exam 1 introduction to nursing

Describe the two types of infections.

*Localized*: Patient experiences localized symptoms such as pain, tenderness, warmth, and redness at the wound site. *Systemic*: An infection that affects the *entire body* instead of just a single organ and can become fatal if undetected.

the LPN provides you with the shift hand off vital signs on four of your patients. based on your knowledge of the pathophysiology for each patient's illness, use clinical judgment to prioritize, in order, the follow-up patient assessments to be made.

1. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 85% 2. 77year old woman with left mastectomy 36 hours ago, temperature 38.3C, pulse 110, RR 22, BP 148/62 3. 54-year-old woman admitted after surgery for repair of a fractured arm, BP 160/86 mm Hg, HR 72 3. 63-year-old man with venous ulcers from diabetes, temperature 37.3C, HR 84

which clients body temperature indicates moderate hypothermia?

1. 88F 2. 92F

while assessing a client's hair, the nurse notices the client has head lice. the nurse teaches the client about hair hygiene and lice control. which client statement indicates an understanding of the teaching?

1. I will clean my comb in ammonia water 2. I should use a dilute vinegar solution to loosen the nits 3. I should use a shampoo treatment once every 24 hours

the AP informs the nurse that the electronic blood pressure machine on the patient who has recently returned from surgery after removal of her gallbladder is flashing a blood pressure of 65/46 and alarming. place the care activities in priority order.

1. assess the patients mental status 2. press the start button on the electronic blood pressure machine to obtain a new reading 3. check the patient's pulse distal to the blood pressure cuff 4. obtain a manual blood pressure with a stethoscope 5. remind the patient not to bend the arm with the blood pressure cuff

To address cultural diversity the nurse needs to

1. be culturally aware and avoid stereotyping bases on gender, race, or education 2. learn to recognize common characteristics and disorders among members of ethnic populations within the community. 3. recognize variations in physical characteristics, such as the skin and musculoskeletal system 4. recognize the impact of cultural difference in racial and ethnic aspects

Contemporary nursing requires that the nurse has knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples? (Select all that apply.) 1. Caregiver 2. Autonomy and accountability 3. Patient advocate 4. Health promotion 5. Lobbyist

1. caregiver 2. autonomy 3. patient advocate 4. health promotion

which nursing interventions would provide safe oxygen therapy?

1. check tubing for kinks 2. post no smoking signs in the client's room

to assess the status of circulation to the foot, which site would the nurse monitor for a pulse?

1. dorsalis pedis artery 2. posterior tibial artery

List the five nursing purposes for performing a physical assessment.

1. gather baseline data about a patient's health status 2. supplement, confirm, or refute subjective data obtained 3. identify and confirm nursing diagnoses. 4. make clinical decisions about a patient changing health status and management. 5. evaluate the outcomes of care.

Infections follow a progressive course by four stages. List and explain each stage.

1. incubation stage- interval between entrance of pathogen into body and apperance of first symptoms 2. prodromal stage- interval from offset of nonspecific signs and symptoms to more specific symptoms. 3. illness stage- interval when patient manifests signs and symptoms specific to type of infection 4. convalescence- interval when acute symptoms of infection disappear

Development of an infection occurs in a cycle that depends on the following elements:

1. infectious agent 2.resevior 3. portal of exit 4. mode of transmission 5. portal of entry 6. host

Explain the normal body defenses against infection.

1. normal flora- the body normally contains microorganisms that reside on the surface and deep layers of skin, in the saliva and oral mucosa, and in the GI and GU tracts. 2. body system defenses- a number of body systmes have unique defenses against infection 3. inflammation- the cellular response of the body to injury, infection, or irritation

when obtaining a health history from the newly admitted client who has chronic pain in the right knee, which pain assessment data would the nurse include.

1. pain history, including location, intensity, and quality of pain 2. pain pattern, including precipitating and alleviating factors.

which of the following patients are at most risk for tachypnea?

1. patient just admitted with four rib fractures 2. woman who is 9 months pregnant 3. 3 pack per day smoker with pneumonia

during admission of an obese patient with heart failure to CNA reports to the nurse that the BP is 140/76 in the left arm and 128/72 in the right. what actions do you take on the basis of this information?

1. repeat the measurements on both arms using a stethoscope 2. review the patients record for her baseline vital signs

a patient presents in the clinic with dizziness and fatigue. the CNA reports a slow but regular radial pulse of 44. place the following care activities in priority order.

1. request the patient to lie on the clinical stretcher 2. have CNA obtain a blood pressure 3. assess the patient's apical pulse for a full minute 4. obtain SpO2 5. prepare to administer cardiac stimulating medications as ordered

a client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. the registered nurse assesses the recorded vital signs. which vital signs requires reassessment?

