Podcast
Questions and Answers
What bed position is recommended for safe care of a client receiving enteral tube feedings due to dysphagia?
What bed position is recommended for safe care of a client receiving enteral tube feedings due to dysphagia?
Semi-Fowler's position
What is the priority action for client transfer?
What is the priority action for client transfer?
Determine client's ability to help.
How can you relieve nighttime breathing difficulty for a client with COPD?
How can you relieve nighttime breathing difficulty for a client with COPD?
Sit on the side of the bed with arms over pillows on a bedside table.
What are some guidelines for preventing nurse injuries?
What are some guidelines for preventing nurse injuries?
What are the key principles of proper body mechanics?
What are the key principles of proper body mechanics?
In a mass casualty event, which client is the highest priority?
In a mass casualty event, which client is the highest priority?
During a mass casualty event, which clients can be safely discharged?
During a mass casualty event, which clients can be safely discharged?
What are some tornado emergency plan instructions?
What are some tornado emergency plan instructions?
What is the correct intervention for a chemical burn?
What is the correct intervention for a chemical burn?
What is an important response action during a bomb threat?
What is an important response action during a bomb threat?
What actions can reduce fall risk in alert clients?
What actions can reduce fall risk in alert clients?
What statement indicates a need for further instruction regarding seizure care?
What statement indicates a need for further instruction regarding seizure care?
What is the priority action when observing smoke?
What is the priority action when observing smoke?
Which client should be placed in the room closest to the nurses' station?
Which client should be placed in the room closest to the nurses' station?
What is the priority action for a newly admitted client with a history of falls?
What is the priority action for a newly admitted client with a history of falls?
What should the nurse do for a coughing and sneezing client?
What should the nurse do for a coughing and sneezing client?
What objects can a nurse touch while maintaining sterile technique?
What objects can a nurse touch while maintaining sterile technique?
What actions contaminate a sterile field?
What actions contaminate a sterile field?
Which food group is highest in carbohydrates?
Which food group is highest in carbohydrates?
How would 200 mL of ice be recorded?
How would 200 mL of ice be recorded?
What is the best dietary choice for wound healing?
What is the best dietary choice for wound healing?
How should red and watery wound drainage be documented?
How should red and watery wound drainage be documented?
How should soiled dressings be disposed of?
How should soiled dressings be disposed of?
What client statement indicates a proper understanding of cane use?
What client statement indicates a proper understanding of cane use?
What does dark amber urine with a foul odor indicate?
What does dark amber urine with a foul odor indicate?
What precautions are necessary for a stem cell transplant?
What precautions are necessary for a stem cell transplant?
What are appropriate interventions for clients with tuberculosis?
What are appropriate interventions for clients with tuberculosis?
What actions demonstrate proper hand hygiene technique?
What actions demonstrate proper hand hygiene technique?
What is a healthcare-associated infection (HAI)?
What is a healthcare-associated infection (HAI)?
What is folic acid?
What is folic acid?
What intervention should be implemented if a client experiences discomfort during an enema?
What intervention should be implemented if a client experiences discomfort during an enema?
What is the most reliable indicator of pain?
What is the most reliable indicator of pain?
What does a clear liquid diet include?
What does a clear liquid diet include?
What intervention should be implemented for sensory overload?
What intervention should be implemented for sensory overload?
What are some ototoxic medications?
What are some ototoxic medications?
What instructions should be provided for bladder retraining?
What instructions should be provided for bladder retraining?
What communication method can be used for expressive aphasia?
What communication method can be used for expressive aphasia?
What does skin turgor tenting indicate?
What does skin turgor tenting indicate?
How is stereognosis evaluated?
How is stereognosis evaluated?
What are some examples of balance tests?
What are some examples of balance tests?
What are some expected changes with aging skin?
What are some expected changes with aging skin?
What risk is a client at after prolonged sitting?
What risk is a client at after prolonged sitting?
What is the first action in the event of a fire?
What is the first action in the event of a fire?
What is the appropriate response to sterile field contamination?
What is the appropriate response to sterile field contamination?
What type of food is apple juice in a clear liquid diet?
What type of food is apple juice in a clear liquid diet?
What action is appropriate if a client reports discomfort during an enema?
What action is appropriate if a client reports discomfort during an enema?
What intervention is appropriate for sensory overload?
What intervention is appropriate for sensory overload?
What are some examples of ototoxic medications?
What are some examples of ototoxic medications?
What methods are used for bladder retraining?
What methods are used for bladder retraining?
What type of communication should be used for someone with expressive aphasia?
