Gero Theory test 1

The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide? "It is important to eat at least five servings of vegetables daily." "Remove your oxygen before cooking near the gas stove." "An electric stove may be a safer choice for you." "Be careful not to trip over your oxygen tubing while cooking."

"An electric stove may be a safer choice for you."

The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output? "If the client's stroke volume is 70 mL and heart rate is 70 beats per minute, then the cardiac output is 4.7 L/minute." "If the client's stroke volume is 80 mL and heart rate is 80 beats per minute, then the cardiac output is 6.0 L/minute." "If the client's stroke volume is 60 mL and heart rate is 60 beats per minute, then the cardiac output is 3.2 L/minute." "If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute."

"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute." The following formula is used to determine cardiac output: Cardiac Output = Stroke Volume x Heart Rate. A client with a stroke volume of 50 mL and heart rate of 50 beats per minute has a cardiac output of 2.5 L/minute. If stroke volume is 70 and heart rate is 70 beats per minute, then the cardiac output is 4.9 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute.

4 stages of infection

1. incubation 2. prodromal stage 3. illness stage 4. convalescence (IPIC)

Normal WBC count

5,000-10,000/mm3

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment? 5,000 mL (5,000 × 109/L) 5,550 mL (5,500 × 109/L) 5,850 mL (5,850 × 109/L) 6,000 mL (6,000 × 109/L)

5,850 mL (5,850 × 109/L)

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? The patient vomits during suctioning. The secretions appear to be stomach contents. The catheter touches an unsterile surface. A nosebleed is noted with continued suctioning.

A nosebleed is noted with continued suctioning.

Prodromal stage

A person is most infectious during the prodromal stage. Early signs and symptoms of disease are present, but these are often vague and nonspecific, ranging from fatigue and malaise to a low-grade fever.

A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended?A postoperative adultAn adult with COPDA teenager with cystic fibrosisA child with pneumonia

A teenager with cystic fibrosis

Virus

A virus is the smallest of all microorganisms, visible only with an electron microscope. cause many infections, including the common cold, hepatitis B and C, and acquired immunodeficiency syndrome (AIDS). Antibiotics have no effect on viruses.

spirometer

An incentive spirometer assists the patient to breathe slowly and deeply and to sustain maximal inspiration.

Infection

An infection is a disease state that results from the presence of pathogens (disease-producing microorganisms) in or on the body.

immune resonse

Antigens fight off antibodies

Nose's role in breating

Breathing through the nose warms, filters, and humidifies the air.

How is MRSA spread?

Close contact Direct contact Indirect contact-objects NOT BY AIR

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. Closely assess the patient before, during, and after the procedure. Hyperoxygenate the patient before and after suctioning. Limit the application of suction to 20 to 30 seconds. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Use an appropriate suction pressure (80 to 150 mm Hg). Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.

Closely assess the patient before, during, and after the procedure. Hyperoxygenate the patient before and after suctioning. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.

CDC Safety

Created standard precautions and Transmission based precautions

C.diff treatment

Disinfect equipment Meds- flagyl or vancomycin (higher cure rate-initial) FDA - recently approved (bezlotoxumb) -single IV dose Wash hands with soap and water

Care of patients with special infections

Ensure that health care provider is healthy Restrict visits from friends and family members who have colds or contagious illnesses Avoid collection of standing water in the room (e.g., humidifiers) to prevent bacteria typically found in this water Avoid plants and flowers—soil is a source of bacteria and mold Follow hospital protocols regarding PPE for neutropenic precautions

normal flora

Flora help to keep potentially harmful bacteria from invading the body. particularly the flora found in the gastrointestinal tract.

Fungi

Fungi, plant-like organisms (molds and yeasts) that also can cause infection, are present in the air, soil, and water. Some examples of infections caused by fungi include athlete's foot, ringworm, and yeast infections.

