Chapter 28 & 29 Infection Prevention and Control & Vital signs Flashcards
(117 cards)
1
Q
Which statement describes why arterial blood gases are used in patient assessment?
A
To obtain baseline values
2
Q
Which step should be performed first in a respiratory assessment?
A
Focused interview
3
Q
When assessing the patients lung sounds the nurse should keep in mind that the right lung has how many lobes?
A
3
4
Q
Where should the nurse auscultate for vesicular or alveolar breath sounds?
A
Posterior lower lobes
5
Q
A nurse assessing a patient suspects moderate to severe hypoxia. Which oxygen saturation range would indicate this condition?
A
85% to 89%
6
Q
Which nursing diagnoses are examples related to ventilation and oxygenation?
A
Anxiety
Acute pain
Activity intolerance
Impaired Gas Exchange
7
Q
Which nursing diagnoses are appropriate initially for a patient in the emergency department who “can’t catch a breath?”
A
Impaired Gas exchange
Ineffective breathing pattern
8
Q
Which goal is appropriate initially for a patient in the emergency department who “can’t catch a breath?”
A
Patient will exhibit regular breathing pattern with ambulation to the bathroom and back within 24 hours
9
Q
Which example provides a realistic goal for a patient with altered ventilation and oxygenation?
A
The patient will develop and maintain an effective breathing pattern before discharge to home.
10
Q
Which desired outcome is appropriate for a patient with altered ventilation and oxygenation?
A
Patient demonstrates normal rate and depth of respiration’s
11
Q
Which value represents acceptable rate for a 15 year old patient
A
15
18
12
Q
A frail older adult patient who is experiencing shortness of breath is only able to breath laying on the right side. The patient has a current respiratory rate of 28 bpm. Which terms describe the signs and symptoms the patient is exhibiting?
A
Dyspnea
Orthopnea
Tachypnea
13
Q
The older adult patient has very poor perfusion on the fingers. Which location should the nurse use to measure oxygen saturation?
A
Toe
Nose
Earlobe
14
Q
The nurse is assessing the patients ventilation status. Which feature will the nurse assess?
A
Chest rise
Respiratory rate
Lung compliance
15
Q
The nurse is caring for the patient diagnosed with a head and brain injury. Which alterations in breathing pattern could possibly occur?
A
Hypoventilation
Biots breathing
Cheyne strokes respiration
16
Q
What % reflects a normal value for SvO2?
A
70%
17
Q
The nurse is in the emergency department where a patient presents as follows : 65 year old, shortness of breath, tripod position, pale skin, 42 bpm, blood pressure 152/95, history of chronic obstructive pulmonary disease. Which objective can the nurse obtain?
A
Pale skin
History of COPD
high blood pressure
18
Q
Which is an initial nursing action for a patient having shortness of breath?
A
Assess pulse oximeter for O2 saturation levels
19
Q
The cerebral cortex of the brain allows voluntary control of breathing. When a patient sings, to which aspect do receptors in the medulla react?
A
Changes in pH
High levels of Carbon Dioxide
20
Q
Which statement describes ventilation
A
Movement of oxygen and carbon dioxide in and out of the lungs
(Inhale, exhale)
21
Q
The student nurse is discussing arterial blood gases (ABG) which statement made by the nurse reflects the student needs further education?
A
Nurses do not draw ABG
22
Q
During the respiratory assessment the nurse hears “wheezes” which type of sound is the nurse hearing?
A
Whistling
23
Q
The nurse obtains an arterial blood gas on a patient and the pH is 7.33 and the PaO2 is 103. Which action should the nurse take?
A
Call the health care provider because these results are abnormal
24
Q
The nurse has a patient who was admitted 24 hours ago for asthma. The patient is currently on 8 liters high flow oxygen with respiratory treatments every 2 hours. Which statement reflects a realistic goal?
A
The patient will demonstrate the ability to complete all activities of daily living with no increase in dyspnea before discharge.
25
Which aspects would the nurse measure to assess respiration and ventilation?
Respiratory rate, depth, rhythm
26
A student nurse is learning about altered oxygen saturation levels. Which statement indicates further teaching is needed?
Nose bleeds are caused by altered oxygen saturation levels.
27
What is an infection?
