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NCLEX REVIEW > Nursing Role Basics > Flashcards

Nursing Role Basics Flashcards

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1
Q

What is medication reconciliation

A

When a run compares current and past meds

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2
Q

When is medication reconciliation done?

A

At every transition in care
Ex: long term- hospital- long term
Floor- floor if new orders change

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3
Q

What is the purpose of medication reconciliation?

A

Omissions
Duplications
Dosing
Interactions

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4
Q

The 5 rights of delegation

A 
Right person- consider experience
Right task
Right circumstances
Right direction & communication
Right supervision and evaluation
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5
Q

If a pt is unstable, should a rn delegate?

A

No

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6
Q

The rn should take which of the following pts

A 
Unstable or potential to be unstable
Blood transfusions
Initial teaching
Feelings- if unstable or post cva 
Initial plan of care
Discharge
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7
Q

What tasks are an lpn allowed to do?

A 
Trach suction
Foley- insert and measure
Dressings
Culture / data collection
Stable pts
Re-I force teaching
Contribute to nsg care plan
Administers IVPB meds
Monitors IV meds
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8
Q

Are lpn’s allowed to do sterile techniques?

A

Yes

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9
Q

What tasks are AP’s allowed to do?

A 
ADL's
VS's
Feeding
Bathing
Ambulating
Wt
I/o's 
Safety
Hygiene and grooming
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10
Q

What is the difference bx actual and potential problems?

A

Actual problems are problems occurring now and must be cared for/ assessed FIRST!

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11
Q

Mallows hierarchy of needs

A 
Physiological
Safety
Love/belonging
Esteem
Self actualization
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12
Q

What are the ABCS?

A

Airway
Breathing
Circulation
Safety

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13
Q

What is the RN’s role in consent?

A

We act as the witness

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14
Q

Types of consent

A

General- procedures and txs

Implied- life or limb, pt incapacitated , lifesaving situations

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15
Q

Who is responsible for dosing med errors?

A

Pharmacy

Doctor and RN

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16
Q

What is negligence/

A

The omission to do something

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17
Q

What is malpractice

A

Failure of a professional person to act or do something

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18
Q

Disaster tagging

A

Black- brain matter, severe head trauma, dilated pupils
Red- Immediate priority, breathing/ airway obstruction
Yellow- can wait a few hours too see( ex: fracture)
Green- walking wounded, (ex: sprains, fractures, general injuries)

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19
Q

When is culturally competent care required?

A 
Birth
Death/ end if life
Procedures
Communication 
Meds- herbs
Hygiene- shaving (particularly head)
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20
Q

Assessing cultural / religious preferences

A

Is it safe

Is it something you can do

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21
Q

In an emergent situation, if restraints are used, when does the order have to be signed?

A

Within 1 hour

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22
Q

How often must pt be released from restraints?

A 
Q2H:
ROM
Bathroom
Ambulate
Perfusion check
Tur and position
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23
Q

How often are VS’s taken when restraints are used?

A

Q 15 min

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24
Q

Seizure safety

A 
Suction in room
Padded side rails
O2
Bed in lowest position
Meds (anticonvulsants)
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25
Q

In-seizure protocol

A 
Get pt into a safe position
Clear the area
Pt on their side
Don't put anything into mouth
Time seizure
What did it look like?
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26
Q

Post seizure protocol

A

Re-orient pt

Clean pt if incontinent

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27
Q

Fire - RACE

A

Rescue
Alarm
Contain fire
Extinguish

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28
Q

What is brachytherapy

A

Sealed source of radiation

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29
Q

Visitor rules for Brachytherapy

A

30 mins per day
6 ft
No pregnancy / children

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30
Q

Nursing rules for brachytherapy

A 
Wear dosimeter badge
Cluster care
Use long tongs of dislodged
Linens don't leave pt room- scanned 
Distance from pt - 6 ft
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31
Q

When is trendelenburg C/I?

A

Brain swelling

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32
Q

Crutches

A

6” in front and sides
3 fingers under axillary
Wt should be bearing on hand bars, not axillary

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33
Q

What is the first question of gaits?

A

Is it wt bearing or not?

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34
Q

Which gait is non-wt bearing ?

A

3 pt gait

35
Q

Which gaits are partial/ wt bearing ?

A

2 and 4 pt gaits

36
Q

4 pt gait

A

Most stable

4 individual separate steps

37
Q

2 pt gait

A

Wt bearing on both legs

38
Q

What is the difference bx 2 and 4 pt gait?

