Exam 1 Practice Questions: Foundations

Questions and Answers

What does the auscultatory gap indicate during blood pressure measurement?

Elevated systolic blood pressure

Continuous Korotkoff sounds

A period of diminished or absent Korotkoff sounds (correct)

Normal diastolic blood pressure

What should be added to the reading where the radial pulse is no longer felt to determine the auscultatory gap?

20 mmHg

40 mmHg

10 mmHg

30 mmHg (correct)

Which of the following situations may lead to orthostatic hypotension?

Getting out of bed after bed rest (correct)

Increased physical exercise

Lying down for extended periods

Drinking plenty of water

What is the minimum change in blood pressure readings that indicates orthostatic hypotension?

20 mmHg systolic and 10 mmHg diastolic Signup and view all the answers

Which of the following is the most reliable method for assessing pain?

Patient's self-report Signup and view all the answers

Which of the following pain scales is NOT commonly used to assess pain?

Blood pressure scale Signup and view all the answers

Who is responsible for managing a patient’s pain in a hospital setting?

Nurses, NP's, pain teams and various disciplines Signup and view all the answers

What does the NCLEX-RN stand for?

National Council for Licensure Examination for Registered Nurses Signup and view all the answers

What does an increased respiratory rate accompanied by a decreasing pulse oximetry reading indicate?

There is a change in or worsening condition. Signup and view all the answers

At what time does the body temperature typically reach its lowest point according to circadian rhythms?

3am Signup and view all the answers

What is the average pulse rate for an adult?

60-100 bpm Signup and view all the answers

Which method of measuring blood pressure requires the use of the brachial artery?

Manual measurement Signup and view all the answers

What does the first Korotkoff sound represent in blood pressure measurement?

Systolic blood pressure Signup and view all the answers

Which pulse rate is typical for a newborn infant?

130-160 bpm Signup and view all the answers

How is the proper cuff size for measuring blood pressure determined?

40% width and 80% length of the upper arm Signup and view all the answers

What is the 4th Korotkoff sound used to assess in children?

Diastolic blood pressure Signup and view all the answers

What does an increased respiratory rate indicate in a patient?

Potential respiratory distress Signup and view all the answers

What is the significance of baseline vital signs?

They indicate a specific patient's usual physiological state Signup and view all the answers

Which of the following best describes Korotkoff sounds?

Sounds heard during blood pressure assessment Signup and view all the answers

How can pulse characteristics, such as rhythm and strength, inform patient assessment?

They help determine the efficiency of the cardiovascular system Signup and view all the answers

What does a temperature reading of 101.8 F suggest about a patient's condition?

There is potential for infection or inflammation Signup and view all the answers

Which vital sign is typically the first indicator of impending distress?

Respiratory rate Signup and view all the answers

In the assessment of blood pressure, what does a high reading typically signify?

Potential hypertension or cardiovascular issues Signup and view all the answers

What is the purpose of using the SBAR tool in healthcare?

To report patient status changes effectively Signup and view all the answers

What is the primary reason for bathing a patient?

To remove dead skin cells and body secretions Signup and view all the answers

Which position is characterized by a 15° to 30° elevation of the head?

Low Fowler's Signup and view all the answers

What is an important consideration when bathing an elderly patient?

Maintaining water temperature and skin sensitivity Signup and view all the answers

What does 'clean to dirty' refer to in the context of bathing?

Starting with the less contaminated areas and moving to more contaminated areas Signup and view all the answers

Which of the following describes a common consideration regarding cultural or religious practices in personal hygiene?

Differences in opinions on the use of deodorant Signup and view all the answers

What should always be prioritized when assisting an obese patient with bathing?

Safety during entering and exiting the shower Signup and view all the answers

Which action helps in effective communication with patients?

Maintaining consistent eye contact Signup and view all the answers

What is a proper method for changing a bed effectively?

Donning clean gloves and using hospital corners Signup and view all the answers

What is a common consequence of immobility related to protein metabolism?

Negative nitrogen balance Signup and view all the answers

Which device is recommended to reduce friction and shear when moving a patient in bed?

Hoyer lift Signup and view all the answers

When dealing with an immobile patient, what elimination issues should be monitored?

