funds week 2

What is the first step in the Week 2 Nurse Thinking Loop?

Prevent - Identify what exposure, transmission route, or predictable complication can be stopped.

What does the second step, 'Prepare,' involve?

Ensuring the right patient, equipment, environment, order, PPE, and supervision are in place.

What is the purpose of the 'Measure' step?

To confirm the correct technique, site, cuff, timing, and equipment were used.

What does 'Compare' refer to in the nursing process?

Evaluating how results compare with baseline, trends, age, diagnosis, medications, and symptoms.

What should be prioritized in the nursing assessment?

Identifying threats to airway, breathing, circulation, neurologic status, sepsis, allergy, or toxicity.

What action is taken during the 'Respond' step?

Determining safe actions within the student role and notifying necessary personnel.

What does the 'Reassess' step entail?

Evaluating whether the intervention was effective and what needs to be documented or escalated.

What is the focus of Chapter 25?

Asepsis and infection control - interrupting transmission and protecting patients.

What is the primary infectious agent?

A microorganism capable of causing disease.

How can a nurse break the chain of infection at the 'Reservoir' link?

Through environmental cleaning, device care, and proper handling of linens/waste.

What is a 'Portal of exit'?

The route through which an infectious agent leaves its host, such as respiratory secretions or blood.

What are the modes of transmission for infections?

Contact, droplet, airborne, vehicle, or vector spread.

What constitutes a 'Portal of entry' for pathogens?

Broken skin, respiratory/GI/GU tracts, mucosa, or invasive devices.

Who is considered a 'Susceptible host'?

A person whose defenses cannot prevent infection.

What are some nursing strategies for infants and young children?

Vaccination support, caregiver hand hygiene, safe feeding/device care, and monitoring behavior/intake/output.

What should nurses monitor in older adults regarding infection risk?

Baseline and subtle cues such as confusion, falls, and reduced appetite/function.

What does leukocytosis indicate?

It may accompany infection, while leukopenia can occur with severe infection or immunosuppression.

What does a left shift in the differential indicate?

Increased immature neutrophils may support a bacterial infection.

What is the significance of cultures and susceptibility testing?

They identify the organism causing infection and which antimicrobials inhibit it.

What do CRP and ESR indicate?

They are inflammatory markers that may rise with infection but are nonspecific.

What does an increase in lactate levels suggest?

It may indicate impaired tissue perfusion and severe illness.

What is the nursing response to a postoperative patient with elevated vital signs?

Assess the patient immediately and verify vital signs and technique.

What should be done if a visitor coughs near an immunocompromised patient?

Offer a mask/source control and teach respiratory etiquette.

What is the nursing significance of the incubation stage of infection?

The patient may transmit infections before symptoms appear; exposure history is important.

What actions should be taken during the convalescence stage?

Continue prevention, support nutrition/activity, and ensure medication completion.

What is the importance of documenting patient responses?

To track cognition, intake/output, function, and results after interventions.

What can cause an increase in lactate levels?

Impaired tissue perfusion and severe illness.

What is the significance of organ-function labs?

They reveal risk/complications and guide drug safety.

What are the essential components for specimen collection?

Correct patient, source, container, technique, label, and prompt transport.

What should be done if a blood culture is ordered after antibiotics have started?

Notify the RN/instructor, clarify the plan, collect as directed, and document details.

When is hand hygiene indicated?

Before touching a patient, before aseptic tasks, after touching a patient, and after glove removal.

When should alcohol-based hand rub be used?

In most clinical situations when hands are not visibly soiled.

What are Standard Precautions?

Infection control measures applied to every patient in every setting.

What are Transmission-Based Precautions?

Additional precautions for suspected or confirmed infections requiring extra controls.

What is the core idea of Contact precautions?

Preventing the spread of organisms through direct touch or contaminated objects.

What should be done for a patient with suspected airborne illness?

Place a mask on the patient, separate them, notify the nurse, and follow airborne-precaution policy.

What is the mechanism of action for beta-lactams?

They inhibit cell-wall synthesis, weakening the bacterial wall.

What distinguishes bactericidal from bacteriostatic drugs?

Bactericidal drugs kill bacteria, while bacteriostatic drugs inhibit growth.

What is intrinsic resistance in bacteria?

A species that lacks the target or has built-in features to exclude or destroy the drug.

What is acquired resistance in bacteria?

A previously susceptible strain changes through mutation or gains resistance genes.

What are the three broad patterns of adverse effects from antibacterial drugs?

Hypersensitivity/allergy, direct toxicity, and superinfection/flora disruption.

What should a nurse do in case of a hypersensitivity reaction?

Stop/withhold the drug, assess ABCs, call for help, and document the reaction.

What is the nursing response to direct toxicity from antibiotics?

Trend labs, monitor symptoms, and assess renal function.

What should be monitored to prevent superinfection?

Watch for diarrhea, thrush, vaginal symptoms, or opportunistic infections.

What is the importance of teaching patients about infection precautions?

To explain precautions, hand hygiene, and how to prevent the spread of infections.

What is the purpose of using teach-back in patient education?

To ensure patients understand how to perform tasks like cleaning catheter tubing.

What should be done immediately after removing gloves?

Perform hand hygiene to prevent contamination.

What is the role of PPE in infection control?

To protect healthcare workers from exposure to infectious materials.

What is the significance of using the correct PPE sequence?

To minimize contamination and ensure safety during patient care.

What should be done if hands are visibly soiled?

Use soap and water instead of alcohol-based hand rub.

What is the correct response if a student forgets to perform hand hygiene after glove removal?

Stop, perform hand hygiene immediately, and clean contaminated equipment.

What is the importance of documenting specimen details?

To ensure accurate treatment and tracking of patient care.

