Nur101 -PCHS -Exam 1
False
Chain of infection is a process that destroys or kills pathogenic organisms? (T/F)?
False
Exogenous is thick walled capsules that can form when conditions for growth are poor, extremely difficult to kill. (T/F)?
Stroke Volume X Pulse Rate
How do you calculate cardiac output?
Used to reduce and prevent infection; and on partial or full-thickness, malodorous, and highly contaminated wounds.
What are the characteristics of Antimicrobial dressing?
apical, carotid, brachial, radial, femoral, popliteal
What are the most common pulse points?
A fever greater than 105.8 degrees F
What is considered hyperpyrexia?
The exchange of oxygen and carbon dioxide in the body through two processes -- chemical and mechanical.
What is respiration?
Anything over 100 degrees F.
What temperature is considered a fever?
Convection
What type of heat transfer happens when you take a warm bath?
Home health - each visit Doctor's visit - each visit Skilled Nursing facility - weekly to monthly
When are vitals taken in the following situations? Home health setting. Doctor's office. Skilled nursing facility.
A. The posterior pocket on either side of the frenulum
Where would the nurse place the oral thermometer for obtaining an oral temperature? A. The posterior pocket on either side of the frenulum B. Under the tip of the tongue C. On the upper side of the tongue D. At the level of the frenulum
A. Oral temperature 98.2 degree F B. Apical pulse 88 beats/minute and regular D. Blood pressure 114/78 mm Hg while in a sitting position
A nurse assesses the vital signs of a 50 year old female client and documents the results. Which of the following are considered within normal range for this client? Select all that apply. A. Oral temperature 98.2 degree F B. Apical pulse 88 beats/minute and regular C. Respiratory rate of 30 breaths/minute D. Blood pressure 114/78 mm Hg while in a sitting position E. Oxygen saturation of 90%
C. percentage of hemoglobin-carrying oxygen
A nurse is measuring a client's vital signs and uses a pulse oximeter to obtain which of the following types of information? A. respiratory rate B. amount of oxygen in the blood C. percentage of hemoglobin-carrying oxygen D. amount of carbon dioxide in the blood
D. Assess the client's apical pulse for a full minute
A nurse is obtaining a client's radial pulse and identifies that the rhythm is irregular. What should the nurse do next? A. Notify the client's primary health care provider B. Obtain the client's blood pressure C. Take the pulse in the other arm D. Assess the client's apical pulse for a full minute
A. 4 ounces of orange juice B. 6 ounces of broth D. 8 ounces of ice cream
A nurse needs to document a patients intake for the shift. Which of the following items would be included in the total? Select all that apply. A. 4 ounces of orange juice B. 6 ounces of broth C. 8 ounces of applesauce D. 8 ounces of ice cream
True
A patient develops non-blanchable erythema on her sacrum after lying on her back for several hours. This indicates a Stage 1 pressure ulcer. (T/F)
Standard
A patient has a mild skin infection. What type of isolation is needed?
Airborne
A patient has a respiratory infection that spreads long distances through the air. What type of isolation is needed?
Contact
A patient has an active super infection in a wound on their foot. What kind of isolation do you put that patient in?
Droplet
A patient has an infection that can spread through their cough. What type of isolation is needed?
E. A and C. only.
A patient has tube feedings ordered every four hours. Her feedings frequently are held due to gastric residual greater than 100mL her nutritional status puts her at risk for pressure ulcers because of: A. Her serum albumin B. Her weight change C. Her Braden Scale nutrition sub score D. All of the Above E. A and C only.
Standard
A patient is admitted with a history of HIV. What kind of isolation is needed?
E. All of the above
A patient is very high risk for developing a pressure ulcer. What preventative interventions are indicated to protect her from developing a pressure ulcer? A. Pad bony prominences when position. B. Reposition her at least q2h C. Use a lift sheet for repositioning her to avoid friction and shear injuries when moving her across the sheets. D. Use the 30 degree lateral side position to avoid positioning onto sacral and trochanteric bony prominences. E. All of the above
D. Gently cleanse her skin, protect it with a barrier cream and use absorbent under pads to wick the moisture from the skin.
A patient's perineum and buttocks are constantly moist due to urinary and fecal incontinence. What is the best prevention plan? A. Place her in diapers. B. Clean her skin vigorously with soap and water after each episode of incontinence. C. Place four blue pads under the patient's buttocks and upper thighs to absorb the urine. D. Gently cleanse her skin, protect it with a barrier cream and use absorbent under pads to wick the moisture from the skin.
