NURS 3005 Concepts - Exam 1 Review

venous access: central venous access

" central line" > inserted closer to the heart at the subclavian site

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client?

"Your elbows will be slightly bent when you are using your crutches." rationale: When using crutches, the elbow should be slightly bent at about 30 degrees, and the hands, not the armpits, should support the client's weight. Supervision of the client learning to use crutches should not be performed by unlicensed assistive personnel (UAP). The client should stop ambulating and sit down if fatigued.

Nursing

"the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations" (ANA, 2010)

five moments for hand hygiene

1. BEFORE touching the patient 2. BEFORE clean/ aseptic procedure 3. AFTER body fluid exposure/risk 4. AFTER touching a patient 5. AFTER touching patient surroundings

removing PPE according to the CDC

1. at the doorway, before leaving patient room or an ante-room 2. remove N95 respirator outside the patient's room, after the door has closed 3. read PPE made easy handout on canvas

What are the nursing considerations when administering sliding scale insulin?

1. check blood sugar BEFORE giving insulin (to determine the unit amount to administer) 2. check pt's food 3. hypoglycemia (low blood sugar)

causes of back injuries

1. forward bending (can over stretch low back muscles) 2. poor posture ( spine's normal curves are exaggerated or decreased)

cardiovascular assessment 1. what to monitor in general 4. orthostatic hypotension (OH) 3. venous stasis 4. DVT

1. general: - dyspnea/SOB - chest pains - HR, RR, BP - fatigue - change in VS from baseline 2. OH: - s/s of lightheadedness, dizziness, faintness - change in apical/peripheral pulses, HR, BP 3. venous stasis: - edema in legs and feet 4. DVT: - posterior calf with pain/tenderness, redness, warmth or swelling

doffing (taking off) PPE

1. gloves 2. goggles/ face shield 3. gown 4. mask/respirator 5. hand hygiene

donning (putting on) PPE

1. hand hygiene 2. gown 3. mask/respirator 4. goggles/ face shield 5. gloves

types of restraints

1. mitt restraints (least restrictive) 2. wrist restraints 3. vest and jacket restraints 4. wrist and ankle restraints (most restrictive) *** must be able to slide two fingers underneath restraint***

GI system assessment 1. what labs to monitor 2. what sounds to assess 3. frequency of last BM

1. monitor labs for low protein (albumin of 3.5-5.0 is normal; 3.5 or less is low) 2. assess for bowel sounds every shift 3. ask pt when was the last time they had a bowel movement

components of a medication order

1. name of patient 2. date and time 3. name of drug 4. dose 5. route 6. frequency/time 7. signed order

Medication Errors > most are preventable > list the three most common causes of medication errors

1. nurse fatigue/ exhaustion 2. nurse distraction by clients, peers, unit occurrences 3. nurse failure to verify MAR and client band

cardiovascular interventions

1. reposition the patient SLOWLY - dangling for OH before standing 2. elevate extremities for edema 3. encourage fluid intake as ordered 4. encourage leg exercises and position changes

Six Rights of Medication Administration

1. right patient 2. right drug 3. right dose 4. right route 5. right frequency/ time 6. right documentation

hand hygiene technique

1. rub soap into hand 2. rub left palm over back of right hand and vice versa 3. rub palm with fingers interlaced 4. rub backs of fingers in opposing palms, with fingers interlocked 5. rotational rubbing of left thumbs clasped in right palm, and vice versa 6. rotational rubbing, backwards and forwards with clasped fingers of left hand in palm of right, and vice versa

restraint orders 1. situational 2. medical 3. behavioral

1. situational: - initiation of restraints only after alternatives have been tried - CANNOT have a prn order for restraints 2. medical: - obtain written/verbal order within 1 hour of initiation - physician exam within 24 hours and before new order - HCP is responsible for making sure order is on the chart 3. behavioral: - may apply in an emergency but must get the doctor's order within 1 hr - HCP must do a face to face assessment within 1 hour

three safety checks

1. when the nurse reaches for the drug as they read it from the eMAR; match the drug label to the computer screen when removing it from the dispenser 2. during preparation before going into the patient's room; matches eMAR to drug label 3. when scanning the drug at the bedside and before administration; nurse visualizes eMAR as they match the drug label to the computer screen; scan each medication

In what time period did nursing care as we know it begin?

18th and 19th century

Mary Mahoney

1st African American professional nurse (1897); worked for acceptance of African Americans in nursing

Nursing students from a community college are most likely students attempting to obtain an associate degree, which is a _____________ year program

2

restraints: remove, assess, and chart every __________

2 hours > skin (integumentary) > circulatory > ROM > re-position > bathroom break > food, water, etc.

Which gauge needle is the nurse expected to use to administer dimenhydrinate 50 mg? 27-gauge 26-gauge 25-gauge 22-gauge

22-gauge The 22-gauge needle is correct, as this size is long enough to reach the client's muscle. Gauges 27, 26, and 25 are not long enough to reach the muscle and therefore are used to administer injectables, such as insulin.

A nurse suspects that a client may be developing sepsis based on assessment findings. The practitioner orders a serum lactate level to be obtained. When reviewing the results, which serum lactate level would the nurse identify as indicative of sepsis? 1.3 mmol/L 2.4 mmol/L 3.5 mmol/L 4.6 mmol/L

4.6 mmol/L Hyperlactatemia is often present in clients with severe sepsis. All clients with elevated lactate levels greater than 4 mmol/L need early, goal-directed therapy for severe sepsis resuscitation bundle, regardless of blood pressure. The actions included in the bundle help to promote better outcomes for the client.

normal WBC count

5,000-10,000/mm3

Any additional items needed must be dropped or poured onto the sterile field from a height of at least____________________

6 inches

Florence Nightingale (1820-1910)

> Crimean War (1836-1856): birth of modern nursing > first nursing theorist/researcher > established standards in education and hospital management

nursing indications for topical administration

> DO NOT APPLY WITHOUT FIRST removing residue from previous applications > wear gloves to prevent transfer of medication to yourself on accident; can use a tongue blade to apply meds too > apply small amounts to the skin > date/time/initial patches examples: hormones nicotine, and nitroglycerin patches

A client expresses concern that there is an increase in urine output after exercising. How would the nurse address the client's concern?

> Explain that urination after exercise is a result of increased circulation to the kidneys and is a normal function > Assess cardiovascular function and blood pressure > Ask the client to provide details of the exercise regimen including frequency and type > Evaluate for diabetes mellitus Urination after exercise is a result of increased circulation to the kidneys and is a normal function. Especially in overweight individuals, the elevated heart rate from exercise can cause temporary high blood pressure and one of the body's first defense mechanisms for high blood pressure is to decrease blood volume, hence fluid is excreted as urine. Certain exercises can increase pressure on the bladder causing the sensation that urination is needed, even if the bladder is not full. While there are several causes that may be benign reasons for increased urination, it can also be caused by more significant issues, including diabetes and urinary tract infections that are not caused by or related to exercise. Therefore, conducting a comprehensive assessment of physical activity, cardiovascular health, and testing for diabetes is needed to determine if increased urine output is due to exercise.

venous access: saline lock (drug infusion lock)

> IV catheter attached to tubing with port at the end > straight into veins (onset is quick/hard to reverse) > high rates for infection > indication: keep vein patent (open) for intermittent drug administration

contact precautions

> MRSA, VRE, VISA, VRSA, Hepatitis A, C.diff, etc. > patient placement: private room > hand hygiene: soap + water for C.diff > gloves and gown: place before entering and remove before leaving > equipment: single-use, stays in the room

needle safety precautions

> NEVER re-cap a used needle (use one-handed scoop method) > dispose of used, uncapped needles and sharps in the puncture proof containers > never bend or break needles before disposal > engage the safety

providing safe care

> Nurse Practice Act > Texas Board of Nursing Rules and Regulations

musculoskeletal assessment

> ROM of joints (need a baseline) > assess for contractures > ability to turn in bed > what are the activity orders > what ADLs can they do?

airbone precautions

> TB, measles, chicken pox > patient placement: negative pressure room with closed door > mask: N95 respirator or PAPR (powered air purifying respirator) > transport patient with a mask on > DO NOT go into a room with airborne warning sign

Medicare and Medicaid will NOT pay for

> UTI (CAUTI- catheter associated urinary tract infection) > vascular catheter associated infection (VACI) > surgical site infection > blood incompatibility > air embolism > objects left in the body > pressure ulcers (stage III and IV) > mediastinitis after CABG

The Joint Commission (TJC)

> accreditation and certification body of hospitals > establishes standards to improve performance > follows sentinel events (e.g. an unexpected occurrence involving death or serious physical or psychological injury ) > publishes National Patient Safety Goals every year > prevention is always the goal!

specific indications for hand hygiene: after

> after contact with the patient's skin, body fluids, excretions, non-intact skin, and wound dressings > after removing gloves

John Hopkins Fall Risk Assessment Tool Categories

> age > fall history > elimination, bowel, urine > medications (PCA/opioids, anticonvulsants, antihypertensives, diuretics, hypnotics, laxatives, sedatives, etc.) > patient care equipment: and equipment that tethers the patient ( e.g. IV infusion, chest tube, catheters, etc.) > mobility > cognition

Subcutaneous injections: > angle of injection > amount to administer: > needle gauge: > needle length:

