Essential Exam 1.txt

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bluemil1
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97171
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Essential Exam 1.txt
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2011-08-16 00:50:12
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Nursing Essentials
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First exam
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  1. Nursing theory, research, and practice are
    Interdependent
  2. Florence Nigthingale
    Saw nurding as an art and science. Supported education. Said the environment directly affects one's health. Cleanliness, Light, Pure air and water.
  3. Hildergard Peplau
    Defined the nurse-client relationship. Stranger, Resource person, Teacher Leader Surrogate, and Counselor
  4. Virginia Henderson
    Defined nursing as assisting a person in the performance of acitivites that will contribute to health or a peacful death. Stressed independence of client
  5. Myra Levine
    Conservation theory- Energy, Structural Intergrity, Personal Intergrity, and Social Integrity.
  6. Dorothea Orem
    I am Nursing. Looked at action by the nurse client and family and said those things are integrated together. Important that the patients do what they can on their own.
  7. Berry Neuman
    Stressors- Intrapersonal, Interpersonal, and Extrapersonal
  8. Intrapersonal
    stresses within (fear of flying)
  9. Interpersonal
    Between 2 individuals (getting into with someone)
  10. Extrapersonal
    Outside the individual (raining)
  11. Madeline Leininger
    Culrture care and culture belief. Accomodation or negotiation (We respect cultural beliefs).
  12. Sister Calista Roy
    Aaptation model- Nursing attempts to alter the environment when the person in not adapting well (i.e. if patient has a problem getting out of the bed, get them a walker). Use of coping systems-Nursing attempts to assist hte client in coping mechanisms.
  13. Jean Eatson
    Human caring. Care and love are the basis for humanity.
  14. Martha Rogers
    • Unitary human beings
    • Nursing as an art and science. Energy fields. Looked at humans as structures that cannot ve seperated into pieces.
  15. National Patient Safety Goals
    • Improve accuracy of client identification
    • Reduce risk of health care associated infection
    • Improve effectiveness of communication
    • Improve safety of usig high-alert med
    • Prevent errors in surgery
    • Improve safety of infusion pumps
    • Effectiveness of clinical alarm systems
    • Reduce the risk of patient harm resulting form falls
  16. Client behavior accident
    Burns/poisonings, Self inflicted cuts
  17. Therapeutic procedure accidents
    • Medication errors
    • Client transfer falls
    • Contamination
  18. Equipment accidents
    • Fire
    • Electrocution
    • Osygen Tank
  19. Resident flora
    Always there. Hands washing alone will not get rid of it. Must use friction by rubbing the hands and scrubbing the nails.
  20. Tranisient flora
    Brief can get rid of with hand-washing.
  21. Biological Agents (chain of infection)
    Viruses, bacteria, fungi, protozoa, Rickettsia
  22. Chemical agents (chain of infection)
    Pesticides, food additives, medications, and industrial chemicals
  23. Physical agents (chain of infection)
    Machine, heat, light, noise, radiation, and machinery
  24. Susceptible host
    Person who lacks resistance to an agent and is vulnerable to disease
  25. Compromised host- a person whose normal defenxe mechanims are impaired and is susceptivle to infection
  26. Modes of transmission
    • Contact
    • Airborne
    • Vehicle
    • Vectorborn
  27. Contact transmission
    Sexually transmitted diseases
  28. Airborne transmission
    Host contacts droplet nuclei or dust particles suspended in the air
  29. Vehicle transmission
    Contaminated inanimate objects such as water, food, drugs and blood
  30. Vector-borne transmission
    mosquitoes, fleas, ticks, lice and other animals
  31. Stages of infection
    • Incubation
    • Prodromal
    • Illness
    • Convalescent
  32. Incubation
    Time interval between entry of an infectious agent in the host and the onset of symptoms.
