fundamentals Flashcards
home health care is what level of health care
restorative
rehabs are what level of health care
restorative
skilled nursing facilities are what level of health care
restorative
emergency departments are what level of health care
secondary
diagnostic centers are what level of health care
secondary
urgent care centers are what level of health care
secondary
level of health care that diagnoses and treats acute illnesses and injuries
secondary health care
oncology centers are what level of health care
tertiary health care
intensive care are what level of health care
tertiary health care
burn centers are what level of health care
tertiary health care
level of health care in which a patient is treated for a brief but severe episode of illness, for conditions that are the result of disease or trauma, and during recovery from surgery is called?
acute care
end of life care is what level of health care
continuing health care
palliative care is what level of health care
continuing health care
hospice is what level of health care
continuing health care
adult day care is what level of health care
continuing health care
assisted living is what level of health care
continuing health care
in home repsite care is what level of health care
continuing health care
level of health care that addresses long term or chronic health care needs over a period of time
continuing health care
fullfilment of promises is what ethical principle
fidelity
what type of law protects individual rights?
civil law
negligence is what type of tort
unintentional
professional negligence is also called
malpractice
confidentiality breaches are what type of tort
quasi intentional
defamation is what type of tort
quasi intentional
what type of tort is assault
intentional
conduct that makes another person fearful and apprehensive is which intentional tort
assault
threatening to place an NG tube in a pt who refuses to eat is which intentional tort
assault
what type of tort is battery
intentional
intentional and wrongful contact with a person that involves an injury or offensive contact is which intentional tort
battery
restraining and giving an injection against a pts wishes is which intentional tort
battery
which type of tort is false imprisonment
intentional
what to do if a dnr pt has no pulse but there is no provider dnr prescription in pts medical record
start cpr
which sentence documents a clients behavior accurately, “client is agitated” or “client pacing back and forth in the room, yelling loudly”.
“client pacing back and forth in the room, yelling loudly” (shows what nurse sees and hears)
can you pre chart an assessment, intervention or evaluation?
no
should advance directives be included in transfer reports?
yes
should medication routine from medication administration record be included in transfer reports?
no unless there is a significant change in the routine (they can read it themselves in the chart)
should an upcoming bone scan be included in transfer report?
yes because nurse might have to modify care to accommodate leaving unit
is. talking about a pt at a nursing station a HIPAA violation?
no
should an incidence report be done for an omitted prescription?
yes
can an AP apply a condom catheter?
yes
what are the 5 rights of delegation
right task
right circumstance
right person
right direction and communication
right supervision and evaluation
can an AP administer a nebulizer treatment to a pt with pneumonia?
no
can an AP measure vitals of stable post op pt?
yes
can an AP give enteral feedings?
no
what does right direction and communication include?
what data to collect
method/timeline for reporting
specific tasks and client specific instructions
results, timelines and follow up communication expectations
making choices without help from others and fully assuming responsibility for choices is what level of critical thinking?
commitment
increasing IV fluid infusion when pt BP shows hypovolemic shock 24 hrs after surgery is what level of critical thinking?
commitment
what are the 3 levels of critical thinking?
basic
complex
commitment
does turning away from a sterile field contaminate it?
yes
time between infection and first symptom
incubation
time between general findings to distinct findings in an infection
prodromal stage
when findings specific to infection occur
illness stage
time between acute symptoms stop and total recovery
convalescence
an increase in what over 20mm/hr indicates active inflammatory process or infection?
ESR (erythrocyte sedimentation rate)
what are protective encironments used for
patient’s who are immunocompromised
what kind of airflow should be used in a protective environment
positive airflow 12
what does positive airflow do?
prevent airborne pathogens from entering
what airflow should be used in airborne precautions
negative pressure airflow
how many exchanges per hr should negative pressure airflow be used
6-12 exchanges/hr
is ibuprofen an antipyretic?
no
what pts should you keep side rails up?
sedated
unconcious
compromised
what rescue equipment should be at bedside for seizure precautions?