> angle of injection: 45 degrees (for thinner/more lean pt) or 90 degrees (for pt with more adipose tissue) > amount to administer: 1.0ml or less > needle gauge: 25-30 G > needle length: 3/8 to 1 inch > length of the needle is based on the amount of adipose tissue > pinch the skin upward > avoid 2" around the umbilicus (belly button) > examples: insulin, heparin, enoxaparin > slow, sustained rate of absorption > onset is faster than oral route but slower than IM or IV > site should be free of hardness, scarring, or inflammation > common sites: abdomen, back of the arms, upper back, thigh area

Intradermal Injections > angle of injection > amount to administer: > needle gauge: > needle length:

> angle of injection: 5 to 15 degrees > amount to administer: usually 0.5ml > needle gauge: 25-27G > needle length: 1/4 to 1/2 inch > commonly given for: allergy testing, skin TB testing, and vaccinations > almost parallel with the skin; bevel up > delivers medication/antigen into tissues just below the epidermis > LONGEST absorption time > evaluate local effect

Intramuscular injections > angle of injection: > amount to administer: > needle gauge: > needle length:

> angle of injection: 90 degree angle > amount to administer: depends on muscle being used - 1ml: small child/older infants - 2ml: thin adults/children/elderly - 3ml: well-developed adult *** 1ml MAX on the deltoid muslce*** > needle gauge: 21-22G > needle length: 1.5 inch *** patient's weight and amount of medication dictate needle length and gauge*** > faster medication absorption than SQ due to greater vascularity > slow sustained release over hours, days, weeks > few sensory nerves, less painful when giving irritating drugs > ANATOMIC LANDMARKS and BOUNDARIES must be identified to avoid complications

how to ensure safe patient handling

> assess the patient's diagnosis, ability to assist, and understanding > have them repeat back the information you taught them > explain procedure to pt > lower/elevate the bed as needed > lock wheels! > watch for tubes and equipment when lowering bed > involve the pt in assisting with move > use lift device when needed/ gait belt *** AVOID friction***

adverse effects on the respiratory system

> atelectasis: complete or partial collapse of a lung or lobe (collapse of the alveoli due to decreased lung expansion) > hypostatic pneumonia caused by: - buildup of secretions - patients inability to cough - bacterial growth

specific indications for hand hygiene: before

> before patient contact > before putting on gloves > before inserting urinary catheters, peripheral vascular catheters, or other invasive devices that do not require surgery

what if the patient vomits immediately or shortly after receiving oral meds?

> check vomit for fragments > clean vomit > notify prescriber (medication might have to be readministered)

sources of injectable medications: ampules

> clear glass container usually designed to hold a single dose of a drug > pre-scored at the neck > must be carefully broken at the neck with gauze or alcohol package (break AWAY from your body) > FILTER NEEDLE is required to filter out any broken glass that might have fallen in > DO NOT touch the rim of the ampule when using needle to remove medication > don't need to push air into the ampule

categories for an Automatic Fall Risk

> complete paralysis or completely immobile > history of one or more falls within 6 months before admission > experienced a fall during hospitalization *** patient is deemed high risk per protocol***

National Council of State of Boards of Nursing

> composed of all 50 states BON, DC, and 4 territories > develops NCLEX-RN, NCLEX-PN exams, National NUrse Aide Assessment Program, and the Medication Aide Certification Examination > legislative initiatives to promote safe nursing care and provide expertise on regulatory issues

vaginal application

> creams, foams, tablets, and suppositories melted by body heat > indication: infection > use a narrow tube applicator with an attached plunger or lubricant on the suppository > position pt on her back with knees flexed > administration should be timed to allow pt to sit down afterward to retain medicine

adverse effects on metabolic/ GI system

> decreased appetite > altered protein metabolism > altered digestion and utilization of nutrients > decreased fluid intake > decreased peristalsis resulting in constipation and fecal impaction

PPE: gloves

> do not wear gloves in the hallway > indications: to protect nurse when holding patient's body substances; protect patient/reduce risk of transmitting microorganisms; monitor for latex allergy

what if the patient refuses to take the medications?

> document refusal and notify prescriber > example: patient might refuse docusate (stool softener) if their stool has been watery for the past few days; ask when was the last time they had BM and its consistency

nasal application

> drops or sprays > avoid contamination of the dropper > remain in position for at least 5 minutes > occlude one nare > indications: cold, allergies, infections, polyps, nosebleeds; local and systemic effects

musculoskeletal interventions

> encourage activity and movement > change position every 2 hours > plantar flexion: use foot board > ROM: - passive: you do the movement for them, with little effort on the pt's part - active: pt moves on their own

COVID patients

> enhanced droplet precautions are used for all COVID patients unless they are on a ventilator/ BIPAP (aerosolized support) > ventilator/ BIPAP: have airborne precautions

when do you assess for fall risk?

> every patient in admission > every shift > as change warrants

ophthalmic administration

> example: eye drops/ ointment > apply medication to the conjunctival sac; pull down on lower lid > do not apply directly to the cornea > apply pressure to the inner canthus to keep medication in

Hospital National Patient Safety Goals

> identify patient correctly > improve staff communication > use medicines safely; use alarms safely > prevent infection > identify patient safety risks > prevent mistakes in surgery

GI system interventions

> increase protein intake; increase calorie intake > monitor dietary intake > record I&O > encourage fluids (2000-2400ml/day) and fiber > give stool softeners or laxatives as ordered > encourage and educate regarding nutrition

adverse effects on the cardiovascular system

> increased cardiac workload > orthostatic hypotension (OH) > venous stasis > thrombus formation > DVT

recommended intramuscular injection sites

> infants: vastus lateralis (middle third area of the thigh) > toddlers/children: vastus lateralis or deltoid (upper arm/shoulder) > adults: ventrogluteal (upper hip area) or deltoid

chain of infection (infection cycle)

> infectious agent (HIV, E. coli, MRSA, C.diff, etc) > reservoir (person, object, animal, food, water,etc.) > portal of exit from reservoir (respiratory, GI, blood, open wound, etc.) > means of transmission (direct or indirect) > portals of entry (urinary, respiratory, GI tract, etc.) > susceptible host (elderly, young children, those who are immunocompromised)

parts of the parenteral equipment that must remain sterile during preparation

> inside of the barrel > part of the plunger that goes into the barrel > the needle itself *** NEVER lay a syringe with an uncovered tip on any surface; NEVER lay a syringe with an uncapped needle on any surface***

alternatives to restraints

> involve the family > reduce stimulation > bed alarm > lower the bed > use therapeutic touch > relocate patient closer to the nursing station > limit the use of unnecessary lines

setting up the sterile field

> keep it in front of you > never turn your back to it > outer 1" of the field is considered contaminated > keep working area above the waist > never reach over the field > only sterile items touch sterile items

antibiotic stewardship and the nurse's role

> know the infectious organisms (triage and initiate precautions, obtain cultures) > know what to do if you suspect infections > educate the patient and family > assess patient allergy and medications > administer antibiotics on time, monitor for improvement, reactions, and appropriate use > antibiotics are only for limited time use since prolonged therapy can lead to resistant

PPE: masks and respirators

> large particles: surgical mask or KN95 > small particles: N95 respirator or PAPR

special considerations with hand hygiene

> length and composition of nails > presence of jewelry > water temperature > hand position (always want them below to elbows) > skin breakdown > uniform contamination

reconstitution of medications

> liquid (solvent or diluent) + powered drug > must be mixed together before it can be injected > common diluents: sterile water and sterile saline > single-dose and multi-dose vials

metered dose inhalers (MDIs)

> local and systemic effects (bronchodilators do dilate the bronchioles, but can cause tachycardia) > indications: respiratory disease (e.g. bronchitis, emphysema, asthma) > use spacer if available > inhaler only: medication is caught in the back of the throat > inhaler + spacer: medication is able to travel further > instruct pt to hold breath for 10-15 seconds then exhale > rinse mouth after steroid

considerations for intramuscular injection sites

> look for signs of infection or injury > presence of bruising or abrasions > location of nerves, blood vessels, and bones > volume of drug to be administered > sites of previous injection sites > muscle mass available (very important!) > use nursing judgement to decide on equipment - size of needle/ length and size of syringe

adverse effects on the musculoskeletal system

> loss of endurance > stiff, painful joints > decreased: - muscle strength and tone - muscle size (atrophy due to disuse and lack of weight bearing) > contractures (permanent contraction - e.g plantar flexion) > disuse osteoporosis

insulin pens and syringes

> measured in UNITS; has its own type of syringe > syringe sizes: 30, 50, 100 > U-50 is used to measure small doses accurately > U-100 is used for larger doses of insulin > insulin pens need to be cleared with 2 units first; count to 6 before withdrawing needle

route of administration: buccal

> medication is placed inside the cheek, between the gums and the mucosa > DO NOT swallow medication; do not eat/drink until it is dissolved > alternate placement sites to avoid irritation

route of administration: sublingual (SL)

> medication is placed under the tongue > DO NOT swallow, allow to dissolve > avoid drinking or eating until drug is dissolved > absorption rate is more rapid than oral administration due to the highly vascular area Example: nitroglycerin tablets are SL since they would not be effective by oral administration due to the first-pass effect

Case Study: Assessment what specific assessments are needed for Mr. Smith? > metoprolol (beta-blocker) > furosemide (loop diuretic)

> metoprolol: assess blood pressure and heart rate > furosemide: urine output (expect the output to be greater than input), edema and any swelling, lab values (potassium)

topical administration

> most common: creams, powders, and patches; others include ophthalmic, otic, shampoos, sprays, etc. > local effect with few side effects (systemic effects are possible) > absorption is dependent on the vascularity of the area > AVOID applying to breaks in the skin

route of administration: oral

> most commonly used > given by mouth and swallowed > examples: liquid, tablet, or capsule > advantages: - most convenient, easiest, fastest - slower onset of action; more prolonged effect - preferred by most patients, less stress - most economical > disadvantages: - cannot be given to those NPO, decreased level of consciousness, or have dysphagia - nausea/vomiting - NGT or OGT

droplet precautions

> mumps, adenovirus > patient placement: private room > mask: within 3 feet, apply when entering the room > transport patient with a mask on

venous access: PICC (peripherally inserted central catheter)

> non-tunneled external catheter > small (20-24" long) flexible catheter inserted into a peripheral vein then threaded so the tip is position at the heart > high rate of infection! > indications: to draw blood; administer fluids (e.g. blood, chemotherapy drugs, nutrition, etc.)

