Midterm study guide

S/sx of wound infections

Redness, warmth, swelling, purulent drainage, foul odor, fever, increased pain, delayed healing.

How do you properly change linens?

Roll dirty linens away from the patient, avoid shaking to prevent contamination, replace with clean linens from clean to dirty areas.

Handling dirty linens as a nurse

Wear gloves, avoid contact with uniform, place in designated laundry bags, never place on the floor.

Understand Maslow's Hierarchy

Physiological > Safety > Love/Belonging > Esteem > Self-actualization (address basic needs first).

intimate space

0-18 inches

Personal space

18 inches to 4 ft

social zone

4-12 feet

public zone

12 feet or more

Understand therapeutic communication skills

Active listening, open-ended questions, empathy, silence, clarifying statements.

What does PERRLA mean?

Pupils Equal, Round, Reactive to Light and Accommodation.

Term for bruising?

Ecchymosis.

What is Alopecia?

Hair loss or baldness.

Locate and name pulse sites of the body

Radial (wrist), carotid (neck), brachial (elbow), femoral (groin), popliteal (knee), dorsalis pedis (foot), apical (heart).

Where do you take the apical pulse? How?

Left midclavicular line, 5th intercostal space; use a stethoscope for 1 full minute.

Why is it important to show the patient around the room?

Reduces anxiety, promotes independence, ensures safety (e.g., call light location).

How do you provide privacy?

Close doors/curtains, cover exposed areas, ask permission before procedures.

Understand phases of wound healing

Hemostasis -> Inflammation -> Proliferation -> Maturation.

Most reliable source for determining a patient's pain

Patient's self-report.

How do you give an enema?

Position patient left Sims, lubricate tip, insert 3-4 inches, administer fluid slowly, encourage retention.

How high can you raise the enema solution?

No more than 18 inches from patient

How do you receive a sterile sample from an indwelling catheter?

Clean port with alcohol, use sterile syringe to aspirate urine from sampling port.

How do you transfer a patient with an indwelling catheter from the bed to the bath?

Secure catheter tubing to leg, ensure bag is below bladder, avoid tension on tubing.

What are the first steps to performing a straight catheter?

Verify order, gather supplies, perform hand hygiene, explain procedure, position patient.

What is a Guiac test?

Fecal occult blood test (detects hidden blood in stool).

Brand new tracheostomy patient; what is the nursing intervention?

Ensure airway patency, monitor for bleeding/occlusion, provide humidified oxygen, keep obturator at bedside.

Calcium sources

Dairy, leafy greens, fortified foods, almonds.

What is included in a clear liquid diet?

Water, broth, apple juice, gelatin, tea (no pulp or solids).

What is the mandible responsible for?

chewing and speech.

ADPIE

Assessment, Diagnosis, Planning, Implementation, Evaluation.

How can you prevent skin breakdown?

Reposition every 2 hours, use pressure-relieving devices, keep skin clean/dry, optimize nutrition.

What is the intervention for a patient that is having a hard time breathing? What position?

High Fowler's position, administer oxygen, assess vital signs.

How do you prepare a patient for an Xray?

Remove metal objects, assess for allergies to iodine or shellfish,

What is dysphagia?

Difficulty swallowing.

Nursing intervention for a Barium Swallow

NPO before test, monitor for aspiration, encourage fluids post-test to prevent constipation.

What is the difference between inter-agency and intra-agency?

Inter-agency = between organizations; intra-agency = within the same organization.

How do you deflate an indwelling catheter?

Insert syringe into inflation valve, withdraw all fluid gently.

What are the muscles of your thigh?

Quadriceps (front), hamstrings (back), adductors (inner).

What are the layers of the skin?

Epidermis, dermis, hypodermis.

Types of cell transport

Passive (diffusion, osmosis), active (pumps), vesicular (endocytosis/exocytosis).

What is keratin? What does it do?

Structural protein; protects skin/hair/nails from damage.

What are the Cavities of your body? What organs are in them?

Cranial: Brain. Thoracic: Heart, lungs. Abdominopelvic: Liver, intestines, bladder.

What organs are in the cranial cavity?

Understand the Urinary process

Filtration (kidneys) > reabsorption/secretion > urine storage (bladder) > excretion (urethra).

Understand the Digestive System and Route

Mouth > esophagus > stomach > small intestine > large intestine > rectum > anus.

Understand the Skeletal system

Supports body, protects organs, produces blood cells, stores minerals.

What bone supports the majority of the body when standing?

Tibia (thigh bone).

Layers of the ears

Outer (pinna), middle (ossicles), inner (cochlea/vestibule).

Parts of the Heart and Flow of blood

RA > RV > lungs > LA > LV > aorta > body.

Structures and function of the eyes

Cornea (refracts light), retina (detects light), lens (focuses).

Lobes of the Brain and their Functions

Frontal: Reasoning/movement. Parietal: Sensory. Temporal: Hearing/memory. Occipital: Vision.

Layers of the Uterus and their Functions

Endometrium (sheds during menstruation), myometrium (contracts), perimetrium (outer layer).

Oxygen use for the Home

Ensure no open flames, secure tanks upright, use humidification if ordered.

Donning PPE

gown, mask, goggles, gloves

Doffing PPE

gloves, goggles, gown, mask