Fundamentals Set One: Weeks 1-3 Exam Prep

converting degrees celcius to F

(TEMP x 9/5) +32

A nurse observes a nursing assistant lift a heavy object from the floor. Which action indicates that the nursing assistant is using inappropriate body mechanics? A. bending knees B. holding object away from body C. placing feet wide apart D. keeping back straight as possible

B. holding object away from body

SBAR =

Situation Background Assessment Report

__ and __ : relax smooth muscle

Tamsulosin and silodosin

pre

before

bronch/o

bronchi

lycis

destruction

myring or tympano

eardrum

tachy

fast

__ establishes a baseline for your nursing care plan development

initial

assessment of urine:

intake and output characteristics of urine: color, clarity, odor

are bruises on the right arms and face subjective or objective?

objective

is a temp of 101F subjective or objective?

objective

is unsteady gait subjective or objective?

objective

ooph/o

ovaries

hyper

over

supine

patient on back

lateral/sims

patient on side

prones

patient on stomach

crani/o

skull

tertiary defenses

specific immunity, lymphocytes

ectomy

surgical removal

__ immune protection by secreting around the body openings - antibodies are secreted by mucous membrane around the body openings, in the intestines, respiratory and urinary tracts, saliva, tears, breast milk.

IgA

__ antibodies form on the surface of B cells and trap potential pathogens

IgD

__ Immunoglobulin for allergic response

IgE

__ most common immunoglobulin in the body, takes 10 days to be produced in response to initial infection (crosses placenta and through breast milk)

IgG

__ first antibody to appear when an antigen is encountered for the first time

IgM

5 Classes of Antibodies:

IgM, IgG, IgE, IgD, IgA

Fowler - High - Semi

45-60 90 30

__: treat urinary retention

Bethanechol

Which range of motion exercise is being performed when the nurse spreads the second and third finger apart? A. opposition B. flexion C. abduction D. adduction

C. abduction

RACE (FIRE) =

Rescue Alarm/Alert Contain fire Extinguish

trans

across

types of nursing diagnosis

actual, risk, wellness, possible, syndrome

__ presence of bacteria in blood

bacteremia

pro

before

thrombo

clot

pathy

disease

peri/card/itis

inflammation around the heart

is vomiting subjective or objective?

objective

pyel/o

renal pelvis

malacia

softening

types of catheters

straight, indwelling, triple-lumen

__ solvent, transport, body structure, formation, and temperature regulation

water

How is data collected vis assessment?

- nursing interview/history - health assessment/ review of systems - physical examination (inspection, palpation, percussion, auscultation)

positioning on bedpan

- prevent muscle strain and discomfort - elevate head of the bed 30-45 degrees - wear gloves when handling bedpans

bowel diversions include:

- temporary or permanent artificial opening in the abdominal walls (STROMA) - surgical opening in the ileum or colon (ileostomy, colostomy)

scientific method:

1. identify problem 2. collect data 3. hypothesis 4. plan of action 5. interpret results 6. evaluate findings

three parts of forming a nursing diagnosis

1. problem statement 2. etiology (what is causing the problem?) 3. defining characteristics/evidence

Baby Jane, a 2 month old infant, goes into the doctor for her initial immunization and well baby check-up. What type of assessment should the nurse perform? A. Comprehensive B. Focused C. Ongoing

A. Comprehensive- It is the initial immunization and well baby check-up

A nurse just finished a complete bath for a client with limited mobility. Which action is most important for the nurse to perform before leaving the bedside of the client? A. Lower the height of the bed to the lowest position B. Position the bedpan in easy reach under the covers C. Raise all of the bedside rails D. Ensure that the water pitcher has fresh water

A. Lower the height of the bed to the lowest position

Which actions are essential when maintaining standard precautions? A. Wearing gloves during contact with a clients body fluids B. Donning a mask with an eyeshield when entering a clients room C. Washing hands only when visably soiled D. Putting on a gown when changing linens

A. Wearing gloves during contact with a clients body fluids

__: treat urinary tract infections

Antibiotics

__: treat urgency, frequency, nocturia and urgency UI

Antimuscarinics

5 Steps of Nursing Process:

Assessment Diagnosis Planning Implementing Evaluation

A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and hard to pass.This type of bowel pattern is consistent with: A. abnormal defecation. B. constipation. C. fecal impaction. D. fecal incontinence.

