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Nurs 2000 Test-questions Solved 100% Correct
How did nursing begin? Began as informal caregiving Who was the founder of modern nursing? Florence Nightingale What did Florence Nightingale do? Emphasized sanitation, education, and statistics How did the civil war impact nursing expanded nursing roles in the United States Aspects of modern nursing evidence-based, patient-centered profession Nursing protection, promotion, and optimization of health Focuses on human responses to health problems regulated to protect public safety State board of nursing licensure, discipline, enforces Nurse Practice Act Nurse Practice ACT (NPA) defines scope of practice, legal responsibilities
Professional organizations (ANA, NLN) set standards and ethics, do NOT issue licenses CNA Certificate, basic care LPN/LVN diploma/certificate, basic nursing care under RN RN (ADN) 2 - year degree, entry-level nursing RN (BSN) 4 - year degree, leadership research, community APRN (NP, CNS, CRNA, CNM) Master's/doctorate, advanced practice NCLEX-PN LPN NCLEX-RN ADN & BSN Nursing role of caregiver direct patient care
- implementation- perform interventions
- evaluation- determine outcomes Health assessment= FIRST step continuous outcomes Holistic health assessment Considers physical, emotional, social, spiritual, and cultural factors. Focuses on the whole person Health history components Biographical data, chief complaint (CC), history of present illness (HPI), past medical history, family history, psychosocial history, review of systems (ROS) Subjective data what the patient says symptoms, feelings, perceptions ex: "I feel short of breath" Objective data what the nurse observes/measures vital signs, physical findings ex: O2 sat 93% General survey the first impression of a patient Parts of a general survey
appearance & behavior level of consciousness posture & gait body language vital signs height & weight scope of practice questions Nurse Practice Act (NPA) Licensure questions State board of nursing Patient reports symptoms Subjective data Measured findings objective data First step of nursing process Assessment Holistic care whole person Infection
Susceptible host someone with a suppressed immune system or is vulnerable to infection factors that increase a person's susceptibility to infection age, underlying diseases, malignancy, transplants, surgical procedures, radiation therapy, indwelling devices Medications: immunosuppressants, antirejection meds, antineoplastics, antimicrobials, corticosteroids, gastric suppressants physical barriers skin, mucous membranes, sweat, tears, cilia, GI flora Other body defenses Neutrophils and macrophages antibodies How does hand hygiene break the chain of infection interrupts the mode of transmission Standard precautions Used for all patients. Gloves used when in contact with body fluids Contact precautions Prevents transmission of infectious agents Gown & gloves EX: IRE & MRSA
Enteric precautions Gown & gloves MUST WASH HANDS WITH SOAP AND WATER EX: C. Diff Droplet precautions Prevent spread of infections via respiratory droplets. Surgical mask, and patient in private room EX: Influenza, rhinovirus Airborne precautions prevent the spread of pathogens that can be transmitted through the air after being expelled N95 or high-level respirator Possible negative pressure room (TB) EX: TB, covid Function of respiratory system process in which oxygen is transported to cells and carbon dioxide in transported from the cells. Gas exchange Structure of respiratory system nose, pharynx, larynx, trachea, bronchi, lungs Upper airway nasopharynx, oropharynx, laryngopharynx
exercise smoking nicotine use bronchodilation expansion of bronchiole airways sympathetic bronchoconstriction narrowing of the bronchiole airways parasympathetic Inspection for oxygenation and gas exchange look for signs in the patient's face, flared nostrils, pursed lips, cyanosis, grunting, breathing pattern, effort and quality of breathing, patient's position Palpation for oxygenation and gas exchange looking for tenderness, Crepitus crackling sound caused by air in the subcutaneous tissue tactile fremitus vibration felt in the chest wall (have patient say 99), decreases with accumulated air of fluid Percussion for oxygenation and gas exchange
assess organ borders and abnormal fluid in the lungs Resonance tone heard over normal lung tissue (low and hollow) dullness heard if fluid is collected over an organ Auscultation for oxygenation and gas exchange Use a zigzag pattern on the chest and back of the patient Bronchial lung sounds high pitched, harsh. Short during inspiration, long during expiration. Upper airway Bronchovesicular lung sounds moderate pitch and amplitude. Same length during inspiration and expiration, Middle of the shoulder blades or sternum Vesicular lung sounds low, breezy and soft. Long during expiration, short during expiration. lower lungs Crackles fine, crackling sounds made as air moves through wet secretions in the lungs. Wheezing A high-pitched, whistling breath sound that is most prominent on expiration, and which suggests an obstruction or narrowing of the lower airways; occurs in asthma and bronchiolitis.