Contact
A patient's stool specimen is positive for C-diff. What type of isolation should this patient be in?
True
A patient's urinary and fecal incontinence are risk factors for pressure ulcer development. (T/F)
B. Portal of exit
A way for the causative agent to escape from the reservoir in which it has been growing (ex. human body: urine, feces, saliva, etc.) A. contaminated B. portal of exit C. portal of entry D. pathogen
A. Ask the client if he needs to use the bathroom, and provide range-of-motion exercises every 2 hours. B. Document the type of restraint used and assess the need for continued use.
An elderly client, who is not oriented to time, place or person, had a total hip replacement. The client is attempting to get out of bed and pull out the IV line that is infusing antibiotics. The client has bilateral soft wrist restraints and a vest restraint. Which of the following interventions by the nurse are appropriate? Select all that apply. A. Ask the client if he needs to use the bathroom, and provide range-of-motion exercises every 2 hours. B. Document the type of restraint used and assess the need for continued use. C. Tie the restraints to the side rail of the bed. D. Obtain a new physician order for the restraint every 12 hours.
Both can take vital signs but a nurse must be the one who interprets those vital signs, the trends and make decisions based on abnormal findings.
As it relates to vital signs, what is the difference in a nurse's responsibility versus an aide?
Swelling (edema), warm, erythema (redness).
Describe inflammation.
When patient has moderate to severe pain, which can alter perceptions of and emotional response to pain.
For what kind of pain would you use opioids?
Sitz, oatmeal.
Give examples of a therapeutic bath?
They are caused by unrelieved pressure to an area, resulting in ischemia.
How are pressure ulcers formed?
Local or systemic Primary or secondary Exogenous or Endogenous Acute, chronic or latent
How are the 4 ways in which infections classified?
Obtain complete pain history (onset, location, aggravating/alleviating factors, etc.) Nonverbal signs (elevated BP, crying, moaning, etc.) Pain Scales (Visual Analogue Scale or VAS, Numeric Rating Scale (NRS), Simple Descriptor Scale, or Wong-Baker Faces Pain Rating Scale.)
How do you assess pain?
One at a time Least contaminated to most contaminated Change gloves and clean hands between wounds
How do you clean multiple wounds?
Release, check circulation and do range of motion exercises every 2 hours at least. Offer toileting Offer fluids and nutrition Take restraints off as soon as possible.
How do you prevent injury to a patient who is restrained?
Sensation level - leads to increased risk for pressure and breakdown Fever - depletes moisture, increases metabolic rate Moisture - leads to maceration Medications - side effects can cause rashes, itching Impaired circulation - negatively affects tissues metabolism
How does decreased sensation level, fever, moisture, medications, and impaired circulation affect skin integrity?
The body will vasodilate if too hot, creating more room in the vessels, cooling down the body. The body will vasoconstrict, if too cold, creating less room in the blood vessels and lowering body temps.
How does thermoregulation work?
A. 30 minutes
How long should the patient remain upright after eating? A. 30 minutes B. 15 minutes C. 10 minutes D. 45 minutes
There are five First - Korotkoff Second - A swooshing as cuff deflates caused by blood turbulence Third - Begins midway through the BP and is a sharp, rhythmic tapping sound Fourth - Like third but is softer and fades Fifth - Silence with diastole
How many sounds do you hear when taking BP?
It should cover 2/3 length of the airm. Too big a cuff can lead to low reading. Too small a cuff can lead to a false high.
How should the blood pressure cuff be positioned?
Within two hours.
How soon can a pressure ulcer form?
Distal to proximal.
In which direction would you work when bathing a patient?
What is complement cascade?
It's part of the immune system that helps antibodies and phagocytes to clear pathogens from an organism. It is part of the innate immune system but it can be triggered by the adaptive immune system.
A. droplet
Must be followed when a patient is known to be or suspected to be infected with pathogens transmitted by large-particle droplets (meningitis, pneumonia, diphtheria, mumps)? A. droplet precautions B. contact precautions C. airborne precautions D. disinfection
False
Non-blanchable reddened areas of skin over bony prominences should be massaged every 2 hours. (T/F)
B. Give a complete bed bath
The client who has a fever experienced significant diaphoresis during the night. The client stated, "I am tired and I just want to sleep." What is the most appropriate action for the nurse to do regarding bathing the client? A. Consult with the physician before providing care B. Give a complete bed bath C. Postpone bathing until the afternoon D. Wait until the client feels better
Clarity
The element of miscommunication in which a nurse distractingly uses the phrase "um" repetitively in her communication.
