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Nursing 101: Test #1 > Safety for Test 2 > Flashcards

Safety for Test 2 Flashcards

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1
Q

What does RACE stand for?

A
  • Rescue and remove all patients in immediate danger.
  • Activate the alarm.
  • Confine fire by closing doors and turning off any oxygen & electrical equipment.
  • Extinguish the fire.
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2
Q

Seizure precautions for nursing

A
  • protect patients from traumatic injury
  • positioning for adequate ventilation
  • drainage of oral secretions
  • providing privacy and support after event.
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3
Q

Describe the auscultation site, cause, and character of: crackles

A
  • Site = r/l lung bases
  • Cause = disruptive passage of air through small airways
  • Character = wet, popping sound not cleared w/coughing
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4
Q

Describe the auscultation site, cause, and character of: wheezes

A
  • SITE = all lung fields
  • CAUSE = narrowed or obstructed airway
  • CHARACTER = high-pitched whistling heard through inspiration/expiration, but louder on expiration
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5
Q

Describe the auscultation site, cause, and character of: rhonchi

A
  • SITE = trachea and bronchi
  • CAUSE = muscular spasm, fluid/mucus in larger airways
  • CHARACTER = loud, low-pitched rumbling/snoring. sometimes cleared w/coughing
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6
Q

Describe the auscultation site, cause, and character of: pleural friction rub

A
  • SITE = anterior lateral lung field
  • CAUSE = inflammation
  • CHARACTER = dry, rubbing, grating heard through inspiration/expiration
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7
Q

Describe vesicular sounds.

A

soft, breezy, low-pitched. Air moving through small airway, inspiration longer than expiration

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8
Q

Describe bronchovesicular sounds.

A

blowing sound, air moving through large airway.

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9
Q

Describe bronchial sounds.

A

loud, high-pitched hollow quality, air moving through trachea.

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10
Q

mitral/tricuspid valve closing = first heart sound

A

S1

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11
Q

Aortic and pulmonic valve closure

A

S2

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12
Q

Heart attempts to fill distended ventricle

A

S3

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13
Q

Atria contracts and ventricular filling

A

S4

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14
Q

Swelling by intestinal gas, tumor, or fluid in abdominal cavity

A

Distention

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15
Q

Movement of contents through the intestines which is normal fx of small and large intestine.

A

Peristalsis

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16
Q

Borborygmi

A

growling sounds, hyperactive bowel sounds

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17
Q

Localized dilation of a vessel wall

A

Aneurysm

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18
Q

Hunchback, exagerration of curvature of thoracic spine

A

Kyphosis

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19
Q

Swayback, increased lumbar curvature

A

Lordosis

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20
Q

Flexion

A

movement decreasing angle between 2 adjoining bones

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21
Q

Extension

A

increasing angle between adjoining bones

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22
Q

Abduction

A

away from midline

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23
Q

Adduction

A

towards the midline

24
Q

Eversion

A

turning body part away from midline

25
Q

Inversion

A

turning body toward the midline

26
Q

Normal, good, unlabored breathing

A

Eupnea

27
Q

Absence of breathing

A

Apnea

28
Q

Distribution of RBC’s to and from the pulmonary capillaries

A

Perfusion

29
Q

Diffusion

A

movement of oxygen and co2 between alveoli & RBC’s

30
Q

Pulse Deficit

A

Apical pulse - radial pulse

31
Q

SaO2 (pulse oximetry)

A

percentage of hemoglobin bound w/oxygen in arteries

32
Q

Peak of max pressure when ejection occurs

A

SYSTOLIC PRESSURE

33
Q

When ventricles relax and blood remaining in arteries exerts minimum pressure

A

DIASTOLIC PRESSURE

34
Q

Pulse pressure

A

Systolic - diastolic

35
Q

2 steps of a nursing assessment

A
  1. Data collection

2. Interpretation and validation of data

36
Q

Subjective vs objective data

A 
Subjective = pt verbal description
Objective = observations/measurements of pt's health status
37
Q

Phases of patient-centered interviews

A
  1. Orientation
  2. Working Phase = assessment
  3. Terminating an interview
38
Q

condition or etiology identified from patient’s assessment data

A

Related Factor “related to”

39
Q

Define the 3 priorities in relation to importance and time when caring for multiple patients

A
  1. HIGH = if untreated, could result in harm to pt or others.
  2. Intermediate = nonemergent, nonthreatening needs of patient
  3. Low = not always directly related to specific illness or prognosis.
40
Q

SMART related to outcome statement

A 
Specific
Measurable
Attainable
Realistic
Time Frame
41
Q

NIC

A

Nursing Interventions Classification

  • level of standardization to enhance communication of nursing care across settings and to compare outcomes.
  • RELIABLE RESOURCE
42
Q

What are ADL’s? Are they direct or indirect?

A

Activities of daily living: ambulation, eating, grooming, dressing, etc. Direct care

43
Q

Standards of documentation by TJC

A

All steps of nursing process, evidence of patient/family teaching, discharge planning.

44
Q

Multidisciplinary care plans that include patient problems, key interventions, expected outcomes.

A

Critical Pathways

45
Q

coordinated efforts of musculoskeletal and nervous system

A

Body Mechanics

46
Q

Actual/potential nursing diagnoses related to immobilized patient

A
  1. Ineffective airway clearance
  2. Ineffective coping
  3. impaired phy
47
Q

Expected outcomes of goal “patient’s skin will remain intact.”

A
  1. skin color/temp return to normal baseline within 20 min of position change.
  2. changes position at least every 2 hours
48
Q

Fowler’s

A

HOB elevated 45-60 degrees w/knees slightly bent

49
Q

Supine

A

Lay flat on back

50
Q

Prone

A

Lies on abdomen w/one head to the side

51
Q

Sims

A

Patient lies on left side w/right knee and hip partially bent forward

52
Q

What is POMR type of documentation?

A

Problem-oriented medical records

  • includes database, problem list, care plan, progress notes
  • DARP = POMR documentation
53
Q

PASS

A

Pull the pin
Aim at base of fire
Squeeze the handle
Sweep side to side

54
Q

Cranial nerve associated with PERRLA

A

III: Oculomotor

55
Q

Romberg Test

A

used to test balance

Nursing 101: Test #1 (5 decks)

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