Nurs 151 Test 1
What is the normal adult vital signs for temperature?
36.1 - 37.2 C or 97-99 F (98.6 F "normal")
What is the normal WBC?
5,000-10,000
What is the normal adult vital signs beats per minute for pulse
60-100 beats per/min
What is the normal pH level?
7.35-7.45
What is the normal adult vital signs for O2 stats?
95-100%
Can be any body orifice (for example, ears, nose, mouth) or can even be through the skin, and it provides a place for infectious agent to replicate or for the toxin to act
Portal of entry
Is the means by which the infectious agent can leave the reservoir
Portal of exit
What is the priority concern when providing oral hygiene for a client who is unconscious?
Preventing aspiration
Abnormal proteins usually in the brain Disease example from this is mad cow disease
Prions
The client begins having symptoms of infection enters the host
Prodromal
What is the most infection stage of infection?
Prodromal
During which stage of infection is the patients most contagious?
Prodromal stage
A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure
Surgeon
"Sterile technique", includes procedures to eliminate microorganisms and spores
Surgical asepsis
The elimination of microbes and their spores
Surgical asepsis
Is required for the infectious agent to take hold and become a reservoir for infection. Not everyone who is exposed to an infectious agent gets sick
Susceptible host
Raises the heart rate
Sympathetic nervous system
Start as local infections then spread to the bloodstream to infect the entire body
Systemic infection
Occurs during ventricular systole, when the ventricles force blood into the aorta and pulmonary artery, and it represents the maximum amount of pressure exerted on the arteries when ejection occurs
Systolic blood pressure
A rate greater than the expected range or greater than 100 beats per/min
Tachycardia
Upholding moral, legal, and humanistic principles
social justice
The nursing student is preparing to take a temperature on a patient on the medical/surgical unit. The nursing students know which of the following are appropriate sites to assess a patients temperature? (Select all) - Oral - Temporal - Rectum - Skin - Urinary Bladder - Axillary
All
A concern for the welfar and well-being of others
Altruism
Framework that clarifies the roles and responsibilities of a nurse
American nurses association-nursing stop of standards of practice
Reflect the force the blood exerts against the walls of the arteries during cardiac muscle contraction (systole) and relaxation (diastole)
Blood pressure
Regular breathing pattern with a rate greater than 20/min
tachypnea
Is a body temperature less than 35 C (95 F)
Hypothermia
The nurse know that all of the following can be causes of tachycardia except? - Medications - Exercise - Hypothermia - Fever
Hypothermia
A nurse is teaching a newly licensed nurse about documenting vital signs. Which of the following documentations made by the newly licensed nurse indicates an understanding of the teaching? - SpO2 95% - BP 148/72 mm Hg - Radial pulse regular 68/min - Temp 36 C (96.8 F)
Radial pulse regular 68/min
What are the characteristics of pulses?
Rate, rhythm, quality
In the body's mechanism for exchanging oxygen and carbon dioxide between the atmosphere and the blood and cells of the body, which is accomplished through breathing and recorded as the number of breaths per minute
Respiration
What are the 5 rights of delegation
Right task, right circumstances, right person, right communication, right supervision
What the nurse does, responsibilities, where and when care is to be performed and how care is achieved
Scope of practice
A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse. The documentation states, "Blood pressure 102/58 mm Hg, client is sitting up in a chair." Which of the following information should the nurse clarify - Unit of measurement - Location of blood pressure cuff - Position of the client - Systolic blood pressure
Location of blood pressure cuff
Bathing hospitalized clients with pre-moistened cloths or warm water that is mixed with chlorhexidine gluconate significantly decreases infection with ___________
MRSA
List the chain of infection
Infectious agent, reservoir, portal of exit, most of transmission, portal of entry, susceptible host
A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPPA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? - "Information about a client can be disclosed to family members at any time." - "HIPPA established regulations of individually identifiable health information in verbal, electronic, or written form." - "A client's address would be an example of personally identifiable information." - "HIPPA is a federal law, not a state law."
Informaiton about a client can be disclosed to famiily members at any time
- Permission to provide care given by the client after relevant information is provided - Consent must be given voluntarily by individual or legal representative
Informed consent
A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the clients hospitalization. The client could rightfully sue the nurse for which of the following? - Battery - Assault - Malpractice - Abuse
Malpractice
(Clean technique) is a term used to reduce the number of disease-causing microorganisms
Medical asepsis
What is the PPE for airborne precautions?
