Exam 2: NUR 152
What method used for sub q injections?
pinch the skin, let go after injection EXCEPT in anticoagulant(heparin/lovenox) keep pinch
which statement indicates that the nurse has a good understanding of teaching/learning?
"teaching is the most effective when it responds to the learners needs"
What drugs do we use for IM deltoid?
-small volume vaccines -tetanus is irritating but given in deltoid
What are the 6 rights of medication administration?
1. Right Patient 2. Right Route 3. Right Time 4. Right Drug 5. Right Dose 6. Right Documentation ALSO- right to refuse, right knowledge
What are differences to remember when dealing w/ narcotics?
1. must be signed out 2. witness if wasted 3. counted before & after shift
What percentage of weight change in 6 months is considered abnormal?
10%
Nurse contaminates plunger when preparing vial after med is drawn into syringe, what to do?
A:administer med as prescribed R:Not necessary to discard, the plunger will enter the barrel and not come into contact w. medication in syringe
young women IV infusion for magnesium sulfate to treat preterm labor, woman develops fever. which is the 1st assessment to make?
A:assess the IV site for redness R: if tender/fever w/o obvious source remove the dressing
4 routes of pharmacokinetics?
ABSORPTION, distribution, biotransformation(metabolism) excretion
When can you not recap?
AFTER ADMINISTERING
What should you do when administering IM?
ALWAYS rotate sites to prevent overuse
Whats a PRN order?
AS NEEDED Ex: inhaler when having breathing troubles
what's a STAT order?
ASAP! - usually an emergency
"C" in PICOT =
Comparison of interest: usually a comparision to another treatment or the standard of care
A nurse is administering a medication to a 78 year old female client who experienced symptoms of stroke. When administering the medication prescribed for her, the nurse should be aware that the client has an increased possibility of drug toxicity due to what age-related factor?
Decline in liver function and production of enzymes needed for drug metabolism.Rationale: older clients are at risk for experiencing a cumulative effect, related to a decreased rate of drug metabolism, higher drug plasma concentrations. This leads to prolonged action and an increased possibility of drug toxicity if the liver function and production of enzymes for metabolism are decreased.
What is quantitative research measured by
NUMBERS #
The way a patient acts when recieving a cancer diagnosis is an example of what type of research?
Qualitative
A nurse may attempt to help a client solve a situational crisis during what type of counseling session?
Short-term counseling
What are IM injections used for
Skin tests; allergy, and TB
What injections are used for anticoagulants?
Sub Q (Heparin & lovenox) *lovehandles
Whats included in SOAP charts?
Subjective, objective, assessment, planning
A client is prescribed an opioid analgesic. The nurse is teaching the client about the need to avoid ingesting alcohol with the drug to prevent an interaction which would potentiate the effects of analgesic. The nurse is describing which event?
Synergism
high pitched sounds in abdominal ausculation is a sign of?
bowl obstruction
Why can't you massage after administering an injection?
can change its metabolization
How can you report quantitative data?
charts & graphs
The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment?
dehydration: The nurse assesses for skin turgor by gently pinching the skin under the clavicle. This technique provides information about the client's hydration status as well as skin mobility and elasticity. Skin is less elastic with aging, but the turgor should remain normal (less than 3 seconds) and not tent, or remain in the pinched position. When a client is dehydrated, the skin will tent for more than 3 seconds. When a client is overhydrated, edema will be present with the skin, and the skin turgor would be normal, or taunt because of excess fluid.
