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Intro to Nursing > Test 1 > Flashcards

Test 1 Flashcards

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1
Q

Goal of asepsis

A
  1. Protect yourself

2. Protect your patient

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2
Q

Bacteria

A

Most common infectious agent

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3
Q

Virus

A

Cannot use “antibiotics” for treatment

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4
Q

Fungi

A

Can be normal flora; problem for immunosuppressed pt’s (mold)

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5
Q

Parasite types

A
  1. Endoparasites: in your body

2. Ectoparasites: outside of you

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6
Q

Common Portals of Exit

A
  1. Respiratory
  2. Gastrointestinal
  3. Genitourinary tracts
  4. Breaks in skin
  5. Blood and tissue
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7
Q

Modes of Transmission

A
  1. Contact route (direct or indirect)
  2. Vehicle route (food, water, blood, equipment)
  3. Airborne route
  4. Droplets (close contact or touching infected objects)
  5. Vectors (mosquito, tick, flea)
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8
Q

Stages of Infection

A
  1. Incubation period
  2. Prodromal stage
  3. Full stage of illness
  4. Convalescent period
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9
Q

Incubation period

A

Organisms growing and multiplying (no symptoms)

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10
Q

Prodromal stage

A

Person is most infectious, vague and nonspecific signs of disease; most contagious

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11
Q

Full stage of illness

A

Presence of specific signs and symptoms of disease

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12
Q

Convalescent period

A

Recovery from the infection

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13
Q

Normal Body Defenses

A
  1. Nasal passages
  2. Skin/mucous membrane
    Skull/Spinal column
  3. GU Tract
  4. GI Tract
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14
Q

Types of normal flora

A
  1. Transient

2. Resident

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15
Q

Transient

A

Bacteria that can be washed off, not permanent

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16
Q

Resident

A

Stays in//on your body, cannot be removed easily

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17
Q

Body’s Defense Against Infection

A
  1. Body’s normal floral
  2. Inflammatory response
  3. Immune response
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18
Q

Inflammatory response

A

Localized response to injury or infection

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19
Q

Immune response

A

Antibody response to specific antigen

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20
Q

Natural immunization

A

After getting the virus you would be immune the next time

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21
Q

Acquired immunization

A

Getting the vaccine

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22
Q

Cardinal Signs of Acute Infection

A
  1. Redness
  2. Heat
  3. Swelling
  4. Pain
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23
Q

Lab data indicating infection

A
  1. WBC (normal is 5,000-10,000/mm3

2. Positive culture (presence of pathogen in urine, blood, sputum)

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24
Q

Nosocomial infection

A

Infections associated with the delivery of health care (pt’s or health care workers)

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25
Q

Common nosocomial infections

A
  1. Urinary tract infections
  2. Surgical site infections
  3. Bloodstream infections
  4. Pneumonia
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26
Q

Standard precautions

A
  1. Wash hands

2. Wear gloves for any contact with body fluids

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27
Q

When do you use a mask

A

During spinal procedures, protects against meningitis specifically

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28
Q

PPE (personal protective equipment)

A
  1. Gloves
  2. Gowns
  3. Masks
  4. Protective eyewear
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29
Q

PPE for airborne

A

N-95 respirator and negative pressure room

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30
Q

Common airborne diseases

A
  1. Tuberculosis
  2. Measles
  3. Chickenpox
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31
Q

PPE for droplet

A

Mask, no N-95 respirator, no negative pressure room, private room

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32
Q

Common droplet diseases

A
  1. Influenza
  2. Whooping cough
  3. Mumps
  4. Meningitis
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33
Q

PPE for contact

A

Gown and gloves

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34
Q

Drug resistant organisms

A
  1. MRSA
  2. VRE
  3. C. diff.
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35
Q

Protective Isolation AKA

A

Neutropenic precautions

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36
Q

Protective Isolation precautions

A
  1. Positive pressure room
  2. No carpet
  3. No flowers
  4. Pt’s wear N-95 respirator when transporting
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37
Q

