Fundamentals Exam 1
name relevant psychosocial hx for resp system
tobacco or marijuana use, low SES, resident of nursing home or shelter, homeless, recent prison inmate, family member of TB client, immigrant from TB prevalent country
Assessment of Precordium
* 5 locations to inspect, palpate, and auscultate! Remember acronym: All People Enjoy Time Magazine
a charge nurse is planning to discuss factors that can influence the clinical decision-making process in client care with a newly licensed nurse. which of the following factors should the charge nurse include? (select all that apply) -appropriate delegation -cost of client care -available resources -awareness of client status -support from other staff
-available resources -awareness of client status -support from other staff
a nurse in the ED is assessing a client who has experienced thoracic trauma from a motor-vehicle accident. which of the following findings is an indication of a pneumothorax? -client's ribs slope downward at a 45 degree angle -client is making a high-pitched crowing sound that can be heard in the neck area -diameter of client's chest appears barrel-like with horizontal ribs -client is experiencing unequal movement of the posterior chest
-client is experiencing unequal movement of the posterior chest
a nurse is reviewing methods created to assist nurses in using evidence-based practice. which of the following is a NCSBN model that can assist the nurse with critical thinking and decision making? -clinical judgment -critical thinking -clinical reasoning -SMART goal
-clinical judgment
what are the steps in the chain of infection?
1. infectious agent 2. reservoir 3. exit portal 4. transmission 5. entry portal 6. susceptible host
Airborne
Private room with negative pressure ventilation Measles, Tuberculosis, Covid-19 You: N-95 masks Pt needs a surgical mask
Droplet
Private room, pt in surgical mask Strep pharyngitis, pertussis, rubella, bacterial meningitis You: Mask + standard precautions Pt needs surgical mask
Reflective process is?
Purposeful recall of situations Opportunity to express experiences Self-evaluation
what is the body's first line of defense?
intact skin, body fluids (chemical barriers), reflexes (like sneezing)
what is vascular efficiency dependent on?
patency and elasticity of vessels
What is RACE?
rescue, alarm, contain, extinguish
what are your vital signs?
temp, pulse, respirations, pulse ox, BP, pain
what happens during percussion?
vibration of body structures, investigates density of underlying tissue. Tympany - Air or fluid Dull - solid tissue
what are some examples of reservoirs?
water, soil, human body
stridor
wheezing, high pitched, upper airway, MED EMERGENCY, inflammation of epiglottis or by croup (viral infection)
What's the apical pulse?
where apex is closest to chest wall and the ONLY place you should feel pulse Stop at mitral area and listen to apical heart rate Sinus rhythm 60-100 beats per minute (expected) Rhythm regular (expected)
What are the seven dimensions of the HPI?
where, quality, quantity, timing and setting, aggravating factors, alleviating factors, associated data
wheezing
whistling or musical noise heard on exhalation. caused by constricted airways, like in asthma or COPD
what do murmurs sound like?
whooshing or blowing sounds
why are the elderly at risk for PV issues?
with age comes increased large artery stiffness, higher BP, loss of arterial elasticity and compliance, leading to stasis and decrease perfusion
AIDET when?
with all pt encounters acknowledge introduce duration expectation thank you!
a person that is afebrile is considered?
without a fever
a charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. which of the following should the nurse use to describe a pleural friction rub? -coarse grating sound -intermittent popping or bubbling sound -heard on I and E -snoring sound on expiration -pain with breathing
-coarse grating sound -heard on I and E -pain with breathing
a nurse is caring for a client who is in an acute care facility. the nurse should recognize that the client's care requires clinical reasoning when it is complicated by which of the following factors? (select that apply) -complex clinical situations -ongoing client and family concerns -cost of healthcare -decreased need for advanced health care practitioner intervention -availability of computerized medical records
-complex clinical situations -ongoing client and family concerns
a nurse is preparing a poster about fire safety for a community health fair. the nurse should include on the poster that which of the following components contains needed elements for fire to occur? (select all that apply) -carbon dioxide -nitrogen -cooking oil -oxygen -heat
-cooking oil -oxygen -heat
a nurse is reviewing the concept of critical thinking with a newly licensed nurse. which of the following statements should the nurse make? -critical thinking is the foundation for clinical decision making. -critical thinking takes into consideration nursing, scientific, and tech knowledge in client situations. -critical thinking is the visible or observed outcome while using evidence-based practice. -critical thinking is necessary for the nurse to collect objective client data.
-critical thinking is the foundation for clinical decision making.
a nurse is caring for a client who had a stroke and reports having difficulty with proprioception. the nurse should plan to assess the client for which of the following? -restricted movement due to abnormal fixation of a joint -a drop in BP that occurs with a change in position -altered gait with dragging of the toes while ambulating -diminished awareness of body position and balance
-diminished awareness of body position and balance
a nurse is assisting with conducting a home hazard assessment for a client who has dementia. which of the following findings indicates an understanding of home safety? -extension cord is secured under a rug -edge of stairs are marked with brightly colored tape -toaster is plugged in when not in use -water heater is set to 55 celsius (131 F)
-edge of stairs are marked with brightly colored tape
a nurse is teaching about the importance of hand-washing to a client. which of the following statements should the nurse make about hand hygiene in a healthcare setting? - it is not important to wash your hands after removing your gloves -effective handwashing can decrease hospital infection rates -infections in health care staff are not considered HAIs -HAIs are a rare event in health care delivery
-effective handwashing can decrease hospital infection rates
a nurse is discussing the role of tooth enamel with a client. which of the following information should the nurse include in the discussion? -enamel protects teeth from pathogens -enamel is a substance that cannot be dissolved -enamel is a soft material that protects the teeth -enamel covers the pulp
-enamel protects the teeth from pathogens
a nurse is caring for an older adult client who has a cognitive impairment and is postop. which of the following actions should the nurse take? -use the crying, requires o2, increases vital signs, expression, sleeplessness pain scale -reassure fam members that older adult clients have a decreased ability to sense pain -evaluate the client for pain by observing their behavior -assign pain scale number based on FACES pain scale
-evaluate the client for pain by observing their behavior
a nurse asks a client to rate their current level of pain using a scale of 0-10 after admin of pain meds 30 min ago. which of the following steps of the nursing process is the nurse performing? -evaluation -implementation -analysis -planning
-evaluation
a nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. which of the following actions should the nurse take? -wrap both arms around the client's arms and shoulders -move both feet together when the client begins to fall -protect client's extremities while lowering them to the floor -extend one leg and allow client to slide down the leg to the floor
-extend one leg and allow client to slide down the leg to the floor
a nurse is preparing to conduct a fall risk screening on a client. which of the following variables will the nurse use to evaluate the client? (select all that apply.) -fall hx -med diag -use of assistive devices -mental status -DNR status
-fall hx -med diag -use of assistive devices -mental status
a nurse is assessing the anterior chest of the client. which of the following findings should the nurse report to the provider? -PMI located at 5th IC space -symmetrical chest movements during I/E -absent visible pulsations in the area of the PMI -forceful chest movement at the midclavicular line at 4th IC space
-forceful chest movement at the midclavicular line at 4th IC space
a nurse is assisting with teaching a class about warning signs from a co-worker that might indicate future workplace violence. which of the following behaviors should the nurse include? -legitimate absenteeism -strict adherence to facility policies -consistent adequate work performance -frequent reports of not being treated fairly
-frequent reports of not being treated fairly
a nurse is assessing a client's jugular veins and carotid arteries. the nurse should assist the client into which of the following positions? -place client in high-fowler's position -have client lay supine with head of their bed at 45 angle -have client seated with their chin touching their chest -place client in L lateral position
-have client lay supine with head of their bed at 45 angle
a nurse in an ED is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. which of the following instructions should the nurse include? -lean on crutches to support your body weight when standing -fully extend your arms when holding onto the hand grips -hold the crutches on your unaffected side when preparing to sit in a chair -hold the crutches 9 inches in front of and to the side of each foot
-hold the crutches on your unaffected side when preparing to sit in a chair
a charge nurse is reviewing the documentation of a new nurse. which of the following entries made by the new nurse is an ex. of correct documentation? -i cannot sleep at night bc I get short of breath -client seems to not like certain staff members -client's partner does not visit the client enough -inspiratory wheeze auscultated at left lateral chest
-inspiratory wheeze auscultated at left lateral chest
a nurse is caring for a client who has a peripheral venous ulcer. which of the following actions should the nurse take? -instruct client to apply warm heat for pain -instruct client to sit with their legs uncrossed -encourage client to avoid tobacco products -instruct client to cleanse area with mild soap -instruct client to wear shoes when ambulating
-instruct client to sit with their legs uncrossed -encourage client to avoid tobacco products -instruct client to cleanse area with mild soap -instruct client to wear shoes when ambulating
a nurse is discussing health promotion programs with a client. which of the following should the nurse include? -it emphasizes behavior changes in relation to prevention of illness -encourages decreased use of health services -restricts client's control over their general health -discourages community involvement
-it emphasizes behavior changes in relation to prevention of illness
a nurse is assisting with teaching a newly licensed nurse about using a lift device to transfer a client. which of the following actions by the nurse indicates an understanding of the teaching? (select all that apply) -locks the brakes on the client's bed -checks the max weight of the lift before using it -places the client on the edge of the sling -uses the lift without assistance from another team member -performs a safety check before lifting the client
-locks the brakes on the client's bed -checks the max weight of the lift before using it -performs a safety check before lifting the client
a nurse is preparing to transfer a client from a bed to a wheelchair. which of the following actions by the nurse demonstrates proper use of body mech? -twisting torso when transferring client -bending at weight when transferring client -placing bed in high position before transferring client -looking at client face to face when transferring client
-looking at client face to face when transferring client
