Untitled Quiz

Pressure Ulcers (Decubitus)

• Stage I: Non-blanchable redness (erythema), superficial (intact skin), epidermis tissue showing.
• Stage II: Red or pink (erythema) ulcer, dermis tissue showing, partial thickness (damage of epidermis and dermis), risk for infection. Hydrocolloid dressing needed for autolytic debridement; should be left on for several days at a time to be effective.
• Stage III: Yellowish ulcer, adipose tissue showing, full thickness (damage of epidermis, dermis, and deeper tissues), wet-to-dry dressing until debrided to establish granular tissue, consult wound care; debridement needed.
• Stage IV: Bone or muscle showing, wet-to-dry dressing until debrided to establish granular tissue, consult wound care; debridement needed.
• Unstageable: Black, unable to assess underlying tissues; wound base is obscured by slough or eschar.

Prophylaxis for Pressure Ulcers

• Basic Care and Comfort: Turn patient every 2 hours, never massage bony prominences, use specialty rotation beds for Stage III and IV pressure ulcers, do range-of-motion (ROM) exercises, use heel cushions.
• Braden Scale Risk Assessment: Six variables evaluated (sensory perception, moisture, activity, etc.), scored 1-4. Risk levels: Severe Risk (Total Score ≤ 9), High Risk (Total Score 10-12), Moderate Risk (Total Score 13-14), Mild Risk (Total Score 15-18).

Taking Care of Skin

• Intact Skin: Soap and water.
• Broken/Infected Skin: Alcohol, diluted hydrogen peroxide, chlorhexidine, neomycin, Betadine, povidone, use normal saline for flushing wounds; avoid cytotoxic agents.

Falls

• Prophylaxis for Falls: Frequent rounding, room close to nurses' station, bed/chair alarms.
• Morse Fall Risk Assessment: History of falls, secondary diagnosis.

Infections

• Horizontal Transmission: Person-to-person, vertical transmission (mother to child). Priority: Handwashing when entering and leaving the room.
• Standard/Universal Precautions: Wear gloves to reduce bodily fluid exposure (blood-borne infectious diseases: Ebola, Hep B, Hep C, HIV, anthrax).
• Contact Precautions: Wear gloves and gown—for C. diff, handwashing with soap and water, severe and foul-smelling diarrhea, VRE/MRSA (including infected open wounds), Gastroenteritis (viral), vomiting and diarrhea, Croup (laryngotracheal bronchitis) caused by diphtheria, virus, barking cough, stridor. Minor: Treat with anti-inflammatories.
• Airborne Precautions: Wear N95 mask or surgical mask and negative airflow room (e.g., herpes zoster, measles, varicella zoster (chickenpox), etc.)

Major Infections

• Major: Treat with epinephrine. Rabies leads to menigitis; Hepatitis A, enteric precautions, Impetigo. Other infections: Lice/scabies, RSV, conjunctivitis (pink eye). Epiglottitis, influenza type b (Hib) (Vaccine to prevent). Meningococcal meningitis, Mumps, Rubella (German measles).

Other Infections

• Pertussis, Parvovirus, Sepsis, Pertussis
• Yersinia pestis (transmitted by rats, fleas), Shigella (salmonella-like), contracted by consuming undercooked food.

Yellow Fever

• Transmitted by mosquitoes, causes headache and vomiting.

West Nile Virus

• Transmitted by mosquitoes
• May lead to meningitis

Other Considerations

• Cohorting of Patients: Post-op patients, no cohorting with risk for infection (immunosuppressed, chronic kidney disease, HIV), no cohorting with actual infections (anything that ends in "itis"). Do not cohort airborne-infection patients, Cohort same infection.
• Transporting of Patients: Contact infection (gown), droplet or airborne infection (mask).
• Neutropenic Precautions: Suppressed immune system (AIDS, major burns, lupus), cryptosporidium. Do not cohort, similar to contact precautions. No fresh fruit, no fresh veggies, no fresh flowers, no pets, kids.
• Open Wounds: Cover wound (in room or transport). Follow contact precautions.
• Removing PPE: Gloves → Goggles → Gown → Mask → Wash hands.
• Preventive Measures: Primary prevention (prevent problem from ever existing; examples: vaccinations, condoms, exercise, diet), Secondary prevention (screenings; examples: mammogram, colonoscopy, PSA blood levels, pap smear).
• Tertiary Prevention: Prevent the progression of disease/illness (example: post-heart attack aspirin regimen). The 5 Ws (Wind, Water, Wound, etc.)

Hospital Personnel

• HCP/MD/NP/PA: Prescribes orders, refers for changes in orders
• Performs procedures: surgeries, scopes, etc.
• Consultations: Nurses may "refer" but not "consult". The various medical providers (HCP/MD/NP/PA) are consulted by the nurses for these issues
• SBAR: Use of SBAR for communications across departments and other personnel
• Nurse Hierarchy, Charge nurse/nurse manager, LPN/UAP (Licensed practical nurses and unlicensed assistive personnel assist RNs in daily care).