Timing
The element of miscommunication in which a nurse is attempting to teach a client about her medications while the client is waiting for a phone call from her granddaughter.
Pacing
The element of miscommunication in which in which the client doesn't ask a question because the nurse is talking rapidly and seems very busy.
Vocabulary
The element of miscommunication in which you use of medical jargon such as "decubitus ulcer."
Connotative meaning
The element of miscommunication in which you write "client complains of" vs. "client reports."
C. Decreased albumin levels D. Malnutrition
The nurse is caring for an 88 year-old man, who has had a 10 pound weight loss in 1 month, and has been experiencing hair loss. What is the patient at risk for? Select all that apply A. Obesity B. High blood pressure C. Decreased albumin levels D. Malnutrition
C. "The cane will help with fatigue while assisting the client with balance and support.
The nurse is working with a middle-aged female after knee surgery. Ambulation is still difficult for the client, and the physical therapist has suggested the client use a cane. The nurse states which of the following with respect to using a cane rather than a walker for this injury? A. "The cane is just a reminder to use good posture." B. "The cane can be more dangerous than helpful, and another type of assistive device should be considered for this client." C. "The cane will help with fatigue while assisting the client with balance and support. D. "A cane does not offer any relief on weight-bearing joints."
C. Obtain a pulse oximetry
The nurse obtains the following vital signs on an adult patient: T: 100.6 F, BP: 100/60, HR 110, respirations:36. What is the first action by the nurse? A. Offer oral fluids B. Begin an IV infusion C. Obtain a pulse oximetry D. Administer oxygen
C. Remind the other nurse that she needs a mask in addition to a gown and gloves for airborne-type precautions.
The nurse witnesses another nurse, wearing a gown and gloves, enter a client room labeled "Airborne Precautions". Which of the following actions by the witnessing nurse is MOST appropriate? A. Notify the nurse manager to discuss policies with the other nurse. B. Ask a physician to give a presentation on which precautions require which types of personal protective equipment (PPE). C. Remind the other nurse that she needs a mask in addition to a gown and gloves for airborne-type precautions. D. Ask the other nurse to look up the policy about precautions.
Focused Skin Assessment Braden scale - based on sensory perception, moisture, activity, mobility, nutrition and friction or shear. It uses a numeric value for six factors related to impaired skin integrity. Any patient whose score is under 18 is at risk Wound assessment - location, size, appearance, drainage, redness, swelling
What 3 things must you do when assessing skin and wounds?
Meticulous skin and moisture control Adequate nutrition Frequent repositioning Therapeutic mattresses Client/family teaching
What are 5 ways to prevent pressure ulcers?
Bed/chair alarms ID risk factors Frequent rounding Call bell and other items within reach Wheels locked Bed in lowest position.
What are 6 ways to prevent falls in healthcare setting?
To ease neuropathic pain. They reduce the amount of opioids used. They can be the primary therapy or in conjunction with opioids.
What are adjuvant analgesics used for?
Hydrocodone Bitartrate Oxycodone Hydrochloride Fentanyl Hydromorphone Naloxone (Narcan)
What are five types of opioids?
HAI (Healthcare acquired infections), which can be exogenous and endogenous
What are nosocomial infections?
Venous stasis - damage to valves in veins. Have irregular border. Below knee, above ankle Diabetic foot ulcer - caused by narrowing of arteries. Typically on pressure points. Arterial ulcer - non-pressure related block. Wound bed has regular border. On foot - heels, tips of toes, between toes, etc.
What are other types of ulcers?
Depth (deep or shallow) Rhythm (pattern and abnormal, as in Cheyne-Stokes) Effort (Dyspnea - labored? Orthopnea - inability to breath when horizontal) Breath sounds.
What are other variations in the breathing rate? Meaning, what are you looking at when assessing respiration?
Age, immature or weakened immune system, environment, lifestyle, and breaks in skin.
What are some factors that increase host susceptibility?
NSAIDs (IB, aspirin, and naprosen) Tramadol Adjuvant analgesics
What are some nonopioid medications?
Cutaneous - TENS, PENS, Accupuncture, Acupressure, massage, heat and cold therapy, contralateral stimulation. Immobilization and rest Cognitive-behavioral interventions - Distraction, progressive muscle relaxation, guided imagery, hypnosis, therapeutic touch, humor and journaling.
What are some nonpharmacological ways to manage pain?
Readiness for enhanced communication Impaired verbal communication Chronic or acute confusion Anxiety Chronic or situational low self-esteem Social isolation Impaired social interaction.
What are some nursing diagnoses that affect communication?
1. Cleansing/irrigating, including drainage devices like a Jackson Pratt or Hemovac 2. Debriding a wound -- (Sharp, mechanical, chemical, enzymatic, autolysis) 3. Applying a negative pressure wound therapy 4. Dressing a wound 5. Applying heat and cold therapy 6. Tissue growth factors 7. Ultrasound 8. Surgery
What are some nursing interventions for wounds?
Admission assessment Reassess risk daily Inspect skin daily Manage moisture Optimize nutrition and hydration Minimize pressure
What are some nursing measures for wounds, starting at admission?
They get a sense of well being. It decreases bacteria and enhances circulation, flow and respiration.
What are some of the benefits of bathing a patient?
Nonopioid analgesics -- NSAIDs, Acetaminophen, Tramadol, Adjuvant analgesics Opioid analgesics - IV, transdermal and epidermal forms; and client-controlled analgesia pump.
What are some pharmacological methods for managing pain?
Skin, Eyes (especially lacrimal glands), nose (cilia), stomach acid, and mucous membranes
What are some primary defenses to infections?
Motor vehicle accidents Pathogens (vector borne, water and airborne) Pollution Lightening strikes
What are some safety hazards in the community?
Phagocytosis, Complement Cascade, Inflammation, Fever
What are some secondary defenses to infections?
CNS depression Respiratory depression GI side effects Urinary Retention/pruritus Physical dependence Anxiety Risk of abuse
What are some side effects of opioids?
Active vs. passive immunity Humoral immunity Cellular immunity
What are some tertiary defenses to infection?
Nociceptive - receptors get message of pain Neuropathic - travels down CNS
What are the 2 classifications of pain by cause?
Intermittent - alternate between fever and normal once a day Remittent - fluctuating temps but always above normal. Constant - always remains high Relapsing - fever keeps coming back every other day.
What are the 4 types of fever?
hemorrhage infection dehiscence evisceration fistula formation
What are the 5 complications that can occur during wound healing?
Incubation - initial contact; pathogen multiplies Prodromal - Vague symptoms appear Illness - Pathogens taken over Decline - Symptoms decreasing Convalescence - No more symptoms; pathogens under control or eliminated
What are the 5 stages of infections and what happens in each stage?
Wheeze: High pitched continuous musical sounds usually heart on expiration. Rhonchi: Low-pitched continuous sounds caused by secretions in the large airways. Crackles: Discontinous sounds usually heard on inspiration. May be high-pitched popping sounds or low-pitched bubbling sounds. Stridor: A piercing, high-pitched sound heard primarily during inspiration. Stertor: Labored breathing that produced a snoring sound.
What are the 5 types of breath sound variations?
Highly absorbent; use it for moderate to large amounts of exudate; not for packing or on non-draining wounds.
What are the characteristics of Absorption dressing?
Made of seaweed and kelp; use it for large amount of exudate; and on wounds that have depth, tracts, tunneling or undermining.
What are the characteristics of Alginate dressing?
Promotes collagen deposition; use on partial or full-thickness, contaminated or infected wounds; and it won't stick to wound bed.
What are the characteristics of Collagen dressing?
Used in IV or transdermal patch. It's for severe, chronic pain. More rapid onset of action than morphine.
What are the characteristics of Fentanyl?
Simplest form; used for heavily draining wounds; and used for packing large wounds, cavities, tracts, deep or dirty wounds.
What are the characteristics of Gauze?
Most often combined with Tylenol, Aspirin or IB. Causes more sedation than Codene.
What are the characteristics of Hydrocodone Bitartrate?
Contains hydrophilic particles; keeps wound moist; provides protective layer; and used for minimally draining wounds.
What are the characteristics of Hydrocolloid dressing?
Promotes patient comfort and moisture to the wounds bed. It's not practical for wounds with significant exudate.