B. constipation.

To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour after meals because: A. the presence of food stimulates peristalsis. B. mass colonic peristalsis occurs at this time. C. irregularity helps to develop a habitual pattern. D. neglecting the urge to defecate can cause diarrhea.

B. mass colonic peristalsis occurs at this time.

Identify the long-term goal: A. Client's pulse oxygenation level will be greater than 92% on room air by tomorrow B. Client will administer his own insulin using correct technique by discharge C. Client's pressure ulcer will show presence of granulation tissue in 30 days D. Client's urine output will be 400 mL per 8-hour shift within 72 hours

C

A nurse is completing a client assessment for the purpose of determining factors that place the client at risk for falls. Which factor should cause the most concern when completing this assessment? A. Use a walker B. Takes a diuretic twice a day C. Has a history of falls D. Has a urinary retention catheter

C. Has a history of falls

The nurse is completing a head-to- toe assessment on her client at the beginning of the shift for the hospital unit. This would be considered what kind of assessment? A. Focused B. Initial C. Ongoing D. Special Needs

C. Ongoing

What should the nurse do first before moving a client from the bed to the chair? A. Assess for all of the factors that may influence the clients mobility B. Select the assistive devices to support the clients functional alignment C. Verify the primary healthcare providers activity prescription/order D. Consider all of the principles of body mechanics that should be followed

C. Verify the primary healthcare providers activity prescription/order

__ have a stronger and more rapid effect on the intestines than laxatives

Cathartics

A health care provider may suspect that a patient is experiencing urinary retention when the patient has: A. large amounts of voided cloudy urine. B. pain in the suprapubic region. C. spasms and difficulty during urination. D. small amounts of urine voided two to three times per hour.

D. small amounts of urine voided two to three times per hour.

Which action by the nurse might be a barrier to obtaining complete and reliable information from an interview with the client? A. Noting that the client's body language indicates that he or she is fatigued B. Maintaining eye contact with the client if it is not culturally inappropriate to do so C. Carefully guiding the conversation so that important topics are discussed D. Asking the client directly, "Why are you not taking your insulin?"

D: avoid asking "why"

__ and __: shrink the prostate

Finasteride and dutasteride

Types of Assessments: (IFOCS)

Initial, Focused, Ongoing, Comprehensive, Special Needs

components of goal statement: (SMART)

Specific Measurable Attainable Relevant Time Bound

__ may act more quickly than oral medications

Suppositories

Factors affecting bowel elimination

age, diet, fluid intake, physical activity, psychological factors, personal habits, position during defecation, pain, pregnancy, surgery, anesthesia, medications, diagnostic tests

__ __ smaller organisms can float considerable distances on air currents (heating, air conditioners, sweeping)

airborne transmission

__ __ (omega 3) is derived from fatty fish

alaphalinoleic acid

(urinary) Responsibilities after testing include:

assessing I&O, voiding, and urine encouraging fluid intake

___ collect, validate and communicate patient data, vital step-all remaining steps depend on complete, accurate, factual data, made at the beginning of care and throughout the course of care, goal is to come up with diagnosis and interventions.

assessment

__ __ __ measure of energy used while at rest in neutral temperature environment and the energy required for vital organs to function

basal metabolic rate

cyst/o

bladder

hemat/o

blood

oste/o

bones

-pnea

breathing

stroke volume + pulse =

cardiac output

__-__ __: destroys microbes with cytotoxic t-cells, helper t-cells, memory t-cells, subsequent t cells

cell-mediated immunity

types of enemas:

cleansing, oil retention, carminative, kayxalate

__ __ require both nursing interventions and medical interventions

collaborative problems

__ surgical opening created at the end of the large intestine to divert waste away from the digestive system

colostomy

cardi/ o

combining form for heart

__ consists of observation, a complete nursing history, physical exam; contains subjective and objective data

comprehensive

__ noninvasive catheterization that have a latex or rubber sheath to place over the penis

condom

portals of entry:

conjunctiva of ete, nostrils, mouth, urethra, vagina, anus, cut, scrape, surgical incision

