Podcast
Questions and Answers
When assessing a client's knowledge about skin cancer prevention, which behavior indicates the need for further teaching?
When assessing a client's knowledge about skin cancer prevention, which behavior indicates the need for further teaching?
- Wearing protective clothing when exposed to the sun.
- Using tanning beds to acquire a base tan before vacation. (correct)
- Avoiding outdoor activities during peak sunlight hours.
- Applying sunscreen with an SPF of 30 or higher daily.
A nurse is assessing a client with decreased skin turgor. Which condition is most likely associated with this finding?
A nurse is assessing a client with decreased skin turgor. Which condition is most likely associated with this finding?
- Dehydration (correct)
- Fluid volume overload
- Inflammation
- Edema
When assessing a client's skin temperature, the nurse notes that the client's feet are cool to the touch. Which action should the nurse take first?
When assessing a client's skin temperature, the nurse notes that the client's feet are cool to the touch. Which action should the nurse take first?
- Document the finding and reassess later.
- Compare the temperature of both feet. (correct)
- Apply warm blankets to the client's feet.
- Notify the healthcare provider immediately.
A nurse is teaching a client about self-assessment for melanoma. Which characteristic should the nurse emphasize as most concerning?
A nurse is teaching a client about self-assessment for melanoma. Which characteristic should the nurse emphasize as most concerning?
During a skin assessment, the nurse observes several small, flat, brown macules on a client's forearms. What is the most appropriate action by the nurse?
During a skin assessment, the nurse observes several small, flat, brown macules on a client's forearms. What is the most appropriate action by the nurse?
A client reports a new, intensely itchy rash after using a new laundry detergent. Upon assessment, the nurse observes erythematous patches with some vesicles. What is the most likely cause of this skin condition?
A client reports a new, intensely itchy rash after using a new laundry detergent. Upon assessment, the nurse observes erythematous patches with some vesicles. What is the most likely cause of this skin condition?
When assessing a client with chronic peripheral vascular disease, which nail finding would the nurse expect?
When assessing a client with chronic peripheral vascular disease, which nail finding would the nurse expect?
A nurse observes clubbing of the fingers in a client with a history of long-term respiratory disease. What physiological change explains this finding?
A nurse observes clubbing of the fingers in a client with a history of long-term respiratory disease. What physiological change explains this finding?
A nurse is assessing a dark-skinned client for cyanosis. Which location provides the most accurate assessment?
A nurse is assessing a dark-skinned client for cyanosis. Which location provides the most accurate assessment?
The nurse is reviewing a client’s health history and notes the client reports having hives after eating shellfish. What type of skin lesion is a hive?
The nurse is reviewing a client’s health history and notes the client reports having hives after eating shellfish. What type of skin lesion is a hive?
A patient reports significant pain in their lower back that radiates down their left leg, worsening with movement. Which focused assessment should the nurse prioritize?
A patient reports significant pain in their lower back that radiates down their left leg, worsening with movement. Which focused assessment should the nurse prioritize?
During a musculoskeletal assessment, a patient reports pain and limited range of motion in their right shoulder following a fall. What is the most appropriate initial nursing intervention?
During a musculoskeletal assessment, a patient reports pain and limited range of motion in their right shoulder following a fall. What is the most appropriate initial nursing intervention?
A nurse is teaching a client with osteoarthritis about joint protection strategies. Which statement indicates a need for further teaching?
A nurse is teaching a client with osteoarthritis about joint protection strategies. Which statement indicates a need for further teaching?
Which assessment finding would be of most concern in a client who has a cast on their lower leg?
Which assessment finding would be of most concern in a client who has a cast on their lower leg?
A nurse is evaluating a client's muscle strength. The client can move their arm against gravity but not against any resistance applied by the nurse. How should the nurse document this finding?
A nurse is evaluating a client's muscle strength. The client can move their arm against gravity but not against any resistance applied by the nurse. How should the nurse document this finding?
A client reports difficulty swallowing and frequent choking. Which cranial nerves should the nurse assess in this client?
