FUNDS Proctor

Biofeedback

use of electronic monitoring device to facilitate learned self control of physiological responses

how to respond to a patient who becomes agitated that their dentures have to be removed prior to surgery

what worries you about being without your teeth

How to check NG tube placement?

x-ray is most accurate pH of gastric residual capnometry

can a client w an NGT receive sublingual medication

yes bc they do not swallow it

Advanced directives include

• living will • durable power of attorney for health care decisions

Tracheostomy Care

-Adjust suction -Don sterile gloves -Check function of suction catheter -Hyperoxygenate patient -Insert catheter without suction -Assess for secretion clearance -Only suction on way out

Patients contraindicated for magnet therapy

-Internal fixation -pacemakes -pregnant (teratogeneic)

Seizure precautions

-Oxygen and suction avaialble -Side rails up and padded -Loose clothing -Bed in lowest position -Pillow under head -Patient in side lying position

What can an LVN be delegated?

-Reteach and reassess. Can Not do initial -Start iv. Can Not push medication

magnesium range

1.3-2.1

Normal Sodium level

136-145

How tight should restraints be?

2 fingers need to be able to fit underneath

Phosphorus range

3-4.5

potassium range

3.5-5

Where do you tie a tourniquet

4-6 inches above insertion site can use blood pressure cuff if no tourniquet available

ph of secretions from NG tube

4.0

Calcium range

9-10.5

Chloride range

98-106

Assisted Personal tasks

ADLs bed making, specimen collection, intake and output, vital signs for stable clients

Chest Physiotherapy considerations

Area with secretions should always be on top so gravity can help drain Administer albuterol prior to chest physiotherapy

Nursing Process

Assessment Diagnosis Planning Implementation Evaluation

Ethical Principles

Beneficence, autonomy, justice, fidelity, veracity.

Key DM patient education to do at home?

Check feet daily Avoid showering with hot water Avoid lotion between toes

How do we mix insulin?

Cloud, clear, clear, cloudy (long acting(- NPH), short acting, shot acting, long acting)

How do we tell conscious patients to give sputum collection?

Cough, but make sure to demonstrate first -we do not want the saliva

Stages of grief

Denial, anger, bargaining, depression, acceptance

Disposition of pt valuables of family not present

Designate safe location and document specific list. Make a copy for record and for family member Have patient sign release to free facility of loss valuables Can tape wedding band Take out any and all piercings

What is proper foot and nail care for patient with Diabetes?

Do not use lotion Do not clip nails No tight fitting shoes- fitted, closed toed Orange stick to clean

How often do you need to get a new order for restraints?

Every 24 hours

Lab tests for hypovolemia

Hematocrit: increased BUN- increased Urine specific gravity > 1.030 Blood sodium > 145 Bloos Osmolality > 295

What do you do if residual is between 100-250mL

Hold feeding and inform MD

what statement indicates a need for clarification about advance directives

I have to choose a family member as my health care proxy

what indicates an understanding of teaching for patient with latex allergy

I will use ink pens for writing

When is the best time for sputum collection?

In the morning before they eat drink or rinse their mouth

Abdominal assessment

Inspect, Auscultate, Percuss, Palpate

Order of Prioritization

Maslow's hierarchy Principles of ABC Nursing Process Disaster/Emergency Lest restrictive to most restrictive Least invasive to most invaseive

Progression of Diet starting at NPO

NPO-> gag reflex->clear liquid->full liquid->regular diet

Maintaining Sterile Field

Never cross sterile field never turn your back Hold items 6 inches above when placing onto sterile field open package away from you first outer 1 inch border is not sterile

Can we use swabs to collect sputum?

No

Can a nurse act as a translator for a patient?

No. a trained medical translator is needed

What can be delegated to a CNA?

Only if patient is stable -assist with ADLs - bathing, changing, eating, ambulate, dink

#1 priority for defective equipment?

Place a tag first and then report it to the team

Solely RN actions

TAPE Teach, assess, plan ,evaluate

Webers Test

Use of a tuning fork to help to differentiate the cause of unilateral hearing loss - see if there is a defect in either ear and if so which one if patient hears better in one ear, do Rinne test

Ginko Biloba

Used to improve memory Avoid using with anticoagulants and NSAIDS

How do we know that adequate teaching of diabetes was performed?

