Alterations in Skin Integrity
What are turn every 2 hours, lift or offload heels from bed, assess nutritional status, complete integumentary assessment, identify risk factors or keep skin clean and dry?
This assessment tool indicates risk for falls
What is the Morse Fall Assessment?
Items included on a full liquid diet.
What are milk, pudding, creamed soups, coffee with cream, or ice cream?
Frameworks that help prioritize client care
What is Maslow's Hierarchy of Needs or ABC(DE)?
Purpose of an Incentive Spirometer
What is to expand lungs, encourage deep breathing, and prevent complications such as pneumonia or atelectasis?
Diabetes, poor nutrition, infection or poor circulation.
What are some reasons wound do not heal well?
The first thing you do if a patient falls.
What is ensure the patient safety?
This action is critical to keep the nasogastric tube (NG) from clogging
What is flushing?
Benefits of hourly rounding.
What are patient safety including fall prevention, ensuring needs are met, patient satisfaction, decreases call lights and build patient/nurse relationship?
The number of liters of oxygen flow used for nasal cannula.
What is 1-6 liters/minute?
Signs of a stage 2 pressure injury.
What is a wound that involves the dermis (partial thickness), may have erythema, pink or red in appearance?
True or False: when using a walker, the client should put their stronger leg forward first?
What is false? (the weaker leg should move forward first to reduce pressure on that leg)
This is the optimal choice for Total Parenteral Nutrition delivery
What is a PICC line?
Factors that hinder patient education.
What are fear, communication, environmental distractions, physical conditions (pain, breathing), timing?
What is the non rebreather?
Common locations for pressure injuries.
What are sacrum, heels, elbows, hips, inner knees, shoulders, or back of head?
Fall precaution interventions
What is yellow or gripping socks, bed or chair alarm, yellow arm band, hourly rounding, or call light in reach?
A serious complication of a nasogastric tube?
What is aspiration?
Conditions when a client would need to have restraints placed
What are harm to self or others?
Nursing interventions to improve oxygenation
What are elevate the head of the bed, promote coughing, deep breathing, use incentive spirometer, suction, apply appropriate oxygen device?
This is what one observes with non blanchable skin.
What is skin does not turns white when pressed (indicates blood is trapped under the skin or deep tissue damage)?
True or false: Decreased mobility can cause a DVT.
What is true? (decreased mobility decreases circulation and if a patient has risk factors associated with clot formation, a DVT may occur)
How to promote NG tube insertion into the esophagus.
What is asking the patient to sip water or swallow when inserting the tube?
Interventions to avoid using restraints.
What are diversion, put the patient close to the nursing station, a sitter, bed or chair alarms, ask for family to be with the patient?
Abnormal assessment findings associated with hypoxemia.
What are tachypnea, tachycardia shortness of breath, cyanosis, confusion, low hemoglobin?