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Lab Flashcards

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1
Q

What are the 6 different bed positions

A

High Fowlers Fowler’s, Semi-Fowler’s, Trendelenburg, Reverse Trendelenburg’s, Flat

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1
Q

Describe the Fowler’s Position

A

Head of the bed is raised to (45-60 degrees) a more semi-sitting position, foot of bed may also be raised at knee.

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2
Q

Uses of the Fowler’s position

A
  • Preferred while patient eats
  • Is used during nasogastric tube insertion and nasotracheal suction
  • Promotes lung expansion
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3
Q

Describe the semi-fowlers position

A

Head of bed raised approximately 30 degrees, food of bed may also be raised at knee

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4
Q

Uses of the semi-fowlers position

A
  • Promotes lung expansion
  • Is used when patients receive gastric feedings to reduce regurgitation and risk of aspiration
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5
Q

Describe Trendelenburgs position

A

entire bed frame with head of bed down

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6
Q

uses of Trendelenburgs position

A
  • Used for postural drainage
  • Facilitates venous return in patients with poor peripheral perfusion
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7
Q

Describe Reverse Trendelenburgs postion

A

entire bed frame tilted with foot of bed down

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8
Q

Uses of Reverse Trendelenburg

A
  • Is used infrequently
  • Promotes gastric emptying
  • Prevents esophageal reflux
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9
Q

Describe the Flat position

A

entire bed frame horizontally parallel with floor

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10
Q

Uses of the flat bed position

A
  • Is used for patients with vertebral inquires and in cervical traction
  • Is used for patients who are hypotensive
  • Is generally preferred by patients for sleeping
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11
Q

Asepsis

A

absence of disease producing microoganisms

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12
Q

Nosocomial

A

associated with or originating in a hospital setting

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13
Q

Antiseptic

A

an agent that inhibits or kills microorganisms on skin or tissue

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14
Q

pathogen

A

a microorganism that produces disease in most circumstances

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15
Q

bacteriostatic agent

A

an agent that prevents the growth and reproduction of bacteria

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16
Q

contaminated

A

possessing pathogenic organisms

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17
Q

medial asepsis

A

practices that limit the transmission of microorganisms, also called clean technique

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18
Q

carrier

A

a person who carries pathogen but is not ill

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19
Q

disinfection

A

a process that eliminates many microorganisms from inanimate environmental surfaces

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20
Q

sterilization

A

complete elimination of all microorganisms including spores

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21
Q

what are the six links for the chain of infection

A
  • infectious agent
  • reservoir
  • portal of exit
  • mode of transmission
  • portal of entry
  • host
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22
Q

what is an infectious agent

A

agent that causes disease

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23
Q

what is a reservoir

A

where a pathogen can survive but may or may not multiply (ie. a human body)

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24
Q

What is a portal of exit

A

the path by which the pathogen leaves the reservoir (mouth, nose, rectal, vaginal, and urethral openings)

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25
Q

What is a mode of transmission

A

how a microorganism is transmitted, can be direct or indirect (ie. chicken pox)

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26
Q

what is a portal of entry

A

how a pathogen enters the body (ie. body openings and breaks in the skin)

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27
Q

describe two infection control measures to reduce the reservoirs of infection

A

change wound dressing that are wet or soiled
empty urine containers properly (use of gloves pls)

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28
Q

what are the four stages of infection

A
  1. incubation period
  2. proximal stage
  3. illness stage
  4. convalescence
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29
Q

define pathogen

A

microorganisms that can cause disease

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30
Q

describe normal flora

A

microorganisms that reside on the surface and in deep layers of the skin. these do not typically cause disease

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31
Q

define sterile

A

disinfected materials, all bacteria and microorganisms are destroyed

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32
Q

define contaminated

A

when an object comes in contact with infectious pr potentially infectious material

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33
Q

define HAI

A

an infection acquired after admission to a health care facility that was not present or incubation at the time of admission

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34
Q

the potential for microorganisms to cause disease depends on what four factors

A
  • client susceptibility
  • disease process
  • medical therapy
  • age, stress, nutritional status
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35
Q

how would you break the chain of infection: wound infection

A

hand hygiene, contact precautions, gloves

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36
Q

how would you break the chain of infection: tuberculosis bacillus

A

N95 mask, now, gloves, negative pressurized room and hand hygiene.

