nursing fundamentals and clinical skills

Question 1

represents the balance between health produced and health lost by the body

Answer 1

body temperature

Question 2

are relatively constant

Answer 2

core temps

Question 3

fluctuate depending on blood flow to the skin and env conditions

Answer 3

surface temps

Question 4

what are the temp measurement sites?

Answer 4

mouth, rectum, axilla, and tympanic

Question 5

reflect fluctuations in the core temp. cannot be used in infants or sm children

Answer 5

oral temps

Question 6

are the preferred method of measurement in young children who cannot use oral thermometers, should not be used for newborns due to the risk of anal perforations

Answer 6

rectal temps

Question 7

is the safest site to measure temperatures in newborns

Answer 7

axillary temps

Question 8

an easily accessible site that provides a core temperature quickly

Answer 8

tympanic membrane temp

Question 9

site in easy to obtain without changing the clients position

Answer 9

temporal artery temp

Question 10

bounding of arterial blood flow that is palpable at various points on the body

Answer 10

pulse

Question 11

heart rate below 60bpm in an adult

Answer 11

bradycardia

Question 12

heart rate above 100bpm in an adult

Answer 12

tachycardia

Question 13

an irregular or abnormal rhythm

Answer 13

dysrhythmia

Question 14

a normal increase in heart rate associated with inspiration

Answer 14

sinus arrhythmia

Question 15

difference between apical and radial pusles

Answer 15

pulse deficit

Question 16

the mechanism that the body uses to exchange gases between the atmosphere and the blood and between the blood and cells

Answer 16

respiration

Question 17

regular but slow breathing at a rates of less than 12 breathes per min

Answer 17

bradypnea

Question 18

regular but rapid breathing at a rate of greater than 20 breaths per min

Answer 18

tachypnea

Question 19

laboured, deep respirations at a rate of greater than 20 breaths per min

Answer 19

hyperpnea

Question 20

temporary cessation of breathing which then resumes

Answer 20

apnea

Question 21

shortness of breath resulting in laboured or difficult breathing

Answer 21

dyspnea

Question 22

an abnormal condition in which a person uses multiple pillows when lying down or must sit with their arms elevated and leaning forward to breathe deeply or comfortably

Answer 22

orthopnea

Question 23

the indirect measure of arterial oxygen saturation and pulse rate

Answer 23

pulse oximetry

Question 24

is the force of the blood under pressure pushing on the walls of an artery

Answer 24

BP

Question 25

the peak of max pressure when the left ventricle contracts and ejects blood under high pressure into the aorta

Answer 25

systolic

Question 26

is the min pressure exerted on the artrial walls when the ventricles relax

Answer 26

diastolic

Question 27

the difference between systolic and diastolic pressures

Answer 27

pulse pressure

Question 28

the temporary disappearance of korotoff sounds during auscultation of bp

Answer 28

auscultatory gap

Question 29

persistently elevated BP and is often asymptomatic

Answer 29

hypertension

Question 30

occurs when the systolic BP falls to 90 or below

Answer 30

hypotension

Question 31

occurs when a person with bp within normal range develops symptoms and low bp when moving to an upright position

Answer 31

orthostatic hypotension

Question 32

is the invasion of the body by pathogens and the rxn of the tissues to their presence and to the toxins generated by them

Answer 32

infection

Question 33

cause more generalized symptoms, such as fever, fatigue, and malise

Answer 33

systemic infection

Question 34

what are the elements of the chain of infection?

Answer 34

infecious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host

Question 35

acquired after admission to a hospital or another HC agency that were not present or incubating at the time of admission

Answer 35

health care associated infections

Question 36

procedures used to reduce and prevent the spread of microorganism

Answer 36

medical asepsis

Question 37

includes all procedures used to eliminate all microorganisms, including pathogens and spores, from an object or area

Answer 37

surgical asepsis

Question 38

are infection control precaution designed for the care of all clients in any setting regardless of their dx or presumed infectiousness

Answer 38

routine practice

Question 39

are designed to contain pathogens in one area, usually in a clients room

Answer 39

additional precautions

Question 40

used for known or suspected infections caused by microbes transmitted by airborne droplets, measles, ckn pox, vericella