What should be done to prevent the spread of resistant organisms?

Use infection precautions and educate patients on proper antibiotic use.

What is the purpose of measuring peak and trough drug concentrations?

To estimate the highest and lowest concentrations of a drug to assess exposure and toxicity risk.

What does a peak concentration indicate?

The highest concentration of a drug after a dose.

What does a trough concentration indicate?

The lowest concentration of a drug before the next dose.

What should be confirmed before collecting drug level samples?

Drug, dose, route, infusion start/stop, level type, and ordered collection time.

What is the modern approach to monitoring vancomycin levels?

Many institutions now use area-under-the-curve (AUC)-guided monitoring rather than trough levels alone.

What is the significance of a trough drawn 30 minutes after an antibiotic infusion?

It does not represent the lowest pre-dose concentration and could lead to harmful dosing decisions.

What are the five essential parts of a meaningful vital sign?

Correct patient and equipment, correct site and technique, patient at rest, comparison with baseline, and clinical context.

What factors can increase body temperature?

Infection/inflammation, exercise, warm environment, hormones, and stress.

What factors can decrease body temperature?

Cold exposure, sleep, some medications, and impaired thermoregulation.

What does pulse reflect?

The rate, rhythm, and strength of cardiac ejection and perfusion.

What factors can increase pulse rate?

Exercise, fever, pain, anxiety, hypovolemia, and stimulants.

What factors can decrease pulse rate?

Sleep, conditioning, hypothermia, vagal stimulation, and rate-slowing drugs.

What is the correct technique for measuring blood pressure?

Use the correct cuff size, support the arm at heart level, and avoid talking during measurement.

What can cause falsely high blood pressure readings?

Using a cuff that is too small, arm below heart level, unsupported arm, and recent activity.

What is the normal pulse range for a newborn?

100-160 beats per minute.

What is the normal respiration rate for an adult?

12-20 breaths per minute.

What is the significance of documenting vital signs?

To provide a record of the patient's status and any changes over time.

What should be done if a vital sign reading is unexpected?

Assess the patient first, then repeat the measurement manually or with corrected technique.

What is the correct method for teaching a patient to check their pulse?

Rest first, use index/middle fingers, and count for a full minute if irregular.

What should be avoided before taking a home blood pressure reading?

Exercise, caffeine, and smoking/nicotine for about 30 minutes.

What is the formula to convert Celsius to Fahrenheit?

°F = (°C × 9/5) + 32.

What is the formula to convert Fahrenheit to Celsius?

°C = (°F − 32) × 5/9.

What should be monitored in a patient with a normal oxygen saturation but distress?

Work of breathing, airway, and overall clinical status.

What is the importance of comparing vital signs with baseline?

To identify trends and changes in the patient's condition.

What is the normal blood pressure category according to AHA?

Less than 120 systolic and less than 80 diastolic.

What should be documented when recording vital signs?

Exact values, time, site/route, position, and any unusual circumstances.

What is the significance of reassessing a patient after an intervention?

To evaluate the effectiveness of the intervention and document the response.

What are critical values that require immediate attention?

Significant change from baseline, abnormal patterns with symptoms, irregular/new pulse, respiratory distress, hypotension with poor perfusion, fever with concerning signs.

What can be delegated to nursing assistive personnel?

Routine measurement of vital signs for stable patients, as permitted by law/policy.

What responsibilities does a nurse retain when delegating tasks?

Assessment, interpretation, clinical judgment, follow-up, and accountability for the care plan.

What should a nurse do after delegating tasks?

Review results promptly and assess new admissions, unstable patients, significant changes, and complex interpretations personally.

In the patient scenario where BP is reported as 88/50 but the patient appears fine, what should be the nurse's response?

Assess the patient immediately, verify BP manually, evaluate pulse/mental status, and notify/escalate if necessary.

What is the medication safety framework?

Verify order, indication, allergies, patient identifiers, formulation, dose calculation, timing, route, contraindications, and interactions before, during, and after medication administration.

What are the common side effects of aspirin?

Dyspepsia, nausea, bruising.

What serious adverse effects can occur with aspirin use?

GI bleeding, hypersensitivity reactions, renal injury, tinnitus, and severe toxicity.

What should patients be taught regarding aspirin use?

Take only as directed, report unusual bleeding, and avoid combining with NSAIDs/alcohol without guidance.

What is the action of ibuprofen?

Reversibly inhibits COX/prostaglandins, providing analgesic, antipyretic, and anti-inflammatory effects.

What are the serious risks associated with ibuprofen?

GI bleed/ulcer, kidney injury, hypertension, and cardiovascular thrombotic events.

What is the action of acetaminophen?

Central analgesic and antipyretic action with minimal anti-inflammatory effects.

What serious adverse effects can occur with acetaminophen overdose?

Dose-related liver injury and severe skin or hypersensitivity reactions.

What should patients be taught regarding acetaminophen?

Avoid doubling up on products containing acetaminophen and seek urgent help after overdose.

What is the action of digoxin?

Inhibits sodium-potassium ATPase, increasing intracellular calcium and myocardial contractility.

What are the common effects of digoxin?

Fatigue, dizziness, nausea, and reduced appetite.

What should be verified before administering digoxin?

Apical pulse for 1 full minute, rhythm, BP, potassium/magnesium/calcium levels, and ordered drug level.

What is the common adult reference dose for ibuprofen?

200-400 mg every 4-6 hours, with a maximum of 1,200 mg/day for OTC use.

What is the common adult reference dose for acetaminophen?

325-650 mg every 4-6 hours or 1,000 mg every 6 hours, not exceeding 4,000 mg/day.

What should be done if a patient reports tinnitus after taking aspirin?

Hold the next dose, notify the RN/prescriber, and assess for symptoms of salicylate toxicity.