AVN 1060 Fundamentals Midterm Study Guide PDF

AVN 1060 Fundamentals Midterm Review 1. PPE for COVID-19: Eye protection, gown, gloves, N-95 respirator mask. 2. Immediate Nursing Intervention when a patient has SOB. Elevate head of bed and apply oxygen (2L nasal cannula) 3. Factors that interfere with sleep: Drinking alcohol and caffeine be...

AVN 1060 Fundamentals Midterm Review 1. PPE for COVID-19: Eye protection, gown, gloves, N-95 respirator mask. 2. Immediate Nursing Intervention when a patient has SOB. Elevate head of bed and apply oxygen (2L nasal cannula) 3. Factors that interfere with sleep: Drinking alcohol and caffeine before bedtime; eating spicy foods before bedtime, loud music. 4. What should a nurse do when a patient asks for pain medication and falls asleep afterwards: Wake the client and administer medication. 5. List non-pharmacological pain management interventions: massage, distraction, guided imagery, hypnosis,. 6. List the best methods of hygiene care for patients with cardiac and respiratory issues: Avoid using the shower or tub bath.  7. Signs and symptoms of low blood pressure: dizziness, lightheadedness, weakness. 8. Intervention to safely provide oral hygiene for a patient who is not conscious: Avoid pouring water in patient’s mouth. Turn patient on side. Use toothed sponges. 9. De ne/describe “total care”: When a patient is unable to care for themselves and the nursing team must provide all care. 10. De ne/describe “contractures”: Permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff. This prevents normal movement of a joint or other body part. Contractures may be caused by injury, scarring, and nerve damage, or by not using the muscles. 11. De ne/describe “orthostatic hypotension”: Orthostatic hypotension, also known as postural hypotension, is a type of low blood pressure that occurs when blood pressure drops when standing up from a sitting or lying position. This can happen when blood vessels don't constrict (tighten) properly when standing. 12. List interventions for venous thrombosis: fi fi fi  Walking, exercising, avoid tight socks and shoes, avoid leaving legs bent or crossed for prolonged periods. 13. De ne/describe “atelectasis” and how to prevent: For people who are bedridden for long periods, encourage them to move around and take deep breaths. After surgery, you can try walking around, doing breathing exercises, and using an incentive spirometer. You can also try changing positions from supine to upright. 14. De ne/describe the “orthopneic” position: The orthopneic position, also known as the tripod position, is a sitting or standing position where a person leans forward and supports their upper body with their hands on their knees or another surface. This position is often used by people who are out of breath or experiencing respiratory distress, such as orthopnea, a type of dyspnea that makes it dif cult to breathe while lying down. 15. De ne/describe “medical asepsis” and list examples: Medical asepsis, also known as "clean technique", is a set of practices that aim to prevent the spread of infection by reducing the number of microorganisms in an environment or on an object. It’s used in all clinical patient care activities and is essential for preventing hospital-acquired infections (HAIs), which kill about 100,000 people in the United States each year. Some key steps in medical asepsis include: Hand hygiene Regular hand washing and using alcohol-based hand sanitizers are essential for preventing the spread of infection. Disinfection Using chemicals to kill microorganisms on contaminated surfaces and used fi fi fi fi  equipment. Disinfectants can be used to clean surfaces, equipment, and other items. Personal protective equipment (PPE) Wearing appropriate PPE, such as gloves, gowns, masks, and eye protection. Proper waste management Regularly emptying the garbage, which can be a perfect environment for pathogen growth. Cleaning the environment Avoiding stirring up dust when cleaning rooms and objects, such as by shaking dirty linens or using a moistened cloth or mop to wipe dust. Personal items Providing each client with their own soap, cups, toothbrushes, and towels, and regularly cleaning personal equipment to prevent the growth of microorganisms. 16. De ne “blood pressure”: Blood pressure is the pressure of blood on the walls of your arteries as your heart pumps blood around your body. Blood pressure does not stay the same all the time. It changes to meet your body's needs, and it is normal for your blood pressure to go up and down throughout the day. 17. De ne/describe the difference between “core temperature” and “tympanic temperature”: Core body temperature, also known as core temperature (Tc), is the temperature of the body's internal organs, such as the brain, heart, liver, and blood. Tympanic temperature, which measures radiating heat from the tympanic membrane, is often used as a surrogate for deep brain temperature. fi fi  18. De ne/describe “pulse oximetry”: Pulse oximetry is a painless, non-invasive test that measures the amount of oxygen in a person's blood, also known as oxygen saturation. It's a quick way to assess how well the lungs are working and how well oxygen is being delivered to the body's extremities. 19. De ne/describe “capillary re ll”: Capillary re ll is a rapid test used for assessing the blood ow through peripheral tissues. It's a quick test performed on the nail beds to monitor the amount of blood ow to tissues and dehydration. Capillary re ll measures the ef cacy of the vascular system of hands and feet as they are far from the heart. 20. De ne/describe “respiratory rate”: The respiration rate is the number of breaths a person takes per minute. The rate is usually measured when a person is at rest and simply involves counting the number of breaths for one minute by counting how many times the chest rises. Respiration rates may increase with fever, illness, and other medical conditions. 21. De ne/describe “stridor”: Stridor is a high-pitched, abnormal respiratory sound that's caused by irregular air ow in a narrowed airway. It's often heard when someone inhales but can also be heard when they exhale. Stridor can sound like wheezing or whistling and is usually most prominent during inhalation. The exact sound of stridor depends on the location of the obstruction. 22. List the most effective way to prevent “health care associated infections” (HAI): Hand hygiene is considered one of the most effective ways to prevent healthcare associated infections. fi fi fi fi fi fi fi fl fi fl fl  23. List the purpose/bene t of a fever: A fever is a temporary increase in body temperature that's part of the body's immune response to ght an infection. Fevers can help the body survive and resolve infections by making it harder for bacteria and viruses to survive. Most bacteria and viruses thrive at a normal body temperature, but a fever makes it more dif cult for them to survive. Fevers also activate the immune system, which sends out white blood cells and other cells to ght and destroy the infection. 