Flashcards in Unit 1 Deck (100):
Average normal range of temperature
36-38 degrees c
96.8-100.4 degrees f
Average oral/tympanic temperature
37 degrees c
98.6 degrees f
Average rectal temperature
37.5 degrees c
99.5 degrees f
Average auxiliary temperature
36.5 degrees c
97.7 degrees f
Acceptable range of adult heart rate
Acceptable ranges of adult respiratory rate
Average optimal blood pressure for 18 years and older
What is the most important and basic technique in preventing and controlling transmission of infections?
When should nurses wash their hands?
Before and after caring for a client, when visibly soiled, after contact with sources of microorganism, after an invasive procedure, and after removing gloves.
What are some examples of medical asepsis?
Changing the bed linens, washing hands, wearing gloves, proper disposal of needles, utilizing isolation precautions when appropriate.
What area of the sterile field is considered sterile?
Only the top surface, one inch in from edges that are above the health care providers waist.
What information do you check on the bottle label?
The expiration date and the name of the solution.
How long is the bottle considered sterile once it has been opened?
It is no longer considered sterile, however, some institutional protocols allow use for up to 24 hours if properly handled.
If you open a new bottle and are going to leave it in the patient’s room, what information do you write on the bottle?
The date and time it was opened and your initials.
If there is opened bottle in the patient’s room without the date it was opened written on it, what do you do with the bottle?
When pouring the fluid from the bottle, why do you place the label in the palm of your hand?
To keep from obscuring the print on the label with the solution if it is allowed to drip down the side of the bottle.
When removing contaminated gloves, why is it important to grab the palm pocket first?
To minimize contamination of underlying skin and keep microorganisms inside gloves upon disposal.
Why do you always remove your gloves, dispose of them, and wash your hands before leaving the patient’s room?
To reduce the risk of cross contamination with other patients.
How do you remove your gown, gloves, and mask when leaving the room of a patient in isolation to prevent contamination of your hands and uniform?
Remove gloves first using procedure above, wash hands, remove mask by untying lower string first and avoiding contact with contaminated portion of mask, and then remove gown by grasping along inside of neck and pulling off while rolling it up with soiled side inside. Discard in appropriate container.
What effect does the size of the cuff have upon the blood pressure reading?
If too narrow will have a false high and if too wide will have a false low.
How do you know you are using the appropriate size cuff?
Ideally the width of the cuff is 40% of the circumference (or 20% wider than the diameter) of the midpoint of the limb. The bladder should encircle at least 80% of the upper arm.
Does optimal blood pressure vary with age?
Lower blood pressure is normal in children than in adults. Normal is
What is the difference in reading between axillary and rectal temperatures as compared to an oral temperature on the same person?
Axillary temp is 1 degree lower than oral & rectal temp is 1 degree higher than oral. But just report the temperature and the method used to take it.
What will you do if the temperature is not normal?
If there is a reason it might be abnormal wait 30 minutes and retake it. If there is no reason for the elevated temp then notify the physician.
What is the best way to assess respirations? Does normal respiratory rate vary with age?
A skillful nurse does not let the patient know that respiratory rate is being taken. The respiratory rate should be counted immediately after the pulse is taken while the nurse’s fingers are in on the patient’s wrist. It is often helpful to place the patient’s arm in a relaxed position across the abdomen so that the nurse’s hand will rise and fall with the respiratory cycle. The depth of the respiration, respiratory rhythm should be assessed as well as the rate.
What are the pulse sites?
The sites are:
popliteal (posterior to patella)
Review taking an apical pulse since it isn’t in assessment and it isn’t part of the skills proficiency either. Take for 30 sec and multiply by 2 if it is regular. If pulse if irregular, count for 60 seconds
Identify the ABCDE clinical approach to pain assessment and management.