Latest superbug: Candida Auris

> often MDRO (multi-drug resistant organism); contact precautions, hand hygiene > difficult to disinfect environment > difficult to diagnose > lives 7+ days on surfaces

prevention of falls

> orient patient to their surroundings > remind them to call for assistance > call light and possessions should be within reach > bed should be at the lowest position > purposeful hourly roundings (check for 5 Ps) > lock the wheels on beds and chairs > slip resistant socks and house slippers > gait belt > alarms for beds, chairs, and commodes

susceptible hosts of infection

> patients with wounds, cracked/dry oral tissues > older/ very young persons > those not current with their immunizations > those with invasive devices (catheters, central lines, etc.) > those with low WBC count (5,000-10,000 is the normal range) > those who are immunocompromised (HIV patients and those who received an organ transplant) > those who are fatigued, stressed, etc. > those with pre-existing illnesses (diabetes, peripheral vascular disease)

with altered mobility, how do you assess the skin?

> perform Braden Risk Assessment scale > identify risk pts > monitory dietary intake

specific isolation precautions

> protective procedure that limits the spread of infectious diseases among hospitalized patients, hospital personnel, and visitors > nurses responsibility to maintain the proper isolation precaution that is indicated

respiratory assessment

> rate, rhythm, and quality of respirations > auscultate the entire lung field > coughing? > observe for respiratory difficulties (e.g. dyspnea or SOB)

Texas State Board of Nursing

> regulates the practice of nursing in the state of Texas > approves nursing education programs

cardiovascular interventions for prevention of DVT

> remove elastic stockings every 8hrs > medications: LMWH (low molecular weight heparins) > Intermittent Sequential Compression Devices - pneumatic compression devices

nursing interventions for those with altered mobility

> reposition patient every 2 hours > monitor skin for redness or pallor every 2 hours > help with hygiene needs and ADLs > elevate extremities to reduce swelling > DO NOT rub over bony prominences > position with wedges, pillow, etc.

further assessment prior to administration

> right reason: do the patient's symptoms/condition warrant this medication? > right assessment data: do you need to re-check VS or lab values specific to the medication? any parameters noted by the HCP? > right education: does the patient know why they are taking this drug? have they been taking it for a while or is this something new? > right response: what do you expect this drug to do? what do you need to check on later? ***think about WHY you are administering this drug and if the dose is APPROPRIATE for the patient based on their age, weight, condition. etc.***

adverse effects of immobility on the integumentary system

> risk of skin breakdown compounded by impaired body metabolism - pressure - friction > formation of pressure injuries/ulcers - external pressure on an area that has decreased circulation - occurs over bony prominences

choice of gauge and length depend on:

> route of administration > viscosity of the medication > quantity delivered > body size of the patient > type of medication

rectal application

> sim's position (pt lying on their left/right side) > lubrication: finger and medication > insert tapered end first into anus, past the internal sphincter (towards the umbilicus) - adult: 3-4 inches - child: 2 inches > remain in sim's position for at least 5 minutes > indications: unconsciousness, vomiting, unable to swallow, enema, NPO > bypasses the GI system and first pass effect > local and systemic effects

advantages of subcutaneous injections

> slower, more sustained drug absorption than IM > minimal tissue injury > little risk for injuring large blood vessels and nerves > easy to administer

sources of injectable medications: vials

> small glass or plastic bottle with self-sealing stopper (diaphragm) > colored cap ensures stability until removed > single or multi-use (usually only lasts 24 hrs) > metal or plastic cap protects rubber seal > diaphragm must be WIPED WITH ALCOHOL BEFORE USE > insert needle into the diaphragm after cleaning > add time/date/initial after opening a multi-dose vial *** inject the same volume of air into the vial as the volume of liquid you are removing - due to the negative pressure inside the vial***

ROM exercises

> start gradually and work slowly; all movements should be smooth and rhythmic > move each joint until there is resistance but NOT pain > return joint to a neutral position (normal position of alignment) > perform exercises 2-5 times a day, twice a day > encourage tasks (eating, dressing, bathing, etc.) > pt's RR and HR should increase slightly during exercise > use passive as needed

proper lifting techniques

> tighten stomach muscles and tuck the pelvis (provides balance and helps protect your back) > bend at the knees (maintains center of gravity; allows strong muscles to do the lifting) > spread feet approximately shoulder width apart and flex at the hip (broadens the base of support and lowers the center of gravity) > place one foot slightly in front of the others to improve balance > lift with the patient close to your body > avoid twisting > use smooth movements > let the patient help as much as they can > know your limits; ask for help when needed > Hoyer Lifts and Sit to Stand Patient Lift

parts of a syringe

> tip (luer lock can cath tip) > barrel > plunger > bevel > shaft >hub > gauge (diameter of the needle) > length

blister packs

> unit dose methods of administration > DO NOT remove from individual package until at the bedside with patient and MAR > safety: - always assess aspiration risk - sitting position > only take as many as you need

respiratory interventions

> use an incentive spirometer > change pt position every 2 hours > monitor O2 saturation and apply O2 prn > encourage adequate fluid intake ( at least 2000ml/day)

Hospital Associated Infections (HAIs)

> used to be known as nosocomial infections > direct result from delivery of health services > approximately 2 million infections annually > preventable! > occur due to poor infection control, during surgery, use of invasive medical devices, poor medical asepsis, etc.

Which type of mobility aid would be most appropriate for a client who had poor balance?

A cane with four prongs on then end Rationale: canes with four or three prongs provide a wide base of support are recommended for those with poor balance; single ended canes with a half circle handle are recommended for clients who require minimal support; single ended canes with a straight handle are recommended for those who have hand weakness

Braden Scale

A tool for predicting pressure ulcer risk sensory perception ( ability to respond meaningfully to pressure-related discomfort) moisture (the degree to which skin is exposed to moisture) activity (degree of physical activity) mobility (ability to change and control body position) nutrition ( usual food pattern intake) friction and shear

Bed trapeze

A triangular metal apparatus above a bed, used to help the patient move and support weight during transfer or position change.; promotes independence when the client is trying to move in the bed

Linda Richards

America's 1st trained nurse (1873); responsible for nurses notes, doctors orders and uniforms; specialized in psychiatric and industrial nursing

AACN

American Association of Colleges of Nursing > focus: educational standards > Commission of Collegiate Nursing Education (CCNE): division within AACN; accrediting body for baccalaureate and higher schools of nursing

Clara Barton

American Civil War nurse; established American Red Cross

The first nursing journal owned, operated, and published by nurses was

American Journal of Nursing

ANA

American Nurses Association

Which nursing group provides a definition and scope of practice for nursing?

American Nurses Association (ANA)

ADPIE

Assessment Diagnosis Planning Implementation Evaluation

CRE

Carbapenem-resistant Enterobacteriaceae > 40-50% mortality rate

C.diff

Clostridium difficile > 14,000 deaths/ year > greater risk: older adults on antibiotics > can live up to 5 months on hard surfaces > NOT killed by alcohol, need to wash hands with soap and water; use bleach to disinfect surfaces

the single most important action to break the chain of infection and limit the spread of infection

HAND HYGIENE

HITECH

Health Information Technology for Economic and Clinical Health Act of 2009: concerned with the use of electronic medical records to improve care coordination and public health

The primary aim of the Healthy People 2020 initiative is

Health promotion

A client had a mild stroke with residual left sided weakness. While teaching the client about walking with the cane, the nurse will offer which instruction?

Hold the cane on your right side Rationale: cane is being used due to weakness, so it should be placed on the "stronger" side, which is the right side in this case. Client should stand tall and not lean on the cane

ICN

International Council of Nurses

Sigma Theta Tau

International Honor Society of Nursing

Who is the founder of public health nursing? And established the first Public Health Service for the sick and poor?

Lillian Wald

Resistant organisms

MRSA VRSA VISA VRE CRE C. diff

NLN

National League of Nursing > individuals + organizations > open to those with an interest in nursing > branch of NLN accredits schools of nursing along with CCNE (baccalaureate and higher) > conducts research data collection on nursing education > CNE certification

NSNA

National Student Nurse Association

What might a nurse need to do to ensure the continuation of his/her nursing license?

Obtain continuing education credits Rationale: defined as professional development experiences designed to enrich the nurses contribution to health

A nurse I'd developing a foreground questions for nursing research using the PICO MODEL. which component would be represented by the statement " a 45 year old male with coronary heart disease and atrial fibrillation"

P Rationale: P patient or problem I intervention considered C comparison if appropriate O outcome of interest or relevant outcomes

A nurse is preparing to turn a client who is unable to mobilize independently. What action best ensures the safety of both the client and the nurse?