What type of communication should be used for someone with expressive aphasia?
What does tenting of the skin indicate?
What does tenting of the skin indicate?
What intervention is appropriate for airway patency?
What intervention is appropriate for airway patency?
What actions reduce the risk of thrombus?
What actions reduce the risk of thrombus?
What does an SCD do?
What does an SCD do?
What instructions are appropriate for safe cane use?
What instructions are appropriate for safe cane use?
How can you promote communication for patients with aphasia??
How can you promote communication for patients with aphasia??
What intervention is appropriate for a patient experiencing sensory overload?
What intervention is appropriate for a patient experiencing sensory overload?
What indicators would suggest Sensorineural hearing loss
What indicators would suggest Sensorineural hearing loss
What behavior shows an understanding of hearing aids?
What behavior shows an understanding of hearing aids?
What medications increase the risk of ototoxicity?
What medications increase the risk of ototoxicity?
Why is self-care important for patients with a terminal illness?
Why is self-care important for patients with a terminal illness?
What stage of grief is associated with smoking cessation?
What stage of grief is associated with smoking cessation?
What response should a nurse have to a grieving partner?
What response should a nurse have to a grieving partner?
What advice should be given for stress urinary incontinence?
What advice should be given for stress urinary incontinence?
What should the recording be for intake and output for ice chips?
What should the recording be for intake and output for ice chips?
What instructions should be given for a bladder retraining program?
What instructions should be given for a bladder retraining program?
List guidelines for preventing nurse injuries when moving or repositioning clients.
List guidelines for preventing nurse injuries when moving or repositioning clients.
True or False: When it comes to proper body mechanics, the lower the center of gravity, the more stable you are; to broaden your base of support, you should spread your feet apart; when you lift an object, you should hold it as close to your body as possible.
True or False: When it comes to proper body mechanics, the lower the center of gravity, the more stable you are; to broaden your base of support, you should spread your feet apart; when you lift an object, you should hold it as close to your body as possible.
In a mass casualty event, which client should be the highest priority?
In a mass casualty event, which client should be the highest priority?
What are tornado emergency plan instructions for bed-confined clients?
What are tornado emergency plan instructions for bed-confined clients?
What is an action to take when responding to a bomb threat over the phone?
What is an action to take when responding to a bomb threat over the phone?
How can you reduce fall risk in alert clients?
How can you reduce fall risk in alert clients?
Which of the following statements indicates a need for further instruction regarding seizure care?
Which of the following statements indicates a need for further instruction regarding seizure care?
What action should the nurse take when caring for a client who is coughing and sneezing?
What action should the nurse take when caring for a client who is coughing and sneezing?
List objects a nurse can touch while maintaining sterile technique.
List objects a nurse can touch while maintaining sterile technique.
List actions that contaminate a sterile field.
List actions that contaminate a sterile field.
How would 200 mL of ice be recorded for intake and output?
How would 200 mL of ice be recorded for intake and output?
How should wound drainage that is red and watery be documented?
How should wound drainage that is red and watery be documented?
True or False: Client understanding proper cane use is demonstrated by stating they will move their cane first, then their weaker leg.
True or False: Client understanding proper cane use is demonstrated by stating they will move their cane first, then their weaker leg.
What type of precautions are needed for a stem cell transplant?
What type of precautions are needed for a stem cell transplant?
List appropriate interventions for a patient with tuberculosis.
List appropriate interventions for a patient with tuberculosis.
List actions demonstrating proper hand hygiene technique.
List actions demonstrating proper hand hygiene technique.
Define Healthcare-associated infection (HAI).
Define Healthcare-associated infection (HAI).
What intervention should be taken if a client experiences discomfort during an enema?
What intervention should be taken if a client experiences discomfort during an enema?
What is a clear liquid diet?
What is a clear liquid diet?
What is an appropriate intervention for sensory overload?
What is an appropriate intervention for sensory overload?
What are some bladder retraining instructions that can teach a client?
What are some bladder retraining instructions that can teach a client?
What communication method would you use with a client who has aphasia?
What communication method would you use with a client who has aphasia?
How do you evaluate stereognosis?
How do you evaluate stereognosis?
Describe some balance tests.
Describe some balance tests.
What is a risk for a patient after prolonged sitting?
What is a risk for a patient after prolonged sitting?
What is the first action to take in the event of a fire?
What is the first action to take in the event of a fire?
What should you do if a sterile field is contaminated?
What should you do if a sterile field is contaminated?
Is food in clear liquid diet?
Is food in clear liquid diet?