• A-Assess pain regularly and systematically
• B-Believe the client and family in their report of pain
• C-Choose pain control options with the client and family
• D-Deliver interventions in a timely, logical manor
• E-Empower clients and their families to have as much control as possible of the clients pain
Identify the common characteristics of pain that the nurse would assess.
• Pain Pattern
• Relief Measures
• Contributing Symptoms
Nonpharmacological interventions such as the following lessen pain. Briefly explain each one.
a. Relaxation: Guided imagery and anything else that has been identified to relax the client
b. Distractions: This can be in many forms, visitors, TV, phone calls, again involve the family.
c. Music: Music Therapy at least 15 minutes to be therapeutic, you can have family help with this by bringing favorite or meaningful music.
d. Cutaneious stimulation:
– Cold or Heat Applications
– Position Change
What are the main types of assistive devices for walking?
Crutches, walkers, canes
When are restraints utilized?
-When a patient is disruptive and/or agitated and at risk for self-injury or violence to self and/or others.
-Sometimes patients may be restrained when they are confused and interfere with the treatment necessary for their recovery (i.e. pull out catheters, IVs, NG, etc).
-Sometimes clients who are at great risk for falls are restrained, but this is not an automatic utilization.
What are some alternatives to using restraints?
Companionship, music, television, reorientation, offer visit to bathroom, assign room close to nurses’ station.
Restraints must be reordered how often?
Every 24 hours
What are some things that can be done to prevent falls?
-Complete a fall risk assessment
-Use no skid slipper socks
-side rails up
-remove unnecessary items from patient room
-hourly rounding to rooms.
What is a falls risk assessment?
Helps nurse assess for potential risks before accidents and injuries occur
What are some of the body systems that can be affected by immobility of a patient?
What are the steps health care members should take to prevent musculoskeletal injuries when working in the health care field?
Weight to be lifted close to body-maintains center of gravity, Bend at knees-maintains center of gravity and uses strong leg muscles, Tighten abdominal muscles and tuck pelvis-balance and protects the back, Do not twist at trunk
Why is it important to face the direction you are moving the client?
Avoids twisting of spine.
Why is it important for the nurse to stand with feet apart, knees flexed when transferring or moving clients?
According to principles of body mechanics, the wider the base of support, the lower the center of gravity, and the closer to the object/client, the greater the stability and balance during the procedure.
Why is it important for the nurse to contract abdominal muscles prior to moving a client?
This helps prevent ligaments and joints from strain and injury
What is the rationale for bending at the knees and hips when moving a client up in bed?
Bending with the knees and hips flexed uses the longest, strongest muscle groups (legs) and helps prevent back strain.
Why is it helpful to raise the level of the bed prior to turning a client?
This brings the client closer to the nurse’s center of gravity and helps prevent unnecessary back strain from leaning over.
Why do you log roll clients?
Keep spinal column in straight alignment to prevent injury.
What is the appropriate way to assist a falling client?
Increase base of support, straighten one leg and allow client to slide down leg, and make sure that client’s head does not hit a hard surface.
What are some of the purposes of positioning?
Maintain skin integrity, promote good body alignment, prevent contractures, promote circulation, provide sensory stimulation, improve ventilation, and promote comfort.
When would you use trendelenburg position? What about sims position? What about Fowlers?
Trendelenburg-Increased blood flow to brain and decrease fluid in lower limbs. Sims-Enema or suppository administration, hemorrhoid assessment. Fowlers-Shortness of breath, vomiting, insertion of nasogastric tube (NG).
Urinary elimination depends on the function of
the kidneys ureters, bladder and urethra.
Kidneys filter wastes from the
Functional unit of the kidney is the
What is proteinuria?
Large proteins in the urine. Sign of glomerular injury.
What substances do the kidneys produce?
What is the function of the ureters?
Transport urine from kidneys to bladder.
What is the function of the bladder?
Muscular organ that stores and excretes urine.
What is the function of the urethra?