N95 mask and gloves
What kind of immunity is breast feeding?
Natural
A nurse plans to leave her scheduled shift an hour early without permission or notification of the charge nurse. The clients in the nurse's assignment are stable. Which of the legal torts applies to this situation?
Negligence
Refers to neutrophils and macrophages and their work as phagocytes
Nonspecific immunity
What is an example of a local infection?
Cut or UTI
What are the routes for temperature?
Oral, tympanic, temporal, axillary, rectal
What is the six QSEN competencies?
Patient-centered care, teamwork and collaboration, evidence based practice, quality improvement, safety, informatics
Deep breathing pattern itch an increased rate; leads to decreased levels of carbon dioxide and hyperoxygenation
Hypoventilation
Shallow breathing patterns with an abnormally low rate
Hypoventilation
What is the temperature for fever?
100.4 or greater
Lowers the heart rate
Parasympathetic nervous system
What is the normal adult vital signs for respiratory rate?
12-20 breaths per/min
What is the normal adult vital signs for blood pressure?
120/80 mm Hg
Strength pulse volume of 0
Absent, unable to palpate
What kind of immunity is getting vaccines?
Acquired
Controls the heart rate
Autonomic nervous system
The right to self-determination
Autonomy
An act of charity, mercy, and kindness; to do good
Beneficence
What is the body's defense against infection?
Body's normal flora, inflammatory response, immune response
A rate less than the expected range or slower than 60 beats per/min
Bradycardia
Regular breathing pattern with a rate less than 12/min
Bradypnea
SYSTOLIC BP: 120 to 129 and DIASTOLIC BP: less than 80
Elevated BP
What kind of patients are known to have a lower WBC count?
Chemo patients
The CDC recommends health care workers use _________ for hand washing when providing care to a client who is immunosuppressed
Chlorhexidine
Ethical decision-making platform
Code of ethics
The client returns to a normal or a "new normal" state of health
Covalescence
- Nurses bound by laws that govern standard of practice - Professional misconduct is subject to criminal & civil penalties
Criminal and civil law
What do you report with incident reports?
Errors, patient harm, equipment failures, falls, near-misses, sentinel events
Usually not harmful unless it exceeds 39 C (102.2 F)
Fever
Patients have a right to fair and impartial treatment
Justice
"Clean technique", includes procedures to minimize the number of microorganisms and their spread
Medical asepsis
Legal, regulatory body in each state
Nursing practice act
What is the most effective way to prevent the spread of pathogens during client care?
Performing hand hygiene frequently and consistently
The flow of red blood cells to and from the pulmonary capillaries
Perfusion
Pulses are palpated over what artery?
Peripheral artery
Eat and destroy microorganisms, thereby helping to protect the body from harm
Phagocytes
Clients who have immune-system compromise, such as clients who have leukemia, major burns, or are receiving chemotherapy or allogenic hematopoietic stem sell transplants require a protective environment to prevent the spread of pathogens to the clients requiring the protective environment. What kind of precaution should the nurse take?
Protective
The difference between the apical rate and radial rate
Pulse deficit
Is the habitat of the infectious agent and is where it lives, grows, and reproduces it's self or replicates
Reservoir
What do you measure ventilation with?
Respiratory rate, rhythm, depth
Reflects the balance between heat the body produces and heat lost from the body to the environment
Temperature
What are vital signs?
Temperature, pulse, respiratory rate, blood pressure, oxygen saturation, pain
What are the locations of peripheral pulses?
Temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis
If a client has less than 5,000 WBC what does this indicate?
They are likely to get an infection
What does it mean when someone has more than 10,000 WBC?
They have an infection
What is nonspecific immunity?
Things we are born with
- Carrying out an act, or failing to act, which results in injury or harm - Torts can be intentional or unintentional - Malpractice insurance
Tort law
A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? - Use a stiff toothbrush to clean the client's teeth - Use the thumb and index finger to keep the clients mouth open - Turn the client on his side before starting oral care - Apply petroleum jelly to the client's lips after oral care
Turn the client on his side before starting oral care
What is an example of a systemic infection?
