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Nursing Fundamentals > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

The fours major areas of nursing practice

A

Promoting Health and wellness

Preventing Illness

Restoring Health

Caring for the Dying

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2
Q

Components of evidence-based practice

A

Clinical Expertise

Best Evidence

Patient Values and Preferences

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3
Q

Nurse Practice Act

A

Protects the public by legally defining the scope of nursing practice

Each state has a nurse practice act

Control practice through licensing requirements

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4
Q

Professional Standards of Nursing Practice

A

ANA standards of practice (17 standards)

Patient Bill of Rights (Hospitals & Nursing Homes)

Facility and certification/accreditation

Institutional policies/procedures

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5
Q

Informed consent

A

An agreement by a client to accept a course of treatment or procedure after being provided complete information.

-Expressed- (Oral/written)

-Implied- (Non-verbal behavior/medical emergency when an individual cannot provide expressed consent)

Exceptions:

-Minors

-Unconscious

-Mentally ill deemed incompetent

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6
Q

The nurse’s role in obtaining informed consent

A

-Responsible for witnessing the client’s signature

-Not responsible for explaining procedure

Signature confirms:

-The client gave consent voluntarily

-The signature is authentic

-The client appears competent to give consent

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7
Q

5 Rights of Delegation

A

Right task

Right circumstance (stable vs unstable)

Right Person (Knowledge, skills, ablities)

Right direction & communication

Right supervision & evaluation

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8
Q

Delegation

A

the process for a nurse to direct another person to perform nursing tasks and activities

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9
Q

MANDATED REPORTERS

A

Required by law to report suspected abuse, neglect, or exploitation.

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10
Q

Negligence

A

misconduct or practice that is below the standard expected of an ordinary, reasonable, and prudent person

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11
Q

Malpractice

A

professional negligence (negligence that occurred while the person was performing as a professional)

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12
Q

Assault

A

stated intent to touch a person in an offensive, insulting, or physically intimidating manner; to threaten someone

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13
Q

Battery

A

the touching of another person without the person’s consent

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14
Q

False Imprisonment

A

Occurs when clients are made to believe they cannot leave a place.

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15
Q

HIPPA

A

the client’s permission is needed before disclosing any information regarding the client, going through the clients’ personal belongings, performing procedures, and photographing the client.

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16
Q

Code of Ethics

A

a formal statement of a group’s ideas and values.

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17
Q

Autonomy

A

right to make one’s own decision

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18
Q

Nonmaleficence

A

do no harm

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19
Q

Beneficence

A

doing good

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20
Q

Justice

A

fairness

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21
Q

Fidelity

A

to be faithful to agreements/promises

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22
Q

Veracity

A

truth-telling

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23
Q

Describe how a nurse acts in the role of the client advocate.

A

Client advocate acts to protect the client.

Represent the client’s needs to other health professionals

Assist clients to speak up for themselves

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24
Q

The Patient Care Partnership

A

High quality hospital care

A clean and safe environment

Involvement in your care

Protection of your privacy

Help when leaving the hospital

Help with your billing claims

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25
Q

interprofessional members

A

Social worker

Dietician

Activity Director

Occupational Therapist

Respiratory Therapist

Physical Therapist

Chaplain/Pastor

Physican

Nurse Practioner

Physician Assistant

Podiatrist

Dentist

Pharmacist

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26
Q

The Nursing Process

A

ADPIE:

Assessment-begins nursing process

Nursing Diagnosis-formulates statement of problem

Planning-set goals

Interventions-carrying out the plan of care

Evaluation-reassessing to determine if goal is met

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27
Q

Differentiate between a medical and a nursing diagnosis.

A

Nursing Diagnosis is a statement of nursing judgement and refers to a condition that nurses are licensed to treat

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28
Q

LPN

A

-simple situations

predictable, no frequent changes

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29
Q

RN

A

-complex situations

not predictable, frequent changes

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30
Q

Plan individualized care for client based on need

A

Set priorities

Establish client goals/desired outcomes

Make desired outcomes measurable

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31
Q

Plan overall strategies to address client problems.

A

Subject-client

Verb-what they are going to do

Condition or modifiers

Criterion of desired performance

Ex: client drinks 2,500 ml of fluid daily.

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32
Q

Independent Interventions

A

Physical care

Ongoing assessment

Teaching & counseling

Emotional Support & Comfort

Enviromental management

Referrals

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33
Q

Dependent Interventions

A

Orders for medications

Intravenous therapy

Diagnostic tests & Treatment

Diet & activity orders

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34
Q

Chain of infection

A

Infectious agent

Reservoir or source

Portal of exit

Mode of transmission

Portal of entry

Susceptible Host

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35
Q

Increase in Neutrophils

A

Bacteria

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36
Q

Increase in Lymphocytes

A

Viral

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37
Q

How can we ID a infection

A

Elevated WBC

Increase in

Neutrophils-bacteria

Lymphocytes-viral

Elevated erythrocyte sedimentation rate

Positive cultures

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38
Q

Medical Asepsis (clean technique)

A

Reduce the number and spread of microorganisms

39
Q

Surgical Asepsis (sterile technique)

A

Eliminate all microorganisms and spores

40
Q

Modes of Transmission

A

Contact

-Direct- skin to skin

-Indirect- contact with contaminated objects

Droplet

-Sneezing

-Coughing

-Talking

Airborne

-Inhaled

Vehicle (Contaminated inanimate objects)

-Water

-Food

41
Q

Antiseptics

A

inhibit the growth of some microorganisms

42
Q

Disinfectants

A

destroy pathogens other than spores

43
Q

Sterilization

A

destroy all microorganisms and spores

44
Q

Skin

A

Largest organ in the body

Genetics, age, health, & medications impact the skin

45
Q

Wounds

A

Trauma/surgery

Pressure Ulcer

46
Q

Wound Cleanliness

A

Clean wounds – Closed (bruises, surgical wounds)

