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NUR111 POWERPOINT Note Cards > Unit One > Flashcards

Unit One Flashcards

1
Q

Two types of body temperature

A

Core temperature and surface temperature

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2
Q

Hyperthermia

A 
More heat produced than lost
Etiology:
-Viral infections
-Bacterial infections
-Tissue breakdown
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3
Q

Hypothermia

A 
More heat lost than produced
Etiology:
-Impairment of hypothalamus
-heat loss greater than heat production
-excessive loss of body heat
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4
Q

Thermoregulation

A

There are more cold receptors than warm receptors

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5
Q

Pyrexia

A

Body temp is above typical range

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6
Q

Hyper pyrexia

A

Very elevated body temp (above 105)

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7
Q

Afebrile

A

Patient does not have a fever

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8
Q

Hypothermia

A

Core body temperature is below limit of normal temp

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9
Q

Data

A
  • Wellness behaviors
  • illness/ signs and symptoms
  • strengths and weaknesses
  • risk factors
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10
Q

Two types of data

A

Subjective and objective

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11
Q

Sources of data

A

Secondary and Primary

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12
Q

Primary Data

A

Comes from pt

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13
Q

Secondary Data

A

Comes from support people, client records, healthcare professionals, literature

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14
Q

Types of assessment

A

Initial
Problem
Emergent
Ongoing

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15
Q

Initial Assessment

A

Establishes baseline data; problem identification

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16
Q

Problem focused assessment

A

Determine status of a previously identified problem

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17
Q

Emergent Assessment

A

During a crisis

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18
Q

Ongoing Assessment

A

Occurs sometimes after initial assessment; comparison of initial and current data

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19
Q

Methods of Assessment

A

Inspection
Palpating
Percussion
Auscultation

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20
Q

Method of Assessment should be done in IPPA order unless

A

You are assessing the abdomen

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21
Q

Profusion

A

The process of the cardiovascular system providing a continuous supply of oxygenated blood to every cell in the body

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22
Q

What to look at when do ing a Perfusion assessment

A 
Skin color
Temp
Abnormal pulsation
Edema
Capillary refill 
Blood pressure
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23
Q

Evidence based practice (EBP)

A
  • An integration of best evidence available, nursing expertise, and the values and preferences of the individual.
  • Serves to bridge the gap between best available evidence and the most appropriate nursing care.
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24
Q

Barriers to EBP

A
  • Work schedule demands
  • Client preferences
  • Access to technology
  • Limited knowledge
  • Lack of support from manager
  • Lack of access to continuing education
  • Attitude of individual nurses
  • Resistance to change
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25
Q

Effects of EBR on nursing

A 
Promotes best practice
Credibility of nursing as a profession
Accountability of nursing practice
Cost effective nursing care
Generate knowledge, and use current problems
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26
Q

Developing EBP

A

Step 1: develop a clinical question
Step 2: Retrieve the evidence
Step 3: Evaluate evidence
Step 4: Apply the evidence

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27
Q

Collaboration

A

Two or more people working towards a common goal by combining skill, knowledge, and resources

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28
Q

Healthy people initiative

A

Initiatives to make our population as a whole better

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29
Q

Maslow’s Hierarchy of Needs

A

Physical, Safety, Love and Belongingness, Self Esteem, Self Actualization

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30
Q

Inflammation

A

The body’s response to help reduce the effects of what the body views as harmful.

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31
Q

Purposes of inflammation

A

Protection
Encourages healing
Preventative

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32
Q

What is inflammation?

A

An adaptive response that brings fluid, dissolved substances, and blood cells into that interstitial tissue.
Non-specific
Neutralizes invader, destroyed tissue is removed, and healing begins
Debridement

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33
Q

Debridement

A

Preparation for wound healing

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34
Q

5 cardinal signs of inflammation

A 
Heat
Redness
Swelling
Pain
Loss of fune
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35
Q

How many stages of inflammation are there?

