RN31 Final Exam – Study Guide
1. Definition of nursing and the implementation of the nursing
process
Nursing is Caring: a compassion, a respect for each client’s
dignity Four Broad Aims of Nursing Practice:
1. To promote health
2. To prevent illness
3. To restore Care
4. To facilitate coping with disability or death
Definition: The protection, promotion, and optimization of health
and abilities, prevention of illness and injury, alleviation of
suffering through the diagnosis and treatment of human
response, and advocacy in the care of individuals, families,
communities and populations
Nursing process: systematic, rational method of planning and
providing individualized nursing care
Assessment
Diagnosis
Planning
Implementati
on Evaluation
2. Difference between the Nurse Practice Act and Standards of
Practice
The Nurse Practice Act is the most important law affecting the
nursing practice. Each state has a nurse practice act that
protects the public by broadly defining the legal scope of nursing
practice. Obtain a copy from your state’s BRN. Each nurse is
expected to care for patients within defined practice limits.
Practicing beyond those limits can put the nurse at risk for violating
the state nurse practice act.
Voluntary standards, developed and implemented by the nursing
profession itself are not mandatory but are used as guidelines for
peer review. Professional organizations reassess the functions,
standards, and qualifications of their members. Examples of
voluntary standards: American Nurses Association (ANA) standard
of practice, professional standards for accreditation of education
programs and service organizations, standards for certification.
Legal standards: developed by legislature and implemented by
authority granted by state to determine minimum standards for
nursing education, licensure requirements, determining when a
license should be suspended or revoked.
, 3. The health illness continuum
A model that helps with understanding a person’s level of health.
Views health as a constantly changing state with high-level
wellness and death at opposite ends of the continuum. It illustrates
the ever-changing state of health as a person adapts to changes in
internal and external environments. ex: patients w/cancer may
view themselves at different points on the continuum at any given
time, depending on how well they are functioning with the illness.
(Fig 3-3, pg. 60)
4. Know the “chain of infection” and the inflammatory
process Chain of Infection
· Infectious agent - (the microorganism itself) Some of the
more prevalent agents that cause infection are bacteria,
viruses, and fungi
· Reservoir - (where the organism lives) The reservoir for
growth and multiplication of microorganisms is the natural
habitat of the organism. Possible reservoirs that support
organisms pathogenic to humans include other people,
animals, soil, food, water, milk, and inanimate objects.
· Portal of exit -(how the microorganism exits the reservoir -
ex: sneezing, coughing) The portal of exit is the point of
escape for the organism from the reservoir. The organism
cannot extend its influence unless it moves away from its
original reservoir.
· Means of transmission- An organism may be transmitted from
its
reservoir by various means or routes. Some organisms can be
transmitted by more than one route. Organisms can enter the
body by way of contact transmission, either directly or
indirectly.
o Direct
▪ person to person, Ex: kissing, hugging, touching
o Indirect
▪ vehicle born - ex: objects, food, water
▪ vector born- ex: animals, insects
o Airborne
▪ through droplets in the air
· Portals of entry- (How does the microorganism get into the
host? ex: mouth, eyes, nose, blood, impaired skin.) The portal
of entry is the point at which organisms enter a new host.
The organism must find a portal of entry to a host or it may
die. The entry route into the new host is often the same as
the exit route from the prior reservoir.
· Susceptible host- Microorganisms survive only in a
source that provides shelter and nourishment (a host),
,and only if the
microorganisms overcome any resistance mounted by the
host’s
, defenses. Susceptibility is the degree of resistance the
potential host has to the pathogen.
Break the chain:
· Handwashing (breaks the portal of entry)
· Clean surfaces (method of transmission)
· Nutrition/Vaccine/Sleep/Exercise (susceptible host)
· Antibacterial cleanse ( reservoir)
The Inflammatory Process
The inflammatory response is a protective mechanism that
eliminates the invading pathogen and allows for tissue repair to
occur.
Signs of acute infection are redness, heat, swelling, pain, and loss
of function, usually appearing at the site of the injury/invasion.
The body’s response occurs in two phases that are responsible
for these signs:
Vascular Phase
· Small blood vessels constrict in the area followed by
vasodilation of arterioles and venules that supply the
area.
· This increase in blood flow results in redness and heat in the
area.
· Histamine is released, leading to an increased permeability
of vessels, which allows protein-rich fluid to pour into the
area.
· At this point, swelling, pain, and loss of function can occur
Cellular Phase
· White blood cells (leukocytes) move quickly into the area.
· Neutrophils, the primary phagocytes, engulf the
organism and consume cell debris and foreign
material.
· Exudate composed of fluid, cells, and inflammatory
byproducts is released from the wound. The exudate may be
clear (serous), contain red blood cells (sanguineous), or
contain pus (purulent). The amount of exudate depends on
the size and location of the wound.
· The damaged cells then are repaired by either
regeneration (replacement with identical cells) or the
formation of scar tissue
5. How does the respiratory tract defend against infection?
· The first line of defense starts with the nasal passage where
hairs at the entrance of the nares trap large particles in the
air.
