Nursing Exam #1 Practice Flashcards

HGTC Integrated Nursing Concepts and Aims

• HGTC 5 Integrated Concepts:

  • 1. Safety
  • 2. Teamwork & collaboration
  • 3. Clinical decision making
  • 4. Professional behaviors
  • 5. Patient centered care

• Aims of Nursing:

  • Promote health
  • Prevent illness
  • Restore health
  • Facilitate coping with disability/death

Nursing Standards, Legislation, and the Nursing Process

• Nursing Practice Standards:

  • These protect the patient, the nurse, and the institution.
  • They define how a nurse's roles are normally done.

• Nurse Practice Acts:

  • These regulate nursing practice in each individual state; every state has a different act.
  • They specify the exact acts nurses can and cannot perform.
  • Reciprocity: Occurs when one state recognizes a nursing license granted in another state.
  • Not knowing the nurse practice act of a specific state is not considered a legal defense.

• ADPIE: The Nursing Process:

  • Assess: Collecting data.
  • Diagnose: Identifying the problem.
  • Plan: Establishing goals.
  • Interventions: Taking action.
  • Evaluation: Checking if the goals were met.
  • Example (Post-appendectomy):
    • Assess: Pain scale is documented as $8/10$.
    • Diagnosis: Surgical pain.
    • Plan: Goal is to make the patient feel better.
    • Interventions: Administering medications, applying an ice pack, or repositioning the patient.
    • Evaluation: Determining if the intervention worked and if the pain is relieved.

Nursing Knowledge, Reasoning, and Research Methodology

• Nursing Knowledge Categories:

  • Traditional Knowledge: Wisdom handed down from nurse to nurse. This is not always accurate; it is simply "the way things are done."
  • Authoritative Knowledge: Knowledge from an expert nurse. Example: A wound care nurse teaching how to clean a wound vac.
  • Scientific Knowledge: Knowledge derived from research and science, which involves proving and demonstrating findings.

• Nurses' Reasoning:

  • Inductive Reasoning: Based on the principle of $2+2=4$. It follows a pattern of performing specific steps to achieve a result (Do this, do that, this is what you get).
  • Deductive Reasoning: Based on the principle of $4=2+2$. It looks at the result and identifies the cause (Because of this you have this).

• Nursing Research Fundamentals:

  • Involves using data to drive high-quality nursing care rather than simply following history.
  • Qualitative Research: Used to gain insight into the "art of nursing" and human experiences, typically through interviews.
  • Quantitative Research: Provides data for the "science of nursing" via statistics.

• PICOT Framework (Structured Research):

  • P (Patient, population, or problem of interest): HGTC Georgetown campus nursing students.
  • I (Intervention of interest): Having Nursing 101 as a hybrid class.
  • C (Comparison of interest): Performing the class in person.
  • O (Outcome of interest): Student satisfaction with the hybrid model.
  • T (Time): One semester.

Infection Control Principles and Terminology

• Key Definitions in Infection Control:

  • Endemic: A disease that lives in a specific area constantly.
  • Pandemic: A disease that spreads rapidly around the world.
  • Endogenous: Originates inside the body.
  • Exogenous: Originates outside the body.
  • Fomite: A nonliving object that can carry microorganisms.
  • HAIs: Healthcare-associated infections.
  • Asphyxiation: When the body does not receive enough $O_2$.

• The Infection Cycle:

  1. Infectious Agent: Bacteria, fungus, virus, or parasite.
  2. Reservoir: Human, soil, food, animal, or water.
  3. Portal of Exit from Reservoir: Opening in the skin or mucous membranes.
  4. Means of Transmission: Touching, breathing, or coughing.
  5. Portal of Entry: Nose, skin, or ingestion.
  6. Susceptible Host.

• Infectious Agents and Treatments:

  • Bacteria: Characterized by shape, gram stain, and $O_2$ needs. Treated with antibiotics like amoxicillin or cipro.
  • Fungus: Includes mold. Treated with antifungals.
  • Viruses: Must be inside a human cell to replicate (e.g., the flu). Treated with antivirals.
  • Parasite: Includes lice and scabies.

Clinical Stages of Infection and Prevention

• Five Moments for Hand Hygiene:

  1. Before touching a patient.
  2. Before a clean or aseptic procedure.
  3. After bodily fluid exposure risk.
  4. After touching a patient.
  5. After touching patient surroundings.

