Podcast
Questions and Answers
A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which bed position promotes safe care for this client?
A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which bed position promotes safe care for this client?
- Supine
- Trendelenburg
- Semi-Prone
- Semi-Fowler's (correct)
A nurse is helping a client who wants to return to bed from a chair. What action should the nurse prioritize?
A nurse is helping a client who wants to return to bed from a chair. What action should the nurse prioritize?
- Determine client's ability to help with transfer. (correct)
- Use transfer belt to assist client back to bed.
- Call for help with transfer.
- Obtain a walker for the client to use to transfer back to bed.
Which statement by a client with COPD demonstrates understanding of managing difficulty breathing at night?
Which statement by a client with COPD demonstrates understanding of managing difficulty breathing at night?
- Sit on side of bed with arms over pillows on bedside table. (correct)
- Lie on side with weight on hip and should with arms flexed in front of her
- Lie on back with head and shoulders on pillow
- Lie flat on stomach with head to one side.
A nurse manager is reviewing guidelines for preventing staff injury. Which instructions should the nurse prioritize including? (Select all that apply.)
A nurse manager is reviewing guidelines for preventing staff injury. Which instructions should the nurse prioritize including? (Select all that apply.)
A nurse educator is teaching about proper body mechanics. Which statements show the attendee understands? (Select all that apply)
A nurse educator is teaching about proper body mechanics. Which statements show the attendee understands? (Select all that apply)
During a mass casualty event, which client should the nurse prioritize?
During a mass casualty event, which client should the nurse prioritize?
During a mass casualty event, which clients can the nurse safely discharge to free up beds? (Select all that apply)
During a mass casualty event, which clients can the nurse safely discharge to free up beds? (Select all that apply)
A nurse educator is discussing tornado protocols. Which instructions should the nurse include? (Select all that apply)
A nurse educator is discussing tornado protocols. Which instructions should the nurse include? (Select all that apply)
An occupational health nurse is caring for an employee exposed to an unknown dry chemical, resulting in a chemical burn. Which intervention is appropriate?
An occupational health nurse is caring for an employee exposed to an unknown dry chemical, resulting in a chemical burn. Which intervention is appropriate?
During bomb threat training, which statement by a nurse indicates understanding of proper procedure?
During bomb threat training, which statement by a nurse indicates understanding of proper procedure?
What actions are appropriate to decrease the risk of falls for a newly admitted, oriented client who can follow directions? (Select all that apply.)
What actions are appropriate to decrease the risk of falls for a newly admitted, oriented client who can follow directions? (Select all that apply.)
During a review of seizure care, which statement by a nurse requires further instruction?
During a review of seizure care, which statement by a nurse requires further instruction?
A nurse observes smoke coming from under the door of the staff lounge. Which is the priority action?
A nurse observes smoke coming from under the door of the staff lounge. Which is the priority action?
Based on fall prevention, which newly admitted client should be assigned to the room closest to the nurses' station?
Based on fall prevention, which newly admitted client should be assigned to the room closest to the nurses' station?
A newly admitted client has a history of falls. Which of the following is the nurse's priority action?
A newly admitted client has a history of falls. Which of the following is the nurse's priority action?
When preparing a sterile field during a dressing change, a nurse notes that the client is coughing and sneezing. What action should the nurse take?
When preparing a sterile field during a dressing change, a nurse notes that the client is coughing and sneezing. What action should the nurse take?
Which objects can the nurse touch without breaching sterile technique while wearing sterile gloves? (Select all that apply)
Which objects can the nurse touch without breaching sterile technique while wearing sterile gloves? (Select all that apply)
A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface. Which flap should the nurse unfold first?
A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface. Which flap should the nurse unfold first?
