Download NSG 3100 Exam 2 Study Guide: Vital Signs, Infection Control, and Wound Care and more Exams Nursing in PDF only on Docsity!
NSG 3100 EXAM 2 Study Guide Questions and Answers
Factors affecting blood temperature - ANSWER age exercise hormones cardiac rhythm stress environment smoking Heat exhaustion - ANSWER •Occurs when extreme or prolonged environmental heat exposure leads to profuse sweating with results in excessive water/electrolyte loss. What is heat stroke - ANSWER Prolonged exposure to the sun or high environmental temperatures overwhelms the body's heat loss mechanisms high mortality rate Risk factors of heat stroke - ANSWER very young or very old cardiovascular disease diabetes alcoholism exercise or working outdoors in predisposing conditions signs and symptoms of heat stroke - ANSWER confusion delirium excessive thirst nausea
muscle cramps high temperature and heart rate Hot, dry skin and absence of sweating are other features of heat stroke. how do you take a tympanic temperature of ages 4 and older? - ANSWER gently grasp the pinna of the ear and pull it up and back what is an apical pulse? - ANSWER a central pulse that can be auscultated over the apex of the heart at the point of maximal impulse (PMI). what is a peripheral pulse? - ANSWER pulses away from the heart that needs to be palpatated what effect does age have on the pulse rate? - ANSWER as we age the pulse rate decreases how does gender affect pulse rate? - ANSWER after puberty , men have lower pulse rates than women how does a fever affect pulse rate? - ANSWER pulse increases how does hypovolemia affect pulse? - ANSWER loss of blood is going to increase pulse what do we do when the heart rate is irregular - ANSWER take the apical pulse for accuracy what factors affect oxygen saturation? - ANSWER hypotension lung disease decreased circulation a too narrow cuff will give what type of BP reading - ANSWER a erroneously high BP
when do we put patients in tripod position? - ANSWER patients that have dyspnea ( difficult breathing) when does a patient have low blood pressure? - ANSWER 90/ when does a patient have stage 1 high blood pressure? - ANSWER 130 - 139/80- 89 when does a patient have stage 2 high blood pressure? - ANSWER 140/ what does auscultation mean - ANSWER listen with a stethoscope what does orthopnea mean? - ANSWER difficult breathing while doing anything other than sitting or standing 5 inflammatory response signs - ANSWER pain swelling redness heat loss of function what is bacterium? - ANSWER a culture of the persons blood revels microorganisms what is septecemia? - ANSWER when bacterium results in systemic function? signs and symptoms of infection? - ANSWER fever increased pulse increased RR
malaise anorexia enlargement of lymph nodes elevated WBC susceptibly of infection - ANSWER age( very young and very old) heredity levels of stress nutritional status(antibodies are protein's) current medial therapy current disease processes nosocomial means? - ANSWER Infections that originate in the hospital What does nosocomial endogenous mean? - ANSWER Originate from the client themselves What does nosocomial exogenous mean? - ANSWER Originate from the hospital environment and or personnel What are the modes or transportation for nosocomial infections? - ANSWER Direct Indirect Vehicle - borne( inanimate object) Vector(animal) Ways to defend against infecting - ANSWER Hygiene Nutrition Fluid
Mask(surgical) What nursing interventions should be implemented for someone in droplet precaution? - ANSWER *wear surgical mask if you're within 3 feet of patient Place surgical mask on patient if they leave the room What type of diseases for airborne precaution - ANSWER Measles Varicella TB Covid- 19 What PPE should be worn for airborne precaution? - ANSWER N95 respirator mask Gown Gloves What type of room do you put a airborne precaution patient in? - ANSWER A negative pressure room Nursing interventions for airborne precaution - ANSWER Keep door closed N95 mask when entering Susceptible people should not enter Surgical mask of client leaves Sequence for donning (putting on ) PPE - ANSWER 1. Gown
- Mask
- Goggles 4.gloves
Sequence for removing PPE - ANSWER 1. Gloves 2.goggle 3.gown 4.masks Factors affecting skin integrity? - ANSWER Genetics Age Chronic illness Medications Fecal incontinence Urinary incontinence Nutrition status Trauma WBC and infection - ANSWER Increases Hemoglobin and infection - ANSWER Decreases Serum proteins and infection? - ANSWER Indicates the body's nutritional reserves for rebuilding cells Albumin and infection - ANSWER Įess than 3.5 poor nutrition affecting would healing Wound cultures and infection - ANSWER Confirm or rule out presence of infection What part of the body is most at risk for pressure ulcers? - ANSWER Heels
