midterms Flashcards
Nurse practice act
The law in each state that governs nurses’ actions addresses each level of nursing.
HOSA
(Health occupations students of America) National organization specifically for student nurses.
ISBAR
(communication) Introduce yourself Situation Background Assessment Recommendation
The professional organization for LPN is the
National federation of LPN
The purpose of critical thinking connection is
Identify actions to take and inform to consider when caring for patients.
Concerns when providing care for an elderly patient
These patients often have chronic illness, sensory deficits, and multiple medications.
When you care for younger patients in a health-care provide’s office, you must keep in mind that…
Have difficulty understanding what is happening and expressing themselves during a procedure.
A unique aspect of home health is that
fewer supplies and less equipment are available than in a hospital setting.
the nurse is alone in the home with no other health-care staff to help make decisions about care.
When working in long-term care…
The setting is more homelike
You will need to use an easy, calming approach to residents.
Change in behavior can indicate health problems in the elderly.
Responsibilities as a nursing student regarding lab and diagnostic test result.
Check the test results often and note any abnormal findings.
Notify the health-care provider of significant abnormal results.
Post conference connection
To help evaluate the clinical experience off caring for patient in the clinical connection.
Responsibilities of a nurse
caring for more than on patient at a time
Helping families understand the care of the patient after discharge
notice any changes in the patients condition and notify the appropriate health-care professional.
student organization that is connected with the American nurses ass.
NSNA
QSEN ties into providing individuallized care for patients, including their
Preference, values, and needs in their plan care..
Quality improvement
Patient-centered care
Nursing care plan
A documented strategy that includes the health- care provider’s orders, nursing dx, and nursing orders
Rapport
creating trust between the nurse and the patient.
Nursing diagnosis
the consice statement of a problem that the patient is experiencing as a result of the patients diagnosis
Nursing goal
the overall direction that will indicate improvement in a problem.
Defining characters
the signs and symptoms experience by the patient that directly influence the nursing diagnosis.
Validate
overlapping, five-step method decision making.
Expected outcome
are statements of measurable action for patient within specific time frame in response to nursing interventions.
Independent intervention
actions the nurse performs that do not require a written order
Dependent intervention
actions the burse performs that requires a written order
Collaborative intervention
nursing actions that involve working with other disciplines such as physical therapy or social services.
Direct patient care
when an individuall nurse performs hands-on or one-on-one nursing interventions
Indirect patient care
activities that a nurse performs that do not involve hands on patient care.
How would you obtain information about your patient so that you can begin to develop a plan of care?
a. read the nursing admission assessment and recent nurses’s notes
b. read the health-care provider’s admission note and recent progress notes.
c. listen to the end-of-shift report at the nurse’s station
d. review the medication administration record and any treatment plans or notes.
Which step of the nursing process is concerned with identifying physical findings?
Assessment
Which step of the nursing process would you look at outcomes?
Evaluation
which step of the nursing process are priorities set?
Planning
Which step of the nursing process do you label problems
Diagnosis
Which step of the nursing process is most associated with action?
Implimentation
You are performing the daily assessment of your patient’s status. You notice some purplish marks on her arm where thebandage for her IV had been and the patients skin is torn. What type of assessment techniques did you use to obtain these data?
Inspection
To asses bowel sounds, which assessment technique will you use?
Auscultation
Your patient has severe peripheral vascular disease (poor circulation) in both lower extremities. You document that the patien’ts pedal pulses are absent. Which assessment teqnues did you use?
Palpation
You are assessing the NP with her assessment of an elderly, confused woman. You watch as the NP placesher hand on the woma’s back and then taps her own middle finger with her other hand. This assessment is called
Percussion
How is Maslow’s hierarchy of human needs used by nurses in a clinical setting?
It helps in prioritizing nursing diagnosis and care.
According to The Joint commision, all patients have the right to
Recieve medical care considerate of their culture, religion, and spiritual beings.
Cultural diversity in a hospital
Having employees from variety of countries and cultures
Employeing people of variety races
Employing people who may speak a variety of language as well as english
When an LPN is providing home care for patients of different cultures or religions the nurse should…
Show respect for the patient’s believs
Adapt their services even more than in the hospital setting.
When a patient is in a spiritual distress you should…
Use therapudic communiction techniques to encourage expression of feelings.
Allow the patient plenty of opportunities to explain his or her feelings.
Offer precense
Spend adequate time with the patient and pay attention to his or her actions.
CPR
Actions to restart the heart or breathing in an unresponsive patient
Leg monitor
Attaches to the patient and generates alarm when the leg is in a dependent position
Rescue breathing
Breathing for a person in respiratory arrest who still has a pulse
Heimlich maneuver
An action to relieve chocking by thrusting just below the xiphoid process.
Body mechanic
refeers to the movement of the muscles of the body for balance and leverage.
Base of support
feet and lower legs
Even if you delegate checks and releases what are your responsibilities when a patient must be restrained?