What sites for IM injections?
deltoid, ventra gluteal, vastus lateralis
What do you do when performing scientific data
collect data, anaylze, communicate findings
What are the purpose of medical records?
communicate accurate & timley. Legal documentation, financial billing, education, research, audits
what does accurate documentation inculde?
concise/clear, correct spelling, quoting family/p.t, ending with nurses full signature.. and NO blank spaces
which cranial never is important for sense of smell
cranial nerve 1
Mrs. Shields is a 46-year-old obese woman diagnosed with hypertension and type 2 diabetes. She tells the nurse that she knows she needs to lose weight. She recently visited her local fitness club, obtained a membership and has signed up for their next water aerobics class. According to the Transtheoretical Model of Change, what stage of change is Mrs. Shields in related to her weight loss?
preparation
factual documentation includes?
objective info about what the patient says, what the nurse sees hears feels and smells
what should you avoid when documenting?
opinions/judgements
"O" in PICOT=
outcome of interest: identify outcome to enable a literature search to find evidence
"P" in PICOT =
patient, population, or prob of interest :need for DEEP description
What is percussion?
percussion is the act of striking one object against another to produce sound
A home health nurse states to her client, "I am very proud of you. You gave your first insulin injection without a problem. You have done wonderfully and are learning fast." What technique is the nurse using to compliment the client's progress?
positive feedback
SBAR helps by doing what?
presenting data/info quickly, choerent manner
What are anticoagulants used for? (Heparin/lovenox)
prevents the formation of clots but does not dissolve them
Which med can a nurse (RN) as a (LPN) to do?
A: antibiotic via peripheral IV R: blood products, IV pushes, and flushes are not allowed for LPN to do
Pharmacokinetics teaching would be successful when students identify what process med is delivered to the target cells & tissue
A: distribution R: process by which med is distributed to cell and tissure is called distribution absorption= med into bloodstream synergism= drug interaction that increases drug effect metabolism= in liver chemically changing
nurse preparing med gets called away what to do with the meds?
A: lock the meds into the cart R: once meds are prepared nurse must stay w/ them or lock them away -> new nurse cannot administer
Why do we repeat back TO orders?
Accuracy, misunderstanding, accents hard to understand over the phone
how does SBAR help?
provides a framework, prevents delay in treatment, gets point across quickly
What to assess when teaching a client?
1. Knowledge =identify what the patient considers of importance to learn, as well as new knowledge, attitudes, or skills necessary for patients and families to learn in order to manage their health care 2.Readiness=The patient's anxiety, motivation for learning, willingness to engage in the teaching-learning process, and support system contribute to readiness to learn 3.Ability to learn=Physical condition Cognitive ability to learn Acuity of senses Developmental considerations Level of education Literacy Communication skills Preferred language 4.strenghts=personal resources that can be harnessed to facilitate the teaching-learning process
How can you evaluate if learning outcomes were met?
1.Observe a return demonstration 2.Ask the patient to restate the instructions 3.Ask the patient questions to determine whether 4.teaching reinforcement is needed 5.Use written test or questionnaires 6.Consult with the patient's family 7.Consider patient feedback and comments
How can you evaluate your teaching plan?
1.a quick review of how well you feel you implemented the plan. Mentally noting both the strengths and weaknesses of the teaching session helps you plan better for subsequent sessions. 2.you can also seek feedback from patients. You can use a simple questionnaire at the end of a teaching session or after discharge to gain the patient's perception of your teaching effectiveness.
Onset of IM injections
10-15 min (rapid absorption, cause vascular)
When administering solid dose PO drugs through enteric tube how much water to flush and when?
15-30 ml before, during, and after.
if connected to suction how long to keep enteric tube off after administering drugs?
20-30 mins to allow for absorption
While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is:
Blurred: Visual problems with close objects occur more frequently after the age of 40.
How can we make it easier for a patient to take a P.O med?
Can crush into pudding, break in 1/2
What is affective learning?
Changes in attitudes, feelings, and values. EX: the patient expresses renewed self-confidence after physical therapy
The nurse is providing care for a male client age 69 years who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the client's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. What should the nurse document as being present?
