funda day 1

Change of shit report

- RN-RN - pt needs

hypertonic Dextrose + other soln

- cell will shrink; ind: cerebral edema

hypotonic <0.9% Na Cl

- cell will swell; ind: cerebral dehydration, polydipsia

isotonic 0.9% Na Cl (PNSS); PLR D5W

- equal concentration to cell; ind: shock, HPN, Blood loss

Reporting

- simple, specific, concise info - oral/ written

1. Arm band, name 2. arm band 3. MD 4. 3x 5. check pt for the possible effect of the error

1. Confirm Client's Identity 2. Best way to Identify Client 3. Who will reach out if the order does not comprehend? 4. How many times will you verify your drug before giving to your client? 5. In case, medication error what is your best action?

1. Primary (vaccine) 2. Secondary 3. Tertiary (prevent other compli) 4. Secondary (determine- detection) 5. Secondary (tx) 6. Secondary (tx)

1. Administering Chloroquine before Palawan trip 2. IMCI 3. 02 Humidification 4. Determine if manila has epidemic of COVID 19 5. Combination of chemotherapy in a pt with Hodgkin's dse. 6. Radiation therapy in pt with laryngeal cancer.

1. stop 2. N-acetylcysteine 3. ototoxicity 4. anesthetics 5. MD order, Consent

1. Burning fan at ward, First thing to do? 2. Antidote of paracetamol? 3. Irreversible toxicity of aspirin? 4. Best example of chemical restraint? 5. Nursing consideration before having restraints?

1. HCT, pt, students, graduates 2. communication (delay plan of care) 3. Fact, accurate, complete, concise 4. Source-oriented and Problem-oriented 5. Charting by exception

1. Who can access chart? 2. Documentation's primary purpose? 3. How to Maintain Effective Documentation? 4. Two types of medical Record? 5. Document only any abnormal findings?

6. Witness 7. no. emancipated, yes 8. MD 9. Invalid 10. yes. X o thumb mark

6. Significance of nurse's signature in consent? 7. Can a minor sign the consent? 8. Who will explain the procedure to the client? 9. Involuntary makes the consent? 10. Can we provide consent to a client with low literacy?

1. Patient 2. Medication 3. Dose 4. Time/ Frequency 5. Route 6. Documentation 7. Assessment 8. Evaluation 9. Refuse 10. Education

10 rights of medication administration

D. 20 years old

During a health awareness presentation about preventing breast cancer, someone asks you when did breast self-examination begin. Which of the following is the best nurse response? A. 45 years old B.18 years old C.Menarche D.20 years old

- voluntary - informed (by MD) - competent to sign

Elements of consent

- Emancipated minor - military member w/ hs diploma

Exceptions for who can sign the informed consent

Rescue Alarm Contain (close door) Extinguish (Remember START triage)

Fire safety in Hospital setting: MAJOR fire

Rescue Extinguish

Fire safety in Hospital setting: MINOR fire

-name - band bracelet

2 patient identifiers

Formal and legal document

Medical Record includes the client information and plan of care. It is considered as ____ & _______ document

a. "hear ringing in my ears." (ototoxicity)`

A 12-year-old with rheumatic fever has a history of long-term aspirin use. Which statement by the client indicates that the nurse should notify the health care provider? A." hear ringing in my ears." B."Is it alright to put lotion on my itchy skin?" C. My stomach hurts after I take that medicine." D. "My mouth is bleeding."

A.

A client who is scheduled for gallbladdersurgery is mentally impaired and is unable to communicate. In regard to obtaining permission for the surgical procedure, which nursing intervention would be most appropriate? A.Ensure that the family has signed the informed consent B.Ensure that the client has signed the informed consent C.Use the client's Thumb mark for signing informed consent D.Inform the family about the process of a living will

D.Check the patient's condition to note any possible effect of the error A.Record the error on the medication sheet B.Notify the physician regarding course of action. C. Complete an incident report, explaining how the mistake was made (in order)

A nurse discovers that she has made a medication error. Which of the following should be her first response? A.Record the error on the medication sheet B.Notify the physician regarding course of action. C. Complete an incident report, explaining how the mistake was made D.Check the patient's condition to note any possible effect of the error

B. Performing a tracheostomy

A toddler is brought to the emergency room after ingesting an undetermined amount of drain cleaner. The nurse should expect to assist with which of the following first? A.Administering an emetic. B.Performing a tracheostomy. C.Performing gastric lavage. D. Inserting an indwelling urinary (Foley) catheter.

Vit. K; Induce vomiting & Lavage

Antidote for aspirin toxicity; Nursing mgt

Upper outer axilary

Breast self examination detects breast cancer. It is characterized by a movable painless tumor usually located in___________

20-35 years old

Breast self examination is a health screening done to detect breast cancer. It is performed during the age of ____-_____ y old where the breast is fully developed.