Results when a pathogen invades tissues and organs and begins growing within a host
28
What is colonization?
Presence and growth of a microorganism within a host but without tissue invasion or damage
29
Communicable disease
Infectious disease Transmitted directly from one person to another
30
Chain of Infection
```
Infectious agent or pathogens
Reservoir or source for pathogen growth
Port of exit from reservoir
Mode of transmission
Port of entry to a host
Susceptible host
```
31
Resident organisms
Normal flora
Permanent resident on the skin and within the body
Survive without causing illness
32
Virulent
Ability to produce disease
33
Bronchitis
S. pneumoniae, H. influenzae, respiratory viruses
34
Device-related
Coagulase-negative staphylococci, Corynebacterium sp.
35
Empyema
S. aureus, streptococci, anaerobes
36
Endocarditis
S. viridans, S. aureus, enterococc
37
Gastroenteritis
Salmonella sp., Shigella sp., Campylobacter sp.,
38
Meningitis
E. coli O157:H7, viruses
39
Which factor contributed to the development of health care acquired respiratory infection in a ambulatory diabetic patient receiving an intravenous antibiotic?
Current comorbidity
There is clear evidence to support the patients comorbidity of diabetes mellitus. It placed the patient at increased risk for development of a health care associated infection.
40
Prior to discharge what will the nurse teach patients about antibiotics to help prevent anti microbial resistance?
Take of of there medication for the full time prescribed.
This is important to help prevent anti microbial resistance.
41
A patient infected with which pathogen cannot be treated with antibiotics because the infectious agent has a protective envelope?
Virus
42
Which precautions will be implemented for a patient admitted for suspected West Nile virus?
Standard
43
Which patient is considered to be susceptible host in the chain of infection?
70 year old with diabetes learning about insulin therapy.
| Diabetes is a chronic disease
44
Which infections are considered health care associated (HAI)?
Urinary tract infection related to in dwelling catheter
Pneumonia related to presence of ventilator
Wound infections related to surgical incision
45
A nurse recognizes which microorganisms as blood borne pathogens that can be transmitted by needle sticks?
Hep B virus
HIV
46
Antibiotic use in animals contributes to human anti microbial resistance through which effect?
Creates a reservoir of potentially resistant bacteria
47
The nurse recognizes which infectious agents as having acquired drug resistance within health care settings?
Methicillin resistant Staphylococcus aureus (MRSA)
Vancomycin resistant staphylococcus aureus (VRSA)
Vancomycin resistant enterococci (VRE)
Clostridium difficile (C-Diff)
48
An 82 year old patient is 2 days postoperative with right hip replacement. The patient has comorbidity of hypertension, arterial fibrillation, and type 2 diabetes. The patient is scheduled for transfer to a rehab unit later today. Vital signs have been stable since surgery. How often should the patients vital signs be monitored?
Vital signs need to monitored at the time of morning care and again 1 hour before transfer
49
The nurse is ready to give a 60 year old patient the daily cardiac medication. The CNA reports that the patients vitals are pulse 42 bpm, blood pressure 148/86 mm Hg, and respiration’s 20 bpm. What interpretation will the nurse make?
Withhold the cardiac medication.
Recheck the patients vital signs
Compare the current vital signs with this patients baseline data.
50
A 6 year old is carried into the emergency department (ED) by the mother. The child has a history of asthma and is gasping for breath and wheezing. The child’s vitals are respiration’s of 30bpm, pulse 120 bpm, SpO2 92% and BP 90/50mm/ Hg. The nurse takes which actions?
Obtain oxygen saturation measurement
Call for the appropriate care provider to quickly evaluate
Ask the mother for medical history including any medications
Initiate standing protocols for childhood asthma until the appropriate care provider arrives.
51
The charge nurse in an assisted living community has just arrived for the evening shift. During repot the nurse is told a long time resident fell in the patients room 2 hrs ago. The day nurse contacted the primary care provider who ordered the patient to be observed unless the patient complains of severe pain. The charge nurse is making the shift assignment for the unlicensed assistive personal (UAP) this evening. Which parameters will the charge nurse consider when assigning the UAP this evening?
UAP obtain vital assessment of stable patients
The patient is fully conscious and aware of the surroundings
The patient has had a continuous drop in blood pressure since the fall.