O2
oral airway
suction equipment
side rail padding
how many hrs of restraint does a prescription allow for an adult
4 hrs
how many hrs does a restraint prescription allow for a pt 9-17 yrs old
2 hrs
how many hrs does a restraint prescription allow for pt younger than 9 yrs old
1 hr
what class of fire extinguishers are for combustibles?
class A
what are examples of combustibles?
paper
wood
rags
class of fire extinguishers for flammable liquids and gas fires?
class b
class of fire extinguishers for electrical fires?
class c
should you go to the nurses station for help when a pt is having a seizure?
no stay with pt and use call light to call for help
what position to place pt having seizure
side lying (prevent choking on tongue)
what should you place along base of door to contain fire and smoke?
wet towels
how should infant be placed to rest?
on their back (back to sleep)
can you leave a mobile toy over a infants bed if they’re able to push up?
no
what kind of bed should climbing toddler be put in?
low bed
how should infants/toddlers under 2 yrs old car seats be placed?
rear facing
what kind of harness should be used for infant/children?
5 point harness
what should be used after a child outgrows a forward facing car seat?
booster seat
what spf of sunscreen should be used for toddlers
30 spf or higher
who should use booster seats?
children less than 4’9
weigh less than 40lbs
4-8 yrs old
children under what age should sit in backseat
under 12
where should bullets be stored
different location from guns
water heaters should not be higher than what temperature
120 degrees Fahrenheit
where should ice packs be placed for heat stroke pt
axillae
chest
groin
neck
should a burn pt be NPO?
yes
how does CO2 reduce the oxygen
binding to hemoglobin
can nail polish be used near pt receiving oxygen?
no (its flammable)
what material of clothing and bedding should a pt receiving oxygen use
cotton (*wool/synthetic create static electricity/fires)
HOB elevated 15-45 degrees is what position
semi fowlers
HOB elevated 45-60 degrees is what position
fowlers
what position for NG tube insertion and suctioning
fowlers (45-60 degrees)
what position to prevent regurgitation and aspiration for dysphagia pts
semi fowlers
position for pts with dyspnea or receiving mechanical ventilation
semi fowlers
pt lying supine with HOB elevated 60-90 degrees
high fowlers
position for severe dyspnea and prevents aspiration during meals
high fowlers
supine is also known as
dorsal recumbent
which position prevents hip flexion contractions after lower extremity amputation
prone
position for COPD
orthpneic
pt sitting with arms resting on pillow on overbed table across their lap is what position
orthopneic
position for hypovolemia
modified trendelenburg
when should you take a break from repetitive movements to flex/stretch joints and muscles
every 15-20 mins
how should knees be when sitting for long periods of time
higher than hips
how to treat anthrax inhalation
cipro & doxy plus 1 or 2 additional antibiotics
how to treat cutaneous anthrax
just cipro and doxy
how to treat mass casualty tularemia
cipro or doxy
how to treat general tularemia
streptomycin or gentamicin
what to do for bed confined pts during tornado
place blankets over them
should u apply water to a dry chemical exposure?
no (could activate chemical)
how to get dry chemical off
use brush to remove from skin and clothing
how often should dental assessments be done
every 6 months
how often should TB skin tests be done
every 2 years
how often should skin assessments be done for ages 20-40
every 3 yrs
how often should skin assessments be done for ages 40+
annually
how much weight do newborns gain a week in the 1st 6 months
5-7 oz
when should an infant demonstrate a head lag
1 month
when should an infant have a strong grasp reflex
1 month
what should a 1 month old infant have
head lag
strong grasp reflex
when should infant be able to lift head off mattress when prone
2 months
when should infant hold hands in open position and grasp reflex fade
2 months
when should infant raise head and shoulders off matress when prone
3 months
when should infant have only a slight head lag
3 months
when should an infants grasp reflex disappear
3 months
when should infant keep hands loosely open
3 months
when should an infant roll from back to side
4 months
when should infant be able to grasp objects w both hands
4 months
when should infant be able to put objects in mouth
4 months
when should infant roll from back to front
6 months
when should infant hold bottle
6 months
when should infant bear full weight on feet
7 months
when should infant sit leaning forward on both hands
7 months
when should infant be able to move objects from hand to hand
7 months
when should an infant be able to sit unsupported
8 months
when should infant start using pincer grasp
8 months
when should infant be able to pull to a standing position
9 months
when should infant have crude pincer grasp.