What are the characteristics of Hydrogel dressing?
Used in PCA. Causes less nausea but more orthostatic hypotension.
What are the characteristics of Hydromorphone?
For mild to moderate pain. Side effects include less respiratory depression, GI side effects, less risk of physical dependence, dizziness, hallucinations, anxiety, nervousness, tremors, restlessness, agitation. They have antipyretic and anti-inflammatory properties. Used on peripheral sites. Does not produce severe adverse effects. GI ulceration and bleeding.
What are the characteristics of NSAIDs?
It competes with opioid agonists, so it antagonizes all effects. It reverses respiratory depression and coma. Often used with heroin overdoses.
What are the characteristics of Naloxone?
Often combined with Tylenol or Aspirin. Less nausea, vomiting, hallucinations.
What are the characteristics of Oxycodone Hydrochloride?
Creates a protective layer
What are the characteristics of Skin sealants and moisture barriers?
Acts on the CNS. Does not cause GI ulceration or severe respiratory depression.
What are the characteristics of Tramadol?
They are clear, semipermeable, nonabsorbent and allow for exchange of air and water vapor. Typically used to dress IV sites.
What are the characteristics of Transparent film dressings?
It's an unpleasant sensory/emotional experience. Can have destructive effects. Can warn of potential injury It's a multidimensional experience.
What are the characteristics of pain?
Regeneration -- seen in epidermal wounds. No scar Primary intention - clean surgical incision. Edges approximated. Minimal scarring Secondary intention - Wound edges not approximated. Tissue loss. Heals from inner layer to surface. Tertiary intention - Granulating tissue brought together. Delayed closure of wound edges.
What are the characteristics of the 4 wound healing processes?
Stage I - unblanchable redness or discoloration in localized area. Skin intact. Stage II - partial-thickness loss of dermis. Skin starts to open and is shallow with red, pink wound bed Stage III The opening goes through the layers of skin and starts to get into fat tissue. Deep crate with full-thickness skin loss with damage or necrosis of subcutaneous tissue. Undermining may be present. Stage IV - All layers of the skin are gone into the muscle and possibly the bone. Slough or eschar are present. Tissue necrosis Unstageable - There is black dead tissue over the wound called eschar. Deep Tissue Injury - skin intact but deep purple.
What are the characteristics of the 6 different stages of pressure ulcers?
Implanted pumps - continuous infusion Blocks - nerve block or epidural (Short term relief) Surgical procedures - interruption of pain conduction pathways. Permanent destruction of nerves. Reserved for intractable pain.
What are the chemical and surgical methods of pain control?
Neuropathic - nerve endings Phantom - Pain from location not on pt. anymore Psychogenic - stemming from psche Visceral - deep inside (from organs) Somatic - from moving parts like joints and ligaments. Usually superficial. Sharp & localized Nociceptive - Arising out of receptors (trauma, surgery).
What are the different kinds (or causes) of pain?
Impaired skin integrity Risk for Impaired skin integrity Impaired tissue integrity Risk for Infection Acute Pain
What are the different kinds of nursing diagnoses for wounds?
Exudate Serious exudate Sanguineous exudate Serosanguineous drainage Purulent
What are the different kinds of wound drainage?
Standard - for all patients, no matter what the diagnosis or suspected diagnosis Contact - used for patients who have confirmed or suspected infection or colony of infectious agents that are transmitted by direct touch Ex: MRSA, VRE Droplet - used for patients who have infections or suspected infections that are transmitted via short distances on large particles. Ex: Flu, pneumonia Airborne - Used for patients who have infections or suspected infections that can be spread via long distances, like through ventilation. Ex: TB, Measles
What are the different types of isolation?
Friction Pressure Shearing Exposure to moisture Trauma Bony Prominences
What are the extrinsic factors for developing pressure ulcers?
Open/closed Acute/chronic Clean/contaminated/infected Superficial/partial or full thickness Penetrating
What are the five classifications of wounds?
Get the person's attention Express your concern State the problem Propose an action Reach a decision
What are the five steps of assertive communication?
Immobility Impaired sensation Malnourishment Aging Fever
What are the intrinsic factors for developing pressure ulcers?
From outermost to innermost: Epidermis, Dermis and Subcutaneous layers.
What are the layers of skin?
Stratum corneum and Stratum germinativum
What are the layers of the Epidermis?
Protective or reverse isolation.
