Fundamentals: Exam 1

Clinical decision-making uses data and nursing knowledge to choose what?

the safest and most effective action

Clinical decision-making considers what?

risks, benefits, client preferences, and urgency

When using clinical decision-making always priortixe what?

the ABC, safety, and life-threatening issues

When using the nursing process for clinical judgment ensure what?

organized thinking, prevents missed cues, and supports optimal outcomes through continuous reassessment

What are the elements of the chain of infection?

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

What are the body’s defenses:

first line, second line, and third line

What is the first line of the body’s defenses

skin, mucous membranes, normal flora

What is the second line of the body’s defenses?

inflammation

What is the third line of the body’s defenses?

immune response (antibodies

What is a medical asepsis

(clean technique) the reduction of disease-causing micro-organisms to reduce infection risk (isolation precautions)

What is a surgical asepsis

sterile technique gloves and equipment are sterile, meaning that they do not have micro-organisms present on them

What is standard precuation?

infection prevention practices applied to all clients whether or not they are known to have an infectious agent used for all patients (such as hand hygiene)

What is transmission-based precautions for contact?

should don PPE gown and gloves at minimum

What is transmission-based precautions for droplet

surgical mask, gown, and gloves

What is transmission-based precautions for airborne?

N-95 respirator, gown, gloves, and eye protection

How to remove PPE properly

remove the gloves, google/face shield, gown, and then mask

How to maintain a sterile field

should be prepared as close to the time of the procedure to decrease possibility of contamination from airborne micro-organisms or from another ppl accidently contaminating the field

What is the role of the body in maintaining the first line of defense against pathogens

intact skin prevents pathogen entry

What is a complete bed bath?

usually, required for those clients who are unable to ambulate to the bathroom and bathe themselves; can be given with soap and water or disposable wipes

What is a partial bath?

only certain parts of the body are washed, not the entire body

What is a therapeutic bath?

bath done for treatment not just hygiene (warm, cool, medicated, or sitz bath)

What is a packaged bath?

uses pre-moistened, disposable washcloths warmed in a bag

Assist a client with shaving

first explore facial contours and feel the areas need in shaving,, using an empty razor or with electric razor turned off

The procedure for making an occupied bed

before changing determine if the client will need any PRN pain medication before beginning the procedure

Weight gain can be what?

intentional or unintentional

When a client experiences unintentional weight gain, the cause of the increase pounds should be identified to determine what?

to determine if there is an underlying health issue

Basic information about parenteral nutrition

dietary intake that is administered IV can prevent malnutrition by replacing miss nutrients that would otherwise be consumed with eating or digestive system that cannot absorb

Basic information about enteral nutrition

prescribed for clients who do not have adequate oral intake or nutrition that can meet their metabolic needs; cannot eat safely due to swallowing or dysphagia

What are some indications for administration of enteral nutrition

cannot eat safely due to swallowing, dysphagia, or cannot meet nutritional needs

What is the purpose of Hemoglobin A1C test

the purpose is to measure the average blood glucose over 2-3 months

What are normal ranges for A1C

less than 5.7%

What are prediabetic ranges for A1C

5.7-6.4%

What are diabetes ranges for A1C

diabetes less than 6.5%

How to manage diabetes diagnosis and management with abnormal ranges

teach lifestyle changes, medication adherence, and monitor

How A1C reflects average blood glucose levels over time (2-3 months)

measure how much glucose has been attached to hemoglobin during the entire lifespan of a red blood cell

Factors that may affect A1C results include

when there is anything effecting red blood cell, hemoglobin structure, or glucose attachment

Interpret sample A1C results and determine whether they indicate controlled or uncontrolled diabetes

A1C results tell you whether diabetes is controlled or uncontrolled based on how high the percentage is

What is normal fasting glucose ranges?

74 to 106

What are prediabetic fasting glucose ranges?

100 to 125

What are diabetic fasting glucose ranges

less than 126

Importance of fasting prior to the test and how improper preparation affects results

NPO for at least 8 hours and improper preparation raises triglycerides and can falsely elevate LDL and total cholesterol

Nursing responsibilities when caring for pts undergoing glucose testing

educate pt on values, ensure fasting and document results

Identify the components of a lipid profile

total cholesterol, LDl, HDL, and trigcerides

Describe the purpose of lipid testing in assessing cardiovascular risk

to measure cholesterol and triglycerides levels to determine how much plaque-building risk a person has to directly predict their likelihood of cardiovascular risk

Differienate between desirable lipid values

Total: less than 200, LDL less than 100, Trig: less than 150, and HDL for men is less than 40 and less 50 for women

Discuss lifestyle factors that influence lipid levels

diet, exercise, smoking, and alcohol

Interpret lipid profile results and identify pts at increased risk for cardiovascular disease

high LDL and high triglycerides

Critical thinking is used to make clinical decisions using what?

both experience and evidence-based practice guidelines

Nursing process is to guide nurses in delivering what?

holistic, client-centered care that takes into consideration the entire person

The holistic process includes multiple elements that consider what?

