Midterm Flashcards
When do you wash your hands?
- Before touching a patient
- Before a clean or aseptic procedure
- After a body fluid exposure risk
- After touching a patient
- After touching patient’s surroundings
What are the four hospital acquired infections?
- Catheter-associated urinary tract infection (CAUTI)
- Surgical site infection (SSI)
- Central line-associated bloodstream infection (CLABSI)
- Ventilator-associated pneumonia (VAP)
What are used to prevent hospital accquired infections?
chlorhexidine gluconate wipes
What are the key elements of the communication process in healthcare?
Source: Patient, Doctor, Nurse, Family, Manager Doctors
Message: Verbal, Nonverbal, Nursing notes, Doctor consults
Channel: Auditory, Visual, Touch
Receiver: Interprets Message
Feedback: Confirmation they received the message
Noise: Distractors in the process
What are key considerations for verbal and nonverbal communication in healthcare?
Verbal Communication Considerations: Intellectual development, Primary Language, Culture
Nonverbal Examples: Touch, Eyes, Facial Expressions, Posture, Gait, Gestures, Physical Appearance, Sounds, Silence
Why is mobility important?
- Prevent DVTs and increases perfusion
- Helps open our lungs and prevent atelectasis/ closed alveoli which can cause pneumonia
- Increases strength, joint mobility, and coordination
- Increases gastric motility
When using a gait belt, which side of the patient do you stand on?
Patient’s weaker side
What are key guidelines for using a walker?
Proper fit: 15° angle at the elbows
- Move walker, then step into it with the weak side first
- Do not use on stairs
What are key guidelines for using a cane?
Proper fit: 15° angle at the elbow
- Cane goes on the strong side
- Weak leg and cane move at the same time
What steps should you follow after a needle stick injury?
Follow hospital policy
- Immediately wash the area with soap and water
- Notify the charge nurse
- Go to the ER and get labs drawn
- Follow up with employee health
What is the normal temperature range in Celsius and Fahrenheit?
35.9°C to 38°C (96.7°F to 100.4°F)
What nursing care is provided for a fever?
Focus on increasing comfort and preventing complications. Typically provide Tylenol or Ibuprofen for temps >101°F (or as ordered) and use ice packs.
What nursing care is provided for hypothermia?
Focus on warming the patient using a Bair Hugger (medical heating blanket) or warm blankets from a heater.
What are the five common temperature sites and their key details?
Oral: Must close mouth; wait 15-30 mins after eating hot/cold
Tympanic (Ear)
Temporal (Forehead)
Axillary (Armpit): Common in pediatrics
Rectal: Most accurate
What is the normal pulse range for adults?
60 to 100 beats per minute
What factors contribute to tachycardia?
- Decrease in BP (e.g., blood loss)
- Elevated temperature (HR increases 7-10 bpm per 1°F)
- Medications
- Exercise
- Existing conditions (e.g., chronic pulmonary disease, anemia)
- Prolonged heat exposure (vessel dilation increases HR)
- Strong emotions
What factors contribute to bradycardia?
- Sleep
- Medications (e.g., Metoprolol - beta blocker)
- Hypothermia
- Heart blocks
- Vagal stimulation (vagus nerve)
What are the pulse amplitude ratings and their meanings?
0 ⇒ Unable to palpate
+1 ⇒ Weak pulse
+2 ⇒ Brisk (expected) = NORMAL
+3 ⇒ Bounding (too strong)
What is the apical pulse, and when is it required?
The apical pulse is listened to at the apex of the heart and is required before giving Digoxin (heart medication).
What is a pulse deficit?
The difference between the apical and radial pulse.
What is the normal range for respirations in adults?
12 to 20 breaths per minute
What are the blood pressure categories and their ranges?
Normal: Systolic < 120, Diastolic < 80
Elevated: Systolic 120-129, Diastolic < 80
Stage 1 Hypertension (HTN): Systolic 130-139, Diastolic 80-89
Stage 2 Hypertension (HTN): Systolic ≥ 140, Diastolic ≥ 90
What is the normal range for O2 saturation, and what can affect the reading?
Normal O2 saturation is >94%
Nail polish may affect the reading.
What does the PQRST assessment stand for?
P = Provoking factors: What causes the discomfort?
Q = Quality: Ask the patient to describe the pain/discomfort.
R = Region/Radiation: Where is the pain? Does it radiate? Is there pain anywhere else?
S = Severity: How painful on a scale (e.g., 1-10)?
T = Time: How long has the patient had the pain? Does anything make it worse/better?
What is the Wong-Baker Faces scale used for?
It is used to assess pain in pediatric or non-verbal patients, with a scale of 0-10 based on facial expressions.
What is a Doppler ultrasound used for, and how is it performed?
It is used to find pulses that are not palpable. Apply ultrasound gel to the tip of the Doppler and try to locate the pulse. You will hear the pulse when it’s found.
What factors are considered in a Fall Risk Assessment Tool?
- Age
- Fall history
- Elimination (bowel and urine)
- Medications
- Patient care equipment
- Mobility
- Cognition
What are examples of physical restraints in healthcare?