When the patient can perform return demonstration- teach back

Responsibility

Willing to follow through on promises

nurse should delegate a UAP to collect vitals from which patients

a client who has a history of heart failure and is ready for discharge a young adult who is 24 hr post op appendectomy an older client who is 36 hr post op from a traditional cholecystectomy

what can be delegated to UAP

accompany client w depression to OT check position of client w soft wrist restraints sit w a client who has alcohol use disorder and whose last drink was 5 days ago

child is postop following a tonsillectomy. what is the nursing action

administer analgesics to the child on a routine schedule

what nursing role protects the client and supports their decisions

advocate

protocol for administering 2 kinds of insulin

air into cloudy air into clear withdraw clear withdraw cloudy

findings that indicate relaxation techniques are effective

arousal reduction decreased blood pressure decreased heart rate increased peripheral skin temperature

first step for NGT feedings

aspirate stomach contents

Intentional Torts

assault, battery, false imprisonment

First priority when give patient wrong medication?

assess patient before completing an incidence report

what information should the nurse document in the client's record

assessment

where is the final medication check performed

at the client's bedside before administration

how to improve client's commitment to a long term goal of weight loss

attempt to increase the client's self motivation

priority assessment for immobile client

auscultate breath sounds at least every 2 hours

what kind of tort is this example: nurse administers antibiotics after client has refused it

battery

When do we check gastric residual?

before we feed a patient

where to dispose dressing covered in blood and purulent drainage

biohazard container

#1 concern for patient who has had a mastectomy?

body image

Concerns for patient who has had mastectomy

body image give options on support gorups provide emotional support and therapeutic communication teach about resources

Albuterol function

bronchodilator that relaxes and dilates airway to promote gas exchange. Facilitates removal of secretions as chest wall is percussed in chest physiotherapy

clear liquid diet

broth, bouillon, coffee, tea, clear fruit juice, popsicles

nurse accidentally has blood spill on her gloved hand. what is nursing action

carefully remove glove and follow w hand hygiene

patient is experiencing anxiety, discomfort, and bloating after having an NGT placed. what is nurse's priority intervention

check to see if suction equipment is working

best antiseptic used to prep skin before inserting IV catheter

chlorhexidine

IV procedure order

cleanse site apply tourniquet dilate vein insert catheter flush catheter

what action should nurse take when administering an enteral feeing through an NGT

cleanse the top of the can of formula with an alcohol wipe

full liquid diet

clear liquids with smooth textured dairy, custards, vegetable juice, fruit juice

Beneficence

commitment to always care for patient in the best way possible

veracity

commitment to tell the truth

a nurse is teaching CPR to newly licensed nurses. what is the first response in CPR

confirm unresponsiveness

the nurses signature on the patient's consent means what

confirms the patient appears competent to provide consent

nursing intervention when noticing an irregularity in client's pulse

count apical pulse for 1 full minute

risks for psychological changes in older clients

decreased gastric motility decreased skin elasticity increased pain threshold

what nurse include in a presentation at a senior center about age related muscloskeletal changes?

decreased muscle mass

pancytopenia

deficiency of all types of blood cells

client comes to the ED that had a traumatic amputation of the left arm in an industrial accident. the nurse should expect which stage of Kubler-Ross's stages of grief

denial

a nurse is teaching a client how to draw up regular insulin and NPH into the same syringe. which instruction should the nurse include

discard regular insulin that looks cloudy

Nonmaleficence

duty to do no harm

Rinne test

hearing test using a tuning fork; checks for differences in bone conduction and air conduction if bone conduction is longer the deficit is in ear canal if air conduction is longer, deficit in mastoid bone

Ways to promote vein dilation

heat, tourniquet

client with type 1 DM and is lying in bed sweating and reports feeling anxious. what finding should the nurse expect

hypoglycemia

diabetic patient reports a headache, restlessness, fatigue, and hunger. what is the expected finding

hypoglycemia

When to use restrains on a patient

if they are a danger to self, others, or property AFTER trying other methods of control

expected finding in client with fluid volume defecit

increased BUN

what physiological response is expected in a patient who is immobile, has emphysema, and spends most of the day in a reclining chair

increased calcium excretion

FRACCS

information about psychosocial aspects of patient Financial status Relationships Ability to perform ADLs Concern about living or work situation Support System Spiritual Health

