Nclex Review Final Flashcards
The B in the SBAR technique is
Background, what the clients treatments are
SBAR stands for
Situation
Background
Assessment
Recommendation
If a UAP who usually works on a different unit, is assigned to your unit what is the first question you should ask
What type of care did they provide
If a client has breakfast around the time he prays or meditates, and he doesnt want to be interrupted what is the best thing to do
Talk with the client to work out a plan
What task should be given to a UAP on a client with severe hyperglycemia
Vital Sign checks
90 year olds coming back to the hospital 2 weeks after they have been let go, what are 3 common reasons for this
Family preferences
Clients Health status
Poor communication among providers
Which client should be taken care of first
A - 70 year old male with history of heart failure, who reported going to the bathroom too much after taking a diuretic
B - 81 year old female with a history of coronary artery disease reporting dyspnea, nausea, and unusual discomfort in back
C - 86 year old male diagnosed with hypertension, whose last recorded B/P was 180/90 after learning a close friend was hospitalized
D - 94 year old female diagnosed with Peripheral artery disease reporting cramp like pains in both calf muscles following physical therapy
B
History of coronary artery disease, and client reproting dyspnea, nausea, and unusual discomfort , can be signs of what
Myocardial Infarction
What do you tell a 75 year old clients son, when the son says “ i do not understand the need for a living will”
Health Care decisions can be made based on clients wishes
What is a living will
a written statement detailing a person’s desires regarding their medical treatment in circumstances in which they are no longer able to express informed consent, especially an advance directive.
What nursing practice best reduces the chance of communication errors that might otherwise lead to negative client outcomes
Use standardized forms for client handoffs
An 80-year old client is hospitalized for a chronic condition, The client informs family members that a living will has been prepared and client wants no life-prolonging measures performed. The client becomes unresponsive and deteriorates. What is your first action
Notify the attending physician
Even if you are not using the clients name or any identifiers before discussing something outside of work what should you do
Nothing you can be fired for breaching confidentiality
If a nurse becomes attracted to one of there patients what should happen
The nurse transfers the care of the client to another nurse
The overall goal of CQI is
improve quality of health care
A client with a diagnosis of bipolar disorder has been ordered to a halfway house to be considered for placement. A social worker telephones the hospital unit and asks for information about the clients mental status and adjustment. What must the nurse understand before releasing any information
Make sure there is written consent from the client
A child is newly diagnosed with hepatitis A, what teaching instructions would the nurse reinforce with childs parents
Wash hands with soap and water after contact with child
If a radioactive bomb goes off in a shopping area what should a corresponding nurse instruct everyone to do first
cover mouth and nose
Why should a newly diagnosed patient with Active Tuberculosis be reported to health department
Contacts needs to be traced and screened
What is a very important patient teaching to a patient just prescribed oral solution of radioactive iodine.
Urine and saliva will be radioactive for 24 hours after ingestion
How should we transfer a patient who can only partially bear weight on a casted leg
Two caregivers must use a Stand-pivot technique and wide base of support when transferring
What action is priority for a 2 month old post op cleft lip and cleft palate repair
Bilateral elbow restraints must be used continuously
What should you do right after being accidentally stuck with a needle while changing linens
Wash hands vigorously
A child at home just swallowed poison and wants to know if they should induce vomiting what is your response
Vomiting should never be induced unless the poison control center tells you, just tell them to empty mouth of any remains
Adolescent hemophiliacs should be aware that contact sports can cause
Bleeding
rare bleeding disorder in which the blood doesn’t clot normally
Hemophilia
Older adults are at greater risk for experiencing adverse effects from medications because of what two things
Decrease in total body water and increase in fat
A nurse observes a newborn whose apgar score is 8 and then 9 at 5 minute evaluation. these scores would be more commonly related to what abnormality
Color
The most common apgar score deduction is
Acrocyanosis (color)
A parent asks what should i say to my child who asks where do babies come from, what should you tell them to say
Give a simple answer
What finding in newborns is due to maternal hormones
Enlargement of breasts
Short term memory loss is commonly mistaken for
Hearing loss
What is important to do when discussing a matter with an adolescent
Leave presence of guardians
A home health nurse is making an initial visit to a 70 year old client what is the first action
Identify learning needs
When a client is unconscious and involuntary forgetting painful events, ideas, conflicts this is called
Repression
When a client is conscious and forgetting voluntarily this is called
Supression
When a client blames someone else for a situation this is called
Projection
A newly diagnosed cancer patient tells you that you are stupid what should you do
a - Accept the clients statement
b - make no comment
c- tell the client that is is inappropriate
d - explore what is going on with the client
D
What are the only two FDA approved medications for treatment of Post traumatic stress disorder
Zoloft and Paxil
When a client says he refuses to eat because the food is cold what should you do
Ask client what foods are acceptable
A drunk driver got into an accident and 12 hours after admission is diaphoretic, tremulous, and irritable, b/p elevated. Client says i have to get out of here. what does this suggest
Client is in early stage of alcohol withdrawal
Caring for a client with an unstable spinal cord injury at the T-7 level, which nursing intervention should be priority for this client
Place client on pressure reducing mattress
For a child with atopic dermatitis, what is something we should enforce
Have child wear mittens and socks to prevent scratching
Children with celiac disease follow what kind of diet.
gluten-free
What is the expected urine output of children per hour
1 ml / kg / hour
For a patient with osteoporosis what should we ask them to perform
weight bearing activities
Chalky white to yellowish staining and pitting of the enamel are signs of what
excessive fluoride intake (fluorosis)
When performing manual fecal impaction removal, what is one thing we must know
patient can experience bradycardia during removal
Patients with Coronary artery disease should be eating how
small frequent meals.
avoid large heavy meals
What is common side effect of Pepto-bismol
Black tongue
What is a side effect of Nifedipine (Procardia)
Facial Flushing
Xanax taken for 3 days, what response should nurse see in patient
tranquilization, numbing of emotions
What is important to tell a patient taking bactrim, septra, and sulfatrim for UTI
Drink at least 8 glasses of water a day
What finding shows clients is no accepting Gentamicin correctly
Borderline renal function
Humalog is a _________ insulin and so it onsets in _____
Rapid-acting
10-15 minutes
Antihistamines may cause what in older patients
Confusion
For a client taking Tylenol 3 what is common side effect seen after 3 days
No bowel movement
Why might a nurse receive an order for a deep injection
Prevents medication from tissue irritation
Deep injection is also known as
Z track
A nurse is preparing a client scheduled for a Intravenous pyelogram (IVP) what is the most important information to collect prior
Allergy history
What can we expect in a 16 year old with a femur fracture 14 hours after surgery, Tachycardia, increased shortness of breath, a temperature of 100.1, feelings of anxiety, and a SaO2 of 88%
Fat embolism
Whats the most important data to collect after following an episode of Epilepticus
Level of Consciousness
If a nurse detects blood tinged fluid leaking from the nose and ears of a client diagnosed with trauma what should we do
Apply bulky, loose sterile dressings to the nose and ears
Which finding should nurse report immediately to charge nurse in 1 month old infant
A - inspiratory grunting
B - Increased heart rate with crying
C - Abdominal respirations
D - Irregular breathing rate
A
What is an important nursing action to a patient complaining of discomfort, after below the knee amputation
elevate stump
What is common to expect with a patient with portal hypertension
Ascites
What acronym should we use when determining priority in emergency situations
Airway
Breathing
Circulation
What does I PASS the BATON stand for
I = introduction (introduce yourself and your role/job) P = patient (name, identifiers, age, gender, location) A = assessment (presenting chief complaint, vital signs and symptoms and diagnosis) S = situation (current status/circumstances, including code status, recent changes, response to treatment) S = safety concerns (critical lab values/reports, socio-economic factors, allergies, alerts such as falls, isolation, etc.) B = background (co-morbidities, previous episodes, current medications, family history) A = actions (what actions were taken or are required and provide brief rationale) T = timing (level of urgency and explicit timing, prioritization of actions) O = ownership (who is responsible - nurse/doctor/team and patient/family responsibilities) N = next (what will happen next? anticipated change? what is the PLAN? what is the contingency plan?)
What does CUS stand for
C = concern ("I am concerned...")
U = uncomfortable ("I am uncomfortable...")
S = safety ("this is unsafe...")Because UAP’s are unlicensed they have
No scope of practice
What are the 5 rights of delegation
✓Right Task ✓Right Circumstances ✓Right Person ✓Right Direction/Communication ✓Right Supervision/Evaluation
What are the 4 C’s of communication
- Clear - Does the team member understand what I am saying?
- Concise - Have I confused the direction by giving too much unnecessary information?
- Correct - Is the direction given according to policy, procedures, job description, and the law?
- Complete - Does the delegatee have all the information necessary to complete the task?
What does ADPIE stand for
A = Assessment D = Diagnosis P = Planning I = Implementation E = Evaluation
COACTS for documentation stand for
Confidential Organized (chronologically) Accurate Complete Timely Subjective and objective data
What does SOAP stand for
S = subjective; what client tells you O = objective; what you observe, see, etc. A = assessment; what you think is going on based on the data P = plan; what you are going to do
What does DAR stand for
D = data - collecting information about a problem A = action - the task to be completed about the problem R = response - the client's response to the problem
True or False
A nurse has a legal duty to provide good samaritan care at the site of a traffic accident.
False - Nurses are protected from legal liability when they provide good samaritan care, but are not legally required to provide it.
True or False
A nurse has a legal duty to prove that he or she was not the “proximate cause” of damage to a client.
False - It is the plaintiff who must prove that the nurse was the proximate cause of damage; if accused, nurses must defend against the charge.
True or false
A nurse has a legal duty to encourage the client to sign the consent form if the nurse believes the procedure will really benefit the client.
False - The nurse should not try to influence the client, but should explain the procedure, its risks and benefits, and its alternatives.
True or false
A nurse has a legal duty to use the most secure form of restraint if the provider orders restraints.
False - The nurse should use the least restrictive form of restraint.
The health care provider has written an order for “morphine sulfate 2 mg IV push every 3 to 4 hours as needed for pain” for a 75 year-old client in an extended care facility. The licensed practical nurse (LPN) in charge has no other licensed persons working that shift. Which action should the LPN take first?
Nothing because IV Push is not under LPN scope of practice
A client refuses to take the medication prescribed because the client prefers to take an herbal preparation. What is the first action the nurse should take?
Remember, the collection of additional data is typically the initial approach when problems arise. Although the client has the right to refuse the medication, it’s possible that the herbal preparation does not have the intended purpose of the prescribed medication or may even have unintended side effects.
What does race stand for
Rescue or remove clients
Activate fire alarm system
Contain fire by closing doors and windows
Extinguish flames (with fire extinguisher)
If someone becomes poisoned in a nursing home what two things will stop us from inducing vomiting
alkaline or acid agents. Such poisons include lye, household cleaners, oven cleaner, furniture polish, metal cleaners, battery acids, or petroleum products.
FRAIL MOM & DAD stands for
Falls Relative or caregiver strain Activities of daily living Incontinence Living situation
Memory Impairment
Oculo-otic impairment (visual and auditory problems)
Malnutrition
Drugs
Advance directives
Depression
When handling and moving clients how high or low should bed be
at waist level
What are the 6 steps in chain of infection
Causative agent (Pathogen) Reservoir Portal of Exit Transmission Route Portal of Entry Susceptible host
The precaution we use for all clients for care is called
Standard Precautions
With patients with C.diff why must we wash our hands and not use hand sanitizer
because hand sanitizer does not kill C difficile spores
What do we wear for transmission based precautions
gown and gloves
What do we wear for droplet precautions
gown, gloves, surgical mask
What do we wear for airborne precautions
Respiratory protection with N95 respirator
what do we wear for neutropenic precautions
health care workers will wear gowns, masks, gloves when providing care
What must we avoid giving patients that are on neutropenic precautions
Must avoid giving raw fruits and vegetables
Immunity that is obtained by the development of antibodies resulting from an attack of infectious disease
naturally acquired immunity
Immunity that is obtained by vaccination
artificially acquired immunity
Immunity that is obtained by the transmission of antibodies from the mother through the placenta to the fetus or to the infant through the colostrum
naturally acquired immunity
Difference between passive and active immunity is
In active we produce our own antibodies
Passive is not permanent
Bacillus anthracis also known as ________ usually comes from
Anthrax
Farm animals
What is the drug of choice for Anthrax
ciprofloxacin hydrochloride (Cipro), drug of choice
Yersinia pestis also known as ______ usually comes from
Plague
Rodents or Fleas
What are the 4 drugs of choice for Plague
streptomycin
gentamycin (Garamycin)
doxycycline (Vibramycin)
ciprofloxacin hydrochloride (Cipro)
