Fundamental part 1

How often should friction is required?

15-20 seconds. friction is required to loosen and remove dirt and pathogens from the hands.

What is the width of the cuff bladder?

40% of the circumference of the client's arm.

what does tertiary prevention focus on?

restoration and rehabilitation prevent complication and help people recover from an existing illness.

What is Maslow's hierarchy of needs?

1. Physiological needs 2. Safety and Security needs 3. Love and Belonging Needs 4. Self esteem 5. self actualization

Hand hugience should be performed with warm water. Warm water preserves the protective oil of the skin better than hot water true or false

true

True or false Nurse should assess all peripheral pulses to determine the equality of blood perfusion to the extremities.

true

Who gets tympanic route?

young children but avoid if they have ear infection, or has tympanostomy.

Where should nurse place the probe if pt is diaphoretic (Sweating more than normal)

Behind the ear

What does Aortic stenosis produces?

Midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.

Where is fifth intercostal space just medial to the midclavicular line located?

Mitral valve

What is an example of primary prevention?

Educating parents of young children about dangers of flu. Administering flu vaccine.

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

Evaluate pedal pulses - this determines adequate blood supply to the foot. Nurse should apply the safety and risk reduction priorty-setting framework. This framework assigns priority to teh factor posing the greatest safety risk to the client. When there are several risks to the client's safety, the one posing the greatest threat is the highest priority. use maslow's, ABC and nursing knowledge to identify the greatest risk to the client.

When should we use Doppler ultrasound stethoscope?

If pulse that is nonpalpable or very difficult to palpate

A nurse is performing an *abdominal assessment* for an adult client? which is the correct sequence?

Inspection Auscultation Percussion Palpation (IAPP)

A nurse is performing other assessment for an adult client which is correct sequence??

Inspection Palpation Percussion Auscultation (IPPA)

Can you place probe over an area covered with hair?

Nope.

*A nurse is preparing to provide tracheostomy care for a client which of the folloiwng actions should the nurse take first?*

Perform hand hygiene. - according to evidence-based practice, the nurse should first perform hand hygiene before touching the client or performing any skills, such as tracheostomy care. This is important bc contamination of the nurse's hands is a primary source of infection.

Where is Second intercostal speace to the let of the sternum located?

Pulmonic valve

who should get rectal?

Rectal route is very accurate for body temp in young children, but should avoid if patient is having diarrhea.

A community health nurse is preparing a campaign about seasonal influenza. which of the following plans should the nurse include as a secondary prevention?

Screening groups of older adults in nursing care facilities for early influenza - screening older adults who ahve some manifestation of illness to determine if they have flu is an ex of secondary prevention.

A nurse at a screeening clinic is assessing a client who reports a hx of a heart murmur r/t aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

Second Intercostal space to the right of the sternum.

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

Sit and hold the client's hand - this is therapeutic techniques of silence, touch and offering of self to the client. Do not leave the room to allow ct to cry privately because this does not acknowledge ct's distress. Offering to call ct minister is non therapeutic bc it shift responsibility of helping ct to someone else. contacting family and asking them to stay with ct this does not respond to ct's immediate needs and shifts responsibilities of helping to others. **always address ct's immediate needs first**

A nurse is planning to obtain the vital signs of a 2 year old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature?

Temporal - It is not as accurate as rectal route but it is non-invasive and can be used to obtain temp in TODDLER who might have a ear infection and who is having diarrhea.

A nurse is teaching an assistive personnel ap about proper hand hygiene. which of the statements by AP indicates an understanding of the teaching?

There are times I should use soap and water rather than an alcohol based hand rub to clean my hands. - alcohol based hand rubs are effective as soap and water in providing proper hand hygience, but CDC recommends washing hands with soap and water at certain times, such as when hands are visibly soiled with dirt or body fluids such as diarrhea.

When should nurse assess pedal pulses?

To determine circulation in the ct's lower extremities.

Temportal artery route can be used with who?

Toddlers (Forehead) This can be used as an alternatives if patient have ear infection.

Where is fifth intercostal space to the left of the sternum located?

Tricuspid valve

A nurse observes an AP preparing to obtain blood pressure with a regular size cuff for a ct who is obese. which of the following explanations should the nurse give the AP/

Using a cuff that is too small will result in an inaccurately high readings. Blood pressure comes in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. BP readings can be falsely high if the cuff is too small for the client. a cuff that is incorrect size for the ct will not yeild an accurate reading.

Who should get oral route for temperature?

children above 3+.

A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take first?

count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.

what is an example of tertiary prevention?

finding rehabilitation programs for older adults who have complication from flu.

Primary prevention focuses on?

health promotion and protection against specific health problems prevent people who are healthy but in danger of becoming ill.

what does secondary prevention focus on preventing?

it focus on preventing complications of an illness or providing care to prevent illness from becoming severe.

How should you dry your hands after washing it?

perform from cleanest area (fingertips) to the least clean area (forearms) to prevent contamination of the newly cleaned hands.