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PCC2 > exam 4 > Flashcards

exam 4 Flashcards

1
Q

What is the definition of delegation?

A

transferring responsibility for the performance of an activity or task while retaining accountability for the outcome

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2
Q

who wrote the definition for delegation?

A

ANA

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3
Q

What are questions the nurse should ask themselves before delegating a task to someone else?

A

Is it safe for patient and staff? Have they been trained to do it? Who is the safest person for the skill?

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4
Q

what are advantages to delegation?

A

improved efficiency, productivity, and job enrichment

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5
Q

What are the 5 rights of delegation?

A

right task, right circumstances, right person, right direction/ communication, right supervision

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6
Q

What does right task mean when referring to delegation

A

nothing is done out of scope

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7
Q

What does right circumstance mean when referring to delegation

A

safety for staff and patient

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8
Q

What is closed-loop communication?

A

feedback from our team once we delegate them a task

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9
Q

What is direct delegation/

A

assigning a task

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10
Q

What is indirect delegation

A

approved list of activities or tasks for someone else

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11
Q

Example of indirect delegation

A

CNA’s taking vital signs q 4 hours as apart of their scope

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12
Q

If a CNA takes a blood pressure and forgets to tell the nurse it is very low, whose responsibility is this?>

A

the nurses

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13
Q

What can we delegate to unlicensed assistive personnel>

A

vital signs, bathing, feeding, ambulation

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14
Q

What can we delegate to licensed practical nurse?

A

for exam, we are the same

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15
Q

What can we delegate to ancillary personnel/

A

answering calls, bringing juice (remember they cannot touch the patient)

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16
Q

are ancillary personnel allowed to touch patients

A

NO

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17
Q

What can we delegate with other registered nurses

A

checking insulin, verifying meds, wasting meds

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18
Q

If our patient is a two max assist, can we send UAP alone?

A

no

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19
Q

If someone is combative, should we enter their room alone

A

NO

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20
Q

Is pain objective or subjective?

A

subjective always

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21
Q

T or F? Clients who abuse substances overreact to discomforts

A

false

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22
Q

T or F? Administering analgesics regularly leads to drug addiction?

A

F

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23
Q

T or F: the amount of tissue damage in an injury accurately indicates pain intensity?

A

False

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24
Q

Health care personnel are the best authorities on the nature of a clients pain. T or F?

A

false (best authority is the patient followed by their families)

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25
Q

Chronic pain is all psychological. T or F?

A

false

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26
Q

Clients who cannot speak cannot feel pain. T or F

A

false

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27
Q

What is onset and duration of pain?

A

when it started/reoccurs and how long it lasts

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28
Q

What is location of pain?

A

where pain is occuring

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29
Q

What are intensity of pain examples?

A

if pain is mild/severe/moderate

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30
Q

What are quantity of pain examples?

A

0/10 (numeric)scale, Faces scale, FLACC scale

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31
Q

Can intensity and quantity of pain be used interchangeably?

A

yes

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32
Q

What are quality of pain examples?

A

aching, burning, shooting, stabbing, etc

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33
Q

What are patterns of pain examples?

A

comes and goes, constant, during certain movements

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34
Q

What is meant by relief factors of pain?

A

makes pain subside

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35
Q

What is meant by aggravating factors of pain?

A

makes it worse

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36
Q

What is the Wong-Baker faces assessment scale?

A

set of faces 0-10 to help determine pain

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37
Q

Who would benefit from using the Wong-baker faces assessment scale?

A

children aged 3 and older ; communicating with those who have a language barrier/nonverbal

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38
Q

What is the numeric pain scale?

A

patient ranks their pain on a scale from 0-10

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39
Q

What is FLACC pain rating scale?

A

pain scale used for unconscious patients

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40
Q

what does FLACC Stand for?

A

face, legs, activity, cry, consolability

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41
Q

What does A stand for in ABCDE of pain management?

A

A = ask about pain regularly ; assess systemically

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42
Q

What does B stand for in ABCDE of pain management?