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37
Q

how would you break the chain of infection: H.I.V

A

wear PPE

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38
Q

how would you break the chain of infection: Salmonella

A

hand hygiene and cook food properly

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39
Q

how would you break the chain of infection: FRI (febrile respiratory illness)(airborne)

A

PPE, hand hygiene, wiping surfaces, mask, clean face of client

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40
Q

how would you break the chain of infection: MRSA

A

contact precautions, hand hygiene, gowns, gloves, eye wear, isolated room

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41
Q

how would you break the chain of infection: C. difficile

A

contact precautions, gown, gloves, eye wear, isolated room

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42
Q

how would you break the chain of infection: VRE

A

contact precautions, hand hygiene, gown, gloves, isolated room

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43
Q

how would you break the chain of infection: COVID - 19

A

N95 mask, eye wear, gloves, hand hygiene, gown

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44
Q
A
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45
Q

Asepsis

A

absence of disease-producing microorganisms

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46
Q

nosocomial

A

associated with or originating in a hospital setting

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47
Q

antiseptic

A

an agent that inhibits or kills microorganisms on skin or tissues

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48
Q

pathogen

A

a microorganism that produces disease in most circumstances

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49
Q

bacteriostatic agent

A

an agent that prevents the growth of of reproduction of bacteria

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50
Q

contaminated

A

possessing pathogenic organisms

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51
Q

medical asepsis

A

practices that limit the transmission of micro-organisms, also called clean technique

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52
Q

carrier

A

a person who carries pathogens but is not ill

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53
Q

disinfection

A

a process that eliminates many microorganisms from inanimate environmental surfaces

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54
Q

sterilization

A

complete elimination of all microorganisms including spores

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55
Q

the six links that the chain of infection include

A
  • infectious agent
  • reservoir
  • portal of exit
  • mode of transmission
  • portal of entry
  • host
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56
Q

describe an infectious agent

A

agent that causes disease (virus, bacteria, fungi, protozoa)

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57
Q

describe a reservoir

A

where a pathogen can survive but may or may not multiply (a human body)

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58
Q

describe a portal of exit

A

the path by which the pathogen leaves the reservoir (mouth, nose, rectal, vaginal, and urethral openings)

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59
Q

describe a mode of transmission

A

how a microorganism is transmitted, can be direct or indirect (ie. chicken pox)

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60
Q

Describe a portal of entry

A

how a pathogen enters the body (ie. body opening and breaks in the skin)

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61
Q

describe two infectious control measures

A
  • change wound dressings that are wet or soiled
  • empty urine containers properly usual gloves
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62
Q

name the four stages of infection

A
  1. incubation period
  2. prodomal stage
  3. illness stage
  4. convalescence
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63
Q

define pathogen

A

microorganism that can cause disease

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64
Q

describe normal flora

A

microorganisms that reside on the surface and in deep layers of the skin. These do not typically cause disease

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65
Q

describe sterile

A

disinfected materials, all bacteria and microorganisms are destroyed

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66
Q

describe contaminated

A

when an object comes contact with infectious material or potentially infectious material

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67
Q

describe HAI

A

an infectious acquired after admission to a health care facility that was not present or incubating at the time of admission

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68
Q

the potential for microorganisms to cause disease depends on which four factors

A
  • client susceptibilities
  • disease process
  • medical therapy
  • age, stress, nutritional status
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69
Q

How would you break the chain of infection: wound infection - staph aureus

A

hand hygiene
contact precautions
gloves

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70
Q

How would you break the chain of infection: tuberculosis bacillus

A
  • N95 mask
  • gown
  • gloves
  • negative pressurized room
  • hand hygiene
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71
Q

How would you break the chain of infection: H.I.V

A

wear PPE

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72
Q

How would you break the chain of infection: Salmonella

A

cook food properly
hand hygiene

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73
Q

How would you break the chain of infection: FRI (febrile respiratory illness)(airborne)

A
  • PPE
  • hand hygiene
  • wiping surfaces
  • mask
  • clean face of client
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74
Q

How would you break the chain of infection: MRSA

A
  • contact precautions
  • hand hygiene
  • gloves
  • gowns
  • eye wear
  • isolated room
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75
Q