24. De ne/describe “medical asepsis” and list examples: Medical asepsis, also known as "clean technique", is a set of practices that aim to prevent the spread of infection by reducing the number of microorganisms in an environment or on an object. It’s used in all clinical patient care activities and is essential for preventing hospital-acquired infections (HAIs), which kill about 100,000 people in the United States each year. Some key steps in medical asepsis include: Hand hygiene Regular hand washing and using alcohol-based hand sanitizers are essential for preventing the spread of infection. Disinfection Using chemicals to kill microorganisms on contaminated surfaces and used equipment. Disinfectants can be used to clean surfaces, equipment, and other items. Personal protective equipment (PPE) Wearing appropriate PPE, such as gloves, gowns, masks, and eye protection. Proper waste management Regularly emptying the garbage, which can be a perfect environment for pathogen growth. Cleaning the environment fi fi fi fi fi Avoiding stirring up dust when cleaning rooms and objects, such as by shaking dirty linens or using a moistened cloth or mop to wipe dust. Personal items Providing each client with their own soap, cups, toothbrushes, and towels, and regularly cleaning personal equipment to prevent the growth of microorganisms. 25. PPE required for tuberculosis: Eye protection, gown, gloves, N-95 respirator mask. 26. Restraints should only be used as a last resort to ensure the safety of patients, staff, and others, and should be used in compliance with safe and appropriate techniques. They should not be used as a form of punishment or convenience. Here are some guidelines for using restraints in nursing: Use the least restrictive type Apply snugly but not tightly Check for tightness by inserting two ngers under the restraint Estimate the patient's range of motion and stay beyond that range until ready to apply restraints Apply limb restraints around the patient's wrist or ankle, with the soft part toward the patient's skin Secure the strap through the D-ring Restraints can cause injury or death, so some risks to consider include aspiration, suffocation, strangulation, and psychological trauma. Some alternatives to restraints include: Having staff or a family member sit with the patient, Using distraction or de-escalation strategies, Offering reassurance, Using bed or chair alarms, and Administering certain medications. fi  Once a patient is no longer a danger to themselves or others, restraints should be immediately removed. The nurse must provide nutrition, hydration, toileting, remove restraints every 2 hours and perform range of motion (ROM), repositioning Q2 hours, neurovascular check every 30 minutes (check circulation/capillary re ll, check skin integrity, check skin temperature), assess for the ongoing needPage 5 of 28 for restraints, obtain an order every 24 hours, use the least restrictive restraint device, and document response to restraints. 27. Immediate action to take in case of re: The acronym R.A.C.E. is a re safety protocol that helps people remember what to do in the event of a re: Remove: R Get people away from the re and help others if needed Alarm: A Tell others about the re by shouting "FIRE" or "CODE RED" Con ne: C Close doors to the re to prevent it from spreading to the rest of the building Evacuate or Extinguish: E Leave the building as directed by the re safety plan or EHS-approved local plan 28. Types of resources that nurses use for evidence-based research: Nurses use a variety of resources for evidence-based research, including: Systematic reviews These reviews use rigorous methods to identify and synthesize evidence to provide reliable answers to research questions. They are a key part of evidence-based practice in healthcare settings. Databases Some databases are designed speci cally for nurses and provide evidence-based fi fi fi fi fi fi fi fi fi fi  information for nursing research, continuing education, and point of care. Cochrane Library This database and journal is a leading resource for nding systematic reviews in healthcare. It can be a powerful tool to help nurses improve their decision making and healthcare knowledge. Clinical expertise Nurses can also use their clinical experience as a source of evidence. For example, a perianesthesia nurse might search an online formulary for alternatives. Evidence-based nursing journals Some journals, like Evidence-Based Nursing, cover the eld of evidence-based nursing. These journals are peer-reviewed and can be abstracted and indexed by Index Medicus, Scopus, and Excerpta Medica/EMBASE. Journal clubs Journal clubs can help nurses and nursing students develop the discussion and competence skills needed to produce evidence-based care. 29. De ne/describe “clinical practice guidelines”: Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for speci c clinical circumstances. 30. De ne/describe the “identifying” step of the QI process: o Identify opportunities, and recognize the need for change. o De ne objectives and requirements. o Gather and sort data. o Determine the root cause. o Ideate and implement possible solutions. o Continuously monitor. fi fi fi fi fi fi  31. De ne/describe the supervision required for LVNs to practice: The LVN must practice under, and must be supervised by a physician, dentist, or registered nurse. 32. Interventions to improve safety of a client while in bed: Keep wheels locked, keep bed in lowest position. 33. Elements of a “therapeutic response”: Supportive, non-judgmental, acknowledge feelings, use open-ended questions. 34. De ne/describe “chronic pain”, and associated conditions: Chronic pain is pain that lasts longer than three months, or longer than the normal healing period. It can be continuous or come and go, and it can affect many aspects of daily life. Chronic pain can be caused by injury, disease, or unknown causes, and it can persist even after the original cause has healed. Some causes of chronic pain include: Arthritis and other joint problems Back pain Headaches Muscle strains and sprains Repetitive stress injuries Fibromyalgia Nerve damage Lyme disease Broken bones fi fi  35. List objective ndings of pain: Objective ndings of pain include nonverbal indications and physiological markers: Nonverbal indications These include: Facial expressions: Grimacing, frowning, wincing, eye tightening or closing, distorted facial expressions, and rapid blinking, sweating/diaphoresis Behavior: Restlessness, agitation, writhing, constant shifting in bed, appearing uneasy and tense, drawing legs up, kicking, guarding the area of pain, or withdrawing from touch to that area Sounds: Moaning, groaning, or whimpering Physiological markers These include: Vital signs: Changes in heart rate, blood pressure, and respiratory rate Skin conductance: Increases due to activation of the autonomic nervous system during the pain response Biopotentials: These are electric potentials that transfer information between living cells and can be measured as electrocardiography (EEG), electroencephalography (EMG), or electromyography. 36. Characteristics of the epidermis: The epidermis is the most super cial layer of the skin and provides the rst barrier of protection from the invasion of substances into the body. The epidermis has multiple layers of cells, including the stratum, stratum basale, stratum granulosum, and stratum spinosum. It is an avascular skin layer, so it does not contain blood vessels. fi fi fi fi  37. Education for infection prevention when cleaning the eyes: Wash hands, use a clean washcloth, wipe from the inner to the outer canthus, use a different part of the washcloth for each eye. 38. How can pain affect sleep: Pain can result in a person not receiving adequate sleep. 