Lab Flashcards
(234 cards)
1
Q
What are the 6 different bed positions
A
High Fowlers Fowler’s, Semi-Fowler’s, Trendelenburg, Reverse Trendelenburg’s, Flat
1
Q
Describe the Fowler’s Position
A
Head of the bed is raised to (45-60 degrees) a more semi-sitting position, foot of bed may also be raised at knee.
2
Q
Uses of the Fowler’s position
A
- Preferred while patient eats
- Is used during nasogastric tube insertion and nasotracheal suction
- Promotes lung expansion
3
Q
Describe the semi-fowlers position
A
Head of bed raised approximately 30 degrees, food of bed may also be raised at knee
4
Q
Uses of the semi-fowlers position
A
- Promotes lung expansion
- Is used when patients receive gastric feedings to reduce regurgitation and risk of aspiration
5
Q
Describe Trendelenburgs position
A
entire bed frame with head of bed down
6
Q
uses of Trendelenburgs position
A
- Used for postural drainage
- Facilitates venous return in patients with poor peripheral perfusion
7
Q
Describe Reverse Trendelenburgs postion
A
entire bed frame tilted with foot of bed down
8
Q
Uses of Reverse Trendelenburg
A
- Is used infrequently
- Promotes gastric emptying
- Prevents esophageal reflux
9
Q
Describe the Flat position
A
entire bed frame horizontally parallel with floor
10
Q
Uses of the flat bed position
A
- Is used for patients with vertebral inquires and in cervical traction
- Is used for patients who are hypotensive
- Is generally preferred by patients for sleeping
11
Q
Asepsis
A
absence of disease producing microoganisms
12
Q
Nosocomial
A
associated with or originating in a hospital setting
13
Q
Antiseptic
A
an agent that inhibits or kills microorganisms on skin or tissue
14
Q
pathogen
A
a microorganism that produces disease in most circumstances
15
Q
bacteriostatic agent
A
an agent that prevents the growth and reproduction of bacteria
16
Q
contaminated
A
possessing pathogenic organisms
17
Q
medial asepsis
A
practices that limit the transmission of microorganisms, also called clean technique
18
Q
carrier
A
a person who carries pathogen but is not ill
19
Q
disinfection
A
a process that eliminates many microorganisms from inanimate environmental surfaces
20
Q
sterilization
A
complete elimination of all microorganisms including spores
21
Q
what are the six links for the chain of infection
A
- infectious agent
- reservoir
- portal of exit
- mode of transmission
- portal of entry
- host
22
Q
what is an infectious agent
A
agent that causes disease
23
Q
what is a reservoir
A
where a pathogen can survive but may or may not multiply (ie. a human body)
24
What is a portal of exit
the path by which the pathogen leaves the reservoir (mouth, nose, rectal, vaginal, and urethral openings)
25
What is a mode of transmission
how a microorganism is transmitted, can be direct or indirect (ie. chicken pox)
26
what is a portal of entry
how a pathogen enters the body (ie. body openings and breaks in the skin)
27
describe two infection control measures to reduce the reservoirs of infection
change wound dressing that are wet or soiled
empty urine containers properly (use of gloves pls)
28
what are the four stages of infection
1. incubation period
2. proximal stage
3. illness stage
4. convalescence
29
define pathogen
microorganisms that can cause disease
30
describe normal flora
microorganisms that reside on the surface and in deep layers of the skin. these do not typically cause disease
31
define sterile
disinfected materials, all bacteria and microorganisms are destroyed
32
define contaminated
when an object comes in contact with infectious pr potentially infectious material
33
define HAI
an infection acquired after admission to a health care facility that was not present or incubation at the time of admission
34
the potential for microorganisms to cause disease depends on what four factors
- client susceptibility
- disease process
- medical therapy
- age, stress, nutritional status
35
how would you break the chain of infection: wound infection
hand hygiene, contact precautions, gloves
36
how would you break the chain of infection: tuberculosis bacillus
N95 mask, now, gloves, negative pressurized room and hand hygiene.