What are the methods used to protect certain patients from microorganisms present in the environment, mainly immunocompromised patients, or those whose body defenses are not capable of protecting them infections and diseases, like bone marrow transplants, chemotherapy.)
Initial - febrile episode or onset Second - reaches its max and stays there Third - (defervescence) - returns to normal
What are the phases of fever?
Pre-interaction - (reading over chart) Orientation - Introduce yourself. Orient pt to room. Building trust Working - communicating caring and that you both are partners to healing. Termination - conclusion of relationship, whether pt. is discharged or your shift ends, etc.
What are the phases of therapeutic communication?
Superficial Visceral Somatic Radiating (or referred) Phantom Psychogenic (PPRSSV)
What are the six classifications of pain by origin?
Inflammatory Phase - 1 to 5 days Proliferative Phase - Days 5-21 Maturation Phase - begins in 2nd or 3rd week
What are the stages of wound healing?
Rate - either apnea (cessation of breathing); bradypnea (abnormally slow); tachypnea (abnormally fast).
What are the terms used for variations in breathing rate, whether fast, slow or absent?
Needle sticks Workplace violence Back injury Radiation
What are the top 4 hazards to healthcare workers?
Developmental level Knowledge and cognitive levels Cultural/religious reasons Economic status or living environment Personal preferences
What are the top 5 factors that influence hygiene and self care practices?
Restraints Falls Equipment malfunctions Violence/Needle sticks Fire and electrical hazards
What are the top 5 safety hazards in healthcare?
Poison Fires Falls Suffocation/Affixation Scalds/burns
What are the top 5 safety hazards in the home?
Skin Nose Eyes Mouth Hair Ears
What are the top 6 areas of hygiene?
1:1 supervision Move pt. closer to nurse's station Seek out unmet needs Reduce anxiety
What are the top alternatives to using restraints?
Antiseizure drugs - Gabapentin, Pregabalin Antidepressants - Paxil Corticosteroids - Decadron Local anesthetics - Mexitil Muscle relaxants - Ativan Bone-specific agents - Zometa
What are the types of Adjuvant Analgesics?
Pyrogens induce secretion of substances (prostaglandins) that reset the hypothalamic thermostat at a higher temperature.
What causes a fever?
Excessive carbon dioxide and lack of oxygen in the blood.
What causes cyanosis?
Susceptible host
What do you call a person who is likely to get an infection or disease, usually because the body defenses are weak?
Pain management plan Expected outcome Present pain level Response to interventions Any adverse reactions Be accurate and adequate and doc in real time.
What do you want to document when it comes to a patient's pain?
Whether rate is regular or irregular. Quality of the pulse (bounding or thread?)
What do you want to note when obtaining pulse rate?
R - Rescue A - Alarm C - Contain E - Extinguish
What does RACE stand for?
Sphygmomanometer and stethoscope.
What equipment is used to indirectly monitor BP?
Age Impaired circulation Mobility Status Medications Nutrition/hydration Moisture Sensation level Fever/Infection Lifestyle
What factors affect a person's risk for reduced skin integrity?
Meaning (connotative or denotative) Pace Intonation
What factors affect verbal communication?
Clarity Brevity Timing Relevance Credibility Humor
What factors improve communication?
Past experience with pain Emotions Sociocultural factors Communication skills Developmental Stage Cognitive impairments Other illnesses contributing to pain
What factors influence pain?
RR increases up to 4 breaths per minute for every degree rise in temperature.
What happens to respiratory rate when the temperature increase?
Vasodilation occurs, blood rushes to area. Area becomes bright red, called reactive hyperemia.
What happens to skin when pressure is relieved?
Skin becomes pale or blue, and cool
What happens when ischemia occurs?
A way to assess pain: Precipitating Factors, Quality, Radiating, Severity, Time.
What is PQRST?
Pulse Oximetry - which is an external device that measures oxygen saturation.
What is a noninvasive way to measure oxygenation without lab tests?
97 to 100.8 degrees F. (It's usually 1-2 degrees F higher than skin temperature)
What is a normal range for the core temperature?
The first infection a patient gets -- the reason for medical problems the pt. is experiencing.
What is a primary infection?
A subsequent infection caused by a lowered immune response thanks to the primary infection.
What is a secondary infection?
Portal of Entry
What is a way for the causative agent to enter a new reservoir or host?
