Podcast
Questions and Answers
A client who is immobile due to a recent stroke is being assessed for pressure injury risk. Which assessment finding indicates the highest risk?
A client who is immobile due to a recent stroke is being assessed for pressure injury risk. Which assessment finding indicates the highest risk?
- The client frequently shifts position independently.
- The client has good nutritional intake and hydration.
- The client's skin is intact with some areas of mild erythema that blanch with pressure.
- The client demonstrates occasional urinary incontinence and limited sensation in the lower extremities. (correct)
A patient with a confirmed Clostridium difficile (C. diff) infection requires frequent monitoring and hygiene care. Which of the following actions is most appropriate for the nursing staff?
A patient with a confirmed Clostridium difficile (C. diff) infection requires frequent monitoring and hygiene care. Which of the following actions is most appropriate for the nursing staff?
- Don disposable gloves, but handwashing is only needed if visibly soiled.
- Clean all surfaces in the room with a bleach-based disinfectant. (correct)
- Wear a N95 respirator mask during all interactions with the patient.
- Use alcohol-based hand sanitizer before and after each patient contact.
A nurse is delegating tasks to assistive personnel (AP) on a busy medical-surgical unit. Which of the following tasks is appropriate for the nurse to delegate to the AP?
A nurse is delegating tasks to assistive personnel (AP) on a busy medical-surgical unit. Which of the following tasks is appropriate for the nurse to delegate to the AP?
- Documenting a patient's intake and output from the previous shift.
- Providing instructions to a patient about medication side effects.
- Assisting a stable patient with ambulation after surgery. (correct)
- Assessing a newly admitted patient's risk for falls.
A nurse is caring for an older adult patient who is experiencing changes in their nutritional status. What intervention should the nurse initiate to support adequate nutrition?
A nurse is caring for an older adult patient who is experiencing changes in their nutritional status. What intervention should the nurse initiate to support adequate nutrition?
A nurse is educating a client about the importance of managing their glaucoma to prevent further vision loss. What accurately reflects the primary physiological concern related to glaucoma?
A nurse is educating a client about the importance of managing their glaucoma to prevent further vision loss. What accurately reflects the primary physiological concern related to glaucoma?
A community health nurse is planning an intervention to reduce the incidence of type 2 diabetes in a high-risk population. Which activity would be considered primary prevention?
A community health nurse is planning an intervention to reduce the incidence of type 2 diabetes in a high-risk population. Which activity would be considered primary prevention?
A patient recovering from a stroke is being discharged. Which of the following interventions represents tertiary prevention?
A patient recovering from a stroke is being discharged. Which of the following interventions represents tertiary prevention?
A public health initiative aims to reduce the spread of influenza during the winter season. Which intervention exemplifies secondary prevention?
A public health initiative aims to reduce the spread of influenza during the winter season. Which intervention exemplifies secondary prevention?
A nurse is caring for a patient with a Clostridium difficile (C. diff) infection. Besides wearing gloves, which action is MOST important to prevent the spread of infection?
A nurse is caring for a patient with a Clostridium difficile (C. diff) infection. Besides wearing gloves, which action is MOST important to prevent the spread of infection?
A patient's heart rate is consistently between 40-50 bpm. Which assessment finding is MOST concerning and should be reported immediately?
A patient's heart rate is consistently between 40-50 bpm. Which assessment finding is MOST concerning and should be reported immediately?
A nurse is assessing an older adult patient who reports feeling dizzy upon standing. What is the MOST appropriate method for assessing orthostatic hypotension?
A nurse is assessing an older adult patient who reports feeling dizzy upon standing. What is the MOST appropriate method for assessing orthostatic hypotension?
The charge nurse observes a new nurse preparing to administer a medication. Which action by the new nurse would require immediate intervention by the charge nurse to ensure patient safety, according to the principle of nonmaleficence?
The charge nurse observes a new nurse preparing to administer a medication. Which action by the new nurse would require immediate intervention by the charge nurse to ensure patient safety, according to the principle of nonmaleficence?
During a home visit, a nurse observes significant earwax buildup in an older adult patient who reports difficulty hearing. After removing the earwax, which of the following actions would be MOST important?
During a home visit, a nurse observes significant earwax buildup in an older adult patient who reports difficulty hearing. After removing the earwax, which of the following actions would be MOST important?