37
how would you break the chain of infection: H.I.V
wear PPE
38
how would you break the chain of infection: Salmonella
hand hygiene and cook food properly
39
how would you break the chain of infection: FRI (febrile respiratory illness)(airborne)
PPE, hand hygiene, wiping surfaces, mask, clean face of client
40
how would you break the chain of infection: MRSA
contact precautions, hand hygiene, gowns, gloves, eye wear, isolated room
41
how would you break the chain of infection: C. difficile
contact precautions, gown, gloves, eye wear, isolated room
42
how would you break the chain of infection: VRE
contact precautions, hand hygiene, gown, gloves, isolated room
43
how would you break the chain of infection: COVID - 19
N95 mask, eye wear, gloves, hand hygiene, gown
44
45
Asepsis
absence of disease-producing microorganisms
46
nosocomial
associated with or originating in a hospital setting
47
antiseptic
an agent that inhibits or kills microorganisms on skin or tissues
48
pathogen
a microorganism that produces disease in most circumstances
49
bacteriostatic agent
an agent that prevents the growth of of reproduction of bacteria
50
contaminated
possessing pathogenic organisms
51
medical asepsis
practices that limit the transmission of micro-organisms, also called clean technique
52
carrier
a person who carries pathogens but is not ill
53
disinfection
a process that eliminates many microorganisms from inanimate environmental surfaces
54
sterilization
complete elimination of all microorganisms including spores
55
the six links that the chain of infection include
- infectious agent
- reservoir
- portal of exit
- mode of transmission
- portal of entry
- host
56
describe an infectious agent
agent that causes disease (virus, bacteria, fungi, protozoa)
57
describe a reservoir
where a pathogen can survive but may or may not multiply (a human body)
58
describe a portal of exit
the path by which the pathogen leaves the reservoir (mouth, nose, rectal, vaginal, and urethral openings)
59
describe a mode of transmission
how a microorganism is transmitted, can be direct or indirect (ie. chicken pox)
60
Describe a portal of entry
how a pathogen enters the body (ie. body opening and breaks in the skin)
61
describe two infectious control measures
- change wound dressings that are wet or soiled
- empty urine containers properly usual gloves
62
name the four stages of infection
1. incubation period
2. prodomal stage
3. illness stage
4. convalescence
63
define pathogen
microorganism that can cause disease
64
describe normal flora
microorganisms that reside on the surface and in deep layers of the skin. These do not typically cause disease
65
describe sterile
disinfected materials, all bacteria and microorganisms are destroyed
66
describe contaminated
when an object comes contact with infectious material or potentially infectious material
67
describe HAI
an infectious acquired after admission to a health care facility that was not present or incubating at the time of admission
68
the potential for microorganisms to cause disease depends on which four factors
- client susceptibilities
- disease process
- medical therapy
- age, stress, nutritional status
69
How would you break the chain of infection: wound infection - staph aureus
hand hygiene
contact precautions
gloves
70
How would you break the chain of infection: tuberculosis bacillus
- N95 mask
- gown
- gloves
- negative pressurized room
- hand hygiene
71
How would you break the chain of infection: H.I.V
wear PPE
72
How would you break the chain of infection: Salmonella
cook food properly
hand hygiene
73
How would you break the chain of infection: FRI (febrile respiratory illness)(airborne)
- PPE
- hand hygiene
- wiping surfaces
- mask
- clean face of client
74
How would you break the chain of infection: MRSA
- contact precautions
- hand hygiene
- gloves
- gowns
- eye wear
- isolated room
75
How would you break the chain of infection: C. difficile
- contact precautions
- gowns
- gloves
- eye wear
- isolated room
- hand hygiene
76
How would you break the chain of infection: VRE
- contact precautions
- gowns
- gloves
- eye wear
- isolated room
- hand hygiene
77
How would you break the chain of infection: COVID-19
- N95 mask
- eye wear
- gloves
- hand hygiene
- gown
78
what does cross contamination mean and how do you prevent it
cross contamination id the transmission of microorganisms, to prevent this you must wear the proper PPE and dispose of anything contaminated properly, and make sure that soiled items and equipment must not touch nurses clothing. Plus proper hand hygiene
79
when would you wear clean examination gloves
whenever you need to touch a patient, and or do an examination
80
when would a gown be appropriate
when PPE is required, when with a patient who has an infectious disease.
81
when would you wear eye protection
when in contact with someone who is isolated, or with someone who has an airborne disease
82
how would you dispose of a used syringes
sharps container
83
how do you handle client care equipment
clean in between clients
84
what is the proper way of dispose of soiled linen
through into the laundry (moisture resistant bag)
85
what is your responsibility if you have an open or draining lesion
talk to the manager and look it up in your works policy to see if you can work with that lesion.
wear a bandage
86
what are the two goals when making a bed
- clean
- comfortable
87
what are the reasons for completely finishing one side of the bed and then moving to the other side
- minimizing the time and use of energy
- decreases the amount of time the client would have to move if the bed were occupied
88
the important safety features on beds include
- locks on the wheels
- alarms
- side rails
89
the most important safety step to remember when making an occupied bed is
- check the patients mobility, ensure they are able to role back and forth without harming themselves.
