exam 2

Question 1

What the clinical judgement model is not…

Answer 1

-The nursing process, instead it aims to help the nurse apply the nursing process to patient care
-Diagnose or use NANDA diagnosis
-A theory but a way of processing information

Question 2

Clinical judgement model?

Answer 2

-Recognize cues
-Analyze cues
-Prioritize hypotheses
-Generate solution/ expected outcomes
-Take action/ interventions
-Evaluate outcomes

Question 3

why does clinical judgement work?

Answer 3

-By following this model you become a self-directed thinker
-You don’t need a set nursing diagnosis to tell you how to analyze the data, you can do this yourself by applying all the content you have learned to situation you are in

Question 4

what is step 1 of clinical judgement?

Answer 4

recognize cues: gathering data phase, validate information, vital signs, scanning your environment

Question 5

why can we not believe report at face value?

Answer 5

many things are passed nurse to nurse, and not validated, changes no one has seen, always check your orders, new lab values, bias, patient can change in minutes

Question 6

step 2 of clinical judgement?

Answer 6

analyzing cues: cluster data in groups, distinguish relevant and irrelevant data, label each group

Question 7

step 3 of clinical judgement?

Answer 7

prioritize: which is more important, always pick airway, breathing, and circulation first, judgement call after ABCs

Question 8

step 4 of clinical judgement?

Answer 8

generate outcomes/solutions: providing quality patient care to improve patient, create solutions, timeframe, must be appropriate for nurse, scope of practice

Question 9

step 5 of clinical judgement?

Answer 9

interventions: how do you plan to accomplish a goal, assessing patient, tasks, teaching

Question 10

step 6 of clinical judgement?

Answer 10

evaluate: early and often, reduce healthcare errors, include assessment, state improving, unchanged, suggest modification

Question 11

drug nomenclature

Answer 11

chemical name, generic name, official name, trade name

Question 12

Drug classification?

Answer 12

-Drugs are classified by their effect on the body, chemical composition, clinical indication, or therapeutic action
-Two primary classifications: pharmaceutical class and therapeutic class

Question 13

six rights of medication administration?

Answer 13

right client, medication, dose, route, time, and documentation

Question 14

additional patient rights related to medication administration?

Answer 14

right to refuse, right assessment, right education, right response/evaluation

Question 15

Additional safety strategies for medication administration:

Answer 15

Checking the medication against the MAR and dispensing device, checking the drug once prepared, checking the drug again prior to administration

Question 16

medication reconciliation?

Answer 16

preformed every time the patient is transferred from one healthcare professional to another (readmissions or transfer within hospital)

Question 17

pharamcodynamics:

Answer 17

study of how a drug effects the body

Question 18

Therapeutic actions: medications

Answer 18

-Drugs turn on, off, promote, or block responses that are part of body’s processes
-Drug receptor interaction ?
-Drugs can also combine with other molecules to achieve their effect
-Other drugs act on cell membranes or alter the cell environment to achieve their effect

Question 19

Factors affecting drug action:

Answer 19

developmental, weight, gender, cultural/ genetic, psychological, pathology, environment, timing of admin.

Question 20

Therapeutic range:

Answer 20

concentration of drug in the blood serum that produces the desired effect without causing toxicity

Question 21

Half-life:

Answer 21

amount of time it takes for 50% of blood concentration of a drug to be eliminated from the body

Question 22

Peak plasma level:

Answer 22

when a drug is at its highest concentration, does not mean it is at its most therapeutic level

Question 23

Trough serum level:

Answer 23

the lowest levels of concentration of a medication that correlates to the rate of elimination

Question 24

Drug reactions:

Answer 24

side effects, allergic reactions, drug tolerance, toxic effect, idiosyncratic effect, drug interactions

Question 25

Serious adverse drug event (ADE):

Answer 25

life threatening reaction that requires medical intervention to prevent death or permanent disability

Question 26

Allergic reactions:

Answer 26

allergic or hypersensitivity, develops when body perceives a foreign substance as an allergen

Question 27

Pharmacokinetics:

Answer 27

study of ADME, of drugs in the human body, what the body does to the drug

Question 28

Absorption:

Answer 28

route of administration, lipid solubility, pH, blood flow, local conditions at site of admin., drug dosage

Question 29

Metabolism:

Answer 29

biotransformation is the process of converting a medication to a form that is easily excreted , liver is where most metabolized, kidneys and small intestine too

Question 30

Prodrugs:

Answer 30

inactive chemicals that are transformed through metabolism to become active before they have therapeutic effect

Question 31

First pass effect:

Answer 31

results in lower concentration of the meds in the systemic circulation

Question 32

Excretion:

Answer 32

process of removing drugs from the body, kidneys are primary organ responsible

Question 33

Teratogenesis:

Answer 33

known to cause fetal defects (ex. Anti-infectives)

Question 34

Medication order: a complete medication order should contain:

Answer 34

Patient name, date/time order written, drug name, dosage, route of administration, frequency, indication for use, provider name

Question 35

Identifying the patient

Answer 35

Checking the identification bracelet, validating the patients name, validating the patients identification number, MRN, and birthdate, comparing with the MAR, asking the patient to state their name

Question 36

Types of medication orders:

Answer 36

standing order-routine carried out until it is cancelled by another order, PRN order- as needed, single or one time order, STAT order- carried out immediately

Question 37

High-alert medications:

Answer 37

drugs that are associated with an increased risk of causing harm when administered error, insulin, opiates, narcotics, IV heparin, injectable KCI, to reduce the risk of harm is an independent double check with two nurses verifying the drug and order before administration (A PINCH)

Question 38

Oral medications:

Answer 38

-Solid form: tablets, capsules, pills -Liquid form: elixirs, spirits, suspensions, syrups -Oral route: having patient swallow drug -Enteral route: administering drug through enteral tube -Sublingual: placing drug under tongue -Buccal: placing drug between tongue and cheek

Question 39

Topical medications:

Answer 39

skin application, eye installation and irrigation, ear installation and irrigation, nasal installation, vaginal application, rectal instillation

Question 40

Parenteral medications:

Answer 40

-Subcutaneous injections: subcutaneous tissue -Intramuscular injection: intradermal injection: under epidermis -Intravenous injection: vein -Intra-arterial: artery -Intracardial injection: heart tissue -Intraperitoneal injection: peritoneal cavity -Intraspinal injection: spinal canal -Intraosseous injection: bone

Question 41

Sites of IM injections:

Answer 41

ventrogluteal, vastus lateralis, deltoid, dorsogluteal- not recommended

Question 42

Preparing medication for injection:

Answer 42

ampules, vials, prefilled cartridges or syringes, mixing medication in one syringe, mixing insulin in one syringe, reconstituting powdered medications

Question 43

Intradermal injections: 

Answer 43

-Administered into the dermis -Longest absorption time of all parenteral routes -Used for sensitivity tests and local anesthesia -Bodys reaction to substances is easily visible -Sites commonly used are inner surface of forearm, upper back, under scapula -¼" to ½" -25- or 27- gauge needle -Angle is 5-15 degrees -Dosage given intradermally is small, usually less than 0.5 ml

Question 44

Subcutaneous injections:

Answer 44

-Administered into adipose tissue layer just below epidermis and dermis -Sites used: Outer aspect of upper arm, Abdomen, Anterior aspects of thigh, Upper back, Upper ventral or Dorso gluteal area

Question 45

Intravenous administration:

Answer 45

-Delivers drug directly into bloodstream -Immediate effect and cannot be recalled or slowed -Route most often used in emergency situations

Question 46

time:

Answer 46

Time critical medications are those administered either 30 minutes after the scheduled time that can cause harm to the client or have less than desired effects

Question 47

Documentation:

Answer 47

-Scanning into eMAR- does not eliminate need to identify rights of administration -Name and dosage -Route and time -Name of person administering -Site used for injection -Location of topical or transdermal application -Nares, eyes, or ear used -Omitted drugs (intentional or inadvertent) -Refused drugs -Medication errors

Question 48

Types of medication errors:

Answer 48

-Inappropriate prescribing of the drug -Extra, omitted, or wrong doses -Administration of drug to wrong patient -Administration of drug by wrong route or rate -Failure to give medication within prescribed time -Incorrect preparation of drug -Improper technique when administering drug -Giving drug that has deteriorated

Question 49

Medication errors:

Answer 49

-Check patient's condition immediately -Observe for adverse effects -Notify provider -Notify nurse manager -Complete form used for reporting errors -Do you tell the patient? -Do you tell the family?