Regular: 7 days after first day of Period Irregular: Same day each month

Breast self examination; when to perform? Regular: ______ Irregular: _____

Prostate cancer; 40 y and above

Digital rectal exam detects ________. It is performed at the age of ___________ ever year.

Calcium EDTA (chelation therapy)

Drug used to manage lead poisoning (removes heavy blood)

mouth care

Health teaching for a patient using inhalation route

ALL levels

Health teaching is done on what level of prevention?

at least 2 RNs - Receive order — witness (no NA)

How many RNs should be present at a telephone order?

inner to outer

How to administer optic ointment?

pull pinna up and back (adUlt)

How to instill ear drops for children 3 yrs & up?

pull pinna down and back (chilDOWN)

How would you straighten the ear canal of a child 2 year old and below?

length: 3/8-5/8 gauge: 26-27

ID; length and gauge

length: 1/8-1 1/2 gauge: 24-25 child 23-24 adult

IM; length and gauge

X or thumbmark

If a client is low literacy, the nurse should assess first the level of understanding. In an event where the pt cannot read or write, he/she can put a ________ instead

- name - amount - time

In a poisoned client, the nurse should assess the ____, _____, _____, of last ingested posion

Sims position

In digital rectal exam, the nurse should position the client in a _____

- soil, paint, pencil

Lead poisoning is usually obtained from which objects?

- MD order - consent Emergency: allowed but inform MD (Paternalism)

Legal considerations for restraints includes:

40 years old and above

Mammography is a health screening done to detect breast cancer. It is usually done at the age of ______, every year.

D.Ask Mr. T. to sign an authorization, and have someone review the chart with the cousin.

Mr. T. is a client on your medical-surgical unit. His cousin is a physician and wants to see the chart. Which of the following is the best response for the nurse to take? A. Tell the cousin that the request cannot be granted. B.Hand the cousin the client's chart to review. C.Call the attending physician and have the doctor speak with the cousin. D.Ask Mr. T. to sign an authorization, and have someone review the chart with the cousin.

B.Write the word " mistaken entry" after a straight line and followed by initial.

Ms. S. is brought in after a motor vehicle accident. She has suffered a head injury and possible spinal injury. During the documentation, Nurse X made a charting mistake. Which of the following nursing actions is appropriate if nurse x has charting mistakes? A.Write the word "error" after a straight line followed by initial. B.Write the word " mistaken entry" after a straight line and followed by initial. C.Write your initial " after a straight line D.Use correction tape or Liquid pen eraser

A. Poisoning

Nurse Jessica having a lecture about the different dangers in different age group, which of the following danger is most correct answer in age group of toddlers? A.Fall B.Burn C.SIDS D. Poisoning

D. Prevent a patient from becoming confused or disoriented.

Nurse Jonas caring confused client and relative ask you about the used of restraints, the nurse statement is correct when he state that purpose of restraint except to: A.Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary catheters. B.Prevent a patient from falling out of bed or a chair. C.Discourage a patient from attempting to ambulate alone when he requires assistance for his safety. D. Prevent a patient from becoming confused or disoriented.

C. All Except 3 (MD role is to countersign)

Nurse's responsibilities in telephone order 1. Document 2. Sign the telephone order 3. Counter Sign 4. Clarify the order A. AlI Except 2 B. All Except 4 C. All Except 3 D. All Except 1

Prepare antidote Organ support Induce vomiting (non corrosive) Stop activation (activated charcoal -NGT) Observe airway (corrosive) NGT - lavage (draining, sx)

Nursing interventions for a poisoned client`

- O2, trach tube insertion (prepare)

Nursing mgt for pt ingested with corrosive substance

INFILTRATION; 1. stop IV flow rate 2. remove IV line 3. elevate ext 4. warm compress (absorption) 5. re-insert 6. document

Patient with IV line complained pain on the IV site. Upon assessment, you noticed that it is cold to touch and the dressing is wet. What type of IV complication and what is your nursing intervention?

- Health promotion - Illness Prevention - Delay occurrence of disease

Primary prevention; goal

Healthy

Primary prevention; who?

- communication, prevents delay of care (PRIMARY purp) - legal documentation - education - audit assessment of goals in standard of care - research -plan of care -reimbursement

Purposes of Medical record

Document, verify, confirm = READ BACK sign order (RN) countersign (MD) = w/in 24 hrs

RN roles in telephone order

Nursing Rounds

RN-RN with a pt - discussion of evaluation-management

Telephone report

RN-RN/ RN-MD - change of condition (emergency order) - transfer of pt

FALSE Client refused= health teaching first Still refused= accept resistance then sign waiver

T/F In a situation where in the patient refused a care, the nurse should accept the resistance then let the patient sign a waiver.

