough
-decreased capillary action
-atelectasis
-snap, crackle, pop lung sounds
-mucous collects and pools, causing hypostatic pneumonia

53
Q

What are the nursing interventions for the immobility of the respiratory system?

A

-Turn deep breathe and cough q 1-2 h to mobilize static mucous

-Incentive spirometer q1h while awake (10 inhales)

-Chest physiotherapy - postural drainage

-Respiratory assessment every 2 hours

-Fluid intake 2L per day to thin out mucous

-monitor O2 sat

54
Q

What are the adverse effects of immobility on metabolism?

A

-homeostasis
-balance of electrolytes
-acid-base balance
-hormones in the body
-decreased metabolic rate
-anorexia
-slow GI tract
-negative nitrogen balance (burning more than you are taking in)

55
Q

What are nursing interventions for adverse effects on metabolism?

A

-Diets high in protein, calories, Vit B, Vit C, and Calcium
-Total Parenteral Nutrition
-Enteral/ GI feedings

56
Q

What are the interventions that reduce the effects of GI/GU body systems?

A

-2L of non-caffeinated fluid to void large amounts of clear, yellow urine
-intake approx. = to output
-check for bladder distention
-promote urination
-Diet: high fiber, fresh fruits, veggies and fluid
-elevate HOB after meals to prevent esophageal reflux

57
Q

What are the adverse effects of immobility on the cardiovascular system?

A

-orthostatic hypotension
-blood pools in immobility because of gravity

58
Q

Interventions for adverse effects of immobility of the heart

A

-Raise HOB when sitting to encourage blood flow
-dangling at the bedside before transfer
-slow position changes
-early mobilization
-anti-embolism stockings
-check VS within 3 minutes of a position change
-discourage breath-holding
-encourage breathing out

59
Q

Discuss nursing interventions for adverse effects of the integumentary system.

A

-proper positioning
-lift devices
-rule of 30
-skin assessment every 2h
-braden scale
-routine skin and perineal care
-turning every 1-2h
-limit chair time to 1h
-shift weight every 15 minutes
-pressure-reducing surfaces
-float or bridge heels

60
Q

interventions for musculoskeletal adverse effects

A

-ROM 2-3 times a day every 8h, 5x per joint
-prone positioning
-CPM machine
-prevent foot drop
-isometric exercises QID
-sitting, ambulation

61
Q

What are the safe practice guidelines to reduce injuries for nurses?

A

-get enough help when moving patients
-encourage the patient to assist
-keep a center of gravity
-tighten abdomen
-do not bend or twist
-bend hips and knees, keep feet wide apart
-do not use back
-if the person you are lifting can not do a share of the lifting, you will need assistance
-back brace for heavy lifting

62
Q

What is the pacemaker of the heart? What rates does it produce?

A

The SA node. An intrinsic rate rate of 75 cardiac action potentials per minute.

63
Q

What are some conditions affecting chest wall movement?

A

pregnancy, obesity, neuromuscular disease, musculoskeletal abnormalities

64
Q

What are the factors affecting oxygenation in chronic diseases?

A

Barrel chest, flattened diaphragm, lung fields are overdistended, clubbing fingers and toes, RBCs increase to try and increase O2 carrying capacity

65
Q

What are some ways you can implement airway management?

A

-early ambulation
-sit patient up (semi-fowlers 45 degrees)
-reduce pressure on the abdomen
-promote postural drainage
-chest percussion therapy

66
Q

What is the teaching for an incentive spirometer?

A

Breathe into the machine every hour you are awake 10 breaths

67
Q

Nasal Cannula

A

Least invasive

1 L per minute

Humidify if more than 4 L

67
Q

What position best facilitates breathing?

A

Fowlers or Semi-Fowlers (you want them in the upright position

67
Q

Simple Mask

A

6-10 L per minute

35-60%

short period of time (less than 12 hours)

good for blocked nasal passages and mouth breathers

68
Q

partial rebreather mask

A

6-15 LPM

70-90%

69
Q

Non-rebreather mask

A

6-15 LPM

60-100%

can be low-high flow

70
Q

Venture Mask

A

4-10 LPM

24-55%

most precise concentration

71
Q

How much oxygen is in room air?

A

22%

72
Q

What are the signs of oxygen toxicity?

A

Chronic: atelectasis, coughing, dyspnea, pleuretic chest pain, chest heaviness

Acute: affects CNS: twitching of the hand muscles, nausea, generalized convulsions, dysphoria, tinnitus.

73
Q

What are the purposes of a chest tube? And nursing guidelines?

A

To drain out air or blood from pleural space.

-do not knock over
-hang below the chest
-monitor water seal
-Mark the level of drainage

74
Q

Describe the drive to breathe for healthy lungs vs COPD.

A

COPD patients have a hypoxic drive to breathe healthy lungs have a normal drive to breathe

75
Q

Risk Management

A

The process reducing risk of errors by understanding the causes and beginning to change the culture with communication and collaboration of individual staff and management.

76
Q

Incident Reports

A

Documentation of errors and the factors leading up to and including when an error occurs in the healthcare system

77
Q

Root cause analysis

A

Follows the Joint Commission’s directive to investigate an incident to determine what happened and how to prevent it from happening again

78
Q

Outcome indicators

A

Changes in a person’s health that occur due to an intervention

79
Q

What is Direct Care?

A

-Treatments performed through interactions with patients
-Medication Administration
-Insertion of Intravenous
-counseling during times of grief
-ADL’s
-Lifesaving measures

80
Q

What is indirect Care?

A

-treatments performed away on the behalf of the patient or group of patients
-managing the patient’s environment
-Documentation
-Interdisciplinary collaboration
-delegating, supervising, and evaluating the work of others

81
Q

What is a SMART goal?

A

Specific, Measurable, Attainable, Realistic and Timed

82
Q

Nurse initiated interventions

A

independent and do not require any supervision

83
Q

Healthcare provider interventions

A

Dependent- require an order from a physician or other HCP. require specific nursing responsibilities and technical nursing knowledge.

84
Q

Collaborative interventions

A

Interdependent- requires combined knowledge, skill, and expertise of multiple healthcare professionals

85
Q

What is an SBAR?

A

Situation- Identify yourself and your position, the patient’s name, and the correct situation. Give a clear, concise overview of the pertinent issues.

Background: State the relevant history and physical assessment pertinent to the problem. treatment/clinical course summary and any pertinent changes

Assessment: Offer your conclusion about the present situation. Summarize facts and give your best assessment. What is going on? use your best judgment

Recommendations: Explain what you think needs to be done. what the patient needs and when

86
Q

What education should be provided regarding oxygen use?

A

-no smoking around oxygen
-use prescribed drug and amount
-limit items that can cause static electricity, such as wool, nylon, and synthetics
-smoke alarms and fire extinguishers must be present
-keep nail polish remover and heating oil away from the O2

Intro to Nursing Practice (2 decks)

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