Position a friction reducing sheet under the client to facilitate movement Rationale: bed should be at a comfortable working position ( not lowered) and leg muscles should be used to pull the client to the side

how to use an inhaler

Shake the canister to distribute the drug in the pressurized chamber. Place the inhaler in your mouth and close your lips around the mouthpiece. Press down on the canister once to release the medication. As the medication is released, breathe in slowly through your mouth for 3-5 seconds. Hold your breath for 10 seconds. Clean the inhaler daily by rinsing it in warm water daily.

The registered nurse communicates with the PT that a client is now on stitch bed rest due to bradycardia. What best explains the standard exemplified by the nurse?

The RN coordinates care delivery

Theory of animism

The belief that everything in nature was alive with invisible forces and endowed power. Good spirits brought health; evil spirits brought sickness and death.

The nurse id providing care for clients in a long term care facility. What should be the central focus of this care?

The client receiving the care Rationale: the client receiving care is always the central focus of the nursing care provided. Patient always comes first

In an assessment for proper body alignment of a standing patient, what finding is normal?

The weight of the body is distributed on the soles and heels

A registered nurse wishes to work as a nurse researcher. What is true regarding nurse researchers?

They are responsible for the continued development and advancements of nursing

correct steps to remove a gown

Unfasten the ties. Touching only the inside of the gown, pull away from the torso. Keeping hands on the inner surface of the gown, pull gown from arms. Turn gown inside out. Fold or roll the gown into a bundle. Discard the gown.

VISA

Vancomycin Intermediate Staphylococcus aureus

VRSA

Vancomycin-resistant Staphylococcus aureus > can survive 5-7 days on surfaces

The need for university based nursing education programs was brought to light during which important historical time?

World War II

Which clients are most at risk for falling due to altered mobility? Select all that apply. a. A client with a spinal cord injury b. A middle-aged woman who had surgery 2 weeks ago and wears high heels c. All older adults d. An older adult client with an unsteady gait e. A client who requires crutches in unfamiliar health care settings

a. A client with a spinal cord injury d. An older adult client with an unsteady gait e. A client who requires crutches in unfamiliar health care settings Limitations in mobility are unsafe and can cause client injury. The nurse should be aware that clients with spinal cord injuries, older adults with unsteady gaits, and clients who require assistive walking devices such as crutches, especially in unfamiliar health care settings, may be at risk for falling. Not all older adults are at risk for falls. Most females who wear heels are not most at risk for falls, even if they had surgery 2 weeks ago.

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply. a. Drowsiness b. Fever c. Headache d. Increased thirst e. Vomiting

a. Drowsiness c. Headache e. Vomiting Concussions are a frequently seen sports injury in school-age children. Nurses should be aware of symptoms that may indicate that a concussion or more serious head injury is present. Symptoms of a concussion include headache, vomiting, problems with balance, fatigue, dazed or stunned appearance, difficulty concentrating and remembering, confusion, forgetfulness, irritability, nervousness, very emotional behavior, drowsiness, difficulty falling asleep, and sleeping more or less than usual. Fever and increased thirst are not symptoms usually seen with a concussion.

The nurse provides care for a client who has had a stroke and is at high risk for aspiration. In which position(s) does the nurse place the client to maintain an open airway? Select all that apply. a. Fowler b. Semi-Fowler c. Upright d. Supine e. Modified supine

a. Fowler b. Semi-Fowler c. Upright The Fowler position is a sitting position, also known as upright, that raises the client's head 80 to 90 degrees and benefits the client by preventing aspiration, promoting ventilation, facilitating eating, and improving cardiac output. The semi-Fowler position is a 45-degree angle, which also allows for ventilation without aspiration. The supine and modified supine (pillow under knees) would not be appropriate for facilitation ventilation and preventing aspiration.

Question: a nurse in the emergency department hears a patient and a family member arguing with each other in a room at the end of the unit. What should the nurse do first? a. Get another staff member and go into the room together b. Ask what is going on then set firm limits c. Have a security guard and handle the situation d. Go to the room and try to intervene

a. Get another staff member and go into the room together

A father asks the nurse who is caring for his 13-year-old daughter why his daughter could be performing poorly in school lately, and why she is distancing herself from friends and family. Which of these possibilities would the nurse consider as the priority risk? a. She may be the victim of cyber-bullying. b. She has lost interest in academics because she has a boyfriend c. now. c. She may be beginning her menses. d. She may be developing nutritional deficiencies from poor dietary habits.

a. She may be the victim of cyber-bullying. Symptoms of cyber-bullying include faltering school achievement, absenteeism, health concerns, isolating oneself from peers/friends, and increased anxiety and depression symptoms. Adolescents may neglect academics when involved in personal relationships, but that is a common milestone of the age group. Achieving menarche may alter mood, but it is not a risk concern. Nutritional deficits can be seen in adolescence and may need to be investigated with this client, but it is not the priority at this time.

The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply. a. The client is wearing the oxygen around the neck. b. There is spilled water on the floor. c. The IV is not infusing at the correct rate. d. The skin is a bluish-color. e. The client's television is turned off.

a. The client is wearing the oxygen around the neck. b. There is spilled water on the floor. c. The IV is not infusing at the correct rate. d. The skin is a bluish-color The situational assessment includes: ABCs, IVs, tubes, oxygen, safety, and environmental safety, including the nurse's intuition, hearing, smelling, seeing, or feeling that something needs to be explored. The client wearing oxygen around the neck is a concern in a situational assessment, because the client's SpO2 may be decreased if the oxygen is not worn properly. Moreover, tubing around the neck presents a safety issue, as does spilled water on the floor. The client's television is of no importance to the situational assessment. The situational assessment should check whether the IV is infusing at a correct rate. The client's skin being a bluish color is also a concern during situational assessment; it could be related to not wearing the oxygen correctly or indicate

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation? a. The hospital must bear any costs incurred for treating the client's injury. b. The hospital will be fined by CMS because the client developed a pressure injury. c. CMS will bear the hospital's costs if the client chooses to sue the hospital. d. CMS may choose to divert clients to other health care facilities in the future.

a. The hospital must bear any costs incurred for treating the client's injury. If "never events" occur while a client is hospitalized, the cost of the care associated with that event will not be paid by CMS, but will be borne by the hospital. Fines are not levied against the hospital, however, and CMS does not actively divert clients to other facilities. CMS does not pay damages on behalf of hospitals.

The American Nurses Association (ANA) Standards of Professional Nursing Practice provides standard of care for all nurses. Which statement on the assessment of the nursing process is accurate? a. The nurse collects comprehensive data pertinent to the client's health or situation. b. The nurse dictates the plan that prescribes strategies of care. c. The nurse monitors the ethical conduct of authorities and clients. d. The nurse evaluates progress toward implemented actions.

a. The nurse collects comprehensive data pertinent to the client's health or situation. The nursing process is used for all nurses as the standard of care. In the assessment phase, the RN collects comprehensive data pertinent to the client's health or situation. In the diagnosis phase, the RN analyzes the assessment data to determine the diagnoses or issues pertinent to the client. Next the RN identifies expected outcomes for a plan individualized to the client or the situation and develops a plan that prescribes strategies and alternatives to attain expected outcomes. The nurse does not dictate the plan. The RN implements the identified plan. This includes coordination of care, health teaching and health promotion, consultation, and prescriptive authority and treatment. Finally, in the evaluation phase, the RN evaluates progress toward attainment of outcomes. From the ethical standpoint, the nurse advocates for the client and makes sure that ethical standards are upheld, but this is not part of the nursing process.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report? a. The nurse should record the incident in the client's medical record and fill out a safety event report separately. b. The nurse should include a note on the client's chart that mentions the report. c. The nurse should await the results of the x-ray before filing the report. d. The nurse should make a copy of the safety event report and place it in the client's medical record.

a. The nurse should record the incident in the client's medical record and fill out a safety event report separately. The nurse completes the safety event report immediately after an unintentional injury and is responsible for recording the incident and its effect on the client in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. The nurse should not wait until after the x-ray to complete the form.

Which factor is related to the highest proportion of falls in long-term care settings? a. Toileting b. Agitation c. Polypharmacy d. Impaired sleep patterns

a. Toileting More than 42% of falls in an acute care agency were toileting related, often involving getting out of bed or ambulating to the bathroom, slipping from the toilet or commode, or standing to use the urinal. This exceeds the role of other variables, including agitation, polypharmacy and impaired sleep

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct? a. Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. b. Logrolling can be performed by one experienced nurse. c. Logrolling will maintain straight alignment when the client is sitting in a chair. d. It is acceptable to twist the client's head, but not the hips, while logrolling.

a. Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. Logrolling requires the assistance of two or three nurses. Logrolling will maintain straight alignment when the client is being turned. The nurse should use a drawsheet or a friction-reducing sheet to facilitate smooth movement. The nurse should avoid twisting the client's head, spine, shoulders, knees, or hips while logrolling. A chair is not used with logrolling.

The nurse is preparing medications for enteral tube administration. Which nursing action(s) is appropriate? Select all that apply. a. Use the liquid form of the drug if available. b. Mix powdered drugs with hot water. c. Pulverize enteric-coated medications. d. Open the shell of capsules to release the powdered drug. e. Add bulk-forming laxatives to the mix.

a. Use the liquid form of the drug if available. d. Open the shell of capsules to release the powdered drug. Liquid forms of drugs should be used, as this promotes tube patency. Powdered drugs should be mixed with warm, not hot, water. Medications, with the exception of enteric-coated drugs, should be pulverized. The shell of capsules should be opened to release the powdered drug. Bulk-forming laxatives should not be administered through an enteral tube if possible, since this can cause tube obstruction.