Ural sepsis that started in the urinary system and now in the blood stream
The exchange of oxygen and carbon dioxide in the lungs through inspiration and expiration.
Venitalation
Do no harm
Veracity
The ability to cause disease
Virulence
SYSTOLIC BP: less than 120 and DIASTOLIC BP: less than 80
Normal BP
An irregular heart rhythm, generally with an irregular radial pulse
Dysrhythmia
Manifestations of the specific infectious disease process are obvious and may become severe
Acute illness
What kind of bacteria is it if it needs oxygen to live?
Aerobic
What are factors that can affect the pulse?
Age, biological sex, physical activity, fever, fluid balance, stress, medications, disease
Occurs when small particulates move into the airspace of another person
Airborne
A client who has mor might have tuberculosis requires airborne precautions. What kind of room would this client need?
A private room with negative-pressure airflow
A nurse on a medical unit is planning care for several clients. Which of the following clients should benefit most form the nurse acting as an advocate? - A client who has previously undergone a procedure that is to be performed a second time - A client who has been educated on treatment options and chooses alternative treatments - A client who makes an informed decision not to participate in chemotherapy treatment - An older adult client who has no family and is uncertain about moving to assisted living
An older adult client who has no family and is uncertain about moving to assisted living
What kind of bacteria is it if is doesn't need oxygen to live?
Anaerobic
What fights against an antigen?
Antibodies and white blood cells
Respiratory rate, depth, and work of breathing are increased; common during exercise
Hyperpnea
The nurse is assessing a patient's bilateral pulses for symmetry. Which pulse site should not be assessed on both side of the body at the same time?
Carotid
What are the four major HAIs?
Central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), surgical site infections (SSIs), ventilator-assisted pneumonias (VAPs)
The client's temperature at 0800 using an oral electronic thermometer is 36.1 C (97.2 F) if the respiration, pulse, and blood pressure were within normal range, what should the nurse do next? - Wait 15 minutes and retake it - Check what the client's temperature was the last time it was taken - Retake the temperature, using a different thermometer - Chart the temperature, it is normal
Check what the client's temperature was the last time it was taken
Occurs when microorganisms move form an infected person to another person
Contact
Occurs during ventricular diastole, when the ventricles relax and exert minimal pressure against arterial walls, and represents the minimum amount of pressure exerted on the arteries
Diastolic blood pressure
The exchange of oxygen and carbon dioxide between the alveoli and the red blood cells.
Diffusion
Strength pulse volume of 1+
Diminished, weaker than expected
True to values, principles, and standard
Fidelity
A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? - Increased respiratory rate from 18 to 44/min - Increased oral temperature from 36.6 C (97.8 F) to 37 C (98.6 F) - Increased blood pressure from 112/68 to 120/72 mm Hg - Increased heart rate from 68 to 72/min
Increased respiratory rate form 18 to 44/min
Strength pulse volume of 3+
Increased, strong
An infection enters the hot and begins to mulitply
Incubation
What are the stages of infection in order?
Incubation, prodromal, acute illness, covalenscene
Contact transmission occurs when microorganisms are moved form the infected person to another person with a contaminated object or person between the two
Indirect contact (coughing/sneeszing on another surface)
Something that contains bacteria, fungi, virus, parasite, or prion
Infectious agent
Increased respiratory rate, regular pattern, But abnormally deep
Kussmaul respirations
Are confined to one area of the body. Can be treated with topical antibiotics or oral antibiotics
Local infection
Following rules of the regulatory body (state) and individual facilities
Policies and procedures
What do you measure diffusion with?
Pulse oximetry
What do you measure perfusion with?
Pulse oximetry
Responsibility of each person to act professionally within their role of the nurse
Self-determination
Occurrence that results in permanent disability, temp injury or death
Sentinel events
A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI - The client had an appendectomy 6 months ago - The client has bipolar disorder - The client is a male - The client is 71 years old
The client is 71 years old
A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. Which of the following instructions should the nurse include? - Return any fresh linen not used for a client to the linen supply area - Use double bagging to remove soiled linen from the client's room - Tie linen bags securely at the top - Fill linen bags with as much soiled linen as possible
Tie linen bags securely at the top
True or False: Clients older than 70 years of age are at an increased risk for acquiring an HAI.