Order for skin assessment

inspect, palpate, percuss

what developmental stage includes acceptance of death

integrity vs. despair

finding in male patient with peripheral artery disease

leg pain at rest

Living Will

legal document stating that patient can make their own decisions when it comes to medical treatment

actions when transferring client from bed to wheelchair

lock wheels of bed and wheelchair

acupuncture

manipulation of a series of channels or meridinas to re-establish the flow of vital energy (qi) within the body -effective in pain, depression, addiction

patient teaching about herbal therapies

many herbal products have not undergone long term testing for safety and efficacy

best IV site for older patient

median vein in forearm

what adhering device is best for patient who has penrose drains that decreases skin irritation

montgomery straps

Airborne precautions

n-95 mask patient in negatiev air presure room ex: Measles, Tuberculosis, Varicella

Unintentional torts

negligence and malpractice

Mastectomy and assessment

never check bP or draw blood on same side of mastectomy.

Do incident reports get included in patient charts?

no

Battery

physical contact with a patient -like administering med against pt will

Maslow's Hierarchy of Needs

physiological, safety, social, esteem, self-actualization

technique used to transfer a client who is unable to walk from a bed to a wheel chair

place wheelchair at 45 degree angle to the bed

s/s hyperglycemia

polyphagia, polyuria, polydipsia, weight loss, increased vitals blurred vision, fruity breath, hot and dry?

Immunocompromised precautions

positive pressure room nurse wears mask to protect patient NO flowers/plants in room

Confidentiality

protecting patient's privacy

Advocacy

providing client rights, their safety, and that they are getting the level of care that they should be

how to remove restraints

remove the restraints one at a time

How to collect sputum with unconscious patients?

suction using a Yankauer device

what health care professional is responsible for obtaining informed consent

surgeon

Droplet precautions

surgical mask ex: Influenza, pertussis, respiratory MRSA

client who has type 1 DM and is resistant to self injecting insulin. what statement should nurse make

tell me what I can do to help you overcome your fear of giving yourself injections

what should nurse consider when using 5 rights of delegation to a UAP

the AP has the knowledge and skill to perform the task

client is A&O x 3 and has advanced directives. client needs a procedure the requires informed consent. who should sign the informed consent

the client

Reiki

therapist places hands on/above pt body to transfer universal energy (ki) to restore balance

manifestation of DVT

unilateral leg edema

s/s dehydration

Thready pulse Low BP Tachycardia elevated BUN and creatinine Hypoxia poor skin turgor, thirst, dry mucous membrane, decreased urinary output

Assault

threatening a patient

Magnet Therapy

used to diagnose and treat conditions like cancer, AIDS, MS -Can stimulate the immune system and suppress cancer cells?

IV sites to avoid

varicose veins, flexion areas, near valves, lower extremeties, back of hand, av graft or fistula

example of negligence

a nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the proved in the early afternoon

False Imprisonment

all 4 bed rails up restraints agains will or on longer than prescribed

what can be delegated to UAP

ambulate client transfer client to stretcher record urinary output

what client would benefit most from the nurse acting as an advocate

an older adult client who has no family and is uncertain about moving to assisted living

in a legal proceeding what standard will be used to determine if a nurse was negligent

another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation

what action should nurse take first when transferring a client from a bed to a chair

determine if the client can bear weight

nursing interventions for a client who does not speak the same language as the nurse

determine the client's level of fluency in his primary language

what action should nurse take when initiating continuous enteral feeding through an open system

discard unused formula after 8 hr

protocol for disposing of a used needle

dispose of needle uncapped

a nurse is caring for a client who is unresponsive following a car crash. the client's son states that he does not want any heroic measures performed. which of the following responses by the nurse is appropriate

does your father have advanced care directives

the client expresses concern about the risk of acquiring an infection from the blood transfusion. what statement should the nurse make to the client

donate autologous blood before the surgery

DPOA

durable power of attorney patient designates person to make decisions for the patient- can change anytime pt wants

what demonstrates client advocacy

encourage client to verbalize questions

nursing action for client 8 hr post op for a total knee replacement

encourage increased fluid intake

What is the #1 goal when taking care of patients with dementia/alzheimer's?

encourage independance

Goals for patients with dementia/alzheimer's

encourage independence use short, simple sentences Have a routine/schedule Install handrails in bathroom/shower/tub

prescription for client who is post op hip arthroplasty

enoxaparin

How to prevent restrains?

ensure effective pain management attend to client's needs assign client to room close to nurse station

nursing action for patient who has decreased circulation in his right leg

evaluate pedal pulses

How often to reassess restraints?

every 2 hours

How often should females do self-examination of breasts?

