delegation/prioritization Flashcards
IV medications LPN information
LPN can give ivy piggyback: secondary IV medications without assistance.
but there are many primary bags they cannot run without assistance
can LPN administer blood products, chemo meds
no absolutely not
LPN cannot administer blood products or chemo meds.
can uaps remove peripheral IV lines
yes, they can remove peripheral IV lines, for ex: if the client needs to go to the bathroom
but they cannot disconnect IV’s
risk for falls
age
alzeihmers disease, delirium, memory problems
incontinence, not being able to control one’s bladder: trying to get to the bathroom wet
recent hip surgery: decreases range of motion
risk for impaired skin integrity/pressure ulcer
Braden scale score of 18 or less, indicates risk of pressure injury
range from 6 - 23
the lower the score, the higher the risk
older age = higher risk of pressure injury
recent hip surgery = might have issues w/ mobility
non-blanchable redness (not stage 1 yet but at risk of progressing)
alzeihmers (memory problems): also at risk, clients unaware that they’re wet.
incontinence: wetness and soiling makes skin break down more easily
does lifts reduce risk for falls
yes, the use of assistive devices like canes, walkers, lifts, wheelchair, ambulation belts
is it good to put furtnitures all over the house so that the elderly can grab on so that they don’t fall?
no it is not. the house should be clear of clutter. furnitures in place to grab on is not safe, using assistive devices like lifts to get up, belt, cane, walkers, crutches are better.
electric cords should be against the wall behind the furniture, or in a safe place.
first thing to do when a pneumonia patient is in distress and has restraint to receive medicatons
vital signs b/c pneumonia can cause resp distress. check their vitals and perform appropriate interventions for the o2 stat.
Can RN assign LPN to monitor vitals during a blood transfusion and monitoring clients bowel sounds
yes most likely rn would have already taken the first set of vitals. LPN can monitor vitals and will be reporting to rn
LPN can monitor bowel sounds (but not do the initial assessment), they can listen to lung sounds, etc…
what to do first
rn gave saline instead of opiods cause the opiods med is not due yet
should rn report incident and let RN manager know first
or
should rn notify healthcare provider about the client uncontrolled pain first
1: assessing the client’s needs before any documentation
the client is in pain, that needs to be assess first.
rn manager don’t work as rn, so they would not participate in the client care in that sense, but the provider is responsible for that, as well as the charge rn
which needs to be monitor first
client needs schedule dose for aspirin after an MI (st elevation) 2 days ago
or
client receiving parenteral nutrition
client receiving parenteral nutrition b/c if u receive parenteral nutrition it means you can’t tolerate enteral feeding or po feedings or have gi disruption. and TPN put clients at risk of hyperglycemia which can cause coma or even death.
the medication can be given 1hr later and it will still be fine, its not immediate
rn should monitor for polyuria, polydipsia, headache, blurred vision
bruising behind the ears
this indicates a basilar skull fracture and needs immediate intervention, more impt than a peds client who’s vomiting even after eating. b/c if they eat that sitill good but they need antiemeics and possibly antibiotics. but the bruising behind the ear indicates intracranial injury
periorbital hematoma (raccoon eyes) are s/s
seizure precautions
what to do during an active seizure or what to make sure of
during a seizure
dim the light if needed (bright light can trigger seizure)
ensure side rails are padded
ensure oxygen and suction is at the bedside
remove things next to client that could cause injury
stay with the client
CUSHION THEIR HEAD (put a small pillow/towel/folded blankets on their head to prevent injury)
note time of seizure
remove clothing that may be restriceed, specially from the neck
make sure client is on the floor, place pillow under them
monitor airways, administer oxygen as needed (if you see sign of cyanosis or respiratory distress**
do not place anything in their mouth (no foods, no liquids, no nothing)
possible interventions for a blood clot (dvt or pulmonary embolism) true or false, may have multiple answers
compression devices
thrombolytics
both are true, ans: was wrong on this one.
