LVN Fundamentals Ch 5,9, and 10
Case management is the assignment of a health care provider to a patient so the care of that patient is overseen by one individual. This individual is typically a:
Nurse
Which type of patient is prone to develop a pressure sore?
Chronic renal failure patient who requires assistance getting out of bed
The nurse is preparing to bathe a patient. What should the room temperature be set at?
68-74 degrees F
What room temperature is good for a patients hospital room?
68-74 degrees F
All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focussed assessment?
A patient with a PERFORATED ULCER is considered critically ill. Therefore, this patient should receive a focussed assessment.
The nurse assesses a red blister over the right superior iliac area of the patient. What stage is this decubitus injury?
A pressure injury demonstrating blisters is at stage 2 decubitus injury
What framework does the establishment of priorities of care during the planning phase of the nursing process often use?
A useful framework to guide prioritization is MASLOWS HIERARCHY of needs.
The nurse must follow the principles of medical asepsis while making a patients bed, including procedures for handling linens. How should the nurse handle soiled linens?
Soiled linen should not come into contact with a uniform.
What is the basis for designing and selecting nursing interventions to meet patient needs?
The PATIENT PROBLEM is the basis for developing nursing interventions
Who is the person responsible for analyzing and interpreting data to arrive at a patient problem?
The RN is responsible for analyzing and interpreting Data
The assessment process is best described as one in which the nurse:
Collects information and analyzes data
What type of problem is a major concern for older adults?
Driving, hospitalizations, accidental poisoning, and loneliness
What is an example of a patient problem?
Impaired skin integrity is the only example of a patient problem; all other options are examples of medical diagnoses
What documentation reflects implementation?
Implementation is the nurse carrying out orders to promote outcome achievement
What is an important consideration when developing the plan of care?
Plans are more effective when the patient is involved in the process. The patients problems are not evaluated; patients process toward the outcome is.
What is an example of a medical diagnosis?
Pneumonia is the only example of a medical diagnosis; all other options are examples of patient problems
What does RACE stand for?
Rescue, Alarm, Confine and Extinguish
A health care provider orders a patient to be placed in the Trendelenburg's position. How will the nurse position the bed?
The entire bed is positioned downward with the head of the bed down when placing a patient in the Trendelenburg's position
Clear water is used to cleanse the eyes. It is important to use proper technique when cleaning the eyes to prevent infection. What direction will the water flow when cleansing a patients eyes?
The eye is cleansed from the inner to outer canthus
How should the nurse cleanse the meatal opening when performing male perineal care?
The nurse should clean the metal opening from the meatus outward
The nurse is assisting a patient to perform personal hygiene. What is the most important focus of the nurse when assisting the patient?
The nurse should encourage the patients independence as much as possible.
What are the two primary methods used to collect data?
The two primary methods of collecting data are INTERVIEWING AND PHYSICAL EXAMINATION
What are some safety considerations a nurse should contemplate when caring for an older adult?
Their visual acuity is not good, and their reflexes are slow
Why should a hospital have a disaster plan?
To be prepared in times of an emergent community situation with the possibility of a large number of casualties
During the evaluation phase, the nurse should make one of three judgments regarding the desired outcome. These judgments regarding the outcome are:
achieved, not achieved, or partially achieved
Nursing interventions are:
actions selected or prescribed by the nurse to achieve the desired patient outcome
During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?
complaint of Nausea, descriptions of pain, fatigue and anxiety are examples
What process in the framework for the practice of nursing?
Nursing process
Which type of substance is used for a medicated bath?
Oatmeal
Whats is an example of objective data?
Objective data are observable and measurable signs
what is classified as information provided by the family when a patient is unable to provide data during assessment?
SECONDARY sources include family members
Which type of perineal care should be performed at least twice a day?
Urinary catheter care
A "possible" patient problem statement is utilized when:
a problem is feasible
A sitz bath cleanses which area?
perineal and rectal areas
Which condition contraindicates a massage?
pulmonary embolism
When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process?
During the PLANNING phase, the nurse connects nursing interventions to nursing orders.
What type of fire extinguisher should the nurse use when the oxygen concentrated machine malfunctions and causes an electric fire?
Electric fires require type C fire extinguisher
The nurse lowers the bed to place the patient on the bedpan. The angle of the head of the bed should be:
Elimination is facilitated with the head of the bed elevated 30 degrees.
A nurse is formulating a patient problem. What is an example of an appropriately written patient problem?
Risk for impaired skin integrity related to physical immobilization is the only appropriately written patient problem.
What does SRD stand for?
Safety Reminder Device
Patient problem statements are ranked in order of priority of the patients health and safety issues. Which problem statement would be the highest priority?
impaired breathing related to SOB
What should the nurse do when encountering a mercury spill?
interior doors should be closed and outside windows should be opened. The spill should not be vacuumed
The nurse attempts to avoid a pressure injury for a bedridden patient by turning the patient frequently. What is the most favorable position for the nurse to move this patient into?
it is preferable to use the 30-degree lateral incline position
Clinical pathways are a _____ plan that schedules clinical interventions over an anticipated time frame?
multidisciplinary
What objective data should the nurse include after a patient assessment?
objective data are OBSERVABLE and MEASURABLE by people other than the patient
What is the most common problem that nurses need to address to ensure the safety of their patients?
percentage of falls in the facility
What type of physician should be consulted for a diabetic patient with thick, long, yellow toenails?
podiatrist
Which is not a factor affecting personal hygiene?
product preferences
What needs to be removed from a fire extinguisher before it can be activated?
the pin
What organized approach might the nurse use when performing a complete physical examination?
A HEAD-TO-TOE format provides a systemic approach
What national organization provides guidelines to protect health care workers in their environment?
Occupational Safety and Health Administration OSHA
The nurse is admitting a patient who is confused and lethargic at times. The patients family is at the bedside. The nurse obtains information from the family regarding the patient. This type of data is considered:
Secondary
What skills should health care workers frequently attend in-services about to ensure the staff has competent skills and risk for falls can be decreased?
The majority of patient falls occur during transfers
What does universal carry mean?
how to remove a patient from the bed to the floor
What important safety precaution should the home health nurse teach parents in order to prevent burns to small children?
To protect infants and children from burns, turn the pot handles on stoves away from the Childs reach
What must the nurse do before applying a safety reminder device? (SRD)
An order is necessary that specifies the type of SRD and the duration of its application
When cleansing this area, the nurse should use clear, clean water only?
Eyes
What type of assessment is performed continuously throughout the nurse-patient contact?
FOCUSED ASSESSMENTS are performed continuously throughout nurse-patient contact based on the nursing care plan.
What should the nurse do when offering a cup of hot coffee to a frail, older adult patient?
Filling the cup halfway
Proper hair care is important for the patients self image. What is the proper water temperature when shampooing a patients hair?
Water at 110 degrees F should be used to shampoo a patients hair
Which skin integrity problem can occur when improperly lifting or pulling a patient up in bed?
friction
Components of the patient problem statement consist of:
signs and symptoms, cause, and defining characteristics