- Restoration/Palliative care - Rehabilitation - Prevent other complications - Maintenance Medications

Tertiary prevention; goal

-Post treatment - Diagnosed Patient

Tertiary prevention; who?

12-35 years old; warm bath

Testicular self examination detects testicular cancer that is done at the age of ____-_____ y old every month. It is advised to be performed after a ________ for more accuracy

length: 1/2-1 gauge: 25-26

SQ; length and gauge

- Early detection/ Diagnosis - Treatment - Prevent complication - Prophylaxis

Secondary prevention; goal

High risk

Secondary prevention; who?

B. Client signed the consent form (witness)

The nurse has been asked to witness an informed consent for surgery. The nurse understands that he or she is witnessing is that the: A. Informed consent took place B. Client signed the consent form C. Client was fully informed about the procedure. D. Family consented to the procedure

B arm band

The nurse is administering medication in an extended care facility. What is the best way for the nurse to correctly identify the client before administering the medications? A.Ask Client to state their name B.Check the arm band C.Check the name on the bed D.Check the name on the room door

- Ask last ingestion - Weigh the pt - observe s/sx

The nurse should assess the ff to a poisoned client: _______ _______ _______

C.First week after first day of menstruation.

The nurse teaches a female client that the best time in the menstrual cycle to examine the breasts is during the: A.Week that ovulation occurs. B.Week that menstruation occurs. C.First week after first day of menstruation. D.Week before menstruation occurs.

B. Secondary (high risk)

The patient will have a bilateral mastectomy despite the fact that she has no evidence of breast cancer, but she has stated that her mother and another relative died from breast cancer. Which level of prevention is this? A. Primary B. Secondary C. Tertiary D. Rehabilitation

D. 1,2,3,4

What are the components of Problem-Sourced Medical Record Select all that apply 1. Database 2. Problem List 3. Plan of care 4. Progress notes A. All except 1 B. All except 2 C. All except 3 D. 1,2,3,4

- To serve as a legal witness (voluntary, authentic, competent) - client advocate

What is the nurse's role in informed consent?

ID note: bevel up; 0.9 water, 0.1 med

What route should be used when doing mantoue test?

Stop and unplug the machine

When a machine malfunctions, the nurse's best action is to____

D. If a nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the client is "informed." —-SHOULD BE SIGNED

Which is not true about informed consent? A. Obtaining consent is the responsibility of the physician. B. A nurse may accept responsibility for witnessing a consent form. C. A physician subjects himself or herself to liability of the physician withholds any facts that are necessary to for the basis of an intelligent consent. D. If a nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the client is "informed."

A. Nurse on Duty

Who is eligible to receive telephone orders? A. Nurse on Duty B. Nurse on Call C. Nursing attendant D. None of the above

B. Rehabilitative

You suggested the patient who was due for discharge today eat in accordance with the food pyramid; at what degree of prevention does your suggestion fall out? A.Screening B. Rehabilative C. Promotive D. Detection

Papanicolau Smear test; 18 years old and above

___________ detects cervical cancer usually done at the age of ______, for 3 consecutive years every 3 years.

N-acetylcysteine (NACS!)

antidote for acetaminophen toxicity (within 8 hrs after ingestion

Band bracelet

best patient identifier

front of thigh, abdomen, side/back of upper arm

common site for SQ adm

adm q morning (no sweat)

if Topical route should be used, when is the best time to adm it?

- Developmental Delay (leaD) - severe abdominal pain - neurological disturbances

late sign of lead poisoning

Restraints (LAST RESORT)

medical devices that limit client's mobility and used too prevent harm, fall, and removal of contraptions.

STAT order

medication order; Immediate, now

PRN

medication order; as needed

Standing order

medication order; may or may not have expiration date. may have exact date of termination ex. Vitamins daily OD

Single order

medication order; one time dose (usually sa OR)

assess HR prior

nursing consideration before using rectal route of adm

Oral

route of med adm; - most common/convenient/safest. - slow

SL

route of med adm; - under tongue, fast absorption - sip water prior to moisten

- bleeding - RINGING of ear (ototoxicity) (worst: no antidote)

sign and symptoms of aspirin toxicity

assess q 2 hrs, remove for 15 mins

the nurse should prevent neuromuscular complications in restraints devices by: assessing q _____ and removing q _______

RUQ pain (liver)

usual sign of an acetaminophen toxicity

- client - HCT - student (res & educ) - graduates

who has access in Medical Record?

toddler, preschool, and elderly

who is at most risk for fall?