Aseptic Technique

A

Includes all activities to prevent or break the chain of infection

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38
Q

Categories of aseptic technique

A
  1. Medical asepsis (clean technique)

2. Surgical asepsis (sterile technique)

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39
Q

Medical asepsis

A

Things are assumed clean unless proven dirty

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40
Q

Surgical asepsis

A

Things are assumed dirty until proven clean

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41
Q

Rules for surgical asepsis

A
  1. Don’t touch anything not sterile
  2. Don’t reach over sterile field
  3. Hands above waist
  4. Do not turn back on sterile field
  5. Peel open packages away from you and drop items
  6. Pour liquids carefully
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42
Q

Communication

A

Interchange of information or thoughts

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43
Q

Levels of communication

A
  1. Intrapersonal: Self-talk
  2. Interpersonal: Two or more people
  3. Group: Small group
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44
Q

Forms of communication

A
  1. Verbal: Spoken, written

2. Nonverbal: Body language

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45
Q

Things that influence/effect communication

A
  1. Developmental level
  2. Gender
  3. Values
  4. Environment
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46
Q

Types of proxemity

A
  1. Intimate zone (0-18 inch)
  2. Personal zone (18in-4ft)
  3. Social zone (4-12 ft)
  4. Public zone (12-25 ft)
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47
Q

Helping relationship

A
  1. Not spontaneous
  2. Unequal sharing of info
  3. Nurse is helper, pt is being helped
  4. Used to establish rapport and helping-trust relationships
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48
Q

Social relationship

A
  1. Spontaneous
  2. Equal sharing of info
  3. Both people’s roles are equal
  4. Used to establish rapport and trust
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49
Q

Phases of the helping relationship

A
  1. Orientation phase
  2. Working phase
  3. Termination phase
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50
Q

Orientation phase

A
  1. Introductions
  2. Clarify roles (I am you SN…)
  3. Establish agreement about the relationship
  4. Orient pt to the health care system
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51
Q

Working phase

A
  1. Work together to meet pt’s needs
  2. Provide assistance to meet goals
  3. Provide teaching and counseling
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52
Q

Termination phase

A
  1. Examine goals
  2. Make suggestions for the future
  3. Encourage pt’s to express emotions about the termination
  4. Help pt establish a helping relationship with another nurse
  5. Assist pt in transferring
53
Q

Therapeutic interviewing questions

A
  1. Open-ended questions
  2. Closed questions
  3. Validating questions
  4. Clarifying questions or comments
  5. Reflective questions or comments
  6. Sequencing questions or comments
  7. Directing questions or comments
54
Q

Types of nursing notes

A
  1. Narrative

2. Flowsheet

55
Q

Narrative

A

Uses sentences to describe the pt’s progress and what just happened

56
Q

Flowsheet

A

Uses checklists and is usually electronic, only charts significant findings or exceptions to the norm (charting by exception)

57
Q

HIPPA stands for

A

Health Insurance Portability and Accountability Act

58
Q

Drug/medication

A

Any substance that modifies the body functions when ingested

59
Q

Examples of drug/medications that you wouldn’t think of

A
  1. Over the counter meds
  2. Herbal supplements
  3. Marijuana
  4. Caffeine
  5. OXYGEN
  6. Alcohol
60
Q

Chemical name

A

Identifies drug’s atomic and molecular structure

61
Q

Generic name

A

Assigned by the manufacturer that first develops the drug

62
Q

Official name

A

Name by which the drug is identified in official publications. (usually generic name)

63
Q

Trade name

A

Brand name copyrighted by the company that sells the drug

64
Q

Pharmacodynamics

A

Process by which drugs alter cell physiology and affect the body

65
Q

Types of parenteral medication injections

A
  1. Subcutaneous injection
  2. Intramuscular injection
  3. Intradermal injection
  4. Intravenous injection
66
Q

Types of medication orders

A
  1. Standing order: Carried out until cancelled by another order
  2. PRN: As needed
  3. Single or one-time
  4. Stat: Carried out immediately
67
Q

