The scopes of practice of RNs, LPNs, and UAPs are determined by this.
What is the state's Nurse Practice Act or NPA?
When documenting an evaluation of whether or not a goal has been met, these five components must be included.
What are specificity, measurement, achievability, relevance, and a time frame (e.g., SMART goal standards)?
When a client develops severe respiratory side effects and hypotension in response to an IV antibiotic, you should take this action first.
What is discontinue the medication?
Vomiting causes this acid-base imbalance.
What is metabolic alkalosis?
Asking the client open-ended, focused questions is an example of cultural _________.
What is cultural congruence?
True or false: If someone is incontinent, it is always appropriate to insert an indwelling urinary catheter.
What is
What is by saying, "that is outside of my scope of practice"?
There are several modifiable risk factors for illness. List three (3) of them.
What are obesity, smoking, a diet high in transfats, and a sedentary lifestyle?
This is an unintended but often predictable and generally well-tolerated effect of a medication.
What is a side effect?
These two interventions are how you can objectively measure and trend a client's fluid status.
What are daily weights and I&O?
Morphine
Acetaminophen
Hydrocodone
Ibuprofen
Aspirin
Out of the drugs listed above, these are non-opioid analgesics.
What are acetaminophen, ibuprofen, and aspirin?
Several interventions can help a client who is experiencing difficulty sleeping at night. List three of them.
What is reading a book each night before bed, utilizing blackout shades in the bedroom, creating a calming and relaxing sleep environment, developing a pre-sleep routine, and exercising (more than two hours before bed)?
Exercise within two hours of bedtime and caffeine consumption prior to bedtime interfere with good sleep hygiene.
A nurse notices that the patient has a decrease in level of consciousness in the early morning and reports it to the provider during afternoon rounds. This is an example of which torte?
What is negligence?
These exercises help to calm the parasympathetic nervous system, which makes it a great stress management technique.
What are deep breathing exercises?
This color change results in a loss of pink or red tones.
What is pallor?
This vital sign measurement can provide insight into why a client is experiencing dizziness.
What are orthostatic BP readings?
This type of learning helps learners learn by hearing and listening.
What is auditory learning?
There are several questions you should ask a client as part of a pain assessment- list three.
When did it start? What makes it better? What makes it worse? How often do you have pain?
The LPN assisting the client with their ADLs is an example of this ethical principle.
What is Beneficence?
This is when you should listen to an apical pulse for one full minute.
What is HR less than 60 or greater than 100; any time a HR is irregular; and before administering medication that can effect HR (e.g., digoxin, beta blockers, etc.)?
When administering an enteric coated medication, you never do this.
What is crush, chew, or disrupt the pill in any way?
What is keep the weight close to the body?
This is the importance of culturally competent care.
What is culturally competent care creates trusting relationships and improves client outcomes.
Cultural Competency:
➤ Both nurse and patient better understand the disease process and treatment management.
➤ The patient is more likely to adhere to the treatment protocols.
➤ Patient outcomes are improved.
The terms cultural awareness, cultural sensitivity, and cultural competence are often used interchangeably; however, they are not the same.
Working night shift disrupts the _______ rhythym.
What is circadian?
(Circadian rhythm = the physical, mental, and behavioral changes an organism experiences over a 24-hour cycle.)
There are several actions that promote communication with clients. State two (2) of them.
Respect personal space. Sit next to the client when asking questions. Restate what the client says to clarify. Do not impose your opinion. Do not offer approval or disapproval.
A client has a temperature of 102F, a HR of 124, a RR of 32, a BP of 108/62, an O2 sat of 95%, and a pain score of 0/10. The nurse will address the client's ______ first.
What is their fever?
There are several steps that a nurse can take to protect the privacy of a client's EHR. List two of them.
What are only access records you have a professional reason to view; do not leave a computer unattended after logging in; do not leave client information displayed/a screen pulled up or open where others can see it; and use privacy screen filters?
Passive range of motion helps to prevent this hazard of immobility.
What are contractures?
This type of learning helps learners learn by seeing, reading, and watching.
What is visual learning?
What is a full glass of water or juice only?
This is a nonverbal action that communicates caring to clients.
What is therapeutic touch (e.g., holding the client's hand, a hand on the shoulder, etc.)?
These are included in a focused respiratory assessment. (List three.)
What are
1) auscultation of lung sounds
2) inspection of skin and mucous membranes
3) respiratory effort
4) chest appearance
5) oxygenation status
6) measurement of oxygen saturation?
This is who would need to complete an incident or occurrence report.
What is anyone who witnessed or was involved in the care process of the incident?