1. respiratory rate 2. oxygen saturation 3. blood pressure

which question would the nurse ask the client when obtaining their health history?

1. tell me about your food habits 2. do you use alcohol or tobacco 3. have you ever experienced any allergic reactions

a 52-year-old woman is admitted with pneumonia, dyspnea, and discomfort in her left chest when taking deep breaths. she has smoked for 35 years and recently lost over 4.5 kg. she is started on intravenous antibiotics, high protein shakes, and 2 liters of O2 via nasal cannula. her vital signs at the start of treatment are HR 112, BP 138/82, RR 22, tympanic temperature 37.9C, and oxygen saturation 94%. which of the vital signs taken 4 hours later reflect a positive outcome of treatment interventions?

1. temperature 37C 2. radial pulse 98 3. respiratory rate 18 4. oxygen saturation 96%

the nurse assesses for which client symptoms that indicate hyperthermia?

1. vasodilation 2. dry and flushed skin 3. decreases urinary output

Client is ordered to receive 3 mg of ondansetron. Available are vials of ondansetron 2 mg in 1 mL. What do you give the client?

1.5mL

the registered nurse notices a new employee, who is obtaining the blood pressure of a client, is deflating the cuff too rapidly. if the actual blood pressure of the client was 140/90 mm Hg, which blood pressure reading is the new employee most likely to have obtained?

130/100 mm Hg

Order: acetaminophen 0.325 g po tid. Supply: acetaminophen suspension 100 mg/5 mL. What do you give

16.25mL

Client is ordered lisinopril 0.6 g. Available is lisinopril in. 300 mg tablets. How many tablets should be given.

2 tabs

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. Incorrect 1 Dyspnea 2 Flushed face 3 Precordial pain 4 Increased pulse rate 5 Increased blood pressure

2. flushed face 4. increased pulse rate

Client ordered to receive 200 mg of Metformin. Available are 100 mg tablets. What should be administered?

2mg

A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure the: 1 Respiratory rate. 2 Amount of oxygen in the blood. 3 Percentage of hemoglobin-carrying oxygen. 4 Amount of carbon dioxide in the blood

3. percentage of hemoglobin carrying oxygen

. Client is ordered to receive 90 mg. of metoprolol. Available are 30 mg scored tablets. What do you administer?

3mg

communicable disease

A disease that can be spread from one person or species to another.

infectious disease

A disease that is caused by a pathogen and that can be spread from one individual to another.

American Nurses Association (ANA)

ANA and CNA are national professional nurses' organizations for the United States and Canada. The ANA and CNA set standards for nursing care and professional practice. These professional organizations are political advocates for the nursing profession and the practicing nurse

before meals:

Ac

The goals of any professional nursing organization are to:

Address member concerns Present educational programs Publish journals

Certified Registered Nurse Anesthetist (CRNA)

Administers anesthesia and provides care during procedures under the supervision of an anesthesiologist

Certified Nurse-Midwife (CNM)

An APRN who is also educated in midwifery and is certified by the American College of Nurse-Midwifes

Clinical Nurse Specialist (CNS)

An advanced practice nurse who provides direct care to clients and participates in health education and research.

Pathogen

An organism that causes disease

Bactericidal

Capable of destroying bacteria

Hypothalamus

Controls body temperature

how to calculate dosages

D/H x V = amount to give

date of birth:

DOB

Define the term genomics.

Describes the study of all the genes in a person, as well as interactions of those genes with each other and with that person's environment.

Continuing education

Education that is employment or license related; used to motivate, enrich, update skill sets, satisfy licensing requirements, or further your career.

Master's degree

Emphasizes advanced knowledge in basic sciences and research-based clinical practice

How did Florence Nightingale see the role of the nurse in the early 1800s?

Established first nursing philosophy based on health maintenance and restoration

Clinical Nurse Specialist

Expert clinician in a specialized area of practice.

Educator

Explains, demonstrates, reinforces, and evaluates the patient's progress in learning.

Mary Mahoney

First professionally trained African American nurse

a registered nurse teaches a new nurse about when a client with a high blood pressure would follow up with the primary health care provider. which statement made by the new nurse indicates effective learning?

I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year.

intravenous

IV

What are the external forces that have affected nursing practice in the twentieth-first century?

Importance of nurses' self-care Health care reform and costs Demographic changes Medically underserved

Mary Adelaide Nutting

Instrumental in moving nursing education into universities.

Clara Barton

Launched the American Red Cross in 1881. An "angel" in the Civil War, she treated the wounded in the field.

The factor that best advanced the practice of nursing in the twentieth-first century was:

Nurse educators are revising practice and school curricula to meet the ever-changing needs of society.

out of bed

OOB

left eye:

OS

as needed.

