Exam 2 Study Guide PDF

Here are the answers to numbers 1-36 of your study guide, using the provided sources: Exam #2 Study Guide Answers 1. Correctly worded patient goals/outcomes and nursing interventions: Goals must be SMART (Specific, Measurable, Achievable, Relevant, Time-based). For example, a goal co...

Here are the answers to numbers 1-36 of your study guide, using the provided sources: Exam #2 Study Guide Answers 1. Correctly worded patient goals/outcomes and nursing interventions: Goals must be SMART (Specific, Measurable, Achievable, Relevant, Time-based). For example, a goal could be Patient will ambulate 10 feet with the assistance of a walker by the end of the shift. 2. Complications of immobility: o Muscle atrophy o Decreased muscle strength and endurance o Foot drop o Pressure ulcers o Toileting issues o Poor circulation o Thrombus: development of a clot o Embolus: dislodged clot 3. DVT prevention: DVT prevention measures include anti-embolism stockings and sequential compression devices (SCDs). Anti-embolism stockings should be applied in the morning and removed at least once a shift to assess the skin. SCDs are often applied before surgery and used until the patient is able to ambulate. 4. Passive and active ROM – differences/appropriate guidelines: o Active ROM: Patient performs isotonic exercises involving movement of the limbs with muscle contraction. Examples include flexion, extension, hyperextension, abduction, and adduction. o Passive ROM: Patient is unable to perform movement, so the nurse performs active movement for the patient. Typically involves flexion and extension. 5. Safety in patient transfers: o For the patient: Assess their sensory status, cognitive level, strength, and mobility. If they have unilateral involvement, transfer to the unaffected (strong) side. Stabilize the patient's knees and feet. Make certain the chair or wheelchair is locked. o For the nurse: Use proper body mechanics to avoid injury. Bend your knees and raise the bed to waist level, lowering it before transferring the patient to a chair. Support the patient’s neck, shoulders, and behind their knees. Allow the patient to sit at the edge of the bed for a few minutes before transferring to a chair. Get help from coworkers when necessary. 6. Safety in patient ambulation: o Use a gait belt to help maintain control of the patient. o For weak patients, have someone with a wheelchair follow behind. o If a patient starts to fall, lower them to the floor using your body to avoid injury to both of you. Don't try to catch them. o Get assistance to help the patient back into a chair. o If the patient is injured, notify the provider and fill out an incident report. 7. Domains of learning: o Cognitive: New knowledge is acquired through intellectual thinking and behaviors. An example is a patient listing three foods low in sodium.  o Affective: Patients express feelings, opinions, or values related to a newly learned concept, such as attending a grief support group. o Psychomotor: New knowledge is demonstrated through physical skills and muscular activity. An example is a patient demonstrating the application of a colostomy appliance. 8. Factors impacting patient learning: o Attentional set o Motivation o Psychosocial adaptation to illness o Developmental level o Physical capability o Cognitive ability o Literacy o Environmental conditions 9. Injection technique: o Intradermal: Injected into the dermis only using a tuberculin syringe at a 15- degree angle with the bevel up, typically 1mL or less. This technique is used for skin testing such as TB or allergy tests, and forms a bleb. o Subcutaneous: Medication injected into the loose connective tissue under the dermis, with slower absorption than IM injections. Common medications include heparin and insulin. Use a 25-gauge, 1/2 to 5/8 inch needle. Pinch 2 inches (5 cm) of tissue and insert at a 90-degree angle, or pinch 1 inch (2.5 cm) of tissue and insert at a 45-degree angle. o Intramuscular: Faster medication absorption than SQ injections. Typically use a 1 to 1.5 inch long needle (19 to 21 gauge) and insert at a 90-degree angle. An average adult volume is 2 to 3 mL. The site must be properly landmarked to avoid injury. o Z-Track: Recommended for most IM injections to reduce localized skin irritation by sealing the medication in the muscle. Pull the skin laterally or downward, inject the medication slowly, and keep the needle in place for approximately 10 seconds. Release the skin after withdrawing the needle. This method is particularly important for medications with known caustic effects on the skin. 10. Appropriate sites for injections: o SQ: Posterior aspect of upper arms, abdomen, anterior thighs, scapular area of upper back. Avoid sites with lesions, bony prominences, large underlying muscles, and nerves. o IM: ▪ Ventrogluteal: Patient lying laterally, landmark with the heel of the hand on the greater trochanter, thumb towards the groin, and index finger towards the anterior superior iliac spine. ▪ Vastus Lateralis: Middle third of the thigh, landmark by placing one hand below the groin and the other above the knee, forming "goal posts". ▪ Deltoid: Smaller muscle, suitable for volumes of 2 mL or less (e.g., flu shot). Landmark by placing three fingers below the acromion process. 