ATI Exam

List at least five tasks the delegating nurse must perform when supervising and evaluating a delegatee.

1. Provide supervision, either directly or indirectly (assigning supervision to another licensed nurse) 2. Monitor performance 3. Intervene if necessary (for unsafe clinical practice) 4. Provide feedback: a. Did the delegatee complete the tasks on time? b. Was the delegatee's performance satisfactory? c. Did the delegatee document and report unexpected findings? d. Did the delegatee need help completing the tasks on time? 5. Evaluate the client and determine the client's outcome status 6. Evaluate task performance and identify needs for performance-improvement activities and additional resources

Five "Rights" of Delegation

1. Right task 2. Right circumstances 3. Right person 4. Right direction and communication in writing, orally, or both 5. Right supervision and evaluation

Spiritual Distress

A challenge to belief systems or spiritual well-being. It often arises as a result of catastrophic events. The client can display hopelessness and decreased interactions with others. Nursing interventions are directed at identification, restoration, and/or reconnection of clients and families to spiritual strength.

Nonmaleficence

A commitment to do no harm

Veracity

A commitment to tell the truth

A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (Select all that apply.) A. Review a signal the client can use if feeling any distress. B. Lay a towel across the client's chest. C. Administer oral pain medication. D. Obtain a Dobhoff tube for insertion. E. Have a petroleum-based lubricant available.

A, B

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply.) A. Apply the oxygen source loosely if the SpO2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer cannula surfaces in a circular motion from the stoma site outward. D. Replace the tracheostomy ties with new ties. E. Cut a slit in gauze squares to place beneath the tube holder.

A, B, C

A nurse is instructing a group of assistive personnel in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply.) A. Place the client in semi-Fowler's position. B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate. D. Count the rate for 30 sec if it is irregular. E. Count and report any sighs the client demonstrates.

A, B, C

A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply) A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks

A, B, C, E

A nurse manager is providing information about the audit process to members of the nursing team. Which of the following information should the nurse manager include? (Select all that apply.) A. A structure audit evaluates the setting and resources available to provide care. B. An outcome audit evaluates the results of the nursing care provided. C. A root cause analysis is indicated when a sentinel event occurs. D. Retrospective audits are conducted while the client is receiving care. E. After data collection is completed, it is compared to a benchmark.

A, B, C, E

A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.) A. Hold the cane on the right side. B. Keep two points of support on the floor. C. Place the cane 38 cm (15 in) in front of the feet before advancing. D. After advancing the cane, move the weaker leg forward. E. Advance the stronger leg so that it aligns evenly with the cane.

A, B, D

A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes and blood pressure 102/64 mm Hg. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? (Select all that apply.) A. Decreased skin turgor B. Concentrated urine C. Bradycardia D. Low-grade fever E. Tachypnea

A, B, D, E

A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. Which of the following are manifestations of a systemic infection? (Select all that apply.) A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate

A, B, E

A nurse orienting a newly licensed nurse is reviewing the procedure for taking a telephone prescription. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands the process? A. "A second nurse enters the prescription into the client's medical record." B. "Another nurse should listen to the phone call." C. "The provider can clarify the prescription when they sign the health record." D. "I should omit the 'read back' if this is a one-time prescription."

B

Hydrogel

Composition is mostly water. Gels after contact with exudate, promoting autolytic debridement and cooling. Rehydrates and fills dead space. Might require a secondary occlusive dressing. - For infected, deep wounds or necrotic tissue - Not for moderately to heavily draining wounds - Provides a moist wound bed - Soothing and can reduce wound pain - Prevents skin breakdown in high-pressure areas (eg the sacrum)

Justice

Fairness in care delivery and in the use of resources

Psychomotor learning

Gaining skills that require mental and physical activity. Relies on perception (sensory awareness), set (readiness to learn), guided response (task performance with an instructor), mechanism (increased confidence allowing for more complex learning), adaptation (the ability to alter performance when problems arise), and origination (use of skills to perform complex tasks that require creating new skills). An example of this is when clients practice preparing insulin injections.