PRN

nurse anesthetist

Plans and delivers anesthesia and pain management to patients across the life span.

Thermoregulation

Process of maintaining an internal temperature within a tolerable range.

Nurse Midwife

Provides independent care, including pregnancy and gynecological services.

the examination for RN licensure is the same in every state in the United States. This examination:

Provides the minimal standard of knowledge for an RN in practice.

Doctor of Philosophy

Rigorous research and theory development

The value of certification is

That the nurse may choose to be certified in a specific area of practice by meeting the practice requirements

What is the purpose of nurse practice act?

The law in each state that governs the practice in that state and define the scope of practice

Convection

The transfer of heat by the movement of a fluid

Communicator

The use of effective interpersonal and therapeutic communication skills to establish and maintain helping relationships with patients of all ages in a wide variety of health care settings

Major route of transmission

Unwashed hands of a health care worker

Nonshivering thermogenesis

Vascular brown tissue is metabolized for heat production in the neonate

white blood cells:

WBC

Baccalaureate degree

a four-year degree in a specific subject, sometimes called a bachelor's degree or an undergraduate degree

Nurse Practitioner

a nurse with graduate training who often works as a primary care provider

Manager

a person who has the upper hand; a person who is in charge of someone or something

Explain compassion fatigue.

a term used to describe burnout and secondary traumatic stress, which impact the health and wellness of nurses and the quality of care provided to patients.

Doctor of Nursing Practice

a terminal degree that provides a clinical doctorate in nursing

Portal of exit

a way for the infectious agent to escape from the reservoir in which it has been growing

Proper preparation for examination should include:

a. Infection control b. Environment c. Equipment d. Physical preparation of the patient e. Psychological preparation of the patient

identify the guidelines that assist the nurse with incorporating vital sign measurements into practice.

a. The nurse may delegate the measurement of vital signs but is responsible for analyzing and interpreting their significance and selecting appropriate interventions. b. cleans all devices used to measure vital signs between patients, decreasing the risk of infection. c. Assess ensure that is working correctly to provide accurate findings. d. Select equipment needs on the basis of the patient's condition and characteristics. e. Know the patient's usual range of vital signs f. Know the patient's health history, therapies, and medications g. Control or minimize environmental factors that affect vital signs h. Use an organized and systematic approach i. Collaborate with health care providers to decide on the frequency of vital sign assessment j. Use measurements to determine the indications for medication administration k. Analyze the results of the measurements on the basis of the patient's condition l. Verify and communicate significant changes with the patient's health care provider m. Educate the family or caregiver in the assessment and the significance of findings

Virulence

ability to produce disease

a nurse is caring for a patient with end stage lung disease. the patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the operation to the family and discuss the patient's wishes with them. The nurse is acting as the patients:

advocate

Associate degree

an earned education certificate track after an individual has successfully completed the necessary course requirements for a particular field at a community college

A group that lobbies at the state and federal levels for advancement of nurses' role, economic interests, and health care is the:

answer- American Nurses Association. rationale- the ANA's purpose is to improve the professional development and general welfare of nurses.

The factor that best advanced the practice of nursing in the twentieth-first century was

answer- Better education of nurses. rationale- Nursing is a combination of knowledge from the physical sciences, humanities, and social sciences along with clinical competencies

Graduate nurses must pass a licensure examination administered by the:

answer- State Boards of Nursing. rationale- Candidates are eligible to take the NCLEX-RN to become registered nurses in the state in which they will practice.

What are the American Nursing Association (ANA, 2020) Standards of Nursing Practice?

assessment diagnosis outcomes identification planning implementation evaluation

Standards of Nursing Practice

assessment, diagnosis, outcome identification, planning, implementation, evaluation

Anaerobic bacteria

bacteria that do not require oxygen to survive

Osteopathy:

bone disease

which condition would the nurse associate with a client regular and slow respiratory rate?

bradypnea

which factor would elevate a clients oxygen saturation?

carbon monoxide

Describe ANA's Nursing Code of Ethics.

carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession

Nurse researcher

conducts evidence-based practice and research to improve nursing care and further define and expand the scope of nursing practice

you are preparing a presentation for you classmates regarding the clinical care coordination conference for a patient with terminal cancer. As part of the preparation, you have your classmates read the nursing code of ethics for professional registered nurses. your instructor asks the class why this document is important. which statement best describes this code.

defines the principles of right and wrong to provide patient care.