How would you break the chain of infection: C. difficile

A
  • contact precautions
  • gowns
  • gloves
  • eye wear
  • isolated room
  • hand hygiene
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76
Q

How would you break the chain of infection: VRE

A
  • contact precautions
  • gowns
  • gloves
  • eye wear
  • isolated room
  • hand hygiene
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77
Q

How would you break the chain of infection: COVID-19

A
  • N95 mask
  • eye wear
  • gloves
  • hand hygiene
  • gown
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78
Q

what does cross contamination mean and how do you prevent it

A

cross contamination id the transmission of microorganisms, to prevent this you must wear the proper PPE and dispose of anything contaminated properly, and make sure that soiled items and equipment must not touch nurses clothing. Plus proper hand hygiene

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79
Q

when would you wear clean examination gloves

A

whenever you need to touch a patient, and or do an examination

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80
Q

when would a gown be appropriate

A

when PPE is required, when with a patient who has an infectious disease.

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81
Q

when would you wear eye protection

A

when in contact with someone who is isolated, or with someone who has an airborne disease

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82
Q

how would you dispose of a used syringes

A

sharps container

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83
Q

how do you handle client care equipment

A

clean in between clients

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84
Q

what is the proper way of dispose of soiled linen

A

through into the laundry (moisture resistant bag)

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85
Q

what is your responsibility if you have an open or draining lesion

A

talk to the manager and look it up in your works policy to see if you can work with that lesion.
wear a bandage

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86
Q

what are the two goals when making a bed

A
  • clean
  • comfortable
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87
Q

what are the reasons for completely finishing one side of the bed and then moving to the other side

A
  • minimizing the time and use of energy
  • decreases the amount of time the client would have to move if the bed were occupied
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88
Q

the important safety features on beds include

A
  • locks on the wheels
  • alarms
  • side rails
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89
Q

the most important safety step to remember when making an occupied bed is

A
  • check the patients mobility, ensure they are able to role back and forth without harming themselves.
  • Also leave the rail up on the opposite side of the bed for the patient to hold onto
  • BREAKS ON
  • move the bed up to a comfortable height.
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90
Q

difference between an open and closed bed

A

an open bed id when the covers are folded to about the middle of the bed so the client can easily get into the bed
a closed bed is when the sheets are more drawn back

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91
Q

how does the nurse maintain proper body mechanics when making a bed

A
  • the bed should be raised to an appropriate height
  • make sure these rails are down
  • BREAKS ON
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92
Q

TRUE or FALSE: a turning sheet helps decrease friction and prevents skin injury when moving a client up in bed

A

true

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93
Q

TRUE or FALSE:the further the client is from the nurses centre of gravity the more stable the situation is and the client will have less fear of falling.

A

false
- the closer they are the more stable and comfortable they are.

94
Q

TRUE or FALSE: when a client is lying on their side, a pillow between the legs prevents abduction

A

false
it prevents adduction

95
Q

TRUE or FALSE: when transferring a client, the client should grasp the nurses neck

A

false
this can cause serious injury for the nurse

96
Q

TRUE or FALSE: a trochanter roll will help prevent the external rotation of the leg

A

true

97
Q

describe how you would prepare a client for ambulation

A
  • ensure they dont feel dizzy or lightheaded
  • able to sit in the upright position comfortably
  • check the floor incase it wet
  • ensure they understand what’s happening
  • make sure you have the right amount of people to help
98
Q

give reasons for bathing our client

A
  • they have discomfort in an area
  • they are letting off an odour
  • to preform a skin assessments
99
Q

what is the difference between a partial and complete bath

A

a complete bath is used with patients who are completely dependant and require total hygiene care.
A partial bath involves bathing only those body parts that would cause discomfort or odour id not cleaned, and those areas not easily reached by the patient

100
Q

5 guidelines that should be used when bathing a client

A
  • privacy
  • maintain safety
  • maintain warmth
  • promote indépendance
  • anticipate needs
101
Q

how are eyes cleansed

A

from inner to outer canthus

102
Q

When washing a clients arms and legs, the nurse washes from ________ to ______ proximal. This stimulates _______ blood flow

A

distal; proximal; venous

103
Q

TRUE or FALSE: harsh rubbing can cause tissue damage

A

true

104
Q

TRUE or FALSE: alcohol is better than lotion for back rubs because it toughens the skin

A

False

105
Q

TRUE or FALSE: soap increases surface tension in order to hold moisture in the skin.