What should you do if a client is experiencing discomfort during enema?
What should you do if a client is experiencing discomfort during enema?
When pain assessment is performed, what is key?
When pain assessment is performed, what is key?
Intervention for sensory overload?
Intervention for sensory overload?
Ototoxic medications examples?
Ototoxic medications examples?
Bladder retraining methods?
Bladder retraining methods?
Effective communication for expressive aphasia?
Effective communication for expressive aphasia?
Skin turgor assessment?
Skin turgor assessment?
Airway patency intervention?
Airway patency intervention?
Thrombus risk reduction actions?
Thrombus risk reduction actions?
Sequential compression devices (SCDs) understanding?
Sequential compression devices (SCDs) understanding?
Safe cane use instructions?
Safe cane use instructions?
Communication promotion for aphasia?
Communication promotion for aphasia?
Sensory overload intervention?
Sensory overload intervention?
Sensorineural hearing loss indicators?
Sensorineural hearing loss indicators?
Hearing aids understanding?
Hearing aids understanding?
Medications increasing ototoxicity risk?
Medications increasing ototoxicity risk?
Sterile field contamination action?
Sterile field contamination action?
Self-care importance for terminal illness?
Self-care importance for terminal illness?
Stage of grief for smoking cessation?
Stage of grief for smoking cessation?
Nurse response to grieving partner?
Nurse response to grieving partner?
Advice for stress urinary incontinence?
Advice for stress urinary incontinence?
Intake and output recording for ice chips in mL?
Intake and output recording for ice chips in mL?
Bladder retraining program instructions?
Bladder retraining program instructions?
What are some elements to understanding proper body mechanics?
What are some elements to understanding proper body mechanics?
Which clients can be safely discharged during a mass casualty event?
Which clients can be safely discharged during a mass casualty event?
What instructions should be given during a tornado emergency plan?
What instructions should be given during a tornado emergency plan?
How should you respond to a bomb threat?
How should you respond to a bomb threat?
What statement indicates further instruction is needed for seizure care?
What statement indicates further instruction is needed for seizure care?
What precautions should the nurse take when caring for a coughing and sneezing client?
What precautions should the nurse take when caring for a coughing and sneezing client?
What statement by a client indicates proper cane use understanding?
What statement by a client indicates proper cane use understanding?
What type of precautions are necessary for stem cell transplant recipients?
What type of precautions are necessary for stem cell transplant recipients?
What interventions are appropriate for a client with tuberculosis?
What interventions are appropriate for a client with tuberculosis?
What is the purpose of folic acid?
What is the purpose of folic acid?
What intervention should be taken for enema discomfort?
What intervention should be taken for enema discomfort?
What intervention should be taken for sensory overload?
What intervention should be taken for sensory overload?
What instructions should be given for bladder retraining?
What instructions should be given for bladder retraining?
What communication method is appropriate for a client with expressive aphasia?
What communication method is appropriate for a client with expressive aphasia?
What tests are used to assess balance?
What tests are used to assess balance?
What is the risk after prolonged sitting?
What is the risk after prolonged sitting?
What should you respond with if a sterile field is contaminated?
What should you respond with if a sterile field is contaminated?
What food is considered part of a clear liquid diet?
What food is considered part of a clear liquid diet?
Provide examples of ototoxic medications
Provide examples of ototoxic medications
What methods are included in bladder retraining?
What methods are included in bladder retraining?
What is an effective communication method for expressive aphasia?
What is an effective communication method for expressive aphasia?
What does skin turgor assessment indicate?
What does skin turgor assessment indicate?
To promote airway patency, what intervention should be taken?
To promote airway patency, what intervention should be taken?
What actions reduce thrombus risk?
What actions reduce thrombus risk?
What statement indicates understanding of sequential compression devices (SCDs)?
What statement indicates understanding of sequential compression devices (SCDs)?
What instructions should be given for safe cane use?
What instructions should be given for safe cane use?
What are the indicators of sensorineural hearing loss?
What are the indicators of sensorineural hearing loss?
What statement indicates understanding of hearing aids?
What statement indicates understanding of hearing aids?
What medications increase ototoxicity risk?
What medications increase ototoxicity risk?
What action could contaminate a sterile field?
What action could contaminate a sterile field?
Why is promoting self-care important for those with a terminal illness?
Why is promoting self-care important for those with a terminal illness?
What stage of grief is bargaining?
What stage of grief is bargaining?
What is the nurse's best response when interacting with those in the grieving process?
What is the nurse's best response when interacting with those in the grieving process?