Follow up every 2 hours to be sure the patient is released from restraints and has been checked on every 30 minutes.
When a patient in a home setting uses supplemental O2, what teaching should you provide?
No one can smoke in the same room as the O2
No candles can be burned in the same room as the O2 source.
Patient using O2 should not use wool blankets or wear wool swaters.
Before applying restraints to any patient, you must first take…
Try using restraint alternatives without success.
Identify the need for restraints to prevent harm to the patient.
Obtain a health-care provider’s order for the type of restraint and the length of time it is to remain in place.
Hospitalized patients often have impaired mobility causing risk for injury because of…
They maybe weak as a result of surgery or bedrest.
How are fall assessment used?
To predict the patient’s risk for falls while in the hospital.
You walk into the patient’s room and you discover that he has fallen, what will you do first?
Check the patient for any obvious injuries, including hip fracture and paralysis.
How often do you check on patient’s who are restraints?
Every 2 hours.
When a patient is relseased from wrist restraints, what assessment should you take?
Assess the hands and wrist for edema.
Check capillary refill
Assess the patien’ts ability to move and feel sensations in the arm and hand.
Assess the skin of the wrists for any open areas.
Assess the skin under the restraints for redness.
What must you always do when you apply restraints?
Tie them tightly so the patient cannot struggle.
To practice good body mechanics,
Turn your whole body or pivot
Bend your knees, not your back
How can nurses avoid being harmed by radiation?
Wear lead apron
Limit the time you spend with patients who have internal or implanted radiation
What do you do when you discover a fire?
Rescue
Alarm
Confine
Extenguish
How to use fire extiguisher?
Pull
Aim
Squeez
Sweep
Health care assosiated infection
Acquired while a patient is being cared
Primary infection
infection by one pathogen only
Septicemia
Microorganisms present and multiplying in the blood
Disinfectant
Cleaning agent that removes most pathogens
Direct contact
Person to person
Vector
an insect, tick
THe sequesnce of events that must occur for infection to spread from one person to another is called
Chain of infection
An infection caused by a different pathogen that the primary pathogen is called
Secondary infection
When examining a wound drainage specimen under the microscope, you see sphere-shaped micro in chains
Streptococci
Gram positive bacteria
Appear in purple or blue
Whe would emptying the bedside commode be a nursing responsibility rather than a house keeping
Nurses are responsible for measuring urine output and creating a pleasant environment for patients.
Delagating Cdiff to UAP
Ensuring that the UAP knows the correct precautions to take to prevent transmission of bacteria.
Observe the UAP carefully to ascertain his or her abilities regarding transmission-based precautions.
Kindly pointing out any errors in technique to protect the UAP and other patients.
Types of pathogen
Bacteria Viruses Protozoa Fungi Helminths
Types of bacteria
Cocci, Bacili, spirilla
Rickettsia
Rickettsia
spread through vectors
Viruses
TIny parasites the live within cells of hosts and produce there
Protozoa
Single-celled animals that live in water and cause intestinal illness when ingested..
Fungai
May be made up of one or more cells: Enters through cuts and cracks of skin.
Bacteria
One celled micro classifies by shapes
Proper squence of donning full PPE
Hand hygine Gown Mask eye protection hair covering shoe covering Gloves
Removing PPE
gloves Gown eye protection mask hair covering show covering hand hygiene
You are removing a feeding pump from the room of a patient who is being discharge
Disinfect it according yo yhr facility policy
Sterilize it using steam under pressure
Lesion
open areas
Excoriation
scrapes
mottling
purple blotch
maceration
soften skin
vasodialation
widening of blood vessel
Seborrhea
thick, oily scalp.
Draw sheet
A narrow sheet with two narrow hems at each end. Use to position the patient
Miltered corner
Use to anchor linens more firmly
Baths
Perform the bath as assigned
Composed of dead keratin cells
Hair and Nails
Bathing and caring for the skin of older adults
Apply lotion frequently to prevent dryness
Keep room warm during bath to prevent chilling
sebaceous and sweat glands produce less oil and sweat.
Provacy for school-age children
Place a “bath in progress” sign outside the door to prevent interruptions
Always knock before enter the patient’s room
Functions of sebum
Protect the skin from cracking
Lubricates
If a resident in a long-term care facility has been incontinent but is not scheduled for a bath or shower until tomorrow…
Provide perineal care to prevent skin breakdown and odor.
AM care
Hair Bath Shaving Oral care back massage dressing straightening linens
It is important to stay with a patient during the first bath or shower after surgery because the patient may be…
Experience vasodialation and become dizzy or faint.
Providing oral care for unconcious patient
posistion the patient on the left or right side with bed flat
Assess the mouth for session and sores
Keep a suction device on and ready for use.
Stoke patient with partial paralysis of his throat, oral care, what will you do
Stay with the patient in case she chokes while performing oral care, and assist her as needed.
