Assistive devices
A nurse is caring for a patient who recently started using crutches for an ankle injury. The patient complains of tingling and discomfort in the shoulder and axillary area. What is the nurse’s best response?
“Let me see how you ambulate using your crutches.”
ADPIE
assessment
diagnosis (nursing diagnosis)
planning
implementation
evaluation
3 fall prevention interventions
Remove obstacles from walking path
ensure adequate lighting in bathroom, hallways, stairs,
use assistive devices consistently and properly when walking
2 important components to reaching critical judgment
Which of the following is the first priority in preventing infections when providing care for a client?
hand washing with soap and water
As the nurse in an ambulatory care area, you see a new client enter with a cane that appears too short for the client. What should you do?
Teach the client about the proper length of a cane.
Impaired mobility r/t alterations in gait AEB requires walker to ambulate from bed to bathroom
Name 2 seizure precautions
supplemental oxygen equipment and suction kept at bedside
A nurse is caring for a patient who sustained a spinal cord injury in a recent fall and is now post-op from spinal surgery. Which of the following indicates good clinical reasoning?
The nurse logrolls the patient when repositioning.
Proper motion for hand hygiene
The best way to transfer a completely immobile client from bed to chair would be to use what?
A mechanical lift
To administer oral care to a semi-comatose client, the nurse should place the client in which of the following positions?
Side-lying with the head slightly lowered and turned toward the nurse
3 safety assessment areas in the home
Fire prevention
poison prevention
carbon monoxide levels
child safety
lead
pg467
A 61-year-old client with diabetes mellitus has physician’s orders for meticulous foot care. When teaching the client about foot care, the nurse shares that the primary short-term goal is to prevent what?
Infection
3 different types of baths in hospital
complete bedbath
sink bath
shower
* BONUS* give a patient example for each
The nurse is teaching a client about the safe use of a walker. Which of the following would be a correct statement?
"The hand bar of the walker should be just below the client's waist."
SMART
Specific, measurable, attainable, realistic, timely
4 alternatives to physical restraints
Orient patient to surroundings
relocate pt to a room near the nurse's station
minimize environmental stimuli
Use UNTIED cloth padded protective mitts on the patient's hands to prevent the patient from removing tubes or drains
What is clinical reasoning
using data from the patient to set goals and interventions.
2 reasons for good foot care
prevent infection, promote circulation
*BONUS* what patient type is most critical for proper foot care?
The nurse is teaching a client with right-sided weakness how to use the cane. What information is appropriate to give to the client?
You will hold the cane in your left hand and move it at the same time as your right leg.
Example of evaluation
Goal met/ Goal partially met/ goal not met
3 techniques for restraint use
Obtain correct restraint for the situation
tie the end of the strap to the appropriate location using a slip-knot
assess skin and range of motion every 2 hours or more often for skin breakdown and circulation
The nurse should avoid using lemon-glycerin swabs on a client’s tongue and mucous membranes because regular use of this product does what?
Erodes the tooth enamel.
3 techniques used during bedbaths
Raise bed to working height
cover patient with bath blanket or linens for comfort
Assess the skin thoroughly throughout bath