What advice should be given for those experiencing stress urinary incontinence?
What advice should be given for those experiencing stress urinary incontinence?
If a client is given ice chips, how many mL should be recorded?
If a client is given ice chips, how many mL should be recorded?
What instructions should be given for those starting a bladder retraining program?
What instructions should be given for those starting a bladder retraining program?
Flashcards
Semi-Fowler's position
Semi-Fowler's position
Recommended bed position for safe care of a client receiving enteral tube feedings due to dysphagia.
Priority action for client transfer
Priority action for client transfer
Assess the ability of the client to assist in the transfer process to ensure safety.
Relieving nighttime breathing difficulty for COPD
Relieving nighttime breathing difficulty for COPD
Sit on the side of the bed with arms supported on pillows placed on a bedside table.
Guidelines for preventing nurse injuries
Guidelines for preventing nurse injuries
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Understanding proper body mechanics
Understanding proper body mechanics
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Highest priority client in mass casualty
Highest priority client in mass casualty
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Clients safely discharged during mass casualty
Clients safely discharged during mass casualty
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Tornado emergency plan instructions
Tornado emergency plan instructions
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Correct intervention for chemical burn
Correct intervention for chemical burn
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Response to bomb threat
Response to bomb threat
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Reducing fall risk in alert clients
Reducing fall risk in alert clients
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Further instruction needed for seizure care
Further instruction needed for seizure care
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Priority action when observing smoke
Priority action when observing smoke
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79-year-old post-op below-the-knee amputation
79-year-old post-op below-the-knee amputation
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Fall-risk assessment
Fall-risk assessment
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Coughing and sneezing client
Coughing and sneezing client
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Sterile technique objects
Sterile technique objects
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Contaminating actions for sterile field
Contaminating actions for sterile field
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Food group highest in carbohydrates
Food group highest in carbohydrates
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200 mL of ice
200 mL of ice
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Best dietary choice for wound healing
Best dietary choice for wound healing
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Red and watery wound drainage
Red and watery wound drainage
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Soiled dressing disposal
Soiled dressing disposal
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Proper cane use understanding
Proper cane use understanding
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Dark amber urine with foul odor
Dark amber urine with foul odor
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Precautions for stem cell transplant
Precautions for stem cell transplant
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Interventions for tuberculosis
Interventions for tuberculosis
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Proper hand hygiene technique
Proper hand hygiene technique
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Healthcare-associated infection (HAI)
Healthcare-associated infection (HAI)
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Folic acid
Folic acid
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Enema discomfort intervention
Enema discomfort intervention
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Most reliable indicator of pain
Most reliable indicator of pain
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Clear liquid diet
Clear liquid diet
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Sensory overload intervention
Sensory overload intervention
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Ototoxic medications
Ototoxic medications
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Bladder retraining instructions
Bladder retraining instructions
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Expressive aphasia communication method
Expressive aphasia communication method
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Skin turgor tenting indication
Skin turgor tenting indication
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Stereognosis evaluation
Stereognosis evaluation
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Balance tests
Balance tests
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Expected changes with aging skin
Expected changes with aging skin
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Risk after prolonged sitting
Risk after prolonged sitting
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First action in event of fire
First action in event of fire
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Sterile field contamination response
Sterile field contamination response
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Food in clear liquid diet
Food in clear liquid diet
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Client discomfort during enema
Client discomfort during enema
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Pain assessment
Pain assessment
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Intervention for sensory overload
Intervention for sensory overload
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Ototoxic medications examples
Ototoxic medications examples
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Bladder retraining methods
Bladder retraining methods
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Study Notes
Positioning and Transfer
- Semi-Fowler's position is recommended for clients receiving enteral tube feedings, especially those with dysphagia.
- When transferring a client, the priority is assessing their ability to assist.
- Request assistance when repositioning patients to prevent injury.
- Avoid twisting the spine or bending at the waist, using smooth movements when lifting/moving clients
- Sit on the side of the bed with arms supported on pillows over a bedside table to ease nighttime breathing for COPD.
Body Mechanics
- Stability increases with a lower center of gravity.
- A wider base of support, achieved by spreading the feet apart, enhances stability.
- Hold objects close to the body when lifting minimizes strain.
Emergency Response
- Prioritize clients with partial and full-thickness burns to the face, neck, and chest during mass casualty events.
- In mass casualty events, clients scheduled for an appendectomy or 24 hours post-mastectomy are safe for discharge.
- For a tornado, place blankets over bed-confined clients, move beds away from windows, and close drapes/shades.
