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