An infection that comes from our own natural flora that grows out of control. Ex: getting C diff after receiving antiobiotics.
What is an endogenous infection?
It's the amount of force put on arterial walls during a cardiac contraction.
What is blood pressure?
When BP is persistently higher than normal. Anything above 140 mm Hg systolic or greater than 90 mm Hg diastolic on two or more separate occasions.
What is considered hypertension?
A BP reading of 120-130 mm Hg systolic or 80-89 mm Hg diastolic. You must take these readings twice, six minutes apart and with client sitting.
What is considered prehypertension?
Minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest.
What is diastolic pressure?
Rapid and deep breathing resulting in excess loss of carbon dioxide (hypocapnea). Client may complain of feeling light-headed or tingly.
What is hyperventilation?
When body temperature is lower than 95 degrees F and is usually caused by extended exposure to cold, such as extreme weather or being submersed in cold water.
What is hypothermia?
The rate and depth of respirations are decreased and carbon dioxide is retained.
What is hypoventilation?
They are a way of assessing vital or critical physiological functions. Variations can reflect a person's health or functionality of one's body systems.
What is important about vital signs?
Most common type of pain. Includes dx of Herpes zoster, acute trauma, cancer, and autoimmune disorders. Medicine used includes Gabapentin and Lyrica.
What is neuropathic pain?
A. Work environment B. Stress D. Alcohol
What is nutrition affected by? Select all that apply A. Work environment B. Stress C. Gender D. Alcohol
A sudden drop in BP on moving from a lying to sitting or standing position.
What is orthostatic or postural hypotension?
It's diagnosed when there is no known cause for the increase.
What is primary or essential hypertension?
The difference between systolic and diastolic pressure.
What is pulse pressure?
The quantity of blood pumped out by each contraction of the left ventricle.
What is stroke volume?
Peak pressure exerted against arterial walls as the ventricles contract and eject blood.
What is systolic pressure?
Link 1 - Infectious Agent Link 2 - Reservoir Link 3 - Portal of Exit Link 4 - Mode of Transmission Link 5 - Portal of Entry Link 6 - Susceptible Host
What is the chain of infection?
The exchange of oxygen and carbon dioxide. Transport of oxygen and carbon dioxide throughout the body. Exchange of gasses between capillaries and tissues.
What is the chemical process of respiration?
Threading a catheter into an artery under sterile conditions. The catheter is connected to an electronic monitoring system. Pressure is constantly displayed as a waveform on monitor system. Only done as inpatient.
What is the direct method of measuring BP?
Pain
What is the fifth vital sign?
Korotkoff sound (Happens during systole)
What is the first sound as you deflate BP cuff?
Pulmonary ventilation (or breathing). The active movement of air in and out of the respiratory system using ribs and diaphragm to create negative pressure. (inspiration). Relaxation of thoracic muscles and diaphragm expel air from lungs.
What is the mechanical process of respiration?
Primary or essential hypertension. Accounts for 90 percent of all cases of hypertension.
What is the most prevalent form of hypertension?
60-100 bpm (70-80 bpm is average)
What is the normal radial pulse for adults?
C. 48 hours
What is the time for the nurse to complete the nutrition screening upon admission to the hospital? A. 24 hours B. In the emergency room after admission has been decided C. 48 hours D. At the time of discharge
Contaminated
What is the type of wound called when organisms and pathogens are present?
Arterial blood gasses. (ABGs), which directly measures the partial pressures of oxygen, carbon dioxide, and blood pH.
What lab test do you use to measure oxygenation?
pallor (paleness) or cyanosis (blue or grayish color of skin)
What may skin look like if circulation is compromised?
15 percent - hospitalized 20 percent - long-term care
What percentage of hospitalized patients have pressure ulcers? And how many long-term care patients?
B. High fowler's
What position should the patient be placed in when assisting a patient with meals? A. Supine position B. High fowler's C. Lateral recubment position D. Semi-fowler's at 30 degrees
Tachy - above 100 bpm Brady - below 60 bpm
What pulse rate is tachycardia and bradycardia?
Ask whether the patient has eaten, smoked or had something to drink within the last 30 minutes.
What should you ask a patient before taking his or her temperature?
Cardiac function Peripheral vascular resistance Blood volume
What three factors influence blood pressure regulation?
Evaporation
What type of heat transfer happens when you breathe?
Radiation
What type of heat transfer happens when you enter a room full of people?