39. List non-pharmacological interventions to help with sleep: massage, soft music, reduce noise, dim lights, back rub, warm milk, and regular exercising in the mornings which helps to improve sleep pattern. 40. Purpose of hygiene: Help prevent infection, help prevent skin breakdown, provides a sense of well-being. 41. De ne/describe “gingivitis”: Gingivitis is the earliest stage of gum disease. It happens when plaque and bacteria build up on your teeth and cause infection. Common symptoms include red, swollen, bleeding gums. Treatments include regular dental cleanings and improved oral hygiene at home between visits. fi  42. Purpose of ossing: Flossing is an important oral hygiene practice that helps remove plaque and food particles from between teeth and along the gum line where a toothbrush can't reach. Plaque is a sticky lm that can lead to cavities and gum disease. If left untreated, plaque can harden into tartar, which can cause gum disease and tooth discoloration. Flossing can also help prevent bad breath, which is caused by bacteria that thrive in places where a toothbrush can't reach. 43. Why is it dif cult for nurses to assess and manage pain for children: Children have dif culty articulating/describing pain. Children do not like to take medication and have a fear of needles if a shot is needed for pain control. 44. De ne/describe “indirect transmission” of microorganisms: Indirect contact transmission occurs when there is no direct human-to-human contact. Contact occurs from a reservoir to contaminated surfaces or objects, or to vectors such as mosquitoes, ies, mites, eas, ticks, rodents or dogs. 45. De ne/describe “droplet transmission” Droplet transmission is a mode of transmission that occurs when a pathogen is carried to a host's body by a droplet from coughing, sneezing, or talking. The transmission can happen in a few ways: Inhaling droplets Droplets entering the mucous membranes of the face Touching droplets that have settled on surfaces and then touching the face The length of time a pathogen can survive outside of a host depends on the type of pathogen. Some pathogens can live for minutes to hours, while others can survive for days. fi fi fl fl fi fi fi fl  46. Signs and symptoms of a surgical site infection: Signs and symptoms of a surgical site infection (SSI) include: Pain: Pain or tenderness around the surgical site, especially when moving Redness: Redness around the surgical site Swelling: Swelling around the surgical site Drainage: Cloudy, yellow, or pus-like uid draining from the surgical wound Fever: A fever, or chills Other symptoms: Nausea or vomiting that doesn't get better, pain that doesn't get better with medication, cough, chest pain, dif culty breathing, or coughing up yellow, green, or bloody mucus 47. De ne/describe “orthostatic hypotension/postural hypotension”: Orthostatic hypotension, also known as postural hypotension, is a type of low blood pressure that occurs when blood pressure drops when standing up from a sitting or lying position. This can happen when blood vessels don't constrict (tighten) properly when standing. Symptoms of orthostatic hypotension include: Dizziness, Lightheadedness, Blurry vision, Mental confusion, Nausea, and Fainting. If systolic blood pressure drops by at least 20 millimeters of mercury (mm Hg) or diastolic blood pressure drops by 10 mm within ve minutes of standing, the patient has orthostatic hypotension. 48. De ne/describe “pulse”: A series of pressure waves/blood ow within an artery caused by contractions of the left ventricle and corresponding with the heart rate (the number of times the heart beats per minute). Normal adult pulse rate is 60-100 BPM. fi fi fl fl fi fi  49. De ne/describe Korotkoff Sounds: Korotkoff sounds are a series of sounds produced by blood pulsing through arteries when a blood pressure cuff is de ated. The sounds are created by vibrations in the artery wall caused by spurts of blood. 50. De ne/describe bradycardia, and list signs and symptoms of bradycardia: Bradycardia is a type of abnormal heart rhythm, or arrhythmia. It occurs when the heart beats very slowly — less than 60 beats per minute. A normal heartbeat begins with an electrical impulse from the sinus node, a small area in the heart's right atrium (right upper chamber). The electricity travels through the heart and causes the muscle to contract between 60 and 100 times each minute. Bradycardia, or a slow heart rate, can cause a number of symptoms, including: Fatigue: Feeling weak or tired, especially during exercise Dizziness or lightheadedness Mental confusion Fainting: Or near-fainting, which can be caused by a drop in blood pressure Shortness of breath Chest pain: Or a feeling of your heart pounding or uttering (palpitations) Disturbed sleep 51. Signs and symptoms of a fever: Depending on what's causing a fever, other fever signs and symptoms may include: Sweating. Tachycardia/fast heartbeat Chills and shivering. Headache. Muscle aches. Loss of appetite. Irritability. Dehydration. General weakness fl fi fi fl  52. : De ne/describe “eupnea”: Eupnea is a term used to describe normal, healthy, and unlabored breathing in mammals, including humans. It's also known as quiet breathing or resting respiratory rate. When breathing in a state of eupnea, the lungs use only their elastic recoil to expire. Eupnea is characterized by rhythmic, continuous breathing without any noticeable pauses in the cycle. 53. List important Joint commission National Patient Safety Goals: Correct identi cation of patients Improve staff communication Safe medication use Safe alarm use Prevent infection/surgical site infections Identify patient safety risks Improve health care equity Prevent mistakes in surgery 54. Chain of Infection: The chain of infection, also known as the chain of transmission, is the process that must occur for an infection to take place. It has six links, or stages, that describe how an infection spreads: Infectious agent The disease-causing pathogen, such as a virus, bacteria, fungi, or parasite Reservoir The environment or habitat where the pathogen can live and multiply, such as animals, soil, water, sewage, or food Portal of exit How the pathogen leaves the reservoir, such as through vomit, saliva, blood, or stool Mode of transmission fi fi  How the pathogen spreads from one person or place to another, such as through contact with hands, toys, or sand, or through droplets from speaking, sneezing, or coughing Portal of entry How the pathogen enters another person, such as through the mouth, cuts in the skin, or the eyes Susceptible host The person who is vulnerable to infection, such as babies, children, the elderly, people with weakened immune systems, or people who are unimmunizedPage 11 of 28 Breaking the chain of infection at any link can stop the spread of germs and prevent infection. For example, personal protective measures can break the chain of infection and stop the spread of germs that cause respiratory illnesses. Using multiple measures at once can be more effective because it breaks the chain at multiple points. 