Question 50

patient teaching:

Answer 50

review, remind, instruct, discuss

Question 51

Formula method:

Answer 51

-used when calculating the same units of measure during drug calculation, volume or actual dose is calculated based on this formula, the dose equals the amount to be given (dose ordered x quantity/ available dose) -1 kilogram = 1000 grams -1 gram = 1000 milligrams -1 milligram = 1000 micrograms -1 liter = 1000 milters

Question 52

Role of skeletal system in movement

Answer 52

-Supports the soft tissues of the body -Protects crucial components of the body -Furnishes surfaces for the attachment of muscles, tendons, and ligaments -Provides storage areas for minerals and fat -Produces blood cells

Question 53

Freely moveable joints :

Answer 53

ball and socket, condyloid, gliding, hinge, pivot, saddle

Question 54

Bones classified by shape:

Answer 54

-Long bones: upper and lower extremities -Short bones: wrist and ankle -Flat bones: ribs and skull -Irregular bones: spinal column and jaw

Question 55

Joint movements:

Answer 55

Abduction, adduction, circumduction, flexion, extension, hyperextension, dorsiflexion, plantar flexion, rotation, internal rotation, external rotation, supination, pronation, inversion, eversion

Question 56

Three types of muscles and important functions of muscle:

Answer 56

-skeletal, cardiac, and smooth or visceral -motion, maintenance of posture, support, heat production

Question 57

Ergonomics:

Answer 57

practice of designing equipment and work tasks to confirm to the capability of the worker

Question 58

Factors influencing mobility:

Answer 58

Developmental considerations Physical health: muscular, skeletal, or nervous system problems, problems involving other body systems Mental health Lifestyle Attitude and values Fatigue and stress External factors

Question 59

Effects of immobility on the body

Answer 59

Cardiovascular system, respiratory system, musculoskeletal system, metabolic processes, GI system, urinary system, skin, psychosocial outlook

Question 60

Health history:

Answer 60

Daily activity level, endurance, exercise/fitness goals, mobility problems, physical or mental health alterations, external factors affecting mobility

Question 61

Proper body mechanics

Answer 61

Use of proper body movement in daily activities The prevention and correction of problems associated with posture The enhancement of coordination and endurance

Question 62

Equipment and assistive devices

Answer 62

Gait belts Stand-assist and repositioning aids Lateral-assist devices Friction-reducing sheets Mechanical lateral-assist devices Transfer chairs Powered stand-assist and repositioning lifts Powered full-body lifts

Question 63

Positioning patients :

Answer 63

Pillows, mattresses, adjustable beds, bed side rails, trapeze bar, additional equipment

Question 64

Protective :

Answer 64

Fowlers, supine or dorsal recumbent, side-lying or lateral position, sims position, prone position

Question 65

Physical conditioning:

Answer 65

quadriceps/ gluteal setting drills, push-ups, dangling

Question 66

mechanical aids for walking:

Answer 66

walker, cane, braces, crutches

Question 67

Developmental considerations

Answer 67

Neonate and infant: Fetal considerations, mobility, car seats Toddler and preschooler: Environment, poisoning, asphyxiation, child abuse School age: Accidents, child abduction, bullying Adolescent: Driving, substance use, misuse, abuse, piercings/tattoos, firearms, internet and social, sex trafficking Adult: Drug use and poisoning, intimate partner violence Older adults: Falls, motor vehicle accidents, fire, polypharmacy and poisoning, elder abuse

Question 68

Indications of a concussion

Answer 68

Physical: headache, vomiting, problems with balance, fatigue, dazed or stunned appearance Cognitive: mental foggy, difficulty concentrating and remembering, confusion, forgets recent activities Emotional: irritability, nervousness, very emotional behavior Sleep: drowsiness, difficulty falling asleep, sleeping more or less than usual

Question 69

Safety plan for victims of domestic abuse

Answer 69

Safety while living with an abusive partner Safety planning with children Safety planning for pets Safety planning during pregnancy Leaving a relationship

Question 70

Patient environments:

Answer 70

work, social, home

Question 71

Physiologic Hazards Associated With Restraints

Answer 71

-Increased possibility of serious injury due to fall Skin breakdown Contractures Incontinence Depression Delirium Anxiety Aspiration and respiratory difficulties Death

Question 72

RACE:

Answer 72

-R—Rescue anyone in immediate danger. -A—Activate the fire code and notify appropriate person. -C—Confine the fire by closing doors and windows. -E—Evacuate patients and other people to safe area.

Question 73

safety event report

Answer 73

must be completed after any incident or accident in a health care facility that compromises safety, immediately after, should not be mentioned in documentation