When cleaning dentures
Line sink with clean paper towel
Use cool water
Store them in denture cup with cool water and a cleaning tablet.
Patient with IV containing heparin, you are assisting him with personal care.
Shave him with an electric razor, moving in circular motions over the beard.
Providing personal care with diabetes
File her toe nails straight accrosss but do not clip.
Importance of 2% trilosan products on surgical patients
Prevent patients from MRSA
Omit giving back massage
When a patient has broken ribs or broken spine.
Plantar flexion
foot pointing downward
Fowler’s posistion
Semi-sitting knee slightly elevated and head eleveated
Semi-fowler
45 degrees (tube feeding)
Log roll
Turn patient with the body as one unit
Contractures
Shortening or tightening of muscle as a result of disuse
Trochanter roll
lateral aspect of the patient’s thigh to prevent leg from rotating outward.
Shearing
Occurs when the skin layer is pulled across the muscle and bone, while slides over the bed sheet
Posistion of function
A patient posistion where his extrimities are in alignment to maintain the potential for use and movement
Orthopneic position
When a patient is in sever respiratory distress
Left sims
Administrating ename
How can you be certain that the wheels of a strecher are locked
Physically attemp to move the strecher, even if you have locked the wheels.
Why is it important what you will be doing when you reposition the patient?
The patient may be sedated
The patient will be more cooperative
The patient will be less likely to resist during position change
the patient can more easily assist with the position change
Gastrointestinal complication intervention
Help the patient choose well-balanced meals
Assess bowel sounds
Encourage fresh fruits and veggies
Perineal care position
Dorsal recumbent
Lateral position where would the pillows go?
between the knees and ankles and back
Spinal surgery
Log rolll the patient
Have total of 3 health care staff to assist
Have one person at the patient’s head to direct the turn
Purpose of assisting a patient to dangle
To determine if the patient can tolerate changing positions.
A patient has a viral infection. Which information would the nurse share with the patient?
“The virus can only multiply inside the body.”
The nurse is providing care for a patient who is confused and constantly pulls at an indwelling catheter and nasogastric (NG) tube. The nurse has tried multiple alternatives to restraints, none of which have been effective. Which specific question will the nurse mentally ask before calling the health-care provider for a restraint order?
“Are restraints necessary to maintain tube placement?”
The nurse is caring for multiple patients who are experiencing altered bladder function. Which patient will be the nurse’s priority?
The patient with painful bladder contractions and distention
The health-care provider orders a urinalysis for a patient with an indwelling urinary catheter. Which steps will the nurse perform to obtain the specimen?
Clean the port located in the tubing with an alcohol swab.
Using a blunt needle, withdraw 5 to 8 mL of urine from the port.
Unclamp the catheter tubing to allow the urine to flow freely into the collection bag.
Clamp the tubing below the level of the port to collect fresh urine.
The nurse is collecting data on a patient’s capillary refill. The patient has yellowed, thickened nails. Which technique would the nurse use?
Press the tip of the patient’s finger
Slide sheets are made out of
webbed nylon
Assistive device would you use after the patient had fallen to help him or her return to bed
A battery-operative lift
When performing ROM exercises, which action will you take first
Check the patien’ts chart for any contraindications to full ROM
Dyspnea
Having difficulty breathing
pulse deficit
apical heart rate is higher than radial pulse rate
Hypoxemia
decreased blood level of O2
Stridor
A high pitched crowing respiratory sound
Hypoxia
High-pitched crowing respiratory sound
Cheyne-stoke
Repetitious pattern of respirations that begin shallow.
Pulse sites
Radial Carotid temporal Brancial femoral popliteal proximal tibia distal pedis
Thermogenesis
Body’s heat production
Characteristics of the pulse should you always assess?
Lenght of each beat Strength Rate Depth Rhythm of beats
Ptosis
Numbness or a decreased sensation
Excursion
Chest wall appears sunken in between the ribs or under the xiphoid process as the patient inhales.
Dysphasia
Patient knows what he wants but cannot say the words
Aphasia
Difficulty coordinating and organizing the words correctly.
What type of assessment is performed on admission
Comprehensive health assessment
A patient wa admitted yesterday with pneumonia. When auscultating his breath sounds you detect rales in the right lower lobe. How quickly should you reasses?
within 15 minutes
A 5 year old patient has a fever of 104.4 axillary. When should you reassess the child temperature?
within 60 minutes.
What asessment findings may provide you with neurological status data?
Lethargy
Where do you hear the apical pulse best?
Just to the right of the sternum in the 2nd intercoastal space.
Irregular pulse assessment
Auscultate the apical pulse for 60 minutes.
Pulse characteristics
rate, rhythm, and strenght
Initial shift assessment
Observation, palpation, percussion, auscultation oand olfaction (except for the stomach)
What causes body odor
Bacteria break down sweat
The nurse is caring for a patient who has a leg infection. Which action indicates the nurse is using sterile technique?
Inserts a Foley catheter
