Fundamentals Set One: Weeks 1-3 Exam Prep
converting degrees celcius to F
(TEMP x 9/5) +32
A nurse observes a nursing assistant lift a heavy object from the floor. Which action indicates that the nursing assistant is using inappropriate body mechanics? A. bending knees B. holding object away from body C. placing feet wide apart D. keeping back straight as possible
B. holding object away from body
SBAR =
Situation Background Assessment Report
__ and __ : relax smooth muscle
Tamsulosin and silodosin
pre
before
bronch/o
bronchi
lycis
destruction
myring or tympano
eardrum
tachy
fast
__ establishes a baseline for your nursing care plan development
initial
assessment of urine:
intake and output characteristics of urine: color, clarity, odor
are bruises on the right arms and face subjective or objective?
objective
is a temp of 101F subjective or objective?
objective
is unsteady gait subjective or objective?
objective
ooph/o
ovaries
hyper
over
supine
patient on back
lateral/sims
patient on side
prones
patient on stomach
crani/o
skull
tertiary defenses
specific immunity, lymphocytes
ectomy
surgical removal
__ immune protection by secreting around the body openings - antibodies are secreted by mucous membrane around the body openings, in the intestines, respiratory and urinary tracts, saliva, tears, breast milk.
IgA
__ antibodies form on the surface of B cells and trap potential pathogens
IgD
__ Immunoglobulin for allergic response
IgE
__ most common immunoglobulin in the body, takes 10 days to be produced in response to initial infection (crosses placenta and through breast milk)
IgG
__ first antibody to appear when an antigen is encountered for the first time
IgM
5 Classes of Antibodies:
IgM, IgG, IgE, IgD, IgA
Fowler - High - Semi
45-60 90 30
__: treat urinary retention
Bethanechol
Which range of motion exercise is being performed when the nurse spreads the second and third finger apart? A. opposition B. flexion C. abduction D. adduction
C. abduction
RACE (FIRE) =
Rescue Alarm/Alert Contain fire Extinguish
trans
across
types of nursing diagnosis
actual, risk, wellness, possible, syndrome
__ presence of bacteria in blood
bacteremia
pro
before
thrombo
clot
pathy
disease
peri/card/itis
inflammation around the heart
is vomiting subjective or objective?
objective
pyel/o
renal pelvis
malacia
softening
types of catheters
straight, indwelling, triple-lumen
__ solvent, transport, body structure, formation, and temperature regulation
water
How is data collected vis assessment?
- nursing interview/history - health assessment/ review of systems - physical examination (inspection, palpation, percussion, auscultation)
positioning on bedpan
- prevent muscle strain and discomfort - elevate head of the bed 30-45 degrees - wear gloves when handling bedpans
bowel diversions include:
- temporary or permanent artificial opening in the abdominal walls (STROMA) - surgical opening in the ileum or colon (ileostomy, colostomy)
scientific method:
1. identify problem 2. collect data 3. hypothesis 4. plan of action 5. interpret results 6. evaluate findings
three parts of forming a nursing diagnosis
1. problem statement 2. etiology (what is causing the problem?) 3. defining characteristics/evidence
Baby Jane, a 2 month old infant, goes into the doctor for her initial immunization and well baby check-up. What type of assessment should the nurse perform? A. Comprehensive B. Focused C. Ongoing
A. Comprehensive- It is the initial immunization and well baby check-up
A nurse just finished a complete bath for a client with limited mobility. Which action is most important for the nurse to perform before leaving the bedside of the client? A. Lower the height of the bed to the lowest position B. Position the bedpan in easy reach under the covers C. Raise all of the bedside rails D. Ensure that the water pitcher has fresh water
A. Lower the height of the bed to the lowest position
Which actions are essential when maintaining standard precautions? A. Wearing gloves during contact with a clients body fluids B. Donning a mask with an eyeshield when entering a clients room C. Washing hands only when visably soiled D. Putting on a gown when changing linens
A. Wearing gloves during contact with a clients body fluids
__: treat urinary tract infections
Antibiotics
__: treat urgency, frequency, nocturia and urgency UI
Antimuscarinics
5 Steps of Nursing Process:
Assessment Diagnosis Planning Implementing Evaluation
A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and hard to pass.This type of bowel pattern is consistent with: A. abnormal defecation. B. constipation. C. fecal impaction. D. fecal incontinence.