a nurse is caring for a client who has an rx for knee-length antiembolic stockings. which of the following actions should the nurse take? -place stockings on the client after they ambulate to restroom -ensure client's toes are visible after placing stockings on the client -after applying stockings, place two fingers between client's leg and stocking to check the fit -measure the client's calf circumference and leg length from heel to toe
-measure the client's calf circumference and leg length from heel to toe
a nurse is preparing a poster presentation about the musculoskeletal system. the nurse should include that which of the following is responsible for body posture? -center of gravity -bones -muscles -synovial joints
-muscles
a nurse is assisting with teaching a newly licensed nurse about electrical safety. which of the following actions by the newly licensed nurse indicates an understanding of the teaching? -nurse plugs in a sequential compression device with wet hands -nurse holds onto the plug to unplug a client's electronic BP machine -nurse rolls the client's bed over an electrical cord -nurse uses an extension cord to plug in a client's smart infusion pump
-nurse holds onto the plug to unplug a client's electronic BP machine
a charge nurse is observing a newly licensed nurse perform an anterior chest auscultation on a client. for which of the following actions should the charge nurse intervene? -nurse asks client to cough before beginning the auscultation -nurse is auscultating through the client's gown -nurse places steth on the IC spaces -nurse moves down the chest in a ladder sequence
-nurse is auscultating through the client's gown
a nurse is caring for a client who has right-sided hemiplegia following a stroke. which of the following should the nurse consider when caring for this client? -nurse should perform personal hygiene tasks for the client -client has a minor loss of strength on the right side of the body -nurse should have the client remove clothing from the unaffected side first -oral care is much easier for the client to perform than bathing
-nurse should have the client remove clothing from the unaffected side first
a nurse is caring for a client who has an indwelling urinary catheter in place. which of the following actions is the priority for the nurse to take to reduce the client's risk of developing an HAI? -wipe down client's bedside table with an antiseptic wipe -conduct informal audits of med records to identify the # of HAIs -perform hand hygiene -instruct client on ways to reduce risk of infection
-perform hand hygiene
a nurse is caring for a client who is experiencing a seizure. which of the following actions should the nurse take ? -record time and length of seizure -restrain client's extremities -place client in prone position -monitor client's hemoglobin level
-record time and length of seizure
a nurse is caring for a client who has an rx for wrist restraints. which of the following actions should the nurse take? -tie the restraints to the siderails on the client's bed -remove the restraints with each vital sign check -use a square knot to secure the restraints -make sure one finger can fit under the restraints
-remove the restraints with each vital sign check
a nurse is completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at Level 1 Mobility. The nurse should identify that the client is unable to perform which of the following tasks? -sit on edge of bed for 1 min -stand in place for 5 sec -walk in place -step forward and backward
-sit on edge of bed for 1 min
a nurse is performing a head to toe assessment. which of the following findings indicates the client might be experiencing resp difficulty? -occasionally sighs -sitting in tripod position -RR is 18/min -using pursed lip breathing -appears confused
-sitting in tripod position -using pursed lip breathing -appears confused
a nurse is teaching a client who has a new diagnosis of a skin infection about the function of skin in the body. which should she include? -skin contains Langerhans cells that kill pathogens -skin is smallest organ of body -skin is second line of defense -dermis is outermost layer
-skin contains Langerhans cells that kill pathogens
a nurse is planning to use the identity, situation, background, assessment, recommendation, read back (ISBARR) tool to communicate with a provider about a client. which of the following information is included in the assessment component of ISBARR? -the client's admitting diagnosis -the client's med hx -the client's lab test results -the client's response to treatment
-the client's lab test results
a nurse is reviewing the anatomy of the skin with a newly licensed nurse. which of the following information should the nurse include as a characteristic of the epidermis? -the epidermis acts as a cushion against physical trauma -the epidermis separates the dermis from the underlying organs -the epidermis consists of squamous epithelial cells -the epidermis contains blood vessels and blood
-the epidermis consists of squamous epithelial cells
a nurse is planning to implement the Transforming Care at the Bedside plan on a med surg unit. which of the following interventions should the nurse include in the plan? -require nurses to spend 50% of their time at the bedside of clients -perform change-of-shift report at the nurses' station -complete client rounds every 4 hrs -use a standardized communication tool
-use a standardized communication tool
a nurse is performing foot care for a client. which of the following actions should the nurse take? -soak the feet prior to washing the feet -use hot water when performing foot care -use a towel to completely dry b/w the toes -file the nail edges straight across with a file
-use a towel to completely dry b/w the toes
which of the following actions by the nurse are examples of infection control? -hand washing with soap and water for 15 sec -using an alcohol-based rub when hands are not visibly soiled -using an alcohol pad to wipe the diaphragm of the steth between clients -wearing artificial nails -wearing sterile gloves when opening gauze dressing packages
-using an alcohol pad to wipe the diaphragm of the steth between clients -hand washing with soap and water for 15 sec
a nurse is performing a bed bath for a client. which of the following should the nurse remember when preparing to bathe the client? -bathing the client completely in bed preserves the client's dignity -washing client in bed is less effective than taking a shower -complete bed bath should be performed using basin, soap, and water -perform this type of bath early in the morning
-washing client in bed is less effective than taking a shower
a nurse is providing discharge teaching to a client who has COPD regarding the influenza vaccine. which of the following statements should the nurse make? -it's just a small number of people that get the flu from receiving the vax -call your provider immediately if you have any flu-like sx after receiving the vax -you should make every effort to receive a flu vax every year -the vax becomes effective immediately after the injection
-you should make every effort to receive a flu vax every year
how much oxygen does a NC (nasal cannula) deliver?
1-6 L/min
What are the steps of the nursing process?
1. Assess 2. Analyze 3. Plan 4. Implement 5. Evaluate
normal range for resp rate
12-20 breaths/miin
what are the expected values for RR?
12-20 breaths/min
What is an expected AP:L ratio? (anteroposterior diameter:transverse diameter)
1:2
what are the expected values for temperature?
98.6-100.4 fahrenheit
Physical appearance
Age Dress Cleanliness Posture, gait Facial expression, eye contact State of health
Apply the nursing process to client care
Assessment Gather data to establish a baseline of info Example: Patterns of health and illness, risk factors, resources for coping and adaptation Analysis Identify healthcare need and make clinical decision Plan Develop a plan of care with an ECO Identify nursing actions/interventions Implementation Carry out the plan and provide direct patient care/education Evaluation Report and document Did intervention work? ECO met or unmet?
What is the purpose of documentation?
Documentation is a key communication strategy that produces a written account of pertinent patient data, clinical decisions and interventions, and patient responses in a health record Enhances safe and effective care Focuses on efficiency, accuracy, and minimizing risk of errors
signs and symptoms of localized infection
Erythema (red) Exudate (drainage) Edema Pain, tenderness
How do you describe the expected findings related to a patient's mood and affect?
Euthymic - expected mood Congruent - expected affect
What interventions are used for "high risk" fall patients?
Fall risk sign on door Yellow fall identification armband on pt Yellow non skid footwear Use assistive devices Bed/movement alarm sitter
Sit to stand chair
For patients that need moderate assistance More assistive than a gait belt
Veins:
Function: deliver oxygen depleted blood from periphery to heart Mechanism: unidirectional valves and Venopressor (muscle pump that helps pump blood to heart) Attributes: has valves that don't allow backflow of blood when muscle is relaxed
Arteries:
Function: deliver oxygen rich blood from heart to periphery Mechanism: myocardial contraction Attributes: higher pressure and no valves
Past Medical History (PMH)
General Health Status Childhood Illness Immunzations Hospitals and Surgeries Chronic Illnesses Obstetrical History Allergies Current medications
when assessing the jugular veins, how should a patient be positioned?
HOB elevated 30-45 degrees
Standard Precautions (USED FOR ALL PATIENTS)
Hand Wash Wear Gloves Wear Mask Wear Gown Sharps Disposal
Bed making techniques:
Head of bed (HOB) low or flat Use a turn or draw sheet Keep linens wrinkle free Avoid overuse of pads Use a toe pleat Rational: Maintain skin integrity by decreasing friction Shearing Pressure on skin Wrinkle free=maintenance of skin integrity Long strokes from distal to proximal during bath= increased circulation
Past Med Hx - PV
Heart disease Hypertension Diabetes Varicose veins Phlebitis (inflammation of vein) Peripheral vascular disease
Environmental History and Hazards
Home Work Community Travel
what kind of health education and promotion is given in relation to PVS?
ID and intervene on PVS risk factors by increasing activity levels, managing stress, eating a heart healthy diet, avoid stockings that put pressure on any artery, drink 8 glasses of water a day, elevate legs, airline travel safety
You are assessing a patient and ask about their mood. They tell you that they are feeling very sad because they just experienced a death in the family. You notice that while they are telling you this they are also laughing uncontrollably. How would you describe this behavior?
Incongruent
Discuss alternatives to restraint use
Increase assessment of patient Orient client and family/Provide reality links Provide sensory stimulation or diversion Provide quiet and rest time Family or sitter to stay with patient Review medications Keep all equipment out of view of patient Answer call light immediately Organize and schedule care Move patient to a room closer to nurses' station
What are stages of infection?
Incubation period Prodromal stage Acute illness Decline Convalescent period
what are the components of a mental health assessment?
LOC, intellectual performance, physical appearance, psychomotor behavior, mood/affect, speech, thought process/content
Describe the components of the mental status assessment
Level of Consciousness Intellectual performance Physical appearance Psychomotor behavior Mood/affect Speech Thought process and content
Perineal care:
Male: In supine, sitting position Takeaway: Circular motion from meatus outward, down shaft Female: Dorsal recumbent Takeaway: wash from top of perineum to rectum
Describe the Nursing History
Nursing history is a holistic approach and a way for us to gather information about physical/developmental, cultural, spiritual, intellectual, social, emotional background of patient Takeaway: Nursing history provides SUBJECTIVE info. About patients past and present history
Level of Consciousness
Observing the "state of consciousness" Alert? Awake? Lethargic? Comatose?
Intellectual performance
Orientation x4 (person, place, time, situation) Attention and concentration: ability to focus Ability to understand Abstract thinking Judgment and understanding of outcomes Insight, degree of awareness Short-term memory (3 words) full/intact (expected)
in addition to ambulation, you place TED hose and SCDs on a patient to help prevent (not treat) a DVT. What things should you assess after you apply these devices?