Selecting a vein for IV therapy

Select the vein by using visualization, gravity, fist clenching, friction with the cleaning solution, or heat and choose: - Distal veins first on the nondominant hand - A site that is not painful or bruised and will not interfere with activity - A vein that is resilient with a soft, bouncy sensation on palpation Avoid the following: - Varicose veins that are permanently dilated and tortuous - Veins in the inner wrist with bifurcations, in flexion areas, near valves (appearing as bumps), in lower extremities, and in the antecubital fossa (except for emergency access) - Veins in the back of the hand - Veins that are sclerosed or hard - Veins in an extremity with impaired sensitivity (scare tissue, paralysis), lymph nodes removed, recent infiltration, a PICC line, or an arteriovenous fistula or graft - Veins that had previous venipunctures

Fidelity

The fulfillment of promises

Endotracheal suctioning

Use a suction catheter. The catheter should not exceed one half of the internal diameter of the endotracheal tube to prevent hypoxia. The nurse should use no larger than a 16 French suction catheter when suctioning an 8 mm endotracheal tube or tracheostomy tube. Hyperoxygenate the client using a bag-valve-mask (BVM) or specialized ventilator function with an FiO2 of 100%

Tasks that RNs may delegate to APs

- Activities of daily living (ADLs): + Bathing + Grooming + Dressing + Toileting + Ambulating + Feeding (WITHOUT swallowing precautions) + Positioning - Routine tasks: + Bed making + Specimen collection + Intake and output + Vital signs (for STABLE clients)

Sphygmomanometer

- Comes with a pressure manometer (aneroid or mercury) and a correctly sized cuff - The width of the cuff should be 40% of the arm circumference at the point where the cuff is wrapped - The bladder (inside the cuff) should surround 808% of the arm circumference of an adult and the whole arm for a child - Cuffs that are too large give a falsely low reading, and cuffs that are too small give a falsely high reading

Professional negligence issues that prompt most malpractice suits include failure to...

- Follow professional and facility-established standards of care - Use equipment in a responsible and knowledgeable manner - Communicate effectively and thoroughly with clients - Document care the nurse provided - Notify the provider of a change in the client's condition - Complete a prescribed procedure

Nurses can avoid liability for negligence by...

- Following standards of care - Giving competent care - Communicating with other health team members and clients - Developing a caring rapport with clients - Fully documenting assessments, interventions, and evaluations - Being familiar with and following a facility's policies and procedures

Hypoxemia and Hypoxia

- Hypoxemia: inadequate level of oxygen in the blood. Hypovolemia, hypoventilation, and interruption of arterial flow can lead to hypoxemia. - Hypoxia is a decrease in tissue oxygenation. Early Findings: - Tachypnea - Tachycardia - Restlessness - Pale skin and mucous membranes - Elevated blood pressure - Finding of respiratory distress (use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds) Late Findings: - Confusion and stupor - Cyanotic skin and mucous membranes - Bradypnea - Bradycardia - Hypotension - Cardiac dysrhythmias

Additional guidelines for nasopharyngeal and nasotracheal suctioning

- Insert the catheter into the naris during inhalation - Do not apply suction while inserting the catheter - Follow the natural course of the naris and slightly slant the catheter downward while advancing it. - Advance the catheter 15 to 20 cm (6 to 8 in). - Apply suction intermittently by covering and releasing the suction port with the thumb for 10 to 15 seconds. - Apply suction only while withdrawing the catheter and rotating it with the thumb and forefinger. - Do not perform more than two passes with the catheter. Allow at least 1 minute between passes for ventilation and oxygenation.

Tracheostomy Considerations

- Keep the following at the bedside: two extra tracheostomy tubes (one the client's size and one size smaller, in case of accidental decannulation), the obturator for the existing tube, an oxygen sources, suction catheters and a suction source, and a BVM. - Provide methods to communicate with staff (paper and pen, dry-erase board). - Provide an emergency call system and a call light. - Provide adequate humidification and hydration to thin secretions and reduce the risk of mucous plugs. - Give oral care every 2 hr. - Provide tracheostomy care every 8 hr to reduce the risk of infection and skin breakdown. + Suction the tracheostomy tube, if necessary, using sterile suctioning supplies. + Remove soiled dressings and excess secretions. + Apply the oxygen source loosely if the client's SpO2 decreases during the procedure. + Use cotton-tipped applicators and gauze pads to clean exposed outer cannula surfaces. Use the facility-approved solution. Clean in a circular motion from the stoma site outward. + Use surgical asepsis to remove and clean the inner cannula (with the facility-approved solution). Use a new inner cannula if it is disposable. + Clean the stoma site and then the tracheostomy plate. + Place a fresh split-gauze tracheostomy dressing of nonraveling material under and around the tracheostomy holder and plate. + Replace tracheostomy ties if they are wet or soiled. Secure the new ties before removing the soiled ones to prevent accidental decannulation. + If a knot is needed, tie a square knot that is visible on the side of the neck. Check that one or two fingers fit between the tie and the neck. - Change nondisposable tracheostomy tubes every 6-8 weeks or per protocol. - Reposition the client every 2 hr to prevent atelectasis and pneumonia. - Minimize dust in the room. Do not shake bedding. - If the client is permitted to eat, position them upright and tip the chin to the chest to enable swallowing. Assess for aspiration.

Tasks that RNs may delegate to PNs/VNs

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

Postmortem Care

- Nurses are responsible for following federal and state laws regarding requests for organ or tissue donation, obtaining permission for autopsy, ensuring the certification and appropriate documentation of the death, a nd providing postmortem (after-death) care. - After postmortem care is completed, the client's family becomes the nurse's primary focus.

SCD and IPC - Procedure

- Perform hand hygiene - Assess circulation and skin prior to application - Measure around the largest part of the thigh to determine the stocking size - Apply the sleeves to each leg. Position the opening at the client's knees. - Attach the sleeves to the inflator. - Turn on the device. - Monitor circulation and skin after application. - Remove every 8 hr for assessment of calves. - Document the application and removal of the stockings.

Autopsy Considerations

- The provider typically approaches the family about performing an autopsy. - The nurse's role is to answer the family members' questions and support their choices. - Autopsies can be conducted to advance scientific knowledge regarding diseases processes, which can lead to the development of new therapies. - The law can require an autopsy to be performed if the death is due to homicide, suicide, or accidental death, or if death occurs within 24 hr of hospital admission - Most facilities require that all tubes remain in place for an autopsy - Documentation and completion of forms following federal and state laws typically includes the following: + Who can pronounce the death and at what time + Consideration of an preparation for organ donation + Description of any tubes or lines left in or on the body + Disposition of personal articles + Who was notified, and any decisions made + Location of identification tags + Time the body left the facility and the destination

Nursing Actions when Administering Otic Medication

- Use medical aseptic technique when administering medications into the ears. - Have clients sit upright or lie on their side. - Straighten the ear canal by pulling the auricle upward and outward for adults or down and back for children less than 3 years of age. Hold the dropper 1 cm above the ear canal, instill the medication, and then gently apply pressure with your finger to the tragus of the ear unless it is too painful. - Do not press a cotton ball deep into the ear canal. If necessary, gently place it into the outermost part of the ear canal. - Have clients remain in the side-lying position if possible for 2 to 3 minutes after installation of ear drops.

Nursing Actions for Subcutaneous Injections (Administering Parenteral Medication)

- Used for small doses of nonirritating, water-soluble medications (insulin and heparin). - Use a 3/8 to 5/8 inch, 25-27 gauge needle, or a 28 to 31 gauge insulin syringe. Inject no more than 1.5 mL of solution. - Select sites that have an adequate fat-pad size (abdomen, upper hips, lateral upper arms, thighs). - For average-size clients, pinch up the skin and inject at a 45-90 degree angle. For obese clients, use a 90 degree angle.

A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation

A

A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea

A

A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance? A. Diabetic ketoacidosis B. Heart failure C. Cushing's syndrome D. Thyroidectomy

A

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment. B. Educated the client and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in their possession.

A

A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client? A. "Do not measure the client's temperature rectally." B. "Count the client's radial pulse for 30 seconds and multiply it by 2." C. "Do not let the client know you are counting their respirations." D. "Let the client rest for 5 minutes before you measure their blood pressure."

A

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hr. B. Instruct the client to cough and deep breathe every 4 hr. C. Restrict the client's fluid intake. D. Reposition the client every 4 hr.

A

An RN on a medical-surgical unit is making assignments at the beginning of the shift. Which of the following tasks should the nurse delegate to the PN? A. Obtain VS for a client who is 2 hr postprocedure following a cardiac catheterization. B. Administer a unit of packed red blood cells (RBCs) to a client who has cancer. C. Instruct a client who is scheduled for discharge in the performance of wound care. D. Develop a plan of care for a newly admitted client who has pneumonia.

A

A nurse is caring for a client who has a blood sodium level 133 mEq/L and blood potassium level 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these laboratory findings? A. Three tap water enemas B. 0.9% sodium chloride solution IV at 50 mL/hr C. 5% dextrose with 0.45% sodium chloride solution with 20 mEq of K+ IV at 80 mL/hr D. Antibiotic therapy

A Rationale: Sodium normal range 135-145 mEq/L Potassium normal range 3.6-5.2 mEq/L Enemas would eliminate electrolytes along with water

Ethical Decision Making

A process that requires striking a balance between science and morality. Steps to making this type of decision: - Identify whether the issue is indeed an ethical dilemma - Gather as much relevant information as possible about the dilemma - Reflect on your own values as they relate to the dilemma - State the ethical dilemma, including all surrounding issues and the individuals it involves - List and analyze all possible options for resolving the dilemma, and review the implications of each option - Select the option that is in concert with the ethical principle that applies to this situation, the decision maker's values and beliefs, and the profession's values for client care. Justify selecting that one option in light of the relevant variables. - Apply this decision to the dilemma and evaluate the outcomes.

A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply.) A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Hypertension

A, B, D, E

A nurse manager is developing an orientation plan for newly licensed nurses. Which of the following information should the manager include in the plan? (Select all that apply.) A. Skill proficiency B. Assignment to a preceptor C. Budgetary principles D. Computerized charting E. Socialization into unit culture F. Facility policies and procedures

A, B, D, E, F

A nurse educator is teaching newly licensed nurses about safe medication administration. Which of the following statements indicates understanding? (Select all that apply.) A. "I will observe for adverse effects." B. "I will monitor for therapeutic effects." C. "I will prescribe the appropriate dose." D. "I will change the dose if adverse effects occur." E. "I will refuse to give a medication if I believe it is unsafe."

A, B, E

A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3 C (101 F), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should thee nurse take? (Select all that apply.) A. Obtain culture specimens before initiating antimicrobials. B. Restrict the client's oral fluid intake. C. Encourage the client to rest and limit activity. D. Allow the client to shiver to dispel excess heat. E. Assist the client with oral hygiene frequently.

A, C, E

A nurse is consoling the partner of a client who just died after a long battle with liver cancer. The grieving partner states, "I hate them for leaving me." Which of the following statements should the nurse make to facilitate mourning for the partner? (Select all that apply.) A. "Would you like me to contact the chaplain to come and speak with you?" B. "You will feel better soon. you have been expecting this for a while now." C. "Let's talk about your children and how they are going to react." D. "You know, it is quite normal to feel anger toward your loved one at this time." E. "Tell me more about how you are feeling."

A, D, E

A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (Select all that apply.) A. Apply suction while withdrawing the catheter. B. Perform suctioning on a routine basis every 2 to 3 hr. C. Maintain medical asepsis during suctioning. D. Use a new catheter for each suctioning attempt. E. Apply suction for 10 to 15 seconds.

A, D, E

A nurse is reviewing a client's prescribed medications at the beginning of the day shift. Which of the following 0900 medications can be given any time between 0700 and 1100? (Select all that apply.) A. A once-daily multivitamin B. Eye drops prescribed every 3 hr C. An Antibiotic prescribed every 8 hr D. A blood pressure pill prescribed twice daily E. A subcutaneous injection prescribed once weekly

A, E

The Nursing Process

ADPIE 1. Assessment: Collects information 2. (Nursing) Diagnosis: Describes health problems 3. Planning: Setting priorities and goals 4. Implementation: Carries out the plan (goals) 5. Evaluation: Measures if the goals of the planning step were met

Nursing Process Framework

ADPIE Assessment/data collection Diagnosis/analysis/data collection Planning Implementation Evaluation PNs combine the assessment and analysis steps into a single data collection step

Maleficence

Action that promotes good for others, without any self-interest

Uses of popular herbs/plants

Aloe: wound healing Chamomile: Anti-inflammatory, calming Echinacea: Enhances immunity Garlic: Inhibits platelet aggregation Ginger: Antiemetic Ginkgo biloba: Improves memory Ginseng: Increases physical endurance Valerian: Promotes sleep, reduces anxiety

Protective Environment

An intervention (not type of precautions) to protect clients who are immunocompromised. This includes clients who have had an allogeneic hematopoietic stem cell transplants. It requires: - A private room - Positive airflow 12 or more air exchanges/hr - HEPA filtration for incoming air - Mask for the client when out of the room

Hydrocolloid

An occlusive dressing that swells in the presence of exudate; composed of gelatin and pectin, it forms a seal at the wound's surface to prevent evaporation of moisture from the skin. - Maintains a granulating wound bed - Can stay in place for 3-5 days

Factors affecting mobility

Arthritis Osteoporosis Falls Encourage weight-bearing exercises (at least 30 min, 3-5 times a week) to improve strength and reduce bone loss. Asses the home environment for safety (remove throw rugs, provide adequate lighting, clear walkways) too prevent falls, which can result in fractures. - Reinforce the use of safety equipment and assistive devices. - Clearly mark thresholds, doorways, and steps.

A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family? A. Allowing the client to function independently will strengthen muscles and promote healing. B. The client needs privacy at times for self-reflecting and organizing life. C. The client's sense of loss can be lessened through retaining control of some areas of life. D. Performing ADLs is a requirement prior to discharge from an acute care facility.

B

A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? A. "I will threat the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood." B. "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up." C. "I will apply pressure approximately 1.2 inches below the insertion site prior to removing the needle." D. "I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location."

B

A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (Select all that apply.) A. "I feel lightheaded." B. "I feel as though my heart is racing." C. "I feel a little short of breath." D. "The nurse technician told me that my blood pressure was 150 over 90." E. "I think my ankles are less swollen."

B, C, D

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include? (Select all that apply.) A. Place the client in a room that has negative air pressure of at least 6 exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that might result in contamination from secretions.

B, C, D

A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include? (Select all that apply) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use B. Nail polish should not be used near a client who is receiving oxygen C. A "No Smoking" sign should be placed on the front door D. Cotton bedding and clothing should be replaced with items made from wool E. A fire extinguisher should be readily available in the home

B, C, E

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.) A. Instruct the client not to perform the Valsalva maneuver. B. Apply elastic stockings. C. Review laboratory values for total protein level. D. Place pillows under the client's knees and lower extremities. E. Assist the client to change positions often.

B, E

A PN ending their shift reports to the RN that a newly hired AP has not calculated the intake and output for several clients. Which of the following actions should the RN take? A. Complete an incident report. B. Delegate this task to the PN. C. Ask the AP if they need assistance. D. Notify the nurse manager.

C

A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (Select all that apply.) A. Remove the dentures from the body. B. Make sure the body is lying completely flat. C. Apply fresh linens and place a clean gown on the body. D. Remove all equipment from the bedside. E. Dim the lights in the room.

C, D, E

A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) A. Apply petroleum jelly around and inside the nares. B. Remove the nasal cannula during mealtimes. C. Check the position of the cannula frequently. D. Report any nausea or difficulty breathing. E. Post "No Smoking" signs in prominent locations.

C, D, E

What pathogens require contact isolation?

C. diff., herpes simplex virus, impetigo, MRSA, VRSA

A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which o the following actions should the nurse take? A. Open the windows in the client's room to allow smoke to escape. B. Obtain a class C fire extinguisher to extinguish the fire. C. Remove all electrical equipment from the client's room. D. Place wet towels along the base of the door to the client's room.

D

A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicates understanding? A. "I will set my water heater to 130 degrees Fahrenheit." B. "Once my baby can sit up, they should be safe in the bathtub." C. "I will place my baby on their stomach to sleep." D. "Once my infant starts to push up, I will remove the mobile from over the crib."

D

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness

D

A nurse is teaching a client about medications at discharge. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I Can open the time-release capsule with the beads in it and sprinkle them on my oatmeal." B. "If I am having difficultly swallowing, I will add the liquid medication to a prepared package of pudding." C. "I can crush the enteric coated pill, if needed." D. "I will eat two crackers with the pain pills."

D

Colorectal screening

Every year between the age of 50 and 75 for high-sensitivity fecal occult blood testing, or flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years.

Autonomy

Example: The client exercises their right to make their own personal decision about surgery, regardless of others' opinions of what is "best" for them

How should you handle unused formula, and how long should formula be hanging in continuous-drip feedings?

Follow the manufacturer's recommendations for formula hang time. Refrigerate unused formula, and discard after 24 hr.

Safety/Risk Reduction

Look first for a safety risk. For example, is there a finding that suggests a risk for airway obstruction, hypoxia, bleeding, infection, or injury? Next ask, "What's the risk to the client?" and "How significant is the risk compared to other posed risks?" Give priority to responding to whatever finding poses the greatest (or most imminent) risk to the client's physical well-being.

Alginates

Nonadherent dressings that conform to the wound's shape and absorb exudate - Provides a moist wound bed - Packs wounds - Supports debridement

Nursing Students - Liability

Nursing students face liability if they harm clients as a result of their direct actions or inaction. They should not perform tasks for which they are not prepared, and they should have supervision as they learn new procedures. If a student harms a client, then the student, instructor, educational institution, and facility share liability for the wrong action or inaction.

Oxygen Safety Measures

Oxygen can cause materials to combust more easily and burn more rapidly, the client and family must be provided with information on use of the oxygen delivery equipment and the dangers of combustion. Include the following information in the teaching plan: - Use and store oxygen equipment according to the manufacturer's recommendations - Place a "No Smoking" sign in a conspicuous place near the front door of the home. A sign can also be placed on the door to the client's bedroom - Inform the client and family of the danger of smoking in the presence of oxygen. Family members and visitors who smoke should do so outside the home - Ensure that electrical equipment is in good repair and well grounded - Replace bedding that can generate static electricity (wool, nylon, synthetics) with items made from cotton - Keep flammable materials (heating oil and nail polish remover) away from the client when oxygen is in use - Follow general measures for fire safety in the home (having a fire extinguisher readily available and an established exit route if a fire occurs)

Combustion

Oxygen is combustible Nursing actions: - Post "No Smoking" or "Oxygen in Use" signs to alert others of the fire hazard. - Know where to find the closest fire extinguisher. - Educate about the fire hazard of smoking with oxygen use. - Have clients wear a cotton gown because synthetic or wool fabrics can generate static electricity. - Ensure that all electric devices (razors, hearing aids, radios) are working well. - Make sure all electric machinery (monitors, suction machines) is grounded. - Do not use volatile, flammable materials (alcohol, acetone) near clients receiving oxygen

Collagen

Powders, pastes, granules, sheets, gels, and pastes - Helps stop bleeding - Promotes healing

Airborne precautions

Protect against droplet infections smaller than 5 mcg (measles, varicella, pulmonary , or laryngeal tuberculosis). Airborne precautions require: - A private room - Masks and respiratory protection devices for caregivers and visitors - Use an N95 or high-efficiency particulate air (HEPA) respirator. If the client is known or suspected to have tuberculosis. - Negative pressure airflow exchange in the room of a least 6-12 exchanges per hour, depending on the age of the structure. - If splashing or spraying is a possibility, wear full face (eyes, nose, mouth) protection - Clients who have an airborne infection should wear a mask while outside of the room/home.

Droplet Precautions

Protect against droplets larger than 5 mcg and travel 3 to 6 ft from the client (streptococcal pharyngitis or pneumonia, Haemophilus influenzae type B, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia and sepsis, pneumonic plague). These precautions require: - A private room or a room with other clients who have the same infectious disease. Ensure that clients have their own equipment. - Masks for providers and visitors. - Clients who have a droplet infection should wear a mask while outside of the room/home.

Contact Precautions

Protects visitors and caregivers when they are within 3 ft of the client against direct client and environmental contact infections (respiratory syncytial virus, shigella, enteric diseases caused by micro-organisms, wound infections, herpes simplex, impetigo, scabies, multidrug-resistant organisms). Contact precautions require: - A private room or a room with other clients who have the same infection. - Gloves and gowns worn by the caregivers and visitors. - Disposal of infection dressing material into a single, nonporous bag without touching the outside of the bag.

Medication Reconciliation

The Joint Commission requires policies and procedures for medication reconciliation. Nurses compile a list of each client's current medications, including all medications with correct dosages and frequency. They compare the list with new medication prescriptions and reconcile it to resolve any discrepancies. This process takes place at admission, when transferring clients between units or facilities, and at discharge.

Professional Negligence aka Malpractice

The failure of a person who has professional training to act in a reasonable and prudent manner. The terms "reasonable" and "prudent" generally describe a person who has the average judgment, intelligence, foresight, and skill that a person with similar training and experience would have.

Assessment/Data Collection First

Use the nursing process to gather pertinent information prior to making a decision regarding a plan of action. For example, determine if additional information is needed prior to calling the provider to ask for pain medication for a client.

Hyponatremia - Expected Findings

VS (with hypovolemia): Hypothermia, tachycardia, rapid thready pulse, hypotension, orthostatic hypotension, diminished peripheral pulses Neuromusculoskeletal: Headache, confusion, lethargy, muscle weakness to the point of possible respiratory compromise, fatigue, decreased deep-tendon reflexes (DTRs), seizures, lightheadedness, dizziness Gastrointestinal: Increased motility, hyperactive bowel sounds, abdominal cramping, nausea

Hypovolemia Signs and Symptoms

VS: Hyperthermia, tachycardia (in an attempt to maintain a normal blood pressure), thready pulse, hypotension, orthostatic hypotension, decreased in central venous pressure, tachypnea (increased respirations to compensate for lac of fluid volume within the body), hypoxia Neuromusculoskeletal: Dizziness, syncope, confusion, weakness, fatigue Gastrointestinal: Thirst, dry furrowed tongue, nausea, vomiting, anorexia, acute weight loss Renal: Oliguria (decreased production and concentration of urine)

Is repositioning the client to maintain airway patency and comfort an example of palliative physical care?

Yes

Should you pad clients in restraints?

Yes, pad bony prominences to prevent skin breakdown.