B. constipation.
To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour after meals because: A. the presence of food stimulates peristalsis. B. mass colonic peristalsis occurs at this time. C. irregularity helps to develop a habitual pattern. D. neglecting the urge to defecate can cause diarrhea.
B. mass colonic peristalsis occurs at this time.
Identify the long-term goal: A. Client's pulse oxygenation level will be greater than 92% on room air by tomorrow B. Client will administer his own insulin using correct technique by discharge C. Client's pressure ulcer will show presence of granulation tissue in 30 days D. Client's urine output will be 400 mL per 8-hour shift within 72 hours
C
A nurse is completing a client assessment for the purpose of determining factors that place the client at risk for falls. Which factor should cause the most concern when completing this assessment? A. Use a walker B. Takes a diuretic twice a day C. Has a history of falls D. Has a urinary retention catheter
C. Has a history of falls
The nurse is completing a head-to- toe assessment on her client at the beginning of the shift for the hospital unit. This would be considered what kind of assessment? A. Focused B. Initial C. Ongoing D. Special Needs
C. Ongoing
What should the nurse do first before moving a client from the bed to the chair? A. Assess for all of the factors that may influence the clients mobility B. Select the assistive devices to support the clients functional alignment C. Verify the primary healthcare providers activity prescription/order D. Consider all of the principles of body mechanics that should be followed
C. Verify the primary healthcare providers activity prescription/order
__ have a stronger and more rapid effect on the intestines than laxatives
Cathartics
A health care provider may suspect that a patient is experiencing urinary retention when the patient has: A. large amounts of voided cloudy urine. B. pain in the suprapubic region. C. spasms and difficulty during urination. D. small amounts of urine voided two to three times per hour.
D. small amounts of urine voided two to three times per hour.
Which action by the nurse might be a barrier to obtaining complete and reliable information from an interview with the client? A. Noting that the client's body language indicates that he or she is fatigued B. Maintaining eye contact with the client if it is not culturally inappropriate to do so C. Carefully guiding the conversation so that important topics are discussed D. Asking the client directly, "Why are you not taking your insulin?"
D: avoid asking "why"
__ and __: shrink the prostate
Finasteride and dutasteride
Types of Assessments: (IFOCS)
Initial, Focused, Ongoing, Comprehensive, Special Needs
components of goal statement: (SMART)
Specific Measurable Attainable Relevant Time Bound
__ may act more quickly than oral medications
Suppositories
Factors affecting bowel elimination
age, diet, fluid intake, physical activity, psychological factors, personal habits, position during defecation, pain, pregnancy, surgery, anesthesia, medications, diagnostic tests
__ __ smaller organisms can float considerable distances on air currents (heating, air conditioners, sweeping)
airborne transmission
__ __ (omega 3) is derived from fatty fish
alaphalinoleic acid
(urinary) Responsibilities after testing include:
assessing I&O, voiding, and urine encouraging fluid intake
___ collect, validate and communicate patient data, vital step-all remaining steps depend on complete, accurate, factual data, made at the beginning of care and throughout the course of care, goal is to come up with diagnosis and interventions.