A

Three

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36
Q

Stage one of inflammation

A

Vascular and cellular response:
Can cause edema and pain
Vessels constrict and become permeable and fluid leaks out inter interstitial tissue
It’s swollen

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37
Q

Stage two of inflammation

A

Exudate production:
Helps to dilute any toxins
May have drainage (puss)
Healing is starting to take place

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38
Q

Stage three

A

Reparative Phase:
Regeneration of the tissue
Things start to return to normal
I’d regeneration is not possible you may end up with fibrous tissue

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39
Q

Inflammation can be _________.

A

Acute or Chronic

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40
Q

Chronic Inflammation

A

Lasts longer periods of time

I.E. Lupus

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41
Q

Acute Inflammation

A

Up to 10 days before duration before symptoms subside and repair starts
I.e. bee sting

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42
Q

ESR

A

Erythrocytes Sedimentation Rate:

Tells provider that there is inflammation somewhere n the body

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43
Q

CRP

A

C-reactive Protein; measures how much infection there is

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44
Q

WBC

A

White blood cell count: its going to tell you that infection is present that is causing the inflammation by how high the WBC is.

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45
Q

What interventions are there for Inflammation?

A 
Immobilization 
Antipyretic
Antibiotics
Healthy diet
Instruct patient to take all medications
Change dressings as needed
Surgery
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46
Q

Pharmacological interventions for inflammation:

A

Anti-inflammatory drugs

Corticosteroids for severe inflammation

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47
Q

Chain of infection

A

Infectious agent>Reservoir>Portal of Exit>Means of Transmission>Portal of Entry>Susceptible Host (repeat)

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48
Q

Where can the chain of infection be broken?

A

At means of Transmission

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49
Q

How can the chain of infection be broken?

A

Standard precautions, vaccinations, sterilization, instrument management, hand hygiene

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50
Q

Infectious Agents

A

Bacteria, fungi, viruses, Protozoa

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51
Q

Reservoirs

A

People, environment

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52
Q

Portal of exit:

A

Excretions secretions, skin, droplets

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53
Q

Means of Transmission

A

Direct contact, ingestion, airborne

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54
Q

Portal of Entry:

A

Mucus membrane, GI Tract, Respiratory, Broken Skin

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55
Q

Susceptible Host:

A

Unvaccinated people, immunosuppressant, diabetes, Surgery, burns, cardiopulmonary

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56
Q

What increases the risk for infection?

A 
Age
Heredity
Stressors
Nutrition
Cancer Treatments
Cancer treatments
Medications
Anti-inflammatory meds
Antibiotics
Diseases
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57
Q

Diagnostic tests for Infection?

A 
WBC
Procalcitonin (CTpr; Asepsis)
C&S
Serological Testing
X-rays
Ultrasounds
Lumbar puncture
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58
Q

Antibiotic Peak/Trough

A

Used to test for infection

Verifies medication is in therapeutic range at all times

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59
Q

Peak

A

Highest level of a drug in your system; drawn shortly after medicine is given

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60
Q

Trough

A

Drawn shortly before the next does; measures the lowest level of a drug

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61
Q

Infection is caused by:

A

An organism

I.e. Bacteria, fungus, etc

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62
Q

Inflammation is _________.

A

Just the body’s response

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63
Q

Infection leads to ________.

A

Inflammation

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64
Q

Inflammation and Infection can both be __________ and ___________.

A

Localized and systemic

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65
Q

Localized

A

In one area of the body
Redness swelling heat
I.e. Bee sting, ant bite, pink eye.

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66
Q

Systemic

A

Wide spread throughout the body

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67
Q

Most Common Systemic infection in the hospital:

A

Sepsis

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68
Q

Nosocomial infections

A

Hospital acquired infections (HAI)

Does not originate from the patients original diagnosis

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69
Q

Nosocomial infections become evident ____________ hours after hospitalization.

