Podcast
Questions and Answers
A patient with a chronic respiratory condition has an oxygen saturation (SpO2) reading of 90%. Which action is most appropriate, assuming other vital signs are within acceptable limits for this patient?
A patient with a chronic respiratory condition has an oxygen saturation (SpO2) reading of 90%. Which action is most appropriate, assuming other vital signs are within acceptable limits for this patient?
- Document the finding and continue to monitor the patient's respiratory status. (correct)
- Immediately notify the physician due to indication of severe respiratory distress.
- Administer oxygen via a non-rebreather mask at 15 liters per minute.
- Increase the patient's oxygen flow rate by 1 liter per minute and reassess in 1 hour.
What is the primary rationale for a nurse to use evidence-based practice when planning patient care?
What is the primary rationale for a nurse to use evidence-based practice when planning patient care?
- To standardize care across all healthcare settings.
- To reduce the cost of patient care by using less expensive treatments.
- To minimize the time spent researching interventions.
- To ensure the use of the most effective interventions, improving patient outcomes. (correct)
After assisting a patient with bathing, a nurse observes a new area of skin breakdown on the patient's coccyx. What should be the nurse's first action?
After assisting a patient with bathing, a nurse observes a new area of skin breakdown on the patient's coccyx. What should be the nurse's first action?
- Reposition the patient every 4 hours to relieve pressure.
- Document the finding in the patient's chart.
- Apply a protective barrier cream to the area.
- Report the skin breakdown to the healthcare provider and implement pressure-reducing strategies. (correct)
A nurse is preparing to administer medication to a patient. What is the MOST essential step to ensure patient safety?
A nurse is preparing to administer medication to a patient. What is the MOST essential step to ensure patient safety?
A patient reports a pain level of 7 out of 10 but denies any visible signs of discomfort. How should the nurse proceed with this information?
A patient reports a pain level of 7 out of 10 but denies any visible signs of discomfort. How should the nurse proceed with this information?
Which situation requires a nurse to remove gloves and perform hand hygiene immediately?
Which situation requires a nurse to remove gloves and perform hand hygiene immediately?
A patient who is prescribed droplet precautions needs to be transported to radiology. Which action is MOST important for the nurse to take?
A patient who is prescribed droplet precautions needs to be transported to radiology. Which action is MOST important for the nurse to take?
A nurse assesses a patient and finds the following vital signs: Temperature 101.2°F (38.4°C), pulse rate 110 bpm, respiratory rate 24 breaths per minute, and blood pressure 130/86 mmHg. Which vital sign requires the MOST immediate attention?
A nurse assesses a patient and finds the following vital signs: Temperature 101.2°F (38.4°C), pulse rate 110 bpm, respiratory rate 24 breaths per minute, and blood pressure 130/86 mmHg. Which vital sign requires the MOST immediate attention?
How should a nurse prioritize care for multiple patients, considering ethical principles?
How should a nurse prioritize care for multiple patients, considering ethical principles?
Following catheter insertion, a patient reports burning during urination, and the nurse notices new onset hematuria. What is the nurse's MOST appropriate initial action?
Following catheter insertion, a patient reports burning during urination, and the nurse notices new onset hematuria. What is the nurse's MOST appropriate initial action?
When providing oral care to an unconscious patient, which action is MOST important for the nurse to prevent aspiration?
When providing oral care to an unconscious patient, which action is MOST important for the nurse to prevent aspiration?
A patient is being discharged with a new medication. What should the nurse do to evaluate the effectiveness of patient teaching?
A patient is being discharged with a new medication. What should the nurse do to evaluate the effectiveness of patient teaching?
Which nursing intervention is MOST effective in preventing healthcare-associated infections (HAIs) related to urinary catheters?
Which nursing intervention is MOST effective in preventing healthcare-associated infections (HAIs) related to urinary catheters?
A patient with a history of falls is being admitted to the hospital. Which action is MOST important for the nurse to implement to ensure the patient's safety?
A patient with a history of falls is being admitted to the hospital. Which action is MOST important for the nurse to implement to ensure the patient's safety?
A nurse walks into a patient's room and finds the patient on the floor. What is the nurse's FIRST action?
A nurse walks into a patient's room and finds the patient on the floor. What is the nurse's FIRST action?
