Health Caring Concepts
Define Health Promotion and Give an Example
Health promotion is the process of helping individuals, families, and communities improve their health and well-being by encouraging healthy lifestyle choices, preventing disease, and increasing control over factors that influence health.
Examples:
An 8-year-old understands that pouring water into a taller glass does not change the amount of water.
Concrete Operational
What characteristics should a nurse identify in a pain assessment?
History, onset, location, intensity, duration, and location
A patient is experiencing panic level anxiety. What is the top concern and what communication techniques should the nurse implement?
Top Priority: Safety (Do not leave the patient)
Communication: Provide calm, brief, and direct communication
Name 3 findings of fluid volume excess.
Weight gain, edema, crackles, hypertension, bounding pulses, shortness of breath, orthopnea, jugular vein distention
When should chest physiotherapy (CPT) be performed for a client with cystic fibrosis to maximize airway clearance and reduce the risk of nausea or vomiting?
Before meals or at least 1-2 hours after meals
Name an oral biguanide used to treat Type 2 DM.
Metformin
A nurse is providing discharge education to a 68-year-old client who has been newly diagnosed with heart failure. What dietary changes should the nurse emphasize to help manage heart failure, and why are these changes important?
Reduce Sodium Intake - The client should reduce sodium (salt) intake to help prevent fluid retention, decrease edema, reduce the workload on the heart, and minimize symptoms such as shortness of breath.
What are signs of a hemolytic transfusion reaction?
Fever, Chills, Shortness of Breath, Back Pain
What would your immediate nursing intervention be?
A provider prescribes Vancomycin 1 gram in 250 mL of normal saline to infuse over 90 minutes. The nurse will administer the medication using IV tubing with a drop factor of 15 gtt/mL.
At what rate should the nurse regulate the IV tubing in drops per minute (gtt/min)? Round to the nearest whole number.
Volume x Drop Factor / Time
250x15/90 = 41.7
= 42 gtt/min
A provider orders 1,000 mL of Lactated Ringer's (LR) with 30 mEq of potassium chloride (KCl) to infuse for a client with hypokalemia. The pharmacy supplies KCl at a concentration of 10 mEq per 5 mL.
How many milliliters of KCl should the nurse add to the IV bag?
30/10 x 5 = 15mL
Desired/Have x Quantity
When deciding which client to assess first at the beginning of a shift, what nursing prioritization framework should the nurse use to determine who requires immediate attention?
Use the ABCs (Airway, Breathing, Circulation) first, followed by Maslow's Hierarchy of Needs, acute versus chronic, unstable versus stable, and actual versus potential problems to determine the highest-priority patient.
A toddler child is in the clinic for a well-child visit. The parents ask which toys would best support their child's developmental stage. Name at least three age-appropriate toys or play activities you would recommend for a toddler.
A client is receiving scheduled opioid analgesics following surgery. What nursing nonpharmacological interventions can help improve pain control in addition to medication? Give at least 3 examples. (nonpharmacological)
A client taking haloperidol develops muscle rigidity, a shuffling gait, and a resting tremor. What medication side effect is the nurse recognizing?
Extrapyramidal symptoms
During shift report, the nurse learns that a 9-month-old infant has flu-like symptoms and tachypnea. What priority complication should the nurse anticipate, and what assessment findings would support this concern?
The infant is at greatest risk for dehydration due to increased insensible fluid losses from tachypnea, possible fever, decreased oral intake, and the limited fluid reserves and higher metabolic rate of infants. The nurse should monitor for decreased urine output, dry mucous membranes, sunken fontanel (if applicable), delayed capillary refill, poor skin turgor, irritability, and lethargy.
What are early signs of respiratory distress?
What would you do if you notice signs of respiratory distress?
Tachypnea, Dyspnea, Restlessness, Nasal flaring, Decrease in O2 Saturation
When a pedi patient demonstrates signs of respiratory distress, call for help! Children compensate well until they don't!
What does a A1C indicate? What is an acceptable A1C level for a Diabetic patient?
The A1C is the best indicator of the average Blood Glucose level for the past 120 days. The acceptable range for a diabetic patient is 6.5-8%. A higher A1C in diabetics indicates hyperglycemia and ineffective glucose control. A low A1C in diabetics indicates hypoglycemia.
