Questions and Answers
What are the legal responsibilities of a nurse while observing client care?
To ensure patient safety and provide patient-centered care.
What information should be included in a change-of-shift report? (Select all that apply)
What common abbreviations are used in information technology?
Common abbreviations include IT, EMR, and EHR.
What items should not be kept at the bedside of a patient?
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Which of the following is considered an intentional tort? (Select all that apply)
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What is the expected finding during a Romberg assessment?
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How should a nurse prioritize actions when handling defective equipment?
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Electrical devices should remain on during patient teaching about home safety.
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What are the instructions for assessing a client's blood pressure? (Select all that apply)
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To assist a client in using a fracture pan, the nurse should use a ______ pan.
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What are contraindications for receiving acupuncture?
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What are signs of extracellular fluid volume deficit?
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Which insulin mix contains both intermediate and short-acting insulin?
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A blood pressure reading of 124/92 mm Hg is classified as stage 1 hypertension.
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To verify nasogastric tube placement, aspirate gastric contents and test ______.
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What is an important part of tracheostomy care at home?
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What should be done when performing nasotracheal suctioning?
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What precautions should be taken with a client who has a Clostridium difficile infection?
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Study Notes
Legal Responsibilities: Nursing Role While Observing Client Care
- Nurses must uphold legal responsibilities while providing patient-centered care, adhering to established standards and regulations.
Admissions, Transfers, and Discharge: Preparing Change-of-Shift Report
- Use the SBAR format for reporting:
- Situation: patient's name, room number, diagnosis, age, sex.
- Background: history, allergies, attending physician, consultations.
- Assessment: vital signs, heart rhythm, skin integrity, IV site condition, dressings, dietary needs, fall risk, Foley catheter status, last bowel movement.
- Recommendations: current lab results, pending procedures, nursing concerns.
Information Technology: Commonly Used Abbreviations
- Familiarity with medical abbreviations is essential for effective communication and documentation.
Admissions, Transfers, and Discharge: Dispossession of Valuables
- Valuables include clothing, jewelry, money, assistive devices, and medications.
- Encourage clients to avoid keeping valuables at the bedside and document discussions about items left in the room, ensuring valuables are secured in facility safes.
Legal Responsibilities: Identifying an Intentional Tort
- Assault: Creating fear of harm (e.g., threatening NG tube placement).
- Battery: Intentional harmful contact (e.g., administering an injection against wishes).
- False Imprisonment: Restraining a competent person without consent.
Musculoskeletal and Neurosensory Systems: Performing Romberg Assessment
- Romberg test: Client stands feet together, arms at sides, eyes closed. Expected: minimal swaying for at least 5 seconds.
- Heel-to-toe walk: Client walks in a straight line. Expected: balanced walk without losing stability.
- Muscle strength: Assess through resistance; expected: strength equal or stronger on the dominant side.
Home Safety: Evaluating Client Understanding
- Assess client comprehension regarding home safety practices to prevent accidents.
Client Safety: Priority Action for Handling Defective Equipment
- Immediate removal of defective equipment from use to ensure safety in patient care environments.
Home Safety: Client Teaching About Electrical Equipment Safety
- Instruct clients to turn off oxygen sources and electrical devices to prevent fire hazards.
Vital Signs: Assessing a Client's Blood Pressure
- Avoid nicotine and caffeine 30 minutes prior to measurement. Ensure the patient rests for 5 minutes before measuring BP while seated properly.
Bowel Elimination: Steps to Take When Administering a Large-Volume Enema
- Follow established protocols for safe and effective administration of enemas.
Bowel Elimination: Assisting a Client to Use a Fracture Pan
- Equipment: Use a fracture pan for supine clients or those with leg casts, and a regular pan for seated clients.
Mobility and Immobility: Priority Findings for a Client Who Is Immobile
- Identify key assessments related to the risks faced by immobile clients, including skin integrity and mobilization strategies.
Complementary and Alternative Therapies: Contraindications for Receiving Acupuncture
- Recognize cellulitis as a contraindication for acupuncture treatment.
Fluid Imbalances: Assessment Findings of Extracellular Fluid Volume Deficit
- Isotonic Fluid Volume Deficit (FVD) entails simultaneous loss of water and electrolytes, leading to hypovolemia.
- Dehydration pertains to only water loss, resulting in hemoconcentration with elevated hematocrit and serum electrolytes.
- Older adults are particularly susceptible to dehydration.
Diabetes Mellitus: Mixing Insulin
-
Premixed Insulins:
- 70% NPH and 30% regular (intermediate and short-acting).
- 75% insulin lispro protamine and 25% insulin lispro (intermediate and rapid-acting).
Vital Signs: Nursing Actions for Elevated Blood Pressure
- Elevated blood pressure classification based on the highest reading; stage 1 hypertension defined by SBP > 130 mm Hg or DBP > 80 mm Hg.
- Recommendations for monitoring and follow-up based on repeated elevated readings.
Nasogastric Intubation and Enteral Feedings: Verifying Placement
- Verify tube placement through gentle aspiration, checking gastric contents for pH ≤ 4, assessing color, odor, and consistency.
Airway Management: Teaching Tracheostomy Care at Home
- Guide clients on cleaning the outer cannula and inner cannula with aseptic techniques; use facility-approved solutions.
Airway Management: Nasotracheal Suctioning Technique
- For suctioning, lubricate the catheter, apply suction only while withdrawing, limit passes to two with ventilation intervals.
Bacterial, Viral, Fungal, and Parasitic Infections: Caring for a Client Who Has a Clostridium Difficile Infection
- Implement specific protocols for infection control and patient care concerning C. difficile infections.
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Description
Explore key nursing responsibilities related to patient care and effective communication during admissions, transfers, and discharges. This quiz covers essential concepts from RN QSEN guidelines, focusing on patient-centered care and teamwork. Use these flashcards to enhance your understanding of nursing best practices.
