Nursing Skills Mid-Term: 3350/ 2350

What is the most common way infections are spread?

Touching a patient or equipment, then touching another patient without washing hands.

What are the components of the chain of infection transmission?

Infectious agent, source of infection, portal of exit, mode of transmission, portal of entry, susceptible host

What Link are infections spread by?

Mode of transmission (4th Link)

What is the most important way to reduce infections?

Washing your hands.

When should soap and water be used for hand hygiene?

Before and after eating; after using the restroom; when hands are visibly soiled; and in the presence of infections

What is the proper technique for washing hands?

Wash hands with friction for at least 20 seconds.

What are the 4 bed safety criteria in safe patient care?

Bed in low position, bed wheels locked, lift side rails ×2, call light in reach

What are the 8 critical elements of principle-based procedures?

Wash hands before & after care, gather supplies, introduce self and others, identify patient with 2 identifiers, explain procedure, provide privacy, use good body mechanics, provide patient safety

What are the normal ranges for blood pressure?

Systolic 90–120 mm Hg and Diastolic 60–80 mm Hg

What is the normal pulse range?

60 - 100 beats per minute.

What is the normal temperature range in Fahrenheit?

95.9 - 99.5 °F.

What is the normal respiratory rate?

12 - 20 breaths per minute.

What is the normal oxygen saturation level?

> 95%

Why are vital signs checked?

To monitor body systems, detect changes in health status, evaluate effectiveness of interventions, and identify life-threatening warning signs

When are vital signs checked?

On a regular basis; according to physician orders; based on nursing judgment; the patient's condition; and facility standards

What is the technique for assessing an apical pulse?

Use a stethoscope to listen at the apex of the heart at the point of maximal impulse (PMI), left midclavicular line, 5th intercostal space, count for 1 minute.

What are the names and locations of all peripheral pulses?

Temporal (side of head), Carotid (neck), Brachial (inner elbow), Radial (inner wrist), Femoral (groin), Popliteal (behind knee), Posterior tibial (below inner ankle), Dorsalis pedis (top of foot)

Where is the Temporal Pulse located?

Sides of forehead on Temples

Where is the Carotid Pulse located?

Sides of Neck

Where is the Brachial Pulse located?

Inner Elbow

Where is the Radial Pulse located?

Inner Wrist, Thumb side

Where is the Femoral Pulse located?

Groin Area

Where is the Popliteal Pulse located?

Behind Knee in divit

Where is the Posterior tibial Pulse located?

Below inner Ankle

Where is the Dorsalis pedis Pulse located?

Top of Foot

How do you convert Celsius into Fahrenheit?

1.8 (*C) + 32 = ?

How do you convert Fahrenheit into Celsius?

((*F) - 32) / 1.8 = ?

What is blood pressure physiology?

Heartbeat forces blood against arterial walls, creating a pressure wave; systolic pressure is the peak phase, diastolic pressure is the resting phase.

What is the nursing process?

A method to provide goal-directed, patient-centered care; a thinking template for clinical judgments.

What are the steps of the nursing process?

Assessment, Diagnosis, Planning, Implementation, Evaluation

What is included in the assessment step of the nursing process?

Collecting facts and data, including objective (vital signs, lab tests) and subjective (patient, family, caregiver) information.

What is an example of collecting Objective Data?

vital signs and lab tests

What is an example of collecting Subjective Data?

Information given by a patient, family, or caregiver

What is the difference between objective and subjective data?

Objective data refers to measurable, observable facts; subjective data includes personal opinions, feelings, and experiences.

What are the four phases of the nurse/patient therapeutic relationship?

Pre-interaction phase, Orientation phase, Working phase, Termination phase

What is collaborative communication in nursing?

Communication handoff using SBAR (Situation, Background, Assessment, Recommendation)

What is therapeutic communication?

Patient-centered, goal-directed communication focused on the patient.

What are techniques of therapeutic communication?

Call the patient by their name, use open-ended questions, actively listen, share observations, convey acceptance, offer assistance.

Why is it important to seek clarification in patient communication?

To ensure both parties are on the same page.

What is a technique of non-therapeutic communication?

Using open/closed-ended questions. (yes/no)

What is an example of giving false assurance in communication?

Saying 'Everything is going to be just fine.'

What is a common issue with excessive self-disclosure in communication?

It can detract from the patient's experience.

What are some legal issues related to patient communication?

Confidentiality and social media.

What are some ethical issues in professional boundaries?

Sharing personal information and inappropriate touch.

What percentage of medical errors are due to poor communication?

70-80%.

What is one cause of sentinel events in healthcare?

Breakdown in communication.

What are Activities of Daily Living (ADLs)?

Bathing, Eating, Oral care, Dressing, Grooming, Toileting

What factors can influence a patient's hygiene?

Physical factors, emotional disturbances, personal preference, culture, economic status, knowledge level

What is the recommended frequency for providing oral care to conscious patients who are NPO?

Every 2 hours.

What is the proper way to care for dentures?

Store in a labeled denture cup in water.

What is the first step in providing nursing care involving physical intimate touch?

Get permission first before making contact.

What is a principle of body mechanics when lifting?

Bend from the knees, not the waist.

What are the effects of immobility on the cardiovascular system?

Increased heart rate, venous stasis, orthostatic hypotension, and deep vein thrombosis

What are the psychosocial impacts of immobility?

Depression, loneliness, and altered sleep patterns

What is active range of motion (ROM)?

Movement done by the patient without assistance.

What is passive range of motion (ROM)?

Movement of a joint performed by another person or device.

Who is at risk for falls?

Patients over age 65, history of falls, balance problems, muscle weakness, and visual impairment

What are fall precautions that should be implemented?

Assess fall risk, observe patients frequently, ensure good lighting, and keep belongings within reach of patient

What is the supine position?

Lying on the back.

What is the high Fowler's position?

Sitting at a 90-degree angle.

What is the semi-Fowler's position?

Sitting at a 45-degree angle.

What is the prone position?

Lying on the abdomen.

What is the Sim's position?

Side-lying with hip and knee flexion.

An elderly female is being discharged from the hospital the nurse will assess whether the female needs assistance at home with which of the following Activities of Daily Living?

Bathing, oral care, toileting, grooming, dressing, eating

A nurse has completed a total bed bath. What are the 4 basic safety actions that must be done before you leave the room?

Bed in low position, bed wheels locked, lift side rails ×2, call light in reach

Oral care is an essential nursing intervention that provides patient comfort, removes plaque and bacteria, reduces the risk of tooth decay, and increases halitosis

False

The nurse is preparing to give a complete bed bath. What part of the body should be cleaned first?

Eyes

A patient's extremities should be washed from proximal to distal

True

The nurse is caring for a patient with swallowing concerns and decreased level of consciousness. The nurse knows to put the patient in what position for oral care?

Side-Lying

Which statement is true regarding oral care on patients placed on anticoagulant medications?

Patient should brush with a soft bristled tooth brush

The nurse should carefully inspect the feet of which patient population?

Diabetics

The nurse would identify which of the following blood pressure readings as being within normal adult range?

92/80

Normal Systolic range for a blood pressure

90 - 120 mmHg

Normal Systolic range for a blood pressure

60 - 80

The nurse would identify which of the following pulse rates as being tachycardic?

> 100 bpm

Hypertension is diagnosed when there are two blood pressure readings above 140/90 on more than two occasions taken on separate dates

True

The nurse would identify which following temperatures as the normal range?

95.9 - 99.5*f

The nurse would correctly convert 98.6 to ___ Celsius?

37.0*c