N320 Final Exam Flashcards
5 rights of delegation
- Right task
- Right circumstance
- Right person
- Right directions & communication
- Right supervision & evaluation
supporting and defending a pt
advocacy
This organization was established & wrote the first Code of Ethics for Nursing
American Nurses Association (ANA)
A set of guiding principles that all members of a profession accept and provides a foundation for professional nursing
Code of Ethics
Unethical term used for nurses and taking responsibility for their action
accountability
refers to fairness and distribution of resources
justice
3 major functions of ethics committees
- providing clinical ethics consultation
- developing and/or revising policies pertaining to clinical ethics and hospital policy
- facilitating education about topical issues in clinical ethics
how to resolve an ethical dilemma
- ask if this an ethical problem
- gather info relevant to case. pt, family, health care agency, social perspectives are important sources
- identify ethical elements, distinguish facts, opinions, values
- name the problem
- identify possible courses of action, access others for input and be creative
- create & implement action plan
- evaluate the plan
what has to happen for team nursing?
collaboration
If pt met all their goals in care plan, what do you do?
You discontinue care plan, pt will be leaving most likely.
what to teach a pt about insulin?
rotate injection site
7 rights of medication administration
- right med
- right dose
- right pt
- right route
- right time
- right documentation
- right indication
a pt demonstrating how to give themselves insulin is an example of what?
psychomotor teaching method
when does a pt need to eat if getting insulin
pt needs to eat within 15-30 mins after taking insulin
(Aspart = rapid acting, “get your ass parts moving!”)
how is insulin administered?
subcutaneously.. 45 degrees OR 90
how to give IM injection
angle of needle… 90 degrees always!!!!
how to give intradermal injection
15-30 degrees (tb skin test)
what to do if order is missing something, there’s an error, or you’re questioning the order
call the provider!
library reference page order
- Author, 2. Date, 3. Title, 4. Publisher
4 modes of Roy’s Adaptation theory
- Physiologic
- Self-Concept
- Role Function
- Interdependence
subjective vs objective data
subjective - what the patient said, in direct quotes
objective - measurable data (vitals, wound, etc)
nursing process
Assess
Diagnose
Plan
Implement
Evaluate
when does the nurse gather all the data?
during the assessment! (ADPIE)
If pt has a different heritage & they have an odd behavior, what should you consider?
Their cultural differences
What are the 3 parts of a nursing diagnosis?
- diagnostic label from book
- related to factors
- defining characteristics aka “as evidenced by” aka the evidence or the why
how should denture care be performed?
-w/ soft toothbrush
-keep in mouth when pt dies
what to do first if foley does not have any urine after 2 hours?
-check if there are any kinks
-check location (make sure it is below bladder)
How to prevent orthostatic hypertension
-let pt dangle their feet to help blood flow and sit up for a minute
-ask if they feel dizzy or lightheaded
-pump ankles
-move slow
how to prevent or help stress incontinence?
pelvic muscle exercises AKA Kegels
what is the priority of a pt that is vomiting or has diarrhea?
Fluid & Electrolyte imbalance
preferred NG tube for stomach decompression
Salem Sump
**used for post op abdomen surgery, lavage (irrigation of stomach)
what to monitor for a pt w/ sleep apnea
oxygen! pulseox
how to tell if pt is resting well
slow & even RR, pt’s eyes will be closed, pt will be still (not tossing/turning)
how to wash hands for Cdif pt
soap and water!! NOT alcohol
this test evaluates cortical sensory function and is not usually done. use a blunt object to trace a number on the patient’s palm. Ask the pt to identify which number has been traced
graphesthesia
the test evaluates cortical sensory function and is not usually done. ask the pt to close the eyes and identify a familiar object (coin, key) placed in their palm
stereognosis
what do you do if pt can’t see well / has sensory deficit
Orient pt to their room
what is priority assessment during surgery
respiratory
when to give a pt their insulin
when the insulin peaks, give them their plate!
How to evaluate healing if pt has open wound
look at granulation tissue… measure it!!!!!
Look for REEDA
-Redness
-Edema (swelling)
-Ecchymosis (discoloration of skin due to bleeding underneath aka bruising)
-Discharge/drainage
-Approximation
REEDA
(how to evaluate wound healing)
-Redness
-Edema (swelling)
-Ecchymosis (discoloration of skin due to bleeding underneath aka bruising)
-Discharge/drainage
-Approximation
evisceration vs dehiscence
How to treat evisceration?
evisceration = organs coming out
dehiscence = separation/opening of the wound
*put a soaked in saline dressing on it! This is an emergency. Call the provider.
stool will be more liquid in which type of ostomy? (colostomy or ileostomy)
ileostomy because of location (right side aka stool doesn’t have enough time to fully form yet due to location)
**this makes it harder for meds to absorb so pts w/ an ileostomy cannot have coated tablets bc there is not enough time for med to absorb
a pt w/ an ileostomy cannot have what?
coated tablets or extended release meds
when to empty an ostomy?
1/3 to 1/2 full
what is a complication for pt’s with an ileostomy?
at risk for dehydration due to liquid stool
pts with these need to be monitored due to loss of fluids & sodium
ileostomies (pts w/ colostomies do not have a fluid/sodium loss)
where do you put a chest tube?
below the chest bc drains by gravity so needs to be below chest
Pt is on any kind of mask oxygen, food trays arrive… can they eat?
No, so get provider order first! (they will put on nasal canula which is changing the type of way it’s administered so need order for this)
What pts are at greater risk for med toxicity?
Renal impairment & Liver, elderly bc they don’t process meds as quickly
If you have pt who has impaired renal function, what does the provider have to do?
Change the dosage of the medication!!!! Make it lower dose!!!!!
How is it best to increase pt compliance w/ teaching?
Do it when they want to do it.. the patient, family/support person they have
Quiet learning environment
what are the 3 teaching methods based on domains of learning
- cognitive (occurs when an individual gains info to further develop intellectual abilities, mental capacities, understanding, & thinking processes)
- affective (deals w/ learning how to express feelings & emotions & to develop values, attitudes, beliefs needed toward improving health)
- psychomotor (involves the development of manual or physical skills, such as leaning how to walk or how to type on a computer)
explain what a nurse’s witnessing of a pt’s informed consent indicates
it indicates that the pt voluntarily gave consent, the pt’s signature is authentic, & the pt appears to be competent to give consent
Safety related to restraints
-put on bed frame!!!!
-Quick release or slip knot is used.
-Offer food, water, bathroom to pt
-monitor every 15 mins, remove every 2 hrs
Person w/ chronic disease, how would you ask a physiological question
“how is this affecting your mobility?”
Someone has chronic condition or needs preventative care.. what do you recommend?
getting screenings, vaccines like flu shot or PNA & shingles if they are older
examples of Advanced practice registered nurses
Clinical nurse specialist (CNS) – works on specific unit that specializes in something specific, like diabetes
Nurse practitioner (NP)
Certified nurse midwife (CNM)
Certified registered nurse
anesthetist (CRNA)
indirect care for nursing
(when pt isn’t there)
attending care conferences, documenting, and communicating about client care with other providers.
purpose of incidence report
they collect healthcare incident data with the goal to improve patient safety and care quality
this lets you name someone of your choice to make treatment decisions for you. That person can make most medical decisions - not just those about life-sustaining treatment when you are unable to speak for yourself.
advanced directive
-Failure to follow established standards of care
-Failure to use equipment in a responsible manner
-Failure to communicate
-Failure to document
-Failure to monitor and assess
-Failure to act as a patient’s advocate
negligence
the threat of harm (includes perceived threats)
assault
use of specific nutritional therapies to treat an illness, injury, or condition.
necessary to help body metabolize certain nutrients, correct nutritional deficiencies related to disease, eliminate foods that exacerbate disease symptoms.
medical nutrition therapy
this involves having more roles or responsibilities within a role than are manageable.
example of this is sandwich generation aka those trying to take care of older family members while caring for their own family and maintain career
Role Overload
examples of complimentary medicine
therapeutic touch, hypnotherapy, chiropractic therapy, relaxation, biofeedback, music, hers, mediation, massage
**this is used w/ conventional treatment!
this is a type of mind-body intervention, a process providing a person w/ visual or auditory info about autonomic physiological functions of the body such as muscle tension, skin temp, brain wave activity through the use of instruments
biofeedback
this is a type of energy therapy, traditional Chinese method of producing analgesia or altering the function of a body system by inserting thin needles along a series of lines
acupuncture
local vs systemic infection
local: ex is wound infection, localized symptoms would be pain, tenderness, warmth, redness at site
systemic: affects the entire body instead of a part.. can become fatal if undetected or untreated
patient safety goals
o Identify patients correctly
o Improve staff communication
o Use medications safely
o Use alarms safely
o Prevent infections
o Identify patients’ safety risks
o Prevent mistakes in injury
SBAR
o S- Situation
o B-Background
o A-Assessment
o R-Recommendation