PMSS- perfusion, movement, sensation, and skin
Vascular efficiency is dependent on:
Patency of vessels (no obstruction) Coagulation, constriction, and trauma (edema or vessel damage) Elasticity of vessels Vasodilation: increases the lumen size which decreases resistance to blood flow Vasoconstriction: decreases the lumen size which increases the resistance to blood flow
Discuss elements of establishing a safe environment
Patient safety assessment begins with "noticing" Making sure environment is free of clutter, patient is in good condition, unharmed, safe
How should you auscultate the respiratory system?
Place the stethoscope directly on the skin Have patient fold arms when auscultating on the posterior thorax Move your stethoscope from side to side in order to compare
Identify methods for maintaining and improving the human body's natural defenses against infection
Preventing skin breakdown Rest Plenty of fluids to avoid dehydration Nutrition Vitamin C: increases immunity (water soluble) Protein: energy, tissue
Contact
Prevention by direct or indirect contact MRSA, C.diff, RSV, Impetigo, Lice, Scabies Private Room: pt in fresh gown and linens You: Gloves and Gown Pt needs a clean gown and cover with sheet
Portal of Exit
Prevention of exit from reservoir Cover sites (wounds, mouth), PPE, disposal of contaminated materials, hand washing.
Thought process and content
Process: observed through speech Patterns and forms of verbalizations, assesses pt putting together ideas Content: the specific meaning of pt's communication, what are they thinking? Expected finding: logical, coherent
Identify patient education needs for prevention of infection
Promote natural defense mechanisms (skin, hands, environment, nutrition, rest) Infection control measures (limiting contact with infected persons)
Proper body mechanics for nurses:
Proper body alignment Use large muscles groups, usually legs, to lift Bend at the knees and hips: do not bend at your waist or back Keep your back straight Have a broad base of support: plant feet firmly and keep feet at least shoulder width apart to improve stability and balance Brace for support and use leverage: pivot your feet as you turn Takeaway: always involve the patient if they have the ability to help Work at waist level with low center of gravity *raising bed to comfort level Keep items close to the body Focus on strong core Use smooth controlled movements to lift Push rather than pull Slide, push, rather than lift if possible
Current Medications
RX, OTC, herbal Antiarrhythmics Antihypertensives Anti-cholesterol allergies
The nurse is about to perform a bed bath. What are some actions that the nurse should take to prevent injury to themselves?
Raise the bed to a comfortable level Lower side rails
Infectious Agent
Reduce or eliminate pathogens (fungi, bacteria, viruses) Hand washing, disinfecting chemicals, sterilization-steam, gas, chemicals.
Psychomotor behavior
Reflection of mental and/or neurological status Activity, pace and energy Agitation or retardation Tremors, tics, grimaces Gestures or mannerisms Coordination, balance
Rationale for bathing techniques
Removal of microorganisms Prevention of infection Remove dead skin cells Control spread of pathogens/infection Prevent loss of skin integrity (cracking, maceration) Promote venous return and arterial circulation
Psychosocial Hx - PV
Smoking Alcohol Exercise Stress Nutritional deficiencies (Vitamin D, vitamin B, magnesium, and electrolytes)
Psychosocial - Cardiovascular System
Smoking or exposure to second hand smoke Alcohol, drugs Exercise habits Physical, emotional, occupational stress
Documentation must be:
Specific Factual Accurate Complete Current Organized Signed- e signature when signing on and off of electronic health record
capillary refill
Speed of capillary refill with oxygenated blood <3 seconds (expected) Location: nailbed or any peripheral tissue
peripheral pulses
Strength: 0, 1+, 2+ (expected), 3+, 4+ Symmetry: equal bilaterally (expected)
Describe patient risks for injury in the healthcare setting
Takeaway: Falls (most common hospital injury) HAI: Hospital acquired infection Aspiration Suffocation Poisoning Accidents: patient, procedure, equipment related Fire RACE: rescue, alarm/activate/alert, confine/contain, extinguish/evacuate
What is the primary goal of the nursing process?
Takeaway: To collect and organize information about the patient
What are you looking for when assessing cardiovascular system?
Takeaway: While inspecting and palpating these areas, you are looking for lifts or heaves (unexpected findings), they indicate forceful contractions. Thrills which are vibrations indicate turbulent blood flow
What is the ECO (expected client outcome)?
The outcome we expect to see if the actions are effective. Basically, how we expect the client will respond.
During ventricular emptying (systole) phase:
Tricuspid and mitral valves CLOSE Pulmonic and aortic values OPEN Blood flow through pulmonary artery and aorta
What position might you observe a patient sitting in if they are having difficulty breathing?
Tripod position
How much oxygen can a nasal cannula deliver before needing to switch to another oxygen device?
Up to 6 liters
Bathing techniques:
Use soap (except face) Warm water, gentle friction Work from clean to dirty Eyes: wipe from inner to outer canthus Keep clean linens off floor, no shaking Place soiled linens in designated container Change linens and gown Remove excess moisture Prevent excess dryness Use long, firm strokes distal to proximal (helps circulation!) Massage skin and back rub Implement range of motion activities
causes of hyperventilation
anxiety attacks, pneumonia, COPD, asthma, diabetic ketoacidosis, brain injury
bradycardia
any pulse below 60 BPM
evaluation
assess the effectiveness and achievability of the goals and the need for interventions to be adjusted
why is it important to assess for jugular vein distention?
assessment of jugular veins can give the nurse information about the pressure and blood volume in the right side of the heart could indicate increased central venous pressure and indicative of potential cardiopulmonary condition
nonmaleficence
avoiding harm to all clients
subjective data
based on personal feeling or interpretation, ex. "I don't feel well"
nursing interventions for integumentary issues?
bathing, hair care, nail care, oral and perineal care, linen change
what can you hear with the diaphragm?
big part, high sounds, air and blood
what pulses should we assess?
brachial, radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis (bilaterally)
what's the difference between bradypnea and hypoventilation?
bradypnea - slow HR hypoventilation - breath sounds under 12 breaths/min, inadequate oxygenation
what is the purpose of a nonrebreather? how much o2?
breathe in o2, expel the co2, need increased concentration for o2, never let bag be deflated
what does an AP:L of 1:1 suggest?
children and older adult males
what techniques are used in the respiratory physical exam
client is sitting, blanket and warm room, use stethoscope, don't percuss!
a nurse is preparing to administer medications to a client. which of the following information should the nurse use to identify the client? (select all that apply) clients full name clients DOB clients telephone # client's diagnosis clients room #
clients full name clients DOB clients telephone #
what makes the S1 cardiac sound?
closing of the tricuspid and mitral valves
what is s2? where is it heard best?
closure of aortic and pulmonic valves, heard at base of heart
what makes the S2 cardiac sound?
closure of the aortic and pulmonic valves
what can affect patency of vessels?
clotting (coagulation), constriction, trauma to vessels
what is atelectosis?
collapse of the alveoli in the lung
define hematocrit.
concentration of RBCs in blood
why are the elderly a CV risk?
decreased vessel elasticity, narrowing of the lumen, calcifications, decreased CO
how do you use an incentive spirometer?
deep breath in and out, put in mouth, suck straw to see how lungs do, aim to reach certain level
a nurse is caring for a client who had a stroke and is immobile. the nurse should identify that the client is at risk for which of the following conditions? -deep vein thrombosis -asthma -hernia -hypertension
deep vein thrombosis
Pulse deficit:
difference between apical and radial rate-must be obtained at the same time
define dyspnea
difficult or labored breathing
what are some causes of hypotension?
dilation of vessels, decreased blood volume, and myocardial insufficiency
what direction do you bathe extremities?
distal to proximal to promote venous return
if a person is lying flat, what would be an expected finding of the jugular veins?
distention
what are the risks of supplemental o2 use?
drying of nares, skin breakdown, increased fire risk
what influences can increase HR?
exercise, high temp, emotional response, pain, positive chronotropic drugs, acute hemorrhage, sitting/standing, poor o2 perfusion
what happens if the cuff is too narrow?
false high
what happens if you take BP over clothing?
false high
what happens if the cuff is deflated too slow?
false high diastole
what happens if the arm is below heart?
false high for all
what happens if the cuff is too wide?
false low
what happens if the arm is above the heart?
false low for all
what happens if the cuff is deflated too quick?
false low/high
when do you use the diaphragm?
for lung sounds
CPAP
for sleep apea, creates positive pressure to keep airway open, keeps alveoli open, improves amt of o2 in client's blood
what is systolic?
forced blood into aorta, heart at work
a nurse is planning care for a client who is postop. in which of the following positions should the nurse place the client to prevent atelectasis? -fowlers -lateral -prone -supine
fowler's (promotes lung expansion)
assessment
gather data from the client through interview, physical exam, and observation to make judgments
what type of ppe do you use for bed bath?
gloves
what type of ppe do you use for drawing blood?
gloves
what ppe is worn for contract precautions?
gloves and gown
what type of PPE should the nurse wear as part of contact precautions?
gloves and gown
what type of ppe do you use for taking VS
gloves or none
what type of ppe do you use for irrigating wound?
gloves, face shield, goggles
name interventions for susceptible host
hand washing, nutrition, rest
what interventions can you take to prevent infection?
hand-washing (TOP ONE), disinfecting chemicals, sterilization
how should the patient be positioned for posterior lateral resp. exam?
heads flexed and arms folded in front of sitting
How do we prevent falls?
health promotion (education, exercise, nutrition), good lighting, low bed, wheels locked, 2 side rails up, clutter-free, personal items within reach, non-skid footwear, sign on door and arm band indicating fall risk
what is diastolic?
heart at rest
contractility disorders
heart failure, valvular disease, arrythmias
when do you use diaphragm AND bell?
heart sounds
when changing bed linens, it is important to ensure they are wrinkle free. what is the reason for this?
help maintain the skin integrity of the patient
what can help the drying effect of NC oxygen?
humidifier
what diagnosis is associated with loss of elasticity and thickening of vessel walls?
hypertension
If you notice a patient has increased rate and depth of breathing, what is happening to the patient?