  33. Prodromal stage
    Non specific symptoms
  34. Illness
    Specific Systems
  35. Convalescent stage
    Disappearance of acute symptoms until the client returns to the previous state of health
  36. Emerging Infections- Don't know where they are at or going
    • SARS
    • Hepatitis
    • West Nile Virus/Hantavirus
    • Viral hemorrhagic fevers (ebola)
    • HIV
  37. Nosocomial Infections (most common infection sites greatest to least)
    • GI
    • Urinary
    • Skin
    • Lower Respiratory
    • Conjunctiva
  38. Assesing client in inpatient setting
    • Fall risk every shift
    • Infection (local or systemic)
  39. Assesing client in home
    • Knowledge
    • Asses prior to patient's discharge
  40. Magic number for leukocytes
    10,000
  41. Neutrophils
    Increase in acute sever infection (bacterial)
  42. Lymphocytes
    Increase in chronic bacterial infections
  43. Monocytes
    increased in protozoan and rickettsial infections and tuberculosis
  44. Eosinophils and basophils
    Unaltered in an infectious process
  45. Erthrocytes Sedimentation rate (ESR)
    Elevated in infection
  46. pH in urine, gastric or vaginal secretion
    Elevated in infection
  47. Three things to focus on to reduce exposure to radiation.
    less time, more distance, and more shielding
  48. Medical asepsis
    infection control practice used to reduce number, growth and spread of microorganisms.
  49. Examples of medical asepsis
    Gloves, changing linens daily, cleaning floors, hospital furniture and hand hygiene
  50. Surgical asepsis
    Eliminates microorganisms and spores
  51. Examples of surgical asepsis
    Sterile technique, donning sterile gloves,donning surgical attire, surgical hand antisepis, gowning and closed gloving
  52. Standard precautions
    • Gloves
    • Gown
    • Protective Eyewear
    • Hand Hygiene
  53. Contact precautions
    • In addition to standard
    • Gloves
    • Gowns
    • Disposable equipmemt
  54. Perform areas with contaminated areas when?
    LAST
  55. Droplet Precaution
    • In addtion to standard
    • Eye protection
    • Fluid resistant procedure mask
  56. Airborne Precaution
    • Keep door closed
    • N95 respirator mask
  57. When to use contact precaution
    MRSA, VRE, C.difficile, major wounds with significant damage
  58. When to use airborne precaution
    Tuberculosis,measles,chickenpox, disseminated herpes zoster
  59. When to use droplet precaution
    Influenza, respiratory MRSA,rubella, meningoccocal meningitis, mumps, pertussis
  60. Evaluation
    • Client is free injury
    • Client is free from
    • Self-care needs are met
  61. When to take vital sighns
    • Upon admission
    • Every few hours
    • Anytime there is a change in the patients condition
    • Before procedures (compare when they return)
    • Prior to discharge
  62. How often you take vital signs for med surge?
    Every 8hrs
  63. How often do you take vital signs for ICU?
    Every hour
  64. How often do you take vital signs for Progressive care?
    Every 4 hours
  65. How often do you take vital signs for Hospice?
    May not take them
  66. Normal adult value for oral temperature?
    98.6 F
  67. Normal adult value for axillary?
    97.6 F
  68. Normal adult value for rectal(most accurate)?
    99.6 F
  69. When shouldn't you take a rectal temperature?
    • Patient at risk for perforation
    • Patients who have extremely slow heart rate because it stimulates vegus nerves and can slow the heart rate
  70. Meatabolic heat production
    • Metabolism
    • Shivering (body's own mechanism)
    • Excessive muscle activity
    • Fever
    • Thyroxine production
  71. Heatloss
    • Radiation
    • Conduction
    • Convection
    • Evaporation
  72. Conduction
    Loss of heat to object in contact with the body
  73. Convection
    Using Air
  74. Normal respirations for an adult
    12-20 breaths per minute
  75. When do you check the carotid pulse?
    During cardiac arest, shock, blood pressure very low
  76. How long do you check the apical pulse?
    1 minute
  77. If apical pulse is larger than radial, what may be the problem?
    Circulation problem, the heart is not pumping efficient enough to reach extremeties
  78. What two pulses should you find in every patients besides the normal pulse?
    Posterior tibial and Dorsalis Pedis
  79. Stroke volume
    measure of blood that enters the aorta with each ventricular contractiondiac output
