Fundamentals Flashcards
Ability of the client to make personal decisions, even when those decisions may not be in the client’s own best interest.
Autonomy
Agreement that the care given is in the best interest of the client; taking positive actions to help others.
Beneficience
Agreement to keep one’s promise to the client about care that was offered.
Fidelity
Fair treatment in matters related to physical and psychosocial care and use of resources.
Justice
Avoidance of harm or pain as much as possible when giving treatments
Nonmaleficence
Problem that cannot be solved solely by a review of scientific data, involves a conflict between two moral imperatives, and the answer will have a profound effect on the situation/client.
Ethical dilemma
Support of the cause of the client regarding health, safety, and personal rights
Advocacy
Willingness to respect obligations and follow through on promises
Responsibility
Ability to answer for one’s own actions.
Accountability
Protection of privacy without diminishing access to quality care.
Confidentiality
document that can be used to assist with end-of-life and organ donor issues
Uniform Determination of Death Act (UDDA)
A family has conflicting feelings about the initiation of nasogastric tube feedings for their
father, who is terminally ill
Ethical Dilemma
a nurse fails to implement safety measures for a
client who has been identified as at risk for falls.
Negligence
a nurse administers a large dose of medication
due to a calculation error.the client has a
cardiac arrest and dies.
Malpractice (Professional negligence)
a nurse releases the medical diagnosis of a client
to a member of the press.
Breach of confidentiality
a nurse tells a coworker that she believes the
client has been unfaithful to her spouse.
Defamation of character
the conduct of one person makes another
person fearful and apprehensive (threatening
to place a nasogastric tube in a client who is
refusing to eat).
Assault
intentional and wrongful physical contact with
a person that involves an injury or offensive
contact (restraining a client and administering an
injection against her wishes).
Battery
a person is confined or restrained against his
will (using restraints on a competent client to
prevent his leaving the health care facility).
False imprisonment
T/F: Access to the client’s medical record should be restricted to only those health
care providers who are involved directly in the client’s care.
True
SOAPIE:
S – Subjective data O – Objective data A – Assessment (includes a nursing diagnosis based on the assessment) P – Plan I – Intervention E – Evaluation
PIE:
P – Problem
I – Intervention
E – Evaluation
DAR (focus charting):
D – Data
A – Action
R – Response
Serous
Clear
Sanguinous
contains red blood cells
Purulent
contains leukocytes and bacteria
Airborne Precautions (measles, varicella, tuberculosis)
A private room
Masks/respiratory protection devices for caregivers and visitors
An N95 or high-efficiency particulate air (HEPA) respirator is used if the
client is known or suspected to have tuberculosis.
Negative pressure airflow exchange in the room of at least six exchanges per
hour
Droplet Precautions (Strep, pneumonia, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia/sepsis, pneumonic plague)
A private room or a room with other clients with the same infectious disease
Masks for providers and visitors
Contact Precautions (RSV, shigella, enteric diseases, wound infections, herpes simplex, scabies, MRSA)
A private room or a room with other clients with the same infection
Gloves and gowns worn by the caregivers and visitors
Disposal of infectious dressing material into a single, nonporous bag
without touching the outside of the bag
The use of precise practices to reduce the number, growth, and spread of micro-organisms from an object, person, or area. Previously referred to
as “clean technique,” medical asepsis is used for administering oral medication, managing nasogastric tubes, providing personal hygiene, and performing many other common nursing tasks.
Medical Asepsis
The use of precise practices to eliminate all micro-organisms from an object or area. Also known as “sterile technique,” surgical asepsis is used for parenteral medication administration, insertion of urinary catheters, surgical procedures, sterile
dressing changes, and many other common nursing procedures.
Surgical Asepsis
When entering a client’s room to change a surgical dressing, a nurse notes that the client is coughing
and sneezing. When preparing the sterile field, it is important that the nurse:
place a mask on the client to limit the spread of micro-organisms into the surgical wound
According to Erikson’s developmental theory, which of the following client activities is an indicator
that the client is meeting the tasks expected in middle adulthood?
The client expresses concerns about the next generation
When performing a psychosocial assessment, a nurse should expect a healthy middle adult to
accept one’s life as creative and productive
level of prevention - addresses the needs of
healthy clients to promote health and prevent
disease with specific protections.
•immunization programs
•Child car seat education
•nutrition and fitness activities
•Health education in schools
Primary Prevention
level of prevention - focuses on early identification of individuals or communities experiencing illness, providing treatment, and conducting activities that are geared to prevent a worsening health status.