Bone tendon and muscle not exposed Stage 4 pressure ulcer? - ANSWER Full thickness Exposed or parable muscle , tendon or bone Often include undermining or tunneling Slough and Escher are often present unstageable pressure ulcer - ANSWER Base is completely covered with slough or Escher Cannot see wound be Braden scale at risk - ANSWER Below 18 considered at risk Treatment of pressure ulcers - ANSWER Minimize or reduce pressure Scheduled position changes Pressure reducing devices Surgical asepsis for wound care No alcohol or hydrogen peroxide Obtain culture and swab if infected Educate client ROM RYB color codes - ANSWER Red- protect (cover) Yellow- cleanse Black - debride ( removal of necrotic material ) Sharp wound debridement - ANSWER Removal of dead tissue with a scapegoat or scissors
Mechanical wound debridement - ANSWER Scrubbing or damp dressings Chemical wound debridement - ANSWER Use of enzyme to break down dead tissue( gel) autolytic wound debridement - ANSWER Use a dressing to trap wound drainage against dead tissue so body enzymes can slowly degrade the necrotic tissue Primary intention wound healing - ANSWER Tissue surface has been approximated and there is minimal to no tissue loss Ex. Surgical incision Secondary intention healing - ANSWER Wound that has considerable tissue loss in which edges cannot be approximated Ex. Pressure ulcer Tertiary intention healing - ANSWER Wounds that are left open for 3 - 5 days to allow edema or infection to resolve or exudate to drain and then closed with sutures (delayed primary intent) Serous wound drainage - ANSWER Clear ,watery and thin purelent wound drainage - ANSWER Yellow , thick or green Sanguineous wound drainage - ANSWER Red. Įarge amounts of red blood cells Serosanguineous wound drainage - ANSWER Pink: clear and blood tinged
Newly infected wound Factors affecting would healing.? - ANSWER Poor wound management Įifestyle Age Impaired nutritional status Dehydration Diabetes Impaired blood supply Medications Hemmorrhage - ANSWER Greatest risk 48 hrs after surgery Apply pressure to wound and monitor vital if happens infection - ANSWER 2 - 11 days postoperative Clean wounds inside to out dehinscence - ANSWER Sutured wound ruptured and layers separate causes of dehiscence - ANSWER Obesity Diabetes Steroid use Immune deficiency Malnutrition Evisceration - ANSWER Protrusion of internal viscera through an incision
What are the purposes of wound dressings - ANSWER Protection Provide moisture and insulation Absorb drainage Debridement Pressure if hemmorage Splint or immobilize Risk for impaired skin integrity nursing diagnosis - ANSWER Maintain skin integrity Avoid or reduce risk Increase daily activity Impaired skin integrity nursing diagnosis - ANSWER Progressive wound healing Regain intact skin Increase daily activity Risk for infection nursing diagnosis - ANSWER Acute pain / chronic pain How do we bandage body - ANSWER Bandage normal position with joints flexed Where Do we pad when we bandage wound - ANSWER Between skin and bony prominence What way do we bandage? - ANSWER Distal to proximal. Venous return flow How do we bandage for circulation - ANSWER Bandage with even pressure
Open wounds Contraindications to heat - ANSWER First 24 hrs-increased bleeding and swelling Active hemmorage Non inflammatory edema Skin disorder thst causes redness of blisters Contraindications to cold - ANSWER Allergy or hypersensitivity to cold What is a closed drain called? - ANSWER Jackson - Pratt hemovac When do you empty (JP ) drain? - ANSWER 1/2 full Closed drain rules? - ANSWER Never compress when it is capped Ensure drain remains below level of wound to prevent back flow Ensure collection container is properly compressed What is the steps for the chain of infection - ANSWER 1. Infectious agent
2. Source 3. Portal of exit 4. Mode of transportation 5. Portal of entry 6. Susceptible host What is the infectious agents? - ANSWER Bacterium Virus
Parasite Fungus What is the source (host) of infection? - ANSWER Animal or insect Inanimate object Human being Portal of exit (chain of infection) - ANSWER Respiratory tract gI tract GU tract Blood Skin/mucosal surfaces Mode of transportation (chain of infection ) - ANSWER Contact Airborne Vehicle Droplet Vector- borne Portal of entry (chain of infection ) - ANSWER GI tract GU tract Non- intact skin Respiratory tract Mucous membranes Susceptible host (chain of infection) - ANSWER Immunosuppressed
