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Fundamentals > Final > Flashcards

Final Flashcards

1
Q

Maslow’s hierarchy of needs includes how many levels; what are they?

A

5; physiologic, safety, and security, love and belonging, self-esteem, self actualization

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2
Q

Difference between chronic, acute, and primary illnesses

A

Chronic: persisting for six months or more, develop slowly can we control, but not cured, long lasting

Acute: sudden or less than three months, resolved in a short time

Primary: illness that develops without being caused by another health problem

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3
Q

Sympathetic system during stressful events

A

Pupils dilate

Salivary gland, stimulates thick secretion, causing dry mouth

Bronchial tubes dilate, providing greater airflow

Heart rate increases and strength of contractions increase

Sweat glands stimulates sweat production

Intestines, inhibit mobility - possible constipation

Liver stimulates glycogen breakdown for energy

Adrenal medulla, stimulates, secretion of epinephrine and norepinephrine

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4
Q

Health promotion behaviors:
Wearing seatbelts and helmets
Eating well balanced meals
Not smoking
Avoiding dangerous behaviors
Consuming no, or minimal alcohol
Getting scheduled immunizations and flu vaccines
Exercising regularly
Maintaining ideal body mass index
Wearing sunscreen and sunglasses and avoiding tanning beds

A

Examples of primary prevention

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5
Q

Health promotion behaviors:
Having regular Pap smear test
Performing a monthly testicular self examination
Having mammograms and a colonoscopy as recommended
Getting skin test for TB screening
Having routine tonometry test to detect glaucoma

A

Secondary preventions

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6
Q

Health promotion behaviors:
Following a cardiac or respiratory rehabilitation program
Pursuing a rehabilitation program for stroke, head injury, or arthritis

A

Tertiary prevention

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7
Q

Nurses roll in each step in the nursing process

A

Assessment: recognize clues, collect, organize, document, and validate data about a patient’s health status

Data analysis/ problem identification: analyze clues, form, hypothesis, prioritize hypothesis

Planning: generate solutions

Implementation: take action

Evaluation: evaluate outcomes

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8
Q

Nursing diagnosis consist of: 3 parts

A

Patients problem or potential problem (how the patient is responding)

The causative or related factors, which can include the pathophysiology

Specific defining characteristics are the signs and symptoms

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9
Q

Before carrying out the specific interventions listed on the care plan, identify the reason for the intervention, the rationale for the intervention, the usual, standard of care, the e__ outcome, and any potential dangers

A

Expected

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10
Q

Who constructs the initial nursing care plan

A

RN

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11
Q

Contains data about pt’s stay in facility.
Legal record, contents must be kept confidential, only given out with pt’s written consent, chart is property of health facility or agency- not pt or physician- pt’s do have right to information contained in chart under certain circumstances.
Only health care professionals directly caring for the pt or those involved in research or teaching should have access to chart

A

Medical record

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12
Q

Goal of care intervention is not to provide cure or to recover the lost function but to preserve the quality of life and alleviate suffering

A

Palliative care

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13
Q

Stages of coping with death

A

Denial
Anger
Bargaining
Depression
Acceptance

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14
Q

Grow physically weaker, and begin to spend more time sleeping.
Their appetite decreases, pt may refuse food and fluids.
Urine output decreases, and the urine becomes more concentrated.
May be edema of the extremities, or over the sacrum. Incontinence may occur, possible urinary retention, and need for catheterization.
Pulse increases, becomes weaker or thready.
BP declines, skin of the extremities becomes mottled, cool, and dusky. Respirations become shallow and irregular,
Secretions may pool in the lungs, causing respirations to sound moist. Cheyne-Stokes respirations

A

Impending signs of death

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15
Q

Causative agent
Reservoir
Portal of exit
Mode of transfer
Portal of entry
Susceptible host

A

Chain of infection

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16
Q

Immunity: pt is given an antitoxin or antiserum that contains antibodies or antitoxins that have been developed in another person- ex tetanus