• Communicable disease scr
eening and case
finding
• early detection and treatment of diabetes
• exercise programs for older adult clients
who are frail
Secondary Prevention
level of prevention - aims to prevent the long-
term consequences of a chronic illness or
disability and to support optimal functioning.
• Prevention of pressure ulcers as a
complication of spinal cord injury
• Promoting independence for the client
who has traumatic brain injury
Tertiary Prevention
A 21-year-old male client presents to the health clinic for a sore throat. The client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the
nurse anticipate will be performed for this client?
Testicular Cancer
Rapid over a short period of time (hours or days) LOC is usually altered Increase in Restlessness Rapid personality Change Some perceptual disturbances VS may be unstable Reversible
Delirium
Gradual deterioration of function over months or yrs LOC unchanged Behaviors usually remain stable Personality change is gradual VS usually stable Irreversible
Dementia
Caused by a loss of nerve cells and progressive decrease in dopamine activity
Parkinson’s disease
Genetically transmitted disease in which a profound state of dementia and ataxia occurs within 5 to 10 years of onset
Huntington’s disease
Caused by a transmissible agent known as a “slow” virus; clinical course is rapid, with progressive deterioration and death within 1 year
Creutzfeldt-Jacob disease
Progressive dementia caused by thiamine deficiency, usually occurring due to long-term alcohol abuse
Korsakoff’s syndrome
Both the client and family members may refuse to believe that changes, such as loss of memory, are taking place, even when those changes are obvious to others.
Denial
The client may make up stories when questioned about events or activities that she does not remember. This may seem like lying, but it is actually an unconscious attempt to save self-esteem and prevent admitting that she does not remember the occasion.
Confabulation
The client avoids answering questions by repeating phrases or behavior. This is another unconscious attempt to maintain self-esteem when memory has failed.
Perseveration
Four Stages of Alzheimer’s Disease:
- Forgetfulness
- Confusion
- Ambulatory dementia
- End stage
Legal documents that direct end-of-life issues
Advance directives
Directive documents for medical treatment per client’s wishes.
Living WIll
A document that appoints someone to
make medical decisions when the client is no longer able to do so on his own behalf.
Durable power of attorney for health care
Kubler-Ross: five stages of Grief
Denial – The client has difficulty believing a terminal diagnosis or loss.
Anger – The client lashes out at other people or things.
Bargaining – The client negotiates for more time or a cure.
Depression – The client is saddened over the inability to change the situation.
Acceptance – The client recognizes what is happening and plans for the future.
this grief entails an experienced loss that cannot be publicly shared or is not socially acceptable, such as suicide.
disenfranchised grief
In which stage of grief, per Kübler-Ross, is a client who is terminally ill displaying when she states
that she is going to a clinic for acupuncture?
Bargaining - A client who tries alternative treatments is attempting to negotiate a way to lengthen life or
find cures.
Which of the following is a sign of impending death? A. Elevated blood pressure B. Warm extremities C. Tense muscles D. Labored breathing
Labored breathing
Communication that occurs within an individual.
Intrapersonal communication
Addresses spiritual needs and provides interventions to meet these needs
Transpersonal communication
the incentive or motivation for communication to occur between one person
and another
referent
the method of transmitting and receiving a message (received via sight, hearing, and/or touch)
Channel
- increases blood flow
- increases tissue metabolism
- relaxes muscles
- eases joint stiffness and pain
Therapeutic effect of heat
• decreases inflammation • Prevents swelling • reduces bleeding • reduces fever • diminishes muscle spasms • decreases pain by decreasing the velocity of nerve conduction
Therapeutic effect of cold
Sequential compression devices are used to
promote venous return
Which of the following nursing interventions reduce the risk of thrombus development?
apply elastic stockings, assist the client to change position often
small doses of substances (remedies) that would produce symptoms of the disease state in a well person are given to ill clients to bring about healing.
Homeopathic medicine
diet, exercise, environment, and herbal remedies are used to promote the natural healing of the body.