A

2 pt- crutch and leg moved at the same time

39
Q

Stair rules

A

Good leg goes up first

Bad leg goes down first

40
Q

Canes

A
  • held on strong side
  • advance 6- 10” when walking
  • bad leg steps toward the cane initially
41
Q

What disinfectant kills viruses?

A

Bleach

NOT ALCOHOL

42
Q

Bleach: water ratio

A

1:10

43
Q

Semi-fowlers position

A

HOB > 30

44
Q

Fowlers position

A

HOB > 45

45
Q

High fowlers position

A

HOB > 90

46
Q

Supine position

A

Lying on back with head and shoulders propped up slightly with a pillow

47
Q

Prone position

A

Lying on abdomen with head turned to the side

48
Q

Lateral position

A

Side lying

49
Q

Sims position

A

Aka : semi prone

Lying on the left side with most wt anterior

50
Q

Trendelenburg position

A

Head and body lowered with ft elevated

51
Q

Modified trendelenburg

A

Supine with the legs elevated

52
Q

Reverse trendelenburg

A

Head elevated with ft lowered

53
Q

Dorsal recumbent position

A

Supine with knees flexed

54
Q

What situations do we use standard precautions?

A

Body fluids
Non- intact skin
Mucous membranes

55
Q

What situations do we use airborne precautions?

A

Measles
Varicella
TB

56
Q

PPE needed for airborn precautions

A

Standard PPE and N95 mask

Negative pressure room

57
Q

Situations for droplet precautions ?

A 
Strep
PNA
Scarlet fever rubella
Pertussis 
Mumps
Meningococcal PNA/sepsis
58
Q

Droplet precautions

A

Standard PPE

Same room as pt with same org

59
Q

Situations for contact precautions

A

Wound drainage
Fecal incontinence
Bodily discharges

60
Q

Rules for pt leaving the room on isolation

A

Contact- cover the wound
Droplet- pt wears mask
Airborn- pt wears surgical mask

61
Q

Should you ever leave a pt alone?

A

NO

62
Q

DO WE GIVE BOLUSES OF H2O THROUGH THE NGT?

A

NO

63
Q

What is usually the earliest indicator that something is wrong?

A

Cardiac

64
Q

Pt’s become a priority when they exhibit one or all of the following

A

D- disorientation
A- Airway
B- breathing
C- Circulation

65
Q

When situation is not life threatening, what should the nurse do first?

A

ASSESS

66
Q

Name some examples of situations in which the nurse needs to act immediately before assessing

A

Compartment syndrome

Life endangering situations

67
Q

What are the 5 questions that should be asked when assessing priority patients (priority questions)

A 
1- acute or chronic
2- expected s/s or unexpected?
3- treated or untreated
4- lab values- normal or abnormal?
5- time sensitive?
68
Q

Which nurses get the most stable pts?

A

Floats
New grads
Fill ins

69
Q

Which surgical patients get priority?

A

Consider recovery time

Do they require more than one form of assistance ?

70
Q

What step is always last in priority?

A

Documentation

71
Q

When do we notify the provider?

A

Critical situations

72
Q

What should we did when a family expresses concern?

A

Screen the patient

73
Q

What are the priority actions after a pt falls?

A

Consciousness and vitals

74
Q

What is CAGE?

A

Screening for alcoholism

75
Q

What is the screening for CAGE?

A

C- cut down
A- angry/ annoyed at others?
G- guilt
E- eye opener, need a fix when u first wake up

76
Q

What is one positive aspect of organ donation?

A

Helps grieving process- especially if a child dies

77
Q

How old does someone have to be to give informed consent?

A

17
Married
Pregnant
Emancipated

78
Q

When does a pt first get ambulated after surgery

A

Next shift or next day

79
Q

When should COPD pts rest?

A

In bx activities

80
Q

Older patients are always at risk for what with meds?

A

Toxicity

81
Q

What should be tried first before increasing or adding a pharm?

A

Non-pharm interventions

82
Q

In order to increase muscle strength, have the pt do what?

A

Encourage gross motor mvmt

83
Q

In order to increase coordination, encourage the pt to do what?

A

Encourage fine motor mvmt

84
Q

Incident reports

A
  • internal document only
  • use only facts
  • Do Not mention in patient chart

NCLEX REVIEW (5 decks)

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