Flashcards
Primary Prevention
Primary Prevention
Actions to promote health and prevent disease.
Secondary Prevention
Secondary Prevention
Screening and early detection of diseases.
Tertiary Prevention
Tertiary Prevention
Managing chronic illnesses to prevent complications
C. diff Precautions
C. diff Precautions
Signup and view all the flashcards
Bradycardia
Bradycardia
Signup and view all the flashcards
Orthostatic Hypotension
Orthostatic Hypotension
Signup and view all the flashcards
Assessment
Assessment
Signup and view all the flashcards
Nonmaleficence
Nonmaleficence
Signup and view all the flashcards
Stage 2 Pressure Injury
Stage 2 Pressure Injury
Signup and view all the flashcards
Incubation Period
Incubation Period
Signup and view all the flashcards
Importance of Documentation
Importance of Documentation
Signup and view all the flashcards
Delegated Task to AP
Delegated Task to AP
Signup and view all the flashcards
Cheyne-Stokes Respirations
Cheyne-Stokes Respirations
Signup and view all the flashcards
Study Notes
- Study notes based on provided questions and answers.
Levels of Prevention
- Primary prevention promotes healthy habits like diet, exercise, and immunization.
- Secondary prevention involves screening and early detection, such as mammograms and blood pressure checks.
- Tertiary prevention focuses on managing chronic illness, for example, insulin administration for diabetes.
- Administering insulin is an example of tertiary prevention.
Environmental Elements
- Six elements of the environment: Temperature, ventilation, lighting, noise, odor, and humidity.
Common Reasons for Hospitalization
- Incontinence is the most common reason for adults to be hospitalized.
Biological Theories of Aging
- The Free Radical Theory suggests that environmental toxins damage cells.
Isolation Precautions
- For MRSA or streptococcus, contact precautions are necessary.
- For C. diff, use contact precautions, provide a private room, wash hands with soap and water, wear a protective gown and gloves, and remove PPE in the patient's room.
Vital Signs and Medical Terms
- Bradycardia is the term for a heart rate below 60 bpm.
- Dizziness is a symptom a patient with bradycardia might experience.
- To check for orthostatic hypotension, measure blood pressure while the client is supine.
- If a client's rectal temperature is 35°C, apply a warm blanket.
Nursing Process and Critical Thinking
- Assessment is the first step in the nursing process.
- Analysis is a step of critical thinking.
Ethical Principles
- Nonmaleficence is the ethical principle that involves protecting a client's safety and doing no harm.
- When teaching about client confidentiality, reinforce following the Code of Ethics for Nurses.
Patient Care and Safety
- When caring for a client exposed to an unknown chemical, scrub and wash the client.
Other
- Check pulse deficit by requesting assistance from a second nurse to check pulses simultaneously.
- For a patient with presbycusis (age-related hearing loss), check for earwax buildup.
Pressure Injuries
- A Stage 2 pressure injury is characterized by partial-thickness skin loss with redness.
- An unresponsive client who changes position occasionally is at risk for a pressure injury.
Infection Control
- Incubation (exposure) is the first stage of infection.
- On droplet precautions, wear a surgical mask when leaving the room.
- Wash hands with soap and water when caring for a client with C. diff.
Documentation and Scope of Practice
- Documentation in health records is important to communicate effectively, collaborate on care decisions, and ensure continuity of care.
- The nurse's scope of practice is the set of skills nurses should be competent in and the practices allowed within their role.
Delegation and Client Care
- A nurse can delegate obtaining a daily weight to an AP (Assistive Personnel).
- When teaching older clients, include that a decrease in body fat is an expected physiological change.
Nutrition and Older Adults
- Serving three large meals is not recommended for cognitively impaired patients regarding nutrition.
End-of-Life Care
- Cheyne-Stokes respirations are a clinical sign that a patient is close to death.
Other Key Concepts
- When using an electronic blood pressure monitor, align the cuff with the brachial artery.
- Check for increased intraocular pressure affecting the optic nerve in a patient with glaucoma.
- Floor rugs, cords, and macular degeneration increase the likelihood of falls for clients.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Related Documents
Description
Study notes covering levels of prevention (primary, secondary, tertiary), environmental elements in healthcare, common reasons for hospitalization, biological theories of aging, and isolation precautions for infections like MRSA and C. diff.
