Delegation
This member of the healthcare team can be delegated tasks such as taking VS, assisting with bathing, and ambulating a stable client
Who is UAP (unlicensed assistive personnel)?
This position promotes the greatest ease of lung expansion and is recommended for a client with SOB?
What is high fowlers position?
This is the single most effective action a nurse can take to prevent the spread of infection?
What is proper hand hygiene?
What is right client, right medication, right documentation, right route, right time, right dose?
According to Erikson's stages of development, what stage is a toddler in?
This RN should delegate this task to the LPN when caring for a postoperative client: administering PO medications or completing the initial admission assessment?
What is administering PO medications?
INITIAL assessments cannot be delegated
This urinary output amount indicates adequate kidney perfusion in an adult?
What is at least 30 ml/hr?
This type of PPE must be worn when caring for a client on droplet precautions? Tell me types of droplet precautions?
What is a surgical mask/ influenza, pertussis, mumps, rubella?
Before giving a PO medication, the nurse must verify multiple things, what are they?
What is name, DOB, allergies, if the patient can swallow safely?
Tell me about the 5 stages of grief in Kubler model?
What is Denial, Anger, Bargaining, Depression, Acceptance?
The RN can safely delegate this component of enteral feeding care to a UAP for a stable client: checking feeding tube placement or measuring and documenting intake/ output?
What is measuring and documenting intake and output?
A nurse is teaching a client about how to use an incentive spirometer. What is the key factor when teaching IS use?
What is INHALE slowly?
Name the correct order for donning PPE?
Gown, Mask, Goggles, Gloves
For a subcutaneous insulin injection, the nurse should insert the needle at this angle for an average sized adult?
What is 45 to 90 degrees?
What is the first action a nurse should take when discovering a fire in a client's room? - Think Acronym
What is RACE - Rescue, alarm, contain, extinguish?
A nurse is caring for a client with new onset confusion. The UAP asks if they can help feed the client lunch. According to delegation principles, what is wrong with this situation?
Not a stable client, new onset confusion, may require assessment and care
A nurse is caring for four clients. Which finding requires immediate intervention related to oxygenation?
-O2 Sat of 92% in a COPD client
-Sudden restlessness in a postoperative patient
-Respiratory rate of 22 in an anxious adolescent
-Crackles in the base of client with CHF
What is sudden restlessness in a postoperative client?
A nurse is preparing to enter the room of a client with C. difficile. What type of PPE is required, and what safety action?
What is gown and gloves, and washing hands with soap and water?
To mix regular insulin and NPH insulin, what is the correct order of steps?
What is clear then cloudy, so Regular than NPH?
When transferring a client with unilateral weakness from bed to chair, the nurse should place the wheelchair on which side of the client?
What is the stronger, non affected side?
-Teaching a client about insulin administration
-Evaluating a client's response to IV pain medication
-Updating a plan of care
-Reinforcing teaching on incentive spirometer use
What is reinforcing teaching on incentive spirometer use?
A nurse is caring for a patient with an ileostomy. What would the nurse expect regarding output, assessment of stoma and overall care?
What is liquid, more continuous output, red beefy stoma, round, moist?
A nurse has 4 clients. Which one requires airborne precautions/ what are airborne precautions?
-A client with pertussis
-A client with RSV
-A client with Tuberculosis
-A client with Scarlet fever
What is a client with Tuberculosis? and N95, negative air pressure room
A nurse is preparing to administer an intramuscular injection to an adult. What is the preferred site, and maximum volume for each site?
What is Ventrogluteal site - 3 ml, deltoid - 1 ml, vastus lateris - 3 mls
Before applying a restraint to a client, the nurse must try these interventions first, because restraints are considered a last resort?
What is reorientation, diversion activities, less invasive approach, redirection, distraction, increased supervision?
-restraint safety (hourly rounding, Q2 safety bathroom and water, physical safety/ circulation)