OSHA Safety

Gloves-be aware of Latex allergies Gown before entering the room Eyewear Masks-help prevent inhaling large-particle aerosols and small particle droplets Special masks- HEPA Filter or N95 respirators for TB (filter inspired air) Surgical masks-filter expired air Plastic bags - wrap supplies or double bag if needed All body fluid spills must be cleaned and disinfected Specimen collections-in plastic bags

Bacteria Classification

Gram-positive - The cell wall retains a stain or resists decolorization with alcohol Gram-negative - The cell wall loses a stain or is decolorized by alcohol Aerobic - Depend on oxygen for survival Anaerobic - Do not use oxygen

An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? Tilt the patient's head forward. Hold the mask tightly over the patient's nose and mouth. Pull the patient's jaw backward. Compress the bag twice the normal respiratory rate for the patient

Hold the mask tightly over the patient's nose and mouth.

Hypoxia

Hypoxia is a condition in which an inadequate amount of oxygen is available to cells.

infection cycle

Infectious agent Reservoir Portal of exit Means of transmission Portals of entry Susceptible host

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen? Place the client in the dorsal recumbent position to collect the specimen. Have the client clear the nose and throat and gargle with salt water before beginning the procedure. Instruct the client to inhale deeply and then cough. Discard the first sputum produced by the client.

Instruct the client to inhale deeply and then cough.

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen? It prescribes oxygen concentration. It regulates the amount of oxygen received. It determines whether the client is getting enough oxygen. It decreases dry mucous membranes via delivering small water droplets.

It determines whether the client is getting enough oxygen.

5 moments of hand hygiene

Moment 1 - Before touching a patient Moment 2 - Before a clean or aseptic procedure Moment 3 - After a body fluid exposure risk Moment 4 - After touching a patient Moment 5 - After touching patient surroundings

perfusion

Oxygenated capillary blood passes through the tissues of the body in the process called perfusion

Parasite

Parasites are organisms that live on or in a host and rely on it for nourishment. Malaria is a serious disease that occurs when a parasite infects a certain type of mosquito that then feeds on humans.

pursed lip breathing

Patients who experience dyspnea and feelings of panic can often reduce these symptoms by using pursed-lip breathing. Exhaling through pursed lips creates a smaller opening for air movement, effectively slowing and prolonging expiration.

What are the types of lice?

Pediculosis Capitus-head lice Pediculosis Corporis-body lice Pediculosis Pubis-pubic lice

The health care provider has prescribed an oropharyngeal airway for a client with a decreased level of consciousness. The health care provider has noted gurgling respirations and the client's tongue is in the posterior pharynx. The client vomits as the airway is inserted. Which actions should the nurse take? Select all that apply. Position client onto the side immediately. Remove oropharyngeal airway. Provide oral suctioning and mouth care. Raise the head of the bed to 90 degrees. Assess for bleeding in the mouth.

Provide oral suctioning and mouth care. Position client onto the side immediately. Remove oropharyngeal airway.

A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing method might the nurse use to measure the patient's oxygen saturation? Thoracentesis Pulse oximetry Diffusion capacity Maximal respiratory pressure

Pulse oximetry

A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? Notify the health care provider. Apply an occlusive dressing on the site. Assess the patient for signs of respiratory distress. Put on gloves and insert the chest tube in a bottle of sterile saline.

Put on gloves and insert the chest tube in a bottle of sterile saline.

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom? Rapid respirations Weight loss Increased urine output Mental alertness

Rapid respirations

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. Refrain from exercise. Reduce anxiety. Eat meals 1 to 2 hours prior to breathing treatments. Eat a high-protein/high-calorie diet. Maintain a high-Fowler's position when possible. Drink 2 to 3 pints of clear fluids daily.

Reduce anxiety. Eat a high-protein/high-calorie diet. Maintain a high-Fowler's position when possible.

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the mostappropriate intervention in this situation? Remove the airway, turn the client to the side, and provide mouth suction, if necessary. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. Leave the airway in place and promptly notify the health care provider for further instructions. Suction the client's mouth through the oropharyngeal airway to prevent aspiration.

Remove the airway, turn the client to the side, and provide mouth suction, if necessary.

A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? Remove the catheter. Notify the primary care provider. Check that the airway is the appropriate size for the patient. Place the patient on his or her back.

Remove the catheter.