hyperventilation
define hypopnea and hyperpnea
hypopnea - shallow hyperpnea - deep
what is the difference between pitting and non-pitting edema?
if pressing in the area of the edema an indention is left, then the patient has pitting edema
when would you use a CHG bath?
if someone has a central line or invasive line
who are the at risk clients for respiratory issues?
immobile, hx of smoking, known allergies or respiratory diagnosis, neurological and musculoskeletal disorders, post-op pain or trauma to the thorax or abdomen, lifespan considerations (kids sticking it up their nose)
you have a patient who had abdnominal surgery 3 days ago. despite your best efforts the patient will not ambulate. when thinking about the respiratory and cardiovascular/PV systems, what are your main concerns?
impaired gas exchange, risk for infection (pneumonia), ineffective tissue perfusion - venous stasis, activity intolerance
what does encouraging engagement in ADLS do?
improves activity intolerance, improves range of motion, stimulates circulation, and helps the patient move toward total self care
how does decreased arterial elasticity affect BP? PVR?
increase both BP and PVR
a client reports experiencing stress about their new diagnosis of coronary artery disease. which of the following are manifestations of prolonged stress?
increased cortisol level
what effect does the SNS have on the heart rate?
increases HR
a nurse is teaching an in-service about the use of ergonomics to a group of staff members. which of the following info should nurse include?
increases job satisfaction
what are some concerns for those "at risk" of alteration in respiratory function?
ineffective airway clearance, ineffective breathing pattern, impaired gas exchange, aspiration, higher risk for pneumonia
simple face mask
inexpensive, can be used on mouth breathers, may cause claustrophobia, not recommended for those at risk for CO2 retention, clients may experience nausea/vomiting, 5-8 L/min of 40-60% o2
what's the infection chain?
infectious agent - reservoir - exit portal - transmission - entry portals - susceptible host **if you break cycle, it prevents infection
what techniques are used for peripheral vein assessment?
inspect - saphenous vein for distension, should be flat and blue look for abnormalities like phlebitis, varicosity ,edema, brown pigmentation palpate - character of veins and for edema or tenderness
what techniques are used in physical assessment of the carotid?
inspect - turn head away from inspected artery, palpate symmetrical, auscultate with bell and it should be silent
which of the following is the first action during the physical assessment of the client? -asking the client about any allergies -inspecting the client -palpating any areas of tenderness the client identifies -auscultating for breath sounds, bowel sounds, and heart sounds
inspecting the client
what techniques are used in physical assessment of the jugular?
inspection only - should distend when supine, fat while sitting
how would you describe the nursing process?
it is dynamic
what does diastolic mean?
it is the minimum pressure exerted against arterial walls when the heart is at rest
what are the seven dimensions of pain?
location, quality, quantity, timing, aggravating factors, alleviating factors, associated data
how should a murmur be described?
location, timing, and intensity use the grading scale 1-6 with 2 being a barely audible murmur and 6 being hear without a microscope
what do clubbed fingers indicate?
long-standing hypoxemia, possibly COPD, lung cancer, cystic fibrosis
perineal care for male? female?
male: circular motion from meatus outward, down shaft female: wash from top of perineum to rectum (front to back to avoid UTI)
what are some signs and symptoms that patients may experience when having venous insufficiency?
marked edema, brown pigmentation especially around the ankles, skin thickens, maybe aching pain
signs and symptoms of PVD?
marked edema, darker pigmentation of skin around ankles, thickening of skin, and none-->aching pain depending on the area
a nurse is caring for a client who requires total assistance with mobility. when using the mobility assessment (MAT), which of the following pieces of equipment should the nurse use to transfer the client? -gait belt -mechanical lift -cane -sit to stand lift
mechanical lift
what is the difference between medical and surgical asepsis?
medical asepsis (clean technique) aims to reduce the number of organisms surgical asepsis (sterile technique) aims to eliminate organisms
give examples of minimal, moderate, and maximal assistive devices
minimal: gait belt moderate: sit, stand, lift max: mechanical lift
what is the function of sputum?
moistens bronchia for cilia activity, trapping of microorganisms
The nurse on night shift has been assigned 6 patients and is very busy. They decide to put up all 4 side rails of a patient who continues to get out of bed and walk out of their room. Is this appropriate use of side rails as a restraint?
no - all 4 side rails cannot be used to simply prevent patients from getting up
The same nurse has been caring for a patient who has been combative and has a restraint order. During this shift, the nurse notices the patient is much calmer and decides to remove the restraints completely. Was this action appropriate?
no - permanent removal of restraints requires an order
What's Tanner's Clinical Judgment Model?
noticing, interpreting, responding, reflecting
your patient is being transported to special procedures for a PICC(peripherally inserted central catheter) line placement. The patient is on droplet precautions. What is your priority nursing action to ensure proper transport of the patient?
notify the receiving department and place a surgical mask on the patient
what impacts an infectious agent's ability to infect?
number of organisms ability to multiply susceptibility of host
a nurse is caring for a client who has a foot ulcer. which of the following findings should the nurse identify as consistent with peripheral venous disease? -loss of hair on lower leg -cool skin temp in lower leg -palpable dorsalis pedal pulse -regular, even wound border
palpable dorsalis pedal pulse
what factors influence infection prevention and control?
patients at either end of age spectrum are at an increased risk, nutritional status, stress levels (increased), disease process, recent surgeries, immune conditions, home environment, hygiene access, crowded living space.
what does systolic mean?
peak pressure exerted against arterial walls as ventricles contract and eject blood
what is the difference between diffusion and perfusion?
perfusion is the delivery of blood to the pulmonary capillaries, whereas diffusion is the movement of gases from the alveoli to plasma and red blood cells.
what is the function of the peripheral vascular system?
peripheral tissue perfusion and venous return to the heart
what are the four levels of orientation?
person, place, time, situation
what are some aspects of PMHx relevant to the resp system?
pertinent past med hx, recurrent infections, resp diseas, persistent cough, exercise intolerance, trauma, last CXR, vaccines
describe non-pitting edema.
pitting edema doesn't leave a mark when pressed, it's generalized and feels firm
a nurse is caring for a client who is at risk for suicide. which of the following actions should the nurse take? (select all that apply) place the client on round the clock surveillance remove objects from the room that the client could use to harm themselves search items brought into client's room by visitors refrain from asking the client if they intend to harm themselves screen the client for suicidal ideation
place the client on round the clock surveillance remove objects from the room that the client could use to harm themselves search items brought into client's room by visitors screen the client for suicidal ideation
What's the PMI?
point of maximum impulse Use fingertips to palpate, can ask client to move forward and to the left Location-5th intercostal space, left mid-clavicular line (expected finding) Assess for: strength, diameter, and timing Light tap 1-1.5cm with systole (expected finding)
which pulses are expected to be 1+?
popliteal and posterior tibialis
if a nurse is repositioning a patient every 2 hrs to prevent skin breakdown, what step in the chain of infection is being broken?
portal of entry
nursing interventions for respiratory illness
positioning (good lung UP), incentive spirometer (suck in not blow out), purse-lipped breathing, cascade coughing, suctioning, trach tube, closed chest drainage
what are some nonpharmacologic interventions for pain?
positioning, heat/cold therapy, therapeutic touch, massage, distraction
when auscultating the lungs, what is the order of movement?
posterior, lateral, and anterior
what is blood pressure?
pressure of blood as it is forced against arterial walls during cardiac contraction
BiPAP
pressures are higher when inhaling and lower when exhaling, recommended for those with COPD, heart failure, and sleep apnea
What does an incentive spirometer do?
prevents atelectasis
beneficence
promoting best interests of a client
a nurse is caring for a client with pneumonia. in which of the following positions should the nurse place the client to promote postural drainage? -lateral -supine -prone -fowlers
prone
How to work with proper body mechanics
proper alignment, use legs to lift, bend at the knees, back straight, broad base, pivot feet to turn, work at waist level, keep items close, use core muscles
portal of entry
provides area for replication, ex. skin breakdown
venturi mask
provides precise amt of o2, reduces rebreathing of exhaled air, interferes with eating and drinking, if rate of flow is increased, concentration of o2 remains the same
which valves close in diastole? what sound is this?
pulmonary and aortic, s2, DUB, ventricular relax
what is the common location to assess a pulse on an adult?
radial if regular rhythm, count 30 sec and multiply by 2 if irregular or child: count 1 min, auscultate apical rate, and measure difference if needed
what are you observing for in speech?
rate, volume, amount/quantity, characteristics
rhonchi
rattling, caused by an obstruction of the airway. may be in asthma or COPD patients
what is the clinical judgment model?
recognize cues - analyze cues - prioritize prob/cause - consider potential solutions - take action -evaluate action
partial and nonrebreather mask
recommended for short term use for acute illness/trauma, high percentages of o2 (60-75%; 80-95%) at flow rates of 10-15 L for those with hypoxia, DONT humidify, risk of atelectasis and ox toxicity, bag MUST be inflated
parts of the clinical reasoning cycle
reflect on process, evaluate outcomes, take action, establish goals, collect information, process information, identify problems
a nurse is caring for a client who is at risk for developing atelectasis. which of the following actions should the nurse take? -reposition the client every 2 hr while in bed -remind client to use incentive spirometer -obtain client's weight daily -encourage client to eat foods that are high in fiber
remind client to use incentive spirometer
name some nursing interventions for altered mental status
reorient every 2 hrs or PRN, minimize interruptions/stimuli, remove hazards, and promote cognitive-behavioral relaxation
define peripheral vascular resistance.
resistance in circ system used to create BP and blood flow, component of cardiac function
abnormal BP what do you do?
retake BP either with auto machine or manually, notify instructor, make plan, and document (including position of pt at time) different positions can change the BP (laying down may be lower, BP higher if upright)
according to the chart, the patient's BP has been normotensive for their entire hospital stay. how will you proceed?
