Nursing Process
What is the normal adult pulse rate?
What is 60-100?
The five (if we unfortunately add this sense when performing an assessment) skills used in physical assessment. [We also reviewed that we don't typically use this one skill and skipped over it - no drumming on our patients]
What is inspection, palpation, auscultation, percussion, and olfaction?
The nurse is alerted to the presence of an infectious process based on an elevation of this laboratory value.
What is WBCs?
The form or place in the chart where the nurse documents his or her observations, care given and patient's responses. A free text format.
What is nursing notes.
The client/patient is anxious - is this kind of data.
What is subjective data?
This is the term for the type of fever when a client's temperature alternates between febrile and normal
What is intermittent
Yellow-orangish discoloration most notable at areas of light pigmentation such as sclera and light skin.
What is jaundice?
Explain the proper actions if a sterile glove has come in contact with a dirty surface during setup of a sterile procedure
What is: remove and discard the sterile gloves (and any sterile equipment/setup if any was touched by the contaminated glove), wash hands, obtain new equipment, setup new sterile working area, don new set of sterile gloves
This type of report occurs when there is an actual or potential injury; this report is not a part of the patient record.
What is an incident report?
Development of goals for care and possible activities to meet them occurs during this stage of the nursing process
What is planning?
These are changes observed in skin of someone with a lower than normal temperature
What are cool/cold to touch, pallor, clammy
Common position for surgical procedures and medical examinations involving the pelvis and lower abdomen.
What is lithotomy?
What is - Wash the area with soap and water, encourage bleeding from the puncture (squeeze proximal to the site), Notify the employee health nurse (or facility equivalent), complete an incident report sheet
In military time, 9:00 pm is ___________.
What is 2100?
Which of the following is a nurse-initiated intervention: Administers oral medication, orders laboratory tests, Changes a sterile dressing, teaches hygienic care?
What is teaches hygienic care.
This is the pulse site to be checked if you are concerned about circulation to the lower legs.
What is popliteal?
Abbreviation for Expected outcome during a nursing eye exam.
What is PERRLA? [Pupils Equal Round Reactive to Light and Accommodation]
Health care acquired infections are most reduced by:
What is hand-washing?
During your shift, when is the best time to document?
What is after completion of an intervention or assessment, as soon after the occurrence took place - or ASAP
What component of a SMART goal is missing and how can you change it to be complete? Client's fluid intake will improve within the next 24hrs.
What is 'Measurable", ie. "Client's fluid intake will increase to 2500ml over the next 24hrs.
The six steps in the chain of infection...
What are 1) Infectious Agents 2) Reservoir 3) Portal of Exit 4) Mode of Transmission 5) Portal of Entry 6) Susceptible Host?
What agency specifies guidelines for documentation?
What is the Joint Commission (TJC) or an equivalent accreditation agency