Exam 1 Practice Questions: Foundations

Vital Signs

• Vital signs include measurements of the body's essential functions: temperature, pulse, respiration rate, and blood pressure.
• Important for assessing overall patient well-being and identifying potential health issues.

Adverse Events

• An adverse event can escalate to a sentinel event, significantly impacting patient safety and outcomes.
• Sentinel events are defined as serious, life-threatening incidents that require immediate attention.

SBAR Communication

• SBAR stands for Situation, Background, Assessment, Recommendation, and is used for reporting patient status changes.
• Essential for effective communication among healthcare providers.

Circadian Rhythm and Body Temperature

• Body temperature fluctuates by approximately 2 degrees Fahrenheit within a 24-hour period due to circadian rhythms.
• Lowest temperature recorded around 3 AM during sleep and decreased metabolism.
• Highest temperature observed between 4-6 PM when the body is active and metabolic functions peak.

Core Body Temperature Measurement

• Rectal temperature is typically one degree Fahrenheit higher than oral.
• Tympanic and temporal artery temperatures share blood supply with the hypothalamus, providing reliable core temperature readings.

Pulse Characteristics

• Key pulse characteristics include rate/frequency, rhythm, regularity, quality, and strength.
• Average adult pulse: 60-100 beats per minute (bpm); newborn pulse rate: 130-160 bpm.
• Tachycardia is defined as a heart rate over 100 bpm; bradycardia is under 60 bpm.

Blood Pressure Measurement

• Manual blood pressure measured at the brachial artery in the upper arm.
• Proper cuff sizing: width should be 40% of arm circumference, length should be 80% of arm length.

Korotkoff Sounds

• Sounds used to determine systolic and diastolic blood pressure during manual readings.
• The first Korotkoff sound indicates systolic BP; the fifth sound signifies diastolic BP.
• The fourth Korotkoff sound in children may be muffled and lower in pitch.

Auscultatory Gap

• Refers to a period of diminished or absent Korotkoff sounds during blood pressure measurement.
• Important for accurate reading, as it helps prevent overestimation of diastolic BP and underestimation of systolic BP.

Orthostatic Hypotension

• A significant drop in blood pressure when changing positions (e.g., from lying to standing).
• Common after prolonged bed rest, surgery, dehydration, or in patients with anorexia.

Pain Assessment and Management

• Best assessed through patient verbal reports; vital signs are supplementary.
• Pain scales include Numeric (0-10), Faces, and CRIES.
• Interventions may include massage, hot/cold therapy, medications, relaxation techniques, and distraction.

NCLEX Examination

• NCLEX-RN is a mandatory computer adaptive test for nursing graduates seeking RN licensure in the US and Canada.

Objective vs. Subjective Data

• Objective data consists of measurable factors (e.g., temperature, heart rate).
• Subjective data includes patient statements on their condition (e.g., “I cannot catch my breath”).

Signs of Impending Respiratory Distress

• Early indicators include increased respiratory rate, decreased oxygen saturation, heightened anxiety, and breathing difficulty.
• Monitoring vital signs is crucial for early detection and intervention in respiratory distress scenarios.

Effective Communication

• Demonstrating interest fosters better patient relationships.
• Acceptance is crucial to create a welcoming environment.
• Courtesy and kindness enhance interactions with patients.
• Sincerity builds trust in the caregiver-patient relationship.
• Maintaining confidentiality protects sensitive patient information.
• Compassionate care improves patient comfort and well-being.
• Beware of bias that may affect judgment and interactions.
• Tone of voice can greatly influence patient responses.
• Avoid distractions during communication for improved focus.
• Lack of eye contact may lead to perceptions of disinterest.
• Non-verbal communication can convey unintended messages.

Bathing

• Bathing removes microorganisms, secretions, excretions, and dead skin cells.
• Stimulates circulation and enhances a sense of well-being.
• Promotes relaxation and comfort for the patient.
• Prevents unpleasant body odors and fosters positive rapport between nurse and patient.
• Bathing techniques vary based on patient condition and safety needs.

Infant Bathing

• Safety is a priority; always supervise infants during bathing.
• Control water temperature to prevent burning.
• Clean from clean to dirty, starting with limbs for hygiene.

Bathing Obese Patients

• Prioritize safety when assisting obese patients in the shower.
• Use proper support for areas with skin folds (pannus) such as breasts and thighs.
• Consider specialized gowns for comfort and ease of bathing.
• Pay extra attention to foot care and any skin sensitivities.

Bathing Elderly Patients

• Monitor for dry and fragile skin; use appropriate lotion.
• Be cautious with water temperature due to sensitivity to heat.
• Safety measures are essential to prevent slips or falls.

