Nursing Process
What are the steps in the nursing process (in order)?
Assessment, diagnosis, planning, implementation, and evaluation
Standard Precautions are used when?
Every patient, every time
Focused assessments are performed when?
At the beginning of the shift
A nurse should check a medication how many times before administering it?
3 times
If a patient has dark stool, this may indicate what?
GI bleed
The nurse arrives at a diagnosis through _______?
Assessment of the patient
What is the best prevention for needle sticks?
Never recap a needle, dispose of immediately in the sharps container, never stick hand in a sharps container
Normal Capillary refill is...?
<3 seconds
What are the 6 rights of medication administration?
Right drug, dose, route, time, patient, and documentation
What recommendation would a nurse give for time out for young children/toddlers
1 minute time out per year of age
What occurs during the implementation phase?
What is the best prevention for Healthcare Acquired Infections (HAIs)?
Good hand hygiene and appropriate use of precautions
A patient is considered bradycardic when heart rate is what?
<60
How would a nurse determine why a patient is taking a medication?
Looking at the patient's medical history
Discharge planning begins when?
On admission
According to Maslow's hierarchy of needs, what nursing diagnoses must be managed first?
Physiological health needs (i.e. airway, breathing, circulation, food, water, etc.)
What would a nurse wear prior to entering a contact precaution room?
Gown & gloves in addition to standard precautions
When assessing the abdomen, what would be normal findings the nurse expects?
Positive bowel sounds, soft, nontender, nondistended
Which route of administration would be most rapid?
Intravenous (IV)
How would a nurse determine a trach needs to be suctioned?
Assessment of breath sounds
What must a nurse consider when creating a goal statement?
Specific, Measurable, Attainable, Realistic, Time sensitive
What would a nurse wear before entering a room with airborne precautions?
Gown, Gloves, particulate respirator (N95) in addition to standard precautions
What would a normal pupillary assessment consist of?
Pupils equal, round, reactive to light, and accommodate (PERRLA)
What are some ways a nurse can decrease discomfort when administering Intramuscular (IM) injections?
Utilize the Z-track method and choose the smallest gauge need appropriate for the site
If a patient has a vitamin D deficiency what else should the nurse assess for?
Calcium deficiency