The patient asks to have the UAP provide patient care because the UAP and the patient have a good relationship
52
The UAP reports the current vital assessment on a patient who is in the third recovery day after a fractured femur: BP 156/92 mm Hg, P 84 bpm, R 18 bpm and T 98.8 F. The nurse takes which actions?
Verify the vital signs
Review patients medical history
Review patients vital sign history
53
Which actions take By the nurse when documenting vital signs support the goal of efficient and safe patient care?
Document in a standardized format
Format to easily identify the patients vital signs
Provide multiple sets of vital signs visible at a time
Communicate with all the members of the health care team.
54
Which factors influence the interpretation of vital signs?
Patient status
Patients unique medical condition
Standard range for vital signs values
Consideration of patients baseline vital signs
55
What is a Source of infection?
Inanimate object
56
What is an infectious agent?
Parasite
57
What is a portal exit ?
Blood
58
What is a mode of transmission?
Droplet
59
A HAI may be acquires under which circumstances?
A treatment is received for another condition in the health care setting
60
HAI infections can be acquired by patients while receiving treatment for other conditions. What are these places?
Inpatient acute care hospital
Outpatient setting
(Surgical centers, end stage renal disease)
Long term care facilities
(Nursing homes and rehabilitation centers)
61
The normal pulse range for an adult patient is
60-100
62
When is vital sign measurement for a stable hospitalized patient typically taken?
4-8 hrs for stable patient
63
During which sit-ups vital sign assessment required?
In ongoing care
During inpatient stay
Before and after surgery
As part of the physical assessment
64
Which factors influence the interpretation of vital signs?
Medical history (Renal respiratory or cardiac disease )
Physical environment
Emotional state
Medications
Food and fluid intake
Activity and tolerance
65
What actions must the nurse take before delegating vital sign assessment to UAP?
Assess the patient
Determine the patient to be medically stable
Verify the UAP uses the proper technique for measurement
Ensure the UAP knows what values need to be reported immediately for each patient
66
Which vital sign functions might the nurse delegate to the UAP?
Report, measure vital signs for a STABLE patient
67
A recently hired UAP wants to please the busy staff nurse. The UAP takes vital signs and records data on all the 10 patients on the step down coronary unit. The nurse must discuss this action with the UAP and point out why this is not within her scope of patient care. Which duties are strictly nursing responsibility’s?
Interpret vital signs
Reassess any abnormal values measured by the UAP
Assess patients to determine whether they are medically stable
Report abnormal values to the appropriate health care provider
68
Which actions are requirements for proper documentation?
Documentation of specified form
Documentation in a standardized format
Record normal and abnormal vital sign results
69
Which elements are included in proper vital sign documentation?
Date of assessment
Time of assessment
Assessment results
Name and clinical designation of staff making assessment
Normal and abnormal vital signs
70
Which benefits for patient care result when a nurse uses informatics ?
Navigation of electronic health record
Technology that supports clinical decision making
Data are accessible in a common database form multiple locations
71
Which type of immunity provides long term active immunity for an individual who recovered from a viral infection?
Adaptive immunity
72
The nurse understands that the innate immune response involves which components?
Fungi
Low stomach pH
Skin
Capillary dilation
73
The nurse recognizes which function as an adaptive immune response?
Triggering lymphocytes production
74
Which type of immunity protects a person from infection after receiving a skin laceration?
Innate immunity
75
Introducing the patients normal flora into which body are increases the risk for infection?
Urinary bladder
76
Which component is part of innate immunity and participates in the inflammatory response?
Leukocytes
77
The nurse recognizes which characteristic of adaptive immunity?
Acquired throughout a persons lifetime
Complex highly organized system
Requires exposure to specific antigens
Generates antigen- specific defenses
78
Which event occurs first when the adaptive immune system is stimulated by an invading antigen?
Decoding of non-self marker on antigen surface
79
Which type of immunity will the nurse have after receiving the required three immunizations for HBV (Hep B) ?
Artificially acquired active immunity
80
Which living substance functions as an antigen?
Protein
81
Which type of immunity serves as the body’s first line of defense by providing immediate protection against foreign antigens?