55. De ne/describe “medical asepsis” and list examples: Medical asepsis, also known as "clean technique", is a set of practices that aim to prevent the spread of infection by reducing the number of microorganisms in an environment or on an object. It’s used in all clinical patient care activities and is essential for preventing hospital- acquired infections (HAIs), which kill about 100,000 people in the United States each year. Some key steps in medical asepsis include: Hand hygiene Regular hand washing and using alcohol-based hand sanitizers are essential for preventing the spread of infection. Disinfection Using chemicals to kill microorganisms on contaminated surfaces and used equipment. Disinfectants can be used to clean surfaces, equipment, and other items. Personal protective equipment (PPE) Wearing appropriate PPE, such as gloves, gowns, masks, and eye protection. Proper waste management Regularly emptying the garbage, which can be a perfect environment for pathogen growth. fi  Cleaning the environment Avoiding stirring up dust when cleaning rooms and objects, such as by shaking dirty linens or using a moistened cloth or mop to wipe dust. Personal items Providing each client with their own soap, cups, toothbrushes, and towels, and regularly cleaning personal equipment to prevent the growth of microorganisms. 56. List an essential component of Standard Precautions: Standard precautions are basic infection prevention and control strategies that apply to everyone, regardless of their perceived or con rmed infectious status. The goal is to reduce the risk of transmission of microorganisms from both recognized and non-recognized sources of infection. Here are some examples of standard precautions: Hand hygiene Washing hands with soap and water when visibly soiled and after using the toilet. When hands are not visibly soiled, handrubbing with an alcohol-based hand rub (ABHR) is the preferred method. Respiratory hygiene Covering the mouth and nose with a tissue when coughing or sneezing or using the crook of the elbow to contain respiratory droplets. Wearing a surgical mask if unable to follow basic respiratory hygiene practices. Personal protective equipment (PPE) Wearing PPE that effectively covers personal clothing and skin is likely to be soiled with blood, saliva, or other potentially infectious materials (OPIM). PPE includes gloves, face masks, protective eye wear, face shields, and protective clothing (e.g., reusable or disposable gown, jacket, laboratory coat). Sharps Maintaining separation between patients beds if possible, for needles and other sharps. Placing used sharps and puncture resistant containers. Not recapping, bending, breaking, or hand manipulating used needles. If recapping is required, use a one-handed scoop technique. Other standard precautions include: Patient placement/assessment of infection risk Safe management of the care environment fi  Safe management of care equipment Safe management of healthcare linen Safe management of blood and body uids Waste disposal Cleaning and disinfecting 57. Interventions to improve the safety of a client while in bed: Keep wheels locked, keep bed in lowest position. 58. Nursing responsibility for restraints: Here are some guidelines for using restraints in nursing: Use the least restrictive type Apply snugly but not tightly Check for tightness by inserting two ngers under the restraint Estimate the patient's range of motion and stay beyond that range until ready to apply restraints Apply limb restraints around the patient's wrist or ankle, with the soft part toward the patient's skin Secure the strap through the D-ring Restraints can cause injury or death, so some risks to consider include aspiration, suffocation, strangulation, and psychological trauma. Some alternatives to restraints include: Having staff or a family member sit with the patient, Using distraction or de-escalation strategies, Offering reassurance, Using bed or chair alarms, and Administering certain medications. Once a patient is no longer a danger to themselves or others, restraints should be immediately removed. The nurse must provide nutrition, hydration, toileting, remove restraints every 2 hours and perform range of motion (ROM), repositioning Q2 hours, fi fl  neurovascular check every 30 minutes (check circulation/capillary re ll, check skin integrity, check skin temperature), assess for the ongoing need for restraints, obtain an order every 24 hours, use the least restrictive restraint device, and document response to restraints. 59. De ne/describe the dermal layer of the skin: The dermis is a connective tissue layer sandwiched between the epidermis and subcutaneous tissue. The dermis is a brous structure composed of collagen, elastic tissue, and other extracellular components that includes vasculature, nerve endings, hair follicles, and glands. The role of the dermis is to support and protect the skin and deeper layers, assist in thermoregulation, and aid in sensation. 60. De ne/describe guided imagery: Guided imagery is a relaxation technique that involves using your imagination to visualize positive images or scenarios to help you relax and develop a sense of well- being. It can also be called guided visualization or imagery therapy. 61. How does obstructive sleep apnea (OSA) impact sleep: Obstructive sleep apne (OSA) can impact sleep by causing fragmented, non-restorative sleep. People with OSA experience episodes of partial or complete upper airway collapse, which can decrease oxygen saturation or wake them up from sleep. These repeated awakenings can make it dif cult to get restorative sleep, even after a full night of sleep. People with OSA may wake up 15–25 times per hour, but only for a few seconds each time, leaving them feeling exhausted. OSA results in a poor quality of sleep. fi fi fi fi fi 62. Risks of skin integrity impairment: Skin integrity refers to the skin being whole, intact, and undamaged. When skin integrity is impaired, it can lead to complications that can cause pain, reduced mobility, and poor quality of life. These complications can include: Infections When skin integrity is compromised, it's easier for microorganisms to penetrate the skin and move into the body, increasing the risk of infection. This is especially true for open lesions and breaks in the skin, such as cuts, abrasions, and hangnails, which can ooze serum that may contain pathogens. Skin lesions Impaired skin barrier function can lead to skin dryness, which is a risk factor for severe skin lesions like pressure ulcers and skin tears. Impaired mobility Impaired skin integrity can lead to decreased function and may result in the loss of limbs or, sometimes, life. Other risk factors for impaired skin integrity include: Incontinence People who have problems controlling their urine or bowels are at risk for skin problems, especially near the buttocks, hips, genitals, and perineum. Hot water Using hot water can dry out the skin, which can further impair skin integrity. 63. List characteristics of chronic pain: Chronic pain affects over one-quarter of the United States population and is a prevalent complaint seen in outpatient medical clinics. The condition encompasses a wide range of persistent discomfort lasting beyond 3 to 6 months and often originates from various sources, including injury, disease, or unknown causes. Chronic pain can signi cantly impair an individual's quality of life, leading to physical limitations, emotional distress, and social isolation. Moreover, the failure to diagnose and effectively manage chronic pain can contribute to opioid use disorders and increase morbidity and fi  mortality rates among affected individuals. Chronic pain can sometimes impact vital signs. Some nonverbal signs of chronic pain that the nurse may observe are: tense body language, restlessness, strained facial expressions, sad facial expressions, increased resistance or agitation with movement, guarding the body part where pain is located, and changes in sleeping patterns. 