A client has just returned to the unit immediately following a femoral cardiac catheterization. What complication is the patient at risk for and how do we prevent it?
This patient is at risk for bleeding from the catheterization site.
Prevention: Place the client supine with the head of the bed flat (or no more than 30° per facility protocol) and keep the affected leg straight and extended to prevent bleeding and promote hemostasis at the catheter insertion site.
A client with type 2 diabetes normally manages their blood glucose with oral medications at home. After being admitted to the hospital for a surgical site infection, the health care provider orders insulin instead of the client's usual oral diabetes medication. Why might a hospitalized patient who normally takes oral diabetes medications require insulin?
Hospitalization places the body under physiologic stress, and conditions such as infection, surgery, trauma, or acute illness can increase the release of stress hormones, leading to hyperglycemia. Insulin provides rapid, precise blood glucose control, allowing blood glucose levels to be adjusted quickly as the patient's condition changes. Tight glucose control during hospitalization helps promote healing and reduces the risk of complications.
A nurse is preparing to hang a new bag of enteral feeding for a client receiving continuous tube feedings. According to current best practice, how often should the enteral feeding administration tubing be replaced?
Every 24 hours - Enteral feeding administration tubing used for continuous feedings should be changed every 24 hours to reduce the risk of bacterial contamination and infection.
What lab result can best ensure patient safety when preparing for a blood transfusion?
A crossmatch is a laboratory test performed before a blood transfusion to ensure that the donor's red blood cells are compatible with the recipient's blood. It is the final safety check before blood is administered and helps prevent a life-threatening hemolytic transfusion reaction.
What is the proper technique for administering IV push Rocephin through a 22G IV in the right forearm.
Scrub the Hub, Flush with 5mL, Scrub the Hub, Administer the Medication, Scrub the Hub, Flush with 5mL at the rate of medication administration
A 2-month-old infant is scheduled to receive routine immunizations at a well-child visit. The parents ask what they can do to help reduce their baby's pain and anxiety during the injections.
What education should the nurse provide to the parents? Include at least four evidence-based, nonpharmacologic interventions that can be used to comfort the infant during and after the immunizations.
A nurse administers 2mg of morphine IV to a patient. What is their priority assessment?
Level of consciousness and respiratory rate
Define Assertive Communication and give an example.
Assertive communication is expressing thoughts, feelings, or needs in a clear, direct, and respectful manner while respecting the rights of others.
Examples:
A patient with an NG tube to suction is at the highest risk for what electrolyte imbalance?
Hypokalemia - Gastric suction removes potassium-rich gastric secretions, increasing the risk for hypokalemia. Patients may also develop metabolic alkalosis due to the loss of hydrochloric acid from the stomach.
A client with a severe asthma exacerbation is being assessed for signs of hypoxemia. Which nursing assessment and intervention should the nurse use as the most reliable indicator of central cyanosis?
Assess the oral mucosa (lips, tongue, and oral mucous membranes), as central cyanosis is best identified in these areas and indicates significant hypoxemia requiring prompt intervention.
Apply oxygen therapy as ordered.
A client is sweaty, shaky, tachycardic, and confused. What diabetic condition are you concerned about and what are interventions used for treatment?
Hypoglycemia
Conscious Patient: Rule of 15. Give 15 grams of rapid carbohydrate, recheck glucose level in 15 minutes, repeat if <70, and offer complex carbs when stable.
Unconscious patient: IV D50 or Glucagon 1mg
What are the major risk factors for cardiovascular disease?
Age, Males, Family, Diabetes, Smoking, Obesity, Physical Inactivity, Metabolic Syndrome
What are signs and symptoms of Scarlet Fever? (name 3)
Scarlet fever is a bacterial infection that causes symptoms of a fine red sandpaper rash, White coat on tongue that peels leaving it red (strawberry tongue), fever, flushed cheeks, swollen neck glands, sore throat
What skills or tasks can a RN delegate to an LPN?
An RN can delegate stable, predictable nursing tasks to a LPN including:
What injection site is best to administer an IM injection in a newborn?
Vastus lateralis
A 72-year-old client with chronic kidney disease is alert, oriented, and fully understands the risks and benefits of dialysis. After discussing the treatment with the healthcare team, the client decides to decline dialysis and pursue comfort-focused care. The provider writes the order for dialysis anyway, stating it is "in the client's best interest." Which ethical principle has been violated?
