Nursing Process and Beyond
What are the 5 steps of the Nursing Process?
Assessment/Data Collection
Analysis/Data Collection
Planning
Implementation
Evaluation
pg 31
Responding to call lights in a timely manner, providing regular toileting and hourly rounding, using a gait belt, and adequate lighting are all nursing actions that aid in preventing what safety issues.
Falls
pg 59
Name a nursing action that aids in preventing skin breakdown related to chronic exposure to urine.
Keep the skin clean and dry
Assess for the manifestation of the breakdown
Apply protective barrier creams
Implement bladder-retraining programs
pg 256
This results from distention of the bowel from gas accumulation (can cause cramping or a feeling of fullness)
Flatulence
pg 246
What is the functional unit of the kidney?
Nephron
A&P review
The systematic collection of information about clients' present health statuses to identify needs and additional data to collect based on findings.
Assessment/Data Collection
pg 31
This type of data is what the nurse sees, hears, feels, and smells.
Objective
pg 21
Provide a nursing action that can decrease a client's risk for Catheter-Associated Urinary Tract Infection (CAUTI).
Use an aseptic technique when inserting catheters
Prevent obstruction and backflow of urine through the catheter, drainage tubing, and drainage bag.
Provide perineal hygiene routinely and after soiling.
Assess ongoing need for indwelling urinary catherer daily
pg 253
The inability to control defecation is often caused by diarrhea.
Fecal Incontinence
pg 245
You are teaching a client about home safety with oxygen, name 3 safety interventions that you would include.
Replace bedding that can generate static electricity (wool, nylon, synthetics) with fabric made from cotton.
Keep flammable material (heating oil and nail polish remover) away from the client when oxygen is in use.
Follow general measures for the safetyin the home (having a fire extinguisher readily available and an established exit route if a fire occurs).
pg 67
In nursing, this is an active, orderly, well-thought-out reasoning process that guides a nurse in various approaches to making a nursing judgment by applying knowledge and experience, problem-solving, logic, reasoning, and decision-making.
Critical Thinking
pg 37
How long is a prescription for adult restraints good for?
The prescription allows only 4 hours of restraints for an adult, 2 hours for clients 9-17, and 1 hour for clients under 9 years of age. Providers can renew these prescriptions for a maximum of 24 consecutive hours.
pg 60
Describe 3 clinical manifestations of a Urinary Tract Infection (UTI).
Urinary frequency, urgency, nocturia, flank pain, hematuria, cloudy, foul-smelling urine, and fever.
In older adults clients present with new onset of increased confusion, recent falls, new onset of incontinence, anorexia, fever, tachycardia, and hypotension.
pg 254
This is an intestinal obstruction caused by reduced motility following bowel manipulation during surgery, electrolyte imbalance, wound infection, or by effects of medication.
Paralytic Ileus
pg 246
The provider ordered Lyrica 75 mg by mouth twice a day. Lyrica 20mg per ml is available. How much will the nurse give? Round to the nearest 10th.
Available x ml= 1 ml/20 mg
Ordered 75mg
75mg /20 mg = 3.75
Rounded to the nearest 10th is 3.8 ml
What does each letter of the SBAR represent?
S: Situation
B: Background
A: Assessment
R: Recommendation
These reports are an important part of a facility's quality improvement plan but should never be added to a client's medical record.
Incident Report
pg 22
Your patient complains of leaking urine when she coughs, laughs, sneezes, or lifts heavy objects. What type of incontinence is she exhibiting?
Stress Incontinence
pg 254
Diarrhea can lead to dehydration. Describe 3 clinical manifestations of dehydration.
Hypotension
Poor Skin Turgor
Elevated Body temp
Fluid and Electrolyte Imbalance
Hypernatremia (muscle weakness, lethargy, swollen red tongue)
Hypokalemia (leg cramps, muscle weakness, nausea, vomiting, cardiac dysrhythmia)
pg 249
Will also accept dry mucus membranes.
When administering an enema, the client should be positioned on their ______ side with the ______ leg flexed forward.
Left side with right leg flexed forward.
pg 248
During this phase of the nursing process, the nurse performs nursing actions, delegate tasks, supervise other healthcare staff, and document the care and clients' response.
Implementation
pg 33
Fire response follows the RACE sequence. What does each letter stand for?
R: Rescue and protect clients in close proximity to the fire by moving them to a safer location
A: Alam activate the facility's alarm system and then report the fire's details and location
C: Contain/Confine the fire by closing doors and windows and turning off any sources of oxygen and any electrical devices
E: Extingiuish the fire is possible using the appropriate fire extinguisher
pg 61
You are the nurse assisting with an Intravenous pyelogram (the injection of contrast media for viewing the ducts, renal pelvis, ureters, bladder, and urethra), what is the most significant nursing consideration concerning this diagnostic test?
Allergies to shellfish contraindicate the use of contrast medium.
pg 252
List 2 nursing interventions that can aid in decreasing constipation.
Increase Fiber
Increase Fluids
Encourage Exercise
Give bulk-forming products before stool softeners, stimulants, or suppositories
pg 247
Bradycardia, hypotension, and syncope are a result of what maneuver as it relates to straining and bearing down.
Valsalva Maneuver
pg 249