exam 4 Flashcards
What is the definition of delegation?
transferring responsibility for the performance of an activity or task while retaining accountability for the outcome
who wrote the definition for delegation?
ANA
What are questions the nurse should ask themselves before delegating a task to someone else?
Is it safe for patient and staff? Have they been trained to do it? Who is the safest person for the skill?
what are advantages to delegation?
improved efficiency, productivity, and job enrichment
What are the 5 rights of delegation?
right task, right circumstances, right person, right direction/ communication, right supervision
What does right task mean when referring to delegation
nothing is done out of scope
What does right circumstance mean when referring to delegation
safety for staff and patient
What is closed-loop communication?
feedback from our team once we delegate them a task
What is direct delegation/
assigning a task
What is indirect delegation
approved list of activities or tasks for someone else
Example of indirect delegation
CNA’s taking vital signs q 4 hours as apart of their scope
If a CNA takes a blood pressure and forgets to tell the nurse it is very low, whose responsibility is this?>
the nurses
What can we delegate to unlicensed assistive personnel>
vital signs, bathing, feeding, ambulation
What can we delegate to licensed practical nurse?
for exam, we are the same
What can we delegate to ancillary personnel/
answering calls, bringing juice (remember they cannot touch the patient)
are ancillary personnel allowed to touch patients
NO
What can we delegate with other registered nurses
checking insulin, verifying meds, wasting meds
If our patient is a two max assist, can we send UAP alone?
no
If someone is combative, should we enter their room alone
NO
Is pain objective or subjective?
subjective always
T or F? Clients who abuse substances overreact to discomforts
false
T or F? Administering analgesics regularly leads to drug addiction?
F
T or F: the amount of tissue damage in an injury accurately indicates pain intensity?
False
Health care personnel are the best authorities on the nature of a clients pain. T or F?
false (best authority is the patient followed by their families)
Chronic pain is all psychological. T or F?
false
Clients who cannot speak cannot feel pain. T or F
false
What is onset and duration of pain?
when it started/reoccurs and how long it lasts
What is location of pain?
where pain is occuring
What are intensity of pain examples?
if pain is mild/severe/moderate
What are quantity of pain examples?
0/10 (numeric)scale, Faces scale, FLACC scale
Can intensity and quantity of pain be used interchangeably?
yes
What are quality of pain examples?
aching, burning, shooting, stabbing, etc
What are patterns of pain examples?
comes and goes, constant, during certain movements
What is meant by relief factors of pain?
makes pain subside
What is meant by aggravating factors of pain?
makes it worse
What is the Wong-Baker faces assessment scale?
set of faces 0-10 to help determine pain
Who would benefit from using the Wong-baker faces assessment scale?
children aged 3 and older ; communicating with those who have a language barrier/nonverbal
What is the numeric pain scale?
patient ranks their pain on a scale from 0-10
What is FLACC pain rating scale?
pain scale used for unconscious patients
what does FLACC Stand for?
face, legs, activity, cry, consolability
What does A stand for in ABCDE of pain management?
A = ask about pain regularly ; assess systemically
What does B stand for in ABCDE of pain management?
B = believe the client and family about pain and what relieves it
What is C stand for in ABCDE of pain management
choose pain control options appropriate
What does D stand for in ABCDE of pain management ?
delivery interventions in a timely, logical and coordinated fashion
What does E stand for in ABCDE of pain management>
empower clients and families, enable them to control their course
What is drug tolerance?
body builds up tolerance, need higher dose
What is drug addiction
seeking out med/drug regardless of wellbeing or safety. Continues even with the negative impacts to their life.
What is drug dependence
getting physical symptoms of abruptly stopping/ withdrawing (ex include being sick/having headaches)
If someone experiences dependence and withdrawal, does this always mean they are addicted?
NO
What is breakthrough pain?
flare of pain that may happen even during chronic treatment of pain
How is breakthrough pain treated?
short - acting opioid treatment
What is the reversal agent for opioid overdose?
Narcan/naloxone
What is the reversal agent for benzodiazepines?
Romazican/flumazenil
How to recognize benzodiazepines?
end in -lam and -pam
If our client has a basal dose of 2mg/h and a bolus dose of 0.5 mg q 15 minutes (assume they use it), how many MG would they receive over an hour?
4 mg
If our client has a basal dose of 2mg/hr, a bolus dose of 1mg q 10 minutes, and a lockout of 3/hr, how much would they receive over one hour? (assume they use bolus dose as prescribed)
5 mg
Examples of major surgeries
open heart and brain
Example of a minor surgery
cataracts
What are elective surgeries? Give examples
life enhancing, not sustaining ; joint replacement, plastic surgery
What are urgent surgeries? Give examples
fix before it gets worse ; appendectomy
What are emergency surgeries? Give examples
have to be performed right this second ; ruptured appendix/spleen removal,hemorrhages
What are diagnostic surgeries
used to do biopsies and figure things ut
What are ablative surgeries?
cutting and removing
What are palliative surgeries?
not used to cure but will improve quality of life
What are reconstructive / restorative surgeries?
used to reconstruct body parts
What are organ procurement / transplant surgeries?
used in organ replacements
What are cosmetic surgeries?
used to enhance appearance
What are the requirements for someone to be able to sign an informed consent?
over 18, not under influence of drugs are alcohol, not in a coma, do not have Alzheimers or dementia
If our patient speaks a different language, can they sign an informed consent?
