Unit 1 Flashcards
Average normal range of temperature
36-38 degrees c
96.8-100.4 degrees f
Average oral/tympanic temperature
37 degrees c
98.6 degrees f
Average rectal temperature
- 5 degrees c
99. 5 degrees f
Average auxiliary temperature
- 5 degrees c
97. 7 degrees f
Acceptable range of adult heart rate
60-100
Acceptable ranges of adult respiratory rate
12-20
Average optimal blood pressure for 18 years and older
> 80/>120
What is the most important and basic technique in preventing and controlling transmission of infections?
Handwashing
When should nurses wash their hands?
Before and after caring for a client, when visibly soiled, after contact with sources of microorganism, after an invasive procedure, and after removing gloves.
What are some examples of medical asepsis?
Changing the bed linens, washing hands, wearing gloves, proper disposal of needles, utilizing isolation precautions when appropriate.
What area of the sterile field is considered sterile?
Only the top surface, one inch in from edges that are above the health care providers waist.
What information do you check on the bottle label?
The expiration date and the name of the solution.
How long is the bottle considered sterile once it has been opened?
It is no longer considered sterile, however, some institutional protocols allow use for up to 24 hours if properly handled.
If you open a new bottle and are going to leave it in the patient’s room, what information do you write on the bottle?
The date and time it was opened and your initials.
If there is opened bottle in the patient’s room without the date it was opened written on it, what do you do with the bottle?
Discard it
When pouring the fluid from the bottle, why do you place the label in the palm of your hand?
To keep from obscuring the print on the label with the solution if it is allowed to drip down the side of the bottle.
When removing contaminated gloves, why is it important to grab the palm pocket first?
To minimize contamination of underlying skin and keep microorganisms inside gloves upon disposal.
Why do you always remove your gloves, dispose of them, and wash your hands before leaving the patient’s room?
To reduce the risk of cross contamination with other patients.
How do you remove your gown, gloves, and mask when leaving the room of a patient in isolation to prevent contamination of your hands and uniform?
Remove gloves first using procedure above, wash hands, remove mask by untying lower string first and avoiding contact with contaminated portion of mask, and then remove gown by grasping along inside of neck and pulling off while rolling it up with soiled side inside. Discard in appropriate container.
What effect does the size of the cuff have upon the blood pressure reading?
If too narrow will have a false high and if too wide will have a false low.
How do you know you are using the appropriate size cuff?
Ideally the width of the cuff is 40% of the circumference (or 20% wider than the diameter) of the midpoint of the limb. The bladder should encircle at least 80% of the upper arm.
Does optimal blood pressure vary with age?
Lower blood pressure is normal in children than in adults. Normal is
What is the difference in reading between axillary and rectal temperatures as compared to an oral temperature on the same person?
Axillary temp is 1 degree lower than oral & rectal temp is 1 degree higher than oral. But just report the temperature and the method used to take it.
What will you do if the temperature is not normal?
If there is a reason it might be abnormal wait 30 minutes and retake it. If there is no reason for the elevated temp then notify the physician.
What is the best way to assess respirations? Does normal respiratory rate vary with age?
A skillful nurse does not let the patient know that respiratory rate is being taken. The respiratory rate should be counted immediately after the pulse is taken while the nurse’s fingers are in on the patient’s wrist. It is often helpful to place the patient’s arm in a relaxed position across the abdomen so that the nurse’s hand will rise and fall with the respiratory cycle. The depth of the respiration, respiratory rhythm should be assessed as well as the rate.
What are the pulse sites?
The sites are: carotid brachial radial femoral popliteal (posterior to patella) posterior tibial dorsalis pedis apical. Review taking an apical pulse since it isn’t in assessment and it isn’t part of the skills proficiency either. Take for 30 sec and multiply by 2 if it is regular. If pulse if irregular, count for 60 seconds
Identify the ABCDE clinical approach to pain assessment and management.
- A-Assess pain regularly and systematically
- B-Believe the client and family in their report of pain
- C-Choose pain control options with the client and family
- D-Deliver interventions in a timely, logical manor
- E-Empower clients and their families to have as much control as possible of the clients pain
Identify the common characteristics of pain that the nurse would assess.
- Location
- Intensity
- Quality
- Pain Pattern
- Relief Measures
- Contributing Symptoms
Nonpharmacological interventions such as the following lessen pain. Briefly explain each one.
a. Relaxation: Guided imagery and anything else that has been identified to relax the client
b. Distractions: This can be in many forms, visitors, TV, phone calls, again involve the family.
c. Music: Music Therapy at least 15 minutes to be therapeutic, you can have family help with this by bringing favorite or meaningful music.
d. Cutaneious stimulation:
– Massage
– Cold or Heat Applications
– TENS
– Position Change
What are the main types of assistive devices for walking?
Crutches, walkers, canes
When are restraints utilized?
- When a patient is disruptive and/or agitated and at risk for self-injury or violence to self and/or others.
- Sometimes patients may be restrained when they are confused and interfere with the treatment necessary for their recovery (i.e. pull out catheters, IVs, NG, etc).
- Sometimes clients who are at great risk for falls are restrained, but this is not an automatic utilization.
What are some alternatives to using restraints?
Companionship, music, television, reorientation, offer visit to bathroom, assign room close to nurses’ station.
Restraints must be reordered how often?
Every 24 hours
What are some things that can be done to prevent falls?
- Complete a fall risk assessment
- Use no skid slipper socks
- side rails up
- remove unnecessary items from patient room
- hourly rounding to rooms.
What is a falls risk assessment?
Helps nurse assess for potential risks before accidents and injuries occur
What are some of the body systems that can be affected by immobility of a patient?
Respiratory metabolic circulatory musculoskeletal urinary bowel psychological
What are the steps health care members should take to prevent musculoskeletal injuries when working in the health care field?
Weight to be lifted close to body-maintains center of gravity, Bend at knees-maintains center of gravity and uses strong leg muscles, Tighten abdominal muscles and tuck pelvis-balance and protects the back, Do not twist at trunk
Why is it important to face the direction you are moving the client?
Avoids twisting of spine.
Why is it important for the nurse to stand with feet apart, knees flexed when transferring or moving clients?
According to principles of body mechanics, the wider the base of support, the lower the center of gravity, and the closer to the object/client, the greater the stability and balance during the procedure.
Why is it important for the nurse to contract abdominal muscles prior to moving a client?
This helps prevent ligaments and joints from strain and injury
