final exam Flashcards
(112 cards)
1
Q
priority settings
A
ABC’s takes higher priority
chronic problems take lower priority
2
Q
what conditions trump chronic conditions
A
sudden onset, new onset, acute onset, normal BP but chest pain, when vitals say pt is in shock
3
Q
what can a nurse NOT delegate
A
teaching, assessing, evaluating, medications
4
Q
what is the code of ethics
A
a philosophical idea of right and wrong that can help define principle used to provide care
5
Q
normal BP and how to find pulse pressure
A
120/80. 120-80=40pp. pp=systolic-diastolic
6
Q
normal HR
A
60-100bpm
7
Q
where can you find HR
A
radial, apical, carotid
8
Q
what is a HR of less than 60 called
A
bradycardia
9
Q
what is a HR of more than 100 called
A
tachycardia
10
Q
what is a normal and expected pulse
A
2+
11
Q
normal RR
A
12-20 and regular depth
12
Q
what is RR rate of less than 12 called
A
bradypnea
13
Q
what is a RR of more than 20 called
A
tachypnea
14
Q
normal O2
A
95%-100%
15
Q
what is O2
A
the amount of O2 bound to hemoglobin molecules
16
Q
normal temp
A
98.6-100.4F or 36-38C
17
Q
where can you get temp
A
rectal, oral, axillary, tympanic membrane, temporal, artery
18
Q
where are temps higher
A
the closer to the body core, so rectal
19
Q
what is the 6th vital sign
A
pain 0-10
20
Q
hygiene is
A
individualized
21
Q
what are factors that affect hygiene
A
social patterns, personal preferences, body image, pain, fatigue, SEC status
22
Q
what are 3 different kinds of baths given in the hospital
A
sitz, medicated, chlorhexidine
23
Q
how do you clean the body
A
from cleanest to less clean
24
Q
what is the most important thing to remember for infection control
A
hand hygiene
25
what is the cycle of infection
infectious agent--> reservoir--> portal of exit--> mode of transmission --> portal of entry--> host--> repeat
26
what is incubation stage
appearance of 1st symptoms
27
what is prodromal stage
onset of nonspecific signs and symptoms to more specific symptoms
28
what is illness stage
manifests signs and symptoms specific to the type of infection
29
what is convalescence stage
acute symptoms of infection disappear
30
what is HAI
from delivery of health services in a healthcare facility
31
Iatrogenic HAI
HAI that results from a diagnostic or therapeutic procedure (ex: bronchoscopy)
32
Exogenous HAI
HAI that results from microorganisms outside the individual, not normal flora (ex: salmonella)
33
endogenous HAI
HAI that results when the pts flora becomes altered and an overgrowth results (ex: streptococci)
34
what are examples of droplet precautions
influenza, rubella
35
what are examples of airborne precautions
TB, varicella, measles and you need an N95
36
what is asepsis
absence of pathogenic (disease-producing) microorganisms
37
medical asepsis
includes procedures for reducing the number of organisms present and preventing the transfer of organisms CLEAN TECHNIQUE
38
surgical asepsis
prevents contamination of an open would, serves to isolate the operative area from the unsterile environment, and maintains a sterile field for surgery STERILE TECHNIQUE
39
what are the 6 right of med administration
med, dose, route, time, pt, documentation
40
what are the different types of routes for med administration
IV: into veins, fastest route
SQ: injection into tissue just below the dermis
IM: injection into the muscle
PO: by mouth
41
what are "never events"
surgical, product or device, patient protection, care management, environmental, criminal
42
ages 65+ at risk for...
falls that cause unintentional death
43
younger than 5 at risk for...