Which precaution is MOST important for a nurse to take when caring for a patient with active tuberculosis?
Which precaution is MOST important for a nurse to take when caring for a patient with active tuberculosis?
What is the primary purpose of assessing a patient's skin integrity during basic hygiene care?
What is the primary purpose of assessing a patient's skin integrity during basic hygiene care?
A nurse is preparing to administer an intramuscular injection. Which site is generally recommended and safest for adults?
A nurse is preparing to administer an intramuscular injection. Which site is generally recommended and safest for adults?
A patient's blood pressure reading is consistently around 140/90 mmHg. What education should the nurse provide regarding this finding?
A patient's blood pressure reading is consistently around 140/90 mmHg. What education should the nurse provide regarding this finding?
When taking a patient's pulse, what characteristics should the nurse assess?
When taking a patient's pulse, what characteristics should the nurse assess?
Flashcards
Patient-centered care
Patient-centered care
Focuses on the individual needs, preferences, and values of each patient, ensuring respectful and responsive care.
Holistic care
Holistic care
Addresses the physical, emotional, social, and spiritual dimensions of a patient's well-being, offering comprehensive care.
Evidence-based practice
Evidence-based practice
Using the best available research evidence, clinical expertise, and patient values to guide nursing decisions, ensuring informed practice.
Infection control
Infection control
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Hand hygiene
Hand hygiene
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Personal protective equipment (PPE)
Personal protective equipment (PPE)
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Respiratory hygiene/cough etiquette
Respiratory hygiene/cough etiquette
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Contact precautions
Contact precautions
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Droplet precautions
Droplet precautions
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Airborne precautions
Airborne precautions
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Vital signs
Vital signs
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Pulse rate
Pulse rate
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Respiratory rate
Respiratory rate
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Blood pressure
Blood pressure
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Basic hygiene
Basic hygiene
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Bathing
Bathing
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Oral Hygiene
Oral Hygiene
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Hair Care
Hair Care
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Nail Care
Nail Care
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Perineal Care
Perineal Care
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Study Notes
- Fundamentals of nursing encompass the foundational principles and practices essential for providing quality patient care.
- These fundamentals serve as the bedrock for all nursing activities, ensuring safety, promoting health, and supporting patients through illness and recovery.
Core Principles
- Patient-centered care focuses on the individual needs, preferences, and values of each patient, ensuring that care is respectful and responsive.
- Holistic care addresses the physical, emotional, social, and spiritual dimensions of a patient's well-being.
- Evidence-based practice involves using the best available research evidence, clinical expertise, and patient values to guide nursing decisions.
- Safety is a paramount concern, involving the prevention of errors, adverse events, and harm to patients.
- Quality improvement is an ongoing process of evaluating and improving the delivery of care.
- Collaboration involves working effectively with other healthcare professionals to achieve shared goals.
- Ethical practice involves adhering to moral principles and professional codes of conduct.
Key Nursing Skills
- Assessment involves collecting and analyzing data about a patient's health status.
- Diagnosis involves identifying actual or potential health problems based on the assessment data.
- Planning involves developing a plan of care that outlines specific goals and interventions.
- Implementation involves carrying out the interventions outlined in the plan of care.
- Evaluation involves determining the effectiveness of the interventions and modifying the plan as needed.
- Communication involves therapeutic techniques with patients, families, and other healthcare providers.
- Critical thinking involves analyzing information, solving problems, and making sound clinical judgments.
- Technical skills involve performing procedures such as administering medications, wound care, and monitoring vital signs.
Infection Control
- Infection control refers to the policies and procedures used to minimize the risk of spreading infections, with the goal of preventing healthcare-associated infections (HAIs) and protecting patients and healthcare workers.
Standard Precautions
- Hand hygiene is the single most important measure to prevent the spread of infection.
- Use soap and water when hands are visibly soiled or contaminated; otherwise, use an alcohol-based hand rub.
- Personal protective equipment (PPE) includes gloves, gowns, masks, and eye protection, used when there is a risk of exposure to infectious materials.
- Respiratory hygiene/cough etiquette involves covering the mouth and nose when coughing or sneezing.
- Safe injection practices include using a new sterile syringe and needle for each injection.
- Proper handling of contaminated equipment and linens involves containing and transporting them in a manner that prevents the spread of infection.