Autonomy. The client is competent and has the legal and ethical right to make informed decisions about their own healthcare, including refusing treatment. Proceeding with dialysis against the client's wishes violates the principle of autonomy.
Name 5 signs of failure to thrive in a pediatric patient
Weight & Height below the 5th percentile, Difficulty feeding, Irritability, Lack of Eye Contact, Delayed Developmental Milestones
A client with cancer is receiving scheduled opioid analgesics but continues to experience mild breakthrough pain. The provider prescribes an NSAID in addition to the opioid. Why is combining these two medications often more effective than increasing the opioid dose alone?
Using an opioid together with an NSAID provides better pain control than either medication alone because they work by different mechanisms (multimodal analgesia). This combination can improve pain relief while potentially reducing the amount of opioid needed and minimizing opioid-related adverse effects.
Define Cognitive Therapy
Cognitive therapy is a form of psychotherapy that helps individuals identify, challenge, and replace inaccurate or negative thought patterns with more realistic and constructive thoughts. The goal is to improve emotional well-being and promote healthier behaviors by changing the way a person thinks about situations.
Name at least three conditions that can stimulate increased ADH release.
Hemorrhage, Dehydration, Hypovolemia, Hypotension, Increased serum osmolality (hypernatremia), Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Name 3 signs of a worsening or severe asthma attack.
Increased Inhaler use, Peak Flow Red Zone, Initial loud wheezes that become diminished or silent (silent chest), Tachypnea, Accessory Muscle Use, Nasal Flaring, Agitation, Restlessness, Hypoxia
A client with type 1 diabetes uses a continuous subcutaneous insulin infusion (insulin pump). What type of insulin should be loaded into the pump?
Rapid acting insulin provides a continuous basal infusion and a bolus doses for meals and correction of hyperglycemia.
Untreated essential hypertension increases the risk of what conditions? (name 3)
Myocardial infarction, Chronic Kidney Disease, Kidney Failure, Stroke, Retinopathy, Nephropathy, Neuropathy
A 9-year-old child is attending a birthday party at school. About 10 minutes after eating a cupcake, the child tells the school nurse, "My throat feels funny." Name 5 signs and symptoms of an anaphylactic reaction.
Itchy throat, Angioedema, Wheezing, Dyspnea, Urticaria, Hypotension
Nursing Priority: ABCs!
A nurse is participating in an interdisciplinary meeting to develop a discharge plan for a client whose family members, physical therapist, social worker, and provider all have different recommendations. Which critical thinking characteristic is most important for the nurse to demonstrate, and why?
The nurse should demonstrate openness to various viewpoints. This critical thinking characteristic involves considering different perspectives, evaluating evidence objectively, and remaining willing to modify one's thinking based on new information. Being open to the input of the interdisciplinary team promotes collaborative decision-making and helps develop the most appropriate, patient-centered plan of care.
A nurse is caring for a client with a chest tube following a traumatic pneumothorax. At the beginning of the shift, the chest drainage collection chamber contains 150 mL of fluid. At the end of the shift, the chamber contains 510 mL. During the shift, the nurse instilled 20 mL of sterile saline into the chest tube twice to maintain tube patency as prescribed. How much actual drainage did the client have during the shift?
A hospitalized client says, "I've been waiting over an hour for someone to answer my call light." The nurse replies, "The unit has been extremely busy today, and everyone is working as quickly as they can."
What nontherapeutic communication technique is the nurse using?
Defending -Defending occurs when the nurse attempts to justify or protect the actions of others or the healthcare system instead of acknowledging the client's feelings. This can make the client feel unheard. A more therapeutic response would be:
A 19-year-old client with a history of anorexia nervosa is admitted to the medical unit. The client has experienced significant weight loss, reports restricting food intake, and has a heart rate of 46 beats/min. What is the nurse's priority treatment or intervention for this client?
Correct fluid and electrolyte imbalances. The priority is to stabilize the client's physiological status by restoring fluid and electrolyte balance, monitoring cardiac function, and then beginning nutritional rehabilitation while watching closely for refeeding syndrome.
A client is recovering from an ischemic stroke in a rehabilitation unit. What potential complications should the nurse monitor for, and what nursing interventions can help prevent them?
Aspiration → Perform a swallow screen, keep the client NPO until cleared, and use aspiration precautions.