A

B = believe the client and family about pain and what relieves it

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43
Q

What is C stand for in ABCDE of pain management

A

choose pain control options appropriate

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44
Q

What does D stand for in ABCDE of pain management ?

A

delivery interventions in a timely, logical and coordinated fashion

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45
Q

What does E stand for in ABCDE of pain management>

A

empower clients and families, enable them to control their course

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46
Q

What is drug tolerance?

A

body builds up tolerance, need higher dose

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47
Q

What is drug addiction

A

seeking out med/drug regardless of wellbeing or safety. Continues even with the negative impacts to their life.

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48
Q

What is drug dependence

A

getting physical symptoms of abruptly stopping/ withdrawing (ex include being sick/having headaches)

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49
Q

If someone experiences dependence and withdrawal, does this always mean they are addicted?

A

NO

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50
Q

What is breakthrough pain?

A

flare of pain that may happen even during chronic treatment of pain

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51
Q

How is breakthrough pain treated?

A

short - acting opioid treatment

52
Q

What is the reversal agent for opioid overdose?

A

Narcan/naloxone

53
Q

What is the reversal agent for benzodiazepines?

A

Romazican/flumazenil

54
Q

How to recognize benzodiazepines?

A

end in -lam and -pam

55
Q

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?

A

4 mg

56
Q

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)

A

5 mg

57
Q

Examples of major surgeries

A

open heart and brain

58
Q

Example of a minor surgery

A

cataracts

59
Q

What are elective surgeries? Give examples

A

life enhancing, not sustaining ; joint replacement, plastic surgery

60
Q

What are urgent surgeries? Give examples

A

fix before it gets worse ; appendectomy

61
Q

What are emergency surgeries? Give examples

A

have to be performed right this second ; ruptured appendix/spleen removal,hemorrhages

62
Q

What are diagnostic surgeries

A

used to do biopsies and figure things ut

63
Q

What are ablative surgeries?

A

cutting and removing

64
Q

What are palliative surgeries?

A

not used to cure but will improve quality of life

65
Q

What are reconstructive / restorative surgeries?

A

used to reconstruct body parts

66
Q

What are organ procurement / transplant surgeries?

A

used in organ replacements

67
Q

What are cosmetic surgeries?

A

used to enhance appearance

68
Q

What are the requirements for someone to be able to sign an informed consent?

A

over 18, not under influence of drugs are alcohol, not in a coma, do not have Alzheimers or dementia

69
Q

If our patient speaks a different language, can they sign an informed consent?

A

Yes if they meet all other qualifications and we MUST get an interpreter

70
Q

If our patient cannot read or write, can they sign an informed consent?

A

yes, we must meet them at their needs

71
Q

If our patient has Alzheimers or dementia, can they sign an informed consent

A

NO

72
Q

Can a client revoke their signature for informed consent?

A

Yes

73
Q

If our patient backs out last second from surgery after signing consent, what should the nurse do?

A

inform the surgeon so he can go talk to her

74
Q

What is general anesthesia?

A

loss of all sensations and consciousness

75
Q

Do patients control their own airway under general anesthesia?

A

No

76
Q

What is regional anesthesia?

A

loss of sensation in a certain body area (ex. epidural)

77
Q

What is local anesthesia?

A

smallest area affected; loss of sensation at a site

78
Q

Examples of when local anesthesia may be needed?

A

tooth filling, receiving stitches

79
Q

What is conscious/ moderate sedation?

A

used for procedures not requiring complete anesthesia. Patient controls own airway

80
Q

Which anesthesia has the lowest risk of reaction

A

local

81
Q

What anesthesia has the highest risk of complications

A

conscious sedation

82
Q

What should we keep next to our patient on moderate sedation

A

crash cart

83
Q

How do we monitor our client receiving conscious sedation?

A

make sure they are maintaining their own airway

84
Q

What do we do if our client on conscious sedation begins to go too far under?

A

administer O2 and create an airway (will require a breathing tube)

85
Q

What is paralytic ileus?

A

we are having no peristalsis; complication of surgery

86
Q

Nursing interventions for paralytic ileus?

A

listen to bowel sounds, ask “When was your last bowel movement” “did you pass gas?”

