Card Set Information

2012-03-07 01:50:30
adult exam

modules 6-10,15,16
Show Answers:

  1. describe the stages involved with an infectios process
    -incubation period: interval between the pathogen’s invasion of the body and the appearance of symptoms of infection, organisms are growing and multiplying

    -prodromal stage: most infections stage, early signs and symptoms of disease are present but vague and not specific, pt often doesn’t realize they’re contagious

    -full stage of illness: presence of specific signs and symptoms

    -convalescent period: recovery period from infection
  2. explain the most important action to prevent the spread of infection
  3. laboratory findings that may be present with infection
    • elevated WBC count, increase in specific type neutrophils: normal 60-70% inc.-acute infection that produce pus, stress ; Dec- bacterial infection
    • lymphocytes: normal 20-40% inc. in chronic bacterial/viral infections
    • monocytes: normal 2-8% inc. in severe infection
    • eosinophil: normal 1-4% inc in allergic reactions and parasitic infection
    • basophil: normal .5-1% usually unaffected by infections
    • elevated erythrocyte sedimentation rate: rbc’s settle more rapidly to the bottom when inflammation is present
  4. meaning of standard precautions
    precautions used in the care of all hospitalized individuals regardless of their diagnosis or possible infectious status. Apply to blood, bodily fluids, secretions, excretions, non intact skin, and mucous membranes
  5. identify reason for neutropenic precautions
    what nursing care should be provided
    • -immunosuppresed client
    • restrict visitors who have illnessess
    • avoid standing water in room
    • avoid fresh veggies and fruit (bc food is source of contamination)
  6. identify factors that may compromise the immune system
    • integrity of skin and mucous membranes
    • pH levels
    • integrity and number of wbc
    • age, sex, race, hereditary factors
    • immunization natural vs. acquired
    • general health status
    • stress
    • invasive/indwelling medical devices
  7. describe the procedure to be followed for patients in contact isolation
    • place pt in private room, if available
    • wear PPE whenever you enter the room for all interactions that may involve contact with pt and potentially contaminated areas in pt environment
    • change gloves after having contact with infective material
    • remove PPE before leaving pt environment and wash hands
    • limit movement of the pt out of room and avoid sharing pt care equipment
  8. anticoagulents turn urine what color?
  9. diuretics turn urine what color?
    pale yellow, dilutes urine
  10. pyridium turns urine what color?
    orange to orange red
  11. elavil turns urine what color?
    green or blue green
  12. levodopa turns urine what color?
    brown or black do to chemical content
  13. #1 nursing intervention for a pt. with renal calculi
    • PAIN
    • "kidney stones"
  14. identify factors that may interfere with patient education
    • age and developmental level
    • family support networks
    • financial resources
    • cultural influences
    • language deficits
    • literacy levels
  15. function of pulse oximeter and normal values
    measures the arterial oxyhemoglobin saturation of arterial blood, normal values are 95-100%
  16. function of incentive spirometer
    assists the pt to breath slowly and deeply and to sustain maximal inspiration, optimal gas exchange is supported and secretions can be cleared and expectorated
  17. patient education on incentive spirometer
    • assist pt to upright position
    • demonstrate how to steady device with one hand and hold mouthpiece with the other
    • instruct pt to exhale normally and place lips securely on mouthpiece
    • instruct pt not to breathe through nose
    • instruct pt to inhale slowly and as deeply as possible though mouthpiece, tell pt to hold breath and count to 3
    • check gauge to determine process
    • remove mouthpiece and exhale normally
    • tell pt to complete exercise about 10/hr
  18. Normal lab values for Sodium
    135-145 mEq/L
  19. normal levels of Potassium
    3.5-5.0 mEq/L
  20. procedures taken for patients with airborne precautions
    • infections that spread through the air such as Tb, varicella, rubeola (measles), and SARS
    • place in private room that has monitored neg. air pressure in relation to surrounding areas
    • keep door closed, wear mask or respirator when entering room
    • if pt needs to be transported out of room place a surgical mask on pt if possible
  21. procedures for patients with droplet precautions
    • infection that’s spread by large particle droplets such as rubella, mumps, diphtheria, and adenovirus
    • use private room is possible, door may remain open wear PPE for all interactions that may involve contact with pt and contaminated areas
    • transport pt only when necessary and place surgical mask if possible
    • keep visitors 3ft from infected person
  22. symptoms present in fat emboli
    • chest pain
    • tachypnea
    • dyspnea
    • cyanosis
    • tachycardia
    • decreased PaO2
    • change in mental status
    • petechiae
  23. explain the mechanism of action for antiembolitic stockings
    • by applying pressure, stockings increase velocity of blood flow in the superficial and deep veins and improve venous valve function in the legs promoting venous return to the heart
    • used for pts with risk of DVT, pulmonary embolism, and to help prevent phlebitis