Basic concepts
If a client is refusing a blood transfusion because of religious reasons and you the nurse respect his decision. What ethical principle are you following?
Autonomy is the ethical principle that recognizes the right of a competent individual to make decisions about their own body and health care, even if those decisions conflict with medical advice.
Coumadin ordered 6 mg po stat. The day nurse forgot to sign off the med but gave the med. The evening nurse gave the med and signed off. The patient received 12 mg of coumadin this day. Who made the med error?
The nurse giving it the 2nd time.
If a client is nauseas and vomiting x 3 days, what nursing diagnosis should be considered?
Prolonged nausea and vomiting (3 days) put the client at high risk for dehydration and electrolyte imbalance, making "At risk for Fluid Volume Deficit"
Wha is the most concerning complication of a Patient-Controlled Anelgesia pump?
The complication of a Patient-Controlled Analgesia (PCA) pump that is most concerning a is Respiratory Depression, which manifests as Hypoventilation(shallow breathing where there is not enough oxygen intake or elimination of co2)
What type of asepsis is needed for foley insertion and central line insertion?
What is surgical asepsis or sterile technique?
When a nurse talks badly about a health care provider in front of a group of nurses saying that he's the worst doctor. This can be ....
Slander: Defamation that is spoken (oral). Since the nurse is "talking badly" in front of a group of people, it falls under slander.
Libel: Defamation that is written (e.g., in a document, email, or social media post).
A nurse is administering IV medication and notices the IV is cool to touch and swollen. What should she do?
What is:
Stop the Infusion: Immediately discontinue the IV infusion to prevent further fluid or medication from entering the inflamed or damaged area.
Remove the IV: Gently remove the IV catheter from the site.
Apply Appropriate Compress:
For infiltration (cool to the touch, swollen), a warm compress is generally applied to promote circulation and help the body reabsorb the fluid.
For phlebitis (red, warm, painful), a warm, moist compress is also often applied to reduce inflammation and pain.
A person who hasn't been eating suddenly feels dizzy when getting up from a lying position. This symptom is referred to as...
What is Orthostatic or Postural hypotension?
Orthostatic or Postural hypotension is defined as an abrupt fall in blood pressure when a person stands up or sits up from a lying position.The sudden change in position prevents the circulatory system from compensating quickly enough to maintain blood flow to the brain, leading to symptoms like:In a patient who "hasn't been eating", this may be due to dehydration or fluid volume deficit, which can predispose them to orthostatic hypotension.
This manual technique, often used with postural drainage, involves rhythmically clapping the chest wall to loosen thick secretions?
What is chest percussion?
What type of asepsis is needed for Foley care?
What is medical asepsis?
Why is it necessary to compare vital signs to the patient's baseline?
What is identify significant changes and deviations from the patient's normal physiological status.
A nurse is apply topical silvadene cream to a stage 2 pressur ulcer. Describe a stage 2 pressure ulcer.
Partial-thickness skin loss involving the epidermis and/or dermis.
It presents as a shallow open ulcer with a red-pink wound bed, without slough or bruising.
It may also present as an intact or ruptured serum-filled blister.
It should not have slough, granulation tissue, eschar, or exposed fat.
Which type of parenteral nutrition contains the highest amount of glucose?
The type of parenteral nutrition that contains the highest amount of glucose is Total Parenteral Nutrition (TPN).
The Jeopardy question and answer are:
The high concentration of glucose (dextrose) is the main factor distinguishing TPN from Peripheral Parenteral Nutrition (PPN).
Total Parenteral Nutrition (TPN): TPN is administered via a central line. TPN solutions can contain dextrose concentrations ranging from 5% up to 70%,
Peripheral Parenteral Nutrition (PPN): PPN is administered through a smaller, peripheral vein. Due to the risk of irritating the vein (phlebitis) and causing damage, PPN solutions must have a much lower osmolality and are therefore limited to a lower dextrose concentration, typically 5 to 10%
What type of respiratory reaction is seen with blood transfusion reaction within first 15 minutes of transfusion?
What is dyspnea?
If patient is experiencing hypocalcemia (calcium <8.5), what symptoms might be noted?
What are signs of tetany e.g. Positive Chovstek and Positive Trousseau's signs?
When the nurse notifies the MD of client's advesrse reaction to medication, the role the nurse assumes is called?
What is advocate?The nurse acts as a client advocate when notifying the healthcare provider (HCP) of an adverse reaction to medication because advocacy involves protecting the patient's rights and speaking up on their behalf to ensure their safety and well-being.
A nurse is performing a wet to dry dressing on a stage 4 pressure ulcer. How would you describe a stage 4 pressure ulcer?
What is full thickness skin loss with exposed bone or muscle?
A patient immediately post op ask when he can eat? The nurse responds?
Both the return of bowel sounds (indicating gut motility) and the gag reflex (to ensure the patient can swallow safely and prevent aspiration) are crucial checks before advancing the patient's diet from NPO.
Which type of breathing is encouraged to bring up mucus in the post op patient?
What is huffing?
How does a nurse collect a 24 hour urine for creatinine clearance?
What is start the collection early in the morning by discarding the first void and then collecting the voided urine in a container placed on ice for the remaining 24 hours.
Nurse is collecting objective data from client interview. What are the 4 main techniques used in physical examination?
The four main techniques for collecting objective data during a physical examination are:
Inspection: Carefully watching the patient .
Palpation: Touching or feeling the body for temperature, moisture, masses, and pain.
Percussion: Tapping the body to elicit sounds that reveal the density of underlying tissues.
Auscultation: Listening to sounds produced by the body (e.g., heart, lungs, and bowel sounds)
A health care provider is instilling doxycycline into a patient's chest tube. The nurse notices the color of the fluid in the chest tube after instillation of medication is watery pink. How does he document the color?
What is serosanguinous drainage?
How does nurse confirm proper placement of g tube before providing enteral feedings?
1. X-Ray (Radiographic Confirmation): This is considered the gold standard for confirming initial G-tube placement. An X-ray image definitively shows the tube's tip in the stomach.
2. pH Testing of Aspirate:Gastric Fluid: contents is typically highly acidic, usually less than 4
Which oxygen mask delivers the precise amount of oxygen?
What is the venturi mask?
How does a nurse set up a sterile field for foley catheterization?
What is open the first flap of the foley catheterization kit away from your body?