Falls → Implement fall precautions and assist with ambulation.
Pressure injuries → Reposition regularly and perform frequent skin assessments.
Contractures → Encourage range-of-motion exercises and proper positioning.
Deep vein thrombosis (DVT) → Promote early mobility, leg exercises, and administer anticoagulants as prescribed.
Depression and impaired coping → Assess mood, provide emotional support, and involve rehabilitation and support services.
Impaired communication → Use simple language, allow extra response time, and utilize communication aids as needed.
A nurse is caring for a client experiencing emotional distress. What characteristics of therapeutic communication should the nurse use to build trust, promote effective communication, and encourage the client to express their feelings? Give 5 examples.
Therapeutic communication includes:
A patient with dehydration, a patient with cerebral edema, and a patient with diabetic ketoacidosis (DKA) all require IV fluid therapy. Name one example of a hypotonic, isotonic, and hypertonic IV solution that may be prescribed.
Hypotonic: 0.45% Normal Saline
Isotonic: 0.9% Normal Saline, Lactated Ringer's
Hypertonic: D10W, D5NS
A patient arrives in the emergency department with an acute asthma exacerbation and is experiencing wheezing and bronchospasm. The provider orders a medication that rapidly relaxes the smooth muscles of the airways to improve airflow. What class of medication is being prescribed? Name one example.
A beta₂ agonist. Beta₂ agonists stimulate beta₂ receptors in the lungs, causing bronchodilation and relieving bronchospasm.
Examples:
A 17-year-old with type 1 diabetes is brought to the emergency department with polyuria, polydipsia, nausea, abdominal pain, and deep, rapid respirations after missing several insulin doses. Lab results show a blood glucose of 300 and ketones in the urine. What life-threatening complication is this patient most likely experiencing, and what is the priority treatment?
The patient is experiencing diabetic ketoacidosis (DKA).
Priority treatment:
A client arrives at the emergency department with chest pain suspected to be caused by unstable angina. In addition to nitroglycerin, the nurse administers aspirin. Explain why nitroglycerin and aspirin are important medications in the treatment of angina?
Nitroglycerin is administered to relieve chest pain by dilating coronary arteries, improving blood flow to the heart muscle, and decreasing the heart's workload and oxygen demand. Nitroglycerin can be administered every 5 minutes, up to 3 doses. 1st medication to administer for myocardial ischemia.
Aspirin is administered to prevent platelets from clumping together, reducing the risk of a blood clot forming or enlarging in the coronary arteries and lowering the risk of a myocardial infarction.
What additional medication may be prescribed for analgesia if chest pain persists?
What are the six links in the chain of infection? For each link, provide one example of a nursing intervention that can break the chain and reduce the spread of infection.
1. Infectious Agent: The microorganism that causes disease (e.g., bacteria, viruses, fungi, parasites). Administer prescribed antibiotics or antivirals, disinfect equipment, and sterilize instruments.
2. Reservoir: The place where the microorganism lives and multiplies (e.g., humans, animals, water, equipment). Clean and disinfect patient rooms and equipment, change soiled linens, and maintain proper environmental hygiene.
3. Portal of Exit: The path by which the organism leaves the reservoir (e.g., blood, respiratory secretions, urine, feces). Cover coughs and sneezes, wearing a mask apply dressings over draining wounds, and properly dispose of contaminated materials.
4. Mode of Transmission: How the organism spreads (contact, droplet, airborne, vehicle, vector). Perform proper hand hygiene, wear appropriate PPE, follow isolation precautions, and clean shared equipment between patients.
5. Portal of Entry: The route through which the organism enters a new host (e.g., broken skin, respiratory tract, urinary tract). Use aseptic technique for invasive procedures, maintain catheter care, and keep wounds clean and covered.
6. Susceptible Host: A person at risk for infection due to decreased immunity or other factors. Promote immunizations, encourage good nutrition, manage chronic diseases, and educate patients on infection prevention.
A patient comes is admitted for a GI virus with vomiting and diarrhea. What assessment indicates the most accurate fluid status?
Daily Weight
When providing end-of-life care, what are the goals of holistic nursing care? Give at least three examples of interventions that address the client's physical, emotional, social, spiritual, or cultural needs.
The goal of holistic end-of-life care is to promote comfort, dignity, quality of life, and support for both the client and family. Examples include: