Exam 1

Question 1

Asepsis

Answer 1

freedom from disease-producing microorganisms

Question 2

Sepsis

Answer 2

toxic condition resulting from the presence and multiplication of pathogenic microorganisms or their products in the blood

Question 3

Endogenous

Answer 3

microorganisms already present on the person

Question 4

Exogenous

Answer 4

source of microorganism was from hosiptal

Question 5

iatrogenic

Answer 5

microorganisms coming from catheters, improper iv, improper wound dressing changes, ect.

Question 6

infectious agent

Answer 6

microbial organism with ability to cause disease; bacteria, viruses, fungi, parasites

Question 7

reservoir

Answer 7

place where organisms can thrive and reproduce

Question 8

portal of exit

Answer 8

place where organism can leave the reservoir

Question 9

Mode of Transmission

Answer 9

way an organism is carried from one place to another

Question 10

susceptible host

Answer 10

any one at risk of infection

Question 11

signs and symptoms of infection

Answer 11

fever, increase pulse and resp rate, energy loss, anorexia, nausea, enlarged lymph nodes, elevated WBC and ESR, growth of microorganisms from urine, blood

Question 12

medical asepsis

Answer 12

procedures that reduce number and transfer of pathogens

Question 13

surgical asepsis

Answer 13

practices used to render and keep objects and areas free from microorganism

Question 14

Tier 1 Standard precautions

Answer 14

used by all healthcare professionals for ALL patients: hand hygiene, ppe, safe injection practices, safe handling

Question 15

Tier 2: Transmission-Based Precautions

Answer 15

used for patients with known or suspected infections that spread in 1 of 3 ways: airborne, droplet, or contact

Question 16

Airborne Precautions

Answer 16

patient has private room with negative pressure. 6-13 air changes every hour, N95 respirator, use surgical mask on patient if transporting them

Question 17

Droplet Precautions

Answer 17

private room when available, wear mask, surgical mask on patient during transport, visitors are 3 fee from patient

Question 18

Contact precautions

Answer 18

private room when available, gloves and gown, limit patient movement outside room, delicate use of patient care equipment to this patient

Question 19

Epidemiologically Important Pathogens

Answer 19

MRSA, VRE, C. diff, EVD

Question 20

Preventing Epidemiologically Important Pathogens

Answer 20

clean hands, PPE, patient dedicated equipment (Standard precautions + contact precautions)

Question 21

reverse isolation

Answer 21

for patients who are immunocompromised
private room
no people with resp infections/communicable diseases
no live plants
no fresh produce

Question 22

communication process

Answer 22

Channel: visual, auditory, kinesthetic
receiver
source

Question 23

Standards of Effective Communication

Answer 23

Complete
Clear
Brief
Timely

Question 24

SBAR

Answer 24

situation
background
assessment
recommendation

Question 25

Temperature

Answer 25

normal: 96.8-100.4
oral: under tongue, wait 30 min if patient has been eating, drinking, or smoking
rectal: most accurate, insert 1.5 inch, increased safety concerns
axillary: no clothing in the way
tympanic: adult-pull auricle up and back, children- bull auricle down and back, compares to core reading
temporal artery: middle of dry forehead,

Question 26

Pulse

Answer 26

adult normal: 60-100

Question 27

Respirations

Answer 27

adult normal 12-20

Question 28

Blood pressure

Answer 28

120/80
40% circumference
dont use arm with IV, PICC line, history of mastectomy on that side, dialysis catheter in place

Question 29

Pulse OX

Answer 29

normal 95-100%
placed on finger, ear, bridge, nose, or forehead

Question 30

Nursing process

Answer 30

identify patients health status and actual or potential health care problems or needs
establish plans to meet identified needs
deliver specific nursing interventions to meet needs

Question 31

Assessment

Answer 31

to establish a database about patients response to health concerns or illnesses and ability to manage healthcare needs

Question 32

Diagnosing

Answer 32

nursing diagnosing: clinical judgment about individual, family, or community responses to actual or potential health problems/life processes that can be prevented or resolved by independent nursing interventions

Question 33

nursing diagnoses vs medical

Answer 33

nursing: ineffective breathing pattern, activity intolerance, acute pain, body image disturbance, risk for altered body temp
medical: Chronic obstructive pulmonary disease, cerebrovascular accident, appendectomy, amputation, strep throat

Question 34

nursing diagnosis format

Answer 34

P-problem
E-etiology
D- defining characteristics

Question 35

Planning

Answer 35

Inital: Nursing history and assessment
Address each problem identified upon admission

Ongoing: Carried out by the nurse who is interacting with the patient, Keep plan up to date

Discharge: Sometimes carried out by case manager/care coordinator, Help family and patient maintain health and self-care after discharge

Question 36

Priority Setting

Answer 36

prioritize nursing diagnoses
Maslow’s hierarchy of needs
patient preference
potential future problems
Consider values and beliefs, resources available, urgency of problem, and medical treatment plan

Question 37

goals vs expected outcomes

Answer 37

goals: broad statements, “the patient will” short or long terms, realistic
expected outcomes: specific, obersvable and measurable, realistic, evaluates progress “weight gain 5lb by October 15”

Question 38

nursing interventions/activities

Answer 38

Actions the nurse/patient perform to achieve patient outcomes

Question 39

nurse intiated interventions

Answer 39

Activities nurses are licensed to initiate (i.e., physical care, ongoing assessment)

Question 40

physician initiated interventions

Answer 40

Activities carried out under primary care provider’s orders or supervision, or according to specified routines

Question 41

collaborative interventions

Answer 41

Actions nurse carries out in collaboration with other health team members
Reflect overlapping responsibilities of health care team

Question 42

Implementation

Answer 42

carrying out specific interventions

Question 43

Evaluating

Answer 43

is the patient making progress toward goal/expected outcome
ongoing: formative eval
eval at the end of hospitalization: summative
ex: outcome met aeb
outcome partially met aeb
outcome not met aeb

Question 44

alternatives to restraints

Answer 44

involve the family
assist with toileting frequently
distraction
provide warm beverage, back rubs, soft lighting
determine cause of confusion
rocking chair