64. Immediate nursing intervention(s) for a patient experiencing shortness of breath (SOB): 1. Elevate head of bed. 2. Apply O2 2L nasal cannula. 65. De ne/describe the nurse as an “advocate”: Nursing advocacy is a vital part of nursing that involves ensuring patients are safe, cared for, and heard. Nurses can act as advocates for patients in many ways, including: Protecting patient rights Nurses can help patients understand their legal rights and ensure they receive fair and accurate treatment from insurance providers and medical billers. Improving patient care Nurses can advocate for patients to receive the highest level of care possible, and ensure they are treated with dignity and respect. This can include challenging decisions that may not be in the patient's best interest and ensuring informed consent. Connecting patients to resourcesPage 15 of 28 Nurses can help patients connect with community resources, such as transportation, support networks, and nancial assistance. They can also recognize when patients are scared or overwhelmed and take the time to help them understand their options and medical rights. Acting as a liaison Nurses can act as liaisons between patients and their doctors and communicate with the healthcare team. fi fi  Educating patients and families Nurses can help educate patients and their families, and support patient autonomy. Advocacy can also bene t nurses by improving patient relationships and leading to better working conditions and patient-focused policies. Nurses who are in a position to in uence policies and procedures can promote advocacy strategies at the organizational level, such as serving on ethics committees, requesting ethics consultations, or arranging patient care conferences. 66. How do nurses demonstrate evidenced-based practice? Evidence-based practice (EBP) provides nurses with a method to use critically appraised and scienti cally proven evidence for delivering quality health care to a speci c population. The objective of this study was to explore nurses' awareness of knowledge of, and attitude toward EBP and factors likely to encourage or create barriers to adoption. In addition, information sources used by nurses and their literature searching skills were also investigated. To effectively apply the EBP process, in addition to the basic skills required to undertake nursing work, a nurse must have the ability to: (1) identify knowledge gaps, (2) formulate relevant questions, (3) conduct an ef cient literature search, (4) apply rules of evidence to determine the validity of studies, (5) apply the literature ndings appropriately to the patient's problem, and (6) appropriately involve the patient in the clinical decision making. Previous literature also highlights the challenges for new nurses because EBP involves reconciling client values with evidence and clinical judgment, which may be particularly dif cult for them due to their limited experience. 67. The advantage(s) of preferred provider organizations (PPOs): No referral required for scheduling appointments. Lower cost to the employer for the PPO insured employee. 68. Requirement for nursing licensure: Successful passing of the NCLEX state board examination. fi fi fl fi fi fi fi  69. De ne/Describe Patient Centered Care: Patient-centered care (PCC) is a healthcare model that prioritizes a patient's needs, values, and preferences. It's often associated with person-centered care (PCC), which is an approach that aims to improve patient satisfaction and the quality of care. In PCC, nurses advise, educate, and support patients as they make decisions about their health and treatment plans. This can help nurses earn patients' trust and respect, which can lead to better patient outcomes. Some key elements of PCC include: Listening to patients Nurses should be compassionate, empathetic, and responsive to patients' needs and desires. Educating patients Nurses should educate patients about their conditions and explain the rationale behind different treatment options. Providing emotional support Nurses should address patients' concerns and actively check in on their comfort. Involving patients in their care Nurses should include patients and their families in the decision-making process and empower them to participate in their own care. This can be done through shared decision making and by allowing patients to make choices about things like mealtimes, bedtimes, and what to wear. Creating compassionate environments Nurses should ensure that care settings are welcoming for families and that healthcare facilities have values and goals that align with those of their patients. PCC can also bene t healthcare practitioners by allowing them to spend more time with patients and provide more individualized treatment. 70. List aspiration precaution interventions: Here are some aspiration precaution interventions: Eating and drinking Position: Sit upright at a 90-degree angle when eating and drinking, or use a wedge pillow to elevate yourself in bed. Remain upright for at least 30 fi fi minutes after eating or drinking. Food and drink: Cut food into small bites, take small sips, and chew food well before swallowing. Alternate between liquid and solid swallows and take multiple swallows per bite or sip. Eat and drink slowly and avoid distractions like talking on the phone or watching TV. Other: Take a 30-minute rest before eating and adjust the rate of feeding and size of bites to your tolerance. Avoid rushed or forced feeding and vary the placement of food in your mouth. Other interventions Head of bed: Keep the head of the bed elevated to a minimum of 30 degrees at all times and elevate it to 90 degrees when eating. Feeding tube: If a patient has a feeding tube, check its placement every four hours to ensure it hasn't moved too high.Page 17 of 28 Oral care: Practice routine oral hygiene to reduce bacteria in the mouth that could lead to infection if aspirated. Medications: Review a patient's medication regimen to identify any that might increase re ux, such as benzodiazepines, barbiturates, anticholinergics, or calcium channel blockers. Assistance: Provide 1:1 assistance at meals and instruct visitors not to leave food with the patient. Here are some interventions that can help prevent aspiration during tube feeding: Head of bed elevation Keep the head of the bed elevated at a 30–45° angle, for 30-60 minutes, unless contraindicated. If the patient can't tolerate the backrest elevation, you can try using the reverse Trendelenburg position. If you need to lower the head of the bed for a procedure, return it to the elevated position as soon as possible. Position If possible, have the patient sit up straight during tube feeding, or use a wedge pillow to prop them up in bed. They should remain upright for at least an hour after feeding. fl  71. Purpose of the in ammatory response: The in ammatory response is a defense mechanism that protects the body from injury and infection. It occurs when tissues are damaged by bacteria, heat, toxins, trauma, or other causes. The damaged cells release