Chapter 2/3
What is the nursing process?
Assessment, Diagnosis, Planning, Implementation, Evaluation.
What is the single most important activity for preventing and controlling infection?
Hand hygiene
What are different types of restraints?
Physical, force, mechanical device or equipment, chemical
T or F: The best way to clean hearing aids is to place them in water.
False never place them in water.
What is the difference between a medical diagnosis and a nursing diagnosis?
-Medical- describes a disease or illness. Its purpose is to identify a pathology so appropriate treatment can be given.
-Nursing- a problem response that exists at the time of the assessment.
What are the six chains of infection?
Infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host.
Before applying a restraint you will need to have?
Restraint must be medically prescribed and you must first try all less restrictive interventions first.
What is important to remember when providing patient hygiene.
Every patient is unique and have different personal hygiene practices.
This is a blend of concepts that include thinking, doing, and caring.
Full-Spectrum Nursing
What occurs during he Secondary defense against infection?
Phagocytosis, complement cascade, inflammation, fever.
An older adult has a history of falls. When performing a fall assessment, you will utilize which test?
Get up and Go test
If a patient has a bleeding disorder or receiving anticoagulation therapy, how would you educate them to shave?
Using an electric razor
What are the five components of caring?
Knowing, Being with, doing for, Enabling, Maintain belief.
What is the difference between disinfecting and sterilizing?
Disinfecting- removes pathogens on inanimate objects by physical or chemical means.
Sterilizing- elimination of all microorganisms in or on an object.
When responding to a fire, what does RACE stand for?
Activate the nearest alarm
Confine the fire
Extinguish the fire
What eye care should be performed for an unconscious patient?
-Keep eyes lubricated with saline or artificial tears to protect from corneal abrasions and drying.
-Use a protective eye shield to keep the patient eyes closed.
-Instill eye ointment or drops in lower lid as prescribed.
What are the 5 rights of delegating?
Right Task (Can I delegate it?), Right Circumstance (Should I delegate it?), Right Person (Who is best prepared to do it?), Right Direction/Communication (What does the UAP need to know?), and Right Supervision/Evaluation (How will I follow Up?)
What is the correct order when donning PPE?
Gloves, gown, mask, face shield/eye cover, hair cover, shoe cover.
What are some safety measures when having a patient with a restraint?
-Check restraints every 30mins.
-Release restraint to assess circulation, patient response to intervention and need for continuing restraint every 2 hours.
-Check every 24 hour to see if the restraint prescription has been renewed.
-Remove restraint as soon as possible
What are some tips/ things you should perform when bathing a patient with dementia?
Focus on patient not the task, distract, gentle shower, bathe at regular time, provide privacy, avoid sensory overload, foster independence, explain procedure simply, do not rush, and let patient know before you touch them.