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Fundamentals > Exam 2 fundamentals > Flashcards

Exam 2 fundamentals Flashcards

1
Q

used for hand hygiene when a pt has C-diff

A

soap, water

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2
Q

RACE

A

-rescue/remove pts in immediate danger
-activate the alarm
-confine the fire by closing windows/turning off O2 & electrical equipment
-extinguish fire

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3
Q

PASS

A

-Pull pin
-Aim at base of fire
-Squeeze handles
-Sweep from side to side to coat area evenly

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4
Q

pt w/ this condition will be placed on airborne precautions

A

tuberculosis

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5
Q

airway, breathing, circulation/cardiac, deformities, exposure

A

ABCDE approach to assess pts that are deteriorating or critically ill

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6
Q

PPE worn in room of pt w/ C-diff

A

gowns, gloves

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7
Q

side effect of Oxycodone

A

dizziness

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8
Q

pressure injury when the skin is intact w/ non-blanchable erythema?

A

Stage one

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9
Q

redness of skin

A

erythema

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10
Q

protrusion of visceral organs through a surgical wound?

A

Evisceration

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11
Q

drainage that is pale, pink, watery texture of clear & red fluid

A

serosanguineous

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12
Q

intervention by nurse after a pt is deceased

A

postmortem care

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13
Q

pressure injury with partial thickness, skin loss; the skin might be intact or appear as a ruptured serum blister

A

stage two

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14
Q

drainage that is bright red and indicates active bleeding

A

sanguineous

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15
Q

What aids in wound healing?

A

protein

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16
Q

time interval between when a pathogen enters the body and when the first symptoms appear

A

incubation stage

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17
Q

separation of the edges of a wound, revealing the underlying tissues

A

dehiscence

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18
Q

how should denture care be performed?

A

w/ a soft toothbrush

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19
Q

how to perform oral care on an unconscious pt?

A

turn pt on their side, use sunctioning for oral secretions, do oral care every 2-4 hours

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20
Q

pressure injury where slough/eschar obscures the extent of tissue loss?

A

unstageable

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21
Q

best way to prevent the spread of infection?

A

hand hygiene

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22
Q

drainage that is clear, watery plasma?

A

serous

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23
Q

what is REEDA?

A

-Redness
-Edema (swelling)
-Ecchymosis (discoloration of skin due to bleeding underneath aka bruising)
-Discharge/drainage
-Approximation

*tool used to assess the inflammatory process and tissue healing in the perineal trauma (ex: vaginal birth) through the evaluation of five items of healing

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24
Q

pressure injury where the fat tissue is exposed; can have rolled edges; undermining & tunneling might occur in this stage?

A

stage three

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25
Q

when to hold metoprolol?

A

if pt’s systolic bp is less than 100

26
Q

pressure injury where the fascia, muscle, tendon, ligament, cartilage and/or bone are visible?

A

stage four

27
Q

healing that occurs by filling in an open wound with scar tissue?

A

secondary intention

28
Q

drainage that is thick, yellow, green, tan, or brown?

A

purulent

29
Q

when is the best time to perform a skin assessment?

A

during a bath

30
Q

this is used to prevent or reduce the amount of swelling or edema to an area of inflammation or injury?

A

Ice

31
Q

what do you never give prior to taking a culture?

A

antibiotics

32
Q

if pt has any changes, what do you do?

A

take vitals and call the provider

33
Q

what is the feeling of discomfort, illness, lack of well being

A

malaise

34
Q

how to prevent pressure injuries?

A

reposition pt every 2 hours

35
Q

CAUTI

A

catheter associated urinary tract infection

36
Q

CLABSI

A

central line associated blood stream infection

37
Q

VAP

A

ventilator associated pneumonia

38
Q

what is an avg temperature?

A

98.6 , fever is anything greater than 100.4

39
Q

what is a fever?

A

any temp greater than 100.4

40
Q

normal HR

A

60-100 bpm

41
Q

normal bp

A

120 s / 80 d

42
Q

normal O2

A

greater than 95%

43
Q

when is our temperature the lowest?

A

1am - 4am

44
Q

how to bathe a pt

A

cleanest to dirtiest

45
Q

always check vitals before and after this

A

giving meds

46
Q

if you see red on wound, what do you do?

A

check vitals bc could be infection

47
Q

med used to treat high blood pressure

A

metoprolol

48
Q

how to prevent edema aka swelling

A

cold aka ice, elevate it

49
Q

type of wound healing that would be sutures from surgical wound, wound that is closed, healing by epithelialization

A

primary intention

50
Q

type of wound healing that heals form the inside out, doing its own thing, also has scarring, healing by granulation tissue & epithelialization

A

secondary intention

51
Q

type of wound healing that heals after a debridement of wound, left open for several days with possible drainage

A

tertiary intention

52
Q

what is the first thing you should do if performing a dressing change on level 3 or 4 wound?

A

pre-medicate with pain meds!

53
Q

chain of infection (stages)

A
  1. an infectious agent or pathogen (the microorganism)
  2. a reservoir or source for pathogen growth (place where they can survive, multiply & await transfer to host. ex: humans, animal, food/water)
  3. a port of exit from the reservoir (place after leaving reservoir to enter another host like blood, respiratory tract, GI etc)
  4. a mode of transmission (proper PPE can interrupt this)
  5. a port of entry to a host (organisms enter the body the same routes they use for exiting)
  6. a susceptible host (susceptibility to an infectious agent depends on individual’s degree of resistance to pathogens)
54
Q

what are risks of hypertension related illness?

A

stroke, heart attack, damage to kidneys, retinas, and the peripheral nervous system

55
Q

what are modifiable risk factors for hypertension?

A

-obesity
-cigarette smoking
-heavy alcohol consumption
-high sodium intake
-sedentary lifestyle
-continued exposure to stress

56
Q

4 types of transmission based precautions

A

-airborne (diseases transmitted by small droplets, need negative pressure room & N95 mask for TB)

-droplet (diseases transmitted by larger droplets like the flu, mask is required)

-contact (direct & indirect, requires gloves, gown)

-protective environment precautions (pt w/ underlying conditions/treatment who are highly susceptible to infection, needs positive airflow room w/ filter) Ex: pt underwent kidney transplant, will have to wear mask when leaving his pt room

57
Q

what do you do if an IV pump is not working properly?

A

replace it w/ properly working one, place tag on the faulty one and remove it from service and report malfunction to appropriate department

58
Q

what are issues with restraints?

A

-immobilization such as pressure injuries, PNA, constipation, incontinence, loss of self esteem, humiliation, and agitation
-death if restricted breathing and circulation

59
Q

how often to check pt with restraints

A

q2 hours for nonviolent or q15 minutes for violent pt

assess pt every 60 mins or sooner for violent or self destructive pt

60
Q

what to check on with pts with restraints

A

vitals, skin integrity, nutrition, hydration, circulation, ROM, hygiene, elimination needs, cognitive functioning, psychological status, and need for restraint

61
Q

what are the basic needs that have to be met before safety levels need to be addressed

A

oxygen, fluids, nutrition, body temperature, elimination, shelter, sex (these are physiological needs) have to be met prior to reaching safety and security, then love & belonging needs, then self-esteem, then the top self actualization.

Fundamentals (2 decks)

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