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NURS 201 > Clinical Competency Evaluation 1 > Flashcards

Clinical Competency Evaluation 1 Flashcards

1
Q

how long must you wash your hands?

A

15 - 20 seconds

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2
Q

where on the hands should we pay attention to? –wash thoroughly

A
  • under the finger nails
  • fingertips
  • palms
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3
Q

when do we wash our hands?

A
  • before and after changing patients
  • if ever unsure of transmission or contamination of the hands
  • in contact with patients with C. diff
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4
Q

is hand sanitizer completely reliable?

A
  • helpful and useful to use; but handwashing is much more guaranteed
  • cannot remove all germs
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5
Q

when do we use Personal Protective Equipment (PPE)?

A
  • used for isolation patients
  • used for airborne precautions (such as TB, COVID-19) **need use of an N95 mask
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6
Q

what is the order of PUTTING ON PPE?

A
  • hand hygiene
  • gown
  • mask *N95 if needed
  • goggles/face shield
  • gloves *gloves over cuffs
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7
Q

what is the order of REMOVING PPE?

A
  • gloves
  • gown
  • eye protection
  • mask
  • hand hygiene

*can also BREAKAWAY the gown - breaking it away from you & pulled over head
* use of gloves to remove arms of gown
- mask/face protection
- hand hygiene

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8
Q

what equipment is needed when making a bed?

A
  • fitted sheet
  • flat sheet
  • pillow cases
  • draw sheet
  • chux
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9
Q

describe simply the procedure of bedmaking (occupied)

A
  • bed should be RAISED UP
  • helpful to have a PARTNER; can help move the patient
  • patient is rolled to the side; removal of FITTED SHEET FIRST (cigar rolled under patient)
  • placement of NEW FITTED SHEET + DRAW SHEET + CHUX (cigar rolled as well under the dirty linen)
  • patient is ROLLED TO OTHER SIDE & removal of dirty linen / placement of new clean linen on the other side
  • look and fix wrinkles/tubes under patient
  • remove dirty linen and put into cart
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10
Q

what equipment is needed for a bed bath?

A
  • basin
  • soap
  • wash cloths
  • towels
  • bath blanket
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11
Q

important things to remember when doing a bed bath

A
  • ensure privacy for patient (only exposing what is to be cleaned)
  • observing fall risk or any adverse complications with giving bed bath
  • INFORM the patient you will be giving a bed bath
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12
Q

what equipment is needed for washing the hair?

A
  • basin
  • soap
  • shampoo cap
  • towel
  • comb
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13
Q

important things to remember when doing washing patient’s hair

A
  • follow shampoo cap’s instructions
  • no cap X - get help of partner to lay patient head on top of bed - wash over basin
  • wear gown and equipment when dealing with lice
  • washing from SCALP to END
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14
Q

what equipment is needed when utilizing a glucometer?

A
  • glucometer
  • testing strips
  • lancet
  • alcohol wipes
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15
Q

describe simply the procedure of using a glucometer

A
  • INFORM PATIENT about what is being done
  • hand hygiene / gloves
  • turn on machine
  • scan badge, patient, & strip vial
  • collect & prick finger
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16
Q

describe WHERE & WHY we prick the finger

A
  • must prick at the SIDE OF THE FINGERTIP - less innervated compared to the finger pad
  • must SQUEEZE & DEPLOY the lancet
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17
Q

de we measure the first drop of blood?

A

No, this is to be WIPED AWAY due to it having SEROUS FLUID – can cause incorrect results

  • squeeze the finger again; and UTILIZE THE NEXT DROP
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18
Q

what are the SIX RIGHTS of DRUG ADMINISTRATION?

A
  • right patient
  • right medication
  • right dosage
  • right time
  • right route
  • right reason
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19
Q

How can we AVOID/PREVENT MEDICATION ERRORS?

A
  • make sure when prepping meds you are UNINTERRUPTED
  • always READING BACK VERBAL/TELEPHONE ORDERS to verify
  • understand WHY the patient is giving medication
    what does this med do?
    what are its side effects?
    is my patient in danger if i give this med?
    what must be educated?
  • KNOW THE ALLERGIES of patient
  • prepping meds for a single patient at a time
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20
Q

what medication can we NOT crush?

A
  • enteric coated meds
  • long-acting meds
  • time-released meds
    **make sure to ALWAYS CRUSH COMPLETELY if need be; esp. through catheter
21
Q

what are some precautions that must be done before giving ORAL MEDS?

A
  • observe and ask if patient can SWALLOW
  • observe the risk for ASPIRATION
  • patient must be in a SIT-UP POSITION
  • always document AFTER MED is GIVEN
  • ask for any allergies
  • crushed meds - mixed with applesauce/pudding
  • NEVER crush chemotherapy medications
  • always give BUCCAL or SUBLING last
22
Q

what are the THREE CHECKS that must be done before ADMINISTERING MEDS?

A
  • FIRST CHECK
    at the MAR
  • SECOND CHECK
    at the bedside
  • THIRD CHECK
    before giving medication
    *scan patient & scan medication
23
Q

describe the medication; KEFLEX (CEPHALEXIN)

A
  • type of antibiotic medication
  • help to treat bacterial infections
24
Q

describe the medication; METROPROLOL

A
  • used to help treat blood pressure
  • can make patient tired or dizzy - CAUTION & WARN
25
Q

can a patient refuse the medication?

