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Intro to Nursing > Test 2 > Flashcards

Test 2 Flashcards

(89 cards)

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1
Q

What do laws do

A
  1. Provides framework for nursing actions
  2. Differentiates nursing roles from other healthcare providers
  3. Sets boundaries of what is independent nursing
  4. Serves as a standard of nursing practice
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2
Q

Tennessee Board of Nursing

A
  • Carries out the TN Nurse Practice Act

- Each state has its own

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3
Q

Nurse Practice Act

A

*ON TEST

The law that governs nursing

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4
Q

NCLEX stands for

A

National Council Licensure Exam

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5
Q

Who is responsible for the NCLEX

A

NCSBN (National Council of State Boards of Nursing)

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6
Q

JC (Joint Commission)

A

Accredits healthcare organizations

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7
Q

Nursing School Accreditors

A
  1. AACN (American Association of Colleges of Nursing)

2. NLN (National League of Nursing)

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8
Q

What does the ANA support

A

Collective bargaining (strikes to negotiate)

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9
Q

Types of witnesses that a nurse can be called for

A
  1. Nurse as fact witness

2. Nurse as expert witness

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10
Q

5 Rights of delegation

A
  1. Task
  2. Circumstances
  3. Person
  4. Direction and communication
  5. Supervision and evaluation
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11
Q

What percent of American’s are overweight or obese

A

75%

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12
Q

Activity

A

Body movement that requires energy and produces a positive result

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13
Q

Exercise

A

Planned activity done to improve physical fitness

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14
Q

Types of exercise classifications

A
  1. Source of energy
  2. How activity is initiated
  3. Type of muscle contraction
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15
Q

Exercise based on source of energy

A
  1. Aerobic (Uses oxygen)

2. Anaerobic (No oxygen)

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16
Q

Exercise based on how activity is initiated

A
  1. Passive

2. Active

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17
Q

Exercise based on type of muscle contraction

A
  1. Isometric (Doesn’t shorten)
  2. Isotonic (Muscle shortens)
  3. Isokinetic (Against resistance)
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18
Q

Circumduction

A

In a circle

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19
Q

Musculoskeletal system benefits

A
  1. Increased muscle efficiency (strength) and flexibility
  2. Increased coordination
  3. Reduced bone loss
  4. Increased efficiency of nerve impulse transmission
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20
Q

Hazards of immobility (Musculoskeletal)

A
  1. Disuse atrophy
  2. Contractures
  3. Disuse osteoporosis
  4. Stiff joints
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21
Q

Cardiovascular system benefits

A
  1. Increases strength of contraction
  2. Increases cardiac output
  3. Decreases resting HR and BP
  4. Improves venous return
  5. Increase fibrinolysin (breaks up clots)
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22
Q

Hazards of immobility (cardiac)

A
  1. Decreases cardiac reserve
  2. Increases use of the valsalva maneuver (bearing down)
  3. Orthostatic hypotension
  4. Venous vasodilation and stasis
  5. Dependent edema
  6. Increases thrombus formation
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23
Q

Virchow’s Triad

A
  • 3 things that must happen all together to form a blood clot
    1. Decreased venous return
    2. Hypercoagulable (thick) blood
    3. Vessel wall injury
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24
Q