Crackles: crackles are described as bubbling- or popping-type sounds that are usually audible during inspiration. Wheezes are typically musical in tone and continuous. Sibilant wheezes are high-pitched and shrill-sounding breath sounds that occur when the airway becomes narrowed. They often have a musical quality to them. These are the typical wheezes heard when listening to an asthmatic patient. A sonorous wheeze is an added sound with a musical pitch occurring during inspiration or expiration, heard on auscultation of the chest and caused by air passing through bronchi that are narrowed by inflammation, spasm of smooth muscle, or presence of mucus in the lumen. A friction rub is a continuous, grating-type sound.
examples of psychomotor domain
Demonstration Discovery Audiovisual materials Printed materials
The nurse is caring for an older client who sees several different health care providers and specialists. Which question will the nurse ask?
Do you get all of your medications filled at the same pharmacy?
Whats an incident report used for?
Document any unusual occurrence
what to do when patient refuses a drug that is part of a regemine?
It is important to determine the reason for the refusal and to help the patient accept needed drugs. If the patient is not persuaded by reasonable efforts and adamantly refuses to take a medication, it is unwise to continue urging the patient. Patients have the right to refuse therapy; recognize and respect that right. Describe the refusal to take prescribed drugs and the manner in which the situation was managed in the patient's record and report the refusal according to facility policy.
what's psychomotor learning?
Learning a physical skill involving the integration of mental and muscular activity. EX: the patient demonstrates how to change dressings using clean technique
examples of cognitive domain
Lecture or discussion Panel discussion Discovery Audiovisual materials Printed materials Programmed instruction Computer-assisted instruction programs
Why do IM injections need to be accurate?
Near major BVs, and nerves
While administering IM what should we see?
Needle under the skin, and forms a bleb
what can happen if you dont choose the correct injection site?
Nerve/BV/bone damage. and CAUSES PAIN!
can time release meds be crushed?
No- the enteric coating prevents this. Could cause overdose
Role of nurse in teaching a client?
Nurse= teacher Client=Learner
For Needle safety how do you recap?
ONLY after drawing up med, one handed scoop method
Whats a single/ one time order?
One time ordered med- not routine for the P.T. EX: anxiety med before surgery
what's the first pass affect?
P.O drugs passing through portal circulation before entering bloodstream,. The liver does this w/oral meds)
what rate for mucous membranes/respiratory tract? (inhaler)
Quick- due to vascular tissues
For ventrogluteal site what is the hand placement?
R hand L hip L hand R hip
What should be done when getting a (TO)?
REPEAT the order back
What does "R" in SBAR stand for?
Reccomendation= use critical words "C.U.S" "Concerned for p.t safety" "uncomfortable w/situation" "safety of my p.t at risk"
what order should documentation be in?
Reverse chronological - so new info always in front
examples of affective domain
Role modeling Discussion Panel discussion Audiovisual materials Role playing Printed materials
what rate for topical medication?
SLOW rate
A pediatric nurse provides education to numerous clients in their care. Which group of children benefits most from being involved in the teaching-learning process?
School aged children
Whats the acronym teach?
T: Tune into the patient E: Edit patient information A: Act on every teaching moment C: Clarify often H: Honor the patient as a partner in the education process
what affects absorption rates of medication?
THE ROUTE OF ADMINISTRATION
When establishing a teaching-learning relationship with a client, it is most important for the nurse to remember that effective learning can best be achieved through which concept?
The client and the nurse are equal participants.
what are the 3 learning domains?
cognitive, psychomotor, and affective
A nurse is developing a contractual agreement with a client. Which statement is true of a contractual agreement?
The contract serves to meet the client's learning outcomes.
A nurse is providing teaching to clients in a short-term rehabilitation facility. Which examples are common teaching mistakes made by health care professionals? Select all that apply.
The nurse fails to accept that clients have the right to change their minds.The nurse uses medical jargon frequently when discussing the teaching plan.The nurse ignores the restrictions of the client's environment.
Who is to fill out the incident report?
The nurse who saw the incident occur
A nurse is writing learner objectives for a client who was recently diagnosed with type 2 diabetes. Which statement best describes the proper method for writing objectives?
The nurse writes one long-term objective for each diagnosis, followed by several specific objectives.
what's the teach back method? and why is it good for health literacy?