11. Managing injection sites: Understand when, where, and what time you would give an injection, taking note of bruising or discoloration. 12. Needle safety: o Preventing needle stick injury is crucial, as it can cause exposure to blood- borne pathogens. o Use needle safety devices such as sheaths and retractable needles. o Dispose of sharps in puncture- and leak-proof sharps containers. o Never dispose of sharps in a wastebasket, pocket, patient's bedside, or regular trash. o Never reach into a sharps container. o Don't use a sharps container if it's more than 2/3 full. o Use needleless devices when available. o Take your time and be cautious. o Report any needle stick incidents immediately. 13. Rules for mixing different types of insulin: o Use an insulin syringe only (marked in units). o U-100 is the most common, used with insulin vials of 100 units/mL. o NEVER mix NPH insulin with regular insulin. This is because regular insulin is rapid-acting and used when a patient’s blood sugar is high, while NPH is intermediate-acting and would slow down the onset of action of regular insulin. o Follow the "Nancy Reagan RN" mnemonic: ▪ N: Inject air into the NPH vial. ▪ R: Inject air into the regular vial and invert. ▪ R: Withdraw the desired amount of regular insulin. ▪ N: Withdraw the desired amount of NPH insulin. 14. SBAR format for communication: o S: Situation: State what is happening at the present time that is concerning. Include the admitting and secondary diagnoses and identify the current problem. o B: Background: Briefly state pertinent history. This could include past medical history, lab and test results, psychosocial issues, allergies, and code status. o A: Assessment: Summarize the patient’s condition and state what you think the problem is. This might include recent vital signs, relevant assessment findings, current treatments, and recent lab/test results. o R: Recommendation: State your request - what do you want the physician or other healthcare professional to do? 15. Characteristics of appropriate nursing documentation: o Objective o Non-judgmental o Organized o Concise o Factual o Timely o Legible o Accurate  o Complete o Legally prudent o Confidential 16. Purposes of the medical record/patient chart: o Communication with other healthcare professionals o Legal and historical documentation o Insurance reimbursement o Record of diagnostic and therapeutic orders o Care planning o Record of the use of the nursing process o Quality of care reviews o Research o Decision analysis o Education 17. Documentation of a sentinel event/incident report: Document the incident in the facility’s incident report and in the patient’s notes. Include a factual, honest, and objective description of what occurred, the time, the name of the doctor notified, and the patient's assessment. Document the treatment, follow-up care, and the patient’s response. Do not write “incident report completed” in the chart as this destroys the confidentiality of the report. Include any statements the patient made. 18. "Do Not Use" abbreviations in patient charting: o MSO4 and MGSO4: Write out Morphine Sulfate and Magnesium Sulfate. o U: Write out Unit. o QD: Write out Daily. o QOD: Write out Every Other Day. o IU: Write out International Unit. o Trailing zeroes: Use 3 instead of 3.0. o Lack of leading zeroes: Use 0.3 instead of.3. 19. Discharge instructions: The sources do not provide information on what should be included in discharge instructions. 20. Patient safety considerations: Patient safety considerations include fall prevention, medication safety, safe use of alarms, infection prevention, and suicide risk reduction. 21. Risk management department – purpose, role in patient safety: o Purpose: To ensure appropriate nursing care by identifying potential hazards and eliminating them before harm occurs. o Role in patient safety: Identifying, analyzing, and reducing risks. They also evaluate incidents through occurrence reports to determine corrective measures, prevent recurrence, and alert the team to potential litigation. 