Exam 2 fundamentals

Question 1

used for hand hygiene when a pt has C-diff

Answer 1

soap, water

Question 2

RACE

Answer 2

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

Question 3

PASS

Answer 3

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

Question 4

pt w/ this condition will be placed on airborne precautions

Answer 4

tuberculosis

Question 5

airway, breathing, circulation/cardiac, deformities, exposure

Answer 5

ABCDE approach to assess pts that are deteriorating or critically ill

Question 6

PPE worn in room of pt w/ C-diff

Answer 6

gowns, gloves

Question 7

side effect of Oxycodone

Answer 7

dizziness

Question 8

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

Answer 8

Stage one

Question 9

redness of skin

Answer 9

erythema

Question 10

protrusion of visceral organs through a surgical wound?

Answer 10

Evisceration

Question 11

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

Answer 11

serosanguineous

Question 12

intervention by nurse after a pt is deceased

Answer 12

postmortem care

Question 13

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

Answer 13

stage two

Question 14

drainage that is bright red and indicates active bleeding

Answer 14

sanguineous

Question 15

What aids in wound healing?

Answer 15

protein

Question 16

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

Answer 16

incubation stage

Question 17

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

Answer 17

dehiscence

Question 18

how should denture care be performed?

Answer 18

w/ a soft toothbrush

Question 19

how to perform oral care on an unconscious pt?

Answer 19

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

Question 20

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

Answer 20

unstageable

Question 21

best way to prevent the spread of infection?

Answer 21

hand hygiene

Question 22

drainage that is clear, watery plasma?

Answer 22

serous

Question 23

what is REEDA?

Answer 23

-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

Question 24

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

Answer 24

stage three

Question 25

when to hold metoprolol?

Answer 25

if pt’s systolic bp is less than 100

Question 26

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

Answer 26

stage four

Question 27

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

Answer 27

secondary intention

Question 28

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

Answer 28

purulent

Question 29

when is the best time to perform a skin assessment?

Answer 29

during a bath

Question 30

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

Answer 30

Ice

Question 31

what do you never give prior to taking a culture?

Answer 31

antibiotics

Question 32

if pt has any changes, what do you do?

Answer 32

take vitals and call the provider

Question 33

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

Answer 33

malaise

Question 34

how to prevent pressure injuries?

Answer 34

reposition pt every 2 hours

Question 35

CAUTI

Answer 35

catheter associated urinary tract infection

Question 36

CLABSI

Answer 36

central line associated blood stream infection

Question 37

VAP

Answer 37

ventilator associated pneumonia

Question 38

what is an avg temperature?

Answer 38

98.6 , fever is anything greater than 100.4

Question 39

what is a fever?

Answer 39

any temp greater than 100.4

Question 40

normal HR

Answer 40

60-100 bpm

Question 41

normal bp

Answer 41

120 s / 80 d

Question 42

normal O2

Answer 42

greater than 95%

Question 43

when is our temperature the lowest?

Answer 43

1am - 4am

Question 44

how to bathe a pt

Answer 44

cleanest to dirtiest

Question 45

always check vitals before and after this

Answer 45

giving meds

Question 46

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

Answer 46

check vitals bc could be infection

Question 47

med used to treat high blood pressure

Answer 47

metoprolol

Question 48

how to prevent edema aka swelling

Answer 48

cold aka ice, elevate it

Question 49

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

Answer 49

primary intention

Question 50

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

Answer 50

secondary intention

Question 51

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

Answer 51

tertiary intention

Question 52

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

Answer 52

pre-medicate with pain meds!

Question 53

chain of infection (stages)

Answer 53

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)

Question 54

what are risks of hypertension related illness?

Answer 54

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

Question 55

what are modifiable risk factors for hypertension?

Answer 55

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

Question 56

4 types of transmission based precautions

Answer 56

-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

Question 57

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

Answer 57

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

Question 58

what are issues with restraints?

Answer 58

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

Question 59

how often to check pt with restraints

Answer 59

q2 hours for nonviolent or q15 minutes for violent pt

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

Question 60

what to check on with pts with restraints

Answer 60

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

Question 61

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

Answer 61

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.