· The second line of defense is the Pharynx shared with
1. Definition of nursing and the implementation of the nursing
process
Nursing is Caring: a compassion, a respect for each client’s
dignity Four Broad Aims of Nursing Practice:
1. To promote health
2. To prevent illness
3. To restore Care
4. To facilitate coping with disability or death
Definition: The protection, promotion, and optimization of health
and abilities, prevention of illness and injury, alleviation of
suffering through the diagnosis and treatment of human
response, and advocacy in the care of individuals, families,
communities and populations
Nursing process: systematic, rational method of planning and
providing individualized nursing care
Assessment
Diagnosis
Planning
Implementati
on Evaluation
2. Difference between the Nurse Practice Act and Standards of
Practice
The Nurse Practice Act is the most important law affecting the
nursing practice. Each state has a nurse practice act that
protects the public by broadly defining the legal scope of nursing
practice. Obtain a copy from your state’s BRN. Each nurse is
expected to care for patients within defined practice limits.
Practicing beyond those limits can put the nurse at risk for violating
the state nurse practice act.
Voluntary standards, developed and implemented by the nursing
profession itself are not mandatory but are used as guidelines for
peer review. Professional organizations reassess the functions,
standards, and qualifications of their members. Examples of
voluntary standards: American Nurses Association (ANA) standard
of practice, professional standards for accreditation of education
programs and service organizations, standards for certification.
Legal standards: developed by legislature and implemented by
authority granted by state to determine minimum standards for
nursing education, licensure requirements, determining when a
license should be suspended or revoked.
, 3. The health illness continuum
A model that helps with understanding a person’s level of health.
Views health as a constantly changing state with high-level
wellness and death at opposite ends of the continuum. It illustrates
the ever-changing state of health as a person adapts to changes in
internal and external environments. ex: patients w/cancer may
view themselves at different points on the continuum at any given
time, depending on how well they are functioning with the illness.
(Fig 3-3, pg. 60)
4. Know the “chain of infection” and the inflammatory
process Chain of Infection
· Infectious agent - (the microorganism itself) Some of the
more prevalent agents that cause infection are bacteria,
viruses, and fungi
· Reservoir - (where the organism lives) The reservoir for
growth and multiplication of microorganisms is the natural
habitat of the organism. Possible reservoirs that support
organisms pathogenic to humans include other people,
animals, soil, food, water, milk, and inanimate objects.
· Portal of exit -(how the microorganism exits the reservoir -
ex: sneezing, coughing) The portal of exit is the point of
escape for the organism from the reservoir. The organism
cannot extend its influence unless it moves away from its
original reservoir.
· Means of transmission- An organism may be transmitted from
its
reservoir by various means or routes. Some organisms can be
transmitted by more than one route. Organisms can enter the
body by way of contact transmission, either directly or
indirectly.
o Direct
▪ person to person, Ex: kissing, hugging, touching
o Indirect
▪ vehicle born - ex: objects, food, water
▪ vector born- ex: animals, insects
o Airborne
▪ through droplets in the air
· Portals of entry- (How does the microorganism get into the
host? ex: mouth, eyes, nose, blood, impaired skin.) The portal
of entry is the point at which organisms enter a new host.
The organism must find a portal of entry to a host or it may
die. The entry route into the new host is often the same as
the exit route from the prior reservoir.
· Susceptible host- Microorganisms survive only in a
source that provides shelter and nourishment (a host),
,and only if the
microorganisms overcome any resistance mounted by the
host’s
, defenses. Susceptibility is the degree of resistance the
potential host has to the pathogen.
Break the chain:
· Handwashing (breaks the portal of entry)
· Clean surfaces (method of transmission)
· Nutrition/Vaccine/Sleep/Exercise (susceptible host)
· Antibacterial cleanse ( reservoir)
The Inflammatory Process
The inflammatory response is a protective mechanism that
eliminates the invading pathogen and allows for tissue repair to
occur.
Signs of acute infection are redness, heat, swelling, pain, and loss
of function, usually appearing at the site of the injury/invasion.
The body’s response occurs in two phases that are responsible
for these signs:
Vascular Phase
· Small blood vessels constrict in the area followed by
vasodilation of arterioles and venules that supply the
area.
· This increase in blood flow results in redness and heat in the
area.
· Histamine is released, leading to an increased permeability
of vessels, which allows protein-rich fluid to pour into the
area.
· At this point, swelling, pain, and loss of function can occur
Cellular Phase
· White blood cells (leukocytes) move quickly into the area.
· Neutrophils, the primary phagocytes, engulf the
organism and consume cell debris and foreign
material.
· Exudate composed of fluid, cells, and inflammatory
byproducts is released from the wound. The exudate may be
clear (serous), contain red blood cells (sanguineous), or
contain pus (purulent). The amount of exudate depends on
the size and location of the wound.
· The damaged cells then are repaired by either
regeneration (replacement with identical cells) or the
formation of scar tissue
5. How does the respiratory tract defend against infection?
· The first line of defense starts with the nasal passage where
hairs at the entrance of the nares trap large particles in the
air.
· The second line of defense is the Pharynx shared with
