The Nursing Process
What is the most acute Nursing Diagnosis?
Decreased cardiac output
Anxiety
Risk for bleeding
Knowledge deficit
Decreased cardiac output
What is critical thinking?
A systemic way to shape and form your thinking
Name the four categories of HAIs and what is most important to prevent them.
CAUTI, CLABSI, VAP, and SSI
Hand Hygiene!
Name reasons for why a patient can have tachycardia
Pain
Fever/infection
Anxiety
Medications
Low BP
Bag baths are useful for what type of patient
risk of or skin breakdown
Name the five rights of delegation
Right person, task, circumstance, communication, evaluation
What techniques do you use when performing a physical assessment?
Observation
Auscultation
Palpation
Percussion
True or False: A patient colonized with MRSA cannot spread it.
False
You are unable to palpate peripheral pulses on your patient, where do you think you would go next to obtain the patient's HR
Apex of the heart
You perform a bed bath on an unconscious patient, how would you document this care?
Complete bed bath
When performing an initial comprehensive assessment what type of questions should you ask?
Open ended
True or False: An individualized plan of care should always be apart of planning and outcome identification
True
Hallmark signs of an acute infection
Reddness
Edema
Warmth
Pain
Loss of function
What is classified as apnea?
A temporary cessation of breathing.
Name steps to take when providing oral care to an unconscious patient
Elevate HOB
Turn patient's head to side
Provide a towel underneath their chin
Use emesis basin
have suction ready
Name other sources besides the patient for where you can gather data
Family
Caregivers
EHR
Report
Care plans
Team members
What is an important element during implementation/
Documenting
Place in order donning PPE
Gown
Mask
Goggles
Gloves
Give the amplitude scale with meanings
0 - no pulse or unable to palpate
+1 - weak/thready pulse
+2 - normal/brisk pulse
+3 - bounding
Patient's with Glossitis are said to be deficient in these vitamins and mineral
VB12, folic acid, and iron
Which is a physician-initiated intervention?
Teach the client how to transfer from bed to chair and chair to bed
Administer oxygen at 4 L/min per nasal cannula.
Assist the client with coughing and deep breathing every hour.
Monitor intake and output every 2 hours.
Administer O2 4L NC
Name some factors that can impede a patient's ability to learn?
Anxiety
Pain
Cognitive ability
Physiological barriers
Name the precautions taken with a TB positive patient
N95 mask specific
Negative pressure private room
Door closed at all times
Do not transport patient unless necessary and place mask on them for transport
A nurse would monitor which client's vital signs most frequently?
a client in a critical care unit in septic shock
a client hospitalized with hypertension
a resident in a long-term care facility
a client receiving intravenous antibiotics as an outpatient
a client in a critical care unit in septic shock
True or False: It is ok to use soap and water for patient's at risk for skin breakdown
False