HESI KEY POINTS STUDY THIS.

For a Urine specimen collection

-Discard the first voided specimen.

For JP and Hemovac portable drainage:

-Measure drainage every 8 hours. (Should decrease over time) -Wear gloves when emptying and avoid touching the reservoir. -Reestablish suction after emptying by compressing device and closing cap before releasing pressure. -Often removed 3- days post op.

Safe nursing practice for restraint includes

-checking the restrained patient q30min, -restraints are removed ROM every 2 hours. -documentation should include time and each check and status of client's extremeties.

Removing PPE

-gloves first -mask -gown -eye protection and then wash

When a client has a change in blood pressure you must assess for

-level of consciousness -presence of pule (Apical) -Check equipment.

General Rules for effective documentation

-never assume -only state clear observation and objective assessments -No statements of judgement.

Methods to promote client advocacy

-offer and arrange for translators -communicate changes to RN and MD -Refer client and other members of the healthcare team based on the client's needs.

Do not delegate these tasks to UAPs

-that require nursing judgement -initial new teachings -invasive or sterile procedures -unstable patient

Donning PPE

-wash -place before entering the room -gown -mask -eye protection -gloves

Most important indicators of child abuse

1. Injuries are not congruent with the child's developmental age or skill. 2. Injuries do not correlate 3. Delay seeking medical care. 4. Bruises in unusual places or different stages of healing. 5. Failure to thrive 6. Bedwetting 7. Sexually transmitted diseases.

Priorization of assessment post op

1. MAINTAIN AIRWAY STABILITY 2. Monitor urine out put. 3. Bleeding: Bright red is indicative of active bleeding! 4. Maintain incisional area inegrity. Prevent dehisence and evisceration.

for Braden scales, a score of _____ indicates pressure ulcer risk

18

The nurse is assigned to care for four children. Which child should you prioritize?

18 month old who has cystic fibrosis and is wheezing **AIRWAY is always priority.

A client's indwelling catheter is removed at 9:30Am. The nurse assesses the client every two hours for the desire to void. Which documented assessment requires further investigation by the nurse?

5:30pm; unable to void *After 8 hours!

After the catheter is removed make sure the client voids by

8 hours afterl if not notify the RN or MD>

Which client should the nurse assign to a UAP?

A client who has a regular heart rate after a pacemaker replacement and now needs to amputate. *The client is stable. *No client with pain.

The principle of client advocacy is best demonstrated when the nurse exhibits which behaviors on behalf of the client?

A nurse who translates complaints for a Spanish speaking client to a health care provider

The UAP working in a small community hospital obtains 0800 vital sign measurement warrants immediate intervention by the nurse?

A one-month-old infant with 80 beats per minute. *Should be at least 120-160.

While in a client's room, a healthcare provider tells the practical nurse to trim the toenails of a client with diabetes, which is inconsistent with the policy of the hospital. What action should the PN take?

Advise the healthcare provider of the existing hospital policy.

The scope of practice for the practical nurse includes which patient assessment? *The less critical *Most stable.

An agitated patient with bilateral wrist restraints.

The nurse asks a UAP for feedback about an assigned client. Instead of responding the UAP walks away from the nurse, ignoring the question. What is the best action for the nurse to take?

Approach the UAP to discuss the behavior and obtain the information needed for that client.

A #16 urinary catheter with a 5ml balloon is being removed by the nnurse. After withdrawing 5ml of fluid from the balloon the nurse begins to withdraw the catheter while the client is in a semifowler position. However, the nurse meets resistance and the client voices discomfort. What action should the nurse take next?

Attempt to withdraw additional fluid from the balloon.

A client is admitted with a fever of undetermined origin (FUO). During rounds, the nurse finds the client diaphoretic, and the linens are damp. What should the nurse do first?

Check the client's vital sign and pain scale.

The nurse is inserting an indwelling catheter for an older male client who has urinary retention. What action is most important for the nurse to implement?

Clamp the catheter after 1000 ml is drained from the bladder.

The nurse is changing the dressing on a drainage wound and irrigating the wound with sterile saline solution. What protective equipment should the nurse use?

Clean gloves to removed the soiled dressings and sterile gloves to apply the new dressing.

The nurse is in charge of a nursing unit in a long term nursing care facility. Which task is best to assign to the UAP who is helping the care of several client?

Cleanse the perineal area of a client with urinary incontinence.

The nurse empties a large amount of serous drainage from a postoperative client 's Hemovac drain. In what order should the nurse implement these procedures? (Place the first action on top and the last action on the bottom.) Compress drain... close drain... discard drain... document

Compress the drain Close the drain plug Discard the drainage Document the amount.

In working with an UAP to provide care for an immobile client, which task should the nurse provide rather than the UAP?

Cover a skin tear with a transparent dressing.

If client is DNR then a

DNR bracelet must be placed on the client's wrist.

Which intervention is within the scope of practice of the practical nurse?

