Foundations of Nursing Practice

What is the primary safety risk for infants and toddlers according to nursing standards

Suffocation, aspiration, falls, poisoning, and burns are the primary risks.

For school-age children, what are the key safety hazards to be aware of

Head injuries, sports safety, the need for booster seats, and stranger danger.

What are the major safety concerns specific to the adolescent population

Motor vehicle accidents, substance abuse, and sexually transmitted infections.

What is considered the major safety risk for older adults

Falls are the major risk for older adults.

Name the six components of the Chain of Infection.

Infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.

What is the principle behind breaking the Chain of Infection

Breaking any one of the six links in the chain is sufficient to prevent an infection.

What fall risk assessment scale is mentioned in the nursing foundations text

The Henrich II Fall Risk Scale.

List three key nursing interventions to prevent falls.

Hourly rounding, using low-profile beds, ensuring call light is within reach, clearing pathways, and using non-skid socks.

When should physical restraints be used on a patient

Restraints should only be used as a last resort when other less restrictive measures have failed.

How often must a nurse assess a patient in restraints for skin integrity and circulation

At least every 2 hours.

What four elements must be included in the documentation for a patient in restraints

The type of restraint, justification for use, patient's behavior, and ongoing assessments.

Medical Asepsis is also known as the _ technique.

Clean

What is the goal of Medical Asepsis (Clean Technique)

To reduce the number of microorganisms and prevent their transfer.

Surgical Asepsis is also known as the _ technique.

Sterile

What is the goal of Surgical Asepsis (Sterile Technique)

To eliminate all microorganisms from an object or area.

When is it mandatory to use soap and water for hand hygiene instead of an alcohol-based rub

When hands are visibly soiled or after caring for a patient with C. difficile.

What is the correct sequence for doffing (removing) PPE

Gloves, then Goggles/Face Shield, then Gown, and finally Mask/Respirator.

To which patients do Standard Precautions apply

They apply to ALL patients, regardless of their diagnosis or presumed infection status.

What specific PPE and room type are required for Airborne Precautions

An N95 mask and a negative-pressure room.

Name three diseases that require Airborne Precautions.

Measles, Varicella (chickenpox), and Tuberculosis.

What specific PPE is required for Droplet Precautions when working near a patient

A surgical mask is required when within 3 feet of the patient.

Name two diseases that require Droplet Precautions.

Influenza, Mumps, Rubella, or specific types of Streptococcal pharyngitis.

What PPE is required for Contact Precautions

A gown and gloves.

Name three diseases or conditions that require Contact Precautions.

MRSA, VRE, C. difficile, Scabies, or Herpes simplex.

List the Seven Rights of Medication Administration.

Right Patient, Right Drug, Right Dose, Right Route, Right Time, Right Documentation, Right Indication.

What is the absolute first step a nurse should take after discovering a medication error

Assess the patient's condition immediately.

After assessing the patient, who should the nurse notify about a medication error

The prescriber and the nurse manager.

Which route of medication administration has the slowest rate of absorption

The Oral (PO) route.

Which general route of medication administration has the fastest rate of absorption

The Parenteral (injectable) route.

What instruction should be given to a patient taking a sublingual medication

Do not chew or swallow the medication; allow it to dissolve completely under the tongue.

What is the correct injection angle for an intradermal (ID) injection

A 15-degree angle.

What is the correct injection angle for a subcutaneous (SQ/SC) injection

A 45-degree or 90-degree angle, depending on patient body fat and needle length.

What is the maximum recommended volume for a subcutaneous injection

0.5 to 1 mL.

What is the correct injection angle for an intramuscular (IM) injection

A 90-degree angle.

Which IM injection site is preferred for infants

The Vastus Lateralis.

Which IM injection site is preferred for adults

The Ventrogluteal site.

For which type of medication is the Z-track method recommended for IM injections

The Z-track method is used for irritating medicines to prevent leakage into subcutaneous tissue.

What is the basic formula for dosage calculation

\frac{Dose Ordered}{Dose on Hand} \times Quantity

What does the acronym ADPIE stand for in the Nursing Process

Assessment, Diagnosis, Planning, Implementation, Evaluation.

The first step of the nursing process, _, involves gathering subjective and objective patient data.

Assessment

In the _ step of the nursing process, the nurse analyzes data to identify patient problems.

Diagnosis

What does the acronym SMART stand for in the context of goal setting during the Planning phase

Specific, Measurable, Attainable, Realistic, Timely.

The _ step of the nursing process involves performing the planned nursing interventions.

Implementation

What occurs during the Evaluation step of the nursing process

The nurse determines if the patient's goals were met and revises the care plan as needed.

What is the primary difference between critical thinking and clinical judgment

Clinical judgment is the application of critical thinking in the clinical setting to make patient care decisions.

According to Maslow's Hierarchy of Needs, what type of needs must be prioritized first

Physiological needs (e.g., oxygen, food, water, shelter).

What do the letters in the ABCs of prioritization stand for

Airway, Breathing, Circulation.

What are the cardiovascular effects of immobility

Orthostatic hypotension, increased cardiac workload, and thrombus formation (DVT).

What are the primary respiratory complications associated with immobility

Atelectasis (collapsed alveoli) and hypostatic pneumonia.

What musculoskeletal problems can arise from prolonged immobility

Loss of muscle mass (atrophy), joint contractures, and disuse osteoporosis.

What are the urinary system effects of immobility

Urinary stasis and renal calculi (kidney stones).

What integumentary complication is a major risk of immobility

Pressure injury/ulcers.

What nursing intervention helps prevent atelectasis in an immobile patient

Encouraging deep breathing, coughing, and use of an incentive spirometer every 1-2 hours.

How often should an immobile patient be repositioned to prevent pressure injuries

Every 1-2 hours.

What is the fundamental definition of pain in nursing

Pain is whatever the experiencing person says it is, existing whenever he or she says it does.

What is the key difference in duration between acute and chronic pain

Acute pain lasts less than 6 months, while chronic pain persists for longer than 6 months.

In the PQRST pain assessment model, what does the 'Q' stand for

Quality (e.g., how the pain feels - sharp, dull, aching).

List three examples of non-pharmacological pain relief interventions.

Distraction, relaxation, guided imagery, massage, or heat/cold application.

What is the most serious side effect to monitor for in a patient receiving opioids

Respiratory depression.

What is the most important rule regarding the use of a Patient-Controlled Analgesia (PCA) pump

Only the patient is allowed to push the button to administer the medication.

What is an adjuvant analgesic

A drug that assists in pain relief but is not typically classified as an analgesic, such as an antidepressant or anticonvulsant.

What is the primary focus of patient safety in nursing practice

Recognizing risks and implementing preventive measures across all care settings.

To prevent orthostatic hypotension in an immobile patient, what should the nurse do before ambulation

Have the patient dangle their legs at the side of the bed before standing.

What type of diet is recommended for an immobile patient to prevent metabolic complications like negative nitrogen balance

A high-protein, high-calorie diet.