Clean contaminated wounds- GI Tract open up

Contaminated Wounds- Intestinal spill

Dirty & Infected wound- grass, rocks, bacteria

47
Q

Wound Type

A

Incision- Straight cut

Contusion- bruise

Abrasion- scrap

Laceration- jagged edge

Avulsion- skin tears

Puncture- sharp object punctures

Penetrating wound- gun shot/stabbing wound

48
Q

Thickness of Wound

A

Partial thickness- (dermis & epidermis)

Full thickness (dermis, epidermis, SQ, Muscle, bone)

49
Q

Burns

A

1st-4th degree burns, and pressure ulcers have stages 1-4

4 being the worst

50
Q

Pressure Ulcers

A

Any lesion caused by unrelieved pressure results in damage to underlying tissue.

51
Q

Localized ischemia (lack of blood supply)

A

Tissue Dies

52
Q

Reactive Hyperemia

A

After skin is compressed, it appears pale; when pressure is relieved a bright red flush

Lasts ½ to ¾ as long as pressure

If redness stays, tissue damage has occurred

53
Q

Risk factors which contribute to impaired skin integrity.

A

Friction & Shearing

Immobility

Inadequate nutrition

Decreased protein, carbs, fluids, Vitamin c & Zinc contribute to pressure ulcers.

Fecal & Urinary Incontinence

Maceration- tissue softening

Excoriation- loss of superficial layer of skin

Decreased Mental state- (aren’t able to tell us)

Diminished sensation- (diabetics)

Excessive body heat-(Moist/Sweating)

Advanced Age

Chronic medical conditions

54
Q

System for staging pressure ulcers.

A

RAFM

Stage 1- Redness

Stage 2- Abrasion

Stage 3- Into Fat Layer

Stage 4- Into Muscle and Bone

Suspected Deep Tissue Injury- (Purple or maroon discolored intact skin)

Unstageable- Full thickness tissue loss in which the base of the ulcer is covered by slough/Escar

55
Q

Phases of wound healing

A

Inflammatory (Defensive) 3-5 days

-Hemostasis & phagocytosis

Proliferative (Reconstructive) 4-21 days (about 3 weeks)

-Collagen, new blood vessels & tissue, wound closure

Maturation (Up to 2 years)

Scar tissue gains strength

56
Q

Types of wound drainage

A

Serous Exudate -Clear

Purulent Exudate - (Blue, green, yellow)

Hemorrhagic (Sanguineous) Exudate -Bloody

Serosanguineous Exudate -Pink

57
Q

Complications of wound healing

A

Hemorrhage (Bruise you can feel)

-Hematoma

Infection

Dehiscence (wound opens up)

Evisceration (wound opens up & organs come out)

58
Q

Factors affecting wound healing

A

Developmental considerations

Nutrition

Lifestyle

Medications

59
Q

Factors that are components of the Braden Scale for Predicting Pressure Sore Risk

A

Sensory Perception

Moisture

Activity

Mobility

Nutrition

Friction & Shear

60
Q

Effects of Heat

A

Vasodilation

Increases blood flow

Promotes soft tissue healing

Increases edema & bleeding

*(Should not be used in the 1st 24hrs after injury)

61
Q

Effects of Cold

A

Vasoconstriction

Limits postinjury swelling and bleeding

Reduces blood flow

*(Should not be used on open wounds or impair

ed circulation)

62
Q

Urethra -Female

A

3-5 cm

63
Q

Urethra -Male

A

20 cm

64
Q

Bladder capacity

A

300-600mL

65
Q

Desire to void occurs

A

250-450mL of urine in bladder

66
Q

Usually void _____times per day

A

5

67
Q

Sitting (female) Standing (male)

A

Promotes optimal emptying of bladder

68
Q

Fluid intake

A

1500-2500 mL per day

69
Q

Post void residual

A

Less than 100 cc

70
Q

Diuretics

A

Increase urine production

71
Q

COCA

A

Color, Odor, Consistency, Amount

72
Q

Nocturnal Enuresis

A

Involuntary voiding during sleep (bed wetting)

73
Q

Constipation

A

less than 3 BM per week

74
Q

Fecal Impaction

A

Hard Feces in rectum

75
Q

Diarrhea

A

loose stool

76
Q

Bowel incontinence

A

can’t hold BM

77
Q

Flatulence

A

gas

78
Q

Ostomies

A

Openings on the skin

79
Q

Describe pharmacological and non-pharmacological interventions to treat altered patterns of bowel elimination.

A

Pharmacological

-Bulk forming

-Emollient/ softener

-Stimulant/irritant

-Lubricant

-Saline/osmotic

Non-Pharmacological

-Fiber

-Fluids

-Exercise

80
Q

Urgency

A

a feeling of the need to void

81
Q

Dysuria

A

Painful Urination

82
Q

Frequency

A

Urinating more times then normal

83
Q

Hesitancy

A

starting then stopping flow of urine

84
Q

Ployuria

A

abnormally large quantities of urine

85
Q

Oliguria

A

a dininshed amount of urine

86
Q

Nocturia

A

Excessive urination at night

87
Q

Dribbling

A

to flow in drops or in a thin intermittent stream

88
Q

hematuria

A

abnormal presence of blood in urine

89
Q

Pyuria

A

the presence of WBC in the urine

90
Q

Enuresis

A

incontinence of urine at night

91
Q

Bacteriuria

A

bacteria in the urine

92
Q

Proteininuria

A

Protein in the urine

93
Q

Bacteremia

A

the presence of bacteria in the blood

94
Q

Residual

A

Urine left in the bladder after urination

Nursing Fundamentals (12 decks)

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