UTI and renal calculi Signup and view all the answers

What should be done to check on a restrained patient after applying wrist restraints?

One hour after application, then every two hours Signup and view all the answers

What is the preferred method for safely moving a patient up in bed?

Utilizing a lift device when available Signup and view all the answers

What defines a negative nitrogen balance?

More protein breakdown than synthesis Signup and view all the answers

Why are all four siderails up considered a form of restraint?

They can lead to injury from attempting to climb over Signup and view all the answers

What is the primary reason for using restraints on a patient?

To address confusion or safety threats Signup and view all the answers

What is the purpose of using non-skid socks for patients?

To improve mobility and reduce the risk of falls Signup and view all the answers

In the Fall Risk Assessment, what does a score of 6-13 indicate?

Moderate risk of falling Signup and view all the answers

Which of the following medications is NOT associated with increasing fall risk?

Antibiotics Signup and view all the answers

What does the term 'tethered' refer to in the context of a Fall Risk Assessment?

When a patient has limited mobility due to attachments Signup and view all the answers

Which assistive device is NOT typically used to enhance mobility?

Diabetic shoes Signup and view all the answers

Why is it critical for immobile patients to start moving as soon as possible?

To decrease the risk of complications, including pneumonia Signup and view all the answers

In managing fall risks, how do TEDS and SCDs contribute to patient safety?

They decrease the chance for thrombus formation Signup and view all the answers

Which condition is NOT commonly associated with long-term immobility?

Increased flexibility Signup and view all the answers

What is the primary goal of maintaining a patient's mobility?

To support both physical and psychological health Signup and view all the answers

Which term describes a position with the patient lying on their back with the face up?

Supine Signup and view all the answers

What does NWB stand for in patient mobility status?

Not Weight Bearing Signup and view all the answers

What term is used to describe moving a limb away from the midline of the body?

Abduction Signup and view all the answers

In the context of patient care, what does proper alignment of the body help to maintain?

Reduce pressure and potential damage Signup and view all the answers

What is the purpose of hyperextension during physical movements?

To achieve a full range of motion Signup and view all the answers

Which of the following best describes a patient in a cast?

Experiencing temporary immobility Signup and view all the answers

What action should be taken to prevent foot drop in a patient who is bedridden?

Utilize foot drop splints Signup and view all the answers

What is the maximum duration for suctioning in a single attempt for adults?

15 seconds Signup and view all the answers

Which technique is essential when performing tracheal suctioning to prevent trauma to the airway?

Rotate the catheter while applying suction Signup and view all the answers

What is a significant complication that can arise from improper suctioning techniques?

Hypoxia Signup and view all the answers

How many passes with the suction catheter are recommended in one session?

3 passes Signup and view all the answers

What should be done before initiating suctioning to ensure patient safety?

Hyperoxygenate the patient Signup and view all the answers

What are the three main components contributing to airway obstruction in a patient with asthma?

Bronchoconstriction, Inflammation, Mucous production Signup and view all the answers

What symptom is NOT typically associated with Chronic Obstructive Pulmonary Disease (COPD)?

Increased appetite Signup and view all the answers

What is the position that a patient may adopt to ease difficulty in breathing, often referred to as the tripod position?

Leaning forward with arms resting on a surface Signup and view all the answers

Which accessory muscles are utilized during the effort to breathe in cases of respiratory distress?

Sternocleidomastoid and pectoralis major Signup and view all the answers

What does Cheyne-Stokes breathing indicate about a patient's condition?

Cyclic breathing pattern with periods of apnea Signup and view all the answers

What prediction can be made if a patient exhibits stridor?

They are likely to have upper airway obstruction Signup and view all the answers

In patients with COPD, what physiological change leads to CO2 retention?

Increased airway resistance Signup and view all the answers

What symptom would indicate altered respiratory function in a patient?

Use of accessory muscles Signup and view all the answers

What is a key factor in managing a patient experiencing hyperventilation due to a panic attack?

Providing a partial rebreather mask to increase CO₂ levels Signup and view all the answers

Which oxygen delivery system is recommended for a patient with pneumonia experiencing acute respiratory distress?

Non-rebreather mask with bag at 10-15 L/min Signup and view all the answers

What is an important consideration when weaning a patient off oxygen therapy?

