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Fundamentals > Test 1 > Flashcards

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
Q

Cardiovascular response to hemorrhage

A
  1. Increases pulse rate
  2. Decreases BP
26
Q

Sites for and Causes of Health Care-Associated Infections

A
  • Impoper hand hygiene increases patient risk for HAI
  • Urinary & respiratory tracts
  • Surgical and traumatic wounds
  • Bloodstream
27
Q

Tier One Precautions

A

Standard precautions for use with all patients

28
Q

Tier Two-AIRBORNE Precautions

A

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
Q

Tier Two-DROPLET Precautions

A

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
Q

Tier Two-CONTACT Precautions

A

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
Q

Tier Two-Protective Equipment

A

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
Q

Principals of medical asepsis and when they are used

A

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
Q

Principals of SURGICAL ASEPSIS and when they are used

A
  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
Q

Infectious Process

A
  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
Q

Etiology of Hep B, C, and A

A
  • Hep A - Feces
  • Hep B - Blood and certain body fluids, sexual contact
  • Hep C - Blood and certain body fluids, sexual contact
36
Q

Nosocomial

A

Hospital-acquired infections

37
Q

Iatrogenic

A

infection from a diagnostic or therapeutic procedure

38
Q

Endogenous

A

part of the body’s normal flora becomes altered or an overgrowth results

39
Q

Exogenous

A

comes from microorganisms outside of the individual; these do not exist in the body’s normal flora

40
Q

Chain of Infection

A
  1. Infectious Agent
  2. Resevoir
  3. Portal of Exit (coughing, sneezing)
  4. Mode of transmission
  5. Portal of entry
  6. Host
41
Q

Putting on PPE

A
  1. Hand hygiene
  2. Apply gown
  3. Apply mask and eyewear or goggles
  4. Apply gloves
42
Q

Removing PPE

A
  1. Remove gloves
  2. Remove eyewear or goggles
  3. Remove gown
  4. Remove mask (outside of patient’s room)
43
Q

Common bed positions, description and uses

A
  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
Q

LEVELS OF CRITICAL THINKING

A
  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
Q

How many mL in One teaspoon

A

5mL=One teaspoon

46
Q

How many mL in One ounce

A

30 mL = one ounce

47
Q

How many pounds in one kg

A

one kg = 2.2 lb

48
Q

How many micrograms in 1 mg

A

1 mg = 1000 mcg

49
Q

How many milligram in 1 g

A

1 g = 1000 mg

50
Q

How many liter = 1000 mL

A

1000 mL = 1L

51
Q

How many mL in One tablespoon

A

15 mL = 1 tablespoon

52
Q

How many grams = 1 kilogram

A

1 kilogram = 1000 g

53
Q

How many ounces in One cup

A

8 ounces = 1 c

54
Q

How many ounces in One quart

A

32 ounces = 1 qt

55
Q

How many ounces in One pint

A

16 ounces = 1 pt

Fundamentals (7 decks)

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