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Test 1 Flashcards

1
Q

Acceptable temperature range for adults

A

36-38 C (96.8 to 100.4 F)

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2
Q

Average oral/tympanic temp for adults

A

37 C (98.6 F)

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3
Q

Average rectal temp for adults

A

37.5 C (99.5 F)

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4
Q

Average axillary temp for adults

A

36.5 C (97.7 F)

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5
Q

Acceptable Pulse range for adults

A

60 to 100 beats/min

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6
Q

Acceptable Respirations for adults

A

12 to 20 breaths/min

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7
Q

Acceptable Pulse Pressure range for adults

A

30 to 50 mmHg

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8
Q

Who are more at risk for heatstroke?

A

Very young, very old, those with cardiovascular disease, hypothyroidism, diabetes, alcoholism, those who work or exercise strenuously, and those taking certain medications

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9
Q

What are signs and symptoms of heatstroke?

A

*Body temp of 104F or more, sometimes as high as 113F *Increase HR, decrease BP *Giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and incontinence; HOT, DRY SKIN

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10
Q

What is the treatment of heat exhaustion?

A

Transporting patient to cooler environment and restoring fluid and electrolyte balance.

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11
Q

Classification of hypothermia

A

Mild - 93.2-96.8 F

Moderate - 86.0-93.2 F

Severe - <86 F

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12
Q

What is bradycardia?

A

Pulse below 60 beats per min in adults

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13
Q

What is tachycardia

A

Pulse above 100 beats per min in adults

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14
Q

What is dysrhythmia

A

abnormal pulse rhythm

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15
Q

What is hypertension?

A

Often asymptomatic-silent killer Thickening of walls Loss of elasticity (heart pumps harder and blood flow to organs is decreased)

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16
Q

What is orthostatic hypotension and nursing implications?

A

Orthostatic/postural - low blood pressure when rising to upright position NURSING IMPLICATIONS: obtain BP and pulse with patient supine, sitting, & standing, taking readings 1-3 min after position change and observe for other symptoms of hypotension: fainting, weakness, light-headedness

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17
Q

Patient conditions not appropriate for electronic blood pressure measurement

A

*irregular heart rate *Peripheral vascular obstruction *shivering *seizures *excessive tremors *inability to cooperate *Blood pressure less than 90 mmHg systolic

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18
Q

Blood Pressure Classification adults

A

Normal - 120/80

Prehypertension - 120-139/80-89

Stage 1 - 140-159/90-99

Stage 2 - >160/>100

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19
Q

Acceptable blood pressure range for adults

A
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20
Q

Six Critical Thinking Skills

A
  1. Interpretation
  2. Analysis
  3. Inference
  4. Evaluation
  5. Explanation
  6. Self-Regulation
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21
Q

Concepts for a Critical Thinker

A
  1. Truth Seeking
  2. Open-mindedness
  3. Analytic approach
  4. Systematic approach
  5. Self-confidence
  6. Inquisitiveness
  7. Maturity
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22
Q

Five Components of Critical Thinking

A
  1. Knowledge base
  2. Experience
  3. Nursing Process Competencies
  4. Attitudes
  5. Standards
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23
Q

Nursing Process Competencies

A
  1. Assessment
  2. Diagnosis
  3. Planning
  4. Implementation
  5. Evaluation

ADPIE

24
Q

Common Errors in Blood Pressure Assessment

A

ERROR

EFFECT

Bladder or cuff too wide

False-low reading

Bladder or cuff too narrow or short

False-high reading

Cuff wrapped too loosely or unevenly

False-high reading

Deflating cuff too slowly

False-high diastolic reading

Deflating cuff too quickly

False-low systolic and false-high diastolic reading

Arm below heart level

False-high reading

Arm above heart level

False-low reading

Arm not supported

False-high reading

Stethoscope that fits poorly or impairment of examiner’s hearing, causing sounds to be muffled