  80. Cardiac output
    volume of blood pumped by the heart in one minute
  81. Cardiac out put for men?
    5000ml
  82. Cardiac output for women?
    4500ml
  83. Systole
    Depolarization
  84. Diastole
    Repolarization- Most important heart not resting doesn't get oxygen and doesn't allow blood to flow to tissues
  85. Pulse pressure equals
    • Systole/Diastole
    • 120/80= 40
  86. Orthostatic Blood pressure
    • Lay flat, take BP
    • -Wait 5 minutes
    • Sit, take BP
    • -Wait 5 minutes
    • Stand up, take BP
  87. How does fever affect pulse?
    • It is expected to go up
    • peripheral vasodilation and increased metabolic rate
  88. Digoxin increase or decrease pulse?
    Slows it
  89. Epinephrine increase or decrease pulse?
    Increases
  90. Hypovolemia affect on pulse?
    Increases pulse in attempt to raise BP
  91. Position changes affect pulse how?
    Blood pooling causes lower BP and increase in heart rate
  92. Most accurate way of measuring Vital signs?
    Mercury manometer (no longer used)
  93. When is the electronic sphygmomanometer used?
    For frequent vitals, used to see if any changes in BP
  94. What must always be the same when measuring daily weight for fluids?
    Time of day, Same scale, and same clothing
  95. Afebrile
    Absence of fever
  96. Which site does not require a sheath when doing thermoregulation assessment?
    Pulmonary artery (PAT)
  97. What temp is classified as hyperpyrexia?
    Greater than 105.8
  98. Some of the signs associated with hyperthemia?
    Chills, Fever, pyrogens, diaphoresis, elevated pulse and respiration rate.
  99. Signs associated with hypothermia
    Pallor, shivering, cyanotic nail beds, decrease in BP and pulse
  100. What is ineffective thermoregulation
    fluctuation between hypothermia and hyperthermia
  101. Why do you have to be careful when using ice packs to bring down temperature?
    If the patient is shivering (body's own mechanism) the temperature will go up
  102. What will you instruct the patient to do during a fever?
    • Reduce external coverings and keep clothing and bed linen dry
    • Limit physical activity
    • Increase rest periods
    • Increase oral fluids of choice
  103. If unable to palpate the pulse what do you use?
    Doppler (ultrasound) with gel
  104. What is meant by pulse deficit?
    Apical pulse and radial pulse not the same
  105. Pulse characteristics
    quality and rate
  106. Pulse volumes
    • 0- Absent
    • 1- Weak
    • 2- Normal
    • 3- Strong/bounding
  107. Holter monitor
    portable cardiac monitor worn 24 hours used to determine if certain activities such as walking are associated with abnormal transmission of impulses.
  108. Eupnea
    normal rate and depth
  109. bradypnea
    10 or fewer breaths per/minute
  110. hypoventilation
    shallow respirations
  111. tachypnea
    more than 24 breaths per minute
  112. orthopnea
    sit or stand to breathe
  113. Cheyne-Stokes breathing
    gradual increase in depth of respiration followed by gradual decrease in depth of respiration
  114. What muscles are involved in costal breathing?
    External intercostal muscles and accessory muscles
  115. What to do for a patient experiencing costal breathing
    They are going into respiratory distress, place them in an upright position. This helps them breath easier