True
Acting in accordance with an appropriate code of ethics and accepted standard of practice
integrity
Both _______ and ________ are released during the inflammatory response
neutrophils and macrophages
Periods when there is no breathing. Ongoing apneic speeds can lead to respiratory arrest
Apnea
What are the modes of transmission?
Contact, droplet, airborne
A nurse is providing hygiene care who is immobile. Which of the following actions should the nurse take? (Select all) - Check for personal items when changing the bed linens - Place a clean gown on the strongest arm first - Keep the bath water temperature between 43.3 C (110 F) and 46.1 C (115 F) - Shave the client's hair in the direction of the hair growth - Wash the client's extremities from proximal to distal
- Check for personal items when changing the bed linens - Keep the bath water temperature between 43.3 (110 F) and 46.1 C (115 F) - Shave the clients hair in the direction of the hair growth
- Legal documents that identify a clients health care decision - CPR, defibrillation, etc. - DNR, full code
Advance directives
Strength pulse volume of 2+
Brisk, exprected
Is a spore and can sit there for about 300 days
C. Diff
Occurs when airborne droplets from the respiratory tract of a client travel through the air and into the mucosa of a host
Droplet
The nurse should initiate __________ precautions for clients who have infections that spread by droplets larger than 5 microns, including mumps, streptococcal pharyngitis, and pertussis
Droplet
A nurse is admitting a client who has pertussis. Which type of transmission-based precautions should the nurse initiate?
Droplet
Strength pulse volume of 4+
Full volume, bounding
Can cause infection and are present in the air, soil, and water (molds and yeasts)
Fungi
A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include? - "If you wear gloves, you do not have to wash your hands." - "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds." - "Use an alcohol rub when your hands are visibly soiled." - "If you don't have an infection, your hands won't infect others."
Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds
When the nurse enters the room to measure vital signs in preparing the client for a diagnosis test, the client is on the phone. What technique should the nurse use to determine the respiratory rate? - Count the respiratory during conversational pauses - Ask the client to end the phone call now and resume it at a later time - Wait at the client's bedside until the phone call is completed and then count respirations - Since there is no evidence of distress, defer the measurement until after client's phone call
Since there is no evidence of distress, defer the measurement until after client's phone call
Refers to the work of antibodies (also called immunoglobulins) and lymphocytes. Antibodies bind to infectious agents and call the white blood cells and complement to destroy them
Specific immunity
SYSTOLIC BP: 130 to 139 or DIASTOLIC BP: 80 to 89
Stage 1 hypertension
SYSTOLIC BP: greater than or equal to 140 or DIASTOLIC BP: greater than or equal to 90
Stage 2 hypertension
What are the two tiers of precautions?
Standard and transmission
Is a term used to describe the infection prevent practices applied to all clients, whether or not they are know to have an infectious agent
Standard precautions
Can cause infections including the common cold and do not respond to antibiotics (smallest of all microorganisms)
Viruses
A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. What should the nurse do now?
Wait 30 minutes and return to measure the oral temperature
A nurse is caring for a client who is schedules for an elective surgical procedure. Which of the actions should the nurse take regarding informed consent?
Witness the client's signature
A nurse is planning care for a group of clients. The nurse should delegate obtaining viral signs to an assistive personnel for which of the following clients? (Select all) - A middle adult client who has status asthmaticus - An older adult client who has a history of heart failure and is ready for discharge - A young adult client who is 24 hr postoperative following an appendectomy - An older client who is 36 hr postoperative from a traditional cholecystectomy - A young adult client receiving a continuous IV infusion of regular insulin for diabetic ketoacidosis
- An older adult client who has a history of heart failure and is ready for discharge - A young adult client who is 24 hr postoperative following an appendectomy - An older adult client who is 36 hr postoperative from a traditional cholecystectomy
The nurse should initiate __________ precautions for clients who have infections that spreads by droplet nuclei smaller than 5 microns, including measles, chickenpox, and pulmonary or laryngeal tuberculosis
Airborne
A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? - Adjust the water temperature to feel hot - Apply 4 to 5 mL liquid soap to the hands - Hold the hands higher than the elbows - Rub hands and arms to dry
Apply 4 to 5 mL of liquid soap to the hands
A nurse is providing teaching to a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further training? - "As long as I change my gloves between clients, it is not necessary to wash my hands." - "I should wash my hands before I provide client care." - "I will not wear artificial nails when providing care." - "It is acceptable to use alcohol-based hand products after most client contact."
