Fundamentals 1,2,3

1. When does discharge planning begin?

*Begins when the patient is admitted for treatment. *Carried out by the nurse who worked most closely with the patient. *Uses teaching and counseling skills effectively to ensure that homecare behaviors are performed competently.

21. What do you do when you have made a mistake?

*Check the patient. *Call the doctor/notify the charge nurse. *Implement orders. *Complete an incident report.

A nurse working in a mental health facility is preparing to discharge a client who has schizophrenia and requires assistance with housing. Which of the following referral should the nurse recommend to the provider?

Social worker.

What is cranial Nerve II and its function?

( Snellen Chart )A sensory nerve (Afferent),that involves vision, and it transmits sight from the retina to the brain, it enters through the optic canal.

A nurse is planning care for a client who has COPD, requires continuous oxygen therapy, and is being discharged to return home. Which of the following referrals should the nurse recommend?

Social Worker.

A nurse is receiving hey client from the PACU who is postoperative following abdominal surgery. Which of the following action should the nurse perform to transfer the client from the stretcher to the bed?

Lock the wheels on the bed and stretcher.

21. List some reasons we would complete an incident report:

An Incident is the occurrence of an accident or an unusual event. Anything that causes harm or has potential of causing harm. Examples of incidents are medication errors, falls, omission of prescription, missing personal items and needle sticks. Document facts without judgment or opinion. Do not refer to an incident report and a client's medical record. Incident reports contribute to changes to help improve health care quality. When a mistake is made.

Occupational Therapist

Assesses and plans for clients to regain activities of daily living skills, especially motor skills of the upper extremities.

1. Explain AMA and the nurse's role:

Client is legally free to leave. Inform client of risks prior to signing form. Witness client's signature. Form becomes part of medical record. Inform client of risks for increased illness or complications.

21. What are the legal guidelines for documenting?

Begin each entry with the date and time. Record entries legibly, in non-erasable black ink, and do not leave blank spaces in the nurses' notes. Do no use correction fluid, erase, scratch out, or blacken out errors in medical record. Make corrections promptly, following the facility's procedure for error correction. Sign all documentation as the facility requires, generally with name and title. Documentation should reflect assessments, interventions, and evaluations, not personal opinions or criticism about client or other health care professional's care. Nurses should minimize use of abbreviations, and only use those the facility approves. Documentations should be current. Waiting until the end of the shift can result in data omission.

A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview?

Clients level of comfort and ability to participate in the interview.

What is cranial Nerve I and its function?

Olfactory ; Sensory; Sense of Smell

A Nurse is caring for a client who is undergoing a repair of an op abdominal aortic aneurysm. After the surgery an immediate postoperative recovery, the nurse should expect which of the following team members to coordinate the clients ongoing and specific needs for care?

Case manager

A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. The client states she slept while getting out of bed. Which of the following action should the nurse take first?

Check the client for injuries

What is cranial Nerve II and its function?

Optic; Sensory; Vision

21. What is the purpose of documentation?

Communication (main purpose) Diagnostic and therapeutic orders Care Planning Quality process and performance improvement Research, decision analysis Education Credentialing, regulation, and legislation Reimbursement - if did not get charted is did not happen. Legal and historical documentation

What is objective data, Secondary Source ?

Data the nurse collects from other sources ( family, friends, caregivers, health care professionals, literature review, medical records).

1. What is objective data, Primary Source ?

Data the nurse obtains through observation and examination

A Nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the health care facility?

Evacuate clients from the unit.

A Nurse is initiating seizure precautions for a client who has a seizure disorder. which of the following pieces of equipment should the nurse have readily available at the client's bedside?

Oxygen equipment.

What is cranial Nerve III and its function?

Has two different functions: muscle function and pupil response Muscle Function - the oculomotor nerve provides motor function to four of the six muscles around your eyes. these muscles help your eyes move and focus on objects. Pupil Response - helps control the size of your pupil as it responds to light.

Saw Palmetto

Helps prostate issues, BPH (benign prostatic hyperplasia),

21. Define a wheeze:

High pitch whistling, musical sounds as air passes through the narrow or obstructed Airways, usually louder on expiration.

1. How do we prioritize nursing diagnosis?

High priority - greatest threat to patient well being . ABC - airway, breathing, circulation. Medium priority - nonthreatening diagnosis. low priority - diagnosis not specifically related to current health problem.

A nurse is completing an incident report after administering an incorrect dose of medication to a client, even though the client experience no ill effects from the error. What is the purpose of completing the incident report?

Identifying situations that contribute to the occurrence of medication errors.

21. List the steps for taking a telephone order:

If possible 2 nurses should listen on speaker in private area. Make sure prescription is complete by reading it back (clients name, medication name, dosage, time of administration, frequency, and dose. ) To ensure correct spelling use aids such as " B as in Boy " and question any part that is unclear. State number separately : " one, five " for 15. Reminder provider to verify & sign prescription in the facilities policy time. Enter the prescription and a health record.