Which client would most likely require placement of an implantable port? a. a 58-year-old woman with stage 3 breast cancer requiring weekly chemotherapy b. an 18-year-old man s/p gunshot wound in the ICU requiring multiple blood transfusions c. a 12-year-old girl with sickle cell anemia requiring frequent pain medication administration d. a 45-year-old man with a history of colon cancer that is currently in remission

a. a 58-year-old woman with stage 3 breast cancer requiring weekly chemotherapy This client needs frequent IV access. A central port is easily accessed for chemotherapy sessions, then the access is discontinued even though the port remains in place subcutaneously. A central port also allows for the infusion of chemotherapy into a central vessel; this is important because chemotherapy is caustic and severely damages peripheral vessels.

Question: which of the following is the most significant and commonly found infection-causing agent in healthcare institutions? a. bacteria b. fungi c. viruses d. mold

a. bacteria

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized? a. identifying systemic factors on the unit that may have contributed to the event b. reinforcing the standards for nursing care to staff members who were involved c. ensuring that the client's nurse is held accountable and educated about best practice d. communicating the potential consequences of the near-miss to the client involved

a. identifying systemic factors on the unit that may have contributed to the event Central to creating a culture of safety is the need to identify systemic factors that may contribute to errors or near misses. Communicating with the client is necessary, but identifying systemic factors is a priority because of the implications for future clients. Focusing on the nurses who were directly involved demonstrates a narrow and short term perspective of safety, which may be perceived as punitive.

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints? a. investigate the possibility of discontinuing his or her catheter. b. Limit the resident's fluid intake in order to reduce his or her urge to void. c. Collaborate with the resident's health care provider to have his or her diuretics discontinued. d. Increase the resident's physical activity to reduce evening restlessness.

a. investigate the possibility of discontinuing his or her catheter Discontinuing the catheter, if medically prudent, would eliminate the risks associated with the resident's behavior. Limiting fluid intake or reducing diuretics would be unsafe and ineffective. Similarly, increasing the resident's activity is unlikely to reduce restlessness.

The nurse directs the unlicensed assistive personnel (UAP) to assist an inactive client with positioning. Which action by the UAP would cause the nurse to intervene? a. lowering the height of the bed prior to moving the client b. turning the client as a complete unit to avoid twisting the spine c. placing the client in good alignment with joints slightly flexed d. replacing pillows and positioning devices

a. lowering the height of the bed prior to moving the client Lowering the height of the bed is an incorrect action that would require the nurse to intervene. The bed should be raised to the height of the caregiver's elbow, or to a comfortable working height before the client is positioned. All other options are appropriate positioning techniques.

A nurse is caring for four clients. Which client has the highest risk of infection? a. older male with an enlarged prostate b. toddler with a benign heart murmur c. woman in second trimester of pregnancy d. young woman with a history of scoliosis

a. older male with an enlarged prostate An older male with an enlarged prostate can have urine trapped in the bladder leading to urinary tract infections. A toddler with a benign heart murmur is developmental in nature and does not place them at an increased risk of infection. Pregnancy can alter immunity; however, this is not the highest risk. Scoliosis has no impact on the infection.

The nurse is administering a rectal suppository. How far will the nurse insert the suppository? a. past the internal sphincter b. just past the opening of the anus c. far enough to still visualize the end of the suppository d. until the client reports feelings of discomfort

a. past the internal sphincter To be effective, a suppository must be inserted past the internal sphincter, which is about the distance of the finger of insertion.

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client? a. the 24-month-old child who is unable to walk unassisted b. the 3-month-old child who is unable to raise the head when prone c. the 6-month-old child who is unable to roll over d. the 18-month-old child who is unable to stack blocks

a. the 24-month-old child who is unable to walk unassisted At 15 months of age, most toddlers can walk unassisted; there would be concern for a 24-month-old child who could not. At 3 months of age, an infant may be able to raise the head, but this is not expected at this age. Rolling over is usually accomplished between 6 and 9 months of age, so it would not be expected for all 6-month-old infants. Stacking blocks is accomplished by most 3-year-olds, but doing so at 18 months is considered early.

A client with limited mobility has an outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care? a. trochanter rolls b. footboards c. foot splints d. roller sheets

a. trochanter rolls Trochanter rolls prevent the legs from turning outward. The trochanters are the bony protrusions at the heads of the femurs, near the hip. Placing positioning devices at the trochanters helps prevent the legs from rotating outward. Other devices are inappropriate for this client.

Question: standard precautions should be used when caring for a noninfectious postoperative patient who is vomiting blood a. true b. false

a. true standard precautions are taken no matter what

Asepsis

activities to prevent infection or prevent the spread of infection

Goal of the ANA

aims at fostering high standards or nursing in the United States Rationale: membership is not open to all nurses in the US, only to registered nurses

Assessment

always step one; asses the situation and the patient

standard precautions

applies to everyone > hand hygiene > wear clean gloves when touching body fluids; wear additional PPE when appropriate > cough/ sneeze etiquette > environmental controls > room assignments > use safe injection practices

what are the nursing implications for administering lantus? > things you want to know about any diabetic before starting therapy

assess to establish the baseline for beginning therapy assess VS assess skin where med will be administered obtain blood glucose level assess activity level ***monitor urinalysis*** ***monitor renal (kidney) levels*** monitor nutritional status rotate injection sites monitor for adverse effects can't mix with other insulin

The nurse is working the night shift in the ER when an ambulance arrives carrying a man s/p motor vehicle accident (MVA). His initial BP is 100/56 and the nurse notes that he is bleeding heavily from a laceration on the forehead. Fifteen minutes later, the nurse reassesses the client and finds that his BP is 95/58. What IV fluid would the nurse expect to be ordered? a. 0.45% NS b. 0.9% NS c. 3% NS d. D5 ¼ NS

b. 0.9% NS Isotonic fluids are used to increase blood pressure secondary to hypovolemia.

The nurse opens the multidose container of oxycodone. The nurse needs 1.5 tablets to deliver the as-needed dose, and the tablets in the container are not scored. What action by the nurse is best? a. Document the medication dose as not administered. b. Call the pharmacy to request a supply change. c. Cut the second tablet in half using a pill-splitter. d. Administer one tablet until the issue is resolved.

b. Call the pharmacy to request a supply change. The best action by the nurse is to request scored tablets or the correct dose from the pharmacy. If this is not possible, the nurse considers cutting the unscored tablet with the pill splitter, recognizing that this could result in an inaccurate dose. The nurse could choose not to give the medication, but this leaves the client in needless pain. The nurse could choose to administer two-thirds of the dose by giving one tablet, but this leaves the client underdosed for pain relief

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first? a. Request a sedative from health care provider b. Conceal IV tubing with gauze wrap c. Ask visiting family members to stay d. Assure bed alarms are activated

b. Conceal IV tubing with gauze wrap Wrapping the IV line provides protection for the site. Medications used to control behavior can be considered a chemical restraint that is an intervention of last resort. The presence of a family member may assure client safety and alleviate client anxiety, but would not necessarily protect the IV site. As well, it is inappropriate to delegate client safety observation to family members. Bed alarms alert the nurse to the client leaving his or her bed, but not interference with the IV site.

When preparing a sterile field, the nurse notes that the bottle of sterile saline was opened 48 hours ago and is half full. What action does the nurse take to ensure that the saline used is sterile? a. Since the bottle has been open, previously used, and unexpired, "lip" it by pouring a small amount into a waste container or waste cup. b. Discard the bottle and get a new one because the saline has expired. c. Pour the saline into a sterile container on the sterile field by holding it 6 in (15 cm) above the container. d. Use the saline for the procedure and discard the remaining amount because it has been 48 hours since opening.

b. Discard the bottle and get a new one because the saline has expired. Once a bottle of sterile saline is open, the contents must be used within 24 hours of opening. Lipping the opening of the bottle and pouring the saline into a sterile container by holding it 6 in (15 cm) above the container would be appropriate, but contents in the bottle are expired. The nurse should discard the bottle and get a new one.

The nurse is caring for a postoperative client with confusion, a weak and unsteady gait, and a history of falls. The chart has an order for a waist restraint. What is the nurse's best next action? a. Apply the waist restraint over the gown and abdominal dressing. b. Notify the primary care provider and obtain an order for a client sitter. c. Apply bilateral wrist restraints and secure to the bed frame with a quick-release knot. d. Call the out-of-state family and ask if they can take turns watching the client.

b. Notify the primary care provider and obtain an order for a client sitter. The nurse's best next action is to call the primary care provider for a client sitter, an alternative way to provide around-the-clock safety. Alternatives to restraints should be explored first. The client has a postoperative abdominal incision, which is a contraindication for the application of a waist restraint because it would increase intra-abdominal pressure and place strain on the wound. The primary care provider did not order wrist restraints, so the nurse would have to get an order for them, if they were needed. Wrist restraints are applied when a client may try to pull out an intravenous line and harm self from such action. It is not used to help keep the client in bed. The family is out of state and may not be able to come and watch the client around the clock or arrive in a timely manner to be able to help. *** always want to try alternatives before resorting to restraints ****

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards? a. Clostridium difficile and diabetic ketoacidosis b. Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) c. Tuberculosis and pneumonia d. Appendectomy and a draining leg ulcer positive for methicillin-resistant Staphylococcus aureus

b. Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) Reactive airway disease and exacerbation of COPD are both medical diagnoses and not communicable conditions. Clients with these conditions can room together. C. difficile requires contact isolation and is contagious. Diabetic ketoacidosis is considered a medical diagnosis and requires standard precautions. A surgical incision from an appendectomy is considered clean. A draining leg ulcer can transmit an infection to a client with a clean surgical incision. In both of these cases, rooming these clients together violates infection control standards. Tuberculosis requires airborne precautions and pneumonia requires standard precautions. Based on the mode of transmission of tuberculosis, these clients cannot room together.

