Vital Signs
Which would cause an erroneously LOW BP during a general assessment for an adult client?
Bladder to cuff ratio too wide
What is the appropriate way to hold the ear when inspecting the tympanic membrane of a 2 yo client?
Pull the pinna down and back
The correct method in performing a bed bath on a client's leg
Washing, rinsing, and drying the client's leg from ankle to thigh
When mixing 2 insulins in one syringe for a client with diabetes, the nurse should NEVER
Shake the vials
What should the nurse do if the tip of an IV catheter is broken and stuck inside a client's arm?
Apply a tourniquet above the IV site and notify MD
Before completing a BP on an adult, what should the nurse do next after introducing self?
Identify the client with 2 identifiers
Name 5 tasks the nurse can delegate to a nursing assistant.
1. Recording findings from a bath
2. Feeding the patient
3. Repositioning the patient
4. Toileting the patient
5. Answer call lights
To prevent injury to an older adult when performing a bed bath, the nurse should avoid...
Pulling linens underneath the client
4 things for a nurse to check when an occlusion alarm is sounding on an IV pump...
1. IV site
2. Pinched tubing
3. Closed clamp
4. Client positioning
The isolation environment used to prevent the spread of disease which includes basic preventative practices
Standard precautions (previously known as universal precautions)
4 skin characteristics that are more common in an older adult
dry skin, itchy skin, poor healing, increased risk of trauma
5 steps when performing a z-track injection
1. Pull the skin 2.5 to 3.8 cm laterally away from the injection site
2. Maintain displacement and insert needle at 90 degree angle
3. Inject medication slowly, keeping skin taught
4. Withdraw needle
5. Release retracted skin
What location should a nurse prepare to insert an IV in an older adult?
A distal vein