Which of the following nursing diagnoses is written correctly?

Imbalanced nutrition related to insufficient funds in meal budget as evidenced by patient reports not being able to buy groceries.

A nurse is caring for a client who starts to experience a seizure while sitting in a chair. Which of the following action should the nurse take?

Lower the client to the floor in place a pad under the client's head.

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client's body?

Lungs

A nurse is caring for a client who had a stroke and is at risk for falling. Which of the following action should the nurse take?

Monitor the client at least once every hour

A Nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take?

Placed a client in a left Sims position.

A nurse Is providing teaching to a client about a surgical procedure that she is scheduled for later that day. The client states that no one has spoken to her about the procedure before. Which of the following action should the nurse take?

Stop the teaching and check with the surgeon about informed consent.

1. What is subjective data?

Subjective data consists of information elicited and verified only by the client.

A nurse on a medical surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times

Suction equipment.

Speech language pathologist

evaluates and makes recommendations regarding the impact of disorders for injuries on speech, language, and swallowing. Teaches techniques and exercises to improve function.

What are the causes of a wheeze?

Asthma, COPD, Bronchiectasis, Large airway obstruction, Pulmonary oedema.

Chamomile

Increased risk for bleeding with anticoagulants

1. What is subjective data, Secondary Source?

What others tell the nurse.

St. John's wort

used as an antidepressant.

Practical nurse PN

- work under the supervision of the RN. Collaborate with in the nursing process, assist with the plan of care, consult with other team members, and recognize the need for referrals to assist with actual or potential problems. Possess technical knowledge and skills. Participate in the delivery of nursing care, using the nursing process as a framework.

21. Once a patient outcome has been met, what do we do next?

*Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. *They address whether the problems are resolved or to what degree they are improved. *Functional outcomes describe the person's ability to function in relation to the desired usual activities. *Quality of life outcomes focus on key factors that affect someone's ability to enjoy life and achieve personal goals.

21. Explain the different ways to evaluate outcomes:

*Cognitive - asking patient to repeat information or apply new knowledge. *Psychomotor - asking patient to demonstrate new skill. *Affective - Observing patient behavior and conversation. *Physiologic - using physical assessment skill to collect and compare data.

1. What are common errors in writing nursing outcomes?

*Expressing patient outcome as nursing intervention. *Using verbs that are not observable or measurable. *including more than one patient behavior or manifestation in short term outcomes. *Writing vague outcomes.

1. What information is important to obtain at admission?

*Name, Address, and date of birth of patient *Date and time of admission/admitting diagnosis. *Identification number *Patient's allergies - make sure to ask and document all allergies.

Registered Dietitian

- Asses, plans for and educates regarding nutrition needs. Designs special diets, and supervises meal preparation.

A Nurse on a medical surgical unit is admitting a client. Which of the following pieces of information should the nurse document and the client's record first?

Assessment.

A Nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries?

Auscultation of the arteries for bruits with the bell of the stethoscope.

A nurse working at a rehabilitation facility is attending and interdisciplinary Team meeting for a client who had a left hemispheric stroke . Which of the following members of the interdisciplinary team should the nurse recommend to assist this client?

Nurse, occupational therapist, speech therapist, physical therapist.

What is the most common type of wheeze?

Polyphonic wheeze.

Valerian contraindications

herbal valium: increases central nervous system depression if used with sedatives

Valerian-

promotes sleep, reduces anxiety

Social worker

works with clients and families by coordinating inpatient and community resources to meet psychosocial and environmental needs that are necessary for recovery and discharge.

A nurse is caring for a client who had a stroke and requires assistance performing ADL's. the nurse should collaborate with which of the following members of the interprofessional care team?

Occupational therapist.

What is cranial Nerve III and its function?

Oculomotor; MOTOR; Eye movements; pupillary constriction and accommodation; muscles of the eyelid ( using finger or pen light ).

A Nurse on a medical unit is caring for a client who has been coughing intermittently, attempting to clear her throat repeatedly, and eating only a small portion of each milk. Dinner should recommend a referral to which of the following members of the enter professional team to evaluate the client for dysphasia?

Speech language pathologist

What is cranial Nerve I and its function?

Transmits sensory information to your brain regarding smells that you encounter

Spiritual support staff

provide spiritual care ( pastors, rabbis, priest) (Example of when to refer : a client request communion, or the family asked for prayer prior to the client undergoing a procedure.)

Pharmacist

provides, monitors, and evaluates medication. Supervisors pharmacy technicians and states that allow this practice.

St. John's wort contraindications

serotonergic drugs/selective serotonin inhibitors.

A Nurse his caring for an older adult client who was violent and attempting to disconnect her IV lines. The provider prescribed soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

Remove the restraints one at a time

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?

Renew the prescription for the use of restraints within 24 hours.