chemicals that cause blood vessels to leak uid into the tissues, which helps isolate the foreign substance from further contact with body tissues. The in ammatory response also involves the migration of white blood cells, proteins, and uid from the circulation to the site of tissue damage. The purpose of the in ammatory response is to: Prevent infection: Prevent the initial establishment of infection or prevent the spread of infection Remove damaged tissue: Remove damaged tissue components so that the body can begin to heal Trap germs or toxins: Start healing injured tissue 72. Florence Nightingale’s Theory/Concepts: The nursing theory consists of four major concepts including person, health, environment, and nursing. According to the Fundamentals of Nursing, these four concepts “… give nurses a comprehensive perspective that allows you to identify and treat patient’s health care needs at all levels and in all health care settings.” Florence Nightingale’s vision of nursing in the mid-1800s began an evolution of nursing philosophies and theories that encouraged the progression and development of nursing knowledge, quality of care, and the advancement of nursing from a vocation to an academic discipline and profession. 73. List some of the roles of the LVN: Licensed vocational nurses (LVNs) are entry-level nurses who work as part of a healthcare team to provide bedside care for patients in a variety of settings, including hospitals, doctor's of ces, and nursing homes. LVNs often work under the supervision of registered nurses (RNs) or physicians. Their roles include: Patient care fl fl fl fl fi fl fl LVNs provide basic care to patients, such as helping them with eating, bathing, and toileting. They also assist patients with routine tasks like getting dressed and discussing treatment plans. Monitoring LVNs monitor patients for changes in condition and take vital signs, including pulse, blood pressure, and temperature. They also monitor patients after treatments or medications to ensure the treatment is safe and to report any concerns to the charged nurse. Administering care LVNs may administer certain medications, draw blood, and set up ventilators and other breathing treatments. They also dress wounds, apply and change bandages, and organize patients' medications. Communication LVNs communicate with patients and other healthcare professionals, including doctors and RNs. They interview patients to gather information about their medical histories, discuss concerns, and report updates. Other duties LVNs may also review medical records, stock the supply room, and perform other administrative duties. 74. HMO requirements for specialty physician appointments, diagnostic procedures, and outpatient therapy: You must have a referral to see a specialist or get most other services. Your HMO or medical group must approve many of your services before you can get them. Usually, it is your primary doctor who gives you a referral and asks for pre-approval.  75. De ne/describe evidenced-based practice: Evidence-based practice in nursing involves providing holistic, quality care based on the most up-to-date research and knowledge rather than traditional methods, advice from colleagues, or personal beliefs. Nurses can expand their knowledge and improve their clinical practice experience by collecting, processing, and implementing research ndings. Evidence-based practice focuses on what's at the heart of nursing — your patient. Learn what evidence-based practice in nursing is, why it's essential, and how to incorporate it into your daily patient care. 76. Functions of professional nursing organizations: Professional organizations promote safety, health and wellness for patients and nurses in the workplace. Many lobby on behalf of nurses and health care at all levels of government. They work for policy changes advocating on important health issues that affect nurses and the public. 77. Chain of Infection: The chain of infection, also known as the chain of transmission, is the process that must occur for an infection to take place. It has six links, or stages, which describe how an infection spreads: Infectious agent The disease-causing pathogen, such as a virus, bacteria, fungi, or parasite Reservoir The environment or habitat where the pathogen can live and multiply, such as animals, soil, water, sewage, or food Portal of exit How the pathogen leaves the reservoir, such as through vomit, saliva, blood, or stool fi fi  Mode of transmission How the pathogen spreads from one person or place to another, such as through contact with hands, toys, or sand, or through droplets from speaking, sneezing, or coughing Portal of entry How the pathogen enters another person, such as through the mouth, cuts in the skin, or the eyes Susceptible host The person who is vulnerable to infection, such as babies, children, the elderly, people with weakened immune systems, or people who are un-immunized Breaking the chain of infection at any link can stop the spread of germs and prevent infection. For example, personal protective measures can break the chain of infection and stop the spread of germs that cause respiratory illnesses. Using multiple measures at once can be more effective because it breaks the chain at multiple points. 78. How to perform proper hand hygiene: Washing your hands is easy, and it’s one of the most effective ways to prevent the spread of germs. Follow these ve steps every time. - Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap. - Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your ngers, and under your nails. - Scrub your hands for at least 30 seconds. - Rinse your hands well under clean, running water. - Dry your hands using a clean towel or an air dryer. fi fi  79. De ne/describe Medicare insurance: Medicare is a health insurance program administered by the government or on behalf of the government, while private health insurance comes directly from a health insurance company. 80. Management of patients during a re: The acronym R.A.C.E. is a re safety protocol that helps people remember what to do in the event of a re: Remove: R Get people away from the re and help others if needed Alarm: A Tell others about the re by shouting "FIRE" or "CODE RED" Con ne: C Close doors to the re to prevent it from spreading to the rest of the building Evacuate or Extinguish: E Leave the building as directed by the re safety plan or EHS-approved local plan 81. Order in which the nurse should bathe the patient, during a bed bath: Suggested order for washing during a bed bath: - Face: Start by washing the eyelids, moving from the inside out, then the face, ears, and neck. - Arms: Wash each arm individually, then wash the hands. - Chest and belly: Wash the chest and belly, including the belly button. - Legs: Wash one leg, then the other, including the feet and between the toes. - Back: Help the person roll onto their side so you can wash their back. - Genital area: Change the bath water before washing the genital area. For women, wash from front to back, and for men, wash around the testicles. You might need to bend the person's knees or help them roll onto their side to reach the area. fi fi fi fi fi fi fi fi fi - Dry: Rinse each area and pat dry before moving on. If you're using a bag bath or no-rinse cloth, you can let the skin air dry before covering it. Most no-rinse cloths contain moisturizers, so you might not need to rinse, dry, or apply lotion. 