A

48

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70
Q

Nosocomial Infections lead to

A

Increased hospital stays
Increased healthcare costs
Decreased reimbursement from insurance

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71
Q

Nosocomial Infections usually occur in _________ and _____________.

A

Surgical Unit and ICU

72
Q

Ranked total annual costs for HAI’s

A

Surgical site infections
Ventilator-associated bloodstream infections
Central-line associated bloodstream infections
C.Diff infections
Catheter associated UTI’s

73
Q

Infection Prevention Methods:

A 
Hand washing (Best prevention method)
Device care
Clean nails (no fake nails)
Isolation precautions
Infection control bundles
Identify a risk patients
Clean environment
Follow Agency Policies
MINIMAL invasive equipment and procedures
74
Q

PPE for Droplet precautions:

A

Gown
Gloves
Surgical Mask

75
Q

Is a negative pressure room required for droplet precautions?

A

No

76
Q

Patient on droplet precautions must wear _________ when outside their room.

A

Surgical mask

77
Q

Common Conditions that require Droplet precautions

A

Influenza, meningitis, pertussis, rubella

78
Q

Duration of precautions for influenza:

A

7 days from admission for respiratory illness.

79
Q

Duration of precautions for Meningitis:

A

24 hours after effective therapy has started

80
Q

Duration of precautions for Pertussis:

A

5 days after effective therapy has started

81
Q

Rubella

A

(German Measles) 7 days after onset rash

82
Q

PPE for Airborne Precautions

A

N95 OR PAPR

Gown and gloves

83
Q

Does Airborne precautions require a negative pressure room?

A

Yes, door must remain closed at all times

84
Q

Common conditions on Airborne precautions:

A

TB
Chicken Pox
Disseminated Herpes Zoster

85
Q

PPE for contact Precautions Enteric:

A

Gown and Gloves

86
Q

Common Conditions that call for contact precautions:

A

Acute Gastroenteritis
C.Diff
Norovirus
Rotavirus

87
Q

PPE for Contact precautions

A

Gown and Gloves to enter room

88
Q

Common Conditions that call for Contact precautions:

A 
MRSA
Multi-drug resistant organisms:
-CRE
-ESBL
-VRE
89
Q

When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing?
A. The patient states that the Ulcers are very painful
B. The patient has had the heel ulcers for the last 6 months
C. The patient has several old incisions that have formed Keloids
D. The patient takes corticosteroids daily fo rheumatoid arthritis

A

D.

90
Q

Urinary tract includes

A

Kidneys, Ureters, Urinary Bladder, Urethra

91
Q

Second most most infection in children:

A

UTI’s

92
Q

10-15% of patients that have a catheter obtain a ___________.

A

UTI

93
Q

Risk Factors for UTI’s in adult females

A 
Increase with sexual activity
Spermicidal compounds
Pressure from diaphragm
Lack of normally protective mucosal enzyme
Voluntary Urinary retention
94
Q

Risk Factors for Adult Males

A

Prostatic Hypertrophy
Bacterial Prostatitis
Circumcision protective
Anal intercourse

95
Q

FUO

A

Fever of Unknown origin

96
Q

Typical symptoms of a UTI

A

Dysuria, nocturia
Frequency, Urgency
Foul Odor, Pyuria, Hematuria

97
Q

Symptoms of UTI’s in older adults:

A 
They are nonspecific 
“They just don’t feel good”
Confusion 
Behavior change
Disorientation
98
Q

Tests to diagnose a UTI

A

Urinalysis
Gram Stain
Urine C&S
WBC w/ diff

99
Q

Recurrent Urinary Tract Infections can lead to

A

Additional testing
IV pyelography
Voiding Cystourethography
Cystoscopy

100
Q

IVP (Intravenous Pyelography)

A

Evaluates the excretory process of your kidneys

Looking for a problem with the structure of the Urinary tract

101
Q

Pharmacological Treatment for an Uncomplicated lower UTI

A

Short term antibiotic

102
Q

UTI Antibiotic is selected based on

A

Age of client
Sensitivity
Renal Funtion
Clients Signs and symptoms

103
Q

Nonpharmacologic Treatments for a UTI

A

Drinking adequate fluids

Drinking Cranberry juiceAvoid fluids that irritate the bladder such as caffeinated beverages, alcohol, citrus juices

104
Q

What is the Nursing process?

