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foundations of nursing > quiz 1 > Flashcards

quiz 1 Flashcards

1
Q

active immunity

A

host produces antibodies in response to natural antigens (infectious microorganisms) or artificial antigens (vaccines)
- duration: long/many years, immunity must be reinforced with booster

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2
Q

passive immunity

A

host receives natural (from a nursing mother through placenta/colostrum) or artificial (injection of immune serum/antibodies) antibodies produced by another source
- short duration

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3
Q

asepsis

A

freedom from disease-causing microorganisms
2 types: medical asepsis
surgical asepsis

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4
Q

medical asepsis

A

includes all practices intended to confine a specific microorganism to a specific area, limiting the number, growth, and transmission of microorganisms

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5
Q

surgical asepsis

A

aka sterile technique, refers to practices that keep an area or object free of all microorganisms (practices destroy all microorganisms and spores)
- used for all procedures involving sterile areas of body
- objects used in sterile field must be sterile
- become unsterile when touched by unsterile objects
- unsterile when out of sight, below waist or table level
- fluids flow in the direction of gravity
- edges of sterile field are unsterile
- skin cannot be sterilized
- maintain conscientiousness, alertness & honesty

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6
Q

colonization

A

process by which strains of microorganisms become resident flora
- microorganisms may grow and multiply but do not cause disease

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7
Q

bacteremia

A

when a culture of the individual’s blood reveals microorganisms (bacteria in the blood)
- straight line in antecubital and central line placed jugularly/subclavianly
- aerobic & anaerobic (2 sets)

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8
Q

septicemia

A

when bacteremia results in systemic infection

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9
Q

standard precautions

A

used in any situations involving blood; all body fluids, excretions, and secretions except sweat; nonintact skin; and mucous membranes
- includes hand hygiene, use of PPE (gloves, gown, mask, eye protection & face shield), safe injection practices and handling of potentially contaminated equipment/surfaces, respiratory hygiene/cough etiquette
- hand hygiene: most important measure to reduce risk of transmitting organisms from one person to another
- gloves: when touching blood, body fluids, secretions, excretions, contaminated items, mucous membranes, non-intact skin & when performing invasive procedures
- gown: when soiling of clothes is likely, when assessing or changing wound dressing, when having direct patient contact w/ patient who is in contact precautions, when performing invasive procedures
- mask, eye protection & face shield: when splashing or spraying of blood, body fluids, secretions or excretions are likely
- used for care for ALL patients

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10
Q

airborne precautions

A

used for clients known or suspected to have serious illnesses transmitted by airborne droplet nuclei smaller than 5 microns (measles (rubeola), varicella, tuberculosis)
- patient enters through separate entrance
- place patient in airborne infection isolation room (AIIR) w/ negative air pressure
- wear a fit-tested N-95 or higher-level respiration
- patient to wear a facemask when exiting the room, avoid contact with others, practice respiratory hygiene & cough etiquette

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11
Q

contact precautions

A

used for clients known to have or suspected of having serious illnesses easily transmitted by direct client contact or by contact with items in the client’s environment (indirect or direct)
ex. GI, respiratory, skin, wound infections or colonizations with multidrug-resistant bacteria, specific enteric infections such as C. difficile and enterohemorrhagic E. coli O157:H7, Shigella, and hepatitis A, for diapered or incontinent clients; respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants and young children; and highly contagious skin, infections such as herpes simplex virus, impetigo, pediculosis, scabies and MRSA (methicillin-resistant S. aureus).
- MRSA, multiple drug resistant organisms, VRE (vancomycin-resistant enterococcus), ESBL (extended-spectrum beta-lactamase)
- proper hand hygiene before and after patient contact
- put on a gown
- put on gloves
- remove gloves, then gown, & proper hand hygiene before leaving the room