As long as I change gloves between clients, it is not necessary to wash my hands
A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? - Assess the apical pulse for a full minute - Assess the apical pulse with a Doppler device - Assess the pedal pulses for a full minute - Assess the pedal pulses with a Doppler device
Assess the apical pulse for a full minute
What are the 5 steps to making an ethical decision?
Assess the situation, diagnose the ethical problem, plan, implement your decision, evaluate your decision
Is a blood pressure below the expected reference range (systolic less than 90mmHg) and can be a result of fluid depletion, heart failure, or vasodilation
Hypotension
An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1 C (98.8 F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?
Blood pressure
Irregular rate and depth of respirations that follow a cyclical pattern. The client will experience shallow preaches that progress to a normal pattern, and increased rate, then the rate begins to slow again, ending with an apneic period
Chyne-stokes respirations
A nurse is providing nail care for a client. Which of the following actions should the nurse take? - Clean under the nail with an orange stick - File the nails in a rounded shape - Push the cuticles back with a metal nail file - Trim the nails at the lateral corners
Clean under the nail with an orange stick
The nurse should initiate ________ precautions for clients who have infections that spread by direct or indirect contact, including vancomycin-resistant enterococci, methicillin-resistant staphylococcus aureus, clostridium difficulty, and impetigo
Contact
What are the 5 cardinal signs of infection
Heat, swelling, redness, pain, loss of function
Respect for the inherent worth and uniqueness of individuals and population
Human dignity
Contact transmission occurs when microorganisms are directly moved from the infected person to another person without having a contaminated object or person between the two
Direct contact (mononucleosis)
A nurse is caring for a client who refuses treatment and asks to be discharged form the hospital against medical advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse?
False imprisonment
- Became a nurse at age 31 - Organized nursing care during the Crimean War for a military hospital in Turkey - Elevated the status of all nurses - Returned to England after the war and established the first training school for nurses - Wrote books about healthcare and nursing education
Florence Nightingale
What is the PPE for contact precautions?
Gloves and gown
What is the PPE for droplet precautions?
Gloves and mask
- No obligation to provide care outside of employment - These laws help protect an individual if they do render aid - Varies by state - Stipulations apply
Good Samaritan laws
An abnormally elevated body temperature (greater than 40 C [104 F]) due to a failure of the thermoregulatory mechanisms of the body
Hyperthermia
A nurse has completed an informed consent for with a client. The client then states, "I have changed my mind and do not want to have the procedure done." Which of the following actions should the nurse take? - Remind the client that a signed informed consent form is a legally binding document - Notify the surgeon that the client wishes to withdraw informed consent for the procedure - Inform the surgical team to cancel the client's surgery - Proceed with preparation of the patient for the surgical procedure
Notify the surgeon that the client wishes to withdraw informed consent for the procedure
Is a blood pressure that decreases when a client changes position form lying to sitting to standing, and it can result from various causes (peripheral vasodilation, medication adverse effects, fluid depletion, anemia, prolonged bed rest)
Orthostatic (postural) hypotension
A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction? - Wraps the blood pressure cuff snugly around the client's arm - Places the client's arm above the level of the client's heart - Check the instrument gauge to ensure the reading starts at zero - Centers the cuff bloodier over the client's brachial artery
Places the client's arm above the level of the client's heart
Is the measurement of heart rate and rhythm. Corresponds to the bounding of blood flowing through various points in the circulatory system. It provides information about the circulatory status
Pulse
Is the difference between the systolic and the diastolic pressure readings
Pulse pressure
You are taking care of a patient who has a bleeding disorder. You are asked to obtain vital signs every 4 hours. Which route is contraindicated for assessing a temperature?
Rectal
What are erythrocytes?
Red blood cells
What are some examples of medical asepsis (clean technique)?
Regular IV, regular wound care, peri care, drawing blood
When assessing a client's radial pulse, a nurse is unable to feel palpations. What should the nurse do first?
Release the pressure of the fingers slightly while compressing the artery
A nurse is obtaining client's blood pressure. What is reflected by the diastolic blood pressure?
Resting arterial pressure