foundation 2 week

_______ is defined as decreased rate and depth of respirations

hypoventilation

________ application of a device to limit client movement

physical restrains

Never start with restraints; they should be the last resort. If they are necessary, be sure to have an order that specifies type, when they should be used (e.g., type of behavior). , and a specific time frame for use.

restraints

preforming a ______ are example like sensory impairment, potential for falls, level of mobility, skin integrity

risk assessment

Morse Fall Scale high risk means:

score is 45 or higher

_________ is considered restraints, if two are available, use one if four are available, leave at least bottom half down. An exception occurs when trying to keep the sedated client free from falls.

side rails

In addition,___________ precautions can include body substance precautions or the ability to add masks, eye protection (goggles/shields), and gowns when appropriate. For instance, if you are first caring for a client you may not know whether they have any condition but you treat them as though they do anyway.

standard

So, while inserting an IV, you definitely wash your hands before you glove up, you place gloves to prevent you from coming into direct contact with their blood, and finally, you wash your hands after the procedure to be safe this is what type of precautions?

standard

The client with HIV is the most common example for _______ precaution questions, as all other clients should be treated with standard precautions.

standard

________precautions include hand washing and gloves and hand washing following degloving.

standard

_______ removes pathogens in their entirety (free from pathogens) and This includes practices of sterile fields as in Foley insertion, tracheostomy suctioning, and surgical procedures.

sterile technique

_________ is measured as anything greater than 100 bpm but less than 180 bpm.

tachycardia

_____, on the other hand, is defined as more than 24 breaths per minute .

tachypnea

Trauma to the older client in the home may be caused by a variety of factors. These include _______ .

unsteady gait, the presence of unsecured scatter rugs, cluttered passageways, inoperable smoke detectors, and history of previous falls.

______ pain originating in the internal organs in the thorax, cranium, or abdomen

visceral pain

_______ Assess and respond to changes and/or trends in client vital signs.

vital signs

List measures to prevent falls?

➔Keep personal items within reach. ➔Eliminate clutter and obstacles. ➔Provide adequate lighting. ➔Reduce bathroom hazards. ➔Maintain toileting schedule.

List measures to prevent falls?

➔Orient the client to physical surroundings. ➔Instruct the client to seek assistance when getting up. ➔Explain the use of the nurse call system.

List measures to prevent falls?

➔Use safety devices such as floor pads and bed/chair alarms when getting up. ➔Keep the bed in the low position. ➔Lock all beds, wheelchairs, and stretchers.

______ are examples of specific requirements for isolation e.g., Meningitis, Surgical mask when within 3 feet, client wears surgical mask on exit

Droplet

Morse Fall Scale low risk means:

0 to 24

A nurse is assessing a full-term neonate and discovers a heart rate of 100 beats per minute and an axillary temperature of 97.1 F (36.2 C). What action should the nurse take? 1.Place a cap on the neonate's head, and offer the neonate to the mother for skin-to-skin contact. 2.Place the neonate in an incubator, and notify the healthcare provider of the neonate's temperature. 3.Perform a thorough physical assessment including checking a rectal temperature. 4.Encourage the mother to breastfeed the infant as soon as possible.

1

The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client? 1.Private room or cohort client 2.Personal respiratory protection device 3.Private room with negative airflow pressure 4.Mask worn by staff when the client needs to leave the room

1

A nurse is caring for a client diagnosed with Alzheimer's disease who scored a 7 (High risk) on the Hendrich II Fall Risk Model. Which nursing intervention(s) would the nurse implement? Select all that apply. 1.Implement a bed alarm. 2.Place the client in a room near the nurse's station. 3.Maintain the bed in the lowest position. 4.Offer toileting as needed. 5.Apply soft restraints as needed. 6.Close the door at night to minimize distractions.

1,2,3

The home care nurse is performing an environmental assessment in the home of an older client. Which observation by the nurse requires intervention? 1. Unsecured scatter rugs. 2. Clear exit passageways. 3. An operable smoke detector. 4. A prefilled medication cassette

1.

Items we look at for Morse Fall Scale is what ? (7)

1. History of falls 2.Secondary diagnose 3.Ambulatory Aid 4.IV therapy/HepLock 5. Gait 6.Mental staus

what is consider a high temperature or high fever?

100.4 or higher

baseline for respiration rate is ?

12 to 20

what is blood pressure baseline?

120/80

A nursing faculty educates a student regarding principles of hand hygiene. Which statement by the student indicates a need for further teaching regarding principles of hand hygiene? 1."Hand hygiene should be performed before and after touching any patient." 2."Hand hygiene should be performed only before an aseptic procedure." 3."Hand hygiene should be performed when the hands are visibly soiled." 4."Hand hygiene should be performed after touching the patient and/or their surroundings."

2

The nurse on the oncology unit is caring for a client with a total white blood cell (WBC) count equal to 2000/µL (2.0 ×109/L). Which intervention is most important to include in the plan of care? 1.Monitor temperature every 4 hours. 2.Avoid rectal thermometers and suppositories. 3.Perform proper hand hygiene. 4.Restrict visitors and provide a private room.

2

When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is most appropriate? 1.Administering aspirin as ordered 2.Encouraging increased fluid intake 3.Reassessing vital signs every 15 minutes 4.Requesting an antibiotic order

2

when restraint offer fluids and toileting__________

EVERY 2 hours

●Assess skin integrity and circulatory status _______ minutes when in restaints

EVERY 30

A client has returned from cardiac catheterization. Which finding should the nurse report immediately? 1.Respirations of 20 breaths per minute 2.Heart rate of 110 beats per minute 3.Blood pressure of 120/79 mm Hg 4.Temperature of 99.9 F (37.7 C)

2.

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care? 1.Surgical mask and gloves 2.Particulate respirator, gown, and gloves 3.Particulate respirator and protective eyewear 4.Surgical mask, gown, and protective eyewear

2.

A primary health care provider has written a prescription for wrist restraints to be applied on a client from 10:00 p.m. to 7:00 a.m. because the client becomes disoriented during the night and is at risk for pulling out the nasogastric tube and the intravenous catheter. At 11:00 p.m., the charge nurse makes rounds on all of the clients in the unit. When assessing the client with the restraints, which observation by the charge nurse indicates that the nurse who applied the restraints performed an unsafe action? 1.The restraints were applied using a quick-release tie. 2.A safety knot was used to secure the restraints to the bed frame. 3.The nurse offers the client fluids and toileting every 30 minutes. 4.The nurse assesses the client at least every 2 hours.

3.

baseline for temperature in celceus ?

36.4 to 37.5 C

A client in the intensive care unit has an arterial line that reads 58/30 mm Hg on the monitor. What is the nurse's first action? 1.Flush the catheter. 2.Place the client in Trendelenburg position. 3.Recalibrate the arterial line. 4.Obtain a manual blood pressure.

4

A nurse who is 6 months pregnant is assigned to a client with a diagnosis of HIV. The nurse tells the manager that she is unable to care for the client because it would be a risk to her baby. Which is the most appropriate statement by the manager? 1."I will ask that you be transferred to another unit while you are pregnant so there is no risk to you or your baby." 2."There will be no problem with this assignment if you wear a mask and gloves while providing all direct client care." 3."You can decrease the risk of exposure to the virus if the client uses disposable plates and utensils when eating." 4."You will be OK if you follow standard precautions and use protective equipment to avoid contact with blood and body fluids when providing care."

4

The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated? 1.Sterile objects are held above the waist of the technician. 2.Sterile packages are opened with the first edge away from the technician. 3.The outer inch of the sterile towel hangs over the side of the table. 4.Wetness in the sterile cloth on top of the nonsterile table has been noted.

4

Morse Fall Scale moderate risk means:

44 to 25

_pulse range between _____ bpm

60 and 100

baseline for temperature in f?

97.5 to 99.5

●Remove restraints __________

AT LEAST EVERY 2 hours

_____ is Varying depth and rate of breathing, followed by periods of apnea; irregular

Biot's respirations

_______ is defined as the force on the walls of an artery exerted by the pulsating blood under pressure from the heart.

Blood pressure

______ has alternating periods of deep, rapid breathing followed by periods of apnea; regular.

Cheyne-Stokes

_____ are examples of specific requirements for isolation e.g., Tuberculosis, N-95, Negative air pressure room, Client wears surgical mask on exit

airborne

________ start with restraints (e.g., consider bed/chair alarms)

DO NOT

A blood pressure that is known to be hypertensive crisis is what?

Greater than 180

________ most effective method to prevent the spread of infection. This intervention will top most others in prevention of infection because it effectively removes pathogens from the skin and therefore they cannot be passed onto others it includes washing with soap and warm water when the hands are visibly soiled or using an alcohol-based hand rub when not visibly soiled.

Hand hygiene

Extreme exercise, fear, diabetic ketoacidosis (Kussmaul's respirations) are example of what?

Hyperventilation

a personal respiratory protection device and private room with negative airflow pressure are necessary as these are requirements for the client on _____ precautions

airborne

______ protective procedure designed to prevent the transmission of specific microorganisms

Isolation

_______breathing, or rapid, deep breathing without pauses.

Kussmaul

The ______ is used in identifying those clients who have the potential for falls (meaning they have not fallen, at least not during this stay) and providing interventions to reduce the risk for falls.

Morse Fall Scale

●Secure with quick-release ties to the bed frame ____ side rails

NOT

Specific Requirements for Isolation or Transmission-Based Precautions are what?

airborne, droplets, contact

______ are protective devices used to limit the physical activity of a client or to immobilize a client or an extremity.

Restraints (safety devices)

________ should be used in the care of all patients regardless of their diagnosis or current infection status.

Standard Precautions:

____________ CDC precautions used in the care of all patients regardless of their diagnosis or possible infection status; this category combines universal and body substance precautions

Universal/Standard Precautions:

_____ take your client's report of pain for what it is; do not try to compensate for the pain reporting by accusing them of being drug seekers, liars, etc. Pain is whatever the client says it is to them!

subjective

Take the _______ for one full minute and assess in clients with an irregular radial pulse or heart condition, before cardiac medication administration (e.g., digoxin, beta blockers), and in children less than 2 yoa.

apical pulse

___________ reduces the number of pathogens and is known as clean technique. This includes practices of hand hygiene, cleaning least soiled areas first and then the more soiled areas next. For example, cleansing the skin for an injection, performing wound care, washing the hands from tip of fingers to elbow.

aseptic technique

IDEALLY, THE PATIENT SHOULD REMAIN WITHIN NORMAL LIMITS. IF NOT, THEY WILL EXPERIENCE ONE OF TWO EXTREMES. OUR JOB AS NURSES IS TO RETURN THEM TO_______.

baseline or within normal limits

Meningitis, severe brain damage are example of what respirations?

biot's

______ respirations vary in depth and rate followed by periods of apnea; irregular.

biot's

_________ is measured as anything less than 60 beats per minute. It is seen in trained athletes from rest; this is normal for the trained athlete

bradycardia

_______ is defined as less than 10 bpm

bradypnea

________ medications to inhibit a specific behavior or movement

chemical restraint

Drug overdose, heart failure, increased intracranial pressure, renal failure are example of what respirations?

cheyne-stokes repirations

_____ is Alternating periods of deep, rapid breathing followed by periods of apnea; regular

cheyne-stokes repirations

______ are example of specific requirements for isolation e.g., C. difficile, MRSA, Wear gown and gloves

contact

At minimum, the nurse should practice these principles. However, as needed the nurse can add PPE for specific tasks. For instance, you may need a ________ when irrigating a wound (for splashing).

face shield

If necessary, based on contact with bodily fluids, add on personal protective equipment as needed. For example, if you will be splashing fluids (e.g., wound, blood, stool, etc.) then wear a ?

gown and shield with gloves

A blood pressure that is known to be hypertension II is what?

greater than 140

If only changing the linens or similar what type of equipment would you need?

hand hygiene and gloves

Decreased rate and depth; irregular Overdose of narcotics or anesthetics

hyperventilation

Increased rate and depth

hyperventilation

Decreased rate and depth; irregular

hypoventilation

Overdose of narcotics or anesthetics is example of what ?

hypoventilation

Some considerations regarding _____ include: -Affected by many factors that affect respirations -Decreases with age -Increases with emotions, pain, and increased body temperature

pulse

_____ to assess pulse, count the rate, rhythm, strength (force or amplitude), and equality. The rate = number of beats per minute.

pulse

Use ________ or half-bow to secure the device to the bed frame and NOT side rails. When applied, they should still allow for movement.

quick-release tie (aka safety knot)

_____ should not be used in newborns.

rectal temperature

The rhythm can be documented as ____ which is the beats and the pauses between occur at regular intervals

regular

When the order expires (typically 24 hours), it must be ________ restraint can continue.

renewed before

Medications such as morphine (slows ______) can depress (slow) respirations.

respiratory rate

A blood pressure that is elevated is what?

systolic is 120 - 129

A blood pressure that is known to be hypertension I is what?

systolic is 130-139

_____ occurs when ejection occurs and diastolic pressure is the blood remaining in the arteries when the ventricles relax.

systolic pressure

In this case, the body lacks fluid (blood) to circulate, so the heart rate increases in an effort to pump the little blood available around the heart as quickly as possible this is known as _______.

tachycardia

_______ is most often seen in clients with an increase in body temperature and those clients in hypovolemia (deficient fluid volume).

tachycardia

______ means the beats are pauses between beats occur at unequal intervals also known as _____ which is not rhythmic.

irregular/ dysrhythmia

hyperventilation is increased rate and depth also known as?

kussmaul's

➔Assess risk for falling; use agency fall risk scale. ➔Assign to room near nurse's station. ➔Alert all personnel to client's risk for falls; use fall risk alert procedures. ➔Assess the client frequently. these are example of what?

lists measures to prevent falls

Obtain an _______ (to include type, reason, time)

order

To obtain _______ measurements check the BP and pulse with the client supine, sitting, and standing; readings are obtained one to three minutes after the client changes position.

orthostatic

_______ sensation of pain without demonstrable physiologic or pathologic substance; commonly observed after the amputation of a limb

phantom pain