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NUR 324 Fundamentals Exam 1 With
Complete Solutions
examples of pathogens - ANSWER bacteria, viruses, fungi, parasites, prions what is virulence - ANSWER the ability of a pathogen to invade and injure a host what are standard precautions - ANSWER They are used during every patient interaction. Often described as "acting like every patient has a disease that can be easily transmitted to the HCP" examples of standard precautions - ANSWER hand hygiene, PPE, resp. hygiene and cough etiquette, sharps safety, safe injection practices, sterile instruments, and clean/disinfected environmental surface What is the chain of infection? - ANSWER infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host what are resident organisms? - ANSWER the normal flora of the body do resident organisms cause illness to the body? - ANSWER no because these are permanent bacteria that exist on the host's skin and inside the body what 4 factors go into the potential of a disease developing? - ANSWER the number of microorganisms virulence of the microorganisms ability to enter/survive the host susceptibility of the host
what is reservoir? - ANSWER a place where microorganisms survive, multiply, and await transfer examples of reservoirs for pathogens? - ANSWER humans, animals, infects, food, surfaces examples of environmental factors that effect the survival of an organism? - ANSWER food, oxygen, water, temperature, pH, and light what is the "portal of entrance/exit" in the chain of infection? - ANSWER where the microorganism enters or exits the hosts body examples of portals of entrance/exit in the chain of infection? - ANSWER blood, skin, mucous membranes, GI, GU, transplacental what is the most common mode of transportation for pathogens? - ANSWER hands and medical equipment what are 6 modes of transportation in the chain of infection? - ANSWER direct contact indirect contact droplets airborne vehicles vectors what are the 4 steps of the infectious process? - ANSWER incubation prodromal stage
inflammation draws what to the site of a injrury? - ANSWER blood, fluid, and nutrients what age group has a reduced inflammatory and immune response - ANSWER older adults / elderly what are the atypical findings/manifestations that may occur in the elderly when they are experiencing an infection? - ANSWER agitation, confusion, incontinence why does the elderly experience atypical findings when experiencing an infection? - ANSWER because they have diminished immune responses what are HAIs? - ANSWER health-care associated infections what is another name for HAIs? - ANSWER nosocomial infections what is an HAI/nosocomial infection? - ANSWER infections that a client acquires while receiving care in a health care setting a patient reports that they are suffering from a staph infection as a nosocomial infection. where in the hospital were they most likely to contract the infection?? - ANSWER in the ICU what is the best way to prevent HAIs? - ANSWER through hand hygiene what are the common sites of HAIs in the body? - ANSWER urinary tract, surgical wounds, respiratory tract, and bloodstream what are the most common HAIs? - ANSWER s. aureus
e. coli entercocci what is an iatrogenic infection - ANSWER infection caused by medical treatment what does it mean if an HAI is endogenous - ANSWER an overgrowth of the patient's normal flora what does it mean if an HAI is exogenous - ANSWER from outside the person what is the most common cause of HAIs of the urinary tract? - ANSWER unsterile insertion of the urinary catheter and reflux (urine doing back up the foley into the bladder what are the steps of the nursing process - ANSWER assessment diagnosis planning implementation evaluation what WBC lab value would indicate an infection - ANSWER over 10, what ESR (erythrocyte sedimentation rate) lab value would indicate an infection - ANSWER greater than 20 what is asepsis - ANSWER the absence of pathogens what is aseptic technique - ANSWER refers to practices/procedures that help reduce
what is adaptive immunity - ANSWER allows the body to make antibodies in response to the antigen highly specific to identify pathogen what is passive immunity - ANSWER antibodies are produced by an external source example: momma to baby TEMPORARY IMMUNITY + IMMEDIATE PROTECTION a patient has passive immunity to a disease. How long will that immunity last? - ANSWER only temporarily a patient has passive immunity to a disease. how soon after receiving that immunity will they be protected? - ANSWER immediately what is active immunity - ANSWER antibodies are produced in response to an antigen. can occur naturally via exposure to disease or via vaccination TAKE TIME FOR PROTECTION + PROTECTION IS PERMANENT what is the normal lab value for WBCs - ANSWER 5,000-10, what does it mean if a patient has low WBCs - ANSWER bone marrow depression from drugs (cancer chemo, radiation) what does it mean if a patient has too high WBCs - ANSWER indicates an infection