retake BP either with automatic machine or manually, notify instructor or primary nurse, make a plan, and document (including position of the patient when taking the BP)
a nurse is assisting with emergency care of a client who has been exposed to a chemical toxin. which of the following actions should the nurse take? -rinse client's skin with water -remove client's clothing by pulling it over their head -dispose of the client's clothing in a single biohazard bag -prepare to admin potassium iodide to the client
rinse client's skin with water
advantages of nasal cannula
safe, simple, inexpensive, comfortable, decreased likelihood of claustrophobia, avoids rebreathing of cos, delivers oxygen concentrations at lower flow rates (1-6 L/min at 24-44%)
a nurse is completing a med hx on a client. which of the following findings indicates the client has a family hx of cardiovascular disease? -parent with pulm embolism -sibling who has HPT -cousin with diabetes -child who has epilepsy
sibling who has HPT (hypertension)
What is SOLER?
sit facing them, open posture, lean towards them, eye contact, relax, and privay
what are you inspecting for with the peripheral arteries?
skin inspected for mucus membranes (dark pink) and pallor (abnormal)
what are our first line defense mechanisms against infection?
skin, body fluids, reflexes
what are common reservoirs (in the body)?
skin, colon, GI tract, blood, mouth
what are the components of integumentary system?
skin, scalp, hair, nails, sebaceous, sweat glands
Parasympathetic nervous system "rest and digest"
slows down heart rate Vessel dilation which decreased peripheral vascular resistance= decreased blood pressure Decrease the force of contraction= decreased stroke volume
What can you hear with the bell?
small part, low sounds, some blood
causes of hypoxia (lack of o2)
smoke inhalation, high altitudes, COPD, pneumonia, asthma, meds that decrease RR, anemia
psychosocial hx pertaining to CVS?
smoking/vaping, drug use, exercise habits, stress levels
aspects of psychosocial history relevant to PVS
smoking/vaping, exercise pattern, stress, nutrition
vesicular sounds
soft, low, and breezy with inspiration longer than expiration, heard all over lung periphery posterior, anterior, and lateral
Sympathetic nervous system "fight or flight"
speeds up HR Vessel constriction which increases peripheral vascular resistance= increased blood pressure Increase the force of contraction= increased stroke volume
name some causes of pitting edema.
standing for long periods, high protein/salt diet, pregnancy, CHF, kidney disease, burn injury, hepatitis, medications
you begin your nursing shift by conducting a physical assessment. before you begin, the patient tells you they are very nervous today. what type of data is this?
subjective
what's the difference between subjective and objective assessment?
subjective : from the pt, "I feel..." objective: what symptoms do I notice as the provider?
Define subjective data. Define objective data.
subjective = what is reported objective = what can be observed/measured
if a patient is unable to cough, what may be used to rid secretions?
suction (yankauer), respiratory PT
perfusion disorders
surfactant disorders, hypertension, myocardial infarction, CAD
define orthostatic hypotension
symptoms of hypotension when rising from lying to upright position
whats the difference between tachypnea and hyperventilation?
tachypnea - high HR hyperventilation - breath sounds above 20 breaths/min, inadequate oxygenation
how can you easily assess if a patient is experiencing activity intolerance?
take pre-activity. VS and take VS post activity after waiting 5 minutes
what do you do if you get an abnormal temp?
take temp in a different manner, be aware if they just drank or ate something hot or cold, wait 30 min if they did and take oral temp again
S4 gallop sounds like
ten-nes-see, indicates hypertension, hx of myocardial infarction, or aortic stenosis
environmental hazards to avoid in relation to PVS
tight-fitting hosiery/socks, crossing legs
When providing a bed bath for a patient it is important to use long strokes on the extremities moving from distal to proximal. What is the reason for this motion?
to promote circulation
where should the restraints be tied?
to the bed frame
a nurse is teaching a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as an ADL
toileting
what affects PVR?
tone of vascular smooth muscle and diameter of vessel lumen
Therapeutic communication involves which of the following? -touch -open-ended questions -sharing your own personal experience with the client -if the client speaks a different language than the nurse, finding someone in the facility that speaks their language
touch open-ended questions
what are the measurements of pitting edema?
trace (2 mm) with quick rebound mild (4 mm) with 15 sec rebound moderate (6 mm) with 30 sec rebound severe (8 mm) with rebound of >30 seconds
which valves close in systole? what sound is this?
tricuspid and mitral, s1, LUB, ventricular filling
signs of difficulty breathing
tripod position pursed lips, use of accessory muscles, cyanosis, restlessness
what is causing a murmur?
turbulent blood in or near the heart - valves not closing completely
how many times does one auscultate the precordium?
twice - once with diaphragm, once with bell
analysis
use clinical judgment to evaluate data collected to formulate the client's problems, including actual and potential problems
what o2 delivery system is considered high flow?
venturi mask
what factors contribute to infection
# of pathogens present, ability to reproduce disease, ability to enter/exit host, susceptibility of host
a nurse is auscultating heart sounds in a group of clients. which of the following should the nurse identify as an expected variation? -adolescent who has an s3 heart sound -older adult who has a HR of 48/min -young adult who has an irregular apical pulse -middle adult with a murmur
-adolescent who has an s3 heart sound
how would you describe the assessment of a patient's thought process?
-how patient's put together ideas -observed through speech -observe pattern of verbalization
how many lobe are in the right lung?
3
Where is the apex of the heart?
4th and 5th intercostal space Tricuspid L sternal border Mitral L mid-clavicular line
how many places should you auscultate when performing a cardiac assessment?
5
what is the average adult blood volume?
5 L
how much o2 can be delivered using a simple face mask?
6-10 L/min
normal range for pulse
60-100 BPM
Mobility:
Ability to move about freely Enhances functioning of all body systems
Patient education is an essential part of care. What behaviors do patients need to improve learning?
Ability, motivation, and readiness
What's AIDET?
Acknowledge, Introduce, Duration, Expectation, Thank you!
what is the formula for cardiac output? what is the CO for an adult?
CO = SV X HR, 5 L/min
Subjective data needed in assessment of cardiovascular system
Chest pain/tightness Palpitations (dysrhythmia) Excessive fatigue (especially with exertion doing typical ADL) Cough (indication of congestive heart failure, fluid build up) Dyspnea Leg pain or cramps Edema Cyanosis Orthopnea Any limitations in ADLs
Surgical asepsis:
Eliminates ALL microorganisms Sterile technique
Review of PV system to ask pt about
Leg cramps, when walking, standing, or during sleep Numbness, tingling or cold sensations in hands and/or feet Pain, edema, or cyanosis of hands and/or feet
How often should you assist patient in changing position?
Minimum of every 2 hours
patient education is an essential part of care. what behaviors do patient need to improve learning?
ability, motivation, readiness
what are the measures of venous sufficiency?
absence of edema, absence of dilated veins
what is an unexpected finding related to effort of breathing?
accessory muscles used, nasal flaring, leaning forward in tripod position
what does AIDET stand for?
acknowledge, introduce, duration, explanation, thank you
a nurse discovers a small fire in a client's room. after removing the client to safety, which of the following actions should the nurse take next? -extinguish fire -close windows in client's room -close client's door -activate fire alarm
activate fire alarm
what indicates normal perfusion of peripherals upon palpation?
capillary refill <3 seconds
describe pitting edema.
feels squishy and can leave an indentation when palpated
What is sinus arrhythmia?
increase in HR with inspiration, decrease with expiration
bronchovesicular sounds
medium and mixed, 2nd ICS, sternal border anterior, T4 posterior, I=E
how would you describe the health history?
provides subjective information about a patient's past and present history
how should the earpieces of the stethoscope be pointed?
towards the nose
a nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. which of the following actions by the nurse demonstrates correct transfer technique? -positioning chair slightly behind nurse so that seat faces the client's bed -placing client's left leg in front of the right leg just prior to the transfer -aligning the nurse's knees with the client's knees just before transfer -grasping the client under the axillae to assist them to their feet
-aligning nurse's knees with the client's knees just before the transfer
a nurse at an urgent care clinic is auscultating the lungs of a client who reports a cough and shortness of breath. which of the following steps of the nursing process is the nurse using? -evaluation -implementation -analysis -assessment
-assessment
in which order should an RN perform the steps of the nursing process? -analysis -assessment -planning -evaluation -implementation
-assessment -analysis -planning -implementation -evaluation
which of the following techniques is used with palpation? -palpate the tender areas before the other areas -use short, quick taps with palpation -use palmar side of hands or the pads of the fingers -use the stethoscope during palpation
- use palmar side of the hands or pads of the fingers
a nurse is assessing a client's mobility and notes one of the client's feet drags behind them when ambulating. which of the following conditions should the nurse suspect the client is experiencing? -atrophy -foot drop -joint contracture -disuse osteoporosis
-foot drop
a nurse is caring for a client with OSA. which of the following are manifestations of OSA? -loud snoring -restlessness -extreme daytime drowsiness -nausea -headache in evening
-loud snoring -restlessness -extreme daytime drowsiness
which of the following are tools used with auscultation? -dorsal side of hands -stethoscope -penlight -doppler -tape measure
-stethoscope -doppler
what is the expected AP:L diameter?
1:2
Family History
3 Generations Living / Deceased Causes of death and age
Your patient on droplet precautions has family visiting. A family member asks how far they should stand away from the patient while visiting. Your response is:
3 feet or more
your patient on droplet precautions has family visiting. a family member asks how far they should stand away from the patient while visiting. your response is:
3 feet or more
how long should you count respirations?
30 seconds if normal, 1 min if abnormal or child
what are the expected values for pulse?
60-100 BPM
7 dimensions of pain
7 Dimensions: Location - where? Quality - Description (dull, sharp, pounding) Quantity - Scale of 1-10. Constant? Intermittent? Timing and Onset - When? Time of day? Aggravating Factors - What makes it worse? Alleviating Factors - What makes it better? Position? Activity? Noise? Associated Data - Other symptoms that may be occurring
a 71 yo patient is being triaged in the ER for excessive diarrhea. Upon assessment,the patient appears malnourished and dehydrated. The provider is suspicious that the patient may have C. Difficile (c. diff) because of recent antibiotic use. Stool cultures have been ordered. The ER would like to admit the patient to your unit - a cardiac stepdown unit - because there are no other beds available.̶#Based on this information, what factors influence this patient's infection prevention and control?