Which instructions should the nurse include when discussing handwashing with assistive personnel (AP)? (Select all that apply)
Which instructions should the nurse include when discussing handwashing with assistive personnel (AP)? (Select all that apply)
Which events should the nurse recognize as contaminating a sterile field prepared for a chest tube insertion? (Select all that apply)
Which events should the nurse recognize as contaminating a sterile field prepared for a chest tube insertion? (Select all that apply)
A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). What illustrates the rationale for reporting?
A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). What illustrates the rationale for reporting?
A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. What should the nurse include in the plan of care? (Select all that apply)
A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. What should the nurse include in the plan of care? (Select all that apply)
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. Which condition should the nurse suspect?
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. Which condition should the nurse suspect?
A client reports a severe sore throat, pain when swallowing, and swollen lymph nodes. Which stage of infection is the client experiencing?
A client reports a severe sore throat, pain when swallowing, and swollen lymph nodes. Which stage of infection is the client experiencing?
Clinical manifestations of systemic infection include:
Clinical manifestations of systemic infection include:
When assessing a client's skin as part of a comprehensive exam, which findings should the nurse expect? (Select all that apply)
When assessing a client's skin as part of a comprehensive exam, which findings should the nurse expect? (Select all that apply)
Significant tenting of the skin over an older adult's forearm can be explained by which factors? (Select all that apply)
Significant tenting of the skin over an older adult's forearm can be explained by which factors? (Select all that apply)
After knee surgery, what should the nurse examine to assess the client's peripheral vascular system? (Select all that apply)
After knee surgery, what should the nurse examine to assess the client's peripheral vascular system? (Select all that apply)
Which lesions should nursing students recognize as vesicles during integumentary assessments? (Select all that apply)
Which lesions should nursing students recognize as vesicles during integumentary assessments? (Select all that apply)
Which integumentary assessment findings require immediate intervention?
Which integumentary assessment findings require immediate intervention?
When assessing a young adult male's musculoskeletal system, which findings should the nurse expect? (Select all that apply)
When assessing a young adult male's musculoskeletal system, which findings should the nurse expect? (Select all that apply)
When evaluating stereognosis, what action should the nurse take?
When evaluating stereognosis, what action should the nurse take?
A client reports pain during internal rotation of her right shoulder. Which activity is this problem likely to affect?
A client reports pain during internal rotation of her right shoulder. Which activity is this problem likely to affect?
Which tests should the nurse perform to test the client's balance? (Select all that apply)
Which tests should the nurse perform to test the client's balance? (Select all that apply)
Which neurosensory findings should the nurse expect in an older adult? (Select all that apply)
Which neurosensory findings should the nurse expect in an older adult? (Select all that apply)
A client is sitting in a chair for 3 hr. Which problem is the client at risk for developing?
A client is sitting in a chair for 3 hr. Which problem is the client at risk for developing?
Which intervention should the nurse implement to maintain the patency of the client's airway?
Which intervention should the nurse implement to maintain the patency of the client's airway?
Which nursing interventions reduce the risk of thrombus development? (Select all that apply)
Which nursing interventions reduce the risk of thrombus development? (Select all that apply)
Which client statement indicates understanding of the purpose of a sequential compression device?
Which client statement indicates understanding of the purpose of a sequential compression device?
To promote the safe use of a cane, which instructions should the nurse provide? (Select all that apply)
To promote the safe use of a cane, which instructions should the nurse provide? (Select all that apply)
A client with aphasia after a cerebrovascular accident. What should the nurse do to promote communication? (Select all that apply)
A client with aphasia after a cerebrovascular accident. What should the nurse do to promote communication? (Select all that apply)
A client had an amphetamine overdose and has sensory overload. Which intervention should the nurse implement?
A client had an amphetamine overdose and has sensory overload. Which intervention should the nurse implement?
Which assessment findings indicate a sensorineural hearing loss in the left ear? (Select all that apply)
Which assessment findings indicate a sensorineural hearing loss in the left ear? (Select all that apply)
Which statement by a client who started wearing hearing aids indicates understanding of the instructions?
