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FUNDAMENTALS OF NURSING LATEST UPDATE 2024/2025 EXAM WITH 100% VERIFIED ANSWERS origination of the word "nurse" from the latin word "nutrix" meaning to nourish Interrelated roles of nurses communicator, teacher, counselor, leader, researcher, advocate, collaborator coping with disability and death nurses use optimal function of maximum strengths and potentials, refer to community support systems; provide care to families and patients during end-of-life care, hospice The Nursing Process -one of major guidelines for nursing practice -helps nurses implement their roles -integrates art and science of nursing -allows nurses to use critical thinking and clinical reasoning -defines the areas of care that are within the domain of nursing Nurse Practice Acts -define legal scope of nursing practice -create state board of nursing to make and enforce rules and regulation -define important terms and activities in nursing, including legal requirements and titles for RNs and LPNs - established criteria for the education and licensure of nurses 5 vital signs respirations, pulse rate, blood pressure, temperature, and pain Nursing is recognized as profession based on what criteria -well defined body specific and unique knowledge -strong service orientation -recognized authority by a professional group (ANA) -code of ethics -professional organization that sets standards -ongoing research -autonomy and self-regulation Florence Nightingale defined nursing as both an art and science, differentiated nursing from medicine, created freestanding nursing education, published books; founder of modern nursing Clara Barton established red cross; volunteered to care for wounds and feed union soldiers during civil war; served as supervisor of nurses for the army of James sources of knowledge -traditional ( passed down from generation to generation) -authoritative- comes from an expert, accepted as truth based on person's perceived expertise -scientific (obtained through the scientific method-research) objective you can see the object subjective coming from that subject types of knowledge -science (observing, identifying, describing, investigating, and explaining events and occurences that are perceived in world) -philosophy (the study of wisdom, fundamental knowledge, and the processes used to develop and construct on perception on life) -process (a series of actions, changes, or functions intended to bring about a desired result) goals of nursing research -improve care in clinical setting -study ppl and nurse process: education, policy development, ethics, nursing history -develop greater autonomy and strength as a profession -provide evidence-based nursing practice deductive reasoning examines a general idea and then considers specific actions or ideas inductive reasoning one builds from specific ideas or actions to conclusions about general ideas health a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity avoid causing harm beneficence benefit the patient; balance benefits against risks and harms nurse practice acts each state has its own; protects public with legal scope of nursing practice standards used as guidelines for peer review (ANA) establishing an effective nurse-patient relationship -reduce anxiety through therapeutic communication, teaching, and acceptance -remember that the patient has concerns and needs other medical ones -communicate with the patient as an individual -take time to learn about the patient being admitted -provide for the family participation in all aspects of care when does discharge planning start? as soon as the patient comes in the door oral temperature for healthy adult 37.0 C, 98.6 F pulse rate for healthy adult 60-100 (80 average) respirations for healthy adult 12 to 20 breaths/min average blood pressure for healthy adult 120/80 intermittent fever temperature returns to normal at least once every 24 hours remittent fever temperature does not return to normal and fluctuates a few degrees up and down sustained or continuous fever temp remains above normal with minimal variations relapsing or recurrent fever temp returns to normal for one or more days with one or more episodes of fever, each as long as several days rectal temp 37.5 C, 99.5 F axillary temp 36.5 C, 97.7 F tympanic temp 37.5 C, 99.5 F forehead temp 34.4 C, 94.0 F heat production -primary source is metabolism -hormones, muscle movements, exercise increase metabolism -thyroid hormone and shivering also increase heat production - energy production decreases and heat production increases sources of heat loss skin (primary source), evaporation of sweat, warming and humidifying inspired air, eliminating urine and feces radiation diffusion of heat by electromagnetic waves (such as an uncovered head) factors affecting body temp -circadian rhythms -age and gender -physical activity -state of health -environmental temperature pulse is regulated by what? autonomic nervous system through cardiac sinoatrial node parasympathetic stimulation on pulse decreases heart rate sympathetic stimulation on pulse increases heart rate pulse rate the number of contractions over a peripheral artery in 1 minute places you can record a pulse temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis pulmonary ventilation movement of air in and out of lungs diffusion exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood perfusion exchange of oxygen and carbon dioxide between circulating blood and tissue cells eupnea normal, unlabored breathing, one respiration to four heartbeats tachypnea increased respiratory rate; may occur in response to increased metabolic rate bradypnea decreased respiratory rate; occurs in some pathologic conditions apnea periods when no breathing occurs dyspnea difficult or labored breathing orthopnea changes in breathing when sitting or standing assessing blood pressure -listening for korotkoff sounds w/ stethoscope -first sound is systolic -change or cessation