A client reports difficulty swallowing and frequent choking. Which cranial nerves should the nurse assess in this client?
When assessing a client's pupillary reaction, the nurse notes that the right pupil constricts briskly when a light is shined into it, but the left pupil has a delayed and sluggish response. What does this finding suggest?
When assessing a client's pupillary reaction, the nurse notes that the right pupil constricts briskly when a light is shined into it, but the left pupil has a delayed and sluggish response. What does this finding suggest?
A nurse is performing a Romberg test. The client sways and nearly falls. How should the nurse document this finding?
A nurse is performing a Romberg test. The client sways and nearly falls. How should the nurse document this finding?
During a neurological examination, the nurse asks the client to identify a familiar object placed in their hand while their eyes are closed. Which sensory function is the nurse testing?
During a neurological examination, the nurse asks the client to identify a familiar object placed in their hand while their eyes are closed. Which sensory function is the nurse testing?
A nurse is assessing a client who is 3 days post-stroke and notes they have difficulty understanding speech. What term should the nurse use to document this finding?
A nurse is assessing a client who is 3 days post-stroke and notes they have difficulty understanding speech. What term should the nurse use to document this finding?
A nurse assesses a client with a suspected neurological disorder and notes significant weakness in their lower extremities. Which assessment should the nurse prioritize?
A nurse assesses a client with a suspected neurological disorder and notes significant weakness in their lower extremities. Which assessment should the nurse prioritize?
A nurse is assessing a client with a head injury and notices clear fluid leaking from their nose. What should the nurse suspect?
A nurse is assessing a client with a head injury and notices clear fluid leaking from their nose. What should the nurse suspect?
A nurse needs to assess a client's trigeminal nerve (CN V) function. Which assessment is most appropriate?
A nurse needs to assess a client's trigeminal nerve (CN V) function. Which assessment is most appropriate?
When assessing a client's muscle strength, the nurse applies resistance while the client attempts to extend their leg. The nurse documents the strength as 4/5. What does this indicate?
When assessing a client's muscle strength, the nurse applies resistance while the client attempts to extend their leg. The nurse documents the strength as 4/5. What does this indicate?
A nurse is caring for a client with a known seizure disorder. Which intervention is most important to include in the client's plan of care?
A nurse is caring for a client with a known seizure disorder. Which intervention is most important to include in the client's plan of care?
The nurse is preparing to administer an intradermal injection for a tuberculin skin test. Which site is most appropriate?
The nurse is preparing to administer an intradermal injection for a tuberculin skin test. Which site is most appropriate?
When administering a subcutaneous injection, what angle of insertion is most appropriate for an average-sized adult?
When administering a subcutaneous injection, what angle of insertion is most appropriate for an average-sized adult?
A client is receiving heparin subcutaneously. Which action minimizes the risk of bruising and bleeding at the injection site?
A client is receiving heparin subcutaneously. Which action minimizes the risk of bruising and bleeding at the injection site?
A nurse is preparing to administer an intramuscular injection into the ventrogluteal site. Which action is essential to locating this site accurately?
A nurse is preparing to administer an intramuscular injection into the ventrogluteal site. Which action is essential to locating this site accurately?
Which of the following is a contraindication for administering an intramuscular injection into the deltoid muscle?
Which of the following is a contraindication for administering an intramuscular injection into the deltoid muscle?
A nurse is preparing to administer medications from an ampule. What is the most important step to take?
A nurse is preparing to administer medications from an ampule. What is the most important step to take?
A nurse is mixing two types of insulin in one syringe. What is the correct procedure to follow?
A nurse is mixing two types of insulin in one syringe. What is the correct procedure to follow?
What action is essential when reconstituting a medication prior to administration?
What action is essential when reconstituting a medication prior to administration?
A medication order reads, “Administer 250 mg IM of ceftriaxone.” The vial contains 1 gram of ceftriaxone powder to be reconstituted with 3.6 mL of sterile water for a final concentration of 250 mg/mL. How many mL of the solution should be administered?