Monitor vital signs and oxygen saturation levels during the process Signup and view all the answers

Which of the following describes the primary purpose of tracheal suctioning?

To remove secretions and maintain a patent airway Signup and view all the answers

Which assessment finding indicates a need for suctioning in a patient?

Audible gurgling sounds and decreased PaO₂ Signup and view all the answers

What could be a potential complication of improper suctioning techniques?

Tachycardia and cardiac arrhythmias Signup and view all the answers

In preparing to suction a patient, which of the following steps is NOT advisable?

Using excessive force while inserting the suction catheter Signup and view all the answers

Which assessment finding might suggest that suctioning is required due to inadequate airway clearance?

Presence of nasal flaring and retractions Signup and view all the answers

What would be the appropriate documentation for fluid that is pinkish clear in a wound dressing?

Serosanguinous Signup and view all the answers

Why is it a concern if a student reaches over a sterile field to obtain saline?

It can contaminate the sterile field. Signup and view all the answers

How would you classify a wound with visible tendons and full thickness tissue loss?

Stage IV Signup and view all the answers

What is an example of a Hospital Acquired Pressure Injury?

A friction blister from a nasal cannula. Signup and view all the answers

What term is used for a wound that has formed a filled blister on intact skin?

Stage I Signup and view all the answers

Which of the following is a characteristic of purulent fluid from a wound?

Milky, white, yellow, or greenish Signup and view all the answers

What mechanism do drains like Hemovac and Jackson Pratt use to facilitate healing?

Suction Signup and view all the answers

How should a wound with significant amounts of slough or eschar be documented?

Unstageable Signup and view all the answers

Which finding during a skin assessment would be concerning for potential tissue damage?

Painful to touch Signup and view all the answers

What is a likely contributing factor for the pain and redness observed in the patient's sacral area?

Diabetic neuropathy Signup and view all the answers

What stage would the wound correspond to given the presence of a small blister and reddened skin?

Stage II decubitus ulcer Signup and view all the answers

Which immediate action should be prioritized when dealing with a patient experiencing pain and skin changes in the sacral area?

Turn patient Signup and view all the answers

What is the primary purpose of conducting a wound culture in this situation?

To identify potential infection Signup and view all the answers

What is a key characteristic of an unstageable wound?

Visible necrotic tissue Signup and view all the answers

What complication should the nurse monitor closely after identifying a blister and small area of redness?

Infection Signup and view all the answers

What form of documentation is important following wound care procedures?

Detailed description of the wound and care provided Signup and view all the answers

What type of dressing change procedure is indicated for a wound requiring a moist-to-moist dressing?

Irrigate the wound and apply pre-moistened gauze Signup and view all the answers

What is a critical rule for disinfection when managing a patient suspected of having C-Diff?

Soap and water must be used for effective disinfection Signup and view all the answers

In the context of hospital-acquired pressure injuries, what does the term 'documentation of wound care' typically require?

Detailed records of assessments, interventions, and patient responses Signup and view all the answers

Why is it essential to use sterile supplies during a dressing change?

To minimize the risk of introducing pathogens to the wound Signup and view all the answers

What observation would most likely indicate a patient is developing a hospital-acquired pressure injury?

Redness and localized tenderness over bony prominences Signup and view all the answers

When caring for a patient under airborne precautions, what type of PPE is required?

N95 respirator or PAPR, along with gloves and gown Signup and view all the answers

During a dressing change, what step ensures that aseptic technique is maintained?

Opening sterile supplies on a clean, dry surface and avoiding touching non-sterile items Signup and view all the answers

What is the primary purpose of a negative pressure room in a healthcare facility?

To protect healthcare workers by containing airborne infection particles Signup and view all the answers

What is the normal adult resting pulse rate range?

60-100 beats/min Signup and view all the answers

During a post-operative assessment, which vital sign indicates a potential problem if it deviates from its normal range?

Temperature below 36.5°C Signup and view all the answers

What is the appropriate nursing intervention if a patient becomes dizzy after getting up from bedrest?

Assist them in returning to bed Signup and view all the answers

Which of the following options represents a normal respiratory rate for an adult?

12-20 breaths/min Signup and view all the answers

What should be done if a patient is experiencing dehydration post-surgery?