Demonstrating deep breathing and coughing to a post operative patient.

A male client admitted the morning of his scheduled surgery tells the nurse that he drank a glass of water during the night. What intervention should the nurse implement first?

Determine the amount of water and the exact time it was taken.

When a small fire breaks out in the kitchen of a long-term care facility, which task should be performed by the nurse rather than the UAP?

Determine the means by which residents will be evacuated.

The nurse is caring for a client with MRSA. When caring for this client, which precaution should the nurse implement?

Don gown and gloves.

A client is diagnosed with C diff. What action should the nurse to implement to prevent the spread of infection?

Don non-sterile gloves when performing direct care

The nurse should perform oral suctioning for a client with which problem?

Dysphagia

The nurse observes a wife shaving her head with a safety razor by holding the skin taught and shaving in the direction of hair growth. What action should the nurse take?

Encourage the wife too continue shaving her husband.

An older male client is wandering on the skilled nursing unit. When he returns to the room, the UAP applies wrist restraints and tells the client that he is being restrained because he isn't trusted to stay in the room. What violation of the Patient's bill of rights has occurred?

False Imprisonment.

The nurse is caring for an older client with an infection. Which finding should the nurse anticipate as a delayed response in this client?

Fever

A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape in which direction to anchor the shield most effectively? A. Across the eye from the bridge of the nose to the right temple B. Longitudinally from the right forehead to the right cheek C. From the mid-forehead over to the right zygomatic process D. From the right lateral forehead surface to the medial nasal crease

From the mid- forehead over to the right zygomatic process.

The nurse is preparing a client with tuberculosis for transfer to another room. What action should the nurse implement?

Give the client a surgical mask for transport.

LVNs cannot do

Initial assessment, teaching, evaluation, and nursing judgement.

What is the best way for the nurse to assess the management of a client's postoperative pain?

Inquire about the client's pain level 30 minutes following narcotic administration.

When inserting an indwelling urinary catheter in a female client, the nurse observes urine flow into the tubing. What action should the nurse take next?

Insert the catheter another inch.

What objective finding the nurse assessing when surveying the client's first line of defense against infection?

Intact skin integrity

The nurse is providing wound care for a client with a stage III pressure ulcer on the left heel. To achieve the goal, "An increase in granulation tissue will develop within two weeks, " Which intervention should the nurse implement?

Irrigate wound with sterile normal saline.

What is the best intervention for the nurse to implement when providing morning care for an ambulatory client with an indwelling urinary catheter?

Keep the catheter intact while assisting the client with the shower.

The nurse offers daily catheter care for a client with an indwelling catheter to bedside drainage. What interventions should the nurse implement to further prevent the risk for a urinary tract infection?

Keep the spigot and bedside drainage bag off the floor or other contaminated surfaces.

A male preoperative client who has already signed the informed consent for a surgical procedure confides to the PN that he is really frightened and unsure about undergoing to surgery. What is the priority action by the PN?

Notify the charge nurse of the client's concerns about surgery.

Which nursing activity is within the scope of practice for the practical nurse? *No IV pushes or epidural. *No Generalized assessment. only focused. *No critical lines.

Observe a client rotate the subcutaneous site for an insulin pump.

The nurse assigns a UAP to feed a client who is at risk for aspiration. To ensure that the task is safely delegated, what action should the nurse delegate?

Observe the UAP's ability to implement precautions during feeding.

The nurse uses a BP cuff to measure the client's blood pressure in the right arm but is unable to hear a BP. What action should the nurse perform first?

Observe the client's level of consciousness.

Which task could the nurse safely delegate to a UAP?

Oral feeding of a two-year-old child after the application of a hip spica cast.

In order to use a restraint a

PCP's order is required.

The nurse is caring for an older adult who is NPO after surgery. The client complains that his mouth and mucous membranes are dry. Which intervention should the nurse implement to increase the client's comfort?

Perform oral hygiene frequently.

The PN is preparing to insert an indwelling catheter for an 89 year old female client who has severe contractures of both lower extremeties. The client cries in pain when positioned supine while the nurse attempts to abduct the hips to visualize the perimeum. What action should the nurse take?

Position laterally for posterior access in visualizing the meatus for insertion.

The nurse is preparing to perform a sterile wet-to -dry dressing change. In what order should the nurse implement these actions?

Pour sterile saline over sterile gauze dressings Don Sterile gloves Place the wet sterile dressing in the wound cover the wound with a sterile wet to dry dressings.

A 4 year old is admitted with febrile seizure. The nurse obtains an oral temperature of 104.2 degrees Fahrenheit during the morning assessment. What action should the nurse prepare to implement?

Provide a tepid sponge bath.

Any lsat minute questions and concerns before surgery have to be addressed by the

RN or the MD.

Wrist restraints were applied to a client who was severely agitated and disoriented. In monitoring the client, who is now asleep. Which finding should be reported to the charge nurse?

Radial pulse volume decreases from +3 to +1.