- Also leave the rail up on the opposite side of the bed for the patient to hold onto
- BREAKS ON
- move the bed up to a comfortable height.
90
difference between an open and closed bed
an open bed id when the covers are folded to about the middle of the bed so the client can easily get into the bed
a closed bed is when the sheets are more drawn back
91
how does the nurse maintain proper body mechanics when making a bed
- the bed should be raised to an appropriate height
- make sure these rails are down
- BREAKS ON
92
TRUE or FALSE: a turning sheet helps decrease friction and prevents skin injury when moving a client up in bed
true
93
TRUE or FALSE:the further the client is from the nurses centre of gravity the more stable the situation is and the client will have less fear of falling.
false
- the closer they are the more stable and comfortable they are.
94
TRUE or FALSE: when a client is lying on their side, a pillow between the legs prevents abduction
false
it prevents adduction
95
TRUE or FALSE: when transferring a client, the client should grasp the nurses neck
false
this can cause serious injury for the nurse
96
TRUE or FALSE: a trochanter roll will help prevent the external rotation of the leg
true
97
describe how you would prepare a client for ambulation
- ensure they dont feel dizzy or lightheaded
- able to sit in the upright position comfortably
- check the floor incase it wet
- ensure they understand what's happening
- make sure you have the right amount of people to help
98
give reasons for bathing our client
- they have discomfort in an area
- they are letting off an odour
- to preform a skin assessments
99
what is the difference between a partial and complete bath
a complete bath is used with patients who are completely dependant and require total hygiene care.
A partial bath involves bathing only those body parts that would cause discomfort or odour id not cleaned, and those areas not easily reached by the patient
100
5 guidelines that should be used when bathing a client
- privacy
- maintain safety
- maintain warmth
- promote indépendance
- anticipate needs
101
how are eyes cleansed
from inner to outer canthus
102
When washing a clients arms and legs, the nurse washes from ________ to ______ proximal. This stimulates _______ blood flow
distal; proximal; venous
103
TRUE or FALSE: harsh rubbing can cause tissue damage
true
104
TRUE or FALSE: alcohol is better than lotion for back rubs because it toughens the skin
False
105
TRUE or FALSE: soap increases surface tension in order to hold moisture in the skin.
False
- it decreases surface tension and drys out the skin
106
TRUE or FALSE: a doctors note is needed to place oil in th bath water
false
107
explain foot and nail care guidelines and the related assessments
watch diabetes, dont cut the mails. Check between toes, if you do cut nails cut straight across not rounded that can cause ingrown nails and hangnails
108
what would you assess when caring for the feet
when assessing the feet, perform an examination of all the skin surfaces, including the areas between the toes and over the soles of the feet. check the the feet externally for sores as well as assessing temp and colour. check for pulses
109
explain the purpose of oral hygiene
- the purpose of oral hygiene is to make sure the gums and teeth stay healthy
- its necessary to maintain the integrity of tooth surfaces and to prevent gingivitis (gum inflammation) and periodontal disease.
- stimulates appetite
- maintains hydration and cleanliness
- mouth health and heart health have cooralation
110
dermatitis
inflammatory condition of the skin can be chronic or acute
111
ischemia
lack of blood supply to a part of the body
112
turgor
the skins elasticity
113
blanching
when you press on your skin and it goes lighter and the colour returns. when it goes white that's blanching
114
cyanosis
bluish discolouration cause by low oxygen in the blood, low hemoglobin
115
pallor
defiance of colour in the face, pale face (when they are sick, in shock, dizzy, lightheaded)
116
petechiae
tin red spots in the skin that's broken blood vessels. Tiny hemorrhages in the skin
117
hematoma
a pool of mostly clotted blood that forms in an organ, tissue or body spaces like bruises
118
edema
areas of the skin become swollen or edematous from buildup of fluid in the interstitial spaces
119
melanoma
an aggressive form of skin cancer an other cutaneous malignancies are the most common neoplasms seen in patients. black tumour
120
eczema
a condition where your skin is excessive dry and irritated. can become bumpy
121
jaundice
yellow-orangish discolouration. Sign of a problem with the liver. improper breakdown of bilirubin
122
lesions
an area of abnormal or damaged tissue caused by injury, infection or disease. any abnormality on/in the skin
123
induration
when the soft tissue like the skin become thicker and harder from an inflammatory process.