A

Yes, patients can refuse to take medications
- make sure to let their HCP know + document

26
Q

what happens if we need to score a tablet?

A
  • make sure to score at the indicated area
  • if no line indicated, ask the pharmacy to split
27
Q

how to administer rectal medication?

A
  • utilization of MEDICATION & LUBRICANT
  • allow patient to relax in order for anal sphincter to relax
  • turn patient on their LEFT LATERAL SIDE
27
Q

what must you do ALWAYS before administering any type of medication?

A
  • use proper hand hygiene & gloves as needed
  • utilize the SIX RIGHTS of MED ADMIN
27
Q

how to administer ear medication?

A
  • patient turns head to opposite side; AFFECTED EAR UP
  • PULL EAR UP & BACK; CHILDREN >3 / ADULTS
  • PULL EAR OWN & BACK;
    CHILDREN <3
  • gently massage after/ left on side for a couple of minutes
28
Q

what to remember when administering IM injections?

A
  • don’t use a bruised site, indurated, or areas of infection/muscular atrophy
  • use a needle long enough to go through muscle, but not bone
  • use a 90 DEGREE ANGLE
29
Q

what to remember when administering INTRADURAL INJECTIONS?

A
  • BEVEL IS ALWAYS UP
  • looking at a BUMP-LIKE/BLISTER-LIKE shot known as a WEAL/BLEB
  • often use a TB syringe/ 1 mL syringe
30
Q

what to remember during insulin shots?

A
  • careful looking at the UNITS
  • insulin syringe - typically ORANGE
  • ALWAYS CLEAR (REGULAR) OVER CLOUDY (NPH)
  • CANNOT MIX LONG-LASTING INSULIN; can mix either short or rapid insulin + intermediate insulin
  • double check & verify with second nurse
31
Q

how to mix insulin?

A

between NPH & REGULAR;

  • INJECT AIR INTO NPH FIRST
  • followed by INJECTING AIR INTO REGULAR
  • followed by WITHDRAWING REGULAR INSULIN
  • followed by WITHDRAWING NPH INSULIN

**make sure to wipe vials with alcohol wipes

= TOTAL DOSE OF MIXED INSULIN

32
Q

when do we administer insulin?

A
  • looking at high blood sugar rises
    (can be due to stress, use of steroids, etc…)
  • must be given before meals / before bedtime **MUST EAT WITHIN 30 MIN
  • testing can occur no more than 30 min after eating
33
Q

what to look for during WOUND ASSESSMENT?

A
  • saturation
  • moisture; any EXUDATE
  • odor
  • texture
34
Q

what is observed in PRESSURE ULCERS?

A
  • amount of tissue loss
  • intact skin
  • granulation tissue
  • slough
  • necrotic tissue
35
Q

what are the FOUR STAGES OF PRESSURE WOUNDS?

A

STAGE ONE:
- intact skin
- nonblanchable erythema
STAGE TWO:
- partial-thickness skin loss
- exposed dermis
- pink/red moist
STAGE THREE:
- full-thickness loss
- visible adipose + granulation tissue
STAGE FOUR:
- full-thickness loss + tissue loss
- visible muscle tendons + ligaments + bone + tunneling
- slough or eschar

36
Q

describe an UNSTAGEABLE PRESSURE INJURY

A
  • have OBSURED FULL-THICKNESS SKIN and TISSUE LOSS
  • obscured by slough or eschar
37
Q

describe a DEEP-TISSUE PRESSURE INJURY

A
  • often has intact/nonintact skin
  • have a NONBLANCHABLE DEEP RED/MARRON DISCOLORATION
38
Q

what are the two types of debridement?

A
  • CHEMICAL BASED
  • SURGICAL DEBRIDEMENT
39
Q

describe the WET-TO-DRY PROCEDURE

A
  1. do prior MEASUREMENTS with KISS TOOL/indication of tunneling locations
  2. Open up GAUZE/wringed out with saline solution
  3. beginning to push gauze into tunnels/outer ridge
  4. Count the # of gauze used
  5. Dry gauze pad on top
  6. followed by thicker ABD pad
  7. Apply and write date, time, initials on top of dressing
40
Q

what consults can nurses advise?

A
  • diet consult
  • speech consult
41
Q

what type of feeding tubes do we have?

A
  • BASIC BIG TUBE / REGULAR NG TUBE
  • DOPATH TUBE
42
Q

important reminders when applying NG TUBE

A
  • check for bowel sounds within the stomach
  • prime the feeding tube
  • double check LOPEZ VALVE POSITIONS when checking for bowel sounds/inserting or removing any tubes
  • must FLUSH MEDICATION
43
Q

what solutions do we NOT use when irrigating a wound? Why?

A
  • CYTOTOXIC SOLUTIONS
  • HYDROGEN PEROXIDE
  • ACETIC ACID
  • SODIUM HYPOCHLORITE SOLUTION

these solutions can be damaging and even kill healthy tissue/healing tissue

44
Q

do we irrigate the wound when there is active bleeding?

A

no

45
Q

how can we take ASPIRATION PRECAUTIONS?

A
  • can do a bedside swallowing test
  • assessment of level of consciousness for the patient
  • identifying obstructions or medications that can cause side effects
    -putting patient up as much as possible on HOB
  • consultation of speech
46
Q

How do we evaluate SILENT ASPIRATION?

A

use of PULSE OXIMETRY to identify aspiration diagnosis; drop in saturation (2% or more)

NURS 201 (3 decks)

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