Conduction
What type of heat transfer happens when you lay on a cool table?
21 percent
What's the concentration of oxygen in room air?
On admission and daily.
When are patients assessed using Braden score?
Typically 4-8 hours or with change in a patient's condition; upon admission; when getting blood transfusion; at physician's or nurse's discretion.
When are vitals taken in a healthcare facility?
C. A 65 year old man with a respiratory rate of 10
Which assessment result would require the nurse to assess the client further? A. A 21 year old male with a pulse rate of 140 after riding 2 miles on an exercise bike. B. A 50 year old man with a blood pressure of 118/64 upon awakening in the morning C. A 65 year old man with a respiratory rate of 10 D. A 40 year old man with a pulse of 88
Apical (at apex of the heart)
Which is the most accurate way to obtain a pulse rate?
C. Albumin
Which laboratory value is an indicator of malnutrition? A. WBC's B. Hemoglobin C. Albumin D. Blood sugar
D. Hand hygiene before entry to a client's room and upon exit of a client's room
Which of the following actions by the nurse is the MOST appropriate means of preventing infection? A. Washing hands after client contact B. Washing hands after removing gloves C. Hand hygiene between clients D. Hand hygiene before entry to a client's room and upon exit of a client's room
A. Coughing or choking during meal time B. Wet sounding voice C. Drooling D. Pocketing foods in the cheeks of the mouth
Which of the following are possible signs that a patient may have difficulty swallowing? Select all that apply: A. Coughing or choking during meal time B. Wet sounding voice C. Drooling D. Pocketing foods in the cheeks of the mouth
A. Chicken noodle soup C. Whole grains
Which of the following foods are included in a caloried controlled diet? Select all that apply A. Chicken noodle soup B. Soda C. Whole grains D. Cream of potato soup
B. Hard candy D. Apple juice
Which of the following foods could a patient have on a clear liquid diet? Select all that apply A. Milk B. Hard candy C. Chicken noodle soup D. Apple juice
B. Graham crackers with peanut butter
Which of the following is the best snack to offer a diabetic patient on a carbohydrate controlled diet? A. Hard candy B. Graham crackers and peanut butter C. Regular soda D. Chocolate chip cookies
A. Counting the rate for one full minute
Which of the following procedure techniques has the most effect on the accuracy of an apical pulse count? A. Counting the rate for one full minute B. Exposing only the left side of the chest C. Determining why assessment of apical pulse is indicated D. Using your ring finger to palpate the intercostal spaces
B. Wrap the cuff snugly around the client's arm D. Have the client sit with feet flat on the floor
Which of these steps in taking a blood pressure are correct? Select all that apply. A. Use a bladder that encircles 25% of the arm B. Wrap the cuff snugly around the client's arm C. As the client to hold their arm at heart level D. Have the client sit with feet flat on the floor
Airborne precautions
Which precautions should be used for patients who have or are suspected of having pathogens that are transmitted through the air by small particles.
C. Squat when lifting objects off the floor
Which principle of body mechanics should the nurse implement when providing nursing care? A. Hold an object away from the body. B. Extend the arms when lifting objects C. Squat when lifting objects off the floor D. Keep feet together when moving an object
A. "At what point on the scale of 1 to 10 do you feel that you must have pain medication?"
Which question by the nurse best assesses a client's pain tolerance? A. "At what point on the scale of 1 to 10 do you feel that you must have pain medication?" B. "What activities help distract you so that you don't feel the need for pain medication?" C. "How intense on a scale of 1 to 10 is the pain that you feel right now?" D. "Do you take pain medication frequently?"
C. "I usually have pain after I get dressed in the morning."
Which statement by the patient to a nurse indicates a precipitating factor associated with pain? A. "I usually feel a little dizzy and think I'm going to vomit when I have pain." B. "My pain usually comes and goes throughout the night." C. "I usually have pain after I get dressed in the morning." D. "My pain feels like a knife cutting right through me."
D. Neutropenic
Which type of patient problem should be placed into protective isolation? A. C-diff B. MRSA C. TB D. Neutropenic
It increases stress on the heart and blood vessels. If untreated, can lead to heart, renal, cerebral, or respiratory complications.
Why is hypertension a major cause concern?
Quality (strong, weak, dull, aching) Duration (acute, chronic, intractable) Cause (nociceptive, neuropathic)
You can classify pain by three other categories. What are they?