The teach-back method assesses health literacy, seeking to confirm that the learner understands the health information received from the health professional. It is important when a person has difficulty reading and comprehending written materials or has limited English proficiency
Which statement best describes the nurse's rationale for selecting the ventrogluteal site when using the Z track technique for administering an injection?
The ventrogluteal site provides a location with the capacity for depositing and absorbing the drug.
"T" in PICOT=
Time : when the comparison of interest is completed & the outcome can be evaluated
When does discharge planning begin?
Upon admission
A nurse examining the lungs of a client percusses over the anterior thorax using the proper sequence. This technique helps to identify:
density and location of lungs: Percussion over the lung fields helps identify the density and location of the lungs. Palpation assesses for masses, crepitus, muscle development, and tenderness. Lung auscultation assesses for normal breath sounds and for abnormal (adventitious) breath sounds.
What does scientific method include
dependent variable EX: rate of infection independent variable EX:catherer or not? Sample Hypothesis Target population
paresthesia
numbness and tingling
Why are insulin and pain meds administered IM?
FAST onset for these drugs
what rate of administration for (Iv) intravascular ?
FASTEST! directly into bloodstream
Whats DAR charting?
focused on P.T concerns, s/sx, behaviors, changes in condition
where should we avoid giving IM injections?
hairy, tattood, scars could tamper w/results
the nurse should use the bell of the stethescope during ausculation of?
heart murmur
How long for Verbal orders(VO) and Telephone orders(TO) to be signed?
24 Hours
How do you reduce risk of med errors?
3 CHECKS!!!
What angle do you use when administering SUB Q?
90 degree/ 45 for small person
What does the FIRST CHECK include?
=in the med room includes: selecting Right med from drawer, correct P.T., Med approriate? dose appropriate? route appropriate? time? CHECK ALLERGIES/EXPIRATIONS!
Important to use z-track method on what client?
A: 70 yr old w/muscle waisting prescribed chlorpromazine R: z track is suggested for older adults w decreased muscle mass
A client that is at greater risk for high affect of IV meds?
A: 73 year old with liver disease R:older adults have decrease in plasma protein, the decrease can increase the amount of meds ciruculating ->increasing the effects!
Which guideline is most important for the nurse to keep in mind when planning to teach an exercise class to a group of older adults?
Allow ample time for psychomotor skills.
A nurse is caring for a client with paraplegia. Using observation to examine the client's skin, what finding might indicate the presence of a pressure injury?
An intact reddened area of the skin in an area that comes in contact with a wheelchair may be a stage I pressure injury. The shoulder blades would be another area of contact for the wheelchair, but a faded purple area indicates a resolving bruise. The neck and forearm are not pressure areas for a paraplegic. Pale red bumps indicate urticaria (hives), while circular red scaly area indicates ringworm.
What is auscultation?
Auscultation refers to the assessment technique of listening with a stethoscope to sounds produced in the body, such as bowel sounds.
What does "B" stand for in SBAR
Background= brief history of situation. includes medical history, current treatment, VS, interventions, abnormal labs & tests
The nurse needs to understand the teaching-learning process when administering
Educational interventions
The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate?
Check the client's ear canals for cerumen: Ear wax (cerumen) becomes drier in older adults and can block the ear canal and cause decreased hearing. Asking the client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating with the hard of hearing, but this client's hearing loss was acute and requires further assessment. When speaking to older adults who are hearing-impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic for older adults.
IM INJECTIONS
Dose= 3ml or less Syringe= 3 ml (TB) for 1 ml or less dose gauge= 19-22, 22-23(most common) Lenghth= 1/ 1.5"
The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse assesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of:
FISSURE: A fissure is characterized as a deep linear separation in the skin that extends into the dermis. Erosion is a loss of superficial epidermis; it is moist and may bleed. An ulcer appears as a loss of epidermis and dermis and may bleed. Crusts are dried residue (serum, pus, or blood) on the skin.
what rate of administration for (IM) intramuscular?