71 yo patient (age) disease process/illness nutrition/hydration status
what is the expected costal angle?
90 degrees
normal range for blood pressure
90-120/60-80
expected pulse ox values?
95-100%
what is the expected pulse ox reading range?
95-100%
normal range for pulse ox
95-100% sat
normal range for temp
96.8-100.4 F
What are standard preventive fall interventions for ALL PATIENTS?
Adequate lighting Place the bed in a low position with wheels locked 2 side rails up (not considered restraint) Unobstructed pathways, clutter free area Place personal pathways, phone, and call light within reach Non-skid footwear
Factors influencing infection prevention and control:
Age Nutritional status Stress Disease process/surgeries Treatments or conditions that compromise the immune system response Other social determinants of health
Where should chest piece be placed?
Always place stethoscope directly on the chest, NEVER over clothes
what is critical thinking?
An active, organized, cognitive process used to carefully examine one's thinking and thinking of others. Clear, precise, accurate decision
define hypoxia
An insufficiency of oxygen in the body's tissues.
Safety/health promotion - PV
Annual blood pressure monitoring, cholesterol Regular exercise, well-balanced diet
Portal of Entry
Any body orifice: nose, mouth, skin lesion Protect natural defense mechanisms Hand washing, maintain skin integrity/cover wounds, limit invasive techniques, no eating or drinking in clinical area, no rubbing eyes/face, apply something to skin
When do you use an alcohol wipe to clean the diaphragm of the stethoscope?
BEFORE use with each and every patient
Define perfusion
BLOOD AND TISSUES. The flow of blood, driven by the cardiopulmonary system, into the alveolar capillaries surfactant issues is a perfusion issue deox blood is exchanged for ox blood, this blood then travels to heart, then pumped to rest of the body oxygenated blood is directed into the capillaries and deox blood is returned to the lungs
what factors influence BP?
BP increases as we age, is higher in post-pubescent males and post-menopausal women, upon waking, during exercise, SNS stimulation, during smoking, while in pain, and with a high fat and sodium diet age, sex, meds, exercise, diet, stress, smoking
you are caring for a 53 year old male patient who was in a recent motor vehicle accident. VS are 160/102, RR 18, HR 88, Temp. 98.0. The patient is reporting a pain level of 0. What is concerning to you based on this information?
BP is elevated
Reservoir
Body: Skin, colon, genital/urinary, blood, mouth Environmental: Soil, water Hand washing, hygiene, proper disposal of contaminated materials
What expected lung sounds should you be able to auscultate over most areas in the lung fields?
Bronchovesicular breath sounds
Family History - Cardiovascular System
CAD, MI, CHF (ask age family member had these because if under 50-55 years of age this puts individual at way higher risk for also developing these) Diabetes Hypertension High cholesterol Obesity
what does barrel chest indicate?
COPD
Pertinent Past Medical History: Cardiovascular System
Congenital heart disease, rheumatic fever, murmur CAD MI Have they had an EKG before or when was their last EKG Congestive heart failure DVT Arrhythmias In addition to specific heart history, also screen for: diabetes, hypertension, and hyperlipidemia because these are often contributors to heart issues
Transmission
Contact, droplet, airborne, vehicles, vector borne, fomites (stethoscope, clothes, medical instruments) Prevent exposure or spread Hand washing, PPE, avoiding contact, cleaning surfaces Direct Transmission: contact with the infected individual or vehicle/vector. Indirect Transmission: contact with a contaminated object or person between the two
Clinical judgement is?
Decision making of nursing. Includes problem solving, decision making, and requires nursing knowledge base
Susceptible Host
Depends on degree of resistance to infection Goal: increase resistance and reduce susceptibility to infection Hand washing, nutrition (ex: vitamin C, protein), rest (restorative)
What is the difference between the bell and diaphragm of the stethoscope?
Diaphragm is used to auscultate high pitched sounds Bell is used to auscultate low pitched sounds
Rules of documentation:
Document only for yourself!! Validate you are documenting on the correct record Date and time each entry Leave no blank spaces Errors: cross through & write "error, initials" Sign all documentation with name and title Only blue or black ink Acceptable abbreviations only
Immobility:
Inability to move about freely Leads to potential for impairment in all body systems Edema, atrophy, skin integrity issues, halt peristalsis
How often should a patient change positions?
Minimum of every 2 hrs to prevent skin breakdown
what does one need to assess for after any device is applied?
PMSS - perfusion, movement, sensation, and skin
What is PASS?
Pull, Aim, Squeeze, Sweep
Reflective practice is:
Purposeful recall of situations Opportunity to express experiences Self-evaluation
tachypnea
RR above 20 breaths/min
Discuss the benefits of hygiene in maintenance of a healthy integumentary system
Removal of microorganisms, prevention of infection Body image Stress relief Comfort Opportunity to do range of motion exercises Improved circulation, energy, appetite Takeaway: Hygiene is an attempt at breaking the chain of infection Nutrition appropriate for age Sufficient hydration Adequate perfusion: oxygen and nutrients Cleanliness Skin integrity Nursing interventions: Bathing Hair care Nail care Oral care Perineal care Nursing intervention: Linen change
What is clinical reasoning?
Similar to critical thinking but requires a nursing specific knowledge base Using specific nursing knowledge and patterns of thinking Takeaway: Professional nursing practice really depends on sound clinical reasoning
In addition to a nasal cannula, what are some other devices that provide oxygen to patients?
Simple face mask Nonrebreather mask Venturi mask
what happens during inspection?
Simultaneous with AIDET - general appearance and environment.
What risks should the nurse be aware of when using oxygen via nasal cannula?
Skin lesions on the ears Drying of the nares Increased risk of fire
Psychosocial History and Religious History:
Support systems Recent loss/grief Social habits Sleep and exercise Nutrition and elimination patterns Activities of Daily Living (ADLs) Religious/Cultural/Spiritual practices that should be considered in care.
Expected values for BP?
Systolic: 90-120 mmHg Diastolic: 60-90 mmHg Median: 110/70 mmHg
How would you describe the nursing process?
Takeaway: It is dynamic and ongoing, not linear and static
Physical Exam - Cardiovascular System
To Begin Physical Exam: Position of patient: HOB at 45 degrees or sitting up at 90 degree angle Tools: stethescope, pen light, second hand watch Techniques: inspection, palpation, and auscultation VS: BP and HR
The assessment is specifically used:
To collect and analyze
The nursing process is designed:
To help provide care for human responses to health problems
How should the earpieces of the stethoscope be pointed?
Towards the nose Fit snugly in ear Follow contour of face
During ventricular filling (diastole) phase:
Tricuspid and mitral values OPEN Blood flows from higher pressure atria to lower pressure relaxed ventricle Pulmonic and aortic values CLOSE
Environmental Hazards - PV
Wears tight fitting hosiery or socks, crossing legs while sitting or in bed Job related: standing or sitting for long periods, cold exposure
how does blood viscosity affect BP? PVR?
a decrease in viscosity decreases both BP and PVR and vice versa
the rate at which the cuff is deflated is important when taking a BP reading. one of the most common errors is deflating the cuff too quickly. what type of BP reading might this lead to?
a low reading
gas exchange is dependent on ____, ______, and _______
adequate respiratory drive, an intact and patent airway, strong muscles of respiration (diaphragm and chest wall), normal alveolar architecture, and adequate pulmonary capillary blood flow
what are the stages of LOC?
alert, awake, lethargic, comatose
what are the five spaces in the precordium and where are they?
aortic and pulmonic (in 2nd ICS, R and L sternal border) Erb's point (3rd ICS, L sternal border) Tricuspid (4th ICS, L sternal border) Mitral (5th ICS, L/R clavicle)
what are the names of those 5 areas?
aortic, pulmonic, Erb's, tricuspid, and mitral
which is a higher pressure system: veins or arteries?
arteries have high pressure; veins have valves to prevent backflow
__________ stay partially constricted to maintain constant flow
arteries/arterioles
the nurse is about to reposition a patient in bed. what should be the nurse's priority action?
assess mobility of the patient first
besides capillary refill, what is another way to assess arterial sufficiency?
assess pulse strength
What are the steps of the nursing process?
assess, analyze, plan, implement, evaluate
signs and symptoms of PAD?
cap refill >3 seconds in upper and lower extremities, pulse <2+, pallor of extremities, thin shiny skin with decreased hair growth, cool temp, cyanosis (in late stages) of the face, lips, nail bed, mucosa, or conjunctivae, and clubbing of the nails
what are the measures of arterial sufficiency?
capillary refill <3 seconds, 2+ pulse strength bilaterally
most pulses should be assessed in a bilateral fashion in order to evaluate strength symmetrically. which pulse should not be assessed simultaneously and why?
carotid pulses should be assessed one at a time to prevent occlusion of blood flow to the brain
where can you obtain the pulse rate?
carotid, PMI, radial (or brachial if infant)
implementation
carry out the interventions that have been established, use clinical judgments to monitor the client's progress towards achieving their goals
crackles
caused by fluid filling air sacs; sounds like popping and crackling, clients with pneumonia or an infection may have crackles
what are the four most common HAIs?
central line infection, catheter associated UTI, surgical site infection, ventilator assisted pneumonia
what nursing history should be taken for the integumentary system?
changes in color, texture, temp, sensation, lesions, odor, possible exposure, hygienic practices, allergies, topical medications, hx of skin disorders
manifestations of hypoxia and/or hypoxemia
confusion, irritability, restlessness, intercostal retractions
what are the modes of transmission?
contact (person to person) droplet (ground) airborne (air) vehicles (passive carry) vector (phone, insects)
what type of isolation precautions would be initiated for this patient?
contact precautions
what are the modes of transmission?
contact, droplet (large and short range), airborne (small, like COVID), passive vehicles, vector borne (insects)
describe abnormal sputum
copious, yellow, hemoptysis (blood in sputum), thick
you begin to take the VS of a patient and notice the pulse feels irregular. how should you proceed?
count the pulse rate for a full minute
name interventions for portal of exit
cover sites (wounds, mouth when coughing) PPE appropriate disposal of contaminated items hand washing
what are the adventitious sounds heard with a stethoscope?