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12
Q

direct transmission

A

involves immediate and direct transfer of microorganisms from individual to individual through touching, biting, kissing, or sexual intercourse
- includes droplet transmission (within 3 ft of each other) -> sneezing, coughing, spitting, singing, talking can spray into conjunctiva or to mucous membranes of eye, nose, or mouth
- droplet precautions: airborne droplet nuclei > 5 microns
ex. diptheria, mycoplasma pneumonia, pertussis, mumps, rubella, strep pharyngitis
- place patient in room w/ closed door
- wear a face mask upon entering room
- patient to wear a face mask when exiting their room, avoid contact with others, practice respiratory hygiene & cough etiquette

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13
Q

indirect transmission

A

transmission that is vehicle borne or vector borne
- vehicle: substance that serves as an intermediate means to transport and introduce an infectious agent into a susceptible host ex. fomites (inanimate materials/objects), water, food, blood, serum, plasma.
- vector: animal or flying/crawling insect that serves as an intermediate means of transporting the infectious agent. transmission can occur by injecting salivary fluid during biting or by depositing feces or other materials on the skin through the bite wound or traumatized skin area

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14
Q

cultures

A

laboratory cultivations of microorganisms in a special growth medium

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15
Q

granulation tissue

A

young connective tissue with new capillaries formed in the wound healing process
- contains connective tissue elements of collagen, blood capillaries, lymphatics, and other tissue-bound substances
- fragile, gelatinous tissue that appears red/pink

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16
Q

healthcare-associated infection

A

infections that originate in any healthcare setting and of hospital-acquired conditions
ex. nosocomial infections, catheter-associated urinary tract infection, surgical site infection, ventilator-associated pneumonia, central line associated blood-stream infection

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17
Q

nosocomial infection

A

infections that originate in the hospital
- can develop during the client’s stay in a facility or manifest after discharge
- subgroup of healthcare-associated infections

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18
Q

inflammation

A

local and nonspecific defensive response of the tissues to an injurious or infectious agent (-itis)
- destroys/dilutes the injurious agent, prevents further spread of injury, promotes repair of damaged tissue
- blood vessels at site of injury constrict -> more blood flows to injured area (redness and heat)
- vascular permeability increases at site of dilation of vessels b/c cell death, chemical mediator release and histamine release
- fluid, proteins, and leukocytes leak into interstitial spaces and signs of inflammation appear
- characterized by pain, swelling, redness, heat, impaired function, -itis
- signs are objective, symptoms are subjective (what’s their pain tolerance?)

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19
Q

leukocytosis

A

in response to exit of leukocytes from the blood into interstitial spaces during inflammation, bone marrow produces large numbers of leukocytes (WBCs) and releases them into the bloodstream
- can rise from 4,500-11,000 to 20,000 or more during inflammation

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20
Q

AAA

A

abdominal aortic aneurysm

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21
Q

A&O

A

alert and oriented

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22
Q

AB

A

abortion

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23
Q

ABG

A

arterial blood gas

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24
Q

ac

A

before meals

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25
Q

AC

A

antecubital

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26
Q

ACE

A

angiotensin converting enzyme

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27
Q

ACS

A

acute coronary syndrome

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28
Q

ADA

A

American Diabetes Association

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29
Q

ADHD

A

attention deficit-hyperactivity disorder

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30
Q

ADL

A

activities of daily living

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31
Q

AED

A

automatic external defibrillator

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32
Q

ad lib

A

as desired

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33
Q

ADH

A

anti diuretic hormone

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34
Q

AIDS

A

acquired immunodeficiency syndrome

35
Q

afib

A

atrial fibrillation

36
Q

AICD

A

automatic implantable cardiac defibrillator

37
Q

AKA

A

above knee amputation

38
Q

ALS

A

advanced life support

39
Q

AMA

A

against medical advice

40
Q

amb

A

ambulance/ambulatory

41
Q

ant

A

anterior

42
Q

AP

A

anteroposterior

43
Q

ARDS

A

acute respiratory distress syndrome

44
Q

AROM

A

active range of motion

45
Q

ASA

A

aspirin

46
Q

ASD

A

atrial septal defect

47
Q

ATN

A

acute tubular necrosis

48
Q

AU

A

both ears

49
Q

AVM

A

arteriovenous malfunction

50
Q

asphyxiation (suffocation)