9 mo
when should infant dominant hand be evident
9 months
when should infant be able to change from prone to sitting position
10 mo
when should infant grasp rattle by its handle
10 mo
when should infant be able to walk while holding onto something
11 mo
when should infant be able to place object into container
11 mo
when should infant develop neat pincer grasp
11 mo
when should infant be able to sit down from standing w/o help
12 mo
when should infant be able to walk with one hand held
12 mo
when should infant be able to attempt to build 2 block tower
12 mo
when should an infant be able to turn pages in a book
12 mo
according to piaget birth to 2 yrs is what stage
sensorimotor stage
when does object permanence develop according to Piaget
9 mo
when will newborn regain birth weight?
2nd week of life
when does the anterior fontanel close?
12-18 months (toddler)
toddler age range
1-3 years
infant age range
2 days-1 year
how many hrs does a toddler sleep a day
15 hrs
when does the posterior fontanel close
2-3 mo (infant)
when should birth weight double
4-6 months
when does birth weight triple?
end of 1st year
how much does infant head circumference increase per month in 1st 3 months
2 cm per month
how much does infant head circumference increase per month in months 4-6
1 cm per month
young adult age range
20-35 yrs old
can a pt on bleedng precautions have a rectal temp taken?
no
a body temp lower than 95 degrees fahrenheit is considered?
hypothermia
what age do female adolescents stop growing
16-17 years old
adolescent age range
12-20 years
when do male adolescents stop growing
18-20 years old
what nutrients are adolescents deficient in
iron
calcium
vitamins A & C
1st sign of female puberty
appearance of breast buds
2nd sign of female puberty
pubic hair growth
3rd sign of female puberty
menstration
1st sign of male puberty
increase in testes & scrotum size
2nd sign of male puberty
pubes
3rd sign of male puberty
rapid genitalia growth
4th sign of male puberty
armpit hair
5th sign of male puberty
mustache
6th sign of male puberty
change in voice
age appropriate activities for adolescents
video games
music
movies
caring for pet
career training program
reading
adolescent immunizations
HPV
Hep A & B
measles
mumps
rubella
varicella
seasonal influenza
meningococcal & polio
young adult age range
20-35 yrs old
what age group does physical senses peak
young adults
what age range do muscles function optimally
25-30
how to position ear when taking tympanic temp of adult
up and back
how to position ear when taking tympanic temp of child younger than 3 yrs old
down and back
can u use electronic ear thermometers for infants 3 months and younger
no
why cant u use electronic ear thermometers for infants 3 months and younger
inaccurate readings
which nervous system controls heart rate
autonomic
which nervous system lowers HR
parasympathetic nervous system
which nervous system raises HR
sympathetic
what should u grade an absent pulse
0
what should u grade a weak pulse
1+
what should u grade a brisk pulse
2+
what should u grade an increased/strong pulse
3+
what should u grade a bounding pulse
4+
how does hypothermia affect HR
slows it down
how does digoxin affect HR
slows it down
how do beta blockers affect HR
slows it down
how do calcium channel blockers affect HR
slows it down
how does goes from standing/sitting to lying down affect HR
slows it down
how does chronic severe pain affect HR
slows it down
how does hypothyroidism affect HR
slows it down
how does changing position from lying down to sitting/standing affect HR
speeds it up
how does epinephrine affect HR
speeds it up
how does levothyroxine affect HR
speeds it up
how do beta-adrenergic agonists affect HR
speeds it up
how does hyperthyroidism affect HR
speeds it up
how does anemia affect HR
speeds it up
how does hypoxemia affect HR
speeds it up
how does hypovolemia affect HR
speeds it up
how does shock affect HR
speeds it up
how does heart failure affect HR
speeds it up
how does hemorrhage affect HR
speeds it up
injury to which part of the brain decreases resp rate and rhythm
brain stem
increased resp rate, reg pattern but abnormally deep is called
kussmaul respirations
which cranial nerves do you test for the head and neck
V, VII, XI
the trigeminal cranial nerve is what number
V
what are u assessing when u check cranial nerve V (trigeminal)
face for strength and sensation
how to assess cranial nerve V motor function
have pt clench teeth and palpate masseter, temporal muscles & temporomandibular joint
how to test sensory function of cranial nerve V
have pt close eyes and touch face gently with wisp of cotton. pt tells u when they feel touch
what cranial nerve is the facial nerve
cranial nerve VII
what does cranial nerve VII assess
symmetrical facial movement
how to assess cranial nerve VII
have pt smile, frown, puff out cheeks, raise eyebrows, close eyes tightly and show teeth
how to asses cranial nerve XI
place hands on pts shoulders and have them shrug against resistance
which cranial nerve is the optic nerve
cranial nerve II
what does cranial nerve II asses
visual acuity and visual fields
which cranial nerve is the oculomotor nerve
cranial nerve III
which cranial nerve is the trochlear nerve
cranial nerve IV
which cranial nerve is the abducens nerve
cranial nerve VI
what does cranial nerve VI asses
extraocular movements
which cranial nerve is the oculomotor nerve
cranial nerve III
what does cranial nerve III asses
pupillary reaction to light
what does cranial nerve V asses
corneal light reflex
what does a thyroid bruit indicate
hyperthyroidism
test for color blindness
ishihara test
which cranial nerve is the olfactory nerve
cranial nerve 1
what does cranial nerve I assess
smell
what does cranial nerve VIII asses
hearing
which cranial nerve is the auditory nerve
cranial nerve VIII
which cranial nerve is the glossopharyngeal nerve
cranial nerve IX
which cranial nerve is the vagus nerve
cranial nerve X
what does cranial nerve X assess
the mouth for movement of the soft palate & gag reflex
what does cranial nerve XII assess
the tongue for movement and strength
where do u place vibrating fork during rinne test
against mastoid bone
where do u place vibrating fork during weber test
on top of pts head
when is optimal time for breast self exams
4-7 days after menses begins or right after menstruation ends
where are the occipital nodes
at the base of the skull
where are the postauricular nodes
over the mastoid
where are the preauricular nodes
in front of the ear
where are the tonsillar nodes
angle of the mandible
where are the submandilar nodes
along he base of the mandible
where are the submental nodes
midline under the chin
where are the anterior cervicle nodes
along the sternocleidomastoid muscle
where are the posterior cervicle nodes
posterior to the sternocleidomastoid muscle
where are the supraclavicular nodes
above the clavicles
what should you have pt do while u palpate thyroid gland
sip water
how should you evaluate further if pts thyroid gland is enlarged upon palpation
auscultate for bruits
what are you assessing when you test pts visual acuity
distant and near vision
what do snellen/rosenbaum charts test
distant vision
what do eye covers test
distant vision
extraocular movements
visual fields
what do ishihara test
color blindness
what do hand held cards test
near vision
how to test ocular internal structures
ophthalmoscope
impaired far vision (nearsightedness) is called what
myopia
what does a snellen chart screen for
myopia
how far should pt stand from snellen chart
20 ft
what does the first number in snellen chart results mean? (ex. the “20” in 20/30 vision)
distance pt stands from the chart
what does the second number in snellen chart results mean? (ex. “30” in 20/30 vision)
distance unimpaired vision can read same line clearly
impaired near vision (farsightedness) is called what
presbyopia
what does the rosenbaum eye chart screen for
presbyopia
how far should rosenbaum eye chart be held away from pts face
14 inches
which cranial nerves test for extraocular movements (eye coordination)
III, IV, VI
what is saccade
rapid movement of the eyes between fixation points (sharingan ignore this)
what does the trochlear (CN IV) do
allows your eye to look down, up and back and forth
what does the abducens nerve (CN VI) do?
controls lateral movement of eye balls
what does the oculomotor nerve (CN III) do?
helps adjust/coordinate eye position during movement
what does the optic nerve (CN II) do?
transmits visual information (retina translates light into electrical signal, optic nerve carries info to brain, brain shows images)
which cranial nerve does glaucoma effect?
optic nerve (CN II)
how to asses visual fields?