Which statement by a client who started wearing hearing aids indicates understanding of the instructions?
Which medication taken by a client with risk factors for hearing loss should alert the nurse to a further risk for ototoxicity? (Select all that apply)
Which medication taken by a client with risk factors for hearing loss should alert the nurse to a further risk for ototoxicity? (Select all that apply)
A nurse is determining a client's ability to assist with a transfer from a chair back to bed. What is the most important reason for the nurse to collect this data?
A nurse is determining a client's ability to assist with a transfer from a chair back to bed. What is the most important reason for the nurse to collect this data?
To assist a client with COPD who reports increasing dyspnea at night, which intervention is MOST appropriate?
To assist a client with COPD who reports increasing dyspnea at night, which intervention is MOST appropriate?
A nurse is teaching proper body mechanics. Which instructions indicate understanding? (Select all that apply)
A nurse is teaching proper body mechanics. Which instructions indicate understanding? (Select all that apply)
During a mass casualty event, the nurse should prioritize treatment for which client?
During a mass casualty event, the nurse should prioritize treatment for which client?
Following a mass casualty event, which clients are appropriate for discharge to create bed availability? (Select all that apply)
Following a mass casualty event, which clients are appropriate for discharge to create bed availability? (Select all that apply)
What should a nurse include in tornado safety protocol education? (Select all that apply)
What should a nurse include in tornado safety protocol education? (Select all that apply)
An employee experiences a dry chemical burn. What is the MOST appropriate first action for the occupational health nurse?
An employee experiences a dry chemical burn. What is the MOST appropriate first action for the occupational health nurse?
A nurse is teaching about bomb threat protocols. Which statement indicates understanding of the proper procedure?
A nurse is teaching about bomb threat protocols. Which statement indicates understanding of the proper procedure?
What interventions are appropriate to decrease the risk of falls for a newly admitted, oriented client. (Select all that apply.)
What interventions are appropriate to decrease the risk of falls for a newly admitted, oriented client. (Select all that apply.)
A nurse is reviewing seizure precautions. Which nursing statement requires further instruction?
A nurse is reviewing seizure precautions. Which nursing statement requires further instruction?
Upon discovering smoke emanating from the staff lounge, what is the nurse's priority action?
Upon discovering smoke emanating from the staff lounge, what is the nurse's priority action?
Based on fall prevention, which newly admitted client should be assigned closest to the nurses' station?
Based on fall prevention, which newly admitted client should be assigned closest to the nurses' station?
A newly admitted client has a history of falls. What nursing action takes priority?
A newly admitted client has a history of falls. What nursing action takes priority?
A nurse is preparing a for a sterile dressing change when they notice the client is coughing. Which intervention is most appropriate?
A nurse is preparing a for a sterile dressing change when they notice the client is coughing. Which intervention is most appropriate?
A nurse is preparing a sterile field. Which actions would contaminate the sterile field? (Select all that apply.)
A nurse is preparing a sterile field. Which actions would contaminate the sterile field? (Select all that apply.)
The nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). Which of the following is the rationale for reporting SARS cases to public health authorities? (Select all that apply.)
The nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). Which of the following is the rationale for reporting SARS cases to public health authorities? (Select all that apply.)
A nurse is contributing to the plan of care for a client with suspected pertussis. Which interventions should be included? (Select all that apply)
A nurse is contributing to the plan of care for a client with suspected pertussis. Which interventions should be included? (Select all that apply)
A client presents with linear clusters of fluid-containing vesicles with some crusting. Which condition is suspected?
A client presents with linear clusters of fluid-containing vesicles with some crusting. Which condition is suspected?
The nurse is educating about systemic infections. What clinical manifestations would support the presence of a systemic infection? (Select all that apply.)
The nurse is educating about systemic infections. What clinical manifestations would support the presence of a systemic infection? (Select all that apply.)
During a skin assessment of a client, what findings should the nurse expect?