__: A symptom, not a disease; infrequent stool and/or hard, dry, small stools that are difficult to eliminate

constipation

__ patients who have prostatic hyperplasia and require a curved tip applicator

coude

__: an increase in the number of stools and the passage of liquid, unformed feces

diarrhea

__ __ _ __: use if enemas fail to remove an impaction or last resort in managing severe constipation

digital removal of stool

__ contact between two people: touch, kiss, sex

direct contact

Modes of transmission:

direct contact, indirect contact, droplet transmission, vector, airborne transmission

ectopy

displacement

__ __ occurs when pathogen travels in water and is expelled as an infectious person inhales, coughs, sneezes, talks, suctioning during oral care

droplet transmission

assessment: elimination factors:

elimination pattern, stool characteristics, routines, bowel diversions, appetite changes, diet history, daily fluid intake, surgery, illness, medication, emotional state, exercise, pain, discomfort, social history, mobility, dexterity

3 types of colostomy

end, loop, double barrel

__ pathogen arises from the patient's normal flora when some form of treatment causes the normally harmless to become a problem

endogenous

cardi/o/megaly

enlargement of the heart

(urinary) Nursing responsibilities before testing:

ensure a signed consent is completed assess the patient for any allergies administer bowel cleaning agents as ordered ensure that the patient adheres to the appropriate diet or NPO

esophag/o

esophagus

__ to determine effectiveness of NCP. Comparison of client behavior and response to established outcome criteria. Continuous review of the nursing care plan and examines if it worked

evaluation

__ pathogen is acquired from a health care environment

exogenous/noncosmonal

blephar/o

eyelid

__ __ __A, D, E, K stored primarily in the liver and adipose tissue

fat soluble vitamins

nasogastric tube: __ or __-__ for medication administration or enteral feedings

fine, small-bore

__: accumulation of gas in the intestines causing walls to stretch

flatulence

rrhea

flow

__ gathers data about a specific problem; limited scope

focused

ostomy

forming artificial opening

quad

four

cholecyst/o

gall bladder

factors influencing urination

growth & development sociocultural factors psychological factors personal habits fluid intake pathological conditions surgical procedures medications diagnostic examinations

hemi

half

cardi/o

heart

__: dilated, engorged veins in the lingo of the rectum

hemorrhoids

__ __ response acts directly against antigens, macrophages, and a class of T-Cells, Helper T-Cells, Stimulate B cells to become plasma cells and produce antibody immunoglobulins (Ig)

humoral immunity

__ surgical opening created in the ileum to bypass the entire large intestine

ileostomy

__: results from unrelieved constipation; a collection of hardened feces wedged in the rectum that a person cannot expel

impaction

__ the "doing" step of the nursing process, carrying out nursing interventions/orders selected during the planning step. Inc: monitoring, teaching, further assessing, reviewing NCP, incorporating physicians orders and monitoring cost effectiveness of interventions

implementation

__: inability to control passage of feces and gas to the anus

incontinence

__ contact by fomite contaminating an object that transmits the pathogen: needle, doorknob

indirect contact

advantages of nursing process:

individualized care, client is involved, promotes continuity of care, promotes communal communication, develops plan of care, enables goals to be attained, professional growth

__ short-term and provide a closed drainage system for urine

indwelling

card/itis

inflammation of the heart

end/o/card/itis

inflammation within the heart

arthr/o

joints

ren/o or nephr/o

kidneys

colo or colon/o

large intestine

nasogastric tube: __-__ (12-French and above) for gastric decompression or removal of gastric secretions

large-bore

(urinary) Continuing and restorative care:

lifestyle changes, pelvic floor muscle training, bladder retraining, toileting schedules, intermittent catheterization (skin care).