Transport urine from bladder outside the body
What structure permits voluntary flow of urine?
External urethral sphincter
Factors that influence urination include: (give examples of each)
a. Physiological factors/disease conditions---Diabetes, multiple sclerosis
b. Psychosocial conditions---Anxiety, emotional stress
c. Diagnostic or treatment induced conditions---Cystoscopy, intravenous pyelogram
Common alterations in urinary elimination include: (describe each)
a) Urinary diversion-Surgical formation temporarily or permanently bypasses the bladder and urethra
b. Urinary retention-Accumulation of urine resulting form inability to empty bladder properly.
c. Urinary tract infections-Bacterial infection of parts on urinary tract
d. Urinary incontinence-Involuntary leakage of urine that is sufficient enough to be a problem
Assessment of urine includes:
a. Color-pale, straw, amber, red, blue, green
b. Clarity-transparent, cloudy, foamy
c. Odor -ammonia-stagnant (incontinent); sweet or fruity-acetone (by products of incomplete fat metabolism) or diabetes or starvation; medications
d. Amount-accurate measurement of what is patients’ fluid intake and output
Urine specimen collection can be clean void, midstream, or a sterile collection. Common laboratory and diagnostic tests of urine include: (describe each)
a. Urinalysis-pH, protein, glucose, ketones, blood, RBCs, WBCs, crystals
b. Specific gravity-concentration of particles in urine
c. Urine culture-check for bacterial growth in urine
d. 24 hour urine collection-Measure levels of steroids, hormones, creatinine or protein quantities
Promoting normal micturition
b. Stimulating micturition reflex
c. Maintain elimination habits
d. Maintain adequate fluid intake
e. Promoting emptying of bladder
f. Preventing infections
1. unable to control urination
2. assessing urine output
3. Urinary tract injuries or trauma
4. Obstruction of outflow
7. terminal illness
How does the nurse promote normal urination?
Education; Assume normal position for voiding; Integrate patients’ elimination habits into nursing care; Maintain adequate fluid intake; Promote complete bladder emptying; Prevent infection; Acidifying urine
What interventions can the nurse utilize to stimulation urination?
Have patient in normal urinating position, provide privacy, give them time to void, run water
How does the nurse assess for a distended bladder?
Palpate above the symphysis pubis. Check to see when patient last voided and how much they voided. If it was small, maybe it was overflow from a distended bladder.
What are the types of catheters?
Intermittent (straight or coude) or indwelling (foley)
Why is a balloon present on an indwelling catheter?
Anchor catheter in place in bladder so it does not come out the urethra.
What is perineal care?
Cleansing area around urethral meatus, catheter, labia, perineum, anus.
Which patients need perineal care?
All patients need catheter care, but women especially because of vaginal discharge.
What is the proper way to remove an indwelling catheter?
Same position as insertion, remove tape, properly place towel in case of urine dripping, insert syringe in balloon injection port, slowly withdraw solution to deflate balloon, prepare patient for withdrawing of catheter, slowly and smoothly withdraw catheter, document.
Why is bladder irrigation utilized?
To maintain patency of indwelling catheter or to flush out particles from the bladder.
What is a Continuous Bladder Irrigation/infusion (CBI)? Why is it used?
It is continuous irrigation of the bladder without disruption of sterile catheter system through use of three way catheter. Used most often after genitourinary surgery to flush out bladder. Prevention of blood clots and mucus fragments.
What is a condom catheter?
Soft, pliable, latex sheath that slips over the penis.
What type of a patient can utilize a condom catheter?
Used for patients who still have complete and spontaneous bladder emptying. Can be incontinent or comatose patients. Can wear it only at night if needed.
s urinary incontinence a normal part of aging?
No, make efforts to assess and provide interventions.
What should the nurse be sure to do after catheterizing an uncircumcised male?
Reduce or reposition foreskin if necessary.
Why are women more prone to UTI’s?