Innate immunity
82
Which term describes a microorganism that causes serious disease?
Pathogen
83
Nurses understand that normal flora protect against infection by which mechanism?
Inhibiting microorganisms from colonizing
84
Which body system has proteins with anti microbial properties and promotes phagocytosis?
Respiratory system
85
The nurse recognizes that normal flora usually resides in which area of the body without causing harm?
Skin
Mouth
Upper throat
Nose
Small intestine
Eyes
Lower urethra
86
Inflammatory response in order
Capillary dilation
Warmth and redness
Increased capillary permeability
Swelling and pain
Exudate formation
87
Which immune response is mediated by circulating antibodies that coat antigens and target them for destruction
Humoral immunity
88
Which cells are responsible for the production of antibodies
B lymphocytes
89
Which adaptive immune system cells release interleukins to stimulate antibody production by B cells?
Helper T cells
90
Which are strategies for collecting patient assessment data?
Performing a general assessment
Speaking with patients family
Performing a physical assessment
Obtaining a thorough history
91
Which patient objective findings alert the nurse to the presence of infection or the risk for infection?
Pressure ulcers
Enlarged lymph nodes
Hyperactive bowel sounds
Decreased breath sounds
92
Which patients symptoms are consistent with a chronic inflammatory disorder?
45 yr old with pain and swelling of the knees from arthritis
Arthritis can last from months to years based on duration of inflammation
93
Which patient susceptible host is at greatest risk for developing an infection?
70 year old with diabetes and an in dwelling urinary catheter
94
The nurse recognizes that’s a patients surgical incision is no longer inflamed but infected by noting which findings?
Greenish drainage
Greenish drainage indicates infection caused by pathogen colonization.
Drainage caused by inflammation is clear or cloudy but not green or foul smelling
95
The nurse recognizes which manifestation indicates systemic infection and warrants further patient assessment?
Temperature 101.3 F (38.5 C) orally
96
Which blood test specifically indicates the presence of an active inflammatory response rather than infection?
Erythrocytes sedimentation rate (ESR)
97
Which laboratory findings is abnormal and must be reported to the health care provider?
Serum complement 140 hemolytic units
This is significantly elevated indicating active inflammation and/ or infection. It definitely needs to be reported to the patients health care provider?
98
Localized inflammation?
Limited to the area of injury
99
Systemic inflammation
Involves multiple organs or tissues
100
Acute inflammation
Quickly severe, lasting only a few days
101
Chronic inflammation
Prolonged response lasting months to years
102
Which factors increase the older adults susceptibility to infections?
Slowing of immune response
Decreased cough reflex
Incomplete bladder emptying
Reduced vascular supply( older adults experience loss of elasticity making them at risk for skin tears)
103
An immobile patient is being discharged to home. The nurse will teach prevention precautions about which potential infections to the patients caregiver?
Skin infections
Urinary tract infections
Respiratory infections
104
Example of Acute infections ?
Develops rapidly (common cold)
105
Example of chronic infection
Last months (mononucleosis)
106
Example of Localized infection
Pain (pressure ulcer)
107
Example of systemic infection?
High fever (sepsis)
108
Which patient finding is indicative of a localized infection?
Abscess
109
In which order does the nurse assess a patient for an infection or risk for infection?
Introduction to self
Collection of subjective data
Head to toe examination
Documentation of findings
110
Which data collected during the nurse-patient interview is a subjective finding?
Allergic to penicillin
111
Which question by the nurse specifically assesses the patient for infection or risk for infection?
“Do you experience urinary pain or frequency?”
112
What provides cell counts for RBCs(Red blood cells), WBC(white blood cells) platelets and reticulocytes?
Complete blood count (CBC)
113
Detects causative organism and determines effective antibiotic?
Culture and sensitivity (C&S)
114
Provides the overall number of each type of white blood cells
White blood cell (WBC) differential
115
Provides the overall number of white blood cells
White blood cell count (WBC)
116
Order of white blood cells from most prevalent to least prevalent in the absence of infection.
Neutrophils 55-70%
Lymphocytes 20-40%
Monocytes 2-8%
Eosinophils 1-4%
Basophils .5-1%
117
The signs and symptoms of inflammation are due to the actions of which WBC?
Basophils