87
Q

How can we prevent DVTs after surgery?

A

administer lovanox and apply SCDs / compression stockings

88
Q

How can we prevent post -op PNA

A

IS, coughing, deep breathing,early ambulation

89
Q

What is the role of the circulating RN?

A

maintaining safety of the client by monitoring sterile fields, making sure everyone is on the same page, and watching monitors

90
Q

How many counts must be done before closing a patient?

A

minimum of 3

91
Q

What is malignant hyperthermia?

A

occurs during or after surgery. Patient gets hot, tachycardia, shake uncontrollably

92
Q

What can we give to treat malignant hyperthermia?

A

dantrolene (muscle relaxer)

93
Q

a patient is having knee arthroplasty. Their vital signs are 86/40 after receiving midazolam (versed). What does the nurse suspect to be administered?

A

500 ML NS bolus

94
Q

What is delirium

A

short term and reversible confusion

95
Q

What is dementia

A

long term confusion, diagnosis before going into OR

96
Q

What is the most dangerous adverse effect of inhaled anesthesia?

A

malignant hyperthermia

97
Q

common opioids used during surgery>

A

morphine, fentanyl

98
Q

Common anesthetic used during srugery

A

propofol (diprivan)

99
Q

Common benzodiazepines used during surgery?

A

versed, valium, lorazepam

100
Q

A score of ____ on the aldrete tool will allow discharge from the PACU?

A

8

101
Q

What is considered as hypotension?

A

90/60

102
Q

What is within normal range for blood pressure?

A

120/80 and less

103
Q

What is considered hypertension?

A

less than 180/100

104
Q

What is hypertensive crisis?

A

over 180/100

105
Q

Patient education for someone on lisinopril (or other HTN meds)

A

take at same time q day, do not stop taking, do not skip doses (even if levels are normal)

106
Q

What food education should we provide our clients on HTN medication

A

avoid high processed foods, fresh and frozen vegetables are better, potassium depending on what type of diuretic it is

107
Q

If they are taking thiazides and loop diuretics, what should recommend our patient take?

A

potassium supplement or eat high potassium foods

108
Q

Example of loop diuretic?

A

furosemide

109
Q

Example of thiazide diuretic?

A

HCTZ (hydrochlorothiazide)

110
Q

Example of potassium sparing diuretic/

A

spironolactone, amiloride

111
Q

What are potassium rich foods we should encourage our client to eat on potassium wasting diuretics?

A

potatoes, bananas

112
Q

Those taking spironolactone or amiloride for HTN should avoid?

A

potassium rich foods,potassium salt substitutes

113
Q

IF our patient drinks wine at night, what time should they take their BP meds

A

in the morning

114
Q

What are reversible/modifiable risk factors/

A

diet, exercise, alcohol consumption, smoking, lifestyle

115
Q

What are irreversible/non-modifiable risk factors

A

gender, age, genetics, family history

116
Q

What are lifestyle changes we can encourage our client with HTN to change?

A

amount of stress, low sodium, smoking cessation

117
Q

What is sensory overload?

A

when too much is happening around our patients

118
Q

What can cause sensory overload?

A

monitors, lights, people coming in and out, monitors, sounds

119
Q

How can we prevent sensory overload?

A

turn off lights, turn down monitors, cluster care, limit visitors

120
Q

What is sensory deprivation

A

not enough stimulation

121
Q

How can we prevent sensory deprivation?

A

clocks, paintings, TV, pet therapy

122
Q

What symptoms can occur from sensory deprivation?

A

depression, hallucinations

123
Q

What symptoms can occur from sensory overload?

A

lack of sleep

124
Q

If our client has impaired vision, what should we implement?

A

clock method for meal tray, declutter floor and lines

125
Q

If we make changes to our patients room to accommodate them, we should

A

make them aware of the changes and tell them when we move it back

126
Q

If our patient is hard of hearing/ has hearing loss, we should

A

face them, get on their level, do not scream (talk normally)

127
Q

If our patient is deaf, we should?

A

find out their best means of communication; have interpreter ready and face them in case they read lips

PCC2 (4 decks)

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