NUR 155 exam 1 questions with 100% correct answers already graded A

C-Diff specifics - not killed by alcohol - wash hands (soap & water) - contact PPE - endospores -patient in contact isolation -private room septesemia When bacteremia results in a systemic infection Bacteremia presence of bacteria in the blood / reveals microorganisms When transferring/moving a patient, you will need a second person when they are over __________ lbs. 35 What movement/transfer is used for a spinal cord injury patient? log roll Transferring a patient bed to wheelchair & vise versa you must: - lock bed & wheelchair - bend and lift with knees - do not use back - use gait belt when appropriate/needed -shoulder width stance Infection control- N95 masks used for: Airborne: Measles, TB, Varicella & Coronavirus it AIRS on MTV in '95 airborne ; Measles, TB, Varicella ; N95 masks Infection Control- surgical masks used for: Droplet: Pneumonia Mumps, Pertussis Droplets STick, Moms SCrub PErfectly Round PPs PNeriodically Diphtheria, STrep, Mumps, SCarlet fever, PErtussis, Rubella, Pnuemonic Plague, PNeumonia Hands Can Stay Clean Even My Vagina CONTACT: Hep a, C.diff, Shigella, Corona, E.coli, Mrsa, Vre How to transfer patients with airborne: patient AND nurse wear surgical mask How to transfer patient with contact: nothing is required How to transfer patient with Droplets: Patient AND nurse wear surgical mask What nurse should wear for a patient with Airborne: N95 mask & gloves What would a nurse wear for a patient with Contact: Gloves & Gown What would a nurse wear for a patient with Droplets: Surgical mask & gloves Nursing Process: Assessment Diagnosis Planning Implementation Evaluation Assess: collect data, collect patient's chief complaint Diagnosis: identifying the problem/risk/strength, analyze data, formulate Dx statement Planning: formulate goals & interventions, what you're going to do Implementation: putting it all to practice/ action Evaluation: evaluate in the goal was met? unmet? progress? Diagnosis formulated: P E D Problem ; Etiology ; Defining Characteristics Goals Formulated: S M A R T Specific, Measurable, Attainable, Realistic, Timely What do you do if you are stabbed/ cut while working: push/ milk out until fresh blood surfaces What do you do if poop/unknown substance splashes in eye/s: -clean/flush out extensively with water/eye station -tell supervisor -fill out incident report -follow up w/ PCP S O A P subjective, objective, assessment, plan Safety measures in room for patient: -clear floor of debris, wires, rugs -bed wheels locked -ambulatory aids within reach (walker/cane) -eye glasses, water, call light, etc w/in reach -bed rails up but not restraining Who is considered a health risk? -elderly adults -infants -immune compromised S B A R Situation Background Assessment Recommendation ROM movements active( activating muscles) vs passive (doing it for the patient) extension: Straightening a body part: head, finger, legs Flextion Bending a body part: head, finger, legs Hyperextension Excessive straightening of a body part: head & fingers Circumduction circular movement of a limb at the far end: head, arms/shoulders, fingers, legs, feet opposition Movement of the thumb to touch the fingertips Abduction Movement away from the midline of the body: legs, arms, fingers Aduction movement toward the midline: legs, arms, fingers Inversion turning inward, i.e., of a foot Eversion moving the sole of the foot outward at the ankle skin disorders Abnormal, primary, secondary Abnormal skin disorder: Jaundice, Cyanosis, Erythema, vitiligo, edema, etc. Primary Skin disorder: skin lesion response to change in external/ internal environment of skin (Ex: blister) Secondary skin disorder: Not initial; result from modification such as a chronicity, trauma, or infection of primary (Ex: erosion from blister) Secondary skin lesions: Atrophy Erosion Lichenification Scales Crust Ulcer Fissure Scar Keloid Atrophy wrinkles erosion scratching Lichenification thick skin ulcer pressure fissure crack, an opening; a groove; a split scar raised or flat scales dandruff crust scabs keloid overgrowth of scar tissue Excoriation rug burn, scratch, chemical burn skin lesion assessment: A - Asymmetry (equal in size) B - Border Irregularity (Jagged edges) C - Color Variegation (pink, brown, etc) D - Diameter greater than 6 mm E- Evolve Changes (re-evaluate for differences, growth, etc.) (Lung sounds) Stridor is a harsh, high pitched sound (Lung sounds) rhonchi are low/ deep pitched, snoring sounds (Lung sounds) wheezes are high pitched, 'squeaky' sounds (Lung sounds) Rales are short 'crackly' sounds/ high pitched bronchial Anterior over trachea, minimal sound Broncho-vesicular At 1st/2nd Intercostal space, moderate sound, normal breath sounds heard over the upper anterior chest and intercostal area Vesicular the soft, low-pitched, normal breath sounds heard over peripheral lung fields Base of lungs, loudest sound Stridor happens at the: Upper airway over trachea noisy/high pitched due to partial block from foreign airway obstruction