Explain the most common modes of transmission.

direct: person to person or physical source and susceptible host indirect: personal contact of a susceptible host with a contaminated inanimate object droplet: large particles that travel up to 3 feet and come in contact with the host airborne: droplets that suspend in the air vehicles: contaminated items vector: internal and external transmissions

The nurse spends time with a patient and family reviewing a dressing change procedure for the patients wound. The patients spouse demonstrates how to change the dressing. The nurse is acting in which professional role?

educator

Identify the ANA (2020) Standards of Professional Performance.

ethics culturally congruent care communication collaboration leadership education evidence based practice and research quality of practice professional practice evaluation resources utilization environmental health

Standards of Professional Performance

ethics, education, evidence-based practice and research, quality of practice, communication, leadership, collaboration, professional practice evaluation, resources, environmental health

when assessing a client's blood pressure, obtained via the clients unsupported left arm, which error would the nurse expect?

false high reading

a client, admitted to the hospital with chest pain, reports shortness of breath, weakness, and vomiting. the nurse suspect's cardiac arrest. at which site would the nurse check the client's pulse rate?

femoral

Immunocompromised

having an immune system incapable of responding normally and completely to a pathogen or disease

Caregiver

help patients maintain and regain health, manage disease and symptoms, and attain a maximal level of function and independence through the healing process

Autonomy

independence

Arthritis

inflammation of a joint

Osteitis

inflammation of the bone

Hepatitis:

inflammation of the liver

a patient has been hospitalized for the past 48 hours with a fever of unknown origin, his medical record indicates tympanic temperatures of 38.7C at 0400, 36.6C at 0800, 36.9C at 1200, 37.6C at 1600, and 38.3C at 2000. how would the nurse describe this pattern of temperature measurements?

intermittent fever pattern

Reservoir

is a place where microorganisms survive multiply and await transfer to a susceptible host.

Define nursing (according to the ANA, 2020).

is the protection, and optimization of health and abilities, prevention of the illness and injury, alleviation of suffering through the diagnosis and treatment of the human response, and the advocacy in the care of individuals, families, communities and populations.

Arthropathy

joint disease

Susceptibility

lack of resistance to a disease

Nursing administrator

manages patient care and the delivery of specific nursing services within a health care agency

Health care reform will bring changes in the emphasis of care. Which of the following models is expected from health care reform?

moving from an acute illness to a health promotion, illness preventing model

a nurse is caring for a surgical client who develops a wound infection during hospitalization. which classification would this infection belong to?

nosocomial

According to Benner, an expert nurse goes through five levels of proficiency. Identify them.

novice beginner competent proficient expert

In-service education

on-site education and training provided by many hospitals and health care agencies for nurses and other employees

Lillian Wald and Mary Brewster

opened henry street settlement, which focused on the health needs of poor people who lived in tenements in NYC

Tony, a student nurse, is preparing to participate in a team care conference for his patient. He listens to the registered dietitian and physical and occupational therapists detail the plan for the patient. Tony then describes the patient's concerns about walking to the group. Explain the QSEN competency here.

patient centered care

Identify the competencies of the Quality and Safety Education for Nurses (QSEN) initiative

patient centered care teamwork and collaboration evidence based practice quality improvement safety information

Carriers

people who have harmful germs living on or in their body, but are not visibly sick

for which involuntary physiological response would the nurse monitor development in a client experiencing pain?

perspiring

Subhepatic

pertaining to below the liver

which position would the nurse utilize to assess the Musco skeletal system, but contradicted for clients experiencing COPD?

prone position

Advanced Practice Registered Nurse (APRN)

registered nurse educated at the master's or post-master's level in a specific role and for a specific population; examples include nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives

the nurse finds the clients fever spikes and falls without a return to a normal level. which pattern of fever is this a characteristic?

remittent

Aerobic bacteria

require oxygen for survival and for multiplication sufficient to cause disease

Shivering

response to cold; body shakes to turn energy from food into body heat

Core temperature

temperature of the deep tissues

The examination for Registered Nurse (RN) licensure provides:

test the abilities, skills, and knowledge of candidates for an effective and safe nursing practice. When the students pass, they will acquire a license as LPN (Licensed Practical Nurse) or LVN (Licensed Vocational Nurse) or RN (Registered Nurse).

pH

the acidity of an environment determines the viability of microorganisms.

Bacteriostasis

the inhibition of further bacterial growth

Colonization

the presence of microorganisms that can cause infection but not to the infection itself.

Basal metabolic rate (BMR)

the rate at which the body burns energy when the organism is resting

three times a day:

tid

Advocate

to recommend; to speak in favor of

the nurse is caring for a client with a temperature of 104.5. the nurse applies a cooling blanket and administers an antipyretic medication. which is the correct rationale for the nurse's interventions?

to reduce brain metabolism and limit hypoxia

Conduction

transfer of heat from one object to another with direct contact

Radiation

transfer of heat from the surface of one object to the surface of another without direct contact

which pulse site would the nurse use to perform an Allen test?

ulnar

Intravenous:

within a vein

Nurse educator

works primarily in schools of nursing, staff development departments of health care agencies, and patient education departments