A health care provider who just arrived on the unit gives a verbal order to the nurse regarding a nonemergent client situation. What is the nurse's appropriate response? a. Input the order into the computerized provider order system. b. Tactfully request the provider to input the order into the computerized provider order system. c. Refuse to implement the order and notify the nurse manager. d. Have another nurse witness and record the order into the medication administration record (MAR).

b. Tactfully request the provider to input the order into the computerized provider order system. Providers are to enter their own orders when they are physically present. It is appropriate for the nurse to tactfully request that the provider do so. The nurse should not input the order, nor refuse to implement it.

The nurse is considering the use of a power stand-assist machine with a client who has difficulty getting out of bed. The nurse will choose a different assistive device if which assessments are present? Select all that apply. a. The client weighs 200 lb (91 kg). b. The client is oriented to self, but not time or place. c. The client has an above-the-knee amputation of the right leg d. The client makes no attempt to help with transfers. e. The client has an abdominal hernia.

b. The client is oriented to self, but not time or place. d. The client makes no attempt to help with transfers. In order to safely use a power stand-assist machine, the client must be able to bear weight on at least one leg, follow directions, and be cooperative. A client who is not oriented to time or place and a client who does not attempt to help with transfers do not meet these criteria.

Question: a nurse is caring for a patient with reduced mobility following hip surgery. How would the nurse best intervene to prevent skin breakdown in this patient? a. Turn and reposition the patient every 4 hours b. Use padding and cushions under the heels and other bony prominences c. Help the patient to maintain skin integrity by teaching them how to move up in the bed d. Massage the bony prominences with emollient cream after giving the patient a bath

b. Use padding and cushions under the heels and other bony prominences *** position changes should be every 2 hours; DO NOT massage bony prominences****

Question: the patient is a chronic carrier for infection. to prevent the spread of infection to other patients or healthcare providers, the nurse emphasizes intervention that do which of the following? a. eliminate the reservoir b. block the portal of exit from the reservoir c. block the portal of entry into the host d. decrease susceptibility of the host

b. block the portal of exit into the host rationale: stopping the way in which the carrier spreads infection prevents transmission

A nurse needs to administer a prescribed medication to a client using IV push. In which way is the medication being administered to the client? a. continuous drip b. bolus administration c. gravity infusion d. electronic infusion device

b. bolus administration A bolus is a relatively large amount of medication given all at once; bolus administration sometimes is described as a drug given by IV push, or rapid intravenous administration. A continuous infusion, also called continuous drip, is instillation of a parenteral drug over several hours. It involves adding medication to a large volume of IV solution. After the medication is added, the solution is administered by gravity infusion or, more commonly, with an electronic infusion device such as a controller or pump.

After administering medication to a client subcutaneously, the nurse removes the needle at the same angle at which it was inserted. Which explains the nurse's action? a. verifies correct injection of the drug b. minimizes tissue trauma to the client c. prevents needlestick injuries d. helps to control the placement of the needle

b. minimizes tissue trauma to the client Removing the needle at the same angle at which it was inserted to administer medication minimizes tissue trauma and discomfort to the client. To verify correct injection of the drug, the nurse pushes the plunger and watches for a small wheal. To prevent needlestick injuries, the nurse covers the needle with a protective cap. Holding the client's arm and stretching the skin taut helps to control placement of the needle.

Question: curricula for nursing education are strongly influenced by which of the following? select all that apply a. physician groups b. professional nursing organizations c. individual state boards of nursing d. the national council of state boards of nursing

b. professional nursing organizations c. individual state boards of nursing d. the national council of state boards of nursing

tie the restraints to the ______________NOT the ________________

bed frame; side rail *** side rail can loosen or tighten the restraint***

Activity orders

bed rest bed rest with BRP (bathroom privileges) up in the chair ambulate activity as tolerated log rolling think about how much activity the pt needs

DVT (deep vein thrombosis)

blood clot formed in a major vein, can eventually travel to the lungs (pulmonary embolism) or heart (stroke)

The nurse is teaching a client with heart failure about taking digoxin safely. Which statement by the client indicates teaching was effective? a. "I will decrease the amount of potassium in my diet." b. "If my pulse is higher than 100 beats/min, I will hold the dose." c. "I will call the health care provider if I develop dizziness, blurred vision, or nausea." d. "I will store this medication in the refrigerator."

c. "I will call the health care provider if I develop dizziness, blurred vision, or nausea." Digoxin is a cardiac glycoside that slows the heart rate and strengthens myocardial contraction. It is imperative to keep therapeutic blood levels of this medication. As such, teaching the client to report signs and symptoms of digitalis toxicity such as dizziness, blurred vision, nausea, and vomiting is imperative. Usually, dietary potassium is increased, not decreased, while taking this medication. Digitalis slows myocardial conduction and should be taken if the heart rate is higher than 100 beats/min. If the heart rate is lower than 60 beats/min, the dose should be held, and the health care provider should be notified. Digitalis is stored at room temperature, not in the refrigerator.

The nurse has just completed a teaching session with clients on safety precautions to take when applying a transdermal patch. Which statement made by the client indicates that the teaching was effective? a. "I will change the patch every 30 days." b. "I will shave my chest before applying the patch." c. "I will dispose of the patch with adhesive sides sticking together." d. "I will keep the patch off twice as much as how often I keep it on."

c. "I will dispose of the patch with adhesive sides sticking together." Disposing of the patch with the adhesive sides sticking together is correct, as this will prevent accidental exposure. Changing the patch every 30 days is incorrect, since it takes 30 minutes to 8 hours for the drug to reach a therapeutic level. Shaving one's chest before applying the patch is incorrect, as this may help adhesion and is not a safety issue. Keeping the patch off twice as much as how it is kept on is incorrect, especially for a nitroglycerin patch, which is to be removed for the same amount of time.

A nurse receives orders from the physician to mix a client's insulin in a syringe with two other medications. What is the recommended guideline in this situation? a. It cannot be done because it is not possible to mix more than two medications in one syringe. b. Call the physician to determine the necessity of mixing the three drugs or to see if they are compatible. c. Call the pharmacist to determine the compatibility of the drugs d. Check with the nursing team before mixing and administering the drugs

c. Call the pharmacist to determine the compatibility of the drugs Mixing three drugs is not recommended, but if it must be done, contact the pharmacist and not the physician to determine the compatibility of the drugs, the compatibility of their pH values, and the preservatives that may be present in each drug. A drug compatibility table should be available to nurses who are preparing medications.

A client's EHR states that two medications are due at the same time, both of which are available in vials and are to be administered by injection. What is the nurse's most appropriate action? a. Recognize that it is not safe to mix two medications in one syringe. b. Page the health care provider to determine whether the drugs can be mixed. c. Determine the compatibility of the two drugs by consulting clinical resources. d. Collaborate with the pharmacy to have one of the times changed.

c. Determine the compatibility of the two drugs by consulting clinical resources. The nurse must determine the compatibility of the two drugs; some drugs can be safely combined in a single syringe. However, this is not determined by paging the health care provider. There is no need to change the times of administration.

While receiving a medication IV piggyback, the client reports discomfort at the IV site. Upon assessment, the site is cool to the touch and slightly swollen. What is the best action by the nurse? a. Apply a cool, moist compress for 20 minutes. b. Slow the rate of infusion until client reports relief. c. Discontinue the IV site and restart IV in a new location. d. Monitor the site closely for any signs of complications.

c. Discontinue the IV site and restart IV in a new location. The assessment reveals the IV has infiltrated (IV med/fluid has leaked into the surrounding tissue). The nurse should stop the IV fluid and remove the IV from the extremity, then restart the IV in a different location. Applying a cool, moist compress or slowing the rate will not address the problem of the IV fluid going into the surrounding tissue instead of the vein. Monitoring the site is not appropriate, because there is already a complication present that requires action by the nurse.

When administering a subcutaneous injection to a client, the needle pulls out of the skin when the skin fold is released. What would be the appropriate next action of the nurse in this situation? a. Pull out and discard the needle. b. Discard the equipment and start the procedure from the beginning. c. Engage safety shield on needle guard and discard needle appropriately. d. Document the incident and inform the primary care provider.

c. Engage safety shield on needle guard and discard needle appropriately. The needle needs to be disposed of properly after engaging the safety guard because the needle cannot be reinserted due to contamination. A new needle can be attached to the syringe and the remainder of the medication administered after cleansing the site again. The incident does warrant notifying the primary care provider.

