NRS 1 Exam 2

What is the primary difference between medical asepsis and surgical asepsis?

Medical asepsis is a clean technique that reduces microorganisms, while surgical asepsis is a sterile technique that eliminates microorganisms.

What is the most important infection prevention measure?

Hand hygiene.

What should you assume about all body fluids?

Assume all body fluids are infectious.

What is the rule regarding sterility in surgical asepsis?

Only sterile touches sterile; if sterility is questionable, it is considered contaminated.

What is a Healthcare Associated Infection (HAI)?

Infections acquired during healthcare treatment that were not present on admission.

What does CAUTI stand for?

Catheter Associated Urinary Tract Infection.

What are the local signs of inflammation?

Redness (erythema), swelling (edema), heat, and pain.

What are the clinical manifestations of sepsis?

Fever, tachycardia, tachypnea, fatigue, malaise, anorexia, hypotension, and confusion.

What is the sepsis bundle to be completed within 1 hour?

Lactate level, blood cultures before antibiotics, broad-spectrum IV antibiotics, IV fluids, and vasopressors if needed.

What are the normal temperature ranges for oral, rectal, axillary, tympanic, and temporal routes?

Oral: 96.8-100.4°F, Rectal: 0.9°F higher than oral, Axillary: 0.9°F lower than oral, Tympanic: 98.2-100.9°F, Temporal: 98.7-100.5°F.

What is considered a fever?

A temperature of 100.4°F or higher.

What is the normal pulse range for adults?

60-100 beats per minute.

What is the normal respiratory rate for adults?

12-20 breaths per minute.

What is the normal range for pulse oximetry?

95-100%.

What are the signs of hypotension?

Dizziness, syncope, and weakness.

What is the first line of defense in the immune system?

Innate immunity, which includes skin, mucous membranes, fever, inflammation, and phagocytes.

What triggers an immune response?

An antigen.

What do antibodies do?

They are produced to fight antigens.

What is anaphylaxis?

A life-threatening allergic reaction characterized by airway swelling, wheezing, hypotension, tachycardia, and hives.

What is the priority intervention for anaphylaxis?

Administer epinephrine.

What are the six activities of daily living (ADLs)?

Eating, bathing, dressing, transferring, toileting, and ambulation.

What is the purpose of immunizations?

To create memory cells and antibodies to prevent future disease.

What is the 15-15 rule for treating hypoglycemia?

Give 15 grams of fast-acting carbohydrates, wait 15 minutes, and recheck glucose.

What are the three P's of hyperglycemia?

Polyuria, polydipsia, and polyphagia.

What is the significance of leukocytosis?

It indicates a high white blood cell count, often suggesting infection.

What is the proper technique for female perineal care?

Clean from front to back.

What is the recommended position for oral care in an unconscious patient?

Side-lying position.

What should be done to prevent falls in older adults?

Keep the bed in a low position, ensure the call light is within reach, use non-slip footwear, and clear pathways.

Leukopenia

Low total white blood cell count, increases risk of infection.

Neutropenia

Low neutrophil count; increases risk of bacterial infection.

Left Shift

Increase in immature neutrophils (bands); usually indicates acute infection

Neutrophils

First responders to infection; engulf and destroy bacteria.

Basophils

Release histamine during allergic and inflammatory responses.

Eosinophils

Fight parasites and participate in allergic reactions.

Monocytes

Large white blood cells that become macrophages and perform phagocytosis

B Cells

Lymphocytes that produce antibodies.

T Cells

Lymphocytes that directly attack infected or abnormal cells.

Antigen

Foreign substance that triggers an immune response.

Antibody

Protein produced by B cells that fights a specific antigen.

Innate Immunity

Nonspecific immunity present at birth; responds immediately and has no memory

Adaptive Immunity

Specific immunity that develops after exposure to a pathogen and has memory

Active Immunity

Body produces its own antibodies

Passive Immunity

Antibodies are received from another source

Anaphylaxis

Severe life-threatening allergic reaction causing airway swelling, wheezing, hypotension, and hives

Priority Treatment for Anaphylaxis

Epinephrine

Latex Allergy

Hypersensitivity reaction to latex products causing rash, itching, or respiratory symptoms

Transfusion Reaction

Adverse reaction to blood transfusion causing fever, chills, dyspnea, back pain, or hypotension

First Nursing Action for Transfusion Reaction

Stop the transfusion immediately

HIV

Virus that attacks CD4 T-helper cells and weakens the immune system

Lupus

Autoimmune disease where the body attacks its own tissues; commonly causes fatigue, joint pain, and butterfly rash

Rheumatoid Arthritis

Autoimmune disease causing chronic inflammation, pain, swelling, and stiffness of joints

Hyperthermia

Body temperature greater than 104.4°F.

Hyperthermia Interventions

Provide fluids, encourage rest, administer antipyretics, and prevent shivering

Hypothermia

Body temperature less than 95°F

Hypothermia Interventions

Use warming blankets, warm IV fluids, keep head covered, and monitor closely

When Should Vital Signs Be Assessed?

On admission, changes in condition, before/after procedures, medication administration, and high-risk activities

Pain

Whatever the patient says it is; considered the fifth vital sign

Nonpharmacologic Pain Management

Repositioning, relaxation, distraction, massage, heat therapy, and cold therapy

Pharmacologic Pain Management

Pain management using medications such as non-opioids and opioids

Pulse Oximetry

Measurement of oxygen saturation in the blood

Normal Pulse Oximetry

95% - 100%

Autonomy

Patient's right to make decisions regarding their own care

Activities of Daily Living (ADLs)

Eating, bathing, dressing, toileting, transferring, and ambulation

Female Perineal Care

Clean from front to back

Male Perineal Care

Clean from the urinary meatus outward in a circular motion

Foley Catheter Care

Clean from the urinary meatus outward along the catheter tubing

Oral Care for Unconscious Patient

Place patient in side-lying position to prevent aspiration

Fall Precautions

Keep bed low, call light within reach, use nonslip footwear, and keep pathways clear

Gait Belt

Safety device used to assist patients during transfers and ambulation

Carbohydrates

The body's primary source of energy

Glucose

Simple sugar produced from carbohydrate metabolism and used for energy

Simple Carbohydrates

Rapidly absorbed carbohydrates that cause a quick rise in blood glucose

Complex Carbohydrates

Carbohydrates that digest slowly and provide a steady release of glucose

Glycemic Index

Measure of how quickly a food raises blood glucose levels

Carbohydrate Counting

Meal-planning method used to manage blood glucose levels

Hypoglycemia

Blood glucose less than 70 mg/dL

Signs of Hypoglycemia

Shakiness, sweating, confusion, hunger, headache, and dizziness

15-15 Rule

Give 15 g of fast-acting carbohydrates, wait 15 minutes, then recheck blood glucose

Hyperglycemia

Blood glucose greater than 130 mg/dL fasting or greater than 180 mg/dL after meals

3 P's of Hyperglycemia

Polyuria, polydipsia, and polyphagia

Protein

Nutrient responsible for growth, tissue repair, and wound healing

Protein Deficiency

Can cause weakness, hair loss, poor wound healing, increased infection risk, and muscle wasting

Patients Who Need Increased Protein

Patients with wounds, burns, surgery, infection, or tissue healing needs

Vaccine

Example of artificial active immunity: stimulates memory cell formation

Low Sodium Diet

Restricts sodium intake; commonly used for hypertension and heart failure

Diabetic Diet

Controls carbohydrate intake to manage blood glucose levels

Renal Diet

Restricts sodium, potassium, phosphorus, and fluids to reduce kidney workload

Clear Liquid Diet

Includes transparent liquids; used before procedures

Broth & jello

Full Liquid Diet

Clear liquids plus foods liquid at room temperature

milk & creamy soups

Soft Diet

Easy to chew, swallow, and digest foods

Scrambled eggs & flaky fish

High Protein Diet

Promotes tissue repair and wound healing

Chicken & turkey breast

Enteral Nutrition

Nutrition delivered through the gastrointestinal tract via feeding tube

Parenteral Nutrition

Nutrition delivered intravenously when the GI tract cannot be used

Malnutrition

Deficiency of nutrients causing weight loss, muscle wasting, weakness, and delayed healing