82. Immobility is implicated in thromboembolism, pneumonia, and respiratory failure. It also contributes to the development of skin integrity impairment/pressure ulcers, loss of bone mineral density, fatigue, and orthostatic hypotension, while increasing the risk of delirium. 83. Sequential Compression Device/Pneumatic Compression Device: SCDs/PCDs are in atable sleeves that t around your legs. The sleeves are attached to a pump that in ates and de ates the sleeves. The pumping action acts like your muscles to help blood ow and prevent blood clots. 84. Nursing intervention to determine pain level: Use the appropriate pain scale to determine pain level – numeric scale, Wong Baker, FLACC... 85. List a secondary line of defense against infection: The secondary line of defense against infection is the immune system's innate immunity, which includes non-speci c phagocytes and other internal mechanisms. These defenses respond the same way to every infection, regardless of the pathogen type. The second line of defense includes: White blood cells These include neutrophils, eosinophils, basophils, monocytes, and natural killer fl fl fl fl fi fi  cells. Neutrophils are a rst line of defense against pathogens, and they rush to ght bacteria at the site of infection. However, they are easily killed and only last a few days in the body, so bone marrow produces more every day. Natural killer cells are lymphocytes that identify and destroy infected cells. In ammatory response When a pathogen stimulates the immune system, blood ow to the infected area increases, causing blood vessels to expand and white blood cells to leak into the tissue. These white blood cells, called phagocytes, then engulf and destroy bacteria. The area may become red, swollen, and painful during this process. Chemicals and proteins These include antibodies, complement proteins, and interferons. Some of these directly attack foreign substances, while others help immune system cells. For example, B lymphocytes produce antibodies that attach to antigens, making it easier for immune cells to destroy them. T lymphocytes attack antigens directly and release cytokines, which control the immune response. Fever The immune system may also release chemicals that increase body temperature, which can slow or stop pathogens from growing and speed up the immune response. 86. Here are some tips for bathing elderly people: -Water temperature Test the water temperature before getting in the shower or tub to make sure it's at the person's preferred temperature. Unexpected temperatures can cause sudden movements that could lead to falls. The recommended temperature is a degree or two warmer than the person's normal body temperature. -Safety bars Use grab bars in the shower and bath to help with stability and prevent falls. You can also add grab bars to the walls or units beside the toilet to help people pull themselves up or sit down. -Shower chair fi fl fi fl Use a sturdy shower chair to support people who are unsteady and to prevent falls. -Shower bench Add a shower bench to the bathroom to make sure people are safe and comfortable, especially if they have trouble standing for long periods of time. -Hand-held shower head A hand-held shower head allows people to clean while seated, which can help them retain their independence and shower without assistance. -Bath lift A bath lift can help people maintain their independence by raising them out of a low-lying tub without the need for assistance. -Routine Consider creating a consistent bathing routine so people don't have to worry about whether or not to shower, but instead when they are going to shower. It's also important to remember that it's not necessary to bathe every day. -Supervision Never leave someone who is confused or frail alone in the tub or shower. If the person has dementia, you should always supervise them in the bathroom. Other items -Keep sharp, dangerous, and breakable items out of reach. Place towels, soap, and other needed materials close at hand. 87. Important factor(s) to consider when assessing a patient’s hygiene: Bathing practices and cleansing habits and rituals vary widely. The patient's preferences should always be taken into consideration, unless there is a clear threat to health. 88. When assessing for pressure ulcers in people with darker skin tones, it's important to consider that initial redness may appear differently and be missed if only looking for that sign. Instead, clinicians can use a combination of visual and tactile cues to look for other indicators of injury, such as: Color changes Look for purple, bluish, or violet discoloration in areas of skin that are subject to pressure. You can also compare the skin color of the area to the surrounding skin. Temperature changes Areas of skin that are subject to pressure may feel warm or cool when touched. Other changes Look for edema, induration, or changes in tissue consistency. Induration is an area of skin hardness that may be more than 15 mm in diameter. Other tips for assessing pressure ulcers in people with darker skin tones include: Using appropriate lighting, such as ambient, natural, or halogen light, to avoid the bluish tint of uorescent light Asking patients how their skin feels or if they've noticed any changes Avoiding comparing skin tones to food Using clear and appropriate language 89. Interventions to prevent pressure ulcers: Nursing interventions can play an important role in preventing pressure ulcers. Some strategies include: Risk assessment: Use a structured tool to assess the patient's risk upon admission and repeat the assessment if their condition changes. Consider factors such as the patient's body size, skin moisture, and level of immobility. Support surfaces: Use specialty beds, egg crates, foam overlays, gel pads, and other support surfaces on chairs, tables, and beds. Avoid donut-shaped cushions, which can reduce blood ow and cause swelling. fl fl  Turning and repositioning: Reposition at-risk patients every 2–4 hours. Positioning devices: Use pillows, foam wedges, or other positioning devices. Pressure-reducing devices: Use foam, gel, air, or water mattresses to reduce pressure. Skin care: Inspect the skin daily for signs of pressure sores, keep it dry and clean, and use body lotion. Other interventions: Keep the patient moving, ensure good nutrition and hydration, and manage chronic health conditions. 90. Nursing interventions for cold therapy: Cold therapy can help reduce pain and swelling by reducing cell metabolism. It can be applied in many ways, including: -Ice packs: Apply a cold compress or ice pack to the a ected area for 20 minutes every 4–6 hours. -Ice massage: Massage the area with an ice pack or ice cube in a circular motion for up to 5 minutes. -Ice baths: Soak in a cold bath to reduce pain and slow blood ow. -Shivering management Nurses should be aware of the harmful e ects of shivering and use the Bedside Shivering Assessment Scale to evaluate patients' responses to interventions. -Fluid monitoring Nurses should monitor uid intake and urine output to check for dehydration or poor renal perfusion. -Electrolyte and blood gas monitoring Nurses should check for electrolytes, arterial blood gases, and oxygen saturation. fl ff ff fl  91. List non-pharmacological interventions to help with sleep: massage, soft music, reduce noise, dim lights, back rub, warm milk, and regular exercising in the mornings which helps to improve sleep pattern. 