__ __ (omega 6) is derived from oil, nuts, seeds

linoleic acid

hepat/o

liver

pneum/o or pnpumon/o

lungs

If a patient has cardiac disease or is taking cardiac or hypertensive medication, obtain a pulse rate, because...

manipulation of rectal tissue stimulates the vagus nerve and sometimes causes a sudden decline in pulse rate.

fecal impactions can be removed by...

mineral oil enemas or digital removal of stool by rotating fingers around the anal cavity

__ are inorganic and they assist in fluid regulation, nerve impulse transmission, energy production, health of bones and blood, and rid the body of by products of metabolism

minerals

or/o

mouth

my/o

muscles

__ __ small tubes tunneled through the skin into the renal pelvis. placed to drain the renal pelvis when the ureter is obstructed

nephrostomy tubes

rhin/o or nas/o

nose

trophy

nourishment

__ __Using critical thinking skills to identify patterns in the data and draw conclusions about the client's health status; Includes strengths, problems, and factors contributing to the problems

nursing diagnosis

pathogens need:

nutrients, moisture, temperature, oxygen, pH, electrolytes, light

__ data that is observable/measureable (sign). Main collection is through a physical assessment, lab, and diagnostic testing BP 130/80

objective data

__ monitoring and observing specific problems

ongoing

dys-

painful, difficult

pancreat/o

pancreas

secondary defenses:

phagocytosis, complement cascade, inflammation, liver

pharyng/o

pharynx

__ this is when the nurse organizes a nursing care plan based on the nursing diagnosis. expected outcomes are identified. interventions (nursing orders) are selected to aid the client reach these goals - prioritize list of client's nursing diagnoses using MASLOW

planning

__ source: client, interview, physical exam

primary source

electr/o/cardi/o/gram

recording the electrical activity of the heart

__ used for postoperative patients that have multiple lumens that allow for drainage of urine, irrigation, and installations of medicationsinstillatiion

retention

5 rights of delegation

right task, right person, right circumstance, right communication, right supervision

__ source: family, friends; other healthcare providers; medical records

secondary source

__ symptomatic systemic infection spread via blood

septicemia

how should the stoma appear?

shiny, red, wet

types of goals:

short term, long term, cognitive, psychomotor, affective

types of ostomies

sigmoid colostomy, transverse colostomy, ileostomy, loop colostomy, end colostomy

primary defenses:

skin, respiratory tree, eyes, mouth, GI tract, genitourinary tract

brady

slow

enter/o

small intestine

__ __: provides an in depth information about a particular are of client functioning: fall status, nutrition, pain, wellness

special needs

Nursing Process:

specific to nursing profession, framework for critical thinking, diagnose human problems to actual/potential problems, goal oriented

the opening of an osmotic is called a __. this is the communicating part of the bowel/bladder that is brought to the surface of the abdomen. Location depends on where the damage is, type of surgery

stoma

gastr/o

stomach

__ one time use and are removed immediately after insertion and drainage of urine

straight

is anxiety subjective or objective?

subjective

is nausea subjective or objective?

subjective

__ data from the client (symptom). This is mainly collected from interview: their feelings, perceptions, and concerns "I have a headache"

subjective data

functions of lipids

supply essential nutrients, energy source, flavor, satiety, insulation, protects vital organs, aids in thermoregulation, enables accurate nerve impulse transmission, cell metabolism, cholesterol function

__ placed through a surgical opening in the abdomen rather than the urethra

suprapublic

cleansing enema types

tap water, normal saline, hypertonic solutions, soapsuds

portals of exit:

through bodily fluids: blood, mucous, saliva, breast milk, urine, feces, vomit, semen

trache/o

trachea

hypo

under

ureter/o

ureters

urethr/o

urethra

__ __ diversion of urine to external source

urinary diversion

__ __ involuntary leakage of urine

urinary incontinence

__ __ an accumulation of urine due to the inability of the bladder to empty

urinary retention

__ __ __ results from cauterization procedure

urinary tract infection

__ allows urine to exit the body after the removal of a diseased or damaged section of the urinary tract

urostomy

a cold pack does what

vasoconstrictor, refrains blood from area (lack of oxygen)

A hot pack does what

vasodilators, brings blood to the area

__ an organism carries a pathogen to a susceptible host (biting, sting)

vector

phleb

veins

scopy

view something with an instrument

__ organic substances necessary for metabolism, building and maintaining body tissues, supporting our immune system to fight disease, ensuring healthy vision, breakdown/use of energy

vitamins

__ __ __ vitamin C, B-Complex: Thiamine, riboflavin, pyridoxine (Vitamin B6), folic acid, pathothenic acid, biotin, cyanocobalamin (B12).

water soluble vitamins

cirrho

yellow