Foundation midterm

Direct contact

Infectious agents that are transmitted directly from person to person are transmitted via direct contact. The nurse should wear personal protective equipment while caring for clients who are on contact precautions to prevent direct contact with the infectious agent.

cognitive learning

Requires intellectual behaviors and focuses on thinking. Ex. client learns the manifestation of hypoglycemia and then verbalize when to notify the provider When a client engages in learning associated with the cognitive domain, they must think through information presented to them and be able to comprehend the information. Question-and-answer sessions are in the cognitive domain of learning.

Psychomotor learning

is gaining skills that require mental and physical activity ex. Client practice preparing insulin injections

Patient education

motivation influences how much and how quickly a person learns

What CAN NOT be delegated?

-Assessment -Analysis -Nursing Diagnosis -Overall Plan -CLIENT EDUCATION -Extensive Teaching/Counseling -Evaluation -Monitoring UNSTABLE Patients -Patients w/ Unpredictable Outcomes *Tasks that can be delegated are usually in the intervention portion of the nursing pocess

Examples of task nurses may delegate to PNs

-Monitoring findings (as input to the RN's ongoing assessment) -Reinforcing client teaching from a standard care of plan -Performing tracheostomy care - Suctioning - Checking NG tube patency - Administering enteral findings - Inserting a urinary catheter -Administering medication (excluding IV)

affective learning

-involves feelings, beliefs, and ideals -example: a client listens to the nurse explain life changes necessary to manage diabetes and then discusses feelings regarding the diagnosis

A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include? (Select all that apply.) A. "Sit with your back supported." B. "Keep your knees at hip level." C. "Use an ergonomically designed computer keyboard." D. "Keep your elbows away from your body." E. "Adjust the monitor screen so that you have to tilt your head slightly to look at it.

A, B, C

The ostomy nurse is educating the client about the new colostomy. Match nursing actions to the appropriate domain of learning. A. The ostomy nurse encourages the client to share their feelings about their colostomy B. The client performs a return demonstration of emptying the colostomy pounch C. The ostomy nurse provides the client with a list of foods they can eat and foods they should avoid in their diet

A. Cognitive B. psychomotor c. Affective

the ostomy nurse is educating the client about diet. Which of the following actions should the nurse take to evaluate the client's learning? A. Encourage the client to ask questions about their diet.. B. Ask the client to list foods to include in their diet. C. Encourage the client to fill out an evaluation form about how the nurse presented the information to the client D. Ask the client if they have additional resources for further instructions about their new diet.

B. Ask the client to list foods to include in their diet.

a charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (select all that apply) A. Cover errors with correction fluid, and write the correct information B. Put the date and time of all entries C. Document objective data, leaving out opinions. D. Use as many abbreviations as possible E. Wait until the end of the shift to document

B. Put the date and time of all entries C. Document objective data, leaving out opinions.

The ostomy nurse is educating the client about how to empty their ostomy pouch. Which of the following actions by the client indicates that psychomotor learning has taken place? A. The client states how often the ostomy pouch should be emptied. B. The client demonstrates emptying the ostomy pouch. C. The client writes the steps of how to empty the ostomy pouch on a piece of paper. D. The client states they understand how to empty their ostomy pouch.

B. The client demonstrates emptying the ostomy pouch.

The ostomy nurse is providing preoperative education for the client who is scheduled for a sigmoid colostomy. The nurse should identify that which of the following client statements is an indication that the client is ready to learn? a) "I will not look at my incision after surgery" B) "Will you give me pain medicine after surgery?' C) "Can you tell me about how long the surgery will take?" D) " I can't remember what my doctor told me about the surgery"

C. When recognizing cues, the ostomy nurse should identify that asking a concrete questions about a procedure indicates that the client is ready to learn about the surgery.

Contact precautions

Contact precautions are transmission-based precautions that are used when caring for a client who has RSV. and vancomycin-resistant enterococcus (VRE)

Indirect contact

Infectious agents that are transmitted from an infected person to another person via a contaminated object are transmitted through indirect contact. The nurse should wear personal protective equipment while caring for clients who are on contact precautions to prevent indirect contact with the infectious agent.

Airborne precautions

Infectious agents, such as tuberculosis, rubeola (measles), and varicella (chicken pox), are transmitted through airborne transmission. Clients who have an airborne infectious agent should be placed in a negative pressure, private room. The door to the client's room door should remain closed, and the nurse should wear an N95 mask when caring for the client.

Telefone orders

It is best to avoid. Necessary during emergencies and unusual times. -Have a second nurse listen to telephone prescriptions. -repeat it back making sure it includes medication's name, dosage, time, route. - Question any prescription that seems inappropriate for the client -Make sure the provider signs the prescription within 24 hrs

A nurse is transferring an older adult client who has right sided weakness from bed to a wheelchair. Which of the following action should t nurse take to provide a safe transfer?

MAINTAIN A STRAIGHT BACK AND BEND AT THE KNEES

Prior to delegating client care, the nurse should consider:

Predictability of the outcomes Potential for harm Complexity of care Need for problem solving and innovation Level of interaction with the client

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?

Raise the level of the bed

Droplet precautions

The nurse should inform the client that influenza is transmitted through large droplets in the air. The client should be placed in a private room, and the nurse should wear a surgical mask when caring for the client. Ex. Pertussis, influenza or rhinitis

Reservoir

The reservoir is the location where the infectious agent lives, grows, reproduces itself, and waits to be transmitted to a susceptible host.

susceptible host

The susceptible host is the client who acquired the infection. The susceptible host becomes a reservoir for the infectious agent.

Delegation

a licensed nurse is responsible for providing clear directions when delegating a task initially, and for periodic reassessment and evolution of the outcomes of the task.

Five Rights of Delegation

a) Right Task b) Right Circumstance c) Right Person d) Right Direction/Communication e) Right Supervision

A nurse manager is precepting a newly licensed nurse. At the end of the day, the nurse manager tells the newly licensed nurse, using a condescending tone and facial expression, that she did a good job considering her newness. Which of the following types and modes of communication are occurring here? (Select all that apply.)

passive agressive, verbal and nonverbal