A

False
- it decreases surface tension and drys out the skin

106
Q

TRUE or FALSE: a doctors note is needed to place oil in th bath water

A

false

107
Q

explain foot and nail care guidelines and the related assessments

A

watch diabetes, dont cut the mails. Check between toes, if you do cut nails cut straight across not rounded that can cause ingrown nails and hangnails

108
Q

what would you assess when caring for the feet

A

when assessing the feet, perform an examination of all the skin surfaces, including the areas between the toes and over the soles of the feet. check the the feet externally for sores as well as assessing temp and colour. check for pulses

109
Q

explain the purpose of oral hygiene

A
  • the purpose of oral hygiene is to make sure the gums and teeth stay healthy
  • its necessary to maintain the integrity of tooth surfaces and to prevent gingivitis (gum inflammation) and periodontal disease.
  • stimulates appetite
  • maintains hydration and cleanliness
  • mouth health and heart health have cooralation
110
Q

dermatitis

A

inflammatory condition of the skin can be chronic or acute

111
Q

ischemia

A

lack of blood supply to a part of the body

112
Q

turgor

A

the skins elasticity

113
Q

blanching

A

when you press on your skin and it goes lighter and the colour returns. when it goes white that’s blanching

114
Q

cyanosis

A

bluish discolouration cause by low oxygen in the blood, low hemoglobin

115
Q

pallor

A

defiance of colour in the face, pale face (when they are sick, in shock, dizzy, lightheaded)

116
Q

petechiae

A

tin red spots in the skin that’s broken blood vessels. Tiny hemorrhages in the skin

117
Q

hematoma

A

a pool of mostly clotted blood that forms in an organ, tissue or body spaces like bruises

118
Q

edema

A

areas of the skin become swollen or edematous from buildup of fluid in the interstitial spaces

119
Q

melanoma

A

an aggressive form of skin cancer an other cutaneous malignancies are the most common neoplasms seen in patients. black tumour

120
Q

eczema

A

a condition where your skin is excessive dry and irritated. can become bumpy

121
Q

jaundice

A

yellow-orangish discolouration. Sign of a problem with the liver. improper breakdown of bilirubin

122
Q

lesions

A

an area of abnormal or damaged tissue caused by injury, infection or disease. any abnormality on/in the skin

123
Q

induration

A

when the soft tissue like the skin become thicker and harder from an inflammatory process.

124
Q

necrosis

A

the death of body tissue
death of cells
goes pail, green, black then falls off

125
Q

basal cell carcinoma

A

a cancerous lesion.
most common in sun exposed areas and frequently occurs in a background of sun damaged skin. does not usually spread to other parts of the body
typically not dangerous

126
Q

list risk situations associated with pressure ulcer development

A
  • prolonged bed rest (impaired mobility)
  • impaired sensory reception
  • decrease blood supply
127
Q

explain shearing force

A

shear force is when gravity is pulling down the body down and there’s a surface (like a bed giving resistance). the skin and subcutaneous layers adhere to the bed, and if the persons body moves their muscles and bones move while their skin stays in the same place

128
Q

explain how moisture contributes to pressure ulcer formation

A

softens the skin which makes it more susceptible to damage

129
Q

explain how anemia contributes to pressure ulcer formation

A

lack of iron in the blood, diminished red blood cells, not getting enough oxygen in the blood which promotes slower healing

130
Q

explain how impaired circulation contributes to pressure ulcer formation

A

???????

131
Q

explain how poor nutrition contributes to pressure ulcer formation

A

food is the first medicine
vitamins and protein are crucial to speed up the healing process

132
Q

how does age contribute to pressure ulcer formation

A

as you get older your body dont work the same. skin gets softer and wrinklier

133
Q

where can pressure ulcers develop

A

in the boney areas of the body
- side of bum
- side of knee
- heel
- ankle
- hips
- tail bones
- elbows

134
Q

What is the high fowlers postition

A

A 90 degree angle, used to watch tv and eat.