abnormal curving of the nails that is often accompanied by enlargement of the fingertips. Caused by chromic hypoxia Eupenea 12 - 20 breaths per min, equal rate and depth, unlabored Bradypenea slow respirations, less than 12 breaths per min tachypnea fast respirations, shallow, and more than 24 breaths per minute Apnea absence of breathing Normal SpO2 range 95 - 100% Hyperventilation increased rate and depth of breathing that can lead to excess loss of CO2 from the blood causes of hyperventilation anxiety attacks, diabetic ketoacidosis, infections, lung disease Hypoventilation shallow breathing with lower respiratory rate, leading to excess CO2 levels and acidosis Causes of hypoventilation
trauma, neurological or neuromuscular disorders, opioids Schramm's model of communication communication is an engaged process where the sender and receiver send feedback messages back and forth and receive feedback Elements of the communication process Sender Message Channel Reciever Verbal Communication What is said Nonverbal communication Body language, facial expressions Electronic Communication communication via digital platforms Written communication communication via written documents (chart, letters, prescriptions) Communication barriers
use short, direct sentences. Allow time for processing strategy to overcome communication barrier- medication effects Use visual aids, ask the pt for their understanding of med and administration strategy to overcome communication barrier- effects of recreational drugs avoid stigmatizing language, be transparent strategy to overcome communication barrier- Distress Don't judge, actively listen to the patient strategy to overcome communication barrier- environmental factors utilize technology when able (video calls, messaging), be understanding, be adaptable I step of I-SBAR-R handoff tool Identify- Introduce yourself and who you are speaking to, or where you are calling from S step of I-SBAR-R handoff tool Situation- client name, age, admitting diagnosis, and CC and/or urgent need for the call B step of I-SBAR-R handoff tool Background- medical history. Includes medications and advanced directives A step of I-SBAR-R handoff tool Assessment- impression and significant findings, diagnostic tests, lab work, and vitals R step of I-SBAR-R handoff tool
Recommendations- treatment provided and the patient's response to it 2nd R step of I-SBAR-R handoff tool Read back- Read back/ repeat the message, treatment, and prescriptions from the provider. This allows for clarification and avoids errors Function of the heart and vascular system Movement of oxygenated capillary blood through tissues Adequate perfusion depends on normal functioning of BOTH the respiratory and cardiac systems Systole contraction phase. Mitral and tricuspid valves close and aortic and pulmonic valves open. It's the S1 sound (lub mitral and tricuspid valves close) Diastole relaxation phase, mitral and tricuspid valves open and the heart fills with blood. It's the S2 sound (dub aortic and pulmonic valves close) Cardaic output volume pumped by left ventricle in 1 min. Normal range for adult - 4 - 6 liters/min and 50% Stroke Volume amount of blood ejected from the left ventricle in 1 contraction (heartbeat)
Systemic racism family history/genetics Murmur Blowing or whoosing sound produced when the back flow of blood through a valve occurs and can be notes in patients with incompetent heart valves. The valves don't close correctly Stenosis Hardening of the valves, valves don't open properly Regurgitation floppy valves, valves don't close properly Bradycardia heart rate of less than 60 bpm tachycardia heart rate of more than 100 bpm Arrhythmia abnormal heart rhythm Ex: bradycardia, tachycardia, atrial fibrillation, ventricular fibrillation Mechanical failure of the heart right and left sided heart failure
Ischemia injured cells in the heart, eventually receive oxygen again Infarction injured cells do not receive oxygen, cells die Wellness strategies to promote heart health Increase fruits and vegetables No more than 2300 mg/day of sodium Less than 13 g/day of saturated fat Avoid sedentary lifestyle Incorporate walking and exercise Sleep 7-9 hrs Medication Stress management Social connections route the blood takes through the heart starting at the right atrium Right Atrium Tricuspid Valve Right Ventricle Pulmonic Valve Pulmonary artery - only artery with deoxygenated blood Lungs