what is the normal range of hemoglobin in MEN - ANSWER 14-18 g/dL what is the normal range of hemoglobin in WOMEN - ANSWER 12-16 g/dL what is the normal range of hematocrit in MEN - ANSWER 42-54% what is the normal range of hematocrit in WOMEN - ANSWER 37-47% normal red blood cell count in MEN - ANSWER 4.2-6.0 x 10^6 mm normal red blood cell count in WOMEN - ANSWER 4.2-5.4 x 10^6 mm what is the normal platelet count - ANSWER 150,000-400, what is the normal blood glucose - ANSWER 70-110 mg/dL what is the hypoglycemic critical value of blood glucose - ANSWER <50 mg/dL what is the hyperglycemic critical value of blood glucose - ANSWER >450 mg/dL what is more deadly- hypoglycemia or hyperglycemia? - ANSWER hypoglycemia Why is hypoglycemia such a dangerous problem? - ANSWER Brain cells die without glucose, brain damage what does hemoglobin a1c measure? - ANSWER percentage of glycosylated
what does the dosage symbol "<" mean? - ANSWER less than what is capillary puncture less invasive than? - ANSWER venipuncture can capillary puncture be delegated to UAP? - ANSWER yes! unlicensed assistive personnel can do this, the RN is responsible for ensuring the task is completed and evaluation of the results what position should a finger be in before receiving capillary puncture?? - ANSWER dependent position below the heart, engorged and held at the junction where should a finger be pricked during capillary puncture - ANSWER on the side of the finger because the tip of the finger has more sensitivity Why do we wipe away the first drop of blood from capillary puncture? - ANSWER to prevent tissue fluid contamination what should a nurse do if taking capillary puncture and the site bruises or continues to bleed? - ANSWER maintain pressure what should a nurse do if taking capillary puncture and the patient doesnt bleed (edema, poor circulation) - ANSWER keep hand in dependent position, add warm pack what should a nurse do if taking capillary puncture and glucose is not within normal limits - ANSWER too high - give sliding scale insulin too low - give glucose source when should blood sugar be tested - ANSWER before meals, before bed, and when
symptomatic what is the saying that describes the symptoms of hypo/hyperglycemia - ANSWER hot and dry = sugar high cold and clammy = needs candy What does HS mean? - ANSWER hour of sleep What does qh mean? - ANSWER every hour what is important to remember when giving a patient insulin? - ANSWER FOOD NEEDS TO BE NEARBY what is the normal values for temperature (vitals) - ANSWER 96.8-100. what are the normal values for pulse (vitals) - ANSWER 60- what are the normal values for respiration (vitals) - ANSWER 12- what is the ideal blood pressure - ANSWER 120/ what is ideal oxygen saturation - ANSWER >95% how many micrograms are in 1 milligram - ANSWER 1000 mcg how many milligrams are in 1 gram - ANSWER 1,000 milligrams
what are the high alert medications when it comes to med cal? - ANSWER insulin heparin chemo vasoactive meds who are the only people allows to receive and record TO and VO? - ANSWER authorized staff. CCNS do NOT do this! what can a nurse do when taking a verbal/telephone order in order to ensure that the order is accurate? - ANSWER read back all orders and have a second RN listen to prevent errors what are the MOST IMPORTANT parts of TO/VO? - ANSWER medication dosage route time/frequency patient name date and time of order patient weight (if needed) signature of HCP what are common special considerations that occur within elderly adults? - ANSWER falls, orthostatic hypotension, heart failure, delirium what does "g" stand for? - ANSWER gram
what does "gtt" stand for? - ANSWER drop what does "IM" stand for? - ANSWER intramuscular what does "IV" stand for? - ANSWER intravenous what does "IVP" stand for? - ANSWER intravenous push what does "kg" stand for? - ANSWER kilogram what does "MI" stand for? - ANSWER myocardial infarction what does "mcg" stand for? - ANSWER microgram what does "mg" stand for? - ANSWER milligram what does "NKDA" stand for? - ANSWER no known drug allergies what does "NKA" stand for? - ANSWER no known allergies what does "NPO" stand for? - ANSWER nothing by mouth what does "oz" stand for? - ANSWER ounce what does "pc" stand for? - ANSWER post meals