How are ticks treated?

Remove tick in 24 hours by grasping with tweezers, pull out slowly, clean with antiseptic.

what is scabies

Scabies-A contagious, intensely itchy skin condition caused by a tiny, burrowing mite.

Convalescent Period

The convalescent period involves the recovery from the infection. The signs and symptoms disappear, and the person returns to a healthy state. However, depending on the type of infection, there may be a temporary or permanent change in the patient's previous health state even after the convalescent period.

incubation period

The incubation period is the interval between the pathogen's invasion of the body and the appearance of symptoms of infection. During this stage, the organisms are growing and multiplying.

inflammatory response

The inflammatory response is a protective mechanism that eliminates the invading pathogen and allows for tissue repair to occur. Inflammation helps the body to neutralize, control, or eliminate the offending agent and to prepare the site for repair

Full Stage of Illness

The presence of infection-specific signs and symptoms indicates the full stage of illness.

Time frame for influenza

Transmitted 1-2 days before onset of symptoms & 4-5 days after onset of symptoms

How is MRSA treated?

Vancomycin, Antimicrobial, incision of abscess

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting? Crackles Bronchovesicular Bronchial Vesicular

Vesicular Sounds

Difference between vesicular sounds and crackle sounds

Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration.

Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway? When holding the airway on the side of the client's face, it should reach from the tragus of the ear to the tip of the nostril. When holding the airway on the side of the client's face, it should reach from the opening of the mouth to the back angle of the jaw. When holding the airway on the side of the client's face, it should reach from the tip of the ear to the nostril times two. The airways come in standard sizes determined by the height and weight of the client.

When holding the airway on the side of the client's face, it should reach from the tragus of the ear to the tip of the nostril.

Virulence

ability to produce disease

localized infection

an infection that is limited to a specific location in the body and has local symptoms localized infection can result in redness, swelling, warmth in the involved area, pain or tenderness, and loss of function of the affected part.

systemic infection

an infection throughout the body systemic infection include fever, often accompanied by an increase in pulse and respiratory rate, lethargy, tenderness and enlargement of lymph nodes

colonization

colonization: presence of an organism residing in an individual's body but with no clinical signs of infection

C.diff precautions

contact precautions

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: crackles. vesicular. wheezes. rales.

crackles

Edemic

endemic: something that occurs with predictability in one specific region or population and can appear in a different geographical location

endogenous

endogenous: infection in which the causative organism comes from microbial life harbored within the person

exogenous

exogenous: infection in which the causative organism is acquired from outside the host

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client? oxygen analyzer nasal strip nasal cannula flow meter

flow meter

MRSA prevention

hand washing, cover cuts, avoid contaminated wounds

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's: hemoglobin level. age. blood pH. sodium and potassium levels.

hemoglobin level.

iatrogenic

iatrogenic: infection that occurs as a result of a treatment or diagnostic procedure

medical asepsis

medical asepsis: practices designed to reduce the number and transfer of pathogens; synonym for clean technique Medical asepsis procedures include performing hand hygiene and wearing gloves.

Bacteria shapes

spherical (cocci), rod shaped (bacilli), or corkscrew shaped (spirochetes)

How are ticks/scabies spread?

spread by direct or indirect contact-clothes, linen, combs, pillows

surgical asepsis

surgical asepsis: practices that render and keep objects and areas free from microorganisms; synonym for sterile technique includes practices used to render and keep objects and areas free from microorganisms. Surgical asepsis procedures include inserting an indwelling urinary catheter or inserting an IV catheter

What diseases can ticks transmit

transmit serious diseases like Rocky Mountain Spotted Fever, Lyme disease

When to use sterile technique

used regularly in the operating room, labor and delivery areas, Procedures that involve the insertion of a urinary catheter, sterile dressing changes, or preparing an injectable medication are examples of surgical asepsis techniques.

Who are at risk for the Flu

young children; pregnant women; people with chronic health conditions like asthma or heart and lung disease; and people 65 years and older. The best way to prevent the flu is by getting vaccinated. All people 6 months of age and older should be vaccinated each year (CDC, 2016a).