Increase their fluid intake gradually Signup and view all the answers

What is the primary responsibility when caring for a complete care patient?

Provide all of the activities of daily living (ADLs) for this patient Signup and view all the answers

When providing a bath using CHG wipes to prevent HAIs, what is a crucial step to consider?

Ensure the room temperature is comfortable for the patient Signup and view all the answers

What is a significant risk associated with bathing an obese patient?

There is a higher chance of skin breakdown due to moisture retention Signup and view all the answers

Which technique is correct for washing a patient's eyes?

Clean from inside to outside Signup and view all the answers

When teaching how to bathe an infant, which of the following is an essential guideline?

Always supervise the bath Signup and view all the answers

Which patient case should not be delegated to a nursing assistant?

The patient who needs a neuro assessment due to sudden disorientation. Signup and view all the answers

When is it acceptable to delegate care to a nursing assistant?

When a patient needs assistance with washing their back. Signup and view all the answers

What is the main difference between medical asepsis and surgical asepsis?

Medical asepsis reduces the number of microorganisms, while surgical asepsis prevents their entry. Signup and view all the answers

Healthcare Associated Infections (HAIs) are defined as infections that:

Occur within a patient's stay and were not incubating upon admission. Signup and view all the answers

Which of the following patient needs should be addressed with nursing supervision rather than delegated?

A patient making a pressure ulcer dressing change. Signup and view all the answers

In the context of aseptic technique, what should be done if an item drops out of the sterile field?

Replace the item with a new one. Signup and view all the answers

Which of the following practices is essential for maintaining medical asepsis?

Washing hands regularly to reduce microorganism spread. Signup and view all the answers

What should be done if a sterile field comes into contact with a nonsterile surface?

Start over with a new sterile field. Signup and view all the answers

What is the primary purpose of surgical asepsis during a medical procedure?

To prevent contamination of sterile environments. Signup and view all the answers

Which factor is NOT associated with impaired wound healing?

Adequate nutrition Signup and view all the answers

When assessing a wound, which type of drainage indicates infection?

Purulent Signup and view all the answers

Which type of wound healing involves the edges being approximated with minimal scarring?

Primary intention Signup and view all the answers

What is often a critical effect of obesity on wound healing?

Decreased delivery of nutrients to the wound Signup and view all the answers

Which type of clinical attire is appropriate before entering a room with a patient exhibiting c.diff in their stool?

Gloves and a gown Signup and view all the answers

How does smoking negatively impact wound healing?

It decreases circulation. Signup and view all the answers

What does a serosanguineous drainage type indicate about a wound's condition?

It is healing properly. Signup and view all the answers

What type of wound is characterized by a partial thickness loss of dermis with a red/pink wound bed?

Partial thickness loss of dermis Signup and view all the answers

What is one of the main benefits of using a Wound VAC?

Promotes granulation tissue growth Signup and view all the answers

What is a common post-operative urinary issue that may occur due to anesthesia or opioid use?

Urinary retention Signup and view all the answers

During the intra-operative phase, who is responsible for ensuring the patient is unconscious?

Anesthesiologist/CRNA Signup and view all the answers

What is the primary intervention to prevent atelectasis post-surgery?

Encouraging coughing and deep breathing Signup and view all the answers

Which condition is a contraindication for the use of a Wound VAC?

Untreated osteomyelitis Signup and view all the answers

What can patients expect regarding urinary patterns within the first 24-48 hours post-surgery?

Decreased urine output due to surgical stress Signup and view all the answers

What is one of the primary nursing roles during the pre-operative phase?

Ensure patient consent is obtained Signup and view all the answers

Which of the following is a potential complication after surgery that requires immediate attention?

Excessive bleeding Signup and view all the answers

What is a potential effect of surgery on the cardiovascular system?

Thrombus formation leading to pulmonary embolism Signup and view all the answers

Which intervention can help alleviate nausea post-surgery?

Administer antiemetics Signup and view all the answers

What should be assessed to ensure adequate recovery of the neurological system post-surgery?

Level of consciousness Signup and view all the answers

What should be included in discharge instructions for post-operative patients?

Information about medication management Signup and view all the answers

What condition can arise from decreased gastrointestinal motility after surgery?

Ileus Signup and view all the answers

Study Notes

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).

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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.