right route right time right drug right dose right documentation right assessment right indication right evaluation right education (patient teaching) what is the time span that a nurse has to administer a medication - ANSWER within 30 minutes, but can be within an hour depending on the facility policy when does regular insulin begin working - ANSWER within 30 minutes When does NPH insulin peak? - ANSWER within 12-24 hours why should a nurse not check BG after a meal? - ANSWER BG will still be spiked. BG should be taken before eating a meal what medication ALWAYS requires critical thinking before administering - ANSWER insulin what system requires nurses to scan barcodes to identify a patient, medication, and ID tag of the nurse administering - ANSWER bar code medication administration system (BCMA) how does buccal (oral) medication administration work? - ANSWER place in the cheek to dissolve
how does sublingual (oral) medication administration work? - ANSWER place under the tongue to dissolve which oral med administration is more effective/faster at absorption - ANSWER sublingual is faster what is a major disadvantage to oral (buccal/sublingual) medication administration - ANSWER cant use with extended release medications what should a nurse teach a patient who is routinely taking buccal medication - ANSWER use alternate cheeks to avoid mucosal irritation when is the peak onset of IM injection - ANSWER 15-30 min when is the peak onset of an IV? - ANSWER 10-15 min when is the peak onset of PO medication - ANSWER 60 min when should GI-irritating medications be taken? - ANSWER before or after meals (ac, pc) when pouring liquid medication, how should the bottle be held - ANSWER hold bottle w label next to palm to avoid soiling label w drips do single doses of medications need to be transferred to a cup? - ANSWER no who is the ideal patient for administering suppositories rectally? - ANSWER infants
what angle should an IM injection go into the arm? - ANSWER 90 degrees should you aspirate an IM? - ANSWER YES, unless its a vaccine what region of the body is avoided when giving injections due to the sciatic nerve? - ANSWER dorsogluteal how should a patient be positioned when receive an enteral med (NG/PEG tube) - ANSWER in semi fowlers what should a nurse verify with a patient with an NG/PEG tub prior to administering medication? - ANSWER verify tube placement and residual volume what should a nurse do before giving a medication to a patient with an NG/PEG tube? - ANSWER unclamp the tub if clamped flush with 30ml of water before, between, and after meds what should a nurse do when administering medication for a patient that has tubes to suction? - ANSWER turn off suction, give med, keep suction off for 60 min, and resume suction what does a nurse do with pills that need to be administered through a NG/PEG tube? - ANSWER crush them and use fluid before, between, and after admin. enteric coated tables and capsules should not be crushed and administered via PEG /NG tube. check with pharmacy for possible substitutions how does a nurse check the residual volume of the stomach prior to administering a medication via NG/PEG tube? - ANSWER aspirate stomach contents with 60mL
syringe. if aspirate is more than 100mL, return the aspirate to the patient and withhold medication when giving multiple medications to a patient via NG/PEG tube, should they be given all at once or one at a time? - ANSWER administer them one at a time to maximize the therapeutic effect of the med what is an important thing to do when it comes to constantly administering 30ml of fluid between medications to a patient with an NG/PEG tube? - ANSWER keep track of how much water is being administered for I+O record what is an acceptable about of fluid to flush an NG/PEG tube with if a patient is on fluid restriction? - ANSWER 5 ml what may help unclog a NG/PEG tube? - ANSWER pancrealipase table and sodium bicarbonate tablet dissolved and left in the tub for 15-30 minutes what are signs and symptoms that your patient may have a NG/PEG tube that is dislocated? - ANSWER gagging, coughing, choking, cyanosis, vomiting, sounds of fluid in the lungs during chest auscultation what is important to remember to do if a patient with a continuous tube feeding is laying supine - ANSWER turn off infusion to prevent aspiration what are the sterile areas of a syringes - ANSWER entire needles tip of the syringe inside barrel stopper end of the plunger