A nurse is caring for clients with alterations in mobility. Which nursing interventions are recommended for these clients? Select all that apply. a. For increased cardiac workload, instruct the client to lie in the prone position. b. For ineffective breathing patterns, encourage shallow breathing and coughing. c. For orthostatic hypotension, have the client sleep sitting up or in an elevated position. d. For impaired physical mobility, perform ROM exercises every 2 hours. e. For constipation, increase fluid intake and roughage. f. For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 hours.

c. For orthostatic hypotension, have the client sleep sitting up or in an elevated position. e. For constipation, increase fluid intake and roughage. f. For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 hours. The nurse would implement the following nursing interventions when caring for clients with alterations in mobility: Have the client sleep sitting up or in an elevated position for orthostatic hypotension; have the client increase fluid intake and roughage (if not contraindicated) to address constipation concerns; reposition the client in correct alignment at least every 1 to 2 hours to address impaired skin integrity issues. The client would decrease the cardiac workload if lying in the prone position. Shallow breathing would not be encouraged with a client with ineffective breathing patterns. Range of motion (ROM) exercises would not be performed as often as every 2 hours for a client with impaired physical mobility.

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings? a. Apply the stockings at night when the client is going to bed. b. Apply the stockings after the client has been sitting up for an hour. c. If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. d. Avoid the use of powders on the legs before applying stockings.

c. If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. Be prepared to apply the stockings in the morning before the client is out of bed. Assist the client to a supine position. If the client has been sitting or walking, have him or her lie down with legs and feet well elevated for at least 15 minutes before applying the stockings. Powder the leg lightly unless client has a breathing problem, dry skin, or sensitivity to the powder. If the skin is dry, a lotion may be used. Powders and lotions are not recommended by some manufacturers; check the package material for manufacturer specifications.

The nurse is assessing a client's ability to use a walker. The nurse would provide additional information if which behavior were observed? a. The client uses the arms of the chair as support when standing up to use the walker. b. The client steps into the walker before moving the walker forward. c. The client pushes the walker ahead, following behind it. d. When arising from a chair, the client puts one hand at a time on the walker.

c. The client pushes the walker ahead, following behind it. Clients can have a tendency to push the walker out in front of them as they lean slightly forward and "follow" the walker. This makes the client and walker unstable and may result in a fall. The remaining statements reveal correct walker technique.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities? a. The nurse should notify the primary care physician about the bruises. b. The nurse should contact the facility's social services department. c. The nurse should question the client about the source of the bruises. d. The nurse should request permission from the client to photograph the bruises.

c. The nurse should question the client about the source of the bruises. The initial action by the nurse would be to determine the source of the bruises. If suspicion remains, the nurse should question the client. If the nurse feels there is potential abuse the nurse is obligated to report it

The nurse performs hand hygiene using soap and water before and after providing client care. Which nursing action is performed correctly according to the procedure? a. The nurse uses soap and cold water to wash hands. b. The nurse uses about 2 tsp (10 ml) of liquid soap to wash hands. c. The nurse washes at least 1 in (2.5 cm) above the area of contamination if present d. The nurse rinses thoroughly with water flowing away from the fingertips.

c. The nurse washes at least 1 in (2.5 cm) above the area of contamination if present The nurse must wash at last 1 in (2.5 cm) above the area of contamination to properly performed hand hygiene. The nurse should use warm to hot water to wash hands. The amount of liquid soap varies depending on the concentration of the soap. The nurse rinses with water flowing toward the fingertips.

A nurse is caring for a client with scabies for which a topical medication has been prescribed. When educating the client on how to use the medication, which should the nurse tell the client regarding the application? a. Remove medication every 12 hours and reapply. b. Do not bathe or rinse off for 24 hours. c. Use gloves to apply. d. Apply medication in a thick layer and cover with gauze or sterile wrapping.

c. Use gloves to apply. The nurse should tell the client that the drug is to be administered by application on the skin wearing gloves because as a topical route of administration gloves can reduce inadvertent absorption through the hands. The medication will be absorbed through the skin so there is no need to remove the previous dose and reapply, avoid taking baths or showers, or cover with gauze.

The rapid response team is present while a client is receiving cardiopulmonary resuscitation (CPR). The health care provider informs the nurse to administer a dose of epinephrine IV. Which method of medication will the nurse obtain? a. an individual supply b. a unit dose supply c. a stock supply d. an automated medication dispensing system

c. a stock supply The nurse will need to obtain the medication rapidly because this is an emergency situation. The fastest method in this scenario is the stock supply, which is a large number of stored drugs that remain on the unit for emergency use. A unit dose supply is a packet that has one pill or capsule for client consumption. An individual supply is a container with enough of the prescribed drug for several days or weeks, which is common in long-term care facilities such as nursing homes. The automated medication dispensing system requires the nurse to access the machine with a specific code and withdraw the one item that is needed. This is a time consuming procedure that is not appropriate for an emergency situation.

which client should the nurse determine is at greatest risk for VRE infection? a. client on a short course of vancomycin b. a client with a history of eczema c. client recieving chemotherapy d. client in the ICU for one day

c. client receiving chemotherapy The nurse should determine that the client receiving chemotherapy is the client at greatest risk for VRE infection due to having a compromised immune system from the chemotherapy. Other risk factors for VRE include recent surgery, presence of urinary or central IV catheter, prolonged antibiotic use (especially with vancomycin), and lengthy hospital stays (especially in an ICU).

What is a benefit of regular exercise over time? a. increased risk for blood clots b. increased work of breathing c. decreased heart rate d. decreased venous return

c. decreased heart rate Regular physical activity over time results in cardiovascular conditioning and therefore decreased heart rate. Regular exercise increases circulating fibrinolysin that serves to break up small clots, thus decreasing the risk for blood clots. Over time, regular exercise leads to improved pulmonary function, including decreased work of breathing. Venous return is improved when contracting muscles compress superficial veins and push blood back to the heart against gravity.

Question: the nurse assesses symptoms of DVT in their patient, which of the following nursing interventions would you perform? a. massage the reddended, sore area b. sit the patient in a chair for meals c. place the patient on bed rest and call the doctor d. encourage the patient to walk in the halls

c. place the patient on bed rest and call the doctor > don't want to risk the clot moving to another region

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk? a. increase in the movement of secretions in the respiratory tract b. increase in circulating fibrinolysin c. predisposition to renal calculi d. increased metabolic rate

c. predisposition to renal calculi In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile client. Immobility also predisposes the client to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. The client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin.

A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response? a. "To preserve your functional ability to grasp and pick up objects." b. "To prevent foot drop." c. "To avoid contractures." d. "To prevent your legs from rotating outward."

d. "To prevent your legs from rotating outward." Trochanter rolls prevent the client's legs from rotating outward. The other statements do not describe trochanter rolls. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop.

The nurse educator is reminding a group of new nurses about precautions. Which statement by a new nurse requires further teaching by the nurse educator? a. "I will always wash my hands thoroughly and often." b. "It is important to refrain from recapping needles." c. "Masks, gloves, and gowns should be used to protect from infectious agents." d. "Wearing an N95 respirator is critical when I care for clients in droplet precautions."

d. "Wearing an N95 respirator is critical when I care for clients in droplet precautions." N95 respirators are used when caring for clients in airborne precautions; therefore this statement requires further teaching. The other statements reflect that teaching has been effective.

A nurse is administering a piggyback infusion to a client with partial-thickness or second-degree burns. Which describes the most important feature of a piggyback infusion? a. The primary IV solution is infused by gravity. b. Medication is given all at one time as quickly as possible. c. Medication locks are changed every 72 hours. d. A parenteral drug is given in tandem with an IV solution.

d. A parenteral drug is given in tandem with an IV solution. In a piggyback infusion, a parenteral drug is administered in tandem with a primary IV solution. Medication locks are not changed during piggyback infusion specifically, but in general to maintain patency. IV medication or fluid is given all at one time as quickly as possible in a bolus administration, not in piggyback infusion. It is not the primary IV solution but the secondary infusions that are administered by gravity in tandem with the currently infused primary solution.

A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client? a. supine b. prone c. Sims' d. Fowler's

d. Fowler's Fowler's position, a semi-sitting position, will assist the client with dyspnea because this position allows the abdominal organs to drop away from the diaphragm. The other position choices do not promote oxygenation.

The nurse must assign a room for a client admitted with endocarditis and methicillin-resistant Staphylococcus aureus (MRSA) in the blood. A client with which diagnosis can share a room with this client? a. Vancomycin-resistant enterococci and urinary tract infection b. Clostridium difficile and colitis c. Coronary artery bypass grafting d. MRSA in the wound

d. MRSA in the wound In many situations, clients with like infections can be placed together. The presence of similar causative microorganisms negates the risks of cross-contamination. Each of the other listed clients would encounter a risk for MRSA.

Question: which professional organization developed a code for nursing students? a. ANA b. NLN c. AACN d. NSNA

d. NSNA

Question: In which case is a restraint properly used? a. Restraint is tied to the raised bed rail of a patient's bed b. The patient is placed in a supine position prior to application of restraints c. Cloth restraint is applied to the left hand of the patient with an IV catheter in the right wrist d. The nurse ensures that 2 fingers can be inserted between the restraint and the patient's wrist

d. Nurse ensures that 2 fingers can be inserted between restraint and patient's wrist

An older adult is admitted to the hospital with a fractured hip. The client suddenly develops acute onset of confusion and hallucinations. Which action should the nurse implement first? a. Leave to notify the health care provider concerning a change in client status b. Apply limb restraints to ensure client safety c. Promptly document the change in client status d. Reduce distressing environmental stimuli to maximize client safety

d. Reduce distressing environmental stimuli to maximize client safety Added stimulation can increase the maladaptive behaviors of the client; therefore, the nurse should first reduce the distressing environmental stimuli. Proper communication of client status change is a legal requirement of nurses, and documentation provides a means of communication between interdisciplinary teams and provides continuing of care. However, notifying the health care provider and documenting the change in status are not the priority action. Restraints are to be used as a last resort in client care.