A medication order reads, “Administer 250 mg IM of ceftriaxone.” The vial contains 1 gram of ceftriaxone powder to be reconstituted with 3.6 mL of sterile water for a final concentration of 250 mg/mL. How many mL of the solution should be administered?
After administering an intramuscular injection, the nurse notes a small amount of blood return when aspirating. What is the appropriate nursing action?
After administering an intramuscular injection, the nurse notes a small amount of blood return when aspirating. What is the appropriate nursing action?
A nurse is preparing to administer a prescribed medication via intramuscular (IM) injection to an adult patient. Which of the following injection sites is generally recommended as the safest for IM injections in adults?
A nurse is preparing to administer a prescribed medication via intramuscular (IM) injection to an adult patient. Which of the following injection sites is generally recommended as the safest for IM injections in adults?
Which action is most important for the nurse to take immediately after administering an intramuscular injection?
Which action is most important for the nurse to take immediately after administering an intramuscular injection?
A nurse is administering an intramuscular injection using the Z-track method. Which statement explains the purpose of this technique?
A nurse is administering an intramuscular injection using the Z-track method. Which statement explains the purpose of this technique?
Which equipment is required when preparing to administer an intradermal injection?
Which equipment is required when preparing to administer an intradermal injection?
A nurse is unable to read a physician's order for a medication. What is the most appropriate action to take?
A nurse is unable to read a physician's order for a medication. What is the most appropriate action to take?
Flashcards
Objective vs. Subjective Data
Objective vs. Subjective Data
Objective data is measurable and observable. Subjective data comes from the patient's perspective.
Skin Assessment
Skin Assessment
Looking at skin's color, moisture, temperature, texture, and integrity.
Skin Turgor
Skin Turgor
The skin's ability to stretch and return to its original state.
Capillary Refill
Capillary Refill
Small blood vessels refill with blood after pressure is applied.
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ABCDE of Moles
ABCDE of Moles
Examine skin moles for asymmetry, border, color, diameter, and evolution.
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Skin Hygiene
Skin Hygiene
Hygiene practices include bathing, cleaning, and moisturizing to maintain skin health.
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Sun Protection
Sun Protection
Using sunscreen and protective clothing to avoid sun damage.
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Hand Hygiene
Hand Hygiene
Wash your hands before medication preparation and administration.
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Medication Checks
Medication Checks
Check the Medication Administration Record (MAR) and medication label against doctor's orders.
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Rights of Medication Administration
Rights of Medication Administration
Right drug, dose, time, route, patient, and documentation.
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Aseptic Technique
Aseptic Technique
Aseptic technique is essential to prevent contamination during injection preparation.
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Intradermal Injection
Intradermal Injection
Intradermal injections deposit small amounts of medication just below the epidermis.
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Intradermal Technique
Intradermal Technique
Insert at a 5-15 degree angle with the bevel up to create a wheal.
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Intradermal Sites
Intradermal Sites
Most Common injection sites for Intradermal- inner forearm and upper back
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Intradermal Purpose
Intradermal Purpose
Purpose: Testing for allergies or TB (PPD).
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Subcutaneous Injection
Subcutaneous Injection
Subcutaneous injections deposit medication into the fatty tissue layer.
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Subcutaneous Sites
Subcutaneous Sites
Sites include the abdomen, upper arm, and thigh; rotate sites to avoid lipohypertrophy.
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Subcutaneous Angle
Subcutaneous Angle
Administer at 45-90 degree angle, depends on needle length and skinfold size.
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Subcutaneous Purpose
Subcutaneous Purpose
Drugs for sustained effects, slower onset.
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Intramuscular Injection
Intramuscular Injection
Intramuscular injections are given deep into muscle tissue for rapid absorption.
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Intramuscular Sites
Intramuscular Sites
Sites include deltoid, vastus lateralis, and ventrogluteal; avoid dorsogluteal due to nerve risks.
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Intramuscular Purpose
Intramuscular Purpose
Used for irritating medications, aqueous suspensions, and solutions in oils.