Parts of the Medication Order

A
  1. Patient’s name
  2. Date and time order is written
  3. Name of drug
  4. Dosage of drug
  5. Route of drug
  6. Frequency of administration
  7. Signature of person writing the order
68
Q

MAR

A

Medical administration record; list of medication of a pt

69
Q

Where do you open a unit dose

A

At the bedside

  • So you don’t mix up
  • If pt refuses
70
Q

5 rights of medication administration

A

Right:

  1. Medication
  2. Patient
  3. Dosage
  4. Route
  5. Time
71
Q

3 checks of medication administration

A
  1. When nurse reaches for medication
  2. After retrieval from drawer and compared with MAR/CMAR
  3. Before giving medication
72
Q

1 kilogram= ?g

A

1,000 g

73
Q

1 gram= ?mg

A

1,000 mg

74
Q

1 mg= ?mc

A

1,000 mc

75
Q

60 mgs= ?gr

A

1 grain

76
Q

1 teaspoon(tsp)= ?mL

A

5 mL

77
Q

1 Tablespoon(Tbsp)= ?mL

A

15 mL

78
Q

1 ounce= ?mL

A

30 mL

79
Q

What is the first identifier when ID’ing a pt

A

Validate the pt’s name

80
Q

What is the second identifier when ID’ing a pt

A

Validate the pt’s ID number, medical record number, or birth date

81
Q

Adverse drug effects

A
  1. Allergic effects (anaphylactic reaction)
  2. Drug tolerance
  3. Toxic effect
  4. Idiosyncratic effect: Wild reaction
  5. Drug interactions (antagonistic and synergistic effects)
82
Q

Antagonistic effect

A

Two meds fight each other off

83
Q

Synergistic effect

A

The two meds work even better together

84
Q

Who can prescribe a narcotic

A

Some states say only physicians, others allow APN’s (Advanced practice nurse) and PA’s

85
Q

What extra security measures are taken for narcotics

A
  1. Must be locked
  2. Record must be kept
  3. Routine counts done
  4. When another nurse comes, they also count and verify any meds that are discarded (if pt refuses)
86
Q

What are the nursing responsibilities concerning meds

A
  1. Give medication appropriately as ordered
  2. Know the indication
  3. Know the drug action
87
Q

Common high alert medications

A
  1. Insulin

2. Anticoagulants

88
Q

What organs should you assess because of their function before giving meds

A
  1. Liver (metabolize meds)

2. Kidneys (eliminate meds)

89
Q

Liver function tests

A
  1. Albumin
  2. ALT
  3. AST
  4. Bilirubin
  5. Total protein
90
Q

Renal function tests

A
  1. BUN
  2. Creatinine
  3. Creatinine clearance
  4. Albumin
91
Q

What to do when you give the wrong med

A
  1. Check pt
  2. Notify manager and PCP
  3. Write description of error
  4. Complete form used for reporting errors
92
Q

When is medication reconciliation required

A
  1. Shift report
  2. Admission
  3. Transfer to another hospital
  4. Discharge
  5. Surgery (usually)
93
Q

Classification of pain based on duration

A
  1. Acute

2. Chronic

94
Q

Sources of pain

A
  1. Nocieptive

2. Neuropathic

95
Q

Types of nocieptive pain

A
  1. Cutaneous (skin)
  2. Somatic
  3. Visceral
96
Q

Nocieptive pain

A

Normal way of interpreting pain; using the pain process

97
Q

Neuropathic pain

A

Nerve problem; no actual stimulus

98
Q

Origins of pain

A
  1. Physical
  2. Psychogenic (unidentified)
  3. Referred (perceived in an area distant from point of origin)
99
Q

Pain process

A
  1. Transduction
  2. Transmission
  3. Perception of pain
  4. Modulation
100
Q

Transduction

A

Activation of pain receptors

101
Q

Transmission

A

Conduction along pathways

102
Q

Perception of pain

A

Awareness of the characteristics of pain

103
Q

Modulation

A

Inhibition or modification of pain

104
Q

Gate control theory of pain

A

Small nerves carry pain stimuli to brain, large diameter nerve fibers inhibit pain stimuli; gating mechanism determines the impulses that reach the brain (you can distract from the pain)

