Priority Problems
Examples of these types of nursing interventions might include: teaching a patient relaxation techniques for anxiety, repositioning a patient every 2 hours to prevent skin breakdown, resting and elevating an edematous ankle to relieve pain.
What are independent nursing interventions?
This would be the best action taken by a nurse to speak with a female Korean patient who cannot speak English and is accompanied by her son?
What is obtain a female interpreter?
This highly contagious infectious disease is from use of antibiotics, requires soap and water hand washing with CONTACT ISOLATION aka gown and gloves.
What is c-diff or clostridium difficile?
This is last step of Lewin's change theory, and usually occurs when an administrative group makes a policy change that is formally put into practice, adopted, and positively received by staff.
What is refreezing?
This order means your patient may no longer eat or drink AT ALL and you must take away their water pitcher, provide regular oral care, and track I/O's as usual.
What is NPO?
According to this theory when chaos exists in a work system the staff will fail to cooperate together.
What is chaos theory?
While not the same as direct care like giving pain medication or changing a dressing, this type of care often focuses on organization or documentation such as arranging for physical therapy or charting wound measurements.
What is indirect care?
Look at the patient when talking, utilize facility provided translation services, provide handouts in pt's primary language.
What are things to do with a non-English speaking patient.
Signs/symptoms of this common problem for incontinent elderly patients may include dysuria, confusion, and cloudy, amber, odorous urine.
What is a UTI or urinary tract infection?
Laws that are created by administrative bodies like the Board of Registered Nursing.
What are Regulatory laws?
The ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs.
What is perfusion?
Your patient has the unexpected finding of black tarry stools so you also assess your patient for other signs of bleeding, save the specimen to send a fecal occult blood test order, and recognize this may be an adverse effect of THIS CLASS OF MEDICATION and needs to be reported to the provider.
What is an anticoagulant? ex: lovenox, plavix, ASA, eliquis, warfarin
Examples of these types of interventions might include: obtain an order for new pain medication for increased pain, consult with a wound care specialist for a pressure ulcer.
What are dependent nursing interventions?
A nurse is aware that this type of community group would have the most health disparities, an increased incidence of disease and trouble accessing care.
What is a low socio-economic community?
This type of isolation requires a gown and gloves, a standard mask, and possible eye protection when in close proximity to a patient.
What is droplet isolation?
Reviewing this guideline will tell you that only a RN may ASSSESS, develop care plans, and pioneer research projects. An LVN can provide nursing care and AP may only do basic delegated tasks such as reposition, take vitals, help pts to the bathroom, and record I/O's.
What is scope of practice?
The process of moving gases into and out of the body with air flowing in and out of the lungs.
What is ventilation?
You find your post op patient that you medicated for pain has slow, shallow breaths. You recognize that your patient is opioid-naive. This would be your first intervention, and it would be something you can delegate to UAP as well.
What is raise the HOB?
These are the PRIORITY AREAS to assess the skin for pressure ulcers. If we see blanching redness we know we need to intervene before a stage I ulcer develops.
What are pressure points or bony prominences?
Assessing your own biases and attitudes, learning about cultural issues involved in the patient’s health care belief system, and enabling patients and families to achieve meaningful and supportive care demonstrates what concept?
What is Culturally Competent care?
This type of isolation requires an N95 mask or PAPR and a negative pressure room in addition to gown and gloves.
What is airborne isolation?
When a nurse signs as a witnesses it means the patient appears competent, their signature is authentic, and was given voluntarily.
What is informed consent?
Recent changes in these California laws that guide what nurses can do now limit certain respiratory related interventions including endotracheal suctioning, ventilator management, and oxygen titration.
What is scope of practice?
You and your faithful UAP are changing and repositioning someone with a PEG tube and continuous tube feeding. You are there to stop the tube feeding and remind your UAP to position the patient with HOB at 30 degrees. Your patient is at high risk for what complication?
What is aspiration?
This is a high priority problem for a postoperative patient with a surgical incision because if left untreated, it could lead to immediate harm.
What is RISK FOR INFECTION?
A better alternative to a yes/no question, this type of questioning elicits a more detailed and descriptive response from a patient. Examples include "Tell me more about...." or "How do you feel when..."
What is an open ended question?
An nurse assessing a wound hopes to see signs of healing with nice pink granulation tissue. Instead she sees s/sx of a local infection including peri-wound edema, erythema, and thick white/yellow/green drainage that would be described as this:
What is purulent drainage?
A patient is refusing his injectable medication even after being educated about it. He's alert, oriented, and capable of making their own decisions. You decide to give it anyways and have just committed this crime.
What is battery?
This is a term used by Florence Nightingale similar to Watson's transpersonal caring theory and would be demonstrated by consoling a fearful mother whos child is in surgery.
What is holistic nursing care?
This hospital charting system improves the accessibility of medical records by multiple people, faster reporting of diagnostic study results, easier readability of documentation, and reduced errors. You must remember to log off the computer prior to walking away to maintain HIPAA.
What is an EHR?