of sound occurs: diastolic pressure - brachial artery and popliteal artery are commonly used begins 2-3 days of injury and may last up to 2-3 weeks, new tissue is built to fill wound space through action of fibroblasts, capillaries grow across wound, thin layer of epithelial cells form across wound, granulation tissue forms a foundation for scar tissue to develop maturation phase final stage of healing, begins 3 weeks to 6 months after injury, collagen remodeled, new collagen tissue is deposited, scar becomes thin white line desiccation dehydration maceration overhydration trauma physical injury edema swelling caused by excess fluid trapped in your body's tissues necrosis death of tissue wound complications -infection -hemorrhage -dehiscence(wound separates) and evisceration(protrusion) -fistula formation Dehiscence Bursting open of a wound, especially a surgical abdominal wound stages of pressure ulcers -stage1: nonblanchable erythema of intact skin -stage2: partial-thickness skin loss -stage3: full-thickness skin loss; not involving underlying fascia( epidermis and dermis) -stage4: full-thickness skin loss with extensive destruction (epidermis, dermis, and subcutaneous) -unstageable: base of ulcer covered by slough and/or eschar in wound bed measurement of pressure ulcer -size of wound -depth of wound -presence of undermining, tunneling, or sinus tract(all on wound bed) when measuring a wound measure from left to right and then top to bottom friction occurs when two surfaces rub against each other shear results when one layer of tissue slides over another layer pressure ulcer wound with localized area of injury to the skin and/or underlying tissue fistula and abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another sinus tract a cavity or channel underneath the wound that has the potential for infection cleaning a pressure ulcer clean w/ each dressing change, gentle motions (patting), use 0.9% normal saline solution to irrigate and clean, report any drainage or necrotic tissue serous drainage clear and watery sanguineous drainage blood cells present; looks like blood serosanguineous drainage mix of serum and blood cells; light pink to blood tinged purulent drainage thick, musty or foul odor, varies in color open drainage system penrose drain; promotes drainage passively closed drainage system -Jackson-pratt drain -hemovac drain may be connected to an electrical suction or built-in reservoir color classification of open wounds -R: red-protect -Y: yellow-cleanse -B: black-debride -mixed wound: contains components of RY&B wounds pain threshold the level at which a person experiences pain pain tolerance the maximum level of pain that a person is able to tolerate acute pain rapid in onset, varies in intensity and duration, protective in nature chronic pain pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period physiological measures that indicate pain increased blood pressure and pulse meaning of healing mending and getting better from disease 6 classes of nutrients supply energy: carbs, proteins, lipids regulate body processes: vitamins, minerals, water carbs -sugars and starches -organic compounds composed of carbon, hydrogen, and oxygen -lactose is an animal source -most abundant and least expensive -classified as simple or complex sugars paralysis absence of strength secondary to nervous impairment hemiparesis weakness of half of the body hemiplegia paralysis one half of the body paraplegia paralysis both legs quadriplegia paralysis of both arms and both legs anuria 24-hour urine output is less than 50mL; complete kidney shut down or renal failure dysuria painful or difficult urination frequency increased incidence of voiding glycosuria presence of sugar in the urine nocturia awakening at night to urinate oliguria scanty or greatly diminished amount of urine voided in a given time; 24-hour urine output is less than 400mL polyuria excessive output of urine (diuresis) proteinurea protein in the urine; indication of kidney disease pyuria pus in the urine; urine appears cloudy suppression stoppage of urine production; normally, the adult kidneys produce urine continuously at the rate of 60 to 120 mL/h urgency strong desire to void urinary incontinence involuntary loss of urine overflow incontinence chronic retention of urine, the involuntary loss of urine associated functional incontinence urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation reflex incontinence experience emptying of the bladder w/o sensation of the need to void total incontinence a continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation dialysis a mechanical way of filtering waste from the blood nursing process for bowels -inspection -auscultation -percussion -palpation (deep palpation is performed by advanced medical personal) when listening to bowel sounds start lower right and go up, across and down occult blood in stool blood that is hidden in the specimen or cannot be seen on gross examination direct studies going inside the body ex. colonoscopy, sigmoidoscopy indirect studies commonly performed through radiography ex. abdominal ultrasound, MRI, abdominal CT scan, small bowel series, barium enema constipation dry, hard stool; persistently difficult passage of stool; incomplete passage of stool laxatives drugs that induce emptying of the intestinal tract enema the introduction of a solution into the large intestine, usually to remove feces suppository a conical or oval solid substance shaped for easy insertion into a body cavity and designed to melt at body temperature ileostomy allows liquid fecal content from the ileum of the small intestine to be eliminated through the stoma colostomy permits formed feces in the colon to exit through the stoma ostomy surgical opening from the inside of an organ to the outside stoma the part of the ostomy that is attached to the skin normal stoma red and moist pale stoma shows signs of anemia ischemia deficiency of blood in a particular area hypoxia