Faster than SQ due to more vascular (in muscle)
what's a standing/routine order?
HCP has given to OK to give meds when needed. EX: stool softener if no bowel- Tylenol when headache
what's a tip for taking buccal/sublingual meds?
Have P.T drink water beforehand- will help the drug dissolve
What is the scientific method?
helps narrow broad area of interest to specific problem
The charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which action, if observed, would require the charge nurse to intervene?
Palpation of both carotid arteries: Palpation of both carotid arteries at once can obstruct blood flow to the brain, potentially causing dizziness or loss of consciousness. The other assessments are correct as described.
A nurse is educating a client with a new diagnosis of diabetes. Which example demonstrates cognitive learning by the client?
The client describes signs and symptoms of hypoglycemia.
What are PRN orders commonly used for?
treatment of symptoms such as nausea, pain relief, sleep aids
What is PICOT used for?
used to ask clinical questions
A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which of the following as a characteristic of an adult learner?
Their readiness to learn is often related to a developmental task or social role.
what are non verbal forms of communication?
Touch(tactile sense) eye contact facial expressions posture/gait gestures
A nurse needs to administer a prescribed injection to a toddler. Which injection site is most suitable for the client?
Vastus lateralis site
ID INJECTIONS
Volume= 0.1 ml syringe= 1 ml guage= 25-29 length= 0.5-5/8'
SUB Q sites
adipose tissue (fatty sites) -lateral arm& thighs -abdomen (always alternate & 2 inch away from ambilicus) -upper hips/back *all areas that are distant from major BV's and bones
what's the enteral route?
administering a drug through a enteral tube
Whats an Sentinel event?
an unexpected occurrence involving death or serious physical or psychological injury
nail clubbing
angle of nail base exceeds 180 degrees
How do Buccal/ sublingual meds work?
area is rich in superficial blood vessels, allow drugs to be absorbed RAPIDLY to the bloodstream.
which nursing action is most appropriate for assessing a patients learnings needs?
assess the patients health literacy
What does "A" in SBAR stand for?
assessment- what you think is going on w/ P.T
when do med errors often occur?
at points of transition in care: on admission to a hospital, at transfer from one department to another, and at discharge home or to another facility
when should things be documented?
at time rendered/ needs to be current
rate for liquid medication?
faster than capsules, due to capsules having coatings
How does lipid solubility affect absorption?
fat soluble meds move across cell membrane more quickly/absorbed faster
The nurse must instruct a 35-year-old client with Down syndrome about use of an albuterol rescue inhaler. Which of the following demonstrates individualization of the education plan for this client?
client understanding of illness, motor skills and developmental stage assessed, clarification provided
What is EBP (Evidence Based Practice)?
clinical decision making based on the best evidence (research), clinical expertise, & P.T values
A student nurse learns that a normal adult heartbeat is 60 to 100 beats/minute. In which domain did learning take place? a. Kinesthetic b. Cognitive c. Affective d. Psychomotor
cognitive
A 20-year-old client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need of a balanced diet and its relationship with a quick recovery. Which domain correctly identifies the client's learning style?
cognitive domain
When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which of the following learning domains does the client's learning style fall?
cognitive domain
How does food affect drug absorption?
depends on the drug- meds interact with food, might need to be given a.c or p.c. (with) or on empty stomach.
what are flow sheets used for ?
documenting routine care/assessments =ONLY FOR "NORMAL"
SUB Q INJECTIONS
dose= 1ml or less Syringe= 1 or 3 ml guage= 25-31 Length= 1/2-7/8 " INSULIN= 30/50/100 UNITS
How are P.O drugs absorbed?
in gastric mucosa, (most) in S.I. sublingual- under the tounge buccal- Cheek/gums
what is complete documentation?
inclusive of care provided/ patients response to care
When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order?
inspection, auscultation, percussion, palpation
"I" in PICOT=
intervention of interest : includes treatment, patient perception, diagnostic tests
Whats the nurses responsibility when giving a drug?
is it appropriate? why am I giving? what IS the drug? Whats my P.T. condition? (safe? p.t history? right time (any reason it need to be held?)
what could go wrong if change of shift report isnt organized?
med errors, infection, falls
Who performs audits?
nurses
Where are the locations for IM injections?
ventral forearm
What happens if a needle stick occurs?
wash soap/water report seek medical treatment
What method used for IM?