Respiratory system benefits

A
  1. Increases O2 intake
  2. Improved diaphragmatic excursion
  3. Improved alveolar ventilation
  4. Prevents pooling of secretions
  5. Decreases effort of breathing
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25
Hazards of immobility (respiratory)
1. Decreases respiratory movement 2. Pooling of secretions 3. Decreases surfactant 4. Atelectasis 5. Hypostatic pneumonia
26
Urinary System Benefits
1. Increased circulation improves efficiency of waste removal 2. Prevents stasis in bladder
27
Hazards of Immobility (urinary)
1. Stasis 2. Alkaline urine (bacteria love this environment) 3. Infection 4. Kidney stones 5. Urinary retention/overflow
28
Gastrointestinal System | Benefits
1. Improves appetite 2. Increases GI tone 3. Improves peristalsis
29
Hazards of Immobility (Gastrointestinal)
1. Constipation | 2. Overuse valsalva
30
Psych/neurological System Benefits
1. Increases sense of well being | 2. Improves stress tolerance
31
Psychoneurological System | Hazards of Immobility
1. Awareness of dependency 2. Time perception changes 3. Lack of intellectual stimulation 4. Anxiety
32
Metabolic System Benefits
1. Increases metabolic rate 2. Decreases triglycerides 3. Decreases cholesterol 4. Enhances insulin (lowers WBC)
33
Integumentary System Hazards and benefits
1. Increases the flow of blood to the skin 2. Immobility decrease skin turgor 3. Immobility increases the risk for pressure ulcers
34
Phases of peri-operative care
1. Pre-operative 2. Intra-operative 3. Post-operative
35
Nursing considerations during the pre-operative phase
1. Risk identification 2. Preparation of pt physically 3. Prepping pt psychologically
36
What is included in the consent given before surgery
1. Description of procedure 2. Common risks 3. Right to refuse 4. Expected outcomes and recovery
37
Who gets the consent
The person performing the procedure
38
What to teach during pre op
1. NPO after midnight 2. Visitors 3. Frequent V/S 4. Importance of early ambulation, coughing, and deep breathing 5. Exercises 6. Pain management
39
Nursing considerations during intra-operative phase
1. Patient identification 2. Prevention of "never events" 3. Positioning 4. Draping
40
Types of anesthesia
1. General anesthesia 2. Moderate sedation 3. Regional anesthesia 4. Topical or local
41
General anesthesia
Depresses CNS, causes LOC, relaxed muscles, depressed reflexes
42
Moderate sedation
Provide pain relief and amnesia of the event
43
Regional anesthesia
Relaxes muscles and may block regional reflexes
44
Topical or local
Relaxes muscles and numbs pain
45
Common cardiovascular post op complications
1. Hemorrhage 2. Shock 3. Thrombophlebitis
46
Common respiratory post op complications
1. Pulmonary embolus 2. Pneumonia 3. Atelectasis
47
Common GI post op complications
1. N/V | 2. Paralytic ileus for 3-5 days
48
Nasal cannula levels
1-6L
49
Simple mask levels
5L
50
Partial rebreather mask levels
8-11L
51
Nonrebreather mask levels
12L
52
Venturi mask levels
4-10L
53
High flow NC levels
60L
54
Functions of skin
1. Protection 2. Body temp 3. Psychosocial 4. Sensation 5. Vitamin D production 6. Immunologic 7. Absorption 8. Elimination
55
What is assessed in braden scale
1. Sensory perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Friction and sheer
56
What number on the braden scale is considered high risk for pressure ulcer
19 and below
57
Stage I pressure ulcer
Nonblanchable intact skin
58
Stage II pressure ulcer
Partial-thickness skin loss (open, blister like)
59
Stage III pressure ulcer
Full-thickness skin loss; not involving underlying fascia (to adipose layer)
60
Stage IV pressure ulcer
Full-thickness skin loss with extensive destruction (ligaments, tendons, bones visible)
61
Unstageable pressure ulcer
Base of ulcer covered by slough and/or eschar
62
Types of wounds (how to classify)
1. Intentional/unintentional 2. Open/closed 3. Acute/chronic 4. Partial thickness/full thickness/complex
63
Types of wounds based on how they are inflicted
1. Incision (intentional cut) 2. Contusion (bruise) 3. Abrasion (scrape) 4. Puncture 5. Laceration (unintentional cut) 6. Avulsion (ring getting caught pulling off skin) 7. Thermal 8. Chemical
64
Phases of wound healing
1. Hemostasis (bleeding stops) 2. Inflammatory 3. Proliferation (2-3 days after, tissue healing) 4. Maturation (3 weeks after, scar formed)
65
Dehiscence
Complication where skin rips open on incision
66
Evisceration
Complication where surgical incision causes organs to come out
67
Fistula
Abnormal opening from one part of the body to the other (colon to vaginal opening)
68
Serous
Clear, yellow, watery
69
Sanguineous
Bloody
70
Serosanguineous
Blood tinged, orangey
71
Purulent
Yellow, cloudy infection
72
Color classification of open wounds
Red: Protect Yellow: Cleanse Black: Debride
73
Wet to dry dressing
Put wet dressing on wound and pull dry dressing off and it will pull off some of the dead tissue
74
Telfa dressing
Gauze impregnated with antibacterial, non adhesive
75
Transparent dressings
Clear so that you can visualize (IV sites, tegaderm)
76
Hydrocollodial dressing
Warmth makes dressing stick to skin
77
Montgomery straps/PRN ties
Strings keep dressing on, easy to remove and change
78
Rebound phenomena
Heat is only good for about 20 minutes, then the capillaries will stop dilating and go back to normal
79
Constipation
Doesn't always relate to time; dry hard fecal material
80
Diarrhea
More than 3 loose stools in a day
81
Melena
Black stool with blood in it; indicates GI bleed
82
Steatorrhea
Fatty stool; indicates poor fat metabolism; grey-yellow stool
83
Esophagogastroduodenoscopy (EGD)
Scope looking at esophagus, stomach, and duodenum
84
Metamucil/Citracal
Bulk forming (fiber) laxative (mild)
85
Colace
Stool softener laxative (mild)
86
Mineral oil
Emollient; lubricates GI tract (less mild)
87
Ducolax
Stimulant; irritates bowel and promotes peristalsis
88
Miralax/GoLYTELY
Osmotic; water absorbs into stool; (more stimulating)
89
Which side do you lay pt on for enema and why
Left side bc descending colon

Intro to Nursing (5 decks)

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