Exam 1

Question 1

What is included in physical assessment

Answer 1

Subjective and objective data

Question 2

Subjective data

Answer 2

Reported by patient, family, another member of health team

Question 3

Objective data

Answer 3

What nurse observes, labs, xrays.

Question 4

Vital signs

Answer 4

Temp
Pulse
Respiration
Blood presusre
Pain
Oxigenation

Question 5

What does elevated temp mean

Answer 5

Infection

Question 6

Is there an infection if body temp is normal

Answer 6

No

Question 7

What does elevated temp do to immune system

Answer 7

Activates immune systsem

Question 8

Hyperthermia

Answer 8

High body temp/fever

Question 9

Hypothermia

Answer 9

Low body temp

Question 10

Things that affect body temp

Answer 10

Food and fluid consumption, menstrual cycle, age, etc

Question 11

Normal body temp

Answer 11

98-98.6 F

Question 12

Pulse

Answer 12

60-100 BPM

Question 13

Respiration

Answer 13

12-20 breaths per min

Question 14

Blood pressure

Answer 14

Below 120/80

Question 15

Elevated

Answer 15

120-129 systolic and below 80 diastolic(double check)

Question 16

Hypertension 1

Answer 16

130-139 systolic or 80-89 dyastolic

Question 17

Hypertension 2

Answer 17

140 or above systolic or 90 or above dyastolic

Question 18

Hypertensive crisis

Answer 18

Above 180 systolic and or above 120 diastolic

Question 19

MRSA

Answer 19

Surgical site contact staph infection

Caused by poor hand hygiene

Question 20

CAUTI

Answer 20

Catheter acquired UTI-reportable to the CDC

Question 21

Indwelling catheter effects

Answer 21

Loss of bladder muscle tone

Question 22

What can catheters cause

Answer 22

UTI and urinary retention after removal

Question 23

How log can a catheter stay in

Answer 23

72 hours

Question 24

Five rights of delegation

Answer 24

Right person

Right task

Right direction

Right curcumstance

Right supervision

Question 25

Right person

Answer 25

Has to be competent to complete task

Question 26

Right task

Answer 26

Has to be within scope of practice, job description

Question 27

Patient centered care

Answer 27

Foundation of nursing. Including patient and all members of treatment team

Question 28

Should nurses always try to make sure patients are informed about care

Answer 28

Yes

Question 29

Do nurses function as advocates

Answer 29

Yes

Question 30

Purpose of nursing process

Answer 30

Identify actual and potential problems Perform interventions to address those problems Protect nurses against legal liability

Question 31

ANA

Answer 31

Nursing organization

Question 32

Assess

Answer 32

Collect and analyze data

Question 33

Diagnose

Answer 33

Interpret data and draw conclusions.

Question 34

Plan

Answer 34

Care plan, goals, outcomes, interventions

Question 35

Intervention

Answer 35

Executing the care plan

Question 36

Evaluation

Answer 36

Did the care plan work

Question 37

Pneumonia

Answer 37

HAI caused by poor hand hygiene

Question 38

Should we take temp on someone who just drank or ate

Answer 38

No. Wait 15-30 mins.

Question 39

Radial pulse

Answer 39

On wrist

Question 40

Apical pulse

Answer 40

Point of Maximum impulse Fifth intercostal space, midcloviculie

Question 41

What type of transmission is TB

Answer 41

Airborne and droplet

Question 42

Ppe for airborne

Answer 42

N95

Question 43

Ppe for contact

Answer 43

Gloves and gown

Question 44

Ppe for droplet

Answer 44

Gloves, mask, gown, goggles

Question 45

Temp routes

Answer 45

Axillary-underarm Tempanic-in ear Oral Rectal Skin

Question 46

What kind of patients receive oral and rectal temp

Answer 46

Stable

Question 47

Dangers of rectal temp

Answer 47

Vagal nerve is affected which can cause cardiac arrest

Question 48

What route do unstable patients use

Answer 48

Axillary and tympanic

Question 49

What is considered a fever

Answer 49

99.6 F and above

Question 50

Hypothermia temp

Answer 50

Below 95 F

Question 51

All pulses

Question 52

Instructions for clients before blood pressure

Answer 52

No smoking or drinking 30 mins prior Record date, time, and pressure Take multiple readings Call provider if there are several high readings

Question 53

Chain of infection

Answer 53

Pathogen Reservoir Portal of exit from reservoir Mode of transmission Portal of entry Susceptible host

Question 54

Types of infection

Answer 54

Local Systemic Bacteremia Septicemia

Question 55

Local infection

Answer 55

Only one part of body

Question 56

Systemic infection

Answer 56

Throughout body

Question 57

Bacteremia

Answer 57

Blood culture shows bacteria/pathogen

Question 58

Septicemia

Answer 58

Systemic bacteremia

Question 59

Acute infection

Answer 59

Sudden and short term

Question 60

Chronic infection

Answer 60

Gradual and long lasting

Question 61

Nosocomial/HAI

Answer 61

UTI-improper catheter care Surgery site- staph infections. Poor hand hygiene. Bloodstream-poor IV care Pneumonia-poor hand hygiene

Question 62

Specific defenses

Answer 62

Active Passive

Question 63

Active immunity

Answer 63

You create your own antibodies naturally

Question 64

Passive

Answer 64

Body gets antibodies elsewhere. Vaccines and breast fewding.

Question 65

Should we investigate cultural preferences

Answer 65

Yes

Question 66

Durable power of attorney

Answer 66

When a competent individual gives someone else legal ability to make decisions if they are ever incompetent

Question 67

Duty

Answer 67

Obligation to do something

Question 68

Injury

Answer 68

Physical or mental harm or violation of a persons rights due to negligence

Question 69

Malpractice

Answer 69

Deviation from standard

Question 70

Negligence

Answer 70

Deviation from standard

Question 71

Example of staph

Answer 71

MRSR and pneumonia

Question 72

Is TB chronic or acute

Answer 72

Chronic