During a skin assessment of a client, what findings should the nurse expect?
What factors can explain significant tenting of the skin over an older adult's forearm? (Select all that apply)
What factors can explain significant tenting of the skin over an older adult's forearm? (Select all that apply)
A nurse assesses a client's vascular system postoperatively. Which components are essential for evaluation? (Select all that apply.)
A nurse assesses a client's vascular system postoperatively. Which components are essential for evaluation? (Select all that apply.)
During an integumentary assessment, which lesions should the nursing students recognize as vesicles? (Select all that apply.)
During an integumentary assessment, which lesions should the nursing students recognize as vesicles? (Select all that apply.)
When assessing the integumentary system, which requires immediate intervention?
When assessing the integumentary system, which requires immediate intervention?
Flashcards
Enteral feeding position
Enteral feeding position
Elevate the head of the bed to 30-45 degrees to prevent aspiration.
Priority before transfer
Priority before transfer
Assess the client's ability to assist with the transfer to ensure safety and prevent injury.
Best position for COPD at night
Best position for COPD at night
Sitting on the side of the bed with arms supported on pillows allows for maximum lung expansion.
Key to safe transfer
Key to safe transfer
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Principles of body mechanics
Principles of body mechanics
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Mass casualty triage
Mass casualty triage
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Safe discharge examples
Safe discharge examples
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Tornado safety
Tornado safety
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Dry chemical burn
Dry chemical burn
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Bomb threat response
Bomb threat response
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Fall prevention
Fall prevention
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Seizure care - next steps
Seizure care - next steps
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Responding to smoke/fire
Responding to smoke/fire
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Fall-risk room placement
Fall-risk room placement
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Priority for fall risk
Priority for fall risk
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Client coughing during dressing change
Client coughing during dressing change
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Sterile field touching
Sterile field touching
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Opening sterile pack
Opening sterile pack
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Handwashing
Handwashing
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Contaminated sterile field
Contaminated sterile field
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Reporting communicable diseases
Reporting communicable diseases
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Pertussis precautions
Pertussis precautions
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Herpes zoster appearance
Herpes zoster appearance
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Illness stage
Illness stage
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Systemic infection signs
Systemic infection signs
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Normal skin findings
Normal skin findings
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Skin tenting causes
Skin tenting causes
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Peripheral vascular exam
Peripheral vascular exam
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Vesicle lesions
Vesicle lesions
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Priority skin finding
Priority skin finding
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Musculoskeletal findings
Musculoskeletal findings
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Stereognosis tests what?
Stereognosis tests what?
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Internal rotation affects...
Internal rotation affects...
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Balance assessment
Balance assessment
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Aging neurosensory changes
Aging neurosensory changes
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Sitting too long causes
Sitting too long causes
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Maintain airway patency
Maintain airway patency
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Prevent thrombus
Prevent thrombus
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SCD purpose
SCD purpose
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Cane usage
Cane usage
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Communication strategies
Communication strategies
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Sensory overload
Sensory overload
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Sensorineural loss findings
Sensorineural loss findings
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Hearing aid care tips
Hearing aid care tips
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Ototoxic drugs
Ototoxic drugs
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Therapeutic communication-death
Therapeutic communication-death
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General adaptation syndrome
General adaptation syndrome
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Role conflict
Role conflict
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Stress coping tools
Stress coping tools
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Coping open structure
Coping open structure
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Study Notes
Enteral Tube Feedings & Bed Position
- Semi-Fowler's position is the safest bed position for a client receiving enteral tube feedings due to dysphagia.
Assisting Client Back to Bed
- Determine the client's ability to help with the transfer is the priority action when assisting a client from chair back to bed.
COPD & Breathing Difficulty at Night
- Clients can sit on the side of the bed with arms over pillows on a bedside table to ease nighttime breathing difficulties.
Preventing Nurse Injury
- Request assistance when repositioning clients.
- Avoid twisting the spine or bending at the waist.
- Use smooth movements when lifting and moving clients.
Proper Body Mechanics
- A lower center of gravity increases stability.
- Broaden the base of support by spreading feet apart.
- Hold objects close to the body when lifting.
Mass Casualty Triage
- A client with partial and full-thickness burns to the face, neck, and chest is the highest priority in a mass casualty event.
Mass Casualty Discharge
- Clients who are 24 hours post-op following a mastectomy can be safely discharged in a mass casualty event
- Elective surgery patients (scheduled for an appendectomy) can be safely discharged in a mass casualty event.
Tornado Protocol
- Place blankets over clients confined to beds.
- Move beds away from windows.
- Draw shades and close drapes.
Chemical Burn from Dry Chemical
- Brush the chemical off the skin and clothing.
Bomb Threat Procedure
- Listen for background noises during a bomb threat phone call.
Fall Risk Reduction
- Ensure the client's call light is within reach.
- Provide the client with nonskid footwear.
- Complete a fall-risk assessment.
Seizure Management
- Do not go to the nurses' station for assistance during a seizure. Stay with the patient.
Fire Safety
- Evacuate clients if smoke is coming from under a door.
Room Assignment Priority
- Assign the client who is post-operative following a below-the-knee amputation and who has documented falls to the room closest to the nurses' station.
Fall Risk Priority Action
- Complete a fall-risk assessment for a newly admitted client with a history of falls.
Surgical Dressing Change & Client Coughing/Sneezing
- Place a mask on the client to limit the spread of micro-organisms into the surgical wound when changing a surgical dressing
Sterile Procedure - What Can Be Touched
- The inner wrapping of an item on the sterile field.
- An irrigation syringe on the sterile field.
- One gloved hand with the other gloved hand.
Unfolding Sterile Pack
- The flap farthest from the body should be unfolded first.
Handwashing Technique
- Wash the hands with soap and water for at least 15 seconds.
- Use a clean paper towel to turn off hand faucets.
Contamination of Sterile Field
- Moisten a cotton ball with sterile normal saline and places it on the sterile field.
- The procedure is delayed 1 hr because the provider receives an emergency call.
- The nurse turns to speak to someone who enters through the door behind the nurse.
Reporting Communicable Diseases Rationale
- Planning and evaluating control and prevention strategies.
- Determining public health priorities.
- Ensuring proper medical treatment.
- Monitoring for common-source outbreaks.
Pertussis Plan of Care
- Wear a mask when providing care within 3 feet of the client.
- Place a surgical mask on the client if transportation to another department is unavoidable.
- Wear a gown when performing care that may result in contamination from secretions.
Skin Condition
- herpes zoster presents with linear clusters of fluid-containing vesicles with some crustings.
Stages of Infection
- Severe sore throat, pain when swallowing, and swollen lymph nodes indicate the illness stage of infection.
Systemic Infection Manifestations
- Fever.
- Malaise.
- Increase in pulse and respiratory rate.
Expected Skin Assessment Findings
- Capillary refill in 2 seconds.
- Thick skin on the soles of the feet.
- Numerous light brown macules on the face.
Tenting of Skin in Older Adults
- Loss of adipose tissue.
- Dehydration.
- Diminished skin elasticity.
Assessing Peripheral Vascular System
- Skin color.
- Edema.
- Skin temperature.
Students recognize vesicles
- Herpes simplex
- Varicella
Skin Findings
- Cyanosis requires immediate intervention.
Musculoskeletal Findings
- A concave lumbar spine posteriorly is normal
- Muscles slightly larger on his dominant side is normal
Neurosensory Evaluation
- Stereognosis is tested by having the client identify familiar objects with their eyes closed.
Shoulder Pain Affecting Activities
- Pain during internal rotation of the right shoulder affects fastening a bra behind the back.
Balance Testing
- Romberg test.
- Heel-to-toe walk.
Neurosensory Changes in Older Adults
- Some vision and hearing decline.
- Slower fine finger movement.
- Slower superficial pain sensation.
Prolonged Sitting Risks
- Pressure ulcer development from prolonged sitting.
Maintaining Airway Patency
- Promote incentive spirometer use for clients on bed rest.
Reducing Thrombus Risk Postoperatively
- Apply elastic stockings.
- Assist the client to change position often.
Sequential Compression Device Understanding
- "This thing will keep the blood pumping through my leg."
Safe Cane Use
- Hold the cane on the right side (strong side).
- Keep two points of support on the floor.
- After advancing the cane, move the weaker leg forward.
Aphasia Communication
- Minimize background noise.
- Allow plenty of time for the client to respond.
- Use brief sentences with simple words.
Sensory Overload
- Provide a private room, and limit stimulation following amphetamine overdose.
Sensorineural Hearing Loss
- Weber test showing lateralization to the right ear.
- No signs of obstruction in the left ear canal.
- Rinne test showing length of time is decreased for air and bone conduction.
Hearing Aid Instructions
- "I take the batteries out of my hearing aids when I take them off at night."
Ototoxic Medications
- Furosemide (Lasix)
- Ibuprofen (Advil)
Surgical Dressing Change and Client Coughing/Sneezing
Place a mask on the client to limit the spread of micro-organisms into the surgical wound.
Unfolding Sterile Pack
- The flap farthest from the body.
Surgical sterile gloving
- The inner wrapping of an item on the sterile field
- An irrigation syringe on the sterile field
- One gloved hand with the other gloved hand
Proper handwashing technique includes these instructions to assistive personal
- Wash the hands with soap and water for at least 15 seconds.
- Use a clean paper towel to turn off hand faucets.
Contaminating sterile field
- The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field.
- The procedure is delayed by 1 hr because the provider receives an emergency call.
- The nurse turns to speak to someone who enters through the door behind the nurse
Grief Response
- "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling."
General Adaptation Syndrome (GAS)
- Alarm stage
Role Problem & Physical Limitations
- Role conflict
Nursing Interventions Stress, Coping, and Adherence
- Allow the client to provide input on the treatment plan.
- Assist the client with time management, and address the client's priorities.
- Encourage the client in the expression of feelings and concerns
Using open structure for coping with crisis
- Convening a family meeting
Communicating Self-Care Rationale
- The client's sense of loss can be lessened through retaining control of some areas of life
Kubler-Ross Model of Grief
- Bargaining
Facilitate Mourning
- "Would you like me to contact the chaplain to come and speak with you?"
- "You know, it is quite normal to feel anger toward your loved one at this time."
- "Tell me more about how you are feeling."
End of Life Expected Findings
- Decreased muscle tone
Postmortem Care Actions
- Apply fresh linens and place a clean gown on the body
- Remove all equipment from the bedside
- Dim the lights in the room
Stress Urinary Incontinence
- Decrease or avoid caffeine
- Avoid drinking alcohol
Indwelling Catheter
- Check to see whether the catheter is patent.
24 Hour Urine Collection
- Discard the first voiding
Increase the Risk of Urinary Tract Infections
- Frequent sexual intercourse, location of the urethra closer to the anus, frequent catheterization
Bladder Retraining Program
- Have the client record urination times.
- Gradually increase the urination intervals.
- Remind the client to hold urine until the next scheduled urination time.
Stroke and Aphasia Communication
- Make sure only one person speaks at a time.
- Allow plenty of time for the client to respond
- Use brief sentences with simple words
Sensory Overload
- Provide a private room, and limit stimulation
Sensorineural Hearing Loss in the Left Ear
- Weber test showing lateralization to the right ear
- Rinne test air conduction is decreased
High Rise of Ototoxicity
- furosemide
- Ibuprofen
Hearing loss review
- "I take the batteries out of my hearing aids when I take them off at night.
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