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Adult Health Nursing I > Clinical Exam > Flashcards

Clinical Exam Flashcards

1
Q

RACE

A

Rescue
Alarm
Confine the blaze
Extinguish or evaporate

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2
Q

PASS

A

Pull
Aim
Squeeze
Sweep

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3
Q

Class A Fires

A

Wood, paper, cloth, rubber, plastics

Prevented by simple housekeeping

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4
Q

Class B Fires

A

Gases, liquids

Prevented by storing combustible liquids and gases in specific areas away from heat sources

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5
Q

Class C Fires

A

Appliances, air conditioning, heating units, motors, generators

Most common fires in health care

Equipment should be kept clean and maintained properly, extension cords should not exceed 6 feet

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6
Q

Class D Fires

A

Certain metals

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7
Q

Licensure

A

The process of granting permission to a person to engage in a specific occupation

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8
Q

Standards of Care

A

The average degree of skill, care, and diligence exercised by members of the same profession under the same or similar circumstances

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9
Q

Negligence

A

When the standards of care are not met

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10
Q

Gross Negligence

A

Intentional disregard

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11
Q

Malpractice

A

A specific type of professional negligence that occurs when the standard of care that can be reasonably expected is not met

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12
Q

Ethics

A

Rightness or wrongness of an action

Goal is to ensure that individual’s rights are protected

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13
Q

Ethical Dilemma

A

Situation that requires a choice between two equally unfavorable alternatives

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14
Q

Five Step Process Tool for Helping with Ethical Dilemmas

A
  1. Collect, analyze, and interpret the data
  2. State the dilemma
  3. Consider the choices of action
  4. Analyze the advantages and disadvantages of each course of action
  5. Make the decision
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15
Q

Code of Ethics

A

A written list of a professional’s values and standards

Framework to help us make decisions

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16
Q

Identify areas of the “patient care partnership”

A 
High quality hospital care
Clean and safe environment
Involvement in your care
Protection of your privacy
Help when leaving hospital
Help with your billing claims
Discuss treatment choices
Discuss treatment plan
Provide information about health
Understanding health care goals and values
Understanding who should make decisions
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17
Q

Nursing Liability

A

Can lead to civil judgment, criminal penalties, imprisonment, restrictions on license

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18
Q

Nurse Practice Act

A

Specific statute from the state that defines and regulates nursing practice

Most important legal statute

Safeguards the patients

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19
Q

EMTALA

A

Emergency Medical Treatment and Active Labor Act

Requires that each facility provides appropriate medical screening within their ability

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20
Q

Patient cannot be transferred unless:

A
  1. They have had appropriate medical screening
  2. They have been stabilized
  3. The other facility has been called
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21
Q

Reporting Duties for Health Care Professionals

A 
Child abuse
Elder abuse
Communicable diseases
Impaired peers
EMTALA violations
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22
Q

Tort

A

A wrongful act committed by one person against another person

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23
Q

Scope of Practice

A

Determined by Nurse Practice
Act

Defines and limits the scope of nursing practice

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24
Q

Common Types of Patient Incidents

A

Falls
Restraints
Burns
Medication Errors

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25
Q

Policy

A

Directive or regulation

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26
Q

Procedure

A

A way of doing something

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27
Q

Describe the purposes for client records

A

Planning client care, communication, legal documentation, reimbursement, quality assurance monitoring, research, education, accreditation and licensing, statistics

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28
Q

SOAP

A

Subjective, Objective, Assessment, Plan

Used in prisons

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29
Q

SOAPIER

A

Subjective, Objective, Assessment, Plan, Implementation, Evaluation, Revision

30
Q

APIE

A

Assessment, Plan, Implementation/Intervention, Evaluation

31
Q

PIE

A

Problem, Intervention, Evaluation

32
Q

DAR

A

Data, Action (nursing), Response (client)

33
Q

FACT

A

Factual, Accurate, Consistent and Complete, Timely

34
Q

SBAR

A

Situation, Background, Assessment, Recommendation

35
Q

Discuss teaching as a major nursing responsibility

A

Teaching improves patient’s health and well-being, is the right of the patient

36
Q

Variables that affect learning abilities

A

Culture, values, physical readiness, emotional readiness, experiential readiness

37
Q

Specific patient factors that affect learning abilities

A

Disability, hearing impairment, visual impairment

38
Q

Gerontological Considerations with Learning Abilities

A

Decreased short term memory, concentration, slow reaction time

Decreased visual acuity

Decreased hearing

39
Q

Methods of preparing for formal and informal clinical teaching situations

A 
Lecture
Group teaching
Demonstration and practice
Teaching aids
Reinforcement and follow-up
40
Q

Why is SBAR needed?