physical, spiritual, and mental well-being for every nursing decision

Nurses must consider both what when caring for clients?

both environmental and individual factors

What does environmental factors include?

the setting and situation, such as safety considerations, equipment, and surroundings,

What does individual factors include?

nurses’ factors such as knowledge and skills (like attitudes, prior experiences, and level of experience, etc)

The nursing process is key to helping the nurse make what?

clinical judgments that are appropriate for clients

Client judgment is performing ongoing and thorough what?

holistic assessments to inform decision intervention in a client problem

A break in any of the links of this chain can prevent the development of what?

of an infection

How are contact is transmitted

transmitted by contact with an object or a person

How are droplet transmitted

through droplets from activities such as coughing, sneezing, and singing

How are airborne transmitted

transmitted through the air

The inflammatory response is the body’s natural defense that is activated when what?

the body is injured, when foreign substances are present, or when an infectious agent attack

What are the manifestations of inflammation (at the level of the tissues) present as what?

heat, redness, swelling, pain, and loss of function in that area

What are local infections

are confined to one area of the body and can be treated with topical and oral antibiotics

What are systemic infections

start as local infections and then move into the bloodstream, from which they infect the entire body (intravenous antibiotics and caring monitoring are both needed to treat systemic infections)

Prior to performing medical procedures when do you wash your hands?

obtaining a throat culture, preparing a sterile field, or donning gloves

Alcohol-based hand santiziers are not effective on what?

visibly soiled hands, Cdiff

Surgical-site infections are intended to prevent what?

postsurgical infections that arise in either the incision, tissue around the incision, or the organs

To perform surgical asepsis you have to do what?

10 min scrubs with brushes and sponges and applying a mixture of chlorhexidine and ethanal to the hands

To prepare a sterile field, the nurse should position what?

a flat work surface closes the client, 12 to 18 in from any walls or potentially contaminating objects, package isn’t damaged by tears or hole

Clients placed on contact precautions should be in a what?

private room (single client only) if possible or placed in a room with another client who has a similar diagnosis if limited to space

The nurse should remove PPE when?

before exiting the client’s room in the trash

Open-glove technique involes what?

used to don sterile gloves using surgical asepsis; gloves are touched directly with the hands

How to apply PPE

gown, mask, goggles, and gloves

What is lateral (or horizontal) evacuation?

clients, visitors, and staff threatened by fire are moved to a safe location on the same floor

National Patient Safety Goals and their relationship to the national safety standards

focus on safe and effective delivery of health care and avoidance of adverse outcomes

What is vertical evacuation?

clients, vistors, and staff threatened by fire are relocated to a different floor

What is the body’s first line of defense against pathogens?

the skin

What is the skins first role in protecting against pathogens?

physical barrier that protects the internal parts of the body from outside world

Higene can be defined as actions the client akes and heazlth practices the clients engages in decreasing what?

the spread or transmission of pathogen; thereby decreasing the risk of illness

What is the skin second role in protecting against pathogens?

contains Langerhans cells that can travel throughout the body and activate body’s immune response

Why is showering the preferred method of bathing?

less risk of a client falling while showering vervus taking a bath

To gain weight in a healthy manner, the client should what?

aim at increasing muscle or bone mass and choose nutrient-rich foods over empty calorie ones

Age can have an impact on a client’s what?

nutritional status, which means that good nutrition remains just as important with againg

Adequate nutrition is evident by a person’s what?

physical appearance, weight, and other measurements

What is a soft diet

contains food that are soft, easy to digest, low in fiber, and can be swallowed without difficult

What is a pureed diet

consists of foods that are soft and smooth and do not need to be chewed

What is a full liquid diet?

diet that contains only fluids, foods that are liquids, and foods that are liquids at room temperature

What are clear liquid diet?

contains only clear liquids or completely melted at room temperature

Solid foods should not be eaten while on what type of diet?

clear liquid diet

What are intended range goal for diabetics

less than 7%

A heart-healthy diet focuses on controlling portions, consuming more what?

more fruits and vegetables, increasing whole grains, limiting unhealthy fats, eating low-fat protein sources, and decreasing sodium intake

What is a renal diet?

limiting sodium intake, avoiding processed meats, and avouding table salt and other added salts

Skeletal muscles are soft tissues that provide what?

the motor power for movement and maintain our posture

The muscular and skeletal systems, along with connective tissue, work as a team, continually adjusting to maintain what?

balance, coordinate the body’s movements, and maintain good body alignment

The muscles generate what?

heat that assists in maintaining body temperature

What is an example of the skeletal muscle generating heat?

shivering

The neurological system communicates with what?

muscles and sensory receptors through a series of chemicla signs, known as neurotransmitters

Although muscle movements are under a person’s conscious control, what coordinates the action?

the brain

A client with a fractured femur is unable to bear weight. Which system is primarily responsible for this limitation?

musculoskeletal

Body mechanics describes how a person uses their body to perform actions such as what?

sitting, standing, lifting, carrying, bending, or lying down