Infection/Hygiene/Wellness
Primary action that prevents the spreading of infection
What is: Handwashing
HR 59 bpm
What is: Bradycardia
When assisting with client care (pain, errors, treatment), what is the first step the nurse should take?
What is: Complete assessment
A nurse failing to implement fall precautions is an example of what unintentional tort?
Negligence
Who may assist patients with ADLs
Must name 3*
AP, LPN, RN
This organization accredits health care organizations in more than nine different types of health care settings and monitors state legislative and regulatory changes and updates its standards accordingly.
Who is: The Joint Commission (TJC)
Common causes of health care-associated infections (HAIs)
What is: Invasive Nursing procedures
(IVs, Catheters, Administration of parenteral medications.)
BP of 135/86
What is: Stage 1 HTN
High Blood Pressure
The kind of data that is measurable
What is: Objective data
A nurse restrains a patient and gives them an injection against their wishes is an example of what intentional tort?
Battery
What task can be delegated to Assistive Personnel
(Must name all 4)
What is:
•Feeding clients, basic care/ADLs (grooming, bathing, transferring, toileting, positioning), measuring and recording vital signs, output, and ambulating clients.
This is reported to The Joint Commission and tracked to help health care organizations improve client safety and quality of care.
What is: Sentinel Event
What are the stages of infection
What is:
•Incubation: interval between the pathogen entering the body and the presentation of the first finding
•Prodromal stage: interval from onset of general findings to more distinct findings; during this time, the pathogen multiplies
•Illness stage (ACUTE/CHRONIC): interval when findings specific to the infection occur
•Convalescence: interval when acute findings disappear, total recovery taking days to months
RR of 24
What is: Tachypnea
This part of the nursing process requires action.
What is: Implementation
If a client wants to leave a facility after being told it is best to stay, what is the nurse's responsibility?
What is: To inform the client that leaving is against medical advice (AMA), provide risks associated, ask them to sign the facility’s AMA form, and document the situation in the client's medical record.
What is the nurses role when obtaining consent
*must name 2
What is:
Witness & Advocate
This, is the (early) detection and treatment of preclinical changes to reduce the impact of disease or injury and limit disability.
What is: Secondary Prevention
This, requires a private room or a room with other clients who have the same infection. Gloves and gowns worn by the caregivers and visitors.
Dedicated stethoscopes, BP cuffs, for individual clients
What is: Contact Precautions
100.5
What is: Hyperthermia/Febrile
Data obtained from the patient
What is: Subjective data
A person confined or restrained against their will, is referred to as what?
What is: False Imprisonment
Silence, Open ended questions, Active listening, Reflecting, & Touch, is known as what?
What is: Therapeutic Communications
First few steps of preparing a sterile field.
What is:
1. Handwashing
2. Center sterile package in the center of clean working space
3. Grasp edge of flap and open away from the body
Clean gloves are worn when touching anything that has the potential to contaminate the hands of the nurse. This includes body secretions, excretions, blood and body fluids, non-intact skin, mucous membranes, and contaminated items.
What is: Standard Precautions
(Tier One)
15 seconds
What is: How long Handwashing should be.
What part of the nursing process is determining if goals have or have not been met
What is: Evaluation
A nurse threatens to place an NG tube in a client who is refusing to eat, is known to be called what?
What is: Assault
4 most important steps when washing hands. (Process of handwashing)
What is:
Wash hands for at least 15-30 seconds, Use warm water and soap, Hold hands below elbows while rinsing, and Use a paper towel to turn off the faucet
Then moisturize after cleaning to promote hydration
Silence, Active listening, Open-ended questions, Clarifying...
What is: Therapeutic Communication
First step, in the Order of Doffing
What is:
1. Gloves
(Know the order)
4
Nonmodifiable
Risk Factors
What is:
Genetics, Ethnicity/Race, Age, and Family History
Maslow's Hierarchy of Needs
What is:
Self-Actualization, Self-Esteem, Love and Belonging, Safety, and Physiological.
This, is the nondisclosure of information except to an authorized person; that is, someone involved in the client’s care or someone the client has given permission for informing
What is: Confidentiality
How does a nurse implement reducing the risk of needlestick injuries?
What is:
Active the safety device immediately after use or Dispose of uncapped needle in a puncture-proof and leak-proof container.
Immunizations are referred to as what because they protect against specific infections and diseases. Before any infection or disease can even be present.
What is: Primary Prevention
This, requires a private room, N95 Masks, and respiratory protection devices for caregivers and visitors.
What is: Airborne precautions
4
Modifiable
Risk Factors
What is:
Smoking, Unhealthy diet, Sunbathing, Fitness lifestyle, Drug/Substance Use, Sleep
What is the purpose of pinching up a fold of skin over the forearm or sternum, to check for turgor?
What is: To check for symptoms of dehydration
Other manifestations: Tenting, Dry & Flaky skin
The ethical principle in client care that means, commitment to tell the truth, is known as what?
What is: Veracity
What nursing considerations should be taken when communicating with older adults.
*Must name 3
What is:
Assess for impairments, Eliminate/minimize distraction, Face and speak to the person directly, Give time to answer, Obtain feedback.
What are ques, that someone needs the Heimlich Maneuver
What is:
Grasping at neck, unable to speak, cough, or breath