Answer 40

airborne precautions

Question 41

used for known or suspected infections caused by microbes transmitted by droplets produced by coughing, sneezing, or talking

Answer 41

droplet precautions

Question 42

used for known or suspected infections caused by direct or indirect contact

Answer 42

contact precautions

Question 43

straight single lumen catheter is introduced to empty thr bladder and removed after the bladder is drained

Answer 43

intermittent catheterization

Question 44

catheter with an inflatable balloon is inserted into the bladder on a short term or long term basis

Answer 44

in dwelling catheterization

Question 45

irrigation or flushes used to maintain the patench of in dwelling catheters or to wash out the bladder and treat local infections

Answer 45

bladder irrigation

Question 46

usually involves infrequent bowel movements, difficult defecation, inability to defecate at will, and hard feces

Answer 46

constipation

Question 47

a condition in which a collection of hardened fleece cannot be expelled from the rectum

Answer 47

fecal impaction

Question 48

the passage of liquid necessary and an increase in the number of stools

Answer 48

diarrhea

Question 49

inability to control the passage of feces and gas

Answer 49

fecal incontinence

Question 50

excessive gas in the stomach and intestine

Answer 50

flatulence

Question 51

are dilated, engorged veins in the rectal area

Answer 51

hemorrhoids

Question 52

divert the feces from the bowel directly to the abdomen surface

Answer 52

fecal diversions

Question 53

are an installation of a solution into the rectum and sigmoid colon

Answer 53

enemas

Question 54

include tap water, NS, low volume hypertonic and soap suds

Answer 54

cleansing enemas

Question 55

lube the rectum and colon

Answer 55

oil retention enemas

Question 56

used when the client has a fecal impaction. nurse breaks up the fecal mass with a finger and removed it in sections

Answer 56

digital removal of stool

Question 57

follow the normal healing process in a predictable and timely fashion

Answer 57

acute wounds

Question 58

do not heal easily, and the normal reparation process is interrupted

Answer 58

chronic wounds

Question 59

have little or no tissue loss, have well approximated wound margins, and heal quickly

Answer 59

primary intention

Question 60

have loss of tissue, such as second or third degree burns, or pressure injuries, and there is no approximation of wound edges

Answer 60

secondary intention

Question 61

occurs when postponing suturing of a wound in which two layers of granulation tissue are sutures together

Answer 61

tertiary intention

Question 62

partial or total separation of the wound layers

Answer 62

dehiscence

Question 63

protrusion of the abdominal organs through wound opening

Answer 63

evisceration

Question 64

abnormal passage between two organs or between an organ and the outside of the body

Answer 64

fistula

Question 65

clear, watery

Answer 65

serous

Question 66

thick green, yellow, or brown and containing pus cells

Answer 66

purulent

Question 67

thin, watery, blood tinged

Answer 67

serosanguineous

Question 68

localized damage to the skin and underlying soft tissue, usually over a body prominence or relates to a medical or other device

Answer 68

pressure injury

Question 69

when two surfaces are rubbed against each other

Answer 69

friction

Question 70

parallel force that happens when the skin and underlying subcutaneous tissue are pulled taut

Answer 70

shear

Question 71

a deep red, purple or maroon localized area of discolored intact skin nonintact skin or blood filed blister

Answer 71

suspected deep tissue injury

Question 72

intact skin with nonblanchable redness of a localized area, usually over a body prominence

Answer 72

stage 1 pressure injury

Question 73

partial thickness of dermis presenting as a shallow open ulcer with a red pink wound bed

Answer 73

stage 2 pressure injury

Question 74

full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle not exposed

Answer 74

stage 3 pressure injury

Question 75

full thickness skin and tissue loss with exposed bone, tendon or muscle

Answer 75

stage 4 pressure injury

Question 76

full thickness skin and tissue loss in which the bas of the injury is covered in slough, escherichia or both

Answer 76

unshakeable pressure injury

Question 77

are losses in the normal function of sensory reception and perception, such as vision or hearing impairment

Answer 77

sensory deficits

Question 78

is the result of inadequate sensory stimuli

Answer 78

sensory deprivation

Question 79

occurs when clients recieve multiple sensory stimuli and cannot disregard or filter out some stimuli

Answer 79

sensory overload