assessment
__ __ __ measure of energy used while at rest in neutral temperature environment and the energy required for vital organs to function
basal metabolic rate
cyst/o
bladder
hemat/o
blood
oste/o
bones
-pnea
breathing
stroke volume + pulse =
cardiac output
__-__ __: destroys microbes with cytotoxic t-cells, helper t-cells, memory t-cells, subsequent t cells
cell-mediated immunity
types of enemas:
cleansing, oil retention, carminative, kayxalate
__ __ require both nursing interventions and medical interventions
collaborative problems
__ surgical opening created at the end of the large intestine to divert waste away from the digestive system
colostomy
cardi/ o
combining form for heart
__ consists of observation, a complete nursing history, physical exam; contains subjective and objective data
comprehensive
__ noninvasive catheterization that have a latex or rubber sheath to place over the penis
condom
portals of entry:
conjunctiva of ete, nostrils, mouth, urethra, vagina, anus, cut, scrape, surgical incision
__: A symptom, not a disease; infrequent stool and/or hard, dry, small stools that are difficult to eliminate
constipation
__ patients who have prostatic hyperplasia and require a curved tip applicator
coude
__: an increase in the number of stools and the passage of liquid, unformed feces
diarrhea
__ __ _ __: use if enemas fail to remove an impaction or last resort in managing severe constipation
digital removal of stool
__ contact between two people: touch, kiss, sex
direct contact
Modes of transmission:
direct contact, indirect contact, droplet transmission, vector, airborne transmission
ectopy
displacement
__ __ occurs when pathogen travels in water and is expelled as an infectious person inhales, coughs, sneezes, talks, suctioning during oral care
droplet transmission
assessment: elimination factors:
elimination pattern, stool characteristics, routines, bowel diversions, appetite changes, diet history, daily fluid intake, surgery, illness, medication, emotional state, exercise, pain, discomfort, social history, mobility, dexterity
3 types of colostomy
end, loop, double barrel
__ pathogen arises from the patient's normal flora when some form of treatment causes the normally harmless to become a problem
endogenous
cardi/o/megaly
enlargement of the heart
(urinary) Nursing responsibilities before testing:
ensure a signed consent is completed assess the patient for any allergies administer bowel cleaning agents as ordered ensure that the patient adheres to the appropriate diet or NPO
esophag/o
esophagus
__ to determine effectiveness of NCP. Comparison of client behavior and response to established outcome criteria. Continuous review of the nursing care plan and examines if it worked
evaluation
__ pathogen is acquired from a health care environment
exogenous/noncosmonal
blephar/o
eyelid
__ __ __A, D, E, K stored primarily in the liver and adipose tissue
fat soluble vitamins
nasogastric tube: __ or __-__ for medication administration or enteral feedings
fine, small-bore
__: accumulation of gas in the intestines causing walls to stretch
flatulence
rrhea
flow
__ gathers data about a specific problem; limited scope
focused
ostomy
forming artificial opening
quad
four
cholecyst/o
gall bladder
factors influencing urination
growth & development sociocultural factors psychological factors personal habits fluid intake pathological conditions surgical procedures medications diagnostic examinations
hemi
half
cardi/o
heart
__: dilated, engorged veins in the lingo of the rectum
hemorrhoids
__ __ response acts directly against antigens, macrophages, and a class of T-Cells, Helper T-Cells, Stimulate B cells to become plasma cells and produce antibody immunoglobulins (Ig)
humoral immunity
__ surgical opening created in the ileum to bypass the entire large intestine
ileostomy
__: results from unrelieved constipation; a collection of hardened feces wedged in the rectum that a person cannot expel
impaction
__ the "doing" step of the nursing process, carrying out nursing interventions/orders selected during the planning step. Inc: monitoring, teaching, further assessing, reviewing NCP, incorporating physicians orders and monitoring cost effectiveness of interventions
implementation
__: inability to control passage of feces and gas to the anus
incontinence
__ contact by fomite contaminating an object that transmits the pathogen: needle, doorknob
indirect contact
advantages of nursing process:
individualized care, client is involved, promotes continuity of care, promotes communal communication, develops plan of care, enables goals to be attained, professional growth
__ short-term and provide a closed drainage system for urine
indwelling
card/itis
inflammation of the heart
end/o/card/itis
inflammation within the heart
arthr/o
joints
ren/o or nephr/o
kidneys
colo or colon/o
large intestine
nasogastric tube: __-__ (12-French and above) for gastric decompression or removal of gastric secretions
large-bore
(urinary) Continuing and restorative care:
lifestyle changes, pelvic floor muscle training, bladder retraining, toileting schedules, intermittent catheterization (skin care).