Z trac, hold skin in Z method until DONE administering
A nurse is preparing to teach a client about heart failure. which environment is best for patient learning?
a well lit, ventilated room
Whats narrative charting?
storylike format from start of day to end =normal/abnormal findings
what is androgogy learning
the art and science of helping adults learn
a nurse is performing eye assessments, which assessment would the nurse document as normal?
the clients pupils are black, equal in size, and round/smooth
Who must document medication errors?
the person who finds the error -requires incident report
what is pharmacokinetics?
the way the body deals with a drug
Whats the reason for SBAR change of shift report?
to prevent miscommunication
what is Qualitiative Research
systemic collection and analysis of narrative data
What is health literacy?
the ability to obtain, read, understand, and act on health information
what is Pedagogy learning
the academic discipline that deals with the theory and practice of teaching and how these influence student learning
A new nurse asks the preceptor why a change-of-shift report is important since care is documented in the chart. What is the preceptor's best response? a. "A hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care." b. "A change-of-shift report provides the oncoming nurse with data to help set priorities and establish reimbursement costs." c. "A hand-off report provides an opportunity for the oncoming nurse to ask questions and determine research priorities." d. "A change-of-shift report provides important information to caregivers and develops relationships within the health care team."
A= hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care."
An older adult female client who is recovering from a stroke is scheduled to be transferred to the rehabilitation unit in the morning. She is tearful and verbalizes that she feels lonely and abandoned in the hospital unit. The nurse noticed that family visits daily and that there are flowers and cards in the room. Documentation in the chart indicates that the client's pastor has been by twice in the past week to visit. Which nursing diagnosis and outcome criteria need to be addressed immediately for this client?
Ineffective Coping; verbalizes support systems.
Does body surface play a role in absorption?
YES- EX: smaller body might need change in the dosage (smaller dose)
Whats Cognitive learning/what does it include?
involves the storing and recalling of new knowledge in the brain (e.g., the patient describes how salt intake affects blood pressure). Cognitive learning includes intellectual behaviors such as the acquisition of knowledge, comprehension, application (using abstract ideas in concrete situations), analysis (relating ideas in an organized way), synthesis (assimilating parts of information as a whole), and evaluation (judging the worth of a body of information).
Whats a prescription ?
meds they can take when they leave hospital
rate for oral administration?
more time due to passage through the G.I. tract (book states the longest time)
What are some health literacy skills?
performing Internet searches, reading health prevention pamphlets, measuring medication doses, and understanding and complying with verbal or written health care instructions
which fields deal w/ qualitiative research
psych, anthro,sociology, hospice (lived experience of P.T) NOT NUMERICAL
what can touch be influenced by?
religion, age, sex, class, culture
What should nursing practice be based on?
research, including agencies policies/procedures
A nurse evaluates whether a middle-age client with chronic back pain has been performing the different exercises and physiotherapy procedures recommended by the physician. What would the nurse most likely use to evaluate the client?
return demonstration
the nurse has performed a romberg test in the context of a clients neuro assessment. the client has failed the test. the nurse should consequently identify what nursing diagnosis?
risk for falls
What does "S" stand for in SBAR
situation, state the prob to the point. include ID self, P.t name, room, admiting DX & date. brief and to the point statement of your concern
what does enteric coating of a PO drug do?
slows the ability of the drug to dissolve
normal lung sounds when assessing sound like ?
soft, low pitched sounds over base of lungs during inspiration
which respiratory sound indicated an upper airway obstruction?
stridor