Legal Aspects
In completing a client’s preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?
A. Witness the client’s signature to the permit.
B. Answer the client’s questions about the surgery.
C. Inform the surgeon the client has questions about the surgery.
D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.
C. Inform the surgeon
It is the surgeon’s responsibility to explain the procedure to the client and obtain the client’s signature on the permit. Although the nurse can witness an operative permit, the procedure must first be explained by the healthcare provider or surgeon, including answering the client’s questions. The client’s questions should be addressed before the permit is signed.
This is the best way to break the chain of infection
What is washing hands?
The nurse should address this population by speaking clearly, turning off background noise, and by speaking in simple sentences
Hard of Hearing
The nurse is preparing a liquid medication for a 2-year-old. The dose is 2.2 mL. What delivery devise will the nurse select to prepare the medication?
A. 30 mL medication cup
B. 10 mL medication spoon
C. 3 mL needleless syringe
D. 5 mL medicine dropper
C. 3 mL needleless syringe
Accuracy is most important when delivering small amounts of medication to a child. The most accurate dispensing devise is the 3 mL needleless syringe that is marked off in increments of tenths.
This law protects nurses, HCPs, and patients from misuse of confidential information
HIPAA
The nurse is preparing the room for a client after a laparotomy with a 5 inch midline abdominal incision. The nurse plans on teaching the client how to splint the wound when coughing or deep breathing. What extra item will the nurse place in the client’s room?
A. Pillow case
B. Pillow
C. Sheet
D. Blue absorbent pad
B. Pillow
The purpose of splinting an incision is to offer additional support to the wound. The client can hold a pillow or rolled up blanket against the abdominal incision. The remaining items do not offer the level of support necessary to splint the wound.
These patients often experience dysphagia, hemiparesis, one-sided neglect, pressure injuries, and poor self esteem
Stroke Victims
A patient would violate this order by consuming a small amount of coffee the day of their surgery
What is NPO
This is one of the 6 rights of med administration, which can be satisfied with a patient's name, date of birth, and a photo ID
Standard of Care
This is the first thing the nurse should do for a patient experiencing respiratory distress
What is repositioning the patient? (ie elevate HOB)
This population is at high risk for atelectasis, muscle atrophy, impaired bone density, fluid imbalance, muscle contracture, and pressure injuries.
Immobile Patients
After vital signs, the nurse will prioritize managing this symptom
A nurse will perform this action before, after, and between medications administered through an NG tube
What is flushing with water?
Which action should the nurse implement when providing wound care instructions to a client who does not speak English?
A. Ask an interpreter to provide wound care instructions.
B. Speak directly to the client, with an interpreter translating.
C. Request the accompanying family member to translate.
D. Instruct a bilingual employee to read the instructions.
Rationale:
B. Wound care instructions should be given directly to the client by the nurse with an interpreter who is trained to provide accurate and objective translation in the client’s primary language so that the client has the opportunity to ask questions during the teaching process. The interpreter usually does not have any healthcare experience, so the nurse must provide client teaching. Family members should not be used to translate instructions because the client or family member may alter the instructions during conversation or be uncomfortable with the topics discussed. The employee should be a trained interpreter to ensure that the nurse’s instructions are understood accurately by the client.
A nurse is caring for a patient with COPD. During this step of the process, they identify outcomes as "patient will maintain an O2 sat of 95% or above by the end of the shift"
What is the planning phase
Hip fractures
During patient education, this is the most effective method for ensuring comprehension of the topic
What is teachback?
At hand-off report the off going nurse reports a new 1000 mL IV bag of D5LR was hung at 1845. The prescribed infusion rate is 75 mL/hr. The oncoming nurse assesses the client at 1915 and notes there is less than 50 mL left in the IV bag. What is the nurse’s next action?
A. Contact the healthcare provider on call.
B. Call in the off going nurse and request an explanation.
C. Tell the client that 950 mL of fluid just accidentally infused.
D. Auscultate the client’s lungs.
D. Auscultate lungs
The client may show signs of fluid overload, such as crackles. Other respiratory signs are dyspnea and increased rate. Assess the client’s reaction to the fluid bolus first and then proceed with notifying the charge nurse and the healthcare provider.
A 76-year-old client has returned from surgery. The nurse plans on decreasing the chance of respiratory compromise for this client. What will the nurse include in this client’s plan of care? Select all that apply
A Raise the head of the bed to no less than a 45 angle.
B. Have the client use an incentive spirometer 10 times every hour while awake.
C. Limit total fluid intake to no more than 1000 mL/day.
D. Have the client sit on the side of the bed instead of getting up and walking.
E. Ask the client to take deep breaths and cough five times every hour while awake. e? (Select all that apply.)
A Raise the head of the bed to no less than a 45 angle.
B. Have the client use an incentive spirometer 10 times every hour while awake.
E. Ask the client to take deep breaths and cough five times every hour while awake.
Which nonverbal action should the nurse implement to demonstrate active listening?
A. Sit facing the client.
B.Cross arms and legs.
C. Avoid eye contact.
D. Lean back in the chair.
A. Sit facing the client
Active listening is conveyed using attentive verbal and nonverbal communication techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing the client, which lets the client know that the nurse is there to listen. Active listening skills include postures that are open to the client, such as keeping the arms open and relaxed, not option B, and leaning toward the client, not option D. To communicate involvement and willingness to listen to the client, eye contact should be established and maintained.
The nurse comes upon an automobile accident involving many cars. Which victim should the nurse see first?
A. The victim who is not breathing and does not have a pulse
B. The victim who is bleeding out of both the ears, and the nose and mouth, with a blank stare
C. The victim who is heavily bleeding bright red blood from a thigh wound
D. The victim who is crying, complaining of arm pain, and no other apparent injuries
C.
Rationale:
The client hemorrhaging from the leg wound is the priority as of the severely injured clients; the nurse can help the client by tying off the leg above the injury and/or applying pressure to the wound site. When there is only one healthcare provider on the scene, the nurse must provide care to those who are most likely to survive. The client without a pulse and respirations is dead. The client with bleeding from the ears, nose, and mouth, with a blank stare, likely has severe head trauma. The victim with arm pain and crying is the lowest priority.
Accomplishing this goal within 24 hours post surgery effectively minimizes risks of complications
Ambulation
What is respiratory and pain assessment