every 4-7 days after menses start inspection at ancillary region

How often to change iV site

every 72 hours if not sooner

How often do you flush an IV?

every 8-12 hours to keep patent and prevent occlusion

neglifence

failure to provide adequate care

justice

fairness to every patient

instructions for client w DVT and is prescribed anticoagulant

flex knees and feet frequently

Fracture bedpan

for patients in leg cast, lower extremity fracture, or is unable to raise their hips

methods of identification

full name date of birth

fidelity

fullfillment of promises - if you say you will be back in 10 minutes, you will be back in 10 minutes

What is the nurses #1 priority for a persons valuables

give it to the family members

contact precautions

gown and gloves ex: C-Dif, MRSA, VRE

how to assess skin turgor

grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back

first step in preparing to provide tracheostomy cre

hand hygiene

Standard isolation precautions

hand hygiene gloves

client asks nurse "are there any other options besides surgery" what is the best response to this statement

have you discussed other treatments with your provider

Ideal IV insertion spot

non-dominant forearm between wrist and elbow

protocol when patient changes mind after giving informed consent for a procedure

notify surgeon that client wishes to withdraw informed consent for the procedure

nurse is caring for a client. what should the nurse do first using the nursing process

obtain client information

a charge nurse observes a newly licensed nurse perform tracheostomy care. what action requires intervention

obtaining cotton balls for the trach care

what kind specialist should assist a schizophrenic patient with ADLs

occupational therapist

Where do you tie restraints?

on the part of the bed that does not move**ATIsaysmoveablepart

risk factor for DVT

oral contraceptive use immobility

Accountability

owning up to your actions and being able to admit actions

a nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. the nurse auscultates a high pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positions at the left sternal border. which of the following heart sounds should the nurse document

pericardial friction rub

Malpractice

professional negligence failure to provide adequate care

Telephone/Verbal prescription considerations

read order back 2nd RN as witness Verify with provider if do not understand Have provider sign within 24 hours

client reports pain at IV insertion site. what is the nursing intervention

remove catheter and insert another into a different site

what to do if a nurse finds an open vial of morphine in a client's room

report discrepancy immediately

priority assessment after administering an IM injection of merperidine

respiratory rate

What do you do if gastric residual aspirated is less than 100mL

return residual and continue with feeding

where to place stethoscope to find aortic valve

second intercostal space to the right of the sternum

What can failure to report defective equipment lead to?

sentinel event (death or harm to a patient due to defective equipment)

s/s hypoglycemia

shakiness/sweating, diaphoresis, anxiety, nervousness, chills, nausea, headache, weakness, confusion, fatigue, hunger

nursing action when observes a client crying

sit and hold client's hand

patient teaching for client who has constipation

sit on toilet for 30 minutes after eating

position for at home enteral feedings

sitting in a chair

a nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. which of the following factors is the most important in determining the client's ability to learn new dietary habits

the involvement of the client in planning the change

autonomy

the patient's right to make their own personal decisions includes care, medications, treatment, and right to refuse

what indicates that the UAP understand teaching about hand hygiene

there are times I should use soap and water rather than an alcohol rub to clean my hands

why is gastric residual measured prior to enteral feeding

to identify delayed gastric emptying

Why do transplant patients fo through chemo?

to suppress immune system so body does not reject the new organ

what diseases are on the list of nationally notifiable infectious diseases

trichomonas vaginlais candidiasis albicans

what to do when BP readings at varied intervals and inconsistent readings

turn on machine every 15 minutes to measure BP

Care for unconscious patients

turn patient on side to avoid aspiration use bite block for oral care- never insert fingers into patients mouth

lab finding in client who has fluid volume deficit

urine specific gravity 1.035

action to transfer client with left sided weakness from bed to chair

use gait belt to stand and pivot client

a nurse observes a UAP preparing to obtain a blood pressure with a regular size cuff for a client who is obese. which of the following explanations should the nurse give the UAP

using a cuff that is too small will result in an inaccurately high reading

what actions should nurse take when obtaining informed consent from a client who is preoperative

validate signature verify client understands the surgical procedure is confirm that the consent is voluntary

nurse is administering 1 mg hydromorphone IV to client. the available does is 2 mg/1dL. what should the nurse do with the excess medication?

waste medication in the presence of another nurse

Oxygen tank education

wear cotton- avoid wool fire safety store upright avoid patroleum based products use a no smoking sign on the door

what question promotes the client to discuss health history upon admission

what brought you to the hospital