• Stages of Infection Development:

  1. Incubation: The moment the agent enters the body; no signs or symptoms are present.
  2. Prodromal: The most infectious phase; the patient feels like they are "getting sick."
  3. Full Illness: The phase where the patient feels the most sick.
  4. Convalescence: The recovery period.

• Cardinal Signs of Acute Infection:

  • Rubor: Redness.
  • Erythema: Heat.
  • Edema: Swelling.
  • Pain.
  • Loss of function.

• Healthcare-Associated Infections (HAIs):

  • CAUTI: Catheter-associated urinary tract infection.
  • SSI: Surgical site infection.
  • CLABSI: Central line associated bloodstream infection.
  • VAP: Ventilator-associated pneumonia.

• Resistant Organisms:

  • Vancomycin-resistant enterococci.
  • Clostridium difficile.
  • Methicillin resistant staphylococcus aureus (MRSA).
  • Multidrug resistant tuberculosis.
  • Carbapenem-resistant enterobacteriaceae.
  • Streptococcus pneumonia.

Transmission-Based Precautions and Asepsis

• Standard Precautions: Used for contact with blood, bodily fluids, secretions, nonintact skin, and mucous membranes (excludes sweat). Requires mask, goggles, gloves, and gown.

• Airborne Precautions (MTV):

  • Applies to Rubeola (measles), TB, and Varicella (chicken pox).
  • Requires a negative pressure room and N95 respirator.
  • Transport the patient only if necessary; visitors must wear a mask.

• Droplet Precautions:

  • Applies to COVID, FLU, rubella, mumps, diphtheria, adenovirus, and pertussis.
  • Requires a private room, mask, and goggles.
  • Visitors must stay at least $3\text{ ft}$ away.
  • The patient must wear a surgical mask if transported.

• Contact Precautions:

  • Applies to MRSA, VRE, ESBL, C. diff, and drug-resistant organisms.
  • Requires gloves and gown; movement of the patient must be limited.

• Enteric Precautions (CDIFF): Hand hygiene must be done with soap and water; surfaces must be cleaned with bleach.

• Aseptic Techniques:

  • Medical Asepsis: Clean technique.
  • Surgical Asepsis: Sterile technique.

• PPE Sequences:

  • Donning: 1. Gown, 2. Mask, 3. Goggles, 4. Gloves.
  • Doffing: 1. Gloves, 2. Goggles, 3. Gown, 4. Mask.

Patient Safety and Injury Prevention

• Cues of Risk in Assessment: Mobility, communication, awareness/orientation, alteration in sensory perception, safety hazards, and signs of domestic violence or neglect.

• Restraints:

  • Should be avoided whenever possible.
  • Physician orders for restraints are only valid for $24\text{ hr}$.
  • Skin must be checked every $2\text{ hr}$.
  • Risks: Increased injury, skin injury, depression, anxiety/delirium, aspiration, and death.

• Safety Concerns for Older Adults: Environment, driving, slow reflexes, vision/hearing loss, smoke detectors, medications, and neglect/abuse.

• Fire Safety (RACE and PASS):

  • RACE:
    • Rescue: Anyone in immediate danger.
    • Activate: Fire code and notify appropriate personnel.
    • Confine: The fire by closing doors and windows.
    • Evacuate: Patients and people to a safe area.
  • PASS:
    • Pull the pin.
    • Aim at the base of the fire.
    • Squeeze the handle.
    • Sweeping motion.

Assistive Devices for Mobility

• Crutches:

  • 3-point and 4-point gaits: 4-point mimics the movement of regular walking.
  • Stair Climbing Up: Good foot first, then bad foot, then crutches.
  • Stair Climbing Down: Crutches first, then bad foot, then good foot.

• Cane:

  • Hold the cane in the hand opposite of the injured leg.
  • Sequence: Bad foot, good foot, then the assistive device.

• Walker:

  • Sequence: Move the walker, then the bad leg, then the good leg.

Fundamentals of Vital Signs

• Key Vital Sign Terms:

  • Afebrile: Absence of fever.
  • Febrile/Pyrexia: Having a fever.
  • Auscultatory Gap: Disappearing of Korotkoff sounds when palpating the brachial pulse while taking blood pressure.
  • Bradycardia/Tachycardia: Slow or fast heart rate.
  • Hypertension/Hypotension: High or low blood pressure.
  • Orthostatic Hypotension: Drop in BP when changing positions.