@home accidents that lead to injury or death
44
when are restraints used
as a last resort when a pt is at risk of injury to themselves or others
45
risks of immobility
DVT, renal calculi, atelectasis, constipation, loss of muscle mass
46
what are the BMAT levels
1. dependent: sit and shake
2. moderately dependent: stretch and point
3. minimal assistance required: stand
4. independent: walk and march
47
foley false info
does not mean incontinence, does not make you pee
48
what does a foley do
drain bladder to avoid water retention
49
transiet incontinence
caused by medical conditions that in many cases are treatable and reversible
50
functional incontinence
because of causes outside the urinary tract
51
overflow incontinence
associated with chronic retention
52
stress incontinence
involuntary leakage of small volumes of urine associated with increased abdominal pressure
53
reflex incontinence
involuntary loss of urine occurring at somewhat predictable times
54
urge or urgency incontinence
involuntary passage of urine often associated with strong sense of urgency related to an overactive bladder caused by neurological problems, bladder inflammation, or bladder outlet obstruction
55
what does heart failure affect
pulmonary system
56
left sided heart failure
backs up into the lungs, left side= lungs
57
right sided heart failure
edema in extremities, low BP, not going to perfuse downstream, kidneys are not getting great perfusion so they start retaining
58
perfusion
cardiovascular system pumping blood to and from the lungs and body
59
ventilation
process of moving gases in and out of the lungs
60
diffusion
exchange of respiratory gases across alveoli capillary membrane
61
potassium
heart. hypo/hyperkalemia leads to dysrhythmias
62
sodium
fluid retention. affects every body system we have. helps CNS function. high or low ay cause altered mental status
63
magnesium
DTRS and cardiac complications
64
calcium
hypocalcemia- trousseau's and chvostek's signs will be positive
65
hydrostatic pressure
a force of fluid pressing outward against a surface
66
capillary hydrostatic pressue
pushes fluid from capillaries into interstitial area
67
interstitial hydrostatic pressure fluid
pushes fluid from interstitial area back into capillaries
68
oncotic pressure
proteins in blood pull from interstitial area back into capillaries
69
isotonic solution
same concentration as cell, no fluid shift. CELL STAYS THE SAME
70
hypotonic solution
less concentrated than cell, fluid shift into cell. CELL SWELLS
71
hypertonic solution
more concentrated than cell, fluid shifts out of cell. CELL SHRINKS
72
type 1 diabetes
insulin dependent. young onset, rapid onset, non obese, body cannot produce insulin, managed by injections, diet, and exercise
73
type 2 diabetes
insulin resistant. older onset, no obvious symptoms, obese, managed by oral medications, injections, diet and exercise
74
normal BG
70-120
75
normal A1C
less than or equal to 6.5%
76
HYPERglycemia
elevated bg, increased urination, weakness, fatigue, blurred vision, headache, n/v, abdominal cramps
77
HYPOglycemia
bg more than 70, cold, clammy skin, numbness of fingers, toes, mouth, rapid HR, unsteady gait, hunger
78
DKA
caused by profound deficiency of insulin
79
stress leads to
illness (increase of cortisol in body)
80
what type of responses are seen with stress
fight or flight
81
GAS general adaptation syndrome
pattern of stress responses
82
Alarm stage of stress
release of stress hormones
83
resistance stage of stress
starting to balance, equilibrium
84
exhaustion stage of stress
can no longer cope
85
chronic stress
can be managed, will probably have a better outcome
86
acute stress
short, will resolve
87
PTSD
maladaptive coping. some types of trauma and there is a trigger
88
primary appraisal
evaluating
89
secondary appraisal
what can i do to fix it
90
coping is
individualized for how people manage situations
91
crisis
usually resolved within 6 weeks, something going on for months and months is not a crisis, its chronic
92
developmental
preteens--> teens who friends are and what their role is-role confusion
93
situational
something out of your control is happening ex: death
94
adventitious
out of ordinary, concerning- major natural man-made disasters ex: 911
95
primary prevention
health promotion and prevention, teach about health eat and exercise
96
secondary prevention
already have symptoms and managing it, determining pts needs
97
tertiary prevention
supporting rehab
98
maturation factors
life-stage changes, maturing
99
circadian rhythm
everyones day-night, 24 hour clock
100
what is sleep regulated by
the hypothalamus
101
sleep restores
biological function and helps with memory storage and learning
102
sleep deprivation and sleep disorders lead to
changes in immune function and metabolism
103
insomnia
difficulty falling asleep, frequent awakenings, short sleep
104
sleep apnea
lack of airflow through nose/mouth for 10 seconds up to 1-2 mins
105
narcolepsy
fall asleep uncontrollable at inappropriate times
106
sleep deprivation
insufficient or disrupted sleep-acute or chronic
107
parasomnias
sleep problems more common in children (SIDS, sleepwalking, night terrors, nightmares, bed-wetting)
108
Stomas should always be
pink, change the pouch when its about 1/3 full
109
higher up the ostomy,
softer the stool, would not be formed
110
primary factors that contribute to pressure ulcers
low protein, immobility, bony prominences, moisture
111
what is the braden scale used for
determining the pts who are at risk for developing a pressure injury
112
stages of PIs
1. non-blanchable erythema of intact skin
2. partial thickness skin loss with exposed dermis
3. full thickness skin loss
4. full thickness tissue loss
unstageable. obscured fill thickness skin and tissue loss- depth unknown
deep tissue. persistent non-blanchable deep red, maroon or purple