Enclosure beds
Mitten restraints
Bed rails x4
Soft wrist restraints (most common)
Freedom splints
What are some alternatives to restraints in healthcare?
- Rule out causes of agitation
- Invite family members to sit at bedside
- Reduce stimulation
- Identify patient’s room (e.g., sign, balloon, picture)
- Use a bed alarm
- Block areas (e.g., plant)
- Allow confused/restless patients to walk freely in a safe environment
- Offer toileting frequently
- Make the environment similar to home
- Offer diversional activities (e.g., TV, puzzle)
- Move patient closer to the nurses’ station
What is sepsis, and why is early detection important?
Sepsis is an overwhelming systemic response to an infection that can lead to vasodilation, shock, organ failure, and death. Early detection and management are key to successful treatment.
What are the criteria for sepsis screening using the SIRS (Systemic Inflammatory Response Syndrome) tool?
Must have suspected or confirmed infection and at least 2 of the following:
Temperature < 36°C or > 38°C
Respiratory rate > 20
Heart rate > 90
WBC count > 12,000 or < 4,000
If positive, implement Code Sepsis and the 1-hour sepsis bundle.
What is included in the 1-hour sepsis bundle?
Measure lactate level (greater than 2.0 mmol/L indicates organ failure)
Obtain blood cultures before administering antibiotics
Administer antibiotics as ordered by MD
Begin 30 ml/kg normal saline IV bolus
Use vasopressors if hypotensive
What are the components of nursing notes?
Data: Your assessments
Action: What you did about it
Response: What happened after and the plan moving forward
What should you check if a patient has decreased LOC or confusion?
Check ABG, blood sugar, and potentially a CT scan. Also, check when the last narcotics or sedatives were given, and consider administering Narcan or Flumazenil (reversal agents).
How should you stimulate a patient who is not waking up?
Start with gentle touch, then perform a sternal rub or pinch the finger and toe nails to produce pain stimuli. This is part of the Glasgow Coma Scale.
What should be done if new or worsening symptoms of stroke occur?
A Code Stroke/Brain should be initiated, notifying the charge nurse/instructor. This calls a neurologist, orders a stat CT, and draws labs. Early recognition and treatment (TPA) are crucial within 3-4.5 hours.
What are the interventions for the following conditions?
Low blood glucose:
Elevated CO2:
Suspected overdose:
Seizure:
Low blood glucose: Give glucose
Elevated CO2: Use BiPAP to help with breathing and release CO2
Suspected overdose: Administer Narcan or Flumazenil
Seizure: Monitor and protect the airway, turn on the side if vomiting, time the seizure, administer Ativan PRN
How can the body’s respiratory and circulatory systems be compared to a train system?
Lungs = Loading docks: Pick up O2 from the air and drop off CO2.
Hemoglobin = Storage containers: Hold O2 away from the lungs and return CO2 to the lungs.
Red Blood Cells = Train cars: Carry hemoglobin, which transports O2 and CO2.
Heart = Engine: Pushes the train (blood).
Blood Vessels = Train tracks: Guide the movement of blood.
Organs = Train stops: Drop off O2 and pick up CO2.
What is the difference between ventilation and perfusion?
Ventilation: Gas exchange, where O2 enters the lungs and CO2 is expelled.
Perfusion: O2 delivery, where O2 is carried by red blood cells (train cars) to organs and tissues.
What are the factors that affect oxygenation?
Bad Heart: reduced blood flow
Arrhythmias: irregular heart rhythm
Low BP: decreased circulation
Anemia: lack of red blood cells to carry O2
Physical Changes: Lungs can’t expand fully
Age: Infants (Smaller lungs, faster O2 exchange) and older adults (Less lung and blood vessel elasticity)
Medications: Narcotics lower respiratory rate (RR)
Exercise: Increased O2 needs, higher RR
Cigarette Smoking: Damaged lungs, poor gas exchange, plaque in blood vessels reducing circulation
Environmental Conditions: Smoke, pollution affect lung function
Psychological Factors: Stress increases O2 demand
What are the treatment for different lungs sounds?
Rales/crackles: needs suction
Wheezing: requires bronchodilator
Rhonci: bronchodilator
Stridor - (EMERGENCY) Give racemic epinephrine
- If ineffective ⇒ intubate.
What are the most common lung sounds and their descriptions?
Rales/Crackles: Crackling sound, often heard in the lungs during inspiration.
Wheezing: Whistling sound, usually heard during expiration, caused by narrowed airways.
Rhonchi: Rumbling or gurgling sound, often related to mucus in the airways.
Stridor: High-pitched whistling sound from the upper airway, indicating a medical emergency.
What assessments and labs are important for chest pain evaluation?
Labs:
BNP: For CHF (Congestive Heart Failure)
Cardiac enzymes: For detecting heart damage
CBC: To evaluate overall health, including oxygen levels (train cars analogy)
Ultrasound: May be needed for further heart or vascular imaging
CXR (Chest X-ray): For assessing lung and heart conditions
Previous Vital Signs: Monitor trends to detect changes over time
History: Consider patient’s medical history to assess risk factors
Medications: Review current medications, especially heart-related drugs
How is edema graded based on pitting depth?