__ __ (omega 6) is derived from oil, nuts, seeds
linoleic acid
hepat/o
liver
pneum/o or pnpumon/o
lungs
If a patient has cardiac disease or is taking cardiac or hypertensive medication, obtain a pulse rate, because...
manipulation of rectal tissue stimulates the vagus nerve and sometimes causes a sudden decline in pulse rate.
fecal impactions can be removed by...
mineral oil enemas or digital removal of stool by rotating fingers around the anal cavity
__ are inorganic and they assist in fluid regulation, nerve impulse transmission, energy production, health of bones and blood, and rid the body of by products of metabolism
minerals
or/o
mouth
my/o
muscles
__ __ small tubes tunneled through the skin into the renal pelvis. placed to drain the renal pelvis when the ureter is obstructed
nephrostomy tubes
rhin/o or nas/o
nose
trophy
nourishment
__ __Using critical thinking skills to identify patterns in the data and draw conclusions about the client's health status; Includes strengths, problems, and factors contributing to the problems
nursing diagnosis
pathogens need:
nutrients, moisture, temperature, oxygen, pH, electrolytes, light
__ data that is observable/measureable (sign). Main collection is through a physical assessment, lab, and diagnostic testing BP 130/80
objective data
__ monitoring and observing specific problems
ongoing
dys-
painful, difficult
pancreat/o
pancreas
secondary defenses:
phagocytosis, complement cascade, inflammation, liver
pharyng/o
pharynx
__ this is when the nurse organizes a nursing care plan based on the nursing diagnosis. expected outcomes are identified. interventions (nursing orders) are selected to aid the client reach these goals - prioritize list of client's nursing diagnoses using MASLOW
planning
__ source: client, interview, physical exam
primary source
electr/o/cardi/o/gram
recording the electrical activity of the heart
__ used for postoperative patients that have multiple lumens that allow for drainage of urine, irrigation, and installations of medicationsinstillatiion
retention
5 rights of delegation
right task, right person, right circumstance, right communication, right supervision
__ source: family, friends; other healthcare providers; medical records
secondary source
__ symptomatic systemic infection spread via blood
septicemia
how should the stoma appear?
shiny, red, wet
types of goals:
short term, long term, cognitive, psychomotor, affective
types of ostomies
sigmoid colostomy, transverse colostomy, ileostomy, loop colostomy, end colostomy
primary defenses:
skin, respiratory tree, eyes, mouth, GI tract, genitourinary tract
brady
slow
enter/o
small intestine
__ __: provides an in depth information about a particular are of client functioning: fall status, nutrition, pain, wellness
special needs
Nursing Process:
specific to nursing profession, framework for critical thinking, diagnose human problems to actual/potential problems, goal oriented
the opening of an osmotic is called a __. this is the communicating part of the bowel/bladder that is brought to the surface of the abdomen. Location depends on where the damage is, type of surgery
stoma
gastr/o
stomach
__ one time use and are removed immediately after insertion and drainage of urine
straight
is anxiety subjective or objective?
subjective
is nausea subjective or objective?
subjective
__ data from the client (symptom). This is mainly collected from interview: their feelings, perceptions, and concerns "I have a headache"
subjective data
functions of lipids
supply essential nutrients, energy source, flavor, satiety, insulation, protects vital organs, aids in thermoregulation, enables accurate nerve impulse transmission, cell metabolism, cholesterol function
__ placed through a surgical opening in the abdomen rather than the urethra
suprapublic
cleansing enema types
tap water, normal saline, hypertonic solutions, soapsuds
portals of exit:
through bodily fluids: blood, mucous, saliva, breast milk, urine, feces, vomit, semen
trache/o
trachea
hypo
under
ureter/o
ureters
urethr/o
urethra
__ __ diversion of urine to external source
urinary diversion
__ __ involuntary leakage of urine
urinary incontinence
__ __ an accumulation of urine due to the inability of the bladder to empty
urinary retention
__ __ __ results from cauterization procedure
urinary tract infection
__ allows urine to exit the body after the removal of a diseased or damaged section of the urinary tract
urostomy
a cold pack does what
vasoconstrictor, refrains blood from area (lack of oxygen)
A hot pack does what
vasodilators, brings blood to the area
__ an organism carries a pathogen to a susceptible host (biting, sting)
vector
phleb
veins
scopy
view something with an instrument
__ organic substances necessary for metabolism, building and maintaining body tissues, supporting our immune system to fight disease, ensuring healthy vision, breakdown/use of energy
vitamins
__ __ __ vitamin C, B-Complex: Thiamine, riboflavin, pyridoxine (Vitamin B6), folic acid, pathothenic acid, biotin, cyanocobalamin (B12).
water soluble vitamins
cirrho
yellow