crackles (fluid, popping) wheeze (narrow of small airway, high/musical sound) rubs (inflammation of the pleura, coarse, leather bag) stridor (high-pitched, high in airway, EMERGENCY) rhonchi (low-pitched wheeze/snoring)
Skin and mucus membrane color
dark pink
a nurse is caring for a client who has been wheezing. the nurse asks an assistive personnel (AP) to use a stethoscope and listen to the client's lung sounds to determine if their wheezing has improved. this is an example of which of the following concepts? -delegation of the right circumstance -delegation of the wrong task -delegation to the right person -delegation of the wrong time
delegation of the wrong task
describe blood flow through the heart
deox blood flows through right side of heart --> lungs for gas exchange --> oxygenated blood flows through left side of heart --> body
Venous return:
deoxygenated blood to the right side of the right
What part of the stethoscope should you use when performing a cardiac assessment?
diaphragm and the bell
what is the difference between the bell and diaphragm of the stethoscope?
diaphragm is used to auscultate high pitched sounds, bell is used to auscultate low pitched sounds
what is the pulse deficit?
difference between apical and radial rate
what are our second line defense mechanisms against infection?
fever, phagocytes, inflammation, vomit/diarrhea
what is the body's second line of defense?
fever, phagocytosis, inflammation
what happens during palpation?
fingertips, palmar, dorsal
a nurse is caring for a client who has been hospitalized and is performing active ROM exercises. which of the following body movements should indicate that the client has full ROM of the shoulder? -adducting the arm so that it lies next to the client's side -flexing the shoulder by raising the arm from a side position to a 180 degree angle -abducting the arm to a 90 degree angle from the side of the body -circumducting the shoulder in a 180 half circle
flexing the shoulder by raising the arm from a side position to a 180 degree angle
fidelity
keeping a promise to a client
S3 gallop sounds like:
ken-tuck-y
when taking a patient's BP what sounds are you paying attention to?
korotkoff phase 1 and 5
name some PCS system specific history you'd want to know about
leg cramps at rest/while walking, standing, or during sleep numbness/tinging or cold sensation in extremities pain edema cyanosis of extremities
what are some interventions for prevention of venous stasis and DVT/VTE?
leg exercises, ambulation, 2-3 L fluids, elevate legs, avoid crossing legs (popliteal vein compression), use SCDs and TEDs
acute pain
less than 6 months
what are you looking for when inspecting the precordium?
lifts and heaves
what happens during auscultation?
listen with stethoscope
how would you document an expected finding for the PMI?
located in the left 5th intercostal space midclavicular line
how are murmurs assessed? what are the grades?
location and timing with systole and diastole, intensity and pitch. 1. barely audible 2. audible but quiet 3. moderately loud 4. loud with thrill 5. very loud, thrill easily palpable 6. louder, heard without steth, see heaves, feel thrill
a nurse stands facing a client to demonstrate active ROM exercises. which of the following actions should the nurse take to demonstrate hyperextension of the hip? move their leg behind their body move their leg forward and up move their leg medially towards their other leg turn their foot and leg away from their other leg
move their leg behind their body
a nurse is assessing a client who is dark-skinned. in which of the following areas of the client's body should the nurse assess the client for adequate oxygenation? -cheeks -nail beds -oral mucosa -sclerae -lips
nail beds oral mucosa lips
define peripheral artery disease
narrowed arteries reduce circulation to the periphery - usually the legs
a nurse is checking a client's allergy bracelet before administering a med and finds the client is allergic to that med. the nurse does not administer the med to the client. this is an example of which of the following unexpected events? -near miss event -client safety event -adverse event -sentinel event
near-miss event
at risk clients for integumentary issues?
neurologically impaired, malnourished, dehydrated, cardiovascular/respiratory compromised, orthopedic treatments, chronically ill, immobilized, very young, older adult
causes of hypoventilation
neuromuscular disorders such as muscular dystrophy, Guillain-Barre syndrome, narcotics/benzodiazepines/barbiturates, neurologic disorders, trauma
what type of ppe do you use for wheelchair?
none
what are the five places to take temperature? which is most accurate?
orally, axillary, tympanic, temperal, rectal; most accurate is rectal
when is pain considered chronic?
over 6 months
where are vesicular sounds heard?
over lung tissue
what do TED hose and/or SCDs do?
prevents venous stasis and a VTE/DVT
What factors increase risk for "fall risk" pt?
previous falls, HAI, aspiration, suffocation, poisoning, accidents, fire
what does PHIVES stand for? WESTDR?
procedure, hand hygiene, ID self/client/procedure, verify 2x, equipment, safety wash hands, equipment, safety (bed low, locked, side rails up), teach client, document, re-evaluate
What is PHIVES for bathing?
procedure, hands, ID self and client, verify ID 2x, explain procedure, equipment, safety
what does elevating the head of bed do?
promotes lung expansion
what health/education/promotion is relevant to respiratory health?
risk factors for resp infections, warning signs of cancer, tobacco and pollution, second hand smoke, home o2 use and safety, annual vax
what are scds? teds?
sequential compression devices thromboembolytic deterrent elastic stockings
who are the at risk CV clients?
the immobile, those with cardiac disease, those with volume depletion, the infant/child (congenital defects), and the elderly
what is heart failure?
the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients
you are assessing a patient and notice unilateral extremity edema, calf tenderness, and erythema in the calf. What do you suspect?
the patient may have developed a DVT
who are the at risk clients for peripheral vascular disease?
those with decreased mobility, cardiac disease, HTN, hyper-coagulability states, hypovolemia, diabetes, trauma to vessels, and increased age
planning
use problem-solving and decision-making skills to prioritize outcomes and goals, and develop interventions to meet those goals
what are some nursing interventions you can implement to help the patient prevent complications related to your concerns?
use the incentive spirometer, apply TED hose and/or SCDs, elevate the head of bed, encourage engagement in ADLs
aerosol mask
used to administer nebulized solutions, ex. asthma, includes corticosteroids to decrease inflammation in lungs and bronchodilators
what is a VTE?
venous thromboembolism
a charge nurse is teaching a new nurse how to recognize the manifestations of decreased oxygenation in a client. which of the following statements by the newly licensed nurse indicates an understanding of the teaching? -a client using thoracic breathing is experiencing a lack of oxygen -a pulse ox reading of less than 95% indicates resp distress -clubbing of the fingers indicates a chronic state of impaired perfusion -a pinkish hue on the cheeks of a client who is light-skinned indicates they are struggling to breathe
-clubbing of the fingers indicates a chronic state of impaired perfusion
a charge nurse is preparing to discuss critical thinking skills with a group of newly licensed nurses. which of the following skills should the nurse plan to include in the discussion? (select all that apply.) -inspection -implementation -inference -creativity -inductive reasoning
-inference -creativity -inductive reasoning
how would you describe/document the expected pulse strength?
2+
Where is the base of the heart auscultated?
2nd Intercostal space Aortic R sternal border Pulmonic L sternal border
Where is Erb's point?
2nd pulmonic area, 3rd intercostal space, left sternal border
The nurse is about to reposition a patient in bed. What should be the nurse's priority action?
Assess mobility on the patient first Takeaway: Always assess the mobility of the patient before moving the patient. If the patient has mobility, this can be helpful in reducing injury to the nurse and also promote independence in the patient.
what are some pertinent subjective findings for the CV system?
CP, palpitations, fatigue on exertion, cough, dyspnea, PND, DOE, leg pain/cramps, edema, cyanosis, syncope, orthopnea, limitations in ADLs
Diet/Nutrition - Cardiovascular System
Caffeine intake (can cause dysrhythmias) High fat and sodium intake Low fiber
Mobility aids:
Cane Walker Crutches
Family Hx - PV system
Cardiac disease Hypertension Peripheral vascular disease Varicose veins
Carotid artery inspection
Carotid artery: assess with client in supine with HOB elevated 30-45 degrees Inspect: turn head slightly away Palpate: Strong thrust (2+) and symmetrical (expected) *only palpate one at a time Auscultate: With bell Silent (expected) Abnormal: bruit=turbulent blood flow
signs and symptoms of systemic infection
Changes in vitals or system function Example: sepsis
What makes a big difference in the healing process?
Mobility, get them up and get them moving
Mood/affect
Mood: Subjective - perception per self-report - "what is your mood today?" Affect: Objective - observed client's emotional tone, expression, body language Affect descriptor: Congruent (expected) or incongruent (not expected, mood and behavior do not match) Mood descriptor: Euthymia/euthymic (expected)
What scale is used to assess fall risk?
Morse fall scale All patients are assessed: Within 8 hours of admission Every shift After any fall With any change in level of care; with or without transfer
Biographical Data
Name, age, race/ethnicity, sex assigned at birth, gender Pain
What is considered correct alignment when positioning patient?