  116. Diaphragmatic breathing
    diaphargm contraction and relaxation observed in the abdomen
  117. Dyspnea
    • labored breathing or forced respirations
    • use accesory muscles and neck to breathe
  118. Normal respirations for a newborn
    30-60
  119. Normal respirations fora an infant (6 months)
    30-50
  120. Normal respirations for a toddler (2 year old)
    25-32
  121. Normal respirations for an adolescent?
    16-19
  122. Does low hemoglobin increase or decrease respirations?
    Increase respirations
  123. The earliest sign a patient is having trouble breathing/
    restlessness
  124. Latest sign a person is having trouble breathing?
    Cyanosis
  125. When would it be hard to measure oxygen saturation of blood using an oximeter?
    If a person is wearing polish or there is swelling
  126. Is taking a brachial BP direct or indirect?
    Indirect
  127. Measuring BP by a catheter in a patient heart direct or indirect?
    Direct
  128. Korotkoff's sound
    • Phase 1-First faint tapping SYSTOLIC
    • Phase 2-during deflation muffling quality
    • Phase 3-period crisp thumb
    • Phase 4-softer blowing, muffled that fades
    • Phase 5-silence DIASTOLIC
  129. Auscultatory gap
    It fades then return during diastolic
  130. Hypotension
    • Systolic blood pressure less than 90mmHg
    • 20-30 mmHg below the clients normal systolic pressure
  131. Can you diagnosis hypertension after one visit to the doctor?
    No. Must be confirmed on 2 seperate visits
  132. Normal BP in adults (not optimal)?
    <130 and <85
  133. If a person has a hemorrhage you would expect the BP to?
    decrease
  134. If a person has a heart attack their BP would?
    decrease
  135. If a person has IV fluid administration their BP would
    increase
  136. If a person has a blood transfusion their BP would
    increase
  137. How long should a blood transfusion take?
    4 hours
  138. What things cause a false high BP reading?
    • Cuff too narrow
    • arm unsupported
    • Insufficient rest before assesment
    • cuff wrapped too loosely
    • deflating cuff to slowly
    • patient talking
    • assesing after meal, smoking, or while in pain
    • repeating assesment too quickly
  139. what causes false low BP reading
    • Cuff too wide
    • deflating cuff too quickly
    • arm above level of the heart
    • failure to identify auscultatory gap
  140. If BP to high or low what steps do you take?
    • Check the BP again in 15 minutes
    • continue to reassess
    • review list of medications to see if there is anything available prn
  141. First step after collecting data
    Compare the data against esablished norms
  142. Specificity
    The ability of a test to correctly idenfiry those individuals who DO NOT have the disease
  143. Sensitivity
    The ability of a test to correctly idenfify those individuals who have the disease
  144. Predictive value
    The ablility of a screening test results to correctly identify the disease state. Dont want a lot of false positives or false negatives.
  145. High hematocrit is a sign of?
    Dehydration
  146. Normal hemoglobin for Men
    13-18
  147. Normal Hemoglobin for Women
    12-16
  148. Normal hematocrit for men
    37-49%
  149. Normal hematocrit for women
    36-46%
  150. Elevation of BB bands mean?
    Brain damage
  151. Elevation of MB bands mean?
    damage to the heart
  152. Elevation of UU bands
    Damage to skeletal muscle
  153. Non invasive radiography
    plain films and mammography
  154. Invasive radiography
    pyelograph and bronchography
  155. Ultrasound (echogram)
    • Noninvasisve study
    • Uses high frequency sound waves
    • Visualise deep body structures
  156. Echocardiogram
    • Abnormal structure or motion of the heart wall and thrombi
    • Radiofrequency ablation
  157. Doppler Ultrasonography
    reveals blood clots and peripheral vascular disease
  158. Where do you aspirate bone marrow?
    From the sternum or illiac crest
  159. What position is used during paracentesis?
    Fowler's position
  160. What are the symptoms of pnuemothormax you should monitor the patient for during thoracentesis?
    Dyspnea, pallor, tachycardia, vertigo, and chest pain
  161. Transparent film (Type of dressing)
    • Impedes moisture less surface friction
    • Used mostly fo IV sites
    • Tegaderm (brand name)
  162. Exudate absorbers (Type of dressing)
    No moisture in the wound
  163. When should you not use cold therapy?
    In patients with neuro sensory impairment, impaired circulation, skin integrity, very young and old, impaired mental status
  164. An example of shearing
    Patient sliding down in bed
  165. An example of friction
    A nurse pulling a patient up in bed
  166. Characteristics of Stage I pressure ulcer and treatment?
    • Stage- Nonblanchable erythema of intact sking
    • Treat- remove pressure, prevent moisture, shear, and friction; promote nutrition and hydration
  167. Characteristics of Stage II pressure ulcer and treatment?
    • Stage- Partial thickness skin loss, involves epidermis or dermis, appears as blister, abrasion, or shallow crater, an open break in skin
    • Treat- Clean with sterile saline, semi-permeable occlusive dressing
  168. Characteristics of Stage III pressure ulcer and treatment?
    • Stage- Full-thickness skin loss,includes subcutaneous tissue, deep crater, may have undermining
    • Treatment- Debridment, topical teatment to promote granulation of tissue, surgical interventions like skin grafting
  169. Characteristics of Stage IV pressure ulcer and treatment?
    • Stage- Full-thickness skin loss, Extensive damage to muscle, bone, or supporting structures, may have undermining
    • Treatment- Same as Stage III
  170. Which debridement is not effective for necrotic tissue?
    Autolytic

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