thrombolytics
compression stockings: can help reduce swelling in a dvt patient, but they are better to prevent clots. they cannot dislodge a clot
people with artery disease should avoid compression stocking
is contrast contraindicated w/ kidney disease
yes
no contrast with kidney disease or high creatnine
HPV
do you get the vaccine if you’re not sexually active?
can warts come back after treatment
- do pap smear if you’re >21, regardless of prior sexual activity
- the HPV vaccine works the most for virgins, but people who are sexually active may still benefit from it
- warts may come back even after treatment (remember, be on the safe side on the nclex)
Zika can cause birth defects, pregnant women should stay away
radiation, including brachytherapy not good for pregnant women and children, stay away
pregnant women should avoid caring for clients w/ herpes zoster (or torch infections) in general
what should you prioritize prior to thrombolytic therapy
best time 3 - 4.5hrs
after 4hrs there’s no evidence that it is beneficial
some studies say up to 6hrs but symptoms within past 6hrs would be inutile and contraindicated
-surgery within 14 days: contraindicated, inc. risk of bleeding
dvt or venous thromboembolism precautions
-don’t put pillows under knees that can compress knees
-elevate legs at heart level
-wear compression stockings
-take anticoagulants
frequent ambulation
how many gloves is 2 pairs of gloves
2 pairs of gloves = 4 gloves and is a myth that 2 pairs of gloves is more effective. a single pair of gloves is enough
if a patient has substernal chest pain, what can you do?
administer nitroglycerin
administer aspirin (antiplatelet, anticlot)
ecg 12 lead
give oxygen as needed
obtain blood specimen to check cardiac enzyme, to see if troponin is high
pt with dementia who is confused and disoriented, can a LPN/lvn care for that patient
a patient taking amitriptyline who is grimacing, what about that pt?
yes b/c confusion and disorientation is expected in a dementia patient
amitryptline is an antidepressant that can cause tardive dyskinesia, this pt is not stable and the rn has to take care
peak flow rate for ashtma:
use highest score, not average
they can do 3x while waiting 30 sec after each
blow as hard as quickly as you can
dyspnea is a priority over fever/child with a catheter (indicates urosepsis)
dyspnea part of abc, a for airway
parkinsons’s disease
what is a symptom to pay attention to?
dysphagia or difficulty swallowing. implement aspiration precautions.
also mnemonic is trap
T: tremor
R: rigidity
A: akinesia (absence of muscle control), ataxia: poor muscle control
P: posture instability
ischemic stroke or possible ischemic stroke order
- gen assessment & stabilization
- Neuro assessment by stroke team
- obtain CT scan
- tpa if it is ischemic stroke (tpa within 3-4.5 hours of entry to hospital, past 6hrs is contraindicated)
chest tube what’s normal, what’s not?
tidaling in the water seal chamber
bubbling in the water seal chamber
continuous bubbling in the suction chamber
tidaling in the water seal chamber is normal, it indicates up and down mvt in the water seal chamber. inc. w/ inspiration & Dec. with expiration.
no tidaling means that an obstruction is present or lungs have re-expanded.
tidaling is not expected in the suction chamber or drainage system.
serosanguineous fluid is expected in the drainage system. 100ml/hr. but red drainage cannot exceed more than 70ml/hr
bubbling in the water seal is ok, but it shouldn’t be continuous, that indicates leak.
continuous bubbling in the suction chamber is normal
pleurisy define
s/s
interventions
pleurisy means inflammation of the pleural cavity
may be caused by bacterial, viral, or pulmonery edema, etc..
treatments is based on the cause of the pleurisy.
if bacteria: antibiotics
if virals: antivirals
if just swollen: anti-inflammatories
s/s: cough, chest pain
afib
irregular heart rhytm, diagnosed by ekg
new onset afib (means newly diagnosed w/ afib)
that new onset afib pt develops chest pain: could indicate MI. if chest pain was already present ok, but anything new onset requires follow up.
more priority over a diabetes patient with infection
clients has speech and balance defects: needs a home health care that can help w/ adls
speech therapist can only help w/ speech and won’t be able to address balance
physical therapist can address balance
sata question: speech t, pt, hha
