Fundamentals Exam 1

What are the components of the infection cycle

Agent, reservoir, portal of exit, transmission, portal of entry, susceptible host

What are the factors affective virulence factors

Numbers of organisms, competency of immune system, length and intimacy of contact

What is an endemic

Predictable, one population

What is a pandemic

Non-predictable, global outbreak

What organisms need PPE

C diff, norovirus, rotavirus

What is included in risk factors for oral, eyes, ears, and nose hygiene

Comatose, dehydrated, confused, depressed, paralyzed, mouth breathers

What is included in the history of hair, nail, foot, perineal hygiene

Washing practices, changes in distribution, footwear worn, UTIs, STIs, and diabetes

How to assess the skin

Good lighting, compare bilateral symmetry, identify risk factors

What are you assessing with the nails and feet

Capillary, intactness, contour, lesions

What hygiene practices are preformed in the morning

Toilet, comfort measures, wash face, mouth care, hair care, dressing

What hygiene practices are preformed in the afternoon

Comfort, toileting, oral care, linens, mobility and repositioning

When do you assess vitals

Admission, change in condition, before/after procedure, before/after activity, before cardio/respiratory drugs

What is released when heat is needed

Norepinephrine and epinephrine

What is radiation

Transfer of heat without contact

What is convection of heat

Physical movement of liquid or gas

What is conduction of heat

Direct physical contact

What does pyrexia mean

With fever

What is an intermittent fever

Temp returns back to normal at least once a day

What is a remittent fever

Temp fluctuates but not back to normal

What is a normal oral temperature

35.9-37.5, 96.9-9.5

What is a normal rectal temp

36.3-38.1, 97.4-100.5

What is a normal axillary temp

35.4-36.9, 95.6-98.5

What is a normal tympanic temp

36.8-38.3, 98.2-100.9

What is a normal temporal temp

36.3-38.1, 98.7-100.5

What nervous system regulates the pulse rate

Autonomic through SA node

What is amplitude measured by

Strong/weak, grade

What is rhythm measured by

Regular/irregular

What controls breathing

Medulla and pons

What is the main respiratory stimulant

Increasing co2

What describes and normal respiratory rate

Eupnea (1:4)

What is dyspnea

Difficulty breathing

What is orthopnea

Changes in breathing when sitting or standing

What is ventilation

Movement of air in/out of lungs

What is diffusion

Exchange of gases b/w lungs and blood

What is perfusion

Exchange fo gases b/w blood and tissues

When is the blood pressure at it’s max

When the left ventricle contracts

What is pulse pressure

Systolic-diastolic

What is the average pulse pressure range

40 - 50

How to prepare for a physical assessment

Explain process, explain should not be painful, explain each procedure, explain privacy will be maintained

What is the dorsal recumbent position used for

Relax ab muscles

What is Sim’s position used to assessment

Rectum or vagina

What is the lithotomy position used to assess

Female genitalia, rectum

What happens to anterior sterile chest diameter in older adults

Increase

What happens to thoracic expansion in older adults

Decrease

What are risk factors of cardio/peripheral assessment

Chest pain, palpitation, dizziness, swelling, medications, family history, exercise

What variations of cardiac assessment are seen in children

Visible pulsation, sinus dysrhythmia, S3, rapid heart rate (<8)

What is in the RUQ

Duodenum, liver, head of pancreas

What is in the LUQ

Stomach, spleen, body oof pancreas

What is in the RLQ

Appendix, cecum

What is in the LLQ

Sigmond colon

What tool is used to assess mental status

Glasgow Coma Scale

What is stereognosis

Perception of solidity of objects

What is kinesthetic & visceral functioning

Basic internal orientating systems

What is proprioception

Orientation of body

What is physical assessment of sensory perception

Ability to preform self care, vision and hearing assessments

What are the 5 wanted patient outcomes for sensor alternations

Live in a stimulating environment, exhibiting level of arousal, schedule appropriate screenings, maintain orientation, appropriate response to stimuli

What is the gate control theory of pain

Describes transmission of pain stimuli and recognizes relationship between pain and emotions

What is the pain process

Transduction, transmission, perception of pain, modulation

What is transduction in the pain process

Activation of pain receptors

What is the transmission in pain process

Conduction along pathway

What is modulation in the pain process

Inhibition or modification of pain

What is nociplastic pain

Bone pain

What is intractable pain

Sustained pain

What are the methods of pain assessment

Self report, causal factors, collateral information, behaviors, physiologic measures, analgesics used

What is the FLACC scale used for

Infants and children

What does FLACC stand for

Face, legs, activity, cry, consolability

How do you manipulate the pain experience

Decrease pain, increase pain tolerance

What does an adjuvant do

Help opioid work

What is the numeric sedation scale

Awake, occasionally drowsy, frequently drowsy, minimal or no stimulus response

What numbers on the sedation scale needs intervention

3 and 4

What are the 3 principles for analgesic administration

Ongoing assessment, manage breakthrough pain, concern with abuse

What is pharmacokinetics

Effects of body on drugs

What is included in pharmacokinetics

Absorption, distribution, metabolism, excretion

What is pharmacodynamics

Effects of drug on the body

What are the three checks for non liquid medications

Reach for container, after retrieval, before giving to patient

What are the 3 checks for administration for liquid medications

Reach for container, before pouring, when replacing to drawer

What are the 5 controlled substances required information

Name of patient, amount used, hour was given, name of prescribing provider, name of nurse

What are the steps in identifying the patient

ID bracelet, validating name, validating birth date, compare with MAR, ask patient to state name

What is the angle for insertion for IM injections

90 degrees

What is the angle of insertion for SubQ injections

45 - 90 degrees

What is the angle of insertion for intradermal

5 - 15 degrees

What are the sites for IM injection

Ventrogluteal, vastus lateralis, deltoid

What are the sites for intradermis injections

Inner forearm, upper back under scapula

What gage syringe do you use for intradermal injections

¼ - ½ (25 - 27)

What are the sites for SubQ injections

Outer arm, upper back, upper ventral/dorsal gluteal, abdomen, anterior thigh

What to do if there is a medication error

Observe for adverse effects, notify nurse manager and PCP, complete documentation

What is integrative health

Combination of complementary and convention health

What is allopathic medicine

Health is absence of disease, mind and body are seperate

What is Holism

All living organism are connected

What is holistic nursing

Healing whole person

What is integrative healthcare

Allopathic and complementary

What are the 3 categories of complimentary health approaches

Mind-body practices, natural products, other CHAs

What is part of mind-body practices

Relaxation, medication, yoga, acupuncture, aromatherapy

What are other forms of other CHAs

Therapeutic touch, healing touch, sound healing

What is ashtanga

Synchronized breathing with fast poses

What is bikram

Hot yoga

What is iyenga

Long poses

What is kripaula yoga

Gentle yoga

what is Qi Gong

Tai chi

What is the premise of therapeutic touch

Human is open energy field, human is symmetrical, illness is imbalance of energy field, humans have ability to transform ways of living