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Intro to Nursing > Test 2 > Flashcards

Test 2 Flashcards

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1
Q

What do laws do

A
  1. Provides framework for nursing actions
  2. Differentiates nursing roles from other healthcare providers
  3. Sets boundaries of what is independent nursing
  4. Serves as a standard of nursing practice
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2
Q

Tennessee Board of Nursing

A
  • Carries out the TN Nurse Practice Act

- Each state has its own

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3
Q

Nurse Practice Act

A

*ON TEST

The law that governs nursing

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4
Q

NCLEX stands for

A

National Council Licensure Exam

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5
Q

Who is responsible for the NCLEX

A

NCSBN (National Council of State Boards of Nursing)

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6
Q

JC (Joint Commission)

A

Accredits healthcare organizations

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7
Q

Nursing School Accreditors

A
  1. AACN (American Association of Colleges of Nursing)

2. NLN (National League of Nursing)

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8
Q

What does the ANA support

A

Collective bargaining (strikes to negotiate)

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9
Q

Types of witnesses that a nurse can be called for

A
  1. Nurse as fact witness

2. Nurse as expert witness

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10
Q

5 Rights of delegation

A
  1. Task
  2. Circumstances
  3. Person
  4. Direction and communication
  5. Supervision and evaluation
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11
Q

What percent of American’s are overweight or obese

A

75%

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12
Q

Activity

A

Body movement that requires energy and produces a positive result

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13
Q

Exercise

A

Planned activity done to improve physical fitness

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14
Q

Types of exercise classifications

A
  1. Source of energy
  2. How activity is initiated
  3. Type of muscle contraction
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15
Q

Exercise based on source of energy

A
  1. Aerobic (Uses oxygen)

2. Anaerobic (No oxygen)

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16
Q

Exercise based on how activity is initiated

A
  1. Passive

2. Active

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17
Q

Exercise based on type of muscle contraction

A
  1. Isometric (Doesn’t shorten)
  2. Isotonic (Muscle shortens)
  3. Isokinetic (Against resistance)
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18
Q

Circumduction

A

In a circle

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19
Q

Musculoskeletal system benefits

A
  1. Increased muscle efficiency (strength) and flexibility
  2. Increased coordination
  3. Reduced bone loss
  4. Increased efficiency of nerve impulse transmission
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20
Q

Hazards of immobility (Musculoskeletal)

A
  1. Disuse atrophy
  2. Contractures
  3. Disuse osteoporosis
  4. Stiff joints
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21
Q

Cardiovascular system benefits

A
  1. Increases strength of contraction
  2. Increases cardiac output
  3. Decreases resting HR and BP
  4. Improves venous return
  5. Increase fibrinolysin (breaks up clots)
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22
Q

Hazards of immobility (cardiac)

A
  1. Decreases cardiac reserve
  2. Increases use of the valsalva maneuver (bearing down)
  3. Orthostatic hypotension
  4. Venous vasodilation and stasis
  5. Dependent edema
  6. Increases thrombus formation
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23
Q

Virchow’s Triad

A
  • 3 things that must happen all together to form a blood clot
    1. Decreased venous return
    2. Hypercoagulable (thick) blood
    3. Vessel wall injury
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24
Q

Respiratory system benefits

A
  1. Increases O2 intake
  2. Improved diaphragmatic excursion
  3. Improved alveolar ventilation
  4. Prevents pooling of secretions
  5. Decreases effort of breathing
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25
Q

Hazards of immobility (respiratory)

A
  1. Decreases respiratory movement
  2. Pooling of secretions
  3. Decreases surfactant
  4. Atelectasis
  5. Hypostatic pneumonia
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26
Q

Urinary System Benefits

A
  1. Increased circulation improves efficiency of waste removal
  2. Prevents stasis in bladder
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27
Q

Hazards of Immobility (urinary)

A
  1. Stasis
  2. Alkaline urine (bacteria love this environment)
  3. Infection
  4. Kidney stones
  5. Urinary retention/overflow
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28
Q

Gastrointestinal System

Benefits

A
  1. Improves appetite
  2. Increases GI tone
  3. Improves peristalsis
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29
Q

Hazards of Immobility (Gastrointestinal)

A
  1. Constipation

2. Overuse valsalva

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30
Q

Psych/neurological System Benefits

A
  1. Increases sense of well being

2. Improves stress tolerance

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31
Q

Psychoneurological System

Hazards of Immobility

A
  1. Awareness of dependency
  2. Time perception changes
  3. Lack of intellectual stimulation
  4. Anxiety
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32
Q

Metabolic System Benefits

A
  1. Increases metabolic rate
  2. Decreases triglycerides
  3. Decreases cholesterol
  4. Enhances insulin (lowers WBC)
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33
Q

Integumentary System Hazards and benefits

A
  1. Increases the flow of blood to the skin
  2. Immobility decrease skin turgor
  3. Immobility increases the risk for pressure ulcers
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34
Q

Phases of peri-operative care

A
  1. Pre-operative
  2. Intra-operative
  3. Post-operative
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35
Q

Nursing considerations during the pre-operative phase

A
  1. Risk identification
  2. Preparation of pt physically
  3. Prepping pt psychologically
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36
Q

What is included in the consent given before surgery

A
  1. Description of procedure
  2. Common risks
  3. Right to refuse
  4. Expected outcomes and recovery
37
Q

