Fundamentals Exam 3 Review

Rickettsiae

Resemble bacteria; like viruses, however, they cannot survive outside another living species.

Lyme disease

A disease caused by Rickettsiae.

Sterile field

A designated area free from all microorganisms.

Breach of the sterile field

Actions that compromise the sterility of the field, such as turning your back or reaching over.

Hand hygiene

Hand washing with either a nonantimicrobial or an antimicrobial soap and water.

Best time for hand washing

Best done when hands are visibly soiled, before eating, and after using the bathroom.

Exposure to germs

Hand antisepsis with an alcohol-based hand rub can be substituted for hand washing before & after contact with client, before & after gloves, and touching anything regarding medical supplies or client.

Surgical hand antisepsis

A medically aseptic hand hygiene procedure performed before donning sterile gloves and garments during operative or obstetric procedures.

Hand antisepsis

Means the removal and destruction of transient microorganisms without soap and water.

Proper order of cleaning

Cleaning should be done in order from cleaner to dirtier areas rather than vice versa.

Donning PPE

The process of applying personal protective equipment for a sterile procedure.

Doffing PPE

The process of removing personal protective equipment after a sterile procedure.

Patient education on infection prevention

Infection prevention strategies like hand hygiene, vaccinations, and isolation protocols.

Personal belongings on admission

Document and secure belongings—placing them in labeled envelopes and storing them in locked areas.

Best practices for personal belongings

Place a client's personal belongings in an envelope to be placed in a locked and secure area.

Commonly used abbreviations in healthcare

Abbreviations that are approved and widely used in healthcare settings.

Nursing responsibilities for transfers

Communication, documentation, and ensuring continuity of care.

Minimum Data Set (MDS)

Used in long-term care settings for assessing resident needs and planning care.

How to assess pain

Use scales like numeric rating or faces scale; assess location, intensity, duration.

Continuity of care

Uninterrupted client care despite a change in caregivers, avoiding any loss of progress.

Special considerations for infants

Infants have a less-developed thermoregulatory system and can lose heat quickly, making them more susceptible to hypothermia and hyperthermia.

Special considerations for older adults

Older adults have a decreased ability to regulate body temperature and may not show a fever even with a serious infection.

Best practice for assessing body temperature

Use the most appropriate site for the patient (e.g., oral, rectal, tympanic, temporal). Rectal temperature is often considered the most accurate, but it is invasive.

Equipment for temperature assessment

Use a calibrated, clean thermometer.

Body Temperature Assessment

Follow the manufacturer's instructions for the specific type of thermometer.

Elderly Body Temperature

Elderly usually have lower body temperature. May not experience fever or signs of infection.

Pulse Pressure Assessment

Involves lightly touching or applying pressure to the body.

Light Palpation

Light palpation involves using the fingertips, the back of the hand, or the palm of the hand.

Deep Palpation

Deep palpation is performed by depressing tissue approximately 1 in (2.5 cm) with the forefingers of one or both hands.

Apical Pulse Assessment

Assessed when the peripheral pulse is irregular or difficult to palpate. The apical heart rate is to the left of the sternum at the interspace below the fifth rib in midline with the clavicle.

Systolic Blood Pressure

Systolic pressure is the pressure within the arterial system when the heart contracts.

Diastolic Blood Pressure

Diastolic pressure is the pressure within the arterial system when the heart relaxes and fills with blood.

Weber Hearing Test

An assessment technique for determining equality or disparity of bone-conducted sound, where the nurse strikes a tuning fork and places the vibrating stem in the center of the client's head.

Wound Definition

A wound is a break in the skin.

Ulcer Definition

An ulcer is an open, crater-like area.

Abrasion Definition

An abrasion is an area that has been rubbed away by friction.

Laceration Definition

A laceration is a torn, jagged wound.

Fissure Definition

A fissure is a crack in the skin, especially in or near mucous membranes.

Scar Definition

A scar is a mark left by the healing of a wound or lesion.

Tracheal Sounds

Tracheal sounds are loud and coarse, equal in length during inspiration and expiration, separated by a brief pause.

Bronchial Sounds

Bronchial sounds are harsh and loud, shorter on inspiration than expiration with a pause between them.

Bronchovesicular Sounds

Bronchovesicular sounds are medium-range sounds that are equal in length during inspiration and expiration with no noticeable pause.

Vesicular Sounds

Vesicular sounds are soft, rustling quality longer on inspiration than expiration with no pause between.

Crackles (Rales)

Crackles are sounds like popping, indicating fluid (pneumonia).

Gurgles (Rhonchi)

Gurgles are another term for rhonchi.

Wheezes

Wheezes are whistling sounds, indicating narrowing of the airway (asthma or allergic reaction).

Stridor

Stridor is a high-pitched sound, indicating obstruction of the airway.

Physical Assessment Steps

Steps of the physical assessment (head to toe) prevent overlooking some aspect of data collection and reduce the number of position changes required of the client.

Prone Position

Examinations of the posterior head, back, buttocks and extremities.

Supine Position

Examinations of the head, neck, chest, abdomen, and extremities.

Dorsal Recumbent Position

External genitalia inspection, vaginal examination, rectal examination, urinary catheter insertion.

Lithotomy Position

Internal pelvic examination (female), obstetric delivery, cystoscopic (bladder) examination.

Sims Position

Rectal examination, vaginal examination, rectal temp assessment, suppository insertion, enema administration.

Knee Chest Position

Rectal and lower intestinal examinations.

Modified Standing Position

Prostate gland examination.

Elements of Informed Consent: Capacity

Indicates that the client has the ability to make a rational decision; if not, a spouse, parent, or legal guardian must do so.

Elements of Informed Consent: Comprehension

Indicates that the client understands the physician's explanation of the risks, benefits, and alternatives that are available.

Elements of Informed Consent: Voluntariness

Indicates that the client is acting of his or her own free will without coercion or the threat of intimidation.

Client Teaching: Teach Back Method

A method used to confirm that the client understands the information provided.

Instilling Ophthalmic Medication

Lower lid margin. Blinking, rather than rubbing, distributes the drug over the surface of the eye.

Instilling Otic Medications

Warm the medication container; manipulate the ear to straighten the auditory canal.

Administration of Nasal Medications

Dropped or sprayed within the nose.

Administration of Sublingual Medication

A drug placed under the tongue is left to dissolve slowly and becomes absorbed by the rich blood supply in the area; the client is instructed not to chew or swallow the medication.

Administration of Inhaled Medications

Handheld devices for delivering medication into the respiratory passages.

Administration of Paste Medications

Preparation rubbed into the skin for administration of a medication (also called oils, lotions, and creams).

Rectally Administered Medication

Cleanses the lower bowel (most common reason), softens feces, expels flatus, soothes irritated mucous membranes, outlines the colon during diagnostic X-rays, treats worm and parasite infestations.

Nursing Responsibilities During a Procedure

Assess the client before the procedure.

General Nursing Responsibilities for Examinations and Tests

Determine the client's understanding of the procedure, witness the client's signature on a consent form, teach or follow test preparation requirements, obtain equipment and supplies, arrange the examination area, position and drape the client, assist the examiner, provide the client with physical and emotional support, care for specimens, record and report appropriate information.