Yes if they meet all other qualifications and we MUST get an interpreter
If our patient cannot read or write, can they sign an informed consent?
yes, we must meet them at their needs
If our patient has Alzheimers or dementia, can they sign an informed consent
NO
Can a client revoke their signature for informed consent?
Yes
If our patient backs out last second from surgery after signing consent, what should the nurse do?
inform the surgeon so he can go talk to her
What is general anesthesia?
loss of all sensations and consciousness
Do patients control their own airway under general anesthesia?
No
What is regional anesthesia?
loss of sensation in a certain body area (ex. epidural)
What is local anesthesia?
smallest area affected; loss of sensation at a site
Examples of when local anesthesia may be needed?
tooth filling, receiving stitches
What is conscious/ moderate sedation?
used for procedures not requiring complete anesthesia. Patient controls own airway
Which anesthesia has the lowest risk of reaction
local
What anesthesia has the highest risk of complications
conscious sedation
What should we keep next to our patient on moderate sedation
crash cart
How do we monitor our client receiving conscious sedation?
make sure they are maintaining their own airway
What do we do if our client on conscious sedation begins to go too far under?
administer O2 and create an airway (will require a breathing tube)
What is paralytic ileus?
we are having no peristalsis; complication of surgery
Nursing interventions for paralytic ileus?
listen to bowel sounds, ask “When was your last bowel movement” “did you pass gas?”
How can we prevent DVTs after surgery?
administer lovanox and apply SCDs / compression stockings
How can we prevent post -op PNA
IS, coughing, deep breathing,early ambulation
What is the role of the circulating RN?
maintaining safety of the client by monitoring sterile fields, making sure everyone is on the same page, and watching monitors
How many counts must be done before closing a patient?
minimum of 3
What is malignant hyperthermia?
occurs during or after surgery. Patient gets hot, tachycardia, shake uncontrollably
What can we give to treat malignant hyperthermia?
dantrolene (muscle relaxer)
a patient is having knee arthroplasty. Their vital signs are 86/40 after receiving midazolam (versed). What does the nurse suspect to be administered?
500 ML NS bolus
What is delirium
short term and reversible confusion
What is dementia
long term confusion, diagnosis before going into OR
What is the most dangerous adverse effect of inhaled anesthesia?
malignant hyperthermia
common opioids used during surgery>
morphine, fentanyl
Common anesthetic used during srugery
propofol (diprivan)
Common benzodiazepines used during surgery?
versed, valium, lorazepam
A score of ____ on the aldrete tool will allow discharge from the PACU?
8
What is considered as hypotension?
90/60
What is within normal range for blood pressure?
120/80 and less
What is considered hypertension?
less than 180/100
What is hypertensive crisis?
over 180/100
Patient education for someone on lisinopril (or other HTN meds)
take at same time q day, do not stop taking, do not skip doses (even if levels are normal)
What food education should we provide our clients on HTN medication
avoid high processed foods, fresh and frozen vegetables are better, potassium depending on what type of diuretic it is
If they are taking thiazides and loop diuretics, what should recommend our patient take?
potassium supplement or eat high potassium foods
Example of loop diuretic?
furosemide
Example of thiazide diuretic?
HCTZ (hydrochlorothiazide)
Example of potassium sparing diuretic/
spironolactone, amiloride
What are potassium rich foods we should encourage our client to eat on potassium wasting diuretics?
potatoes, bananas
Those taking spironolactone or amiloride for HTN should avoid?
potassium rich foods,potassium salt substitutes
IF our patient drinks wine at night, what time should they take their BP meds
in the morning
What are reversible/modifiable risk factors/
diet, exercise, alcohol consumption, smoking, lifestyle
What are irreversible/non-modifiable risk factors
gender, age, genetics, family history
What are lifestyle changes we can encourage our client with HTN to change?
amount of stress, low sodium, smoking cessation
What is sensory overload?
when too much is happening around our patients
What can cause sensory overload?
monitors, lights, people coming in and out, monitors, sounds
How can we prevent sensory overload?
turn off lights, turn down monitors, cluster care, limit visitors
What is sensory deprivation
not enough stimulation
How can we prevent sensory deprivation?
clocks, paintings, TV, pet therapy
What symptoms can occur from sensory deprivation?
depression, hallucinations
What symptoms can occur from sensory overload?
lack of sleep
If our client has impaired vision, what should we implement?
clock method for meal tray, declutter floor and lines
If we make changes to our patients room to accommodate them, we should
make them aware of the changes and tell them when we move it back
If our patient is hard of hearing/ has hearing loss, we should
face them, get on their level, do not scream (talk normally)
If our patient is deaf, we should?
find out their best means of communication; have interpreter ready and face them in case they read lips