Direct Care Intervention

is a treatment performed through and direction with the patients . Direct care intervention include both physiologic and psychosocial nursing actions and include both the " laying of hands " actions and those that are more supportive and counseling in nature.

1. Why do we do a medication reconciliation?

*The goal of Medication reconciliation is to obtain and maintain accurate medication information for a patient. *The purpose of Medication reconciliation is to prevent medication discrepancies from becoming medication errors that harm the patient. *To make sure the hospital's list of a patient's medications matches what the patient is actually taking. *To decrease the number of medication errors that happen during transitions in care.

How does the nurse complete a 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.

1. When do we do a medication reconciliation?

*This process takes place at admission, when transferring clients between units or facilities, and at discharge. *The comprehensive evaluation of a patient's medication regiment any time there is a change in therapy in an effort to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions, as well as to observe compliance and adherence patterns. *medication reconciliation should occur at any transition of care.

Radiologic technologist

- positions clients and performs X Rays and other imaging procedures for providers to review for diagnosis disorders of various body parts.

A Nurse is assessing a client who is unconscious. Family members are present an answer the nurse's questions about the client's medical history. The nurse should document this information as which of the following types of data?

Secondary source data.

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take?

Remove the restraints at least every two hours.

A Nurse in the emergency Department is preparing to obtain informed consent for surgery from a client who received a meperidine hydrochloride IV during transport from a rural hospital. Which of the following actions should the nurse take to obtain consent for surgery?

Obtain consent from a relative of the client.

Laboratory Technician

Obtains specimens of body fluids, and performs diagnostic tests.

A Nurse is caring for a patient who has a fecal impaction. before the digital the middle of the mass, which of the following types of enemas should the nurse plan to administer to soften their feces?

Oil retention

1. How do you preform the weber test?

Place a vibrating tuning fork on top of the client's head. Ask whether the client can hear the sound best in the right ear, the left ear, or both ears equally. Expected Findings: The client hears sound equally in both ears (negative Weber Test)

a Nurse is writing a goal for a client's reaction following the administration of a medication. This action should take place during which of the following phases of the nursing process?

Planning.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?

Position the client on his left side.

1. Know all the components of a nursing diagnosis.

Problem - identifies what is unhealthy about patient (WHAT) Etiology - identifies factors maintaining the unhealthy state (WHY?) Defining characteristics - identify the subjective and objective data that signal the existence of a problem (how do you know?)

A charge nurse is teaching a group of unit nurses about alternative restraints for clients who are confused and wondering. Which of the following pieces of information should the nurse include in the teaching?

Provide the client with a rocking chair.

A nurse Is caring for a client who has admitted to a long term care facility for rehabilitation after a total hip arthroplasty . At which of the following times should the nurse begin discharge planning?

Upon the client's admission to the care facility.

A nurse Is preparing to assist an older adult client with ambulation following bed rest for three days. Which of the following actions should the nurse take to decrease the risk of a fall?

Use a gait belt during ambulation.

A Nurse is caring for a client who reports using several herbal medicines. Which of the following actions should the nurse take?

Verify the herbal supplements do not interact with medications the provider has prescribed.

A Nurse is reviewing informed consent with a patient who is scheduled for a cardiac catheterization. Which of the following is the responsibility of the nurse?

Verifying the client's understanding of the procedure being performed.

1. What is subjective data, Primary source?

What the client tells the nurse.

Assistive personnel AP

Work under the direct supervision of an RN or PN. Position description and the employing facility outline specific tasks. tasks can include feeding clients, preparing nutritional supplements, lifting, basic care ( grooming, bathing, transferring, toileting, positioning ) measuring and recording vital signs, and ambulating clients.

Indirect care of intervention

a treatment performed away from the patient but on behalf of a patient or group of patients

Provider

accesses , diagnosis, and treats disease and injury. Providers include medical doctors(MD's), doctors of osteopathy(DO's), advanced practice nurses and physician assistant.

Chamomile

anti-inflammatory, calming ( often found in tea )

Physical therapist

assesses and plans for clients to increase musculoskeletal function, especially of the lower extremities, to maintain mobility.

respiratory therapist

he evaluates respiratory status and provides respiratory treatments including oxygen therapy, chest physiotherapy, inhalation therapy, and mechanical ventilation.

1. What is objective data?

include information about the client that the nurse directly observes during interaction with him or her and information elicited through physical assessment techniques.

registered nurse RN

is the play team member, soliciting input from all nursing team members and setting priorities for the coordination of client care. Roles and responsibilities : function legally under state nurse practice acts. Perform assessments ; established nursing diagnosis , goals, and interventions : and conduct ongoing client evaluations. Develop enter professional plans for client care. Share appropriate information among team members ; initiate referrals for client assistance, including health education ; and identify community resources.

saw palmetto contraindications

may change the effects of hormonal in oral contraceptives or replacement therapies.