A client has been ordered nasal drops, which the nurse will administer. How should the nurse best position the client? a. Lying flat, with the head extended as much as the client can tolerate b. Seated at a 45-degree angle with the nares flared c. Supine, with the neck in a neutral position d. Upright, with head tilted back

d. Upright, with head tilted back

Question: which of these patients is at the greatest risk of fall? a. a 37 yo pt with impaired renal perfusion b. an 87 yo pt who has low glare floors c. a 77 yo pt that fell 8 years ago d. a 27 yo pt sedated 1 hour ago

d. a 27 yo pt sedated 1 hour ago > anesthesia takes 24 hours to come completely off of

A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from: a. decubitus ulcers. b. pooling of blood. c. blood pressure changes. d. foot drop.

d. foot drop. A footboard or boots should be applied to maintain dorsiflexion and tendon flexibility. Foot drop is a contracture in which the foot is fixed in plantar flexion.

Question: which infection or disease may be spread by touching a contaminated inanimate article? a. rabies b. giardia c. E.coli d. influenza

d. influenza rationale: rabies is spread by animals; E.coli can't live on a surface

Question: which intervention should the nurse implement when withdrawing medication from an ampule? a. do not use if the amplus was opened more than 30 days ago b. ensure that all the medication is in the upper chamber of the ampule c. snap the neck of the ampule so that it opens towards the nurse d. insert the filter needle into the center of the opening of the ampule

d. insert the filter needle into the center of the opening of the ampule - ampules are used only once - medication should be in the lower chamber - should snap away from the nurse

The circulating nurse is observing a surgical technician donning a surgical gown. Which action by the technician indicates that the nurse should intervene to maintain sterile donning technique? a. picking up the gown at the sterile neckline b. holding the gown away from the body and other unsterile objects c. unfolding the gown while avoiding contact with the floor d. inserting an arm within each sleeve while touching the outer surface of the gown

d. inserting an arm within each sleeve while touching the outer surface of the gown To maintain sterile technique while donning the sterile gown, the gown should be picked up at the sterile neckline to preserve the sterility of the outer gown surface. Holding the gown away from the body and any unsterile surfaces or objects prevents contamination of the sterile gown. Allowing the gown to unfold and not touch the floor in the process will prevent contamination. The nurse should intervene and supply a new gown when observing the surgical technician touching the outer surface of the gown.

Question: what is the purpose of the Nurse Practice Acts? a. to guide federal health care policy b. to protect nurses from lawsuits c. to guide workplace policy d. to protect the public health

d. to protect the public health

Evaluation

did the patient reach the goal? if not, start over and go back to planning

can only discuss protected health information (PHI) if it is ___________________________

directly related to treatment

portal of exit from reservoir: ways to break the chain of infection

dry intact dressings hand hygiene wearing gloves if in contact with body fluids cover nose/mouth when sneezing

scientific knowledge

evidence-based practice; current standard of nursing practice

early signs of infection

fever malaise pain swelling warm to touch drainage limited joint movement

thrombus formation

formation of blood clots that may become emboli and travel to other regions *** most dangerous complication of immobility***

Steve Miller

formed Men in Nursing that later became AAMN

Lilian Wald

founder of public health nursing; 1st to offer trained nursing services to the poor in NY

means of transmission: ways to break the chain of infection

hand hygiene use pesticides to eliminate vectors adequate refrigeration

infectious agent: ways to break the chain of infection

hand hygiene sterilization antibiotics/ antimicrobials

portals of entry: ways to break the chain of infection

hand hygiene wearing gloves use masks and appropriate PPE proper disposal of needles/sharps *** getting a catheter increases the chances of getting a UTI***

When moving a client up in bed with the assistance of another caregiver, the nurse should

have the client fold the arms across the chest. Rationale: Positioning the arms across the chest improves assistance reduces friction, and prevents hyper extension of the neck Head of the beds should be flat or as low as the client can tolerate; pillows should be removed from under the clients head

when using a metered dose inhaler, what does a spacer do?

helps disperse the medication

traditional knowledge

how nursing was taught/practiced before evidence-based practice became the standard

susceptible host: ways to break the chain of infection

immunizations screen healthcare workers and other patients

progressing signs of infection

increase in pain elevated WBC increase in drainage increase in redness in surrounding areas confusion (esp. in the elderly) weakness

otic administration > adult > child

indications: infection, analgesia > adult: pull auricle of the ear up and outward > child: pull auricle of the ear down and back

Diagnosis

interpret data, analyze, formula example: pt who might chronic lung disease might have a nursing diagnosis of impaired gas exchange due to narrowed bronchial passages

parenteral route: injecting a drug into the body

intradermal (ID) subcutaneous (SQ) intramuscular (IM) intravenous (IV) > must be performed using asepsis technique > requires the use of syringes and needles

right frequency/time

know how often it should be given e.g. tid, qid, prn, etc.

right drug

know the name of the drug AND its response

right dose

know what the expected or normal dose is for that drug

authoritative knowledge

knowledge learned from those more experienced and perceived as more knowledgeable

ataxia

lack of muscle coordination

When logrolling a client, the nurse should use supportive devices in turning the client in order to

maintain the natural alignment of the client's body.

medical asepsis vs. surgical asepsis

medical asepsis: "cleaning technique" surgical asepsis: "sterile technique"

MRSA

methicillin-resistant staphylococcus aureus > found in nasal passages, skin, and respiratory tract > main mode of transmission: hands of healthcare workers > treatment: vancomycin, linezolid, daptomycin

Hospital Acquired Condition (HAC): Centers for Medicare and Medicaid identified falls as a ____________________________________ because they are preventable and should not occur

never event

Implementation

nursing interventions example: apply O2 cannula, have the pt sit up, administer medication, etc.

Luther Christman

one of the founders for American Assemble for Men in Nursing 1st male president of ANA 1st male to be dean of university of school of nursing

right documentation

only document after the medication has been administered; note any assessment findings

Plan

outcome identification; what goal do you want to accomplish? example: breath more effectively demonstrated by improving O2 saturation

venous stasis

pooling of blood in the veins of the lower legs; can lead to swelling/edema

patient care ergonomics

practice of designing equipment and work tasks to conform to the capability of the worker in relation to patient care

HIPPAA: confidentiality

providers will hold secret all protected health information relating to pt unless they give consent

2020 Hospital Patient Safety Goals

purpose: improve patient safety; goals focus on problems in healthcare safety and how to solve them > identify patients correctly > improve staff communication > use medicines safely > use alarms safely > prevent infection > identify patient safety risks > prevent mistakes in surgery

serious signs of infection

sepsis/shock organ failure low temperature and blood pressure elevated respiratory rate decreased urine output

vastus lateralis site for IM injection

side of the thigh; muscle is thick and well developed procedure/landmark: > divide the ANTERIOR LATERAL (front of the side) aspect of the thigh into thirds, placing one hand just above the knee horizontally and the other hand across the top of the leg by the groin > involves the QUADRICEPS > no large nerves or blood vessels > desirable site for infants and children

right route

some drugs can be administered via various routes (IV, IM, ID, Sublingual, SubQ, Topical, Rectal), so NEVER assume

Lavinia Dock

suffragette that lead right to vote; co-founded the precursor to NLN

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow?

supporting the client's back rationale: The nurse would place the pillow under the client's back to provide support and help maintain the proper position. A pillow can also be placed between the knees. More than one pillow under the client's head is not necessary. Placing a pillow in front of the client's abdomen would be helpful for a client who has undergone abdominal surgery. Placing a pillow under the client's feet is not helpful for the side lying position.

Which explanation accurately differentiates the role of the RN from that of the LPN/LVN?

the LNV/LPN should work under the supervision of an RN

HIPPPA: Privacy

the right of the pt to keep information about him or herself from being divulged to others, including healthcare workers, insurance companies, employers, and even family members unless they give permission

reservoir: ways to break the chain of infection

transmission based precautions sterilization use of disposable supplies

deltoid site for IM injection

upper arm/ shoulder area; close to the radial nerve and brachial artery (best to stay central and north) *** NOTE: only administer 1ml or less*** common for immunizations; rapid absorption, easy access; recommended site for children, adults procedure/landmarks: > palpate the LATERAL ASPECT of the upper arm and the LOWER EDGE OF THE ACROMION PROCESS > place 2-3 FINGERBREADTHS BELOW the acromion process > injection site: upside down triangle area on the thick muscle part of the upper arm

ventrogluteal site for an IM injection

upper hip area; large muscle mass free from major nerves/blood vessels procedure/landmarks: > palm of hand on GREATER TROCHANTER > use right hand on pt's left hip/ left hand on pt's right hip > index finger: ANTEROSUPERIOR ILIAC SPINE > middle finger: ILIAC CREST > injection to be given in the middle triangle between the middle and index finger

transmission based precautions

used in addition to standard precautions > used for clients with known or suspected infections that are spread via several routes > contact precautions > droplet precautions > airborne precautions

VRE

vancomycin resistant enterococcus > spread: by contact with feces, urine, blood, or infected colonized person > usually seen in UTIs > treatment: daptomycin, linezolid, tedizolid

right patient

verify name and DOB (visually check the arm band then computer)

HIPAA: exceptions to the privacy rule include__________________

vitals stats communicable diseases adverse rxn to drugs or medical devices industrial accidents cases of child/elder/domestic abuse GSWs stabbings poisonings associated with criminal activities unknown cause of death