A 
Assessment
Diagnosis
Planning
Implementation
Evaluation
105
Q

MRSA

A

Methicillin-Resistant Staphylococcus Aureus

106
Q

MRSA is a

A

Staph aureus infection that has become resistant to the class of antibiotics.

107
Q

MRSA is caused by

A

Unnecessary antibiotic use, antibiotics in food and water, genetic mutations of bacteria

108
Q

MRSA starts as

A

Small red bumps that resemble pimples, boils, or spider bites. They turn into deep painful abscesses that may require draining,

109
Q

Risk Factors for MRSA

A 
Someone with a current or recent hospitalization
A resident in a long-term care facility
Recent Antibiotic use
Young Age
Weakened immune system
Association with healthcare worker
110
Q

MRSA can be transmitted through

A

Contaminated hands
Sharing towels or any personal hygiene items
Close contact sports
Sharing of IV drunk Paraphernalia

111
Q

How to test for MRSA

A

MRSA screening

C&S from suspended site

112
Q

How to treat MRSA

A

Vancomycin
Cover infected Wounds
Drain infected wounds

113
Q

Prevention for MRSA

A 
Screening 
Hand Washing
Standard precautions
Contact precautions
Patient and Family education
114
Q

A clinical nurse educator is preparing an educational program about transmission of MRSA in hospitalized clients. Which of the following information should the nurse include in the program?
A. Place clients who have MRSA on Airborne precautions
B. MRSA can be effectively treated with an antiviral medication
C. MRSA can live on the hands for 1 hr
D. Bath clients with water and chlorhexidine gluconate

A

D

115
Q

Antibiotics for MRSA

A

Aminglycosides
Cephalosporins
Tetracyclines
Glycyclines

116
Q

Always Assess for __________ when administering an antibiotic.

A

Allergies

117
Q

Do not give Cephalosporins with ______________.

A

Antacids

118
Q

Tetracyclines can cause

A

Liver toxicity, stains teeth, bone damage, photosensitivity

119
Q

Aminglycosides

A

Ototoxcity, kidney damage

120
Q

Do not use ______________ with children, can cause tooth damage.

A

Glycyclines

121
Q

Common side effects of Antimicrobials:

A

Big 3(Nausea, vomiting, diarrhea)
Allergic reactions (redness, labored breathing)
Miscellaneous (photosensitivity, secondary infections, inflammation)
Toxicity

122
Q 
What is a major side effect of Tetracycline?
A. Urinary Retention
B. Photosensitivity
C. Hepatotoxicity
D. Hypersensitivity
A

B and C

123
Q

When discharging a patient on tetracycline, the nurse should instruct the patient to:
A. Take medication with food or milk
B. Don;t use NSAIDS concurrently with your antibiotics
C. Limit the time in the sun
D. Discontinue antacids when taking this medication

A

C

124
Q

The nurse caring for a newly admitted patient knows that effective use of the nursing process is dependent upon communication that:
A. Is structured and goal-directed
B. Meets the needs of both patient and nurse
C. Is spontaneous and affords mutual self-disclosure
D. Fosters emotional distance between patient and nurse

A

A

125
Q

Effective Communication is

A

Clear/Concise
Professional
Congruent (non-verbal and verbal match)

126
Q

The communication process

A

Sender
Message
Receiver
Response

127
Q

Name the two modes of communication:

A

Verbal, Nonverbal

128
Q

Verbal

A

Spoken or written word

129
Q

Nonverbal

A

Gestures, facial expressions, touch

130
Q

In the healthcare setting we want to use ___________ communication.

A

Assertive

131
Q

Sentinel event

A

An unplanned event that in the end, harms the patient

132
Q

What is SBAR

A

Situation, Background, Assessment, Recommendation

Structured to make sure that critical information is communicated between healthcare workers

133
Q

SBAR: Introduction

A

Introduce yourself, identify the area you are calling from

134
Q

SBAR: Situation

A

Tell the physician what situation has occurred that is concerning

135
Q

SBAR: Background

A

Provide information; include why the patient is in the hospital. What is worrying you?

136
Q

SBAR: Assessment

A

What do you think is happening?

137
Q

SBAR: Recommendation

A

What do you think should be done?

138
Q

While assessing a postoperative client for pain, the nurse notices the client is holding the surgical site and making facial grimaces. However, the client claims not to be hurting. What part of the communication process needs to be further clarified?

  1. Sender
  2. Receiver
  3. Message
  4. Feedback
A
  1. Message
139
Q

Document “Do’s”

A

Chart changes, show follow up, read prior notes, be timely, objective, factual, use patient quotes

140
Q

What not to do when documenting

A

Leave blank spaces, chart in advance, use vague terms, chart for others, alter record, record assumptions, include your feelings

141
Q

What should the nurse know when observing and interpreting a patients nonverbal communication?
A. Patients are usually aware of their nonverbal cues
B. Verbal responses are more important than nonverbal cues
C. Nonverbal cues have obvious meaning and are easily interpreted
D nonverbal cues provide significant information and need to be validated

A

D.

142
Q

Which of the following factors has documented negative effects on patient outcomes?
A. Inter professional conflict
B. Ineffective communication between the Neal care personnel
C. Stressful working environment for the nurse
D. All of the above

A

D

143
Q

Top safety risks

A

Falls, improper use of restraints, healthcare associated infections, wrong site surgery, medication errors

144
Q

Seven rights of Medication Administration

A 
Right assessment
Right drug
Right does
Right client
Right route
Right time
Right documentation
145
Q

What is a restraint?

A

Protective devices used to limit physical activity or part of body

146
Q

Types of restraints

A

Physical, chemical

147
Q

Restraints need a __________________

A

Doctors order.

148
Q

Hand off communication

A

Transfer of information during transitions of care across the continuum.

149
Q

Safety Hazards in the workplace

A

Blood borne pathogens, needle sticks, latex allergies, musculoskeletal injuries, stress, violence from clients, incident reporting

150
Q

Which of the first priority in preventing infection when providing care for a client?
A. Hand washing
B. Wearing gloves
C. Using a barrier between client’s furniture and nurse’s bag
D. Wearing gloves and goggles

A

A.

151
Q 
The nurse is assessing a 70-year-old-client and is determining the clients risk for injury status. The nurse would concentrate a safety on:
A. Cognitive awareness
B. Unsafe workplace
C. Brand of car used
D. Number of children in the home
A

A

152
Q 
Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The most important factor to consider in this assessment is:
A. Amount of regular exercise
B. Illumination of the environment
C. The resting pulse rate
D. Status of salt intake
A

B

153
Q

The nurse is planning interventions to address the National Patient Safety Goal of correct client identification. Which nursing action supports this goal?
A. Writing the clients fist name next to the assigned staff on the assignment sheet
B. Placing the clients name on the room door
C. Matching the name on the clients wrist band with the medical administration record
D. Asking “Are you Betty Jones?”

A

C

154
Q

When restraining a client in bed with a sleeveless jacket (vest) with straps, you will do which of the following things?
A. Tie the straps to the side rails
B. Tie the straps to the movable part of the bed frame
C. Tie the straps with a square knot
D. Tie the straps with a quick-release knot

A

D

155
Q

In assessing a patient’s readiness to learn, consider:

A

Physical readiness
Emotional readiness
Cognitive readiness

156
Q 
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ is the strongest predictor of health status, according to the American Medical Association.
A. Income
B. Education
C. Health Literacy
D. Racial or Educational Background
A

C

157
Q

Lifespan Considerations of Children

A

Establish trust

Educate the caregiver more but still educate the child

158
Q

Lifespan considerations for adults

A

How the patients going to learn best
Answer questions
Provide feed back

159
Q

Lifespan considerations for adults

A

Medication
Address things that might effect their comprehension
Allow adequate time

160
Q

Health Literacy means:
A. Able to read and write
B. Able to read and understand health information
C. Able to obtain, process, and understand health information and services needed to make appropriate health decisions
D. The ability to read at the 8th grade level or above

A

C

161
Q 
Patients quickly forget \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ or medical information given to them by a healthcare provider.
A. 10-20%
B. 20-30%
C. 30-60%
D. 40-80%
A

D.

162
Q

What is teach-back?

A

A way to make sure you—the health care provider—explained information clearly; it is not a test or quiz of patients.

163
Q

Saying: “I want to make sure I explained everything clearly to you. Can you please explain it back to me in your own words?” Is an example of using what?

A

Teach back tools

164
Q

While teaching a 32-year-old client about colostomy care, the nurse notes the client has tears in his eyes. The client states, “I cannot believe I have to live with this thing for the rest of my life.” Which nursing response best reflects the nurses understanding of factors that inhibit learning?
A. You’ve been through a lot. As soon as we’re finished I will ask the doctor for a counseling referral.
B. “Let’s reschedule this teaching session for later. I’ll check back with you to pick a time. Right now I’d like to hear more about how you are feeling.”
C. “I’m sorry you have to go through this. Understanding how to take care of yourself should make it a little easier fo you so let’s talk about how to clean your colostomy site.”
D. “I hear you saying that you’re upset. I’ll reschedule your teaching for tomorrow morning. Now please tell me about how you feel.”

A

B.

165
Q

Which client behavior may cause a nurse to suspect a literacy problem?
A. The client displays a pattern of compliance
B. The client reads the instructions slowly
C. The client recognizes that he or she does not know the information.
D. The client displays a pattern of making excuses fo not reading instructions

A

D.

166
Q

What is an important responsibility of the nurse in client education?
A. Insist that all clients use the internet for medical information for medical information
B. Inform clients of reputable sites for healthcare information
C. Tell clients that if they do not know how to use the internet
D. Tell clients that the Internet is not useful in providing medical advice

A

B

167
Q

The nurse is teaching a client about a disease process. The nurse validates that the client understands the teaching by documenting information?
A. A family member’s opinion
B. The responses of the client
C. That the teaching was done
D. That the feedback questionnaires were used

A

B

168
Q

What is accountability?

A

Is being answerable for the outcomes of a task or assignment

169
Q

Quality and safety education for nurses (QSEN)

A 
Client centered care
Teamwork and collaboration
Evidence based practice
Quality improvement
Safety 
Informatics
170
Q

Areas of competence

A

Health and wellness promotion
Illness prevention
Health restoration
Caring for the dying

171
Q

ANA’a standards for professional practice

A 
Quality of practice 
Education
Professional practice evaluation
Collegiality
Collaboration
Ethics
Research
Resource Utilization
Leadership
172
Q

Banner’s stages of nursing expertise:

Five levels of proficiency in nursing

A 
Stage I: Novice
Stage II: Advance Beginner
Stage III: Competent
Stage IV: Proficient
Stage V: Expert
173
Q

NC Nurse Practice Act:

A

Regulates the practice of nursing

174
Q

Purpose of NC Nursing Act

A

To protect the public
Nurses are responsible for knowing their state’s practice acts as it governs their practice
*Delegation Tree

175
Q 
The nurse is aware that keeping abreast of changes in the nursing profession through continuing education is the nurses responsibility. What key factors presently drive changes in the field of nursing?
A. Supplies and technological advances
B. Scientific and technological advances
C. Scientific and human responses
D. Cardiac and neurological information
A

B

NUR111 POWERPOINT Note Cards (8 decks)

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