False-low systolic and false-high diastolic reading

Stethoscope applied too firmly against antecubital fossa

False-low diastolic reading

Inflating too slowly

False-high diastolic reading

Repeating assessments too quickly

False-high systolic reading

Inadequate inflation level

False-low systolic reading

Multiple examiners using different Korotkoff sounds for diastolic readings

False-high systolic and false-low diastolic reading

25
Cardiovascular response to hemorrhage
1. Increases pulse rate 2. Decreases BP
26
Sites for and Causes of Health Care-Associated Infections
* Impoper hand hygiene increases patient risk for HAI * Urinary & respiratory tracts * Surgical and traumatic wounds * Bloodstream
27
Tier One Precautions
Standard precautions for use with all patients
28
Tier Two-AIRBORNE Precautions
**INFECTION/CONDITION** **BARRIER PROTECTION** Measles, chickenpox, disseminated varicella zoster, pulmonary or laryngeal TB Private room, negative-pressure airflow via HEPA, mask or respiratory protection device, N95 respirator
29
Tier Two-DROPLET Precautions
**INFECTION/CONDITION** **BARRIER PROTECTION** Diphtheria, rubella, streptococcal pharyngitis, pneumonia, scarlet fever, pertussis, mumps, *Mycoplasma* pneumonia… Private room or cohort patients; mask or respirator required
30
Tier Two-CONTACT Precautions
**INFECTION/CONDITION** **BARRIER PROTECTION** Colonization or infection with VRE, MRSA, or *C. difficile*, shigella, major wound infections, herpes simplex, scabies, varicella zoster Private room or cohort patients, gloves, gowns
31
Tier Two-Protective Equipment
**INFECTION/CONDITION** **BARRIER PROTECTION** Allogeneic hematopoietic stem cell transplants Private room, positive airflow, HEPA filtration, mask to be worn by patient when out of room
32
Principals of medical asepsis and when they are used
Medical asepsis - clean technique, includes procedures for reducing the number of organisms present and preventing the transfer of organisms. Examples: hand hygiene, barrier techniques, routine environmental cleaning
33
Principals of SURGICAL ASEPSIS and when they are used
1. A sterile object remains sterile only when touched by another sterile object. 2. Only sterile objects may be placed on a sterile field 3. A sterile object or field out of the range of vision or below waist is contaminated. 4. A sterile object or field becomes contaminated by prolonged exposure to air. 5. When sterile surface comes into contact with a wet, contaminated surface, sterile object or field becomes contaminated. 6. Fluid flows in the direction of gravity. 7. The edges of a sterile field or container are considered to be contaminated.
34
Infectious Process
1. Incubation period - time interval between entrance of the pathogen & the appearance of first symptoms 2. Prodromal Stage - interval from the onset of nonspecific signs and symptoms to more specific symptoms 3. Illness Stage - interval wen client manifests signs and symptoms specific to the type of infections 4. Convalescence - interval when acute symptoms disappear (recovery may take several days or months)
35
Etiology of Hep B, C, and A
* Hep A - Feces * Hep B - Blood and certain body fluids, sexual contact * Hep C - Blood and certain body fluids, sexual contact
36
Nosocomial
Hospital-acquired infections
37
Iatrogenic
infection from a diagnostic or therapeutic procedure
38
Endogenous
part of the body's normal flora becomes altered or an overgrowth results
39
Exogenous
comes from microorganisms outside of the individual; these do not exist in the body's normal flora
40
Chain of Infection
1. Infectious Agent 2. Resevoir 3. Portal of Exit (coughing, sneezing) 4. Mode of transmission 5. Portal of entry 6. Host
41
Putting on PPE
1. Hand hygiene 2. Apply gown 3. Apply mask and eyewear or goggles 4. Apply gloves
42
Removing PPE
1. Remove gloves 2. Remove eyewear or goggles 3. Remove gown 4. Remove mask (outside of patient's room)
43
Common bed positions, description and uses
1. Flat-entire bed horizontally parallel with floor; vertebral injuries & in cervical tracion 2. Reverse Trendelenberg's-head up, feet down, bed frame tilted; usually surgical 3. Trendelenberg's-feet up, head down, bed frame tilted; shock 4. Semi-Fowler's-head raised 30-40 degrees 5. Fowler's-60 degree; used for SOB
44
LEVELS OF CRITICAL THINKING
1. LEVEL 1 - Basic - concrete thinking, following rules or procedure 2. LEVEL 2 - Complex - Nurse realizes that judgement calls sometimes need to be made based on situation 3. LEVEL 3 - Commitment - nurses anticipate needs and make decisions without assistance from others
45
How many mL in One teaspoon
5mL=One teaspoon
46
How many mL in One ounce
30 mL = one ounce
47
How many pounds in one kg
one kg = 2.2 lb
48
How many micrograms in 1 mg
1 mg = 1000 mcg
49
How many milligram in 1 g
1 g = 1000 mg
50
How many liter = 1000 mL
1000 mL = 1L
51
How many mL in One tablespoon
15 mL = 1 tablespoon
52
How many grams = 1 kilogram
1 kilogram = 1000 g
53
How many ounces in One cup
8 ounces = 1 c
54
How many ounces in One quart
32 ounces = 1 qt
55
How many ounces in One pint
16 ounces = 1 pt

Fundamentals (7 decks)

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