Bathing Unconscious Patients

• Be aware of potential biting reflexes; use side lying position when needed.
• Suctioning may be necessary to prevent aspiration.
• Communication remains key, even if the patient cannot express pain.
• Assistive measures are crucial for patient safety during bathing.

Cultural/Religious Considerations

• Personal hygiene practices vary, with some cultures preferring daily baths and others weekly.
• Attitudes toward deodorant use may differ significantly.
• Expectations around privacy can vary, impacting bath time logistics.
• Personal hygiene may need to be performed by same-sex caregivers, especially in certain cultures.
• Previous traumatic events can influence a patient's comfort with bathing.

Bed Positions

• Flat position allows for general comfort.
• Low Fowlers (15°-30°) aids in some medical conditions.
• Semi Fowlers (>30°-45°) is common for respiratory and cardiac conditions.
• High Fowlers (80°-90°) benefits patients with severe respiratory distress.
• Trendelenburg position places the head down and feet elevated for specific medical scenarios.
• Reverse Trendelenburg raises the head while the feet remain down, used in certain diagnostics.

Changing a Bed

• Always don clean gloves to promote hygiene.
• Essential linens include fitted sheet, draw sheet, flat sheet, chux, pillowcase, and comforter.
• Ensure proper corner techniques like hospital corners or mitered corners for a neat finish.
• Special techniques are required for making an occupied bed to ensure patient comfort and safety.

Fall Risk Assessment

• Scores range from low (0-5 points) to high (up to 28 points); 6-13 points indicate moderate risk.
• High scores correlate with increased fall risk, necessitating preventive measures.

Medications Affecting Fall Risk

• Medications that heighten fall risk include:
  • PCA/Opiates, anticonvulsants, antihypertensives, diuretics, hypnotics, laxatives, sedatives, and psychotropics.
• Diuretics and laxatives increase fall risk due to more frequent trips to the bathroom.

Patient Tethering

• Tethered refers to being connected to devices that hinder movement, such as IV poles, chest tubes, catheters, and SCDs (Sequential Compression Devices).

Importance of Mobility

• Early mobilization is crucial to maintain functioning systems and prevent respiratory, cardiovascular, and musculoskeletal issues.
• Atelectasis and pneumonia risk heighten with immobility due to poor lung expansion and secretion stasis.
• Cardiovascular risks include orthostatic hypotension and thrombus formation.
• TEDS (Thrombo-Embolic Deterrent stockings) and SCDs are used to minimize clot risk.

Musculoskeletal and Nutritional Risks

• Immobile patients face risks of osteoporosis, contractures, muscle atrophy, decubitus ulcers, and injury.
• Nutrition concerns involve calcium loss and negative nitrogen balance, indicating more protein breakdown than synthesis due to immobility.

Elimination Issues

• Urinary tract infections (UTIs), renal calculi, and constipation are common elimination problems for immobile patients.

Restraints

• Restraints can be physical or chemical to prevent unsafe patient movement.
• Utilization of restraints is necessary when patients pose safety threats.

Monitoring Patients Under Restraint

• Check patients restrained for confusion hourly after application, then every two hours for range of motion and activities of daily living.

Safe Patient Handling

• Use appropriate devices, like Hoyer lifts and draw sheets, to reduce friction and shear when repositioning patients.
• Always use lift devices when available for safer patient movement.

Defining Mobility

• Mobility pertains to a person's ability to move freely and perform daily living functions.
• It is crucial for both physical and psychological health, with variations in individual mobility status.

Immobilization Scenarios

• Bed Rest (BR) indicates patient is to stay in bed.
• Out of Bed (OOB) allows patient to get up.
• Non-Weight Bearing (NWB) restricts weight on a limb.

Patient Positions

• Supine: lying on back.
• Prone: lying face down.
• Abduction: moving arms away from the body.
• Adduction: moving arms toward the body.
• Flexion: decreasing angle at a joint (e.g., bicep curl).
• Hyperextension: extending beyond normal limits (e.g., straightening arm).

Suctioning Principles

• Suction to the end of the tracheostomy tube or maximum 1 cm beyond the tube's length.
• Apply suction only during withdrawal of the catheter, either intermittently or continuously.
• Rotate the catheter while suctioning to enhance effectiveness.
• Limit suction duration to 10-15 seconds; 5-10 seconds for infants/young children.
• Hyper oxygenate the patient before and between suctioning passes.
• Restrict to a maximum of 3 catheter passes in one session.

Complications of Suctioning

• Edema and obstruction due to secretions or foreign bodies.
• Hypoxia leading to bronchospasms.
• Risk of tracheostomy decannulation.
• Potential for infection and hemorrhage.
• Skin breakdown from repeated suctioning.