Who gets the consent

A

The person performing the procedure

38
Q

What to teach during pre op

A
  1. NPO after midnight
  2. Visitors
  3. Frequent V/S
  4. Importance of early ambulation, coughing, and deep breathing
  5. Exercises
  6. Pain management
39
Q

Nursing considerations during intra-operative phase

A
  1. Patient identification
  2. Prevention of “never events”
  3. Positioning
  4. Draping
40
Q

Types of anesthesia

A
  1. General anesthesia
  2. Moderate sedation
  3. Regional anesthesia
  4. Topical or local
41
Q

General anesthesia

A

Depresses CNS, causes LOC, relaxed muscles, depressed reflexes

42
Q

Moderate sedation

A

Provide pain relief and amnesia of the event

43
Q

Regional anesthesia

A

Relaxes muscles and may block regional reflexes

44
Q

Topical or local

A

Relaxes muscles and numbs pain

45
Q

Common cardiovascular post op complications

A
  1. Hemorrhage
  2. Shock
  3. Thrombophlebitis
46
Q

Common respiratory post op complications

A
  1. Pulmonary embolus
  2. Pneumonia
  3. Atelectasis
47
Q

Common GI post op complications

A
  1. N/V

2. Paralytic ileus for 3-5 days

48
Q

Nasal cannula levels

A

1-6L

49
Q

Simple mask levels

A

5L

50
Q

Partial rebreather mask levels

A

8-11L

51
Q

Nonrebreather mask levels

A

12L

52
Q

Venturi mask levels

A

4-10L

53
Q

High flow NC levels

A

60L

54
Q

Functions of skin

A
  1. Protection
  2. Body temp
  3. Psychosocial
  4. Sensation
  5. Vitamin D production
  6. Immunologic
  7. Absorption
  8. Elimination
55
Q

What is assessed in braden scale

A
  1. Sensory perception
  2. Moisture
  3. Activity
  4. Mobility
  5. Nutrition
  6. Friction and sheer
56
Q

What number on the braden scale is considered high risk for pressure ulcer

A

19 and below

57
Q

Stage I pressure ulcer

A

Nonblanchable intact skin

58
Q

Stage II pressure ulcer

A

Partial-thickness skin loss (open, blister like)

59
Q

Stage III pressure ulcer

A

Full-thickness skin loss; not involving underlying fascia (to adipose layer)

60
Q

Stage IV pressure ulcer

A

Full-thickness skin loss with extensive destruction (ligaments, tendons, bones visible)

61
Q

Unstageable pressure ulcer

A

Base of ulcer covered by slough and/or eschar

62
Q

Types of wounds (how to classify)

A
  1. Intentional/unintentional
  2. Open/closed
  3. Acute/chronic
  4. Partial thickness/full thickness/complex
63
Q

Types of wounds based on how they are inflicted

A
  1. Incision (intentional cut)
  2. Contusion (bruise)
  3. Abrasion (scrape)
  4. Puncture
  5. Laceration (unintentional cut)
  6. Avulsion (ring getting caught pulling off skin)
  7. Thermal
  8. Chemical
64
Q

Phases of wound healing

A
  1. Hemostasis (bleeding stops)
  2. Inflammatory
  3. Proliferation (2-3 days after, tissue healing)
  4. Maturation (3 weeks after, scar formed)
65
Q

Dehiscence

A

Complication where skin rips open on incision

66
Q

Evisceration

A

Complication where surgical incision causes organs to come out

67
Q

Fistula

A

Abnormal opening from one part of the body to the other (colon to vaginal opening)

68
Q

Serous

A

Clear, yellow, watery

69
Q

Sanguineous

A

Bloody

70
Q

Serosanguineous

A

Blood tinged, orangey

71
Q

Purulent

A

Yellow, cloudy infection

72
Q

Color classification of open wounds

A

Red: Protect
Yellow: Cleanse
Black: Debride

73
Q

Wet to dry dressing

A

Put wet dressing on wound and pull dry dressing off and it will pull off some of the dead tissue

74
Q

Telfa dressing

A

Gauze impregnated with antibacterial, non adhesive

75
Q

Transparent dressings

A

Clear so that you can visualize (IV sites, tegaderm)

76
Q

Hydrocollodial dressing

A

Warmth makes dressing stick to skin

77
Q

Montgomery straps/PRN ties

A

Strings keep dressing on, easy to remove and change

78
Q

Rebound phenomena

A

Heat is only good for about 20 minutes, then the capillaries will stop dilating and go back to normal

79
Q

Constipation

A

Doesn’t always relate to time; dry hard fecal material

80
Q

Diarrhea

A

More than 3 loose stools in a day

81
Q

Melena

A

Black stool with blood in it; indicates GI bleed

82
Q

Steatorrhea

A

Fatty stool; indicates poor fat metabolism; grey-yellow stool

83
Q

Esophagogastroduodenoscopy (EGD)

A

Scope looking at esophagus, stomach, and duodenum

84
Q

Metamucil/Citracal

A

Bulk forming (fiber) laxative (mild)

85
Q

Colace

A

Stool softener laxative (mild)

86
Q

Mineral oil

A

Emollient; lubricates GI tract (less mild)

87
Q

Ducolax

A

Stimulant; irritates bowel and promotes peristalsis

88
Q

Miralax/GoLYTELY

A

Osmotic; water absorbs into stool; (more stimulating)

89
Q

Which side do you lay pt on for enema and why

A

Left side bc descending colon

Intro to Nursing (5 decks)

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