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Z-track Injection
Z-track Injection
Is a method used to seal the medication in the muscle
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Intramuscular Technique
Intramuscular Technique
Use the correct length (typically 1-1.5 inches) and gauge (22-25G); 90-degree angle
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Reconstituting
Reconstituting
Used to prepare a powdered medication for injection by mixing it with a diluent.
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Z track
Z track
Pull the skin to the side before inserting the needle
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prime needle
prime needle
Injecting the medication right after preparing the solutions
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Administering medications
Administering medications
Observe the 6 rights
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Skin Assessment Learning Objectives
- Discuss the anatomy and physiology related to the skin
- Identify objective and subjective data throughout the physical assessment
- Differentiate between expected and unexpected physical assessment findings
- Analyze data to determine steps for further assessment
- Identify appropriate health promotion interventions for the client
- Discuss documentation of assessment findings
Skin Assessment Topics
- Overview of assessment details, and anatomy and physiology review
- Demonstration of assessment techniques
- Health history interview including clinical questions and case study of an adult with a rash
- Skin color, texture, moisture, and integrity assessment: expected findings, variations, and unexpected findings
- Skin temperature assessment: includes videos on assessing and comparing skin temperature
- Also includes expected findings and variations
- Skin mobility and turgor assessment: includes videos on checking elasticity, turgor, and edema
- Lists expected and unexpected findings
- Nail assessment: includes a video on capillary refill, expected findings, variations, and unexpected findings
- Health promotion: bathing and hygiene practices, skin protection from sun exposure, and self-assessment of moles and suspicious lesions
- Summary of assessment
- Quiz
Head, Neck, and Neurological System Assessment Learning Objectives
- Discuss anatomy and physiology of the head, neck, and neurological systems
- Identify objective and subjective data during the physical assessment
- Differentiate between expected and unexpected findings
- Analyze data for further assessment steps
- Appropriate Health promotion interventions
- Discuss documentation
Head, Neck, and Neurological System Assessment Topics
- Lesson outline with assessment details and anatomy/physiology review
- Demonstration of assessment techniques
- Health history interview, specific system questions, and a case study about a middle-aged patient with headaches
- Includes interventions for orientation deficit
- Head assessment with interventions for facial drooping
- Eye assessment: conjunctiva, sclera, pupillary reaction, and expected findings
- Includes intervention for vision problems
- Ear assessment and interventions if ear drainage or pain exists
- Nose and sinus assessment: a sinus palpation video is included and interventions for sinus congestion
- Mouth and neck assessment
- Interventions if there is a need for assistance, and a lump on the anterior neck
- Health promotion: screenings
- Includes Overview and a case study: an adult with facial drooping and dysarthria
Musculoskeletal and Neurological Systems Assessment Learning Objectives
- Discuss anatomy and physiology related to these systems
- Identify objective and subjective data and differentiate between expected and unexpected findings
- Analyze data to determine further steps and identify appropriate health promotion interventions
- Discuss documentation of assessment findings
Musculoskeletal and Neurological Assessment Topics
- Overview focusing on assessment details, necessary tools, and anatomy review
- Health history covering musculoskeletal disorders, including a case study of an adult with knee pain
- Head and neck assessment: inspection, palpation, range of motion, and muscle strength
- Shoulders and upper extremities: range of motion video
- Spine and body alignment evaluation: symmetry, shape, curvature, muscle alignment, assessing ROM, and interventions for sensory loss in feet
- Hip and lower extremities assessment: evaluation of hips, knees, ankles, and feet, range of motion video, and interventions if an extremity trauma occurs
- Health promotion: ergonomics, injury prevention
- Includes the importance of exercise, calcium and vitamin D
Health Assessment Validation: Steps
- Beginning Steps: Privacy, introduce self, hand hygiene, client identification, allergies, and education
- General Survey: Consciousness, orientation, response to stimuli, posture, facial expression, hygiene, mobility, mood, speech, temperature, BP, heart rate, respiratory rate, oxygen saturation, and pain level
- Skin Examination: Cover unexposed areas, inspect color, palpate texture/moisture, check turgor, hair distribution, lesions, and edema
- Head and Neck Examination: Inspect size/shape/hair, facial symmetry, skin condition, palpate skull/hair/tenderness, trachea alignment, carotid arteries, thyroid enlargement, and lymph nodes
- Eye Examination: Assess eyebrows/eyelashes, eyelids, sclera, conjunctiva, pupils, PERRLA, and extraocular movement
- Ear, Nose, and Throat Examination: Inspect ears, palpate tenderness, test hearing (whisper test), palpate sinuses, check nose alignment, check septum/discharge, nasal mucosa, nares patency, mouth, lips, gums, teeth, tongue, throat, and tonsils. Test for rising uvula
- Respiratory Examination: Count rate/pattern, observe rhythm, depth, and chest expansion. Note posture/tobacco use/lung diseases trauma/surgery/obesity, oxygen, and thorax symmetry. Asses spine, accessory muscles/kyphosis/scoliosis. Palpate anterior/posterior and auscultate all lung fields over the chest
Injection Preparation Considerations:
- Vials and Ampules can be used
- Clean multi-dose vials before use, and use anti-microbial wipes. Indicate the time and date of opening for multi-dose vials.