22. Nursing assessment of fall risks: Conduct a Falls Risk Assessment, including questions about the home environment. Questions might include: o Do you use assistive devices? o Do you have difficulty with personal care or using the bathroom? o Do you have safety bars for the toilet and tub? o Do you have difficulty preparing meals? o What medications do you take? o Have you had any falls at home?  o Do you live in a two-story home? o Are there steps to enter your home? o Do you have someone you can call in case of an emergency? o Do you have any fire hazards? o Do you have working smoke detectors, fire extinguishers, and carbon monoxide detectors? 23. Risk factors for patient falls: o Unsteady gait o Poor balance and coordination o Muscle weakness/deconditioning o Multiple comorbidities o Multiple medications (especially blood pressure medications, diuretics, and pain medications) o Confusion o Mental status changes o Incontinence o History of previous falls 24. Nursing interventions to prevent patient falls: o Use a Falls Risk Assessment Tool to identify patients at high risk. o Educate patients and family members on fall risks. o Provide a call bell and encourage patients to ask for help. o Identify fall risk patients with bracelets. 25. Knowing what goes in a patient’s chart and what does not: This question is a bit broad. The sources provide a lot of information about what should and shouldn't be in a patient's chart, including documentation of procedures and incidents, as well as rules for documentation. 26. Knowing the basics of how to move a patient: Review transfer techniques, proper body mechanics, and the use of assistive devices like gait belts, walkers, and lifts. 27. Reviewing assistive devices and when to use them: The sources discuss various assistive devices, their purposes, and how to use them. 28. Purposes of assistive devices and what they help maintain: o Prevent physical injury to the caregiver and patient. o Promote correct body alignment. o Facilitate coordinated, efficient muscle use. o Conserve energy for the caregiver and prevent undue strain. o Facilitate mobility and activity for the patient. o Increase patient self-esteem by decreasing dependence. o Decrease physical stress on weight-bearing joints and unhealed skeletal injuries. 29. Looking at gait belts: Gait belts help nurses maintain control of patients while walking, reducing the risk of falls. 30. Being able to understand your diagnosis and goals and how they work together: The sources don't explicitly explain how diagnoses and goals work together. However, understanding a patient's diagnosis helps you develop appropriate and relevant goals for their care plan. 31. Falls, risk assessments, diagnoses for fall risks, and prevention for patients and yourself: This refers back to information discussed earlier about fall risks and prevention strategies for both patients and nurses. 32. Knowing your risk management: Nurses must be aware of potential safety hazards and take steps to prevent them. They should be familiar with risk management procedures, including incident reporting. 33. 6 QSEN competencies: o Patient-Centered Care: Respect for patient’s preferences, values, and needs. o Teamwork and Collaboration: Communication and shared decision-making to support quality patient care. o Evidence-Based Practice: Optimal care using best current evidence (along with clinical expertise and patient preferences). o Quality Improvement: Using data to monitor quality and safety in healthcare. o Safety: Minimizing risk of harm to patients and providers. o Informatics: Using technology to mitigate error and support decision-making in healthcare. 34. Applying your domains of learning and knowing the teachings and responses for each domain: This refers back to the three domains of learning and how to apply appropriate teaching methods for each. 35. Knowing therapeutic and non-therapeutic communication: o Therapeutic communication: Techniques that encourage patients to express their feelings and ideas and that convey acceptance and respect. o Non-therapeutic communication: Communication techniques that hinder or damage the professional relationship. 36. Knowing the four phases of motivational interviewing: o Engaging: Developing a therapeutic relationship where the client feels comfortable, understood, and hopeful. o Focusing: Setting the agenda, identifying goals, and providing clear direction. o Evoking: Eliciting the client's own motives for change (also called "change talk"). o Planning: Developing a specific, measurable, achievable, relevant, and time- bound change plan the client agrees to and is willing to follow.