The nurse observes a client whose surgical wound dressing is saturated with serosanguinous drainage 6 hours postoperatively. The JP drainage unit is empty is not compressed and the stopper is open to air. What is the first action the nurse should implement?

Recompress the Jackson-Pratt bulb and put the stopper in place to reestablish the drain's suction.

In assisting a client to obtain a sputum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next? A. Advise the client that suctioning will be used to obtain another specimen B. Re-instruct the client in coughing techniques to obtain another specimen C. Provide the client a glass of water and mouthwash to rinse the mouth D. Label the container and place the container in a bio-hazard transport bag

Reinstruct the client in coughing techniques to obtain another specimen. * We don't just want the saliva we want the sputum from the lungs.

The nurse is changing a postoperative dressing for a client with a horizontal lower abdominal incision. What method should the nurse use to remove the tape from the dressing?

Remove all four sides by moving to the center of the incision.

During vital sign assessment of a client, the nurse counts the left radial pulse at 88, and the pulse oximeter clipped to a finger on the left hand records a pulse rate of 68 with an oxygen saturation of 95%. What is the best initial action by the nurse? A. Count the right radial pulse rate B. Reposition the oximeter clip C. Document a pulse deficit D. Count the apical pulse rate

Reposition the oximeter clip.

The nurse enters a client's hospital room and sees smoke and flames in the wastebasket. Which sequence of action should the PN implement?

Shut the door to the room Activate the fire alarm Call the hospital operator Get the extinguisher.

If you meet resistance or the patient expresses discomfort when pulling the catheter out.

Stop and make sure that the balloon is completely deflated.

The nurse identifies that a UAP has omitted a vital component of the protocol. After implementing the missing component. What action should the nurse take?

Supervise the UAP after reviewing the protocol.

A mother of an 8 year old boy tells the nurse that he fell out of a tree and hurt is arm and shoulder. Which assessment finding is the most significant indicator of possible child abuse?

The mother's version of the injury is different from the child's

The nurse who is working as charge nurse at an extended care facility is making assignments for the UAP working a 12 hour shift. Which resource is most important in guiding the PN's assignments of the UAPs?

The state's Nurse Practice Act regarding delegation to the UAP.

A client with a common cold is seeking treatment at the health clinic. What information should the nurse reinforce to reduce the spread of infection?

Wash hands after each use of tissue or drainage.

To confirm NPO Status before surgery

assess the amount of water drank and time it was taken if the clients state they had PO the night before surgery.

Dramatic signs

bleeding, shock, or cardiopulmonary arrest

For irrigating draining wounds you must use

clean gloves to remove the soiled dressings and clean to apply th enew dressing.

Collecting sputum specimen must be done as

client first wakes. Must be coughed from deep within the cup not just saliva in the cup. -Client also should rinse mouth before trying to expectorate.

For bladder training it is important to always assess the

client's intake and encourage bathroom q2. -Promote fluid intake q1 hour with elderly during waking hours.

For removal of old dressing

decrease tension by removing all four sides and moving on to the center of the incision.

Watch for subtle signs

deteriorating vital signs, decline in urine output and decreasing level of conciousness.

Oral suctioning is required especially with

dysphagia patients with altered level consciousness.

Fever is a delayed response for

elderly clients.

Orders for restrains have to be renewed

every 24 hours.

If restraints are used inappropriately it can be accused of

false imprisonment.

Wet to dry dressing

first wet the new gauze with sterile saline, then done sterile gloves, place wet sterile dressing over wound, and then cover with a dry sterile dressing.

For NPO clients and dry mouth

frequent oral hygiene should be given.

When providing adequate supervision of delegated tasks

guidance and direction evaluation and monitoring follow-up

For a clean catch midstream urine collection

instruct the client to wipe around urinary meatus with wipes first and then refrigerate the specimen until submitted.

When transporting clients with respiratory infections must wear a

mask and infected wounds must be covered.

For undetermined fever.

monitor vital signs and pain scale.

If all the patient's are stable attend who is at

most at risk to become unstable or experience a complication, example post op surgery

For a rectal temperature

must hold the thermometer in place the entire time.

Increase granulation healing by routine

normal saline irrigation of the wound.

Copy of advance directives must be

placed in the medical records.

For contracted clients catheter insertion could also be done by

positioning them laterally for posterior access.

For hygiene care

promote independence as much as possible during care.

Fever in pediatric children

provide a tepid sponge bath.

For child abuse the nurse has to

report to the state and to the RN.

Abused children have difficulty establish trust therefore

select only one consistent caregiver to the child.

LVNs are delegated activities for

stable patients with EXPECTED outcomes.

For catheter insertion

sterile technique is a must!

Purpose of documentation

to indicate and communicate that the standards of practice and proves accountability in providing care.

NEVER allow the spigot to

touch the floor or contaminated objects.

For post op pain management it is best assessed with

vital signs and 30 minutes after every administration.