Operation: Safe Recovery
This technique supports an abdominal incision with a pillow during coughing and deep breathing.
What is splinting?
Comparing a patient’s actual response with the expected outcome occurs during this step of the nursing process.
What is evaluation?
“Tell me what brought you to the hospital” is an example of this type of interview question.
What is an open-ended question?
A nurse speaks up when a patient’s expressed wishes are being overlooked. The nurse is acting in this professional role.
What is a patient advocate?
Before administering medication, the nurse asks the patient to state their name and date of birth and matches them with the medication record and identification band. These are examples of this safety requirement.
What is using at least two patient identifiers?
Before administering a preoperative sedative, the nurse discovers that the patient has unanswered questions about the procedure’s risks. The nurse should take this action regarding consent.
What is pause the consent process and notify the procedural provider to answer the patient’s questions before sedation?
“The patient will walk 50 feet with a walker and standby assistance by 1500 today” is stronger than “The patient will improve mobility” because it includes these two essential outcome characteristics.
What are measurable criteria and a specific time frame?
A patient says, “I’m scared about what the results will show.” Give one therapeutic response that encourages the patient to explore that fear.
What is “Tell me more about what worries you”?
A patient with decision-making capacity refuses a recommended treatment after receiving an explanation. Respecting this choice supports this ethical principle.
What is autonomy?
A patient practices guided imagery while also receiving prescribed analgesics. Because the approaches are used together, guided imagery is being used in this way.
What is complementary therapy?
After general anesthesia, a patient develops loud snoring, seesaw chest movements, and decreasing oxygen saturation. These findings suggest this immediate airway problem.
What is upper airway obstruction?
Of these tasks—initial assessment, teaching a new skill, evaluating pain treatment, or obtaining routine vital signs on a stable patient—this is generally appropriate to delegate to a trained UAP.
What is obtaining routine vital signs on a stable patient?
In SBAR, “I need you to evaluate this patient at the bedside now” belongs in this section.
What is Recommendation?
A nurse realizes that an assessment was never performed, although the electronic record has a space for it. This is the appropriate action regarding documentation.
What is perform the assessment and document the actual findings and time?
A patient says, “Herbal supplements are natural, so they can’t interact with my medications.” The nurse should explain this key safety concept.
What is natural products can cause adverse effects and medication interactions?
Six hours after surgery, a patient’s heart rate rises to 124/min, blood pressure falls to 88/54 mmHg, and the dressing becomes saturated with bright red blood. This complication is the priority concern.
What is postoperative hemorrhage with possible hypovolemic shock?
A UAP reports that a previously stable patient now has a respiratory rate of 30/min and oxygen saturation of 86%. The RN should take this action first.
What is immediately assess the patient?
A patient with limited English proficiency needs an admission interview. This communication resource should be arranged to support an accurate assessment.
What is a qualified medical interpreter?
A nurse discovers that the wrong medication was administered. Before completing an incident report, the nurse’s first priority is this.
What is assess the patient for harm and address immediate needs?
A confused patient repeatedly tries to get out of bed to urinate. Before considering restraints, name two individualized nursing interventions that address the immediate fall risk.
What are assist with toileting and provide close observation?
A postoperative patient’s abdominal incision opens, exposing bowel. While another nurse summons emergency assistance, the bedside nurse should cover the exposed tissue with this.
What are sterile dressings moistened with sterile normal saline?
A patient’s mobility goal was not met. Before simply extending the deadline, the nurse should take this action to determine how the care plan needs to change.
What is reassess the patient and identify barriers or reasons the outcome was not met?
During a routine bedside assessment, a patient develops sudden difficulty speaking and new right-arm weakness. The nurse should interrupt the routine assessment and take this priority action.
What is activate the facility’s stroke/emergency response immediately?
A patient signed a surgical consent form earlier but now says, “I changed my mind. I don’t want surgery.” The nurse should take these two immediate actions.
What are stop preparations for the procedure and notify the surgical team of the withdrawal of consent?
An older adult taking an anticoagulant wants to start an herbal supplement for memory. Before the patient begins taking it, the nurse should take this action and explain why.
What is review the specific supplement with the pharmacist/prescriber for interactions before starting it?