have pt cover one eye and check peripheral vision by having them tell when they see fingers coming in from up, down, temporally and nasally)
bulging eyes are called
exophthalmos
eye crossing is called
strabismus
what is ptosis
eyelid drooping
where are the lacrimal glands
upper outside of eyelids
what is the sclera
white of the eye
what is conjunctiva
inside of eyelids and covers sclera
what color will sclera be in pts with dark complexions
light yellow with possible brown macules
what causes brown spots on sclera
melanin
cloudy are in eye lens is called
cataracts
how big should pupils be
3-7 mm
what does the olfactory nerve (CN I) do
controls sense of smell
which cranial nerve controls facial expressions
facial nerve (CN VII)
which cranial nerve controls tears
facial nerve (CN VII)
which cranial nerve enables swallowing
glossopharyngeal nerve (CN IX)
what does the auditory/vestibular nerve (CN VIII) control
hearing and balance
which cranial nerve controls taste
glossopharyngeal nerve CN IX)
what does the vagus nerve (CN X) do
controls parasympathetic nervous system (digestion, HR, BP, mood, speech etc)
what does the accessory nerve (CN XI) do
controls shoulder/neck muscle movement
what does the trigeminal nerve (CN V) do
controls jaw muscles (biting, chewing), facial, cheeks and scalp sensations
what does the hypoglossal nerve (CN XII) do?
controls tongue
which cranial nerve helps you taste food in the back of your tongue?
glossopharyngeal nerve (CN XI)
which cranial nerve controls the muscle that lifts the larynx and pharynx to allow swallowing
glossopharyngeal nerve (CN IX)
which cranial nerve controls the gland that decreases saliva production when you’re done eating
glossopharyngeal nerve (CN IX)
where is the soft palate
muscular, non bony part of mouth roof
where is the hard palate
bony front part of mouth roof
which cranial nerves does the gag reflex test
glossopharyngeal nerve (CN IX) & vagus nerve (CN X)
should otoscope speculum be touching the ear canal
no
how far into ear canal should otoscope speculum be inserted in ear canal
1-1.5 cm
what color should tympanic membranes be
pearly gray
how should tympanic membranes look
intact, taut and free from tears
asian and native american cerumen will look
dry
what color is moist cerumen
light brown to gray
which cranial nerve does the whisper test assess
auditory nerve (CN VIII)
glare intolerance is an expected change with?
aging
delayed pupillary reaction to light is an expected change with?
aging
thickening of the tympanic membrane is an expected change with
aging
loss of high frequency tone hearing is called
presbycusis
loss of all hearing frequencies is called
strial
loss of hearing at all frequencies but worse with high frequencies is called
cochlear conductive loss
how does voice pitch change with aging
gets higher
where do u auscultate the right middle lobe
the axillae
how many lobes does the right lung have
3
how many lobes does the left lung have
2
how to remember intercostal spaces
corresponds with number of the rib above it
how to treat gastric dilation with NG tube
lavage
how to treat active bleeding with NG tube
lavage
how to treat poison ingestio with NG tube
lavage
washing out stomach with NG tube is called what
lavage
preventing GI or esophageal hemorrage with an internal balloon is called what
compression
what NG tube is used for compression
sengstaken-blakemore
what NG tube is used for lavage
Ewald, Levin, Salem sump
what should you review in pts history before inserting NG tube
nasal problems
anticoagulant use
previous trauma
history of aspiration
what sized catheter tipped syringe should be used. forNG tube
30-60 mL
what is used to measure gastric secretion acidity
pH test strips
what postion should pt be in for NG tube placement
high fowlers
what type of gloves should you wear for NG tube placement
clean gloves
how should you assess abdomen intraprocedure for NG tube placement
ausculate for bowel sounds
palpate for distension, pain and rigidity
what should you do if pt vomits during NG tube placement
clear airway and provide comfort before continuing
what is the expected pH of gastric secretions when u check during NG tube placement
4 or less
what should you assess gastric secretions for during NG tube placement
ph, odor, color, consistency
how. do you confirm NG tube placement
x-ray
can you confirm NG tube placement by injecting air into the tube and auscultating over abdomen
no
where should you secure NG tube after placement verification
the nose
how far should you advance the tube NG tube if its not in the stomach
1-2 in (2.5-5 cm)
should you clamp an NG tube
yes
should you clamp an NG tube if its connected to a suction device
no
can nurses delegate measuring NG tube output?
yes
how long is NG tube therapy meant to be
short term
how long is gastrostomy or jejunostomy therapy meant to be
longer than 6 weeks
how are gastrostomy or jejunostomy tubes inserted
surgically
how long are percutaneous endoscopic gastronomy or jejunostony meant for
longer than 6 weeks
how are percutaneous endoscopic gastronomy or jejunostomy inserted
endoscopically
eneteral access tube syringe size
30-60 mL
what equipment should you have available incase of aspiration during enteral feeding
suction equipment
