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A nurse is caring for a client who has a tracheostomy. What is a priority to reduce infection?
The nurse should perform tracheostomy care every 4 hr to reduce the risk of infection.
What is PIE documentation?
• P – Problem: Identifies the patient's current nursing diagnosis, health issue, or need, often labeled with a number (e.g., P #1: Acute pain related to surgical incision).
• I – Intervention: Details the specific nursing actions taken to address or manage the stated problem
• E – Evaluation: Records the patient's actual response or outcome following the intervention to determine if the problem is resolved, improved, or unresolved.
What barriers can effect a patients discharge?
hearing deficit, environmental factors, pain or distress, and adverse effects of opioid analgesia
Patient has a tracheostomy. What interprofessional team member should be part of the patients care plan?
Respiratory Therapist
A nursing is completing a fall report. What needs to be included
objective terminology when documenting
Which factors are critical to include in the discharge teaching for a client with chronic disorders?
Discharge teaching for clients with chronic disorders should focus on practical aspects such as follow-up appointments, potential complications, dietary and activity restrictions to ensure self-management and prevent readmission.
Protected Health Information includes?
Client’s payment information, as well as any other information that can identify a client, such as date of birth, contact information, and name, is considered PHI.
Patient is discharged needing daily wound dressing changes. What type of after care will the patient be needing?
Home Health provides nursing services for the client in their home such as wound care, tube feedings, and administration of antibiotics.
What does a case manager do for patients?
Organizes client services following discharge
What should be included on a electronic medical record?
medications, allergies, medical history, and demographics data
A nurse is working with an RN to admit a new client. Which of the following steps of the nursing process is the nurse using when assisting to formulate goals for a positive outcome?
Planning. During this step, the PN is assisting and collaborating with the RN, to address the client's problems by formulating individualized interventions and goals to ensure the client achieves a positive outcome.
What is a living will?
Living wills provide information about a client’s choices regarding their end-of-life care. The living will was created when the client was able to make their own decision about their treatment. Family members cannot make changes to this document.
Patient is worried about affording medications. What factors affect the clients health?
Socioeconomic factors that affect a client's health include low-income and poverty levels. The nurse should identify that a client who lives in subsidized housing and is concerned about being able to afford their medications has a socioeconomic risk factor. Clients who have a low-income level might not have medical insurance or the ability to afford their medications or medical treatments.
Why is space for one or two fingers left between the tracheostomy ties and the patient's neck?
Adequate space prevents pressure injuries and ensures comfort.
What is the benefit of the electronic health record for patients?
client is able to access their medical record electronically at any time
What is an important consideration when preparing a discharge plan for a patient leaving against medical advice (AMA)?
While discussing potential complications is crucial, documentation remains the primary responsibility in AMA cases.
What is protected health information (PHI)?
The Privacy Rule defines protected health information (PHI). The Enforcement Rule covers compliance and investigations of HIPAA violations and the administration of financial penalties for those violations.
Patient has hearing loss and is being discharged. What should you do during your discharge education?
To facilitate communication with the client who has hearing loss, the nurse should face the client while speaking. Other actions the nurse can take to facilitate communication are to provide a well-lit environment, ensure any assistive devices used by the client are present and in use, and decrease the noise level in the environment.
Why hyperoxygenate the client before suctioning a tracheostomy?
Hyperoxygenation helps prevent a drop in oxygen levels during suctioning.
What is the difference between modifiable and nonmodifiable risk factors?
Modifiable Risk Factors
These are factors you can change, treat, or control through lifestyle adjustments, medical care, or behavior changes.
Non-Modifiable Risk Factors
These are traits or conditions you cannot change or control.
What should a nurse prioritize when planning discharge for a client returning home?
Discharge planning should prioritize practical arrangements such as transportation, providing necessary information, and ensuring community support for the client’s transition back home.
The nurse is admitting a client who speaks a different language than the nurse. What should the nurse do to support their patient?
The nurse should obtain assistance from the facility's qualified medical interpreter. This would facilitate the nurse with communicating with the client through the admission process. This would also protect the facility, client, nurse, to ensure that the information being translated is correct and accurate.
A nurse is reinforcing discharge teaching for a patient with cognitive disorder. What should the nurse to support their patient?
The nurse should provide short and directive instructions that are free of medical terminology and slang to facilitate communication between the adolescent and their parents.
What do you do as a nurse if you witness a coworker accessing a clients medical record without authorization?
Report the incident to the supervisor immediately.
Unauthorized access to medical records violates HIPAA, and reporting ensures accountability and prevents further breaches.
Which actions can compromise patient safety when documenting in electronic health records?
Patient safety is compromised by delayed documentation, unapproved abbreviations, ignoring adverse effects, and falsifying information. Comprehensive history and accurate recording enhance safety.