105
Q

Common responses to pain

A
  1. Physiologic (sympathetic/parasympathetic)
  2. Behavioral
  3. Affective (facial expression)
106
Q

FLACC pain scale

A 
F: Faces
L: Legs
A: Activity
C: Cry
C: Consolability
- Used for infants, 0-2 points for each item
107
Q

When are PO meds evaluated

A

Within 45-60 minutes of administration

108
Q

When are IV meds evaluated

A

Within 15-30 minutes of administration

109
Q

Analgesic drugs

A
  1. Nonopiod analgesics

2. Opiod or narcotic analgesics

110
Q

Analgesics ladder (what type of pain relief to use first)

A
  1. Nonopiod and/or adjuvant
  2. Opioid and/or nonopiod/adjuvant
  3. Opiod for severe pain and/or nonopiod/adjuvant
111
Q

Narcotic side effects

A
  1. RESPIRATORY DEPRESSION (can kill)
  2. Sedation
  3. Confusion
  4. Hypotension
  5. Constipation
112
Q

Nursing Process

A

A systematic method that directs the nurse (and patient) in planning and providing care

113
Q

Steps of the nursing process

A
  1. Assessing
  2. Diagnosing
  3. Outcome identification and planning
  4. Implementing
  5. Evaluating
114
Q

Characteristics of the Nursing Process

A
  1. Systematic
  2. Dynamic
  3. Interpersonal
  4. Outcome oriented
  5. Universally applicable
115
Q

Types of data you gather during assessment

A
  1. History (subjective)

2. Physical (objective)

116
Q

Types of nursing assessments

A
  1. Initial (comprehensive) assessment
  2. Focused assessment
  3. Emergency assessment
  4. Time lapsed assessment (follow up)
117
Q

Goal of asssessment

A

To identify pt needs by

  1. Take all the data collected
  2. Cluster it into related categories
118
Q

Medical diagnosis

A

A clinical judgment identifying the illness/ disease

119
Q

Nursing diagnosis

A

A clinical judgment on a client’s response to actual or potential health problems or life processes

120
Q

NANDA stands for

A

North American Nursing Diagnosis Association

121
Q

What is NANDA

A
  • An approved standardized list of health problems treated by nurses
  • Organization meets and revises the list every 2 years
122
Q

Types of Nursing Diagnoses

A
  1. Actual nursing diagnosis
  2. Risk nursing diagnosis
  3. Possible nursing diagnosis
  4. Wellness nursing diagnosis
  5. Syndrome nursing diagnosis
123
Q

How do you write a nursing diagnosis

A

They come in 2 or 3 parts (we use 2)

  • First pick best choice from NANDA list (1st part)
  • Then add the phrase “related to” RT
  • Add the etiology (cause/contributing factor) of the problem (2nd part) (*dont include medical diagnosis!)
  • EX. Impaired gas exchange RT mucus in alveoli
124
Q

Maslow’s hierarchy of human needs (lowest to highest)

A
  1. Physiological
  2. Safety
  3. Love/belonging
  4. Esteem
  5. Self-actualization
125
Q

Steps in Planning (nursing process)

A
  1. Identify overall goal
  2. Id. how you will measure the goal (outcomes)
  3. Id. interventions to reach goal
126
Q

How to document goals (example)

A

The pt will have improved mobility AS EVIDENCED BY the ability to raise his arm above his head by discharge

  • Don’t use vague immeasurable sentences, has to be measured in some way
  • Also state a time for this goal to be accomplished by
127
Q

Nursing Interventions

A

Any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes

128
Q

Types of

Nursing Interventions

A
  1. Independent (nurse-initiated): Without physician orders
  2. Dependant (Prescriber-initiated): Initiated by physician
  3. Collaborative
129
Q

How to write nursing interventions

A
  • Be specific (who what where…)
  • Start with action verb (“administer”)
  • Detailed instructions
  • Include a time
    (Ex. Assess respirations for rate, ease, and depth every shift)

Intro to Nursing (5 decks)

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