ch 3/40
What are the 3 types of planning?
What is Initial (begins with first patient contact), Ongoing (changes made as you evaluate), and Discharge (plans when the patient leaves the healthcare setting & begins in at initial assessment)?
A patient who has a deep cut on their arm begins to develop swelling, redness, and warmth around the wound. The patient's white blood cell count increases, and there is a collection of pus at the site.
Which line of defense is primarily responsible for this immune response?
What is... secondary defense
What does P.A.S.S stand for?
What is pull, aim, squeeze, and sweep?
What is the correct procedure for cleaning the perineum of a female patient to prevent contamination of the urethra during perineal care?
What is wash the perineum from front to back, using a clean portion of the wipe for each stroke, to prevent contaminating the urethra with fecal material?
What are some complications of prolonged immobility?
What is pressure injuries, constipation, joint contracture, muscle weakness, DVT, ^risk of mortality?
What are the 5 rights of delegating?
"What is" 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?)
A 25-year-old woman becomes infected with the influenza virus for the first time. She experiences typical symptoms, such as fever, body aches, and fatigue, but recovers after about a week. Afterward, her body is better prepared to fight off the same virus in the future. What type of immunity is?
What is... Natural Active Immunity
A nurse is evaluating the risk factors for needlestick injuries in a healthcare setting. What are some factors that will increase the nurse’s risk of sustaining a needlestick injury?
A patient on anticoagulant therapy requests assistance with razor shaving. To minimize the risk of cuts and bleeding, what alternative method should be recommended?
What is an electric razor?
What are examples of correct body mechanics to educate patient on?
What is to minimize bending and twisting of back, keep objects close to your body, squat to lift heavy objects, use wide base of support (feet spread apart) (clinical insights 29.1)
What are 3 tasks that the nurse could safely delegate to UAPs to complete?
ADLs (feeding, drinking, toileting, grooming, dressing, ambulation), taking vital signs
A patient has been diagnosed with a viral infection. When discussing the course of the illness with the nurse, the patient asks about the most contagious stage of the infection. The nurse provides an explanation and identifies which stage as the most likely period for transmission?
What is... prodromal stage
Name at least 5 Sentinel Event
What is a foreign object (such as a sponge) left in patients after surgery, air embolism, Administering the wrong type of blood, Severe pressure injuries, Falls and trauma, Infections associated with urinary catheters, Infections associated with IV catheters, Symptoms resulting from poorly controlled blood sugar levels, Surgical site infections following certain elective procedures (e.g., certain orthopedic surgeries, bariatric surgery for obesity), Deep vein thrombosis or pulmonary embolism following total knee and total hip replacement procedures?
Select all the correct practices for basic foot care.
A) Wash and rinse feet well, ensuring they are completely dry.
B) Apply lotion between the toes to keep them moisturized.
C) Wear well-fitted shoes with proper arch support.
D) Go barefoot when at home to let your feet breathe.
E) Inspect the feet daily for blisters, cracks, or sores.
What is A, C, and E?
Why should patients be repositioned at least every 2 hours?
What is to prevent skin breakdown, muscle discomfort, damage to superficial nerves and blood vessels, contractures?
A nurse is caring for a patient who claims they have never experienced high blood pressure. However, the nurse obtains a BP reading of 180/98 mm Hg. Which action best demonstrates the nurse's understanding of validating abnormal data?
A. Asking the patient if they have consumed caffeine recently.
B. Retaking the blood pressure using a different sphygmomanometer.
C. Documenting the abnormal BP reading in the patient’s chart immediately.
D. Notifying the healthcare provider without rechecking the BP.
What is 'B'?
As a nurse implementing infection control measures in a hospital, you need to ensure that transmission-based precautions are followed to prevent the spread of infection. What key actions should you take when caring for a patient with a contagious infection?
Ensure proper hand hygiene and appropriate PPE, implement isolation precautions, limit visitors, disinfect equipment, educate the patient and family about following infection prevention measures and proper hygiene
A nurse is caring for an elderly patient who is at high risk for falls. What are some interventions that the nurse