124
necrosis
the death of body tissue
death of cells
goes pail, green, black then falls off
125
basal cell carcinoma
a cancerous lesion.
most common in sun exposed areas and frequently occurs in a background of sun damaged skin. does not usually spread to other parts of the body
typically not dangerous
126
list risk situations associated with pressure ulcer development
- prolonged bed rest (impaired mobility)
- impaired sensory reception
- decrease blood supply
127
explain shearing force
shear force is when gravity is pulling down the body down and there's a surface (like a bed giving resistance). the skin and subcutaneous layers adhere to the bed, and if the persons body moves their muscles and bones move while their skin stays in the same place
128
explain how moisture contributes to pressure ulcer formation
softens the skin which makes it more susceptible to damage
129
explain how anemia contributes to pressure ulcer formation
lack of iron in the blood, diminished red blood cells, not getting enough oxygen in the blood which promotes slower healing
130
explain how impaired circulation contributes to pressure ulcer formation
???????
131
explain how poor nutrition contributes to pressure ulcer formation
food is the first medicine
vitamins and protein are crucial to speed up the healing process
132
how does age contribute to pressure ulcer formation
as you get older your body dont work the same. skin gets softer and wrinklier
133
where can pressure ulcers develop
in the boney areas of the body
- side of bum
- side of knee
- heel
- ankle
- hips
- tail bones
- elbows
134
What is the high fowlers postition
A 90 degree angle, used to watch tv and eat.
135
muscle tone
normal condition of tension of a muscle
136
gait
the way a person walks
137
range of motion
degree of movement possible for each joint
138
ADL
activites of daily living
139
adduction
movement toward midline of body
140
pace
number of steps per minute
141
abduction
movement away from midline body
142
goniometer
device that measures the angle of joint movement
143
passive exercises
exercise in which another provides energy to move
144
active exercises
exercises carried on by the client that moves body parts
145
what shape is the spine of a new born
c
146
T or F: it is normal for an infant to have a extra gluteal fold
False
147
T or F: at 5 months of age a baby rolls from prone to supine and back to prone
True
148
T or F: at 8 months a baby can sit alone
true
149
T or F at 12 months of age a baby may hold a cup and spoon and can feed self
true
150
what is the age a baby can walk
14 months (have until 18)
151
is t normal for toddlers to have lumbar lordosis
true
152
what is lumbar lordosis
lower back is curving in sticking belly out
153
at age 60 decrease in muscle mass, tone, and strength exceeds what percent
9-10%
154
T or F: in the older adult, thinning of the intervertebral discs is normal musculoskeletal change
true
155
the apperance of an older adults stance, posture is on of what
general flexion
156
abnormal results for gait difficulty
- clumsiness
- weakness
- pain
- stiffness
- dizziness or vision problems
157
abnormal results: muscle complaints
- weakness or fatigue
- stiffness
- pain
- paralysis
- spasms or tremors
- muscle atrophy
- muscle hypertrophy
158
abnormal complaints: skeletal complaints
- recent fractures or injury
- abnormalities of skeletal contour
- crepitus
- pain with movement
- ecchymosis or hematoma of injured part
159
abnormal findings: joint complaints
- recent injury
- change in contour or size pf joints
- limitations of joint motion
- pain
- swelling or redness of skin around joint
160
the preferred site of body temperature assesment of children is
tempanic (ear)
161
the average range of adult oral temperature is
36-38 C
162
when is the someones temperature slightly higher during the 24 hour cycle
at 1800h
163
when is someones temp the lowest in a 24 hour cycle
between 0100-0400
164
the appropiate term for fever
pyrexia
165
what are the words you use when describing a clients fever
febrile and unfebrile
166
the most reliable indicator of a persons pain
self report
167
what do the letters stand for in the OPQRSTUV mean
O: origin/onset (where and when did it start
P: Palliative/provocation (what makes the pain feel better or worse)
Q: Quality (what does the pain feel like)
R: Region/radiation/ where is the pain and where does it radiate
S: Severity (Pain 0-10)
T: Timing/treatment (when did the pain begin or end and how long did it last)
U: Understanding (What do you think is causing the symptoms
V: Value (are there any other views or feeling about this symptom that are important to you and the family)