135
Q

muscle tone

A

normal condition of tension of a muscle

136
Q

gait

A

the way a person walks

137
Q

range of motion

A

degree of movement possible for each joint

138
Q

ADL

A

activites of daily living

139
Q

adduction

A

movement toward midline of body

140
Q

pace

A

number of steps per minute

141
Q

abduction

A

movement away from midline body

142
Q

goniometer

A

device that measures the angle of joint movement

143
Q

passive exercises

A

exercise in which another provides energy to move

144
Q

active exercises

A

exercises carried on by the client that moves body parts

145
Q

what shape is the spine of a new born

A

c

146
Q

T or F: it is normal for an infant to have a extra gluteal fold

A

False

147
Q

T or F: at 5 months of age a baby rolls from prone to supine and back to prone

A

True

148
Q

T or F: at 8 months a baby can sit alone

A

true

149
Q

T or F at 12 months of age a baby may hold a cup and spoon and can feed self

A

true

150
Q

what is the age a baby can walk

A

14 months (have until 18)

151
Q

is t normal for toddlers to have lumbar lordosis

A

true

152
Q

what is lumbar lordosis

A

lower back is curving in sticking belly out

153
Q

at age 60 decrease in muscle mass, tone, and strength exceeds what percent

A

9-10%

154
Q

T or F: in the older adult, thinning of the intervertebral discs is normal musculoskeletal change

A

true

155
Q

the apperance of an older adults stance, posture is on of what

A

general flexion

156
Q

abnormal results for gait difficulty

A
  • clumsiness
  • weakness
  • pain
  • stiffness
  • dizziness or vision problems
157
Q

abnormal results: muscle complaints

A
  • weakness or fatigue
  • stiffness
  • pain
  • paralysis
  • spasms or tremors
  • muscle atrophy
  • muscle hypertrophy
158
Q

abnormal complaints: skeletal complaints

A
  • recent fractures or injury
  • abnormalities of skeletal contour
  • crepitus
  • pain with movement
  • ecchymosis or hematoma of injured part
159
Q

abnormal findings: joint complaints

A
  • recent injury
  • change in contour or size pf joints
  • limitations of joint motion
  • pain
  • swelling or redness of skin around joint
160
Q

the preferred site of body temperature assesment of children is

A

tempanic (ear)

161
Q

the average range of adult oral temperature is

A

36-38 C

162
Q

when is the someones temperature slightly higher during the 24 hour cycle

A

at 1800h

163
Q

when is someones temp the lowest in a 24 hour cycle

A

between 0100-0400

164
Q

the appropiate term for fever

A

pyrexia

165
Q

what are the words you use when describing a clients fever

A

febrile and unfebrile

166
Q

the most reliable indicator of a persons pain

A

self report

167
Q

what do the letters stand for in the OPQRSTUV mean

A

O: origin/onset (where and when did it start
P: Palliative/provocation (what makes the pain feel better or worse)
Q: Quality (what does the pain feel like)
R: Region/radiation/ where is the pain and where does it radiate
S: Severity (Pain 0-10)
T: Timing/treatment (when did the pain begin or end and how long did it last)
U: Understanding (What do you think is causing the symptoms
V: Value (are there any other views or feeling about this symptom that are important to you and the family)

168
Q

Bronchial sounds are heard over the

A

trechea

169
Q

Bronchovesicular sounds are heard over the

A

large airways near sternum and between scapulae

170
Q

vesicular breath sounds are heard over the

A

peripheral lung (side)

171
Q

resonance

A

hollow sound heard over normal lungs

172
Q

tympany

A

drum like sound heard over an air-filled stomach or intestines

173
Q

during insperation the diaphragm does what

A

descends and flattens

174
Q

what is the ration of the anteroposterior to transverse diameters of the adult chest wall

A

1:2

175
Q

when examining for tactile fremitus, it is important to

A

ask the patient to cough

176
Q

the pulse oximeter measures

A

arterial oxygen saturation

177
Q

what is the ranfe of respirations in a newborn

A

30-60

178
Q

what are the four characterisitics included in an assessment of respirations

A

rate
rythm/regularity
depth
effort

179
Q

eupnea

A

normal quiet breathing

180
Q

tachypnea

A

respiatory rate more than 24 b/m

181
Q

apnea

A

absence of respirations

182
Q

bradypnea

A

abnormally slow respirations (less than 12)