No excessive strain is placed on person's joints, tendons, ligaments, or muscles, thereby maintaining adequate muscle tone and contributing to balance
Identify strategies for maintaining the safety of the nurse and the client during bathing
Nurse: Proper body mechanics Bed at waist height Side rail down on nurses side Work on nurses' side at all times Gloves or gown Client: Never leave alone Side rail up on far side Privacy Prevent chilling (blanket, room temp) Water temperature Nurse be gentle with sensitive skin Be aware of drain, tubes, or lines.
bradypnea
RR below 12 breaths/min
signs and symptoms : lab values
WBC count cultures (blood, sputum, stool)
what type of ppe do you use for suctioning oral secretions?
gloves, face shield, mask, goggles
what ppe is worn for airborne precautions?
gloves, gown, N-95 mask
what ppe is worn for droplet precautions?
gloves, gown, surgical mask, goggles
what type of ppe do you use for cleaning diarrhea?
gown gloves
what type of ppe do you use for responding to blood spurting?
gown, gloves, mask, face shield
chronic pain
greater than 6 months
Name interventions for infectious agent
hand hygiene, disinfecting chemicals, sterilization - steam, gas, chemicals
name interventions for reservoir
hand washing, general hygiene, proper disposal
name interventions for portal of entry
hand washing, maintain skin integrity/cover wounds, limit invasive techniques, no eating or drinking in clinical area, no rubbing eyes or face
what are you palpating for on the precordium?
pulsations and thrills
reflective practice is:
purposeful recall of situations, opportunity to express experiences, self-evaluation
what is the most common location to assess a pulse on an adult?
radial
the nurse is about to perform a bed bath. what are some actions that the nurse should take to prevent injury to themselves?
raise the bed to a comfortable position lower side rails
a nurse is preparing to conduct a cardiovascular assessment on a client. what should the nurse plan to take? (select all that apply) -auscultate the apical pulse -ask client if they experience any SOB -check color of client's skin -auscultate bowel motility -inspect extremities for presence of edema
-auscultate the apical pulse -ask client if they experience any SOB -check color of client's skin -inspect extremities for presence of edema
a nurse is assisting with teaching a class about HAI. the nurse should include that which of the following a HAI? (select all that apply) -blood transfusion incompatibility -wrong site surgery -ineffective insulin usage -dysphagia following stroke -dehydration due to diarrhea
-blood transfusion incompatibility -wrong site surgery -ineffective insulin usage
a nurse has completed a CV assessment on a client. which of the following findings should the nurse report to the provider? -cap refill of 3 sec -+2 radial pulse -fingernail with 160 degree curvature -ox sat 98%
-cap refill of 3 sec (should be less than or equal to 2 seconds
a nurse is assisting with teaching a class about evidence-based protocols established by the CDC to prevent HAIs. which of the following infections should the nurse include? (select all that apply) -influenza infection -catheter-associated UTI -myobacterium TB infection -central line-associated bloodstream infection -surgical site infection
-catheter-associated UTI -central line-associated bloodstream infection -surgical site infection
a nurse is evaluating a client who has a broken leg and is using crutches. which of the following actions by the client demonstrates proper use of the crutches? -hand grips of the crutches are at the level of client's umbilicus -client's elbows are bent 45 degrees when holding the crutches -client places their weight on their axilla when using crutches -client has the crutches resting 5 cm below their axilla
-client has the crutches resting 5 cm below their axilla
a nurse is preparing to administer a premixed med to a client. the nurse should check the label for which of the following information? -date med was mixed -client's age -clients' room # -dose of mixed med -time med was mixed
-date med was mixed -dose of mixed med -time med was mixed
a nurse is observing an AP who is using a mechanical lift with a hammock sling to transfer a client from the bed to a chair. for which of the following actions by the AP should the nurse intervene? -places a removable cover over the sling -leaves bed in lowest position throughout procedure -locks hydraulic valve before attaching sling to lift -raises head of bed to a sitting position just before transfer
-leaves bed in lowest position throughout procedure
a nurse is providing teaching for a client who injured their ankle. which of the following info should the nurse include? -cartilage is always remodeling and changing -tendons connect muscle to bone -ligaments are flexible connective tissue that coat bony areas -synovial joints attach to the skeleton to maintain posture
-tendons connect muscle to bone
Explain guidelines for safe restraint use
Assess the at-risk status of patient 1st before using Use least restrictive first Know agency policy Obtain order Choose appropriate restraint chemical or physical Takeaway: Restraints should be tied to the bed frame Takeaway:4 rails cannot be used just to prevent patients from getting up Takeaway: Permanent removal of restraints requires an order Continuous evaluation of the need for restraints
what are some factors impacting PVS health?
BP, CO, peripheral vascular resistance, arterial elasticity, blood volume and viscosity
Mechanical lift
For patients that have little to no mobility
Peripheral vein inspection
Inspect: flat or slightly raised, blue (expected) Abnormal: phlebitis, varicosity, edema, brown pigmentation of lower extremities Palpate: Soft, springy Abnormal: cord-like, peripheral edema, tenderness, pain
You ask a patient questions to evaluate their orientation in regards to their mental status. You know that assessment of orientation falls under which category of the mental status exam?
Intellectual performance
Jugular vein inspection
Jugular vein: assess with the HOB elevated to 30-45 degrees, use pen light Inspect only: just above clavicle. May see 2-3 gentle waves Sitting: jugular vein flat without distension (expected) Supine: jugular vein distends and is easily visible (expected)
when taking a patient's BP, what sounds are you paying attention to?
Korotkoff phase 1: 1st sound heard associated with systolic pressure Korotkoff phase 5: disappearance of sound that is associated with diastolic pressure
S2 heart sound:
Ventricular diastole (relaxation) Heard best at BASE S2>S1 CLOSURE OF THE AORTIC AND PULMONIC VALVES
S1 heart sound:
Ventricular systole (contraction) Heard beat at APEX S1>S2 CLOSURE OF TRICUSPID AND MITRAL VALVES
gas exchange requires ______
adequate ventilation and perfusion, pressure gradient
What might you suspect if the patient's AP:L ratio is 1:1?
air trapping could also be a benign finding in an older adult
autonomy
allowing a client to make informed decisions
a nurse is caring for a client with a chest tube and is assessing the drainage. which of the following findings should the nurse document? -amount -odor -color -consistency
amount, color, consistency
define hypercapnia
an excess of carbon dioxide in the blood
how does blood volume affect BP? PVR?
an increase in volume increases both BP and PVR
you perform an assessment of the patient's mental status. What is the next step of the nursing process?
analysis
name the peripheral pulses
bronchial, radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis
what are we inspecting skin for?
changes in color, texture, temp, sensations, lesions, order
what are the signs and symptoms of systemic infection?
changes in vital signs, GI system function
what is cheyne-stokes breathing?
cheyne stokes breathing can occur if the CNS is grossly affected by lack of o2 or disease progression. it appears to have a resp "start-stop" breathing pattern. the client will have a deeper breath that might quicken, followed by hypoventilation and progression to apnea. this is an end-of-life breathing pattern.
name some nursing interventions that can improve at risk/actual concerns for respiratory issues?
elevate HOB 45-90 degrees, deep breathing, exercise and ambulation, incentive spirometry, respiratory therapy consult
a client is having difficulty breathing. what should nurse do first? -instruct client to deep breathe and cough -provide incentive spiro -elevate head of client's bed -reassess by auscultating client's lungs
elevate head of client's bed
why is mobility important?
enhances the functioning of all body systems
what are the signs and symptoms of localized infection?
erythema, exudate, pain, tenderness
what is the medical term for normal breathing?
eupnea
justice
fair treatment of all clients
what are the five stages of infection?
incubation, prodromal, acute illness, decline, convalescence
what is the difference between direct and indirect contact?
indirect contact involves a contaminated object/person between contact, whereas direct contact is person-person
Define ventilation
is the flow of air inside or outside of the alveoli
a nurse is caring for a client who is experiencing episodes of hyperventilation. which of the following manifestations should the nurse expect during hyperventilation? (select all that apply) -numbness and tingling of extremities -decreased chest wall expansion -lightheadedness -periods of apnea -chest pain
numbness and tingling of extremities lightheadedness chest pain
you take the patient's vital signs and notice their BP is 142/89 and HR is 108. what type of data is this?
objective
objective data
observable, measurable, undistorted by personal bias ex "HR is at 80"
Define gas exchange
occurs in the alveoli, delivering o2 from the lungs to the bloodstream, while carbon dioxide passes from the blood to the lungs to later exhale
when should vital signs be assessed?
on admission, before/after any intervention, with a change in client condition, every shift, PRN, and upon discharge
where are bronchial sounds heard?
over the trachea and bronchi
cardiac output
oxygenated blood to the vascular system and cells
what is claudication?
pain in the calf during activity, caused by muscle ischemia
signs and symptoms of VTE?
pain, unilateral edema, erythema (patchy red skin), warmth
what are some signs and symptoms that patients may experience when having arterial insufficiency?
pale skin turning dusky red when extremity is lowered, skin is cool to the touch, pulses are decreased, thin and shiny skin, decreased hair growth, thickened nails, intermittent claudication
what are life-threatening symptoms associated with hypotension?
pallor, confusion, increased HR, splotching of skin, clamminess, decrease urine output
most reliable indicator of pain
patient's self-report of pain
why do we use restraints?
reduce risk of injury to self, others, or for falling
you are about to take a patient's temperature orally. however, you notice the patient sitting in bed drinking ice water. what action should you take?
take the temperature in a different manner. wait 30 minutes and proceed with taking the oral temp.
a nurse is developing a goal for a client to ambulate with assistance at least once by the end of the shift. the nurse should identify that this is an example of which of the following steps of the nursing process? -evalution -implementation -analysis -planning
-planning
Gait belt
For patients that don't need a ton of assistance Helps the nurse gain more stability when assisting patient
Speech
Rate, volume, amount, characteristics Expected finding: speech articulate and clear with moderate pace, volume, quantity, and pitch
Nursing interventions during mental status assessment
Re-orient the patient every 2 hours or as needed Minimize interruptions and keep stimuli to a minimum when providing care Examine and remove hazards from the patient's environment Promote cognitive behavioral relaxation techniques such as music therapy and guide visualization
Chief Complaint (CC)
Reason for seeking care, using quotation marks Ex: "I have a headache" "My arm is missing"
Medical asepsis (clean technique):
Reduce number of infectious organisms and prevent transfer Standard precautions: hand hygiene, PPE, cleaning
What does SMART stand for?
Specific, measurable, attainable, realistic, and timely
Describe the modes of transmission of infection
Takeaway: isolation precautions are based on how the pathogen is transmitted Contact: Skin to skin, connection Droplet: Large, short-range aerosols (5 microns) Sneezing, coughing, talking Airborne: Dust, nuclei Floats in the air much longer, small Vehicles: Food, water, blood, bedding, clothes, passive carriers Vector borne: Insects, fleas, tics
tachycardia
any pulse above 100 BPM
bronchial sounds
loud, high, harsh, inspiration shorter than expansion, heard over trachea
what assessment information does capillary refill provide?
measurement of arterial sufficiency
what is the PMI?
point of maximum impulse; where you take the apical pulse; at the apex of the heart
describe normal sputum
small, clear to whitish, thin and watery