- When preparing needles, tighten the hub to the tip of the syringe.
- Needle length and gauge, choose the correct length and gauge.
- The smaller the number, the larger the needle bore.
- Needle gauge and length for different injections:
- Intradermal: 0.1ml
- Subcutaneous: no more than 1.5ml
- Intramuscular:
- Deltoid- max 2ml
- Vastus lateralis- 1-3ml
- Ventrogluteal- 3ml
- When drawing up medicine, draw air into the syringe, then inject it into the vial.
- Draw up slightly more medication than needed after ensuring that the needle tip is still immersed in liquid.
- Recap using a one-handed technique. Label the medication with the drug name, dose, initials, date, and time.
- Before administrating, change the irritating drug or any needle that has been used more than once.
- Recap clean needles with the one-handed scoop technique.
- Medication Administration
- Wash hands, three medication checks, six medication administration rights, identify patient, explain processes, check allergies, don gloves, select injection site
- Purpose: Deposit small amount of toxin or medication under the skin for PPD or allergy testing.
Injection Types
- Intradermal Injections: The needle bevel should be up when injecting at a 5- to 15-degree angle
- Subcutaneous Injections: inject the medicine into the bodies fatty layer for slow and sustained effect. Common for water soluble, hormone, Insulin or Heparin medications.
- Mixing Insulins: Inspect expiration dates of the insulin vials, NPH insulin will become cloudy when mixed, and regular insulin will be clear. Mix the correct amount by injection air, inject NPH first and Regular insulin afterward.
- The process to mix is, inject amount of air needed for NPH then Regular then pull back regular then NPH.
- Insert the needle for NPH injection, but do not overfill, and pull the needle back out.
- Recap the needle using the one handed technique, clear to cloudy or RN regular-NPH.
- Subcutaneous: With smaller patients pinch skin to 1inch at a 45-degree angle or for larger patients 2 inches at a 90-degree angle.
- Intramuscular: for medication in muscle tissue, and irritating drugs or oily solutions, lack of redness/edema at injection site is desired. Special considerations: confused patients will need assistance for stabilization of injection site and tissue damage from the needle. Review the medication orders, then draw air in the syringe. Add air for the medicine and draw the correct amount after dilution, then prime the needle.
Intramuscular Injection Sites for various locations:
- Deltoid: Located in the upper arm
- Ventrogluteal
- Vastus Lateralis
- Important: Dorsogluteal is no longer an approved injection site.
Injection Evaluation
- Check for patient's tolerance to the shot
- And be aware of conditions at the injection site
- Effects of medication
- Inject the air for medicine
- Select administration gauge
- Prime Needle
- Label Syringe
Drawing up medicine of ampule
- Must use filtered needle
- Discard and apply new needle, never stick patient with filtered needle
- Cannot instill air before injection
- Bring blue bag or container with med admin material
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