A

Poor communication leads to errors

41
Q

Situation

A

What is happening at the present time?

Patient name and room number

Patient problem or concern

Why was this patient admitted?

42
Q

Background

A

What are the circumstances leading up to this situation?

Admit date, surgical day, current medications, lab results, other clinical information

43
Q

Assessment

A

What you found, what you think

Pertinent objective and subjective data

Assessment of the current situation

44
Q

Recommendation

A

What do you want?

Include things that need to be done

45
Q

Hepatitis B

A

1/3 experience no symptoms, 1/3 experience flu-like symptoms, 1/3 experience clinical symptoms of HBV

46
Q

Prevention of Hepatitis B

A

Universal precautions must be observed

Standard precautions apply to blood, nonintact skin, mucous membranes

Blood is the most common source of infection

47
Q

Preoperative Phase

A

Begins when decision is made to have surgery and ends when patient is on the operating table

48
Q

Assessment During Preoperative Phase

A

Health history, physical assessment, medications/herbal supplements/drug use, allergies, alcohol, teeth

Identify health issues that could put a patient at higher risks for complications (COPD)

49
Q

Informed Consent

A

Means that the patient has been told what the procedure involves, the risks and benefits, potential complications, alternative treatments available

Needed for any surgical and/or invasive procedure

50
Q

Preoperative Teaching

A

Deep breathing and coughing, incentive spirometer, splinting

Turning and moving, exercises, ambulating early

Pain control, pain scale

51
Q

Preoperative Nursing Interventions

A

Maintain patient safety

Make sure patient follows NPO orders

Bowel preparation, skin preparation

Helping with preoperative anxiety

52
Q

Nursing Interventions Immediately Prior to Surgery

A

Remove all jewelry, hair accessories, glasses, dentures, contacts, etc.

Baseline vitals, labs, assessment documentation, physician’s H&P

Verify patient, procedure, and site

Preanesthetic medications

53
Q

Intraoperative Phase

A

Consists of the entire time the patient is on the operating table

54
Q

Surgical Team

A

Consists of circulating nurse, scrub nurse/tech, surgeon and assistants, and anesthesiologist

55
Q

Circulating Nurse

A

Helps with getting patient positioned, does further skin preparation, monitors the patient, does all of the documentation, keeps track of time

56
Q

Scrub Nurse

A

Provides sterilized tools to the physician

57
Q

Unrestricted Area

A

Area you can go in your street clothes

58
Q

Semi-Restricted Area

A

Need to be dressed in surgical scrubs

59
Q

Restricted Area

A

Must be in full surgical garb

60
Q

General Anesthesia

A

IV, inhalational-volatile gases

Patient becomes fully unresponsive

61
Q

Regional Anesthesia

A

Epidural, spinal, local conduction blocks

62
Q

Moderate Sedation

A

“Conscious sedation”

Makes patient loopy but able to follow commands

Amnesia afterwards

63
Q

Complications of Anesthesia

A

Anesthesia awareness (need to monitor vital signs)

Nausea and vomiting

Anaphylaxis

Hypothermia

Malignant hyperthermia

64
Q

Postoperative Phase

A

Starts when patient is off operating table and continues until the last follow-up visit

Receive the patient from OR and get their report

Obtain baseline assessment

Reassess every 5-10 minutes

65
Q

Prevention of Postoperative Complications

A

Prevent atelectasis and pneumonia –> make sure patient is deep breathing and coughing

Prevent DVT –> TED hose, ACE wrap, sequential compression devices, LMWH

Assess surgical site and dressing

Watch for hemorrhage

Assess bowel sounds (do not give anything by mouth until you hear bowel sounds)

66
Q

Outpatient Surgery Discharge

A

Provide written and verbal instructions

Discuss actions to take if complications occur

Patients are not to drive home or be discharged to home alone

67
Q

Charting

A

Use facts only, do not summarize, never assign blame

Care plans facilitate the continuity of care

68
Q

Chain of Notification

A

Student should report concerns to clinical instructor (if present), the clinical preceptor, or designated staff person

Then they will contact the unit supervisor (if necessary), and then the physician

69
Q

Hourly Rounding

A

“I’m here to round on you.”

Explanation

Discuss Pain, Potty, Position, and Possessions

Conduct and Environmental Assessment

Explain Clinical Hourly Rounding Log

Close the Round

70
Q

Normal Fasting Blood Glucose

A

Less than 100 is considered normal

100 to 125 is considered prediabetes

126 or higher on two test is diabetes

Adult Health Nursing I (22 decks)

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