168
Bronchial sounds are heard over the
trechea
169
Bronchovesicular sounds are heard over the
large airways near sternum and between scapulae
170
vesicular breath sounds are heard over the
peripheral lung (side)
171
resonance
hollow sound heard over normal lungs
172
tympany
drum like sound heard over an air-filled stomach or intestines
173
during insperation the diaphragm does what
descends and flattens
174
what is the ration of the anteroposterior to transverse diameters of the adult chest wall
1:2
175
when examining for tactile fremitus, it is important to
ask the patient to cough
176
the pulse oximeter measures
arterial oxygen saturation
177
what is the ranfe of respirations in a newborn
30-60
178
what are the four characterisitics included in an assessment of respirations
rate
rythm/regularity
depth
effort
179
eupnea
normal quiet breathing
180
tachypnea
respiatory rate more than 24 b/m
181
apnea
absence of respirations
182
bradypnea
abnormally slow respirations (less than 12)
183
dyspnea
difficult respirations
184
hypoventalation
very shallow respiratins
185
the first heart sound is created by the closure of what valves
mitral and tricuspid
186
the second heart sound is created by the closing of what valves
semilunar
187
the normal angle between fingernail and nailbed
160
188
when checking a clients pulse what 4 things are you assessing
rate
rhythm
strength
symmetry/equality
189
arrhythmia
a pulse with an abnomral rhythm
190
pulse deficit
the difference between the apical and radial pulse
191
tachycardia
pulse rate over 100 beats/m
192
thorax
the chest cavity
193
pulse
wave of blood produced when left ventricle f heart contract
194
bradychardia
a very slow pulse rate
195
carotid
used in cardiac arrest
196
brachial
used ti determine blood pressure and used for infant pulses
197
apical
used to determine discrepancies with radial pulse
198
dorslis pedis
used to determin foor circulation
199
systolic pressure
the pressure of the blood against the arterial walls when ventricles of the heart contract
200
pulse pressure
the difference between diastolic and systolic pressure
201
hypertension
abnormally high blood pressure
202
diastolic pressure
the pressure of the blood against the arterial walls when ventricles of the heart are at rest
203
hypotension
abnormally low blood pressure
204
what is the first phase korotkoff phases
sharp thump
205
what is the fourth phase of kororkoff
a softer blowind sound that fades
206
what is phase five of the korotkoff
silence
207
from blood pressure, information is gained about all the following except;
- the efficiney of the heart beat
- the adequacy of blood volume
- the balance between heat production and loss
- the resistance of the blood vessel
the balance between heat production and loss
208
who is likly to have a high blood pressure
a pregnant women
209
what factors control blood pressure
cardiac output, blood volume, viscosity, peripheral vascular resistance, stress
210
before concluding that bowel sounds are absent how long do you have to listen
five minutes
211
the characterisitic percussion sound elicited over the abdomen is
tymapanny
212
the normal range of the liver span in the midclavicular line is
6-12 cm
213
the normal percussion sound elicited over the liver is
dull
214
to determine the position of the lower liver border, the nurse starts percussing
below he costal marjins and working to the RUQ
215
in light palpation the abdomen wall is depressed ____cm or to the level of __________
2; tenderness
216
T or F: when inspecting the abdomen normally peristalis should be visible
True
217
T or F: Silver-white striae in the lower abdominal area are nomral
True
218
T or F: on light palpation, you should be able to feel the liver, spleen, and kidneys
False
219
T or F: elderly clients often manifest a more lax abnominal tone
true
220
what is in the RUQ
gallbladfer
liver
duodenum
head of the pancreas
221
whats in the LUQ
stomach
body of the pancreas
222
whats in the RLQ
appendix
cecum
223
whats in the LLQ
sigmoid colon
224
urgency
feeling the need to void immediatly
225
dysuria
painful or diffucult voiding
226
frequency
voiding at frequent intervals
227
hesitancy
difficulty getting the flow of urine started
228
obliguria
decreased urine output (less than 400ml/24 hours)
229
nocturia
voiding often during the night
230
dribbling
leakage of urine despite voluntary control of voiding
231
urinary retention
accumulation of urine in th ebladder
232
residual urine
not feeling as if able to empty the bladder (volume of 100ml or more of urine remaining in the bladder after voiding)
233