92. De ne/Describe obstructive sleep apnea (OSA) etiology: People with OSA experience episodes of partial or complete upper airway collapse, which can decrease oxygen saturation or wake them up from sleep. These repeated awakenings can make it dif cult to get restorative sleep, even after a full night of sleep. People with OSA may wake up 15–25 times per hour, but only for a few seconds each time, leaving them feeling exhausted. 93. How is body temperature regulated: The hypothalamus in the brain regulates body temperature through a subconscious re ex. The hypothalamus compares the body's current temperature to a normal temperature of around 37°C (98.5°F) and activates mechanisms to increase or decrease body temperature as needed: - Afferent sensing Thermoreceptors in the skin and internal organs send temperature information to the hypothalamus through nerve cells called thermoreceptors. - Central control The hypothalamus integrates the signals from the peripheral and central thermoreceptors and activates heat regulation mechanisms. - Efferent response The body makes adaptive changes to compensate for temperature changes, such as adjusting breathing rate, blood sugar levels, and metabolic rate. The body also uses heat exchange mechanisms to promote heat loss or retain heat:Page 25 of 28 Heat loss: The body can increase blood ow to the skin to dissipate heat through vasodilation and sweating. It can also reduce muscular activity and use heat-exchange mechanisms to circulate blood near the skin's surface. Heat retention: The body can decrease blood ow to the skin through vasoconstriction to retain heat near the body's core. fl fi fi fl fl 94. Impact of rapid loss of loss of a large volume of blood: Large loss of blood volume can lead to a serious medical condition called hypovolemic shock. When blood volume is lost, the body can't deliver enough oxygen and nutrients to vital organs and cells, which can cause organ failure and death. The amount of blood loss that can be tolerated without complications depends on a person's age, size, and general health. Losing 50% of your blood may be fatal. Here are some of the effects of losing a large amount of blood: Shock When blood loss is severe enough, it can't meet the body's tissue oxygen demands. This can lead to cellular aerobic metabolism shutting down, anaerobic metabolism beginning, and the production of lactic acid. Ischemia When tissue loses its blood supply, ischemia occurs, which can lead to an infarct. Depending on the location of the tissue, an infarct can be fatal. For example, an infarct of the heart is a myocardial infarction, and an infarct of cerebral tissue is a stroke. Sympathetic nervous system activation The body compensates for blood loss by activating the sympathetic nervous system, which diverts blood away from noncritical organs and tissues to preserve blood supply to vital organs like the heart and brain. Symptoms of hypovolemic shock include: Anxiety or agitation Cool, clammy skin Confusion Low blood pressure/hypotension Decreased or no urine output Generalized weakness Pale skin color (pallor) Rapid breathing Sweating, moist skinPage 26 of 28 95. Measures for nurses to prevent back injuries: Here are some ways nurses can prevent back injuries in healthcare: Lifting Use your leg muscles, not your back, and bend at the knees, not your waist. Get close to the patient, face them, and maintain a neutral posture. If you feel strain in your back, stop and try again. Use mechanical lifts when available, and ask for help if needed. Turning patients Position the bed at thigh level, lower the bed rail, and place a knee on the bed. Cross the patient's arms and legs, and place one hand on their shoulder and one on their hip. Then, roll the patient toward you. Adjusting the worksite Identify activities that could cause back strain and adjust the worksite to accommodate them. For example, you can try to keep work between your waist and shoulder height by adjusting chairs, beds, and other surfaces. You can also use lumbar supporting chairs, anti-fatigue oor mats, and footrests. Other measures You can also try: Wearing supportive shoes Maintaining a strong core Getting enough sleep Exercising regularly Avoiding movements that cause pain Participating in regular training Following set rules and procedures Using ergonomic lifting devices Aiming for a healthy weight 96. Nursing interventions for a confused patient who may be at risk for injury: Here are some nursing interventions for a confused patient who may be at risk for injury: fl  Monitor Observe the patient every hour, monitor their mental status, vital signs, and heart rhythm, and check labs. Prevent falls and injury Watch the patient 24/7 to prevent falls. This can include: Ensuring the bed is in a low position with the brakes locked Using bed rails appropriatelyPage 27 of 28 Making sure the patient can reach necessary items Removing excess equipment, supplies, and furniture from rooms and hallways Coiling and securing excess electrical and telephone wires Cleaning spills immediately and placing signs to indicate wet oors Assign a sitter or ask the family to sit with the patient Using a bed and/or chair alarm to alert staff if the patient tries to leave without help Reorient Reorient the patient during interactions and as needed. Communicate Communicate gently with the patient and their family, and educate the family. Reduce stress Keep the room quiet, reduce noise and stimulation at night, and try to limit the number of people around the patient at any one time. Promote sleep Encourage the patient to get up at their usual time and promote sleep hygiene. Assist with activities fl  Assist the patient with bedside sitting, personal hygiene, and toileting. 97. List complications of restraints: Physical complications of restraints include strangulation, as well as poor circulation/ ischemia, cardiac stress, immobility, muscle weakness, skin injury, infection, incontinence, dehydration, and diminished appetite. Psychological effects include: Anger, fear, and frustration: Restraints can make patients feel helpless, tense, and embarrassed. Post-traumatic stress disorder: Restraints can re-traumatize people with a history of sexual trauma or military combat. Other psychological effects: Restraints can also lead to increased behavioral disturbances, apathy, and reduced engagement. 98. De ne/describe Cheyne-Stokes Respirations: Cheyne-Stokes respiration is a breathing disorder that involves a pattern of breathing that alternates between deep, rapid breaths and shallow breaths, with pauses in between. The pattern repeats in cycles that usually last 30 seconds to 2 minutes. 99. Nursing interventions to prevent pressure injuries: Initial and follow up assessment of skin condition, perform wound care, provide nutritional intake increased protein, vitamin C, and zinc, increase uid intake keep patient clean and dry, moisturize skin, turn and reposition every 2 hours. 100. List common areas of injury for patients in a side-lying position: When in the side lying or lateral position, areas that are more prone to skin breakdown, due to the skin and bones are in constant contact with and pressed against the bed are: ears, greater tuberosity of the humerus, trochanter, head of the bula, and the lateral malleolus. fi fi fl