- Brush chemicals off the skin and clothing for a chemical burn.
- Listen for background noises when responding to a bomb threat.
- Evacuate clients immediately upon observing smoke.
- In case of a fire, the first action is to evacuate clients.
- Place a 79-year-old post-op below-the-knee amputation patient closest to the nurses' station.
- In the event of a fire, evacuate clients as the first action.
Fall Risk Reduction
- Ensure the call light is within reach to reduce fall risk in alert clients.
- Provide non-skid footwear to reduce fall risk in alert clients.
- Complete a fall-risk assessment for newly admitted clients, especially those with a history of falls.
Seizure Precautions
- Refrain from going to the nurses' station for help during a seizure; remain with the client and provide support.
Infection Control
- Place a mask on clients who are coughing and sneezing.
- Wear an N95 mask, place the patient in a negative pressure room, assign the patient their own sharps container, and perform hand hygiene frequently when caring for patients with tuberculosis.
- Protective isolation is needed for stem cell transplant patients.
- Hand hygiene involves washing hands for at least 15 seconds with soap and water and using a clean paper towel to turn off faucets.
- A healthcare-associated infection (HAI) is acquired during healthcare treatment for other conditions.
Sterile Technique
- Objects that can be touched while maintaining sterile technique include the inner wrapping of an item on the sterile field, irrigation syringe on the sterile field, and one gloved hand with the other gloved hand.
- Actions that contaminate a sterile field include moistening a cotton ball with sterile saline and placing it on the field, delaying the procedure 1 hour due to an emergency call, and turning to speak to someone entering the room.
- When a sterile field is contaminated, create a new one.
- Turning away from the field contaminates it and requires a new one.
Nutrition and Elimination
- Fruits are the food group highest in carbohydrates.
- Record 200 mL of ice as 100 mL for intake.
- Dark amber urine with a foul odor indicates a bladder infection.
- Proteins are the best dietary choice for wound healing.
- Folic acid is a vitamin that prevents neural tube defects in developing fetuses.
- Lower the enema bag to alleviate discomfort during insertion.
- Clear liquid diets include fluids that are clear and free of solid particles, such as apple juice.
- Apple juice is considered part of a clear liquid diet.
Wound Care
- Document red and watery wound drainage as serosanguineous.
- Discard soiled dressings in a biohazard container.
Mobility
- Understanding of proper cane use is indicated by moving the cane first, then the weaker leg.
- Hold the cane on the stronger side for support.
- Maintain two points of support on the floor at all times.
- Move the weaker leg forward after the cane.
Sensory Impairment
- Furosemide and ibuprofen are examples of ototoxic medications that can contribute to hearing loss.
- Reduce sensory overload by placing the client in a private room with limited stimulation.
- For expressive aphasia, use a communication board to facilitate communication.
- Minimize background noise, allow extra response time, and use brief, simple sentences to promote communication for aphasia.
- Weber test lateralization to the right ear, No obstruction in the left ear canal, and Rinne test showing air conduction shorter than bone conduction are indicators for sensorineural hearing loss.
Assessments
- The client's self-report is the most reliable indicator of pain.
- Skin turgor tenting indicates dehydration, aging skin, or loss of adipose tissue.
- Evaluate stereognosis by asking the client to identify an object placed in their hand.
- The Romberg test and heel-to-toe walk assess balance.
- Expected changes with aging skin include slower light touch sensation, some vision and hearing decline, and slower fine finger movements.
Bladder Retraining
- Bladder retraining involves voiding at scheduled times, gradually increasing urination intervals, and holding urine until the next scheduled time.
- Keep a voiding diary, gradually increase urination intervals, and hold urine until the next scheduled time as instructions in a bladder retraining program.
Risk Factors
- Clients are at risk for pressure ulcers after sitting for 3 hours.
- Actions to reduce thrombus risk include avoiding the Valsalva maneuver, applying elastic stockings, and assisting the client to change positions often.
Assistive Devices
- Sequential compression devices (SCDs) function by keeping blood pumping in the legs.
- Remove hearing aid batteries at night.
Grief and Loss
- Self-care is important for terminally ill patients to maintain independence and control.
- Bargaining is a stage of grief often seen when quitting smoking.
- Respond to grieving partners with empathy, acknowledging their feelings ("It's normal to feel angry," "Tell me more about how you're feeling.").
Other
- The priority action when observing smoke is to evacuate clients.
- Decrease caffeine intake and avoid alcohol for stress urinary incontinence.
- Promote incentive spirometry use to maintain airway patency.
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