Patient Assessment and Conditions

• Patient Roberts exhibits shortness of breath (SOB), increased respiratory rate (RR 28), and oxygen saturation (O2 sat) at 93% while complaining of chest pain (5/10).
• Indicators suggest possible conditions: foreign body aspiration, myocardial infarction (MI), pneumonia, or scoliosis.
• An updated assessment for Roberts shows improved O2 sat (94%) but persistent use of accessory muscles and unchanged pain rating.

Panic Attack Response

• Hyperventilation likely indicates a panic attack, resulting in decreased blood CO₂ levels.
• Treatment includes using a partial rebreather mask to reintroduce CO₂ and providing supplemental oxygen.
• Encourage slow deep breaths through the nose and pursed lips.

Pneumonia and Acute Respiratory Distress

• Symptoms include SOB, cough, high respiratory rate (RR 38), rapid heart rate (HR 106), chest pain, and low pulse oximetry (89-90%).
• Administer a non-rebreather mask with a flow rate of 10-15 L/min to deliver 55-90% oxygen.

Oxygen Weaning Process

• Wean patients from oxygen incrementally, reducing from 3L to 2.5L or 2L based on patient tolerance.
• Monitor oxygen saturation levels, work of breathing, color, and respiratory rate during the process.

Purpose and Assessment for Suctioning

• Tracheal suctioning aims to remove secretions and maintain a patent airway through a tracheostomy.
• Indications for suctioning include audible airway noises, decreased PaO₂, restlessness, agitation, and increased work of breathing.

Airway Obstruction

• Airway obstruction reduces diameter, leading to increased resistance and work of breathing (WOB).
• Key components of asthma-related obstruction: bronchoconstriction, inflammation, and mucus production.

Understanding COPD

• Chronic Obstructive Pulmonary Disease (COPD) involves inflammation and thickening of airways, causing decreased airflow and gas exchange with CO₂ retention.
• Common symptoms of COPD: SOB, productive cough, fatigue, frequent lung infections.

Accessory Muscle Usage

• Accessory muscles (sternocleidomastoid, pectoralis major, trapezius, intercostal, abdominal) are recruited during labored breathing.
• Tripod position often adopted for ease of breathing in patients with difficulty.

Signs of Altered Respiratory Function

• Indicators include cough, dyspnea, sputum production, altered breathing rates (bradypnea/tachypnea/Cheyne-Stokes), chest pain, use of accessory muscles, and adventitious breath sounds.

Specific Breathing Patterns

• Cheyne-Stokes breathing presents as cyclic patterns of increased respiratory rate and depth followed by apnea, often seen in end-stage conditions.
• Stridor: a high-pitched sound during inspiration linked to upper airway obstruction.

Medical Asepsis and Wound Care

• Proper technique is crucial to prevent contamination; reaching over a sterile field can compromise sterility.
• Different types of wound drainage are classified as follows:
  • Serosanguinous: pinkish clear fluid.
  • Sanguinous: bright red fluid indicates active bleeding.
  • Serous: clear fluid.
  • Purulent: milky, white pus with yellow or greenish tinge.

Wound Staging

• Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle; increased risk for osteomyelitis.
• Stage I: Area of redness, potentially painful, with intact skin.
• Stage II: Partial thickness loss, often appears as a blister.
• Stage III: Full thickness tissue loss; may see subcutaneous tissue but no exposed structures.
• Deep Tissue Injury: Intact tissue with a purple/red color, potentially painful.

Hospital Acquired Pressure Injury (HAPI)

• Caused by pressure from medical devices such as nasal cannulas; may lead to blister formation.

Patient Assessment Considerations

• In patients with a fractured femur, pain in the sacral area can suggest:
  • Possible tissue breakdown, diabetic neuropathy, or complications due to immobility.
  • Assess for further complications such as stage II decubitus ulcers or eschar formation.

Nursing Actions

• Prioritize actions around patient comfort and injury prevention, such as:
  • Turning the patient.
  • Wound consultation.
  • Documenting pain and wound assessments.

Surgical Drain Management

• Drains like Hemovac, Jackson Pratt, or Davol require regular emptying and suction to prevent fluid buildup.

Infection Control Precautions

• Contact Precautions: Involves wearing a gown and gloves to prevent the spread of infections.
• Droplet Precautions: Gown, gloves, and mask/shield are necessary for infections like pneumonia.
• Airborne Precautions: N95 mask or PAPR needed for infectious diseases requiring a negative pressure room.

Clostridium Difficile (C-Diff) Precautions

• Symptoms indicative of C-Diff include explosive diarrhea, abdominal discomfort, and dehydration.
• Hand hygiene for C-Diff requires soap and water; alcohol-based sanitizers are ineffective.

