Management

Question 1

RN role

Answer 1

assess
analyze
interpret
critical thinking
provide education
offer counsel and support

Question 2

LPN/LVN role

Answer 2

ASSIST with implementation of define care plan
provide care for stable clients with predictable outcome
collect date for assessment and report to RN
asepsis and dressing changes

Question 3

CNA/UAP role

Answer 3

provide basic care
vitals
ADLs
topical care med and OTC meds
measuring and documenting intake and output
blood sugar check or 12 lead ECG

they may not delegate an assigned task to another UAP

Question 4

when delegating assignment

Answer 4

give the most stable patient

LPN: can reteach

RN: assess evaluate teach

CNA: cannot

anyone returning should be given to RN
if the answers have sxs then that is a clue whether they are stable patients or not
- see which one is the most acute

Question 5

advanced directives

Answer 5

includes a living will and durable power of attorney

nurses and other members of health care team are required to:

• assess clients knowledge of advance directives and their status
• provide info and assistance in developing directives
• plan care that incorporates clients decision making

Question 6

durable power of attorney

Answer 6

names a person to make health care decisions if client is unstable to do so

can make decisions of :

• wehn to admit or discharge
• types of treatmet or meds client can receive
• has access to all health care records

Question 7

DNR

Answer 7

not to perform:
- CPR
- life saving measures such as:
hemodialysis
intubation
emergency meds

healthcare proxy can verablly cancel DNR at any time

Question 8

informed consent

Answer 8

cannot delegate to nurse

- they are only responsible for witnessing and co-signing clients signature

Question 9

nonmaleficence

Answer 9

protect clients safety

Question 10

autonomy

Answer 10

right to make deicisions for themselves, including living wills

Question 11

maslows hierarchy

Answer 11

from priority to less priority:

1. physiolocal needs
2. safety needs
3. social needs
4. esteem needs
5. self actualization

Question 12

prioritzation

Answer 12

1. BLS guidelines
2. ABC
3. Maslows hierarchy
4. nursing process
5. acute or chronic
   - suddent onset or rapid worsening of SOB or pain
6. new onset sxs that doesn’t make sense with diagnosis

Question 13

1st degree heart block

Answer 13

PR internvals greater than 0.2 seconds
regular P waves and R waves
P wave accompanying QRS complex

Question 14

2nd degree heart block type 1 (Mobitz 1)

Answer 14

Pr intervals are progressively lengthening then all of a sudden theres no QRS complex

this is a cycle

Question 15

2nd degree heart block type 2 (Mobitz 2)

Answer 15

theres no pattern in type 2
R waves is irregular
missing QRS complex randomly

temporary pacing is needed immediately

Question 16

3rd degree - complete heart block

Answer 16

P wave will NOT accompany QRS complez

P and R waves are regular

Question 17

cranial nerve II

Answer 17

optic nerve

• confrontation usual field test
• snellen chart for visual acuity

Question 18

cranial III, IV, VI

Answer 18

3: oculomotor
4: trochlear
6: abducens

watch for nystagmus
reactive to light the pupils

Question 19

cranial nerve V

Answer 19

trigeminal nerve

bite down and feel the masseter muscle and temporal muscle
open mouth against resistance

Question 20

cranial nerve VII

Answer 20

facial nerve

close their eyes, smile, frown, puff out cheek

Question 21

cranial nerve VIII

Answer 21

vestibulocochlear nerve

test hearing by occluding one ear and whispering 2 words

Question 22

cranial nerve IX and X

Answer 22

IX: glossopharyngeal
X: vagus

swallow and say “ah”

Question 23

cranial nerve XI

Answer 23

accessory nerve

move head from side to side, up, down, shrug against resistance

Question 24

cranial nerve XII

Answer 24

hypoglossal

have patient stick tongue out and move it side to side