NR 224 FINAL EXAM STUDY GUIDE 2020 / NR224 FINAL EXAM STUDY GUIDE 2020: 100% CORRECT,CHAMBERLAIN COLLEGE OF NURSING
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Course
NR 224 (NR224)
Institution
CHAMBERLAIN COLLEGE OF NURSING
NR 224 FINAL EXAM STUDY GUIDE 2020 / NR224 FINAL EXAM STUDY GUIDE 2020: 100% CORRECT,CHAMBERLAIN COLLEGE OF NURSINGNR 224 FINAL EXAM STUDY GUIDE 2020 / NR224 FINAL EXAM STUDY GUIDE 2020: 100% CORRECT,CHAMBERLAIN COLLEGE OF NURSINGNR 224 FINAL EXAM STUDY GUIDE 2020 / NR224 FINAL EXAM STUDY GUIDE 202...
1. Characteristics of pulses
a. Pulse: palpable bounding of blood flow noted at various points on the
body
b. Sites: temporal, carotid, apical (chest), brachial (elbow), radial (wrist),
ulnar (leg), femoral, popliteal, posterior tibial, and dorsalis pedis
c. Character of pulse:
i. Rate: apical rate: ID S1 and S2 (lub dub= 1 heartbeat)
ii. Rhythm: dysrhythmia: regularly or irregularly regular
iii. Strength: 4+ (bounding), 3+ (full or strong), 2+ (normal), 1+
(weak), 0 (dead, no pulse)
iv. Equality
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d. Factors influencing pulse:
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i. Exercise, temperature, emotions, drugs, hemorrhage, postural
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changes, pulmonary conditions
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2. Stages of the infections process
o.
a. Incubation period: interval between entrance of pathogen into body
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and appearance of first symptoms
ou urc
b. Prodromal stage: interval from onset of nonspecific signs and
symptoms (malaise, low-grade fever, fatigue) to more specific
symptoms. (During this time microorganisms grow and multiply, and
o
patient may be capable of spreading to others)
aC s
c. Illness stage: interval when patient manifests signs and symptoms
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specific to type of infection. For example, strep throat is manifested by
sore throat, pain, and swelling; mumps is manifested by high fever,
parotid and salivary gland swelling
d. Convalescence: interval when acute symptoms of infection
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disappear.
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3. Managing dressing changes to prevent infection spread
a. Always wear gloves when handling wounds and dressing changes,
hand hygiene before and after, and change dressings that become wet
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or soiled
4. Chronic disease process and causes of acquiring infection
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a. People with chronic disease are Immunocompromised and can
acquire infection easily
b. Patents with COPD develop pneumonia easily
c. Patients with heart failure or diabetes develop skin breakdown or
venous stasis ulcers
5. Nursing action in managing postoperative infection
6. Immunocompromised patient and IV technique handling
a. Hand washing before and after, use of gloves
7. Chemotherapy and isolation precautions
a. Reverse isolation (protective)
b. Read below
, 8. Assessing respirations correctly
a. 1 full minute, with hand across chest
9. Temperature routes and comfort for patient
a. Oral (comfortable for patient), rectal (most accurate, only acceptable
when patient is comatose, not confused, or has seizures), axillary,
tympanic (ear), temporal (forehead, comfortable for patient),
esophageal, pulmonary
10. Reverse isolation precautions
a. Private room, positive airflow with 12 or more exchanged per hour;
HEPA filtration for incoming air, mask to be worn by patient when out
of room during times of construction in area. No plants or flowers in
the room, only water bottles
1. PPE and droplet precaution
a. Droplets (large particles that travel up to 3 ft during coughing sneezing, or
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talking and come in contact with susceptible host)
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b. Private room or cohort patients, mask
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c. Examples: rubella, diphtheria, streptococcal pharyngitis, pneumonia,
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mumps, influenza
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1. Older patient normal vital signs
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a. Oral temperature for older adults: 95 deg to 96.8 deg
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b. Pulse: 60-100
c. BP:
d. Respirations: 15-20
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2. Medication class for fever
aC s
a. Antipyretic
vi y re
3. Nursing actions to prevent orthostatic hypotension
a. Hypotension causes pallor, skin mottling, clamminess, confusion,
increased heart rate, decreased urine output
b. Orthostatic hypotension occurs when a normotensive person develops
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symptoms and low BP when rising to an upright position
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c. Patients who are dehydrated, anemic, or on prolonged bed rest and those
who have had recent blood loss are at risk or orthostatic hypotension
d. Have patient sit first and hang legs for about 30 seconds before standing
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up
e. Assess for OH during measurements of vital signs by obtaining BP and
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pulse with patient supine, sitting, and standing
1. Nursing critical thinking skills in recognizing and controlling pain
2. Appropriate action when radial pulse is in question
3. Proper hand washing technique
a. Wash hands with soap and water well in between fingers under nail
beds and rinse under running water for 15 seconds
b. Use warm water and apply 3-5 mL of soap
4. Sustained, intermittent, and relapsing symptom interpretation
a. Sustained: a constant body temperature continuously above 100.4
that has little fluctuation
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