• Vital Sign Normals for Healthy Adults:

  • Temperature (T): $37.0^{\circ}C$ ($98.6^{\circ}F$).
  • Pulse (P): $60\text{--}100$ beats per minute (average is $80$).
  • Respiration (R): $12\text{--}20$ breaths per minute.
  • Blood Pressure (BP): $120/80\text{ mmHg}$.
  • Oxygen Saturation ($O_2$ sat): $>95\%$.
  • Pain: Considered the fifth vital sign.

• When to Assess Vital Signs: Upon admission, during a change in patient status, loss of consciousness, before and after surgery, before and after activity (e.g., ambulation), and before meds affecting CV or respiratory function.

Vital Signs: Temperature Regulation and Management

• Heat Production:

  • Primary source is metabolism.
  • Increased by hormones, exercise, muscle movements, thyroid hormone, and shivering.
  • Epinephrine and norepinephrine alter metabolism when extra heat is needed.

• Sources of Heat Loss: Skin (primary), sweat, breathing, urine, and feces.

• Site-Specific Normal Temperatures:

  • Oral: $37.0^{\circ}C$ / $98.6^{\circ}F$.
  • Rectal (Core): $37.5^{\circ}C$ / $99.5^{\circ}F$ (requires an order).
  • Axillary: $36.5^{\circ}C$ / $97.7^{\circ}F$.
  • Tympanic: $37.5^{\circ}C$ / $99.5^{\circ}F$.
  • Forehead: $34.4^{\circ}C$ / $94.0^{\circ}F$.

• Types of Fevers:

  • Intermittent: Temperature fluctuates but returns to normal at least once every $24\text{ hr}$.
  • Remittent: Temperature fluctuates but does not return to normal.
  • Sustained/Continuous: Remains above normal with minimal variations.
  • Relapsing/Recurrent: Returns to normal for one or more days between fever episodes.

• Fever Effects and Treatment:

  • Effects: Muscle aches, fatigue, increased HR/respiration, electrolyte imbalances, seizures, confusion, headache, thirst.
  • Tx: Comfort, medication, simple carbohydrates, cool baths, increased fluid intake.

Vital Signs: Pulse and Blood Pressure

• Pulse Physiology:

  • Regulated by the autonomic nervous system via the SA node.
  • Parasympathetic: Decreases HR.
  • Sympathetic: Increases HR.
  • Stroke Volume: Volume of blood ejected with each beat.
  • Apical Pulse: Found at the 5th intercostal space, left midclavicular line; listen for $60\text{ sec}$.

• Pulse Sites: Temporal, Carotid, Brachial, Radial, Femoral, Popliteal, Posterior tibial, Dorsalis pedis.

• Blood Pressure Assessment:

  • Systolic: First sound (contraction).
  • Diastolic: Second sound (relaxation).
  • Korotkoff Sounds: The "LubDub" sounds heard with a sphygmomanometer.
  • Pulse Pressure: The difference between systolic and diastolic (e.g., $120 - 80 = 40$).

• Hypertension Categories:

  • Primary (Essential): No known cause.
  • Secondary: Caused by another disease (kidney, adrenal, or aorta disorders).
  • Risk: African Americans have the greatest risk for HTN.

Vital Signs: Respiration and Gas Exchange

• Movement of Oxygen:

  • Ventilation: Air movement in/out of lungs.
  • Diffusion: $O_2$ and $CO_2$ exchange between alveoli and blood.
  • Perfusion: $O_2$ and $CO_2$ exchange between blood and tissue cells.

• Respiratory Control: Managed by centers in the medulla and pons, activated by chemoreceptors. An increase in $CO_2$ is the most powerful respiratory stimulant.

• Respiratory Rates and Patterns:

  • Eupnea: Normal; ratio of $1$ respiration to $4$ heartbeats.
  • Tachypnea: Rate over $24$/min.
  • Bradypnea: Rate under $10$/min.
  • Apnea: No breathing.
  • Dyspnea: Labored breathing.
  • Orthopnea: Changes in breathing when sitting or standing.

Physical Assessment: Fundamentals and Preparation

• Key Physical Assessment Terms:

  • Subjective Data: Symptoms (how the patient feels).
  • Objective Data: Signs (measures/observations).
  • Cyanosis: Blue discoloration.
  • Diaphoresis: Excessive sweating.
  • Ecchymosis: Skin discoloration from bleeding (blue, purple, black, yellow).
  • Jaundice: Yellow.
  • Turgor: Used to assess hydration.
  • Ascites: Fluid buildup in the abdominal cavity.
  • Bruit: Swishing sound over an artery.
  • Pallor: Pale.

• Health Assessment Types:

  • Comprehensive: Upon admission for a baseline.
  • Ongoing Partial: Regular intervals (start of shift).
  • Focused: Assessing a specific problem.
  • Emergency: Determining life-threatening conditions.

• Patient Preparation: Explain the process, ensure it will not be painful, use simple vocabulary, ask them to change into a gown and empty their bladder.

• Environment Preparation: Ensure time does not interfere with meals/visiting, ensure patient is pain-free, gather supplies, provide a curtain for privacy.

Physical Assessment: Positions and Techniques

• Patient Positions:

  • Low Fowlers: HOB elevated $15\text{--}30$ degrees.
  • Semi Fowlers: HOB elevated $30\text{--}45$ degrees.
  • High Fowlers: HOB elevated $60\text{--}90$ degrees.
  • Supine/Prone: Flat on back / Flat on stomach.
  • Lateral: On the side.
  • Sim's: Partially on side and stomach.
  • Lithotomy: Back with legs in stirrups.
  • Trendelenburg: Back with feet higher than head.
  • Reverse Trendelenburg: Back with head higher than feet.
  • Orthopneic: Sitting up and leaning forward with pillow support.

• Physical Assessment Techniques:

  1. Inspection: Assessing size, color, shape, and symmetry visually.
  2. Palpation: Light touch for temperature, turgor, moisture, and shape.
  3. Auscultation: Listening for pitch, loudness, quality, and duration.
  4. Percussion: Tapping to assess location, size, and tissue density.

Regional Physical Assessment and Physiological Variations

• Thorax and Lungs (Older Adult Variations):

  • Increased anteroposterior chest diameter (barrel chest).
  • Kyphosis (increased dorsal spinal curve).
  • Decreased thoracic expansion.
  • Use of accessory muscles for exhalation.

• CV and Peripheral Vascular (Older Adult Variations):

  • Difficult to palpate apical pulse or distal arteries.
  • Varicosities (tortuous blood vessels).
  • Increased systolic and diastolic BP; widening pulse pressure.

• Abdomen Assessment Sequence:

  1. Inspect
  2. Auscultate
  3. Palpate

• Abdominal Findings across Lifespan:

  • Newborns: Umbilical cord falls off in first few weeks.
  • Children: Pot belly (under $5$ years old); visible peristaltic waves.
  • Older Adults: Decreased bowel sounds and abdominal tone; fat accumulation on hips/abdomen.

Abdominal Anatomy and Diagnostic Parameters

• Right Lower Quadrant (RLQ): Cecum, appendix, right ovary/fallopian tube, right ureter/lower kidney, right spermatic cord.

• Right Upper Quadrant (RUQ): Pylorus, duodenum, liver, right kidney/adrenal gland, hepatic flexure of colon, head of pancreas.

• Left Upper Quadrant (LUQ): Stomach, spleen, left kidney/adrenal gland, splenic flexure of colon, body of pancreas.

• Left Lower Quadrant (LLQ): Sigmoid colon, left ovary/fallopian tube, left ureter/lower kidney, left spermatic cord.

• Midline: Urinary bladder, urethra.

• Assessing Level of Awareness:

  • Time: Date, day, season, last holiday.
  • Place: Current location, city, state.
  • Person: Name, age, visitors.

• Nurse's Role in Diagnostics:

  • Assist before, during, and after tests.
  • Witness patient consent (obtaining consent is the provider's job).
  • Schedule tests and transport specimens.

Specialized Clinical Assessments and Skin Conditions

• Medical Skin Conditions:

  • Petechiae: Tiny red blood spots (infection/platelet issues).
  • Purpura: Larger red spots (blood thinners/vitamin deficiency).
  • Early Hematoma: Swollen, hard collection of blood under the skin.
  • Excoriation: Raw skin breakdown.
  • Cellulitis: Red, hot, painful skin.
  • Uremic Frost: Frost-like buildup on skin in dialysis patients.

• Specialized Tests:

  • Weber & Rinne Test: Tuning fork exam for hearing (Conductive vs. Sensorineural).
  • Crepitus: Grinding or crunching in joints.
  • Romberg Test: Standing barefoot with eyes closed to evaluate balance.
  • Glasgow Coma Scale (LOC):
    • Eye opening: spontaneous ($4$) to none ($1$).
    • Verbal response: oriented ($5$) to none ($1$).
    • Motor response: obeys commands ($6$) to none ($1$).
    • Scores: $13\text{--}15$ (mild), $9\text{--}12$ (moderate), $3\text{--}8$ (coma).