Other Hospital Staff: Respiratory Therapist, Social Worker, Case Manager, Pharmacist, Physical Therapist/Occupational Therapist, IT, Chaplain, Housekeeping, Security, Facilities/Maintenance, Radiology, labs.

Scope of Practice: Delegation, understanding scope of practice, knowing what can legally be done by that position, reaching out for help when a problem arises determining if the issue is within a nurse's scope and obtaining help from other departments if needed within the hospital.

How to Follow Orders:

• Use the 3 circumstances: "As ordered", "anticipate giving", "recommend giving" (for medical emergencies, interventions may be performed without rule #1). Nurse-managed orders exist in the chart; execute those.
• Be mindful when referring to a physician if the NCLEX is asking for actions you should take
• Do not click interventions unless answer choice expressly says "as ordered", "anticipate giving", or "recommend giving"

Basic Care and Comfort: Nursing ethics. Autonomy, Justice, Beneficence, Fidelity, Nonmaleficence, Veracity, and different cultural and religious beliefs. IV Gauge/Length, and the different IV problems

Disaster Scenarios: RACE, PASS, Code Black/Pink/White.

• Culture and Religion: Religious beliefs, and different cultural practices.
• Legal Issues: Assault (verbal threats), Battery (physical threats), False Imprisonment, Good Samaritan Law, Informed Consent, Advance Directive (DNR), Post-Mortem Care, Gerontological Considerations (changes of aging).

Myocardial Infarction (Heart Attack):

• Pathophysiology and Causes: Ischemia of heart muscle; Clotting (embolism), Atherosclerotic (narrowed coronary), Vasospastic (Prinzmetal's angina) / stimulants
• Signs and Symptoms: Chest pain, shortness of breath, chest pressure, tachycardia, jaw pain
• Interventions: MONA (Morphine, Oxygen, Nitroglycerin, Aspirin), EKG, ST elevation.

Cardiovascular Conditions:

• Central Line Types
• Heart Failure/Cardiomyopathy
• Interventions

Respiratory Tract Infections (URTIs):

• Rhinitis/Sinusitis
• Strep Throat
• Epiglottitis
• Cystic Fibrosis
• Asthma

COPD

• Pathophysiology (chronic inflammatory disease, bronchitis, emphysema)
• Risk factors—smoking
• Signs and Symptoms (dyspnea, barrel chest, respiratory acidosis, chronic hypoxia)
• Interventions (bronchodilators, inhaled glucocorticoids)

Pneumonia:

• Pathophysiology
• Signs and Symptoms (fever, chills, dyspnea, cough, chest pain, hemoptysis)
• Interventions (acute stabilization, antibiotics)

Pleural Effusion:

• Pathophysiology
• Signs and Symptoms (dyspnea, diminished breath sounds, possible hypoxemia)
• Interventions (pleurocentesis/thoracentesis)
• Chest Tubes

O2 Supplementation and Mechanical Ventilation:

• Purpose and settings: Assisted ventilation of oxygen and carbon dioxide; Endotracheal or tracheostomy; Acute respiratory distress syndrome (ARDS).
• Complications (High-pressure alarm, low pressure, VAP complications). Invasive treatment procedures.
• Non-Invasive Pressure Support Ventilation (BiPAP), continuous pressure support.
• Oxygen Support (Rebreather Mask)

ABGs (Arterial Blood Gases):

• Diagnostics (Allen test)
• Lab Values
• Steps in analyzing ABGs (pH, pCO2, HCO3)

Respiratory Acidosis and Alkalosis:

• Acidosis: Retention of CO2 / Respiratory problems
• Alkalosis: Loss of CO2 / Breathing too quickly
• Interventions

Metabolic Acidosis and Alkalosis:

• Acidosis: Decrease in bicarb (HCO3)
• Alkalosis: Increase in bicarb
• Interventions

Other Respiratory and Pulmonary Issues:

• Hypoxia
• Complications
• Anoxia

EKG Interpretation:

• Steps in interpreting EKGs,
• Rhythm analysis (BPM, P waves, QRS complexes, consistency)

Atrial and Ventricular Arrhythmias:

• Sinus Tachycardia and Bradycardia
• Supraventricular Tachycardia (SVT)
• Atrial Flutter & Fibrillation
• Ventricular Tachycardia & Fibrillation

Other (critical care, miscellaneous)

• Hemodynamic Monitoring
• Arterial Line and Central Venous Pressure
• Additional Considerations
• Pacemakers/Implantable Cardioverter Defibrillator
• Choking