There are several hazards of immobility. State one respiratory symptom and one integumentary symptom.
What are pressure injuries and atelectasis or rhonchi?
There are several fall risk prevention measures the LPN can delegate to the UAP-- list three of them.
Remove clutter, clean spills, place nonskid slippers on all clients, answer call lights in a timely manner, hourly rounding, lock beds and furniture with wheels.
Pyridium is administered to the client experiencing a UTI for this reason.
What is alleviation of the symptom of dysuria (burning during urination)?
This type of infection control precaution should be applied to all clients.
What are standard precautions?
These are findings you can measure that would help you determine whether a client's respiratory status has improved.
What are overall work of breathing, RR, and O2 saturation?
What is elevating the head of the bed greater than 30 degrees?
"Why did this happen to me? This is completely unfair. I am supposed to have my whole life ahead of me!" is an example of which stage of grief?
What is anger?
True or false: Restraints may increase the risk of injury and should be used as a lat resort.
What is
There are several important things to know when caring for someone with an indwelling urinary catheter (e.g., a Foley) to prevent them from developing a UTI. List three.
What is keeping the bag below the level of the bladder (e.g., waist), making sure the tubing does not have any kinks or dependent loops, maintaining aseptic (sterile) technique during insertion, and providing routine catheter care per facility policy?
This type of precaution is indicated for someone with MRSA or VRE (include the appropriate PPE in your response).
What are contact precautions (standard precautions plus gown and gloves)?
This respiratory pattern is demonstrated by an increase in the depth of respiration, then a gradual decrease in depth, followed by a period of apnea before repeating the pattern.
What are Cheyne-Stokes respirations?
This lab reflects that the client has effectively increased the amount of iron in their diet.
This drug eases discomfort and dyspnea at the end of life.
What is morphine?
A client's family asks you to pray for their dying loved one with them. They practice a religion that is different from your own, and you are uncomfortable. This is how you should respond.
What is by asking if it is okay to make a referral to spiritual care/the chaplain or another staff member on the unit who is comfortable with this request?
“Thank you for asking me to pray with you; there is another nurse on the floor who is better at this than I am. May I have your permission to seek that person out for you?” “I am confident that the chaplain can help you in many ways with your request. May I make a referral to the chaplain for you?"
True or false: Incontinence is a normal part of aging, so it is normal for older adults to be incontinent.
What is
This is the most effective way to break the chain of infection.
What is hand hygiene before, during, and after contact with the client?
A client presents with COVID-19-induced COPD exacerbation. They have coarse crackles in the bilateral lung bases and are using accessory muscles to breathe. Their temperature is 99.3F/37.4C, their BP is 148/90 mmHg, and their O2 saturation is 91% on 2 LPM oxygen via nasal cannula. Other than COPD they do not have any past medical history. The LPN prioritizes care and addresses this finding first.
What is the client's work of breathing or respiratory effort?
This lab value, if low, indicates the client is at risk for poor wound healing.
What is albumin?
Several signs and symptoms indicate fluid volume overload. List two of them.
What are the sudden onset of a moist-sounding cough, JVD, bounding pulse, and weight gain?
Medications in these classes increase a client's risk of bleeding during surgery-- provide two classes and an example drug in each.
What are NSAIDs and anticoagulants (e.g., aspirin, ibuprofen (NSAIDs) and heparin, enoxaparin (anticoagulants), etc.)?
The nurse knows to make this simple adjustment if a client experiences difficulty having a bowel movement on a bedpan while lying flat.
What is raising the head of the bed?
There are several organisms that require airborne precautions. List three of them.
What are tuberculosis, chickenpox, and COVID-19?
There are several early signs of hypoxia-- list five of them.
What are:
Agitation
Anxiety
Changes in level of consciousness
Disorientation
Headache
Irritability
Restlessness
Tachypnea
There are seven (7) rights of medication administration. List them all.
What are the right medication, right dose, right route, right time, right reason, right documentation, and right client?
These are symptoms of hyperkalemia. (List five.)
Bradycardia and other arrhythmias, nausea, intestinal cramping, diarrhea, anxiety, muscle weakness, numbness or prickly sensations, flaccid paralysis
There are several post-operative complications. List 5.
Fever, atelectasis, pulmonary embolism, nausea & vomiting, urinary retention, bleeding/hemorrhage, and wound infection.
The nurse is preparing to administer IV fluids to their client. The provider order is: 0.9% sodium chloride IV at 125 mL/hour for 3 liters. The tubing drop factor is 10 drops per mL. This is the drip rate of the infusion (drops per minute, to the nearest whole number).
What is 21 drops per minute?