Naturopathic medicine
guided imagery/visualization therapy - encourages healing and relaxation of the body by having the
mind focus on images
Healing intention - techniques that use caring, compassion, and empathy in the context of prayer to facilitate healing
breath work - various breathing patterns used to reduce stress and increase relaxation
Humor - a coping mechanism used to reduce tension and improve mood
meditation - a technique used to calm the mind and body
simple touch - Communicates presence, appreciation, and acceptance
music therapy - type of relaxation therapy that provides distraction from pain; earphones encourage improvement of concentration
therapeutic communication - allows clients to verbalize and become aware of emotions and
fears in a safe, nonjudgmental environment
Complementary alternative therapies
provide most of the body’s energy and fiber. Each gram produces 4 kcal. Sources include whole grain breads, baked potatoes, and brown rice.
Carbohydrates
are also used for energy and provide vitamins. No more than 30% of caloric intake should be from this source. Each gram produces 9 kcal. Sources include olive oil, salmon, and egg yolks.
Fats
contribute to the growth and repair of body tissues. Each gram produces 4 kcal. Sources include ground beef, whole milk, and poultry.
Proteins
must be consumed daily and are necessary for metabolism. Water-soluable, Fat-soluble
Vitamins, fat-soluble (ADEK)
complete essential biochemical reactions in the body (calcium, potassium, sodium, iron).
Minerals
replaces fluids lost through perspiration, elimination, and respiration
Water
Body weight less than 85% of ideal
■ Fear of being fat
■ Feeling fat
■ With female clients, no menses for at least 3 consecutive months
Anorexia nervosa
determined by dividing weight (in kg) by height (in m2).
BMI
clear and full liquids plus diced or ground foods
mechanical soft
foods that are low in fiber and easy to digest
soft/low-residue
(whole grains, raw and dried fruits)
High-fiber
A nurse is caring for a client who is at high risk for aspiration. Which of the following is an
appropriate nursing intervention?
A. Give the client thin liquids.
B. Instruct the client to tuck her chin when swallowing.
C. Have the client use a straw.
D. Encourage the client to lie down and rest after meals.
Instruct the client to tuck her chin when swallowing
Which of the following is appropriate for a nurse to give a client who is on a low-residue diet? A. Whole grains B. Fruits and vegetables C. Dairy products D. Nuts and legumes
Dairy products
1 mg = 1,000 mcg 1 g = 1,000 mg 1 kg = 1,000 g 1 oz = 30 mL 1 L = 1,000 mL
1 tsp = 5 mL 1 tbsp = 15 mL 1 tbsp = 3 tsp 1 kg = 2.2 lb 1 gr = 60 mg
For dosages less than 1.0, round to the nearest hundredth.
For dosages greater than 1.0, round to the nearest tenth.
General Rounding Guidelines
brand or proprietary name that is given by the company that manufacturers the medication. One medication may have multiple trade names.
Trade name
official or non-proprietary name that is given by the United States. Adopted Names Council. Each medication has only one generic name.
Generic name
Six Rights of Safe Medication Administration:
Right client, Right medication, Right dose, Right time, Right route, Right documentation
A medication may be given within 30 min of the scheduled time.
yep
Which of the following nursing actions may prevent medication errors?
A. Taking all medications out of the unit-dose wrappers before entering the client’s room.
B. Checking with the provider when a single dose requires administration of multiple tablets.
C. Giving the prescribed medication and then looking up the usual dosage range.
D. Relying on another nurse to clarify a medication prescription.
Checking with the provider when a single dose requires administration of multiple tablets.
type of im injection that prevents medication from leaking back into subcutaneous tissue. it is often used for medications that cause visible and/or
permanent skin stains such as certain iron preparations.
Z-track
what needle do you use for intradermal injection?
tb syringe, 26-27 fine gauge needle
what needle do you use for subcutaneous injection?
3/8 to 5/8, 25-27gauge needle
what needle do you use for intramuscular injection?
18-27gauge (22-25gauge), 1-1.5 long needle
After an oral medication has been absorbed, most of the medication is inactivated as the blood
initially passes through the liver, producing little therapeutic effect. This is called
A. tolerance.
B. first-pass effect.
C. antagonism.
D. synergism.
first pass effect
Intravenous administration of a medication eliminates the need for A. absorption. B. distribution. C. metabolism. D. excretion.
absorption
Nitroglycerin (Nitrogard) tablets, which are often prescribed for clients who have cardiovascular
disorders, are given sublingually. This means that the tablets are
A. crushed and taken with a small amount of food.
B. held under the tongue until dissolved.
C. taken by mouth with a small amount of water.
D. placed between the cheek and gums.
held under the tongue until dissolved
reflects the force the blood exerts against the walls of the arteries during contraction (systole) and relaxation (diastole) of the heart.
Blood pressure (BP)
Transfer of heat from the body directly to another surface (when the body is immersed in cold water).
Conduction
Dispersion of heat by air currents (wind blowing across exposed skin).
Convection
Dispersion of heat through water vapor (sweating and diaphoresis).
Evaporation
Transfer of heat from one object to another object without contact between them (heat lost from the body to a cold room).
Radiation
delivers an Fi o2 of 24% to 44% at aflow rate of 1 to 6l/min.
• it is a safe, simple, and easy-to-apply method.
• it is comfortable and well-tolerated.
• the client is able to eat, talk, and ambulate.
Nasal Cannula
It delivers an Fio2 of 40% to 60% at flow rates of 5 to 8l/min.
• the minimum flow rate is 5l/min to ensure flushing of Co2 from the mask.
• a face mask is easy to apply and may be more comfortable than a nasal cannula.
• it is a simple delivery method.
• it is more comfortable than a nasal cannula.
Simple Face Mask
It delivers an Fio2 of 60% to 75% at flow rates of 6 to 11l/min.
• the mask has a reservoir bag attached with no valve, which allows the client to rebreathe up to 1/3
of exhaled air together with room air.
Partial rebreather mask
It delivers an Fio2 of 80% to 95% at flow rates of 10 to 15l/min to keep the reservoir bag 2/3 full during inspiration and expiration.
• it delivers the highest o2 concentration possible (except for intubation).
• a one-way valve situated between the mask and
reservoir allows the client to inhale maximum o2 from the reservoir bag. the two exhalation ports have flaps covering them that prevent room air
from entering the mask.
Nonrebreather mask
It delivers an Fio2 of 24% to 55% at flow rates of 2 to 10l/min via different size adaptors.
• it delivers the most precise oxygen concentration.
• Humidification is not required.
• it is best suited for clients who have chronic lung
disease.
High-Flow Oxygen Delivery System - precise amounts of oxygen
A nurse is caring for a client who is having difficulty breathing. The nurse should place the client in which of the following positions? A. Supine B. Dorsal recumbent C. Fowler’s D. Lateral
Fowler’s
Which of the following oxygen delivery systems should be used when a precise amount of oxygen needs to be delivered? A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask
Venturi mask
Which of the following interventions is appropriate when caring for a client who has a tracheostomy
tube?
A. Use medical asepsis when performing tracheostomy care.
B. Change the tracheostomy ties each time tracheostomy care is given.
C. Keep the cuff pressure between 14 and 20 mm Hg.
D. Clean the stoma site with the prescribed antibiotic solution.
Keep the cuff between 14 and 20mmHg
Intact skin with an area of persistent, non-blanchable redness, typically over a bony prominence, that may feel warm or cool to touch. The tissue is swollen and congested, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple.
Stage 1
Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage.
Stage II
Full thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed
muscle or bone. Drainage and infection are common.
Stage III
Full thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material).
Stage IV
Ulcers whose stage cannot be determined because eschar or slough obscures the wound.
Unstageable
Which of the following can the nurse do to prevent skin breakdown?
A. Massage the client’s bony prominences frequently.
B. Keep the client in high-Fowler’s position while in bed.
C. Have the client sit on a donut-shaped cushion.
D. Encourage repositioning every 15 min while the client is in the wheelchair.
Encourage repositioning every 15min while the client is in the wheelchair
- Little or no tissue loss
- edges are approximated, as with a surgical incision
- Heals rapidly
- low risk of infection
- no or minimal scarring
Primary Intention
• Loss of tissue • wound edges widely separated (pressure ulcers, stab wounds) • longer healing time • increased risk of infection • scarring
Secondary intention
- widely separated
- deep
- spontaneous opening of a previously closed wound
- risk of infection
- extensive drainage and tissue debris
- Closed later
- long healing time
Tertiary intention
Closure of the mitral and tricuspid valves
S1
Closure of the aortic and pulmonic valves
S2
Impeded blood flow in the heart
Murmur
Rapid ventricular filling
S3
Strong atrial contraction
S4
Obstructed blood flow in peripheral circulation
Bruits
Just right of the sternum at the second ICS
Aortic
Just left of the sternum at the second ICS
Pulmonic
Just left of the sternum at the third ICS
Erb’s point
Just left of the sternum at the fourth ICS
Tricuspid
Left midclavicular line at the fifth ICS
Apical/mitral