A

lack of oxygen due to interrupted breathing
- common reason: food or foreign object has become lodged in the throat
- victim grasps anterior neck and is unable to speak or cough
- emergency response: Heimlich maneuver/abdominal thrust -> dislodge the foreign object and reestablish an airway

51
Q

carbon monoxide

A

odorless, colorless, tasteless gas that is very toxic
- can cause headaches, dizziness, weakness, nausea, vomiting, or loss of muscle control
- long term exposure can lead to unconsciousness, brain damage, death
- all gas-powered vehicles, lawn mowers, kerosene stoves, barbecues, and burning wood emits CO

52
Q

chemical restraint

A

using a medication to control behavior or to restrict the client’s freedom of movement and is not a standard treatment for the client’s medical or psychologic condition

53
Q

physical restraint

A

use of an intervention or device that hinders the client from moving or restricts the individual from contact with his or her body
ex. leather or cloth wrist and ankle restraints, soft belts or vests, hand mitts, enclosure beds, gerichairs, over-chair tables
- used to restrict freedom of movement
- goal is a restraint free environment
- less restrictive interventions tried first
- clinically justified (for the safety of patient, staff, or others)
- requires a physician’s order
- inform family
- apply restraints correctly
- document

54
Q

seizure

A

single temporary event that consists of uncontrolled electrical neuronal discharge of the brain that interrupts normal brain function
- partial seizures: electrical discharges from one area of brain
- generalized seizures: affect whole brain
if seizure occurs:
- remain with client
- notify RN
- assist client to floor
- turn client to lateral position
- move items for client safety
- don’t insert anything into mouth
- time seizure duration
- observe progression
- assess oral airway
- RN to administer anticonvulsants

55
Q

seizure precautions

A

safety measures taken by the nurse to protect clients from injury should they have a seizure
- clients that have recurrent seizures/take anticonvulsants should wear a medical identification tag and carry a card listing medications they take
- confirm that clients are taking antiepileptic meds correctly
- discuss safety precautions (some activities require supervision)
- discuss factors that precipitate seizure
- pad bed rales
- ensure oral suction equipment is in place
- care during a seizure is the RNs responsibility

56
Q

attentive listening

A

listening actively and with mindfulness, using all the senses and paying attention to what the client says, does, and feels
- most important technique in nursing and encourages client to trust and talk
- therapeutic communication

57
Q

boundaries

A

defining limits of individuals, objects, or relationships
- keep focus on client and avoid sharing personal information or meeting own needs through nurse-client relationship
- redirect conversation if necessary

58
Q

bullying

A

repeated, health-harming mistreatment of one or more persons by one or more perpetrators
- consistent demonstration of inappropriate behavior/incivility

59
Q

elderspeak

A

speech style that gives the message of dependence and incompetence and is viewed as patronizing by older adults
- inappropriate terms of endearment (honey, grandma)
- inappropriate pronoun use (are we ready for our bath?)
- tag questions (you want to wear this, don’t you?)

60
Q

emotional intelligence

A

ability to form work relationships with colleagues, display maturity in a variety of situations, and resolve conflicts while taking into consideration the emotions of others

61
Q

empathy

A

the ability to experience, in the present, a situation as another did at some point in the past, the ability to put oneself in another individual’s circumstances and imagine what it would be like to share their feelings
- behaviors showing empathy: moderate head nodding, steady gaze, moderate gesturing, little activity/body movement
- respect, genuineness, concreteness, confrontation

62
Q

incivility

A

consists of behaviors that are disrespectful, rude, impolite, and promote conflict while increasing stress
ex. eye rolling, gossiping, spreading rumors, name-calling, condescending tone, sarcasm, public criticism, interrupting

63
Q

lateral violence

A

abusive words or actions of peers in the work environment (gossiping, exclusion of information, threats of harm, actual harm)

