Basic Care & Comfort Flashcards
What intervention can and should always be done to aid in the prevention of falls for all hospitalized clients?
Putting the bed in the lowest position
Putting the bed in the lowest position ensures that if the client does leave the bed or fall, he or she will be falling the smallest distance. Other activities such as ensuring as many side rails as necessary are up are also important. However, if all four side rails are raised, the client can sustain a greater injury if he or she climbs over the side rail and falls from a higher elevation.
What is the “Get Up and Go” test?
This is a limited test to determine a client’s mobility/ambulation and risk for falls
The client is timed while rising from a chair, walking 10 ft, and returning to sit in the chair. The ideal test result is < 10 seconds.
Bedridden clients should have ___ applied to prevent venous stasis & venous insufficiency
sequential devices (SCDs)
SCDs increase blood flow in the lower legs. When clients are bedridden, blood flow can become static * place the client at risk for venous insufficiency, leading to higher risk for ulcers & deep vein thrombosis. SCDs should be removed for routine skin assessments.
How often should immobile clients be repositioned?
Q2H
Immobile clients should be repositioned every 2 hours to prevent skin breakdown
When educating a client regarding the use of crutches, the LPN should instruct the client to keep his or her elbows ___.
bent (at a slight angle)
When using crutches, the elbow should be slightly bent & the hands should have a firm grip on the handles.
What is the potential risk of putting pressure on the armpit when using crutches?
nerve compression and/or damage
If the crutches are too high, the client may put excessive pressure on the axilla and/or all of his or her weight on the top padding of the crutches. This can cause nerve compression and/or damage. Axillary nerve damage can lead to potential paralysis, loss of feeling, or loss of movement in the arm
Checking a feeding tube’s ___ is the most accurate bedside method to confirm the position of the feeding tube.
graduation/measurement marks
Confirming the tube placement at the bedside can be done by checking the tube graduation/measurement marks. If the tube is at a different graduation point, the tube may not be in the correct position, & the care team should be notified. Other bedside methods of confirming tube placement, like air auscultation or gastric residual testing, are not as accurate. Obtaining an x-ray to confirm tube placement is the gold standard if there is any doubt, but this is not a routine method or commonly performed at bedside.
What is the difference between an NG tube, a G-tube, and a J-tube?
An NG tube is inserted through the nares & ends in the stomach,. A G-tube, or gastrostomy tube, is inserted through the skin into the stomach. A PEG tube is a type of G-tube. A J-tube is inserted through the skin into the jejunum.
An NG tube is usually used for short-term purposes * G-tubes & J-tubes may be used long-term. A J-tube may be indicated in clients who have previously undergone gastric surgery or who have impaired gastric motility.
A nasogastric (NG) tube is used for ___ feedings.
enteral
Enteral feedings are given through the GI tract. A nasogastric (NG) tube delivers the feeding directly into the stomach to be absorbed. Parenteral feedings are delivered into the venous system through an IV line, typically a central venousl line.
What is the most appropriate pain scale for a pediatric client between the ages of 3 & 7?
the Wong-Baker Faces scale
Self-reporting is the most accurate method of assessing pain, but for pediatric clients, this can be challenging. The Wong-Baker Faces scales uses a visual scale that can assist the client in describing their level of pain
In the first hours after a bone fracture, is hot or cold treatment more appropriate?
cold treatment
After a bone fracture, a cold treatment such as an ice pack can reduce swelling & cause vasoconstriction. On the contrary, hot treatments cause vasodilation & are contraindicated in the first hours after a bone fracture.
For what disease or condition is any hot/cold treatment contraindicated?
any condition with impaired circulation
For an condition with impaired circulation, such as diabetes or peripheral vascular disease, a hot or cold treatment should not be used as the client would be unable to report pain that could indicate an injury from the treatment, such as a burn.
What is the difference, if any, between palliative care and end-of-life or hospice care?
A patent can receive palliative care while still receiving treatment for the underlying disease.
While both palliative care and end-of-life or hospice care focus on client comfort & quality of life, palliative care can coincide with curative treatments. It is often confused with end-of-life or hospice care, which occurs after the client has stopped receiving curative treatments.
Why is testing skin turgor less effective in elderly clients?
Skin loses elasticity with age.
When testing skin turgor, the skin is pinched & released, & the nurse assesses how quickly the skin returns to its original position. However, elderly clients may have less elastic skin, so their skin turgor tests may not be as accurate.
The LPN begins to irrigate a client’s wound. The LPN knows to start with the ___ part of the wound and end with the ___ part.
cleanest; dirtiest
Ensuring the irrigation flows from clean to dirty prevents contamination of the cleaner parts of the wound form the germs & bacteria in the dirty/infected party of the wound.
