Exam 4 Flashcards
What is delegation?
transferring responsibility for the performance of an activity or task while
retaining accountability for the outcome
What is A of ABCDE of pain management?
A = Ask about pain regularly; assess systematically
What is B of ABCDE of pain management?
B= believe the client and family about reports of pain and what relieves it
What is C of ABCDE of pain management?
C= Choose pain control options appropriate for client, family, and setting
What is D of ABCDE of pain management?
D= Deliver interventions in a timely, logical, and coordinated fashion
What is E of ABCDE of pain management?
E= Empower clients and families; enable them to control their course to the greatest extent possible
Who can a nurse delegate vitals, bathing, ambulation, feeding and repositioning to?
CNAs
Can the nurse delegate administration of medications to a CNA if they have seen the meds given before?
No, CNAs are not able to assist in the administration of medications
T or F: LPNs can perform central line care (dressing changes, meds, etc)?
false
Who can administer chemotherapy?
RNs, this task can not be delegated to LPNs
What may be an effective tool to measure the current severity of pain in children older than 3yrs?
Wong-Baker (Faces Scale)
When may the FLACC pain scale be used?
for patients that are: unconscious, coma, unable to speak
Is pain objective or subjective?
subjective
In relation to pain, what do “mild, severe, excruciating, 4/10, 8/10” represent?
severity
What are examples of quality of pain?
sharp, stabbing, aching, shooting, dull, deep, burning
What is pain that erupts despite ongoing/current treatment of pain?
breakthrough pain
What may be required if a patient develops a tolerance to opioid medications?
increased/more frequent doses to experience therapeutic effect
What signifies addiction?
seeking, regardless of health, well-being or safety concerns
What is the reversal agent for opioid-induced respiratory depression?
naloxone (Narcan)
what interventions can be utilized in the prevention of surgery-related DVTs?
Lovenox, TEDs, SCDs
How can post op pneumonia be prevented?
incentive spirometer, deep breathing, coughing
Can the nurse obtain informed consent?
no, the nurse is a witness, only the person performing procedure/operation can get the informed consent
What is the identifying factor of conscious sedation?
the patient independently maintains airway
What are examples of elective surgeries?
bunionectomy, hernia repair, breast reconstruction, facial plastic surgery
What surgical class are removal of gallbladder due to stones, coronary artery bypass, excision of cancerous tumor?
urgent
What type of surgeries are considered emergency?
control of internal hemorrhaging, repair of perforated appendix
What surgery classification are cataract extraction, facial plastic surgery, and tooth extraction?
minor surgeries
What are examples of major surgeries?
coronary artery bypass, colon resection, removal of larynx, and resection of a lung lobe
What is known as acute, reversible confusion?
delirium
What is used in malignant hyperthermia?
dantrolene
what may indicate malignant hyperthermia?
patient becomes very hot and has severe shaking during surgery
what is romazicon/flumazenil used in the reversal of?
benzodiazepines (midazolam, lorazepam, etc)
What is considered stage 1 hypertension?
130-139/ 80-89 mmHg
What category is a blod pressure that falls within this range: >140/>90?
Stage 2 hypertension
What is considered hypertensive crisis?
> 180/ >120 mmHg
which modifiable risk factor is most significant in the prevention of hypertension?
smoking
what are examples of non-modifiable/irreversible hypertension risk factors?
genetics, age, family history, race, sex
what aldrete score is considered appropriate for a patient to be discharged from PACU?
8-10
What terms are used to describe the seriousness of a surgery?
major and minor
what terms are used to describe the urgency of a surgery?
elective, urgent, emergency
What type of surgical seriousness involves extensive reconstruction or alteration in body parts; poses great risks to well-bring?
major
what type of surgical seriousness involves minimal alteration in body parts; designed to correct deformities; minimal risk to well-being?
minor
what type of surgical urgency is performed on the basis of patient’s choice; is not essential and is not always necessary for help?
elective
what surgical urgency is necessary patients health; prevents additional problems (tissue destruction or impaired organ function)?
urgent
What surgical urgency must be done immediately to save life or persevere function?
emergency
what is the purpose of a constructive surgery?
congenital anomalies
your mom