64
Q

proxemics

A

study of distances that people allow between themselves and objects or other people
- intimate: 0-1.5 ft
- personal: 1.5-4 ft
- social: 4-12 ft
- public: 12ft+
personal space: distance people prefer in interactions with others

65
Q

afebrile

A

client that does not have a fever

66
Q

apical pulse

A

central pulse, located at the apex of the heart
- purpose of assessing apical pulse: to obtain heart rate of adult with irregular peripheral pulse, establish baseline for subsequent evaluation

67
Q

apnea

A

absence of breathing/respiration

68
Q

arrhythmia (dysrhythmia)

A

pulse with an irregular rhythm
- can consist of random, irregular beats or a predictable pattern of irregular beats
- arrhythmia -> apical pulse detection

69
Q

auscultatory gap

A

temporary disappearance of sounds normally heard over the brachial artery when cuff pressure is high followed by the reappearance of sounds at a lower level
- occurs particularly in hypertensive clients

70
Q

basal metabolic rate

A

rate of energy utilization in the body required to maintain essential activities such as breathing
- metabolic rates decrease with age

71
Q

bradycardia

A

heart rate in adults less than 60 beats/min
- apical pulse should be assessed

72
Q

core temperature

A

temperature of the deep tissues of the body
ex. abdominal cavity, pelvic cavity
- relatively constant
- type of body temperature

73
Q

fever (pyrexia, hyperthermia)

A

body temperature above the usual range (99.5 degrees F+) normal = 98.6 F
- increases cellular metabolic rate and thus increases body’s temperature further
nursing care:
- monitor VS
- assess skin
- monitor lab results for dehydration/infection
- appropriate linens
- provide nutrition & fluids
- fans
- adjust room temperature
- measure I & O
- reduce activity
- administer antipyretic
- provide oral hygiene
- provide tepid sponge bath
- avoid shivering

74
Q

mean arterial pressure

A

the pressure actually delivered to the body’s organs
- add 2/3 of diastolic pressure to 1/3 of systolic pressure
- usually 70-110 mmHg

75
Q

orthostatic hypotension (postural hypotension)

A

blood pressure that decreases when the client changes from a supine to a sitting/standing position
- result of peripheral vasodilation in which blood leaves the central body organs, esp the brain, and moves to the periphery, often causing client to feel faint
- hypotension: dilation of arteries, loss of volume, decreased blood flow to vital organs (below 85-110 mmHg in adults)

76
Q

oxygen saturation (SpO2)

A

value is the percent of all hemoglobin binding sites that are occupied by oxygen
- estimated by noninvasive device pulse oximeter:
- normal = 95-100%, life-threatening = < 70%
- detects hypoxemia before clinical signs & symptoms
- factors that affect accuracy: circulation, activity, jaundice, nail polish, carbon monoxide

77
Q

pulse deficit

A

any discrepancy between the apical and radial pulses
- apical pulse rate greater than radial = thrust of blood from the heart is too weak for wave to be felt at the peripheral pulse site or that vascular disease is preventing impulses from being transmitted

78
Q

pulse pressure

A

difference between the diastolic and systolic pressures (normal for adults: 40)
systolic: bp as a result of ventricle contraction (pressure of the height of the blood wave)
diastolic: pressure when ventricles are at rest; present at all times within arteries and is lower
pulse: wave of blood created by contraction of left ventricle
low pp (<25 mmHg): severe heart failure
high pp: arteriosclerosis

79
Q

point of maximal impulse (PMI)

A

point where the apex of the heart touches the anterior chest wall and heart movements are most easily observed and palpated (apical pulse)

80
Q

surface temperature

A

temperature of the skin, subcutaneous tissue, and fat
- rises and falls in response to the environment

81
Q

tachycardia

A

excessively fast heart rate (over 100 beats/min in adults)

82
Q

tachypnea

A

abnormally fast respirations; usually more than 24 respirations per minute

83
Q

tidal volume

A

volume of air that one takes in during normal inspiration and expiration (volume air that is normally inhaled and exhaled)
- normally 500mL of air in adults

foundations of nursing (6 decks)

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