183
Q

dyspnea

A

difficult respirations

184
Q

hypoventalation

A

very shallow respiratins

185
Q

the first heart sound is created by the closure of what valves

A

mitral and tricuspid

186
Q

the second heart sound is created by the closing of what valves

A

semilunar

187
Q

the normal angle between fingernail and nailbed

A

160

188
Q

when checking a clients pulse what 4 things are you assessing

A

rate
rhythm
strength
symmetry/equality

189
Q

arrhythmia

A

a pulse with an abnomral rhythm

190
Q

pulse deficit

A

the difference between the apical and radial pulse

191
Q

tachycardia

A

pulse rate over 100 beats/m

192
Q

thorax

A

the chest cavity

193
Q

pulse

A

wave of blood produced when left ventricle f heart contract

194
Q

bradychardia

A

a very slow pulse rate

195
Q

carotid

A

used in cardiac arrest

196
Q

brachial

A

used ti determine blood pressure and used for infant pulses

197
Q

apical

A

used to determine discrepancies with radial pulse

198
Q

dorslis pedis

A

used to determin foor circulation

199
Q

systolic pressure

A

the pressure of the blood against the arterial walls when ventricles of the heart contract

200
Q

pulse pressure

A

the difference between diastolic and systolic pressure

201
Q

hypertension

A

abnormally high blood pressure

202
Q

diastolic pressure

A

the pressure of the blood against the arterial walls when ventricles of the heart are at rest

203
Q

hypotension

A

abnormally low blood pressure

204
Q

what is the first phase korotkoff phases

A

sharp thump

205
Q

what is the fourth phase of kororkoff

A

a softer blowind sound that fades

206
Q

what is phase five of the korotkoff

A

silence

207
Q

from blood pressure, information is gained about all the following except;
- the efficiney of the heart beat
- the adequacy of blood volume
- the balance between heat production and loss
- the resistance of the blood vessel

A

the balance between heat production and loss

208
Q

who is likly to have a high blood pressure

A

a pregnant women

209
Q

what factors control blood pressure

A

cardiac output, blood volume, viscosity, peripheral vascular resistance, stress

210
Q

before concluding that bowel sounds are absent how long do you have to listen

A

five minutes

211
Q

the characterisitic percussion sound elicited over the abdomen is

A

tymapanny

212
Q

the normal range of the liver span in the midclavicular line is

A

6-12 cm

213
Q

the normal percussion sound elicited over the liver is

A

dull

214
Q

to determine the position of the lower liver border, the nurse starts percussing

A

below he costal marjins and working to the RUQ

215
Q

in light palpation the abdomen wall is depressed ____cm or to the level of __________

A

2; tenderness

216
Q

T or F: when inspecting the abdomen normally peristalis should be visible

A

True

217
Q

T or F: Silver-white striae in the lower abdominal area are nomral

A

True

218
Q

T or F: on light palpation, you should be able to feel the liver, spleen, and kidneys

A

False

219
Q

T or F: elderly clients often manifest a more lax abnominal tone

A

true

220
Q

what is in the RUQ

A

gallbladfer
liver
duodenum
head of the pancreas

221
Q

whats in the LUQ

A

stomach
body of the pancreas

222
Q

whats in the RLQ

A

appendix
cecum

223
Q

whats in the LLQ

A

sigmoid colon

224
Q

urgency

A

feeling the need to void immediatly

225
Q

dysuria

A

painful or diffucult voiding

226
Q

frequency

A

voiding at frequent intervals

227
Q

hesitancy

A

difficulty getting the flow of urine started

228
Q

obliguria

A

decreased urine output (less than 400ml/24 hours)

229
Q

nocturia

A

voiding often during the night

230
Q

dribbling

A

leakage of urine despite voluntary control of voiding

231
Q

urinary retention

A

accumulation of urine in th ebladder

232
Q

residual urine

A

not feeling as if able to empty the bladder (volume of 100ml or more of urine remaining in the bladder after voiding)

233
Q
A

Nursing (6 decks)

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