Infection Prevention
The greatest risk of contracting HIV for healthcare staff is exposure from this.
contaminated needle (needlestick) due to potentially infected blood/bodily fluid
This often presents with localized pain in the right lower quadrant of the abdomen. This pain is typically intense and may be accompanied by nausea, vomiting, and low-grade fever.
appendicitis
This is a serious, emergent complication of diverticulitis when diverticulum perforates leading to infection. Manifestations of this complication include severe abdominal pain, fever, and rigidity.
Peritonitis
This is the priority first action of the nurse when preparing to suction a patient's tracheostomy tube.
Assess and position first.
When nurses are prioritizing care for patients, this mnemonic is used to aid in which patient needs to be seen first.
ABC
This diagnostic test would be done if a patient was suspected of having c. difficile infection.
Stool culture
A nurse is caring for a client who has a history of alcohol use disorder and reports bruising and frequent nosebleeds. The nurse should recognize that this client in manifesting this disease.
Cirrhosis (coagulation defects)
To effectively manage GERD symptoms and prevent further complications, a patient should avoid eating this many hours before laying down.
2-3 hours
This level of moderately thickened liquid is given to dysphagia patients and is characterized by slowly dripping of the end of the spoon.
Honey-like consistency
When collecting a sputum sample, the nurse should have the patient do this before collection to reduce the risk of contamination of the sputum specimen from oral bacteria.
rinse patient's mouth with water
Active or suspected C. difficile infection requires this type of isolation.
Contact
This disease can cause morning headache, fatigue, irritability, snoring, and restlessness.
Obstructive sleep apnea (OSA)
To minimize risk for skin cancer, patients should be instructed to use this, even on cloudy days or in the winter.
sunscreen
pursed-lip breathing
When preparing a sterile field, the nurse places items in the middle of the sterile field. Avoiding this measurement of the outer "contaminated" edge ensures sterility is maintained.
outer 2.5 cm (1 in) border of the sterile field is considered unsterile.
Hepatitis C is transmitted this way.
Blood-to-blood. Contaminated needles/equipment with infectious blood/bodily fluids
To assess skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as these areas.
sclerae, soles of the feet, conjunctivae, and mucous membranes
To prevent surgical complications, such as aspiration, from a g-tube placement, this instruction is provided prior to the procedure.
NPO for at least 8 hours for an EMPTY STOMACH
A client's surgical wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean, moist, and manage exudate. This intervention should be priority when managing dehisced wound.
cover the wound with a moist, sterile, saline-soaked gauze dressing.
This can be used to prevent skin injury when removing medical adhesive from a patient.
Use water or adhesive remover to take off medical adhesive.
When preparing a sterile field, how should packaging be opened?
away from the body
A patient is reporting pain in the area known by the nurse as McBurney's point. This is a classic hallmark indication of this disease.
acute appendicitis
A patient with a NG tube receives intermittent bolus feedings. The nurse notices regurgitation of the enteral formula which may cause this complication.
aspiration from potentially displaced feeding tube
During assessment, the nurse notes an irregular radial pulse. This should be the next step to verify or confirm the irregular pulse.
assess apical pulse for one full minute
The nurse cannot determine what the client feels. When doing an assessment, this type of data includes information that only the client can perceive and report.
Subjective data