Transmission-Based Precautions
- Contact precautions are used for infections spread by direct or indirect contact, requiring the use of gloves and gowns; examples include MRSA and C. difficile.
- Droplet precautions are used for infections spread by large respiratory droplets, requiring the use of a mask; examples include influenza and pertussis.
- Airborne precautions are used for infections spread by small airborne particles, requiring the use of a N95 respirator and airborne infection isolation room (AIIR); examples include tuberculosis and measles.
Vital Signs
- Vital signs are measurements of the body's most basic functions, used to assess a patient's overall health status and detect changes that may indicate a problem.
- The four main vital signs are body temperature, pulse rate, respiratory rate, and blood pressure.
- Pain is often considered the fifth vital sign.
- Oxygen saturation (SpO2) is another important indicator of respiratory function.
Temperature
- Normal body temperature ranges from 97.6°F to 99.6°F (36.4°C to 37.6°C), but may vary depending on the individual and the time of day.
- Common methods of measuring temperature include oral, tympanic, axillary, temporal artery, and rectal.
- Fever (pyrexia) is an elevated body temperature, often caused by infection or inflammation.
- Hypothermia is a decreased body temperature, which can be dangerous if not treated promptly.
Pulse
- Pulse rate is the number of times the heart beats per minute (bpm).
- Normal pulse rate ranges from 60 to 100 bpm in adults.
- Tachycardia is a pulse rate greater than 100 bpm.
- Bradycardia is a pulse rate less than 60 bpm.
- Pulse rhythm refers to the pattern of the heartbeats, which should be regular.
- Pulse strength (amplitude) reflects the force of the heartbeat, described as weak, thready, bounding, or normal.
- Common sites for assessing pulse rate include radial, brachial, carotid, and femoral arteries.
Respiration
- Respiratory rate is the number of breaths a person takes per minute.
- Normal respiratory rate ranges from 12 to 20 breaths per minute in adults.
- Tachypnea is a respiratory rate greater than 20 breaths per minute.
- Bradypnea is a respiratory rate less than 12 breaths per minute.
- Dyspnea is difficulty breathing.
- Oxygen saturation (SpO2) measures the percentage of hemoglobin saturated with oxygen, with a normal range of 95% to 100%.
Blood Pressure
- Blood pressure is the force of blood against the artery walls.
- Systolic blood pressure is the pressure when the heart beats (contracts).
- Diastolic blood pressure is the pressure when the heart rests between beats.
- Normal blood pressure is typically around 120/80 mmHg.
- Hypertension is high blood pressure, typically defined as 130/80 mmHg or higher.
- Hypotension is low blood pressure, typically defined as less than 90/60 mmHg.
Basic Hygiene
- Basic hygiene refers to practices that promote cleanliness and health, preventing the spread of germs and maintaining personal well-being.
Bathing
- Regular bathing removes dirt, sweat, and microorganisms from the skin, reducing the risk of infection and promoting comfort.
- Types of baths include complete bed baths, partial bed baths, tub baths, and showers, depending on the patient's condition and abilities.
- Pay attention to skin integrity during bathing, and use moisturizers to prevent dryness and breakdown.
Oral Hygiene
- Regular brushing and flossing remove plaque and bacteria from the teeth and gums, preventing tooth decay and gum disease.
- Provide oral care for patients who are unable to perform it themselves, using a soft toothbrush and toothpaste, or a moistened swab for unconscious patients.
Hair Care
- Regular hair care helps maintain cleanliness, prevent matting, and promote a sense of well-being.
- Brushing and combing removes tangles and distributes natural oils.
- Shampooing cleanses the hair and scalp, and can be done in the shower, at the sink, or in bed using special shampoo caps.
Nail Care
- Regular nail care prevents the accumulation of dirt and bacteria under the nails, reducing the risk of infection.
- Trim nails straight across and file the edges to prevent ingrown nails.
- Avoid cutting the cuticles, as this can increase the risk of infection.
Perineal Care
- Perineal care involves cleaning the perineal area (genitals and surrounding skin), which is essential for preventing infection and promoting comfort.
- Clean from front to back in female patients to prevent the spread of bacteria from the rectum to the urethra.
- Use warm water and mild soap, and dry the area thoroughly.
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