Because of short urethra and the proximity of the anus to the urethral meatus.
What are the purposes of screening procedures?
Early recognition of a possible health problem, self-testing of an existing health problem, indicates the need for further testing. Screenings are not diagnostic for illness/disease
What are the normal characteristics of urine in relation to color, clarity, and odor?
Yellow to amber, clear without a strong or foul odor.
What information is obtained from this analysis and what is the significance of each test?
a. Blood – >2 RBC’s indicates if kidney disease or damage has occurred, as well as trauma or surgery. May also indicate contamination from menses.
b. Ketone – Presence suggests dehydration, starvation, or poorly controlled diabetes.
c. Leukocytes-can indicate infection
d. Nitrite-can indicate infection
e. Glucose – Presence indicates diabetes.
f. Protein – Presence indicates renal disease or damage.
g. PH – Normal is 4.6-8.0 – Increase or decrease indicates alteration in acid-base balance.
What are the normal characteristics of feces?
Brown, soft but formed, diameter of rectum, with pungent odor.
What abnormal finding is occult fecal test assessing for and what are the implications of a positive result?
Microscopic amounts of blood indicating colorectal cancer, ulcers, GI irritation/inflammation, or polyps.
How many times should the test be repeated and what dietary restrictions are imposed on the client to enhance accuracy of results?
3 times – pre-exam diet should be meat free, increased residue, no NSAID’s, alcohol, iron or Vitamin C.
False positives can be obtained on the fecal occult blood test if the client has
bleeding disorder or GI irritation/disorder or is on anticoagulants.
What is the primary purpose of blood glucose testing?
Assist client in maintaining blood sugar within normal limits. Permit ease of self-monitoring. Aid in monitoring effectiveness of treatment for hypo/hyperglycemia.
When is the best time to perform capillary blood glucose monitoring?
Before meals or two hours after meals.
Why is it important to prick the side of the finger, not the finger pad?
Less nerve endings, capillaries are closer to the skin, pads too thick making it difficult to obtain a "good" droplet of blood.
What are the normal parameters for blood glucose?
AC (before meals) should be 90-130
PC (after meals) should be
What factors can affect the accuracy of blood glucose monitoring?
Location on body where blood obtained, poorly calibrated machine, out of date strips or improperly stored strips.
What procedure should be followed when disposing lancets?
Dispose in sharps container
Why is it important to make sure the clients bed is wrinkle free?
The bed should be wrinkle free to promote comfort and decrease risk of skin breakdown.
How frequently should oral care be administered on a conscious verses an unconscious patient?
In clients with conditions that threaten the integrity of the mucosa oral care should be administered on the conscious client every 4 hours and on the unconscious client every two hours.
In addition to bathing, which intervention best promotes client comfort?
What is the correct method for trimming nails?
When bathing the client what is the appropriate order to bathe the client?
Start at the head and work towards the feet. When washing the extremities make sure to wash from distal to proximal to promote venous return. In the perineal area make sure to clean from front to back.
When changing the patient gown of a person with an IV in the arm which arm should you change first?
Remove gown from unaffected side first.
It is a great time to do what other nursing activity during the bath?
It is a great time to do a total body assessment while you are bathing the client. Checking for any potential areas of break down.
Should you wear gloves when changing the client’s bed?
Gloves should be worn any time that you might come in contact with any body fluids.
What equipment do you need to gather prior to bathing your patient?
2 Washcloths, 2 Bath Towels, Bath blanket, soap and soap dish, water basin, other toiletry items, clean gown or change of clothes, laundry bag and disposable gloves. Don’t forget to warm your room before a bath and provide privacy for your client.
What are pelvic floor exercises?
P. 1170 Exercise that will increase bladder control. Tighten, then relax, the ring of muscle around the urethra and anus, as if trying to prevent urination. 3 sets of 5 contractions a day. Holding the contraction for 10 seconds each. Rest between sets.