Sterile Dressing Changes

• A moist-to-moist dressing change involves irrigating the wound and applying pre-moistened gauze, covered by a thick bandage.
• Using sterile supplies is essential to ensure infection control during the dressing change.

Wound Classification

• Unblanchable redness indicates Stage 1 pressure ulcer.
• Stage 2 ulcer shows partial thickness loss of dermis with a red/pink wound bed.
• Stage 3 ulcer presents full thickness tissue loss with subcutaneous fat visible, without bone, tendon, or muscle exposure.
• Stage 4 ulcer features full thickness loss with exposed bone, tendon, or muscle; may have necrotic tissue.
• Unstageable wounds cannot be assessed due to slough or eschar obscuring the base.

Pin Care

• External fixators stabilize limbs during healing; avoid infection at pin sites.
• Monitor for signs of infection: redness, discharge, or pus.
• Clean pin insertion areas with pressure to prevent skin adhesion.
• Required supplies: Chlorhexidine, long Q-tips, Chucks pad, sterile or clean gloves as per policy.

Wound VAC (Vacuum Assisted Closure)

• Used for irregularly shaped or heavily draining wounds.
• Document drainage’s quality and quantity.
• Benefits: reduces edema, enhances blood flow, promotes granulation tissue, speeds recovery, and decreases hospital stay.
• Contraindications: necrotic tissue, untreated osteomyelitis, cancer in wound, active bleeding, and anticoagulation therapy.

Types of Surgery

• Inpatient surgery involves admission before surgery, transfer to OR, recovery in PACU, and return to the unit.
• Outpatient surgery allows patients to arrive on the same day, undergo surgery, and return home afterward.

Pre-operative Nursing

• Critical phase between surgery decision and transfer to OR.
• Patient consent is necessary: disclosure, awareness, or emergency consent by two doctors.
• Pre-op preparations: patient NPO status, allergy checks, medication review, and education.

Intra-Operative Nursing

• Time from entering the OR until transfer to PACU.
• OR team roles: anesthesiologist oversees until unconscious; surgeon takes over thereafter; scrub nurse assists; circulating nurse manages supplies.
• Maintain sterile technique: hands above waist, avoid touching non-sterile areas.

Post-Operative Nursing

• Continues from PACU admission to discharge.
• Goals: restore patient to pre-operative level, prevent complications, monitor vital signs, and maintain airway.
• Watch for cardiovascular complications: hypotension, shock, DVT, and PE.

Effects of Surgery on Body Systems

• GU System: Decreased urine output; monitor I&Os, may require catheterization.
• GI System: Ileus risk; monitor bowel sounds, provide fluids, and assess for constipation.
• Respiratory System: PE and atelectasis risk; encourage deep breathing and proper respiratory assessment.
• Neurological System: Monitor level of consciousness and perform neuro checks.
• Cardiovascular System: Shock and hemorrhage risks; monitor vital signs, administer fluids or transfusions as needed.

Pain Management

• Pain is a significant postoperative concern; effective management promotes healing.
• Interventions include medication, comfort measures, and promoting mobility.

Complications

• Infection: Look for signs like fever and drainage; treat with antibiotics as necessary.
• Hemorrhage: Report excessive bleeding promptly.

Vital Signs Reference

• Normal body temperature: 36.5°-37.5°C (97.6°-99.6°F).
• Adult pulse: 60-100 bpm; newborn pulse: 130-160 bpm.
• Adult respiration: 12-20 breaths/min; newborn respiration: 40-60 breaths/min.
• Adult BP: Monitor for significant changes upon standing.

Bathing Basics

• Proper identification, preparation, and room temperature are essential.
• Use CHG wipes to reduce infection rates in critical care settings.
• Document care accurately.

Bathing Special Populations

• Infants/Children: Ensure safety, supervise, and control water temperature.
• Obese Patients: Address skin folds, ensuring cleanliness and dryness to prevent infections.

Delegation Principles

• Do NOT delegate: assessments, evaluations, teaching, medications, and tasks involving unstable patients.

Medical vs. Surgical Asepsis

• Medical asepsis: reduces microorganisms and clean techniques.
• Surgical asepsis: maintains a sterile environment to prevent infection during procedures.

Aseptic Protocols

• Maintain a sterile field by avoiding contact with non-sterile items.
• Factors affecting wound healing include nutrition, circulation, immune status, age, smoking, and medications.

Wound Assessment and Healing Intentions

• Types of drainage include serous, sanguineous, serosanguinous, and purulent; assess odor for infection.
• Wound healing can occur by primary intention (clean, approximated edges) or secondary intention (gradual filling with granulation tissue).

Test your knowledge on vital signs, adverse events, SBAR communication, and the relationship between circadian rhythm and body temperature. This quiz will help you understand important healthcare concepts relevant to patient safety and assessment.