A

Passive acquired immunity

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17
Q

reducing the number of organisms present or reducing the risk for transmission of organisms, preventing reinfection and spreading from person to person; disinfecting items, known as clean technique

A

medical asepsis

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18
Q

Preventing pt exposure to living microorganisms; involves sterilization, timed hand scrubs; sterile technique

A

surgical asepsis

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19
Q

Increased susceptibility of the older adult to infection: Homeostasis

A

-Factor: older adults lose their homeostasis state more easily than younger, due to loss of functioning cells in all body organs with aging
-Nursing Interventions: protect from exposure to pathogens, promote good nutrition, exercise, and adequate rest to boost resistance to disease

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20
Q

Increased susceptibility of the older adult to infection: Immune function

A

-Factor: both immediate and delayed immune responses are decreased or altered

-Nursing Interventions: protect from exposure to pathogens, immunize against influenza and pneumonia, promote good nutrition to boost immune system

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21
Q

Increased susceptibility of the older adult to infection:
Respiratory function

A

-Factor: impaired cough mechanism and impaired function of cilia decrease ability to expel foreign substances and mucus from the lungs, predisposing pt to respiratory tract infection
~decreased macrophage activity in lungs
~less ability to expand the thorax predisposes older adults to atelectasis after surgery

-Nursing Interventions: discourage smoking, encourage deep breathing and intake of fluid to keep lung secretions thinned
~encourage good oral hygiene to decrease potential for colonization of trachea and lungs with microorganisms
~help postoperative pt’s maintain a semi-upright position (semi-Fowler) to aid lung expansion
~encourage use of incentive spirometer and deep breathing, ambulate as soon as possible

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22
Q

Increased susceptibility of the older adult to infection:
skin

A

-Factor: decreased elasticity, increased dryness, and decreased vascular supply make the skin susceptible to injury or breakdown and slower to repair
~breaks allow entry of microorganisms

-Nursing Interventions: instruct in appropriate skin care, keeping skin moisturized,
~prevent abrasions by using a draw sheet or trapeze bar
~inspect skin at least once each shift for pressure area

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23
Q

Increased susceptibility of the older adult to infection:
GI system

A

-Factor: decreased secretion of gastric acid resulting in decreased destruction in the stomach of microorganisms ingested in food and drink
~pancreatic enzyme secretion is decreased, causing less destruction of microorganisms in the GI

-Nursing Interventions: promote good oral hygiene to prevent swallowing pathogenic microorganisms
~instruct in proper preparation and storage of food to prevent GI infection

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24
Q

Increased susceptibility of the older adult to infection:
Urinary tract

A

-Factor: prostatic hyperplasia, cystocele, rectocele, and degeneration of nerves to bladder cause urine stasis in the bladder as a result of incomplete emptying. Stasis predisposes to urinary tract infection

-Nursing Interventions: encourage intake of sufficient fluid to keep urine dilute
~ encourage intake of cran juice and other foods that keep urine acidic, which will discourage growth of microorganism

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25
Q

Prevents more harmful microorganisms from colonizing and multiplying within the body by occupying receptor sites on cells, monopolizing the nutrients and secreting substances that are toxic to the other microorganisms

A

normal flora

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26
Q

As a nurse, when do we discontinue the assessment and notify the physician

A

Notify the physician when vital signs or assessment is far from normal or abnormal findings

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27
Q

Where do we place the stethoscope for the PMI

A

fifth intercostal space, left midclavicular line

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28
Q

When can we call bowel sounds absent

A

no sound for 2-5 min in any of the four quadrants

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29
Q

What part of the stethoscope do we listen to abnormal heart sounds

A

Bell; detects low-pitched sounds

30
Q

How do we deal with patient’s jewelry and money that they have

A

‘Valuables should be sent home with a family member if possible, if not, obtain valuables envelope and arrange for safe storage according to facility protocol
-Tape rings down if can not get off; document in vague language ie: clear stone on yellow band

31
Q

Who is responsible for providing orders for transfer to another floor

A

-Primary care provider must be notified and approve the transfer
-Requires specific order by the attending physician

32
Q

What lab do we check for warfarin (Coumadin)

A

Prothrombin time and activated partial prothrombin time

33
Q

Review clinical cues on page 428

A

-Undergoing MRI, remove any transdermal medication patch, nicotine patch- can cause burns
-Ask about any internal prosthetic device that contain metal
-Sedation order may be needed for those who are anxious about being placed in an MRI scanner

34
Q

Position a patient after a liver biopsy

A

right side

35
Q

Difference between isotonic, hypotonic and hypertonic

A

hypotonic solution = cells explode (less concentration in relation to the cells)
hypertonic solution = cells shrinks (greater concentration relation to the cells)

36
Q

Chronic COPD patients are at risk for what metabolic disorder

A

edema

37
Q

Signs and symptoms of fluid volume excess and deficit

A

Deficit: dizzy
confusion
cool, dry skin
dark, concentrated urine
decreased: bp, urine production
dry, cracked lips and tongue
dry mucous membranes
elevated temperature
flat neck veins when lying down
increased pulse rate
poor skin turgor
orthostatic hypotension
thick saliva
thirst
weak, thready pulse
weakness

Excess: weight gain
crackles in the lungs
slow bounding pulse
elevated pressure
possibly edema

38
Q

Where is vitamin B12 absorbed at?

A

in the stomach

39
Q

What changes in the digestive system occur with aging? (page 468)

A

-Increased dental caries and tooth loss may make it harder to chew food normally
-decreased sense of smell and taste may lead to loss of appetite
-decreased gag reflex may increase choking risk and aspiration
-decreased muscle tone at sphincters may increase heartburn or risk of esophageal reflux
-decreased gastric secretions may interfere with digestion of food
-decreased peristalsis may increase the risk of constipation or bowel impaction

40
Q

Foods high in fiber

A

-Fruits: strawberries, grapefruit, cantaloupe, unpeeled apple
-Grains & Cereal: all-bran, cooked oatmeal, shredded wheat
-Veg: raw broccoli, baked sweet potato, whole kernel corn
-Legumes (cooked): black beans, pinto beans, kidney beans

41
Q

Definition of hypoxia and hypoxemia

A

-hypoxia: not enough O2 to meet cellular needs

-hypoxemia: decreased amount of O2 in blood stream

42
Q

how to instruct forceful exhalation

A

pt takes two deep breaths, inhales deeply again, then rapidly, and forcefully exhales with their mouth open

43
Q

Best time for postural drainage treatment

A

In the morning, and 45 to 60 min before a meal

44
Q

Who would benefit from humidifier with oxygen

A

Humidifier is used to moisten the airflow. A pt with sinus issues or dry mucosa membranes could benefit

45
Q

When would someone benefit from a venture mask

A

when pt needs an exact amount of O2 (28% rather than 2L)

46
Q

When would we use a pharyngeal airway

A

to keep the tongue from falling back into the throat on post-op pts until they have recovered from anesthesia

47
Q

How to prevent recurrent cystitis

A

-increase fluid intake to 2500- 3000 mL/day
-avoid citrus fruit and juice because they can cause alkaline urine (bacteria grow more readily in alkaline urine)
-avoid tight clothing; wear cotton underwear
-avoid sitting around in wet bathing suit for extended periods
-females, avoid bubble baths or hygiene sprays
-pee after sex, plus drink two glasses of water
-pee often, to prevent stasis and potential for bacteria to multiply if present

48
Q

What should the suction pressure should be set between

A

80 - 120 mm Hg

49
Q

Lifespan consideration page 553 “older adult”

A

-may develop an infection and not manifest a fever, temp could be lower than norm
-Subtle changes in mental status may be the first symptom of an infection
-monitor closely for changes in alertness and orientation

50
Q

Normal and abnormal characteristics of stool

A

-Abnormal: blood in stool, occult or old blood suspected when stool changes from normal brown to dark black with a sticky appearance
-pale white or light gray indicates absence of bile in intestine (usually due to obstruction in the bile or common duct leading to the intestine from the liver and gallbladder)
-presence of large amounts of:
mucus: indicates irritation or inflammation of the inner surface of the intestines
purulent matter: indicates drainage of an ulcer that is inflamed or infected
parasites (like worms): tapeworm, pinworm, and roundworm

51
Q

Patient education on page 589 “foods to assist a patient with diarrhea”

A

yogurt, drink buttermilk or take probiotics when pt’s begin taking antibiotics (replacing the normal bacteria with those contained in these food products reestablishes the right balance and stops diarrhea)

52
Q

Normal and abnormal findings in assessing bowels

A

Hypoactive: absence or reduction of peristaltic movement of the bowel
-can be a complication of surgery, paralytic ileus
-insufficient dietary fiber and decreased exercise
-constipation most common problem
-at risk for constipation: bed rest pt’s, medications, barium x-ray studies, or recovery from surgery

-Hyperactive: increased motility of the GI tract or increased peristalsis, often this is the body’s way of ridding itself of pathogens or toxins from spoiled food
-causes can include: inflammation the GI tract, certain drugs, infectious agents, and diseases (diverticulitis, ulcerative colitis, Crohn disease, and IBS) gastric bypass surgical pt’s may experience diarrhea

53
Q

What measures do we put into place for a patient who is barium

A

increase fluid intake of 3500 mL/day for next 24 hrs (unless contraindicated)

54
Q

Complications of digitally removing an impaction

A

-must be done gently, pt must be watched for signs of vagal response (may cause slow pulse and cardiac arrhythmia, and an alteration in blood pressure)
-If signs appear immediately stop procedure, place pt in supine position, monitor vital signs, and notify primary care provider

55
Q

Different type of pain (acute vs chronic)

A

Acute: usually associated with an injury, medical condition, or surgical procedure
-short duration, lasting from a few hours to a few days
-increased heart rate, bp, resp. rate
-pain may worsen with fear or anxiety
-cause is usually determined, pain is well controlled with analgesics, surgery, or other techniques (once cause is removed, pain with be relieved)

Chronic: continue for months or years, associated with ongoing conditions (arthritis, back problems)
-can cause long-lasting psychosocial effects
-pain described as: dull, constant, shooting, tingling, or burning
-combination of pharmacologic and nonpharmacologic treatments are recommended (heat, ice, massage, guided imagery)

56
Q

Benefits of an abdominal binder

A

-Used to decrease tension around a wound or suture line, increase patient comfort, decrease lactation after childbirth, or hold dressing in place.

-Provide support and comfort for an abdominal incision when the patient must perform deep breathing and coughing exercises and when getting in and out of bed.

57
Q

Who is responsible for programming the PCA and the benefits of PCA pump

A

RN

reduce pt’s anxiety by putting pt in control (often pt’s end up using less medication)

58
Q

Signs and symptoms of a fentanyl overdose

A

shallow respirations
extreme sleepiness
inability to think, walk, or talk normally
feelings of faintness, dizziness, or confusion

-if symptoms appear, remove patch, cleanse skin, call hcp

59
Q

What assessment does an anesthesiologist need for surgery?

A

Height and Weight

60
Q

QSEN Consideration protocol on page 753

A

3 Parts for preventing surgical error:
Pre-procedure verification process
Marking the procedure site
Performing a time-out before the procedure

61
Q

Aldrete score

A

PACU score system rates a patient’s activity, respiration, circulation, consciousness, and skin color

Total score of 9 or 10 usually indicates that the patient is ready for transfer out of PACU

62
Q

Stages of wound healing

A

The inflammatory phase: begins immediately after injury, lasts approx 3 - 4 days

The proliferation or reconstruction phase: begins on 3 - 4th day, lasts 2 - 3 weeks

The maturation or remodeling phase: begins approx 3 weeks after injury, ends when scar is firm and elastic

63
Q

1, 2, and third intention

A

First intention or Primary Intention (Closure):
Edges of the wound approximate ( Close together)
Slight chance of infection

Secondary intention:
Edges of wound not approximate (Pressure injury or severe laceration- a Torn, ragged, or mangled wound)
Wound is left open and fills with scar tissue
Because of the longer healing period, the chance of infection is higher

Tertiary Intention (known as delayed):
Abdominal wound left open for drainage and then later closed is an example of healing by tertiary intention. Heals from inside out.