0+: No pitting edema
1+: Mild pitting edema (2mm depression; disappears rapidly)
2+: Moderate pitting edema (4mm depression; disappears in 10-15 secs)
3+: Moderately severe pitting edema (6mm depression; disappears in 1 min)
4+: Severe pitting edema (8mm depression; lasts >2 mins)
What are the steps to take if Deep Vein Thrombosis (DVT) is suspected?
Symptoms:
Immediate Actions:
Next Steps:
Symptoms: Swelling and calf pain
Immediate Actions:
- Remove SCDs or TED stockings
- Place the patient on bedrest
Next Steps:
- Consult the MD
- Suggest an ultrasound of the leg to confirm diagnosis
What are heart conditions that affect perfusion?
Cardiac muscle cell death: Reduces the heart’s ability to pump effectively.
Fibrosis: Scar tissue in the heart affects contraction.
Hypertrophy: Thickening of the heart muscle, reducing heart efficiency.
Ischemic tissue: Tissue not getting enough blood, will not contract, leading to decreased cardiac output.
Atherosclerosis: Hardening and narrowing of arteries, restricting blood flow.
What are the signs and symptoms of Right Heart Failure (Right HF)?
JVD (Jugular Venous Distention): Bulging neck veins
Weight gain: Due to fluid retention
Edema: Swelling, often in lower extremities
What are the signs and symptoms of Left Heart Failure (Left HF)?
Pulmonary Congestion: Cough, crackles, wheezes, blood-tinged sputum, tachypnea
Confusion: Due to decreased blood flow to the brain
Fatigue: Reduced oxygenation to tissues
Cyanosis: Bluish skin due to impaired oxygen delivery (perfusion)
What is the purpose of a CSM Assessment (Circulation, Sensation, Movement)?
CSM Assessment is performed anytime an extremity is affected, especially after procedures like a catheterization or orthopedic surgery.
Example Post-Cath Lab Patient:
- The catheter may be threaded into the femoral or radial arteries, affecting the area distal to the puncture site.
Risk: Bleeding or clotting could affect perfusion downstream.
- CSM is monitored to ensure blood flow and nerve function below the site.
Other cases: Fractures or orthopedic surgeries may affect blood flow and clotting, so CSM assessments are performed distal to the injury.
How do you perform a CSM (Circulation, Sensation, Movement) Assessment?
Circulation: Check pulses distal to the affected area for strength and regularity. Feel if the skin is warm and pink in color.
Sensation: Compare sensation to the unaffected extremity. Ask if one side feels sharper or if there’s numbness or tingling distal to the affected area.
Movement: Ask the patient to move the affected area against resistance and assess movement in the area distal to the injury.
What does cloudy urine indicate?
What do sediments in urine indicate?
What does green urine mean?
Cloudy - sign of infection
Sediments – sign of inflammation of the bladder
Green colored= due to side effects of med (propofol)
How often are in and outs measured?
8 hrs
When should MD be called for urinary output?
Urine LESS THAN 30mL/HR
What does elevated BUN and creatinine indicate?
renal failure
What is Dialysis for?
For end-stage kidney failure
Used to filter the blood for the pt
What is an AV fistula?
surgical connection between artery and vein to connect dialysis.
How is a graft different from a fistula?
A graft uses a synthetic tube to connect the artery and vein, while a fistula connects them directly. Both are used for dialysis access.
What is a bruit in an AV fistula?
A rumbling or “whooshing” sound heard with a stethoscope over the fistula.
What is a thrill in an AV fistula?
A rumbling vibration felt over the fistula.
Remember: You can feel the thrill, not hear it.
How can you differentiate between an upper and lower GI bleed?
Lower GI bleed → Bright red blood in stool.
Upper GI bleed → Black, tarry stool (melena) due to blood being digested as it passes through the GI tract.
Why is it important to monitor the last bowel movement (BM)?
If no BM in 4 days, consider stool softeners or laxatives to prevent constipation and complications.
What is occult blood testing?
A test that detects hidden blood in feces, used to check for GI bleeding.
What imaging tests can be used to diagnose GI conditions?
Endoscopy, CT scans, and ultrasounds help visualize the GI tract and detect abnormalities.
What does H/H stand for, and why is it important in bleeding patients?
H/H = Hemoglobin & Hematocrit. It is monitored to assess blood loss in bleeding patients.
Why do lipase and amylase levels increase?
Lipase and amylase levels rise due to pancreatitis, indicating pancreatic inflammation.
: What is a nuclear RBC scan, and how is it used for GI bleeds?
A nuclear RBC scan involves injecting dye-tagged RBCs into the bloodstream. A machine tracks the dye to locate active bleeding in the GI tract.
Why is constipation common in hospitalized patients?
Due to narcotic use (which slows bowel movements) and decreased mobility, leading to reduced GI motility.