64
Q

Signs and symptoms of internal hemorrhaging

A

-Hypovolemic shock may occur with a fall in blood pressure
-Rapid and thready pulse
-increased respiratory rate
-Restlessness
-Diaphoresis
-Cold clammy skin

65
Q

Signs and symptoms of dehiensce and evisceration

A

Dehiscence:
Spontaneous opening of an incision, often also involves separation of the layers beneath the skin
-S/S: increase in flow of serosanguineous drainage into the wound dressing
-Patient may say “Something has given away”

Evisceration: protrusion of an internal organ through the incision
-Risk factors: obesity, poor nutrition, multiple traumas, excessive coughing, vomiting, strong sneezing suture failure, and dehydration

66
Q

How to remove an old dressing that is stuck to the wound

A

Add normal saline to loosen it

67
Q

the benefits of deep breathing exercises, range of motion exercises and air loss mattress

A

-Air loss mattress: distributes air through multiple connected cushions, providing maximum pressure relief, reducing shear and friction, controls moisture on the skin, segments can be deflated for pt care

-ROM: passive or active; maintain joint mobility and muscle integrity (standard for bed rest care)

-deep breathing exercises: help prevent pneumonia and increase general oxygenation

68
Q

Why is buck’s traction used

A

-Type of skin traction in a velcro boot, belt, halter or sling, applied snuggly to skin, and the traction is attached to the appliance

-Advantage: noninvasive, main purpose is to decrease muscle spasms that accompany fractures

-Disadvantage: can damage skin; blisters, rashes from irritation by adhesives, and skin tears and tissue injuries from te shearing effects of the lateral pull across the skin surface (not used in older adults due to skin issue)

-Only used when weight required is less than 15lbs

-Check skin frequently for injury, report any to pcp or traction technician

69
Q

Clinical Cues on page 811

A

When handling the cast during the drying period, use the palm and the flat parts of the fingers rather than the fingertips.
Dents in the cast can lead to circulatory impairment and pressure injuries, and changes in alignment can alter the position of the healing parts or impede circulation

70
Q

Neurovascular assessment on page 815

A

-performed for every pt who has experienced a fracture, whether treated with a cast or traction
-performed every hour for the first 24 hrs, then after cast is dry, every 4-8 hrs

-5 P’s: Pain, Pallor, Paralysis, Paraesthesia, Pulselessness
-Pain: ask about the degree, location, nature, and frequency of pain, noting any increase in intensity or change in type of pain
-Pallor: Inspect skin distal to the injury, noting color, compared to other extremity. Palpate skin temp and compare, check cap refill
-Paralysis: have pt move the area distal to the injury or move it passively, there should be no discomfort
-Paraesthesia: ask about feelings of numbness or tingling (paraesthesia), check sensation with a paper clip and compare bilaterally, sensation should be the same
-Pulselessness: palpate pulses distal to the injury, compare bilaterally

71
Q

Patient education on fracture and cast care on page 816

A

-keep casted limb elevated above heart whenever possible to prevent swelling
-call pcp if :
~fingers or toes become numb, tingle, turn blue, or are cold to the touch
~develop a fever, have unusual pain in the casted extremity, or notice a bad odor coming from the cast (signs of infection)
~if cast becomes loose or slides (probably needs changing)
-regularly perform exercises to help retain muscle
-do not get plaster wet
-do not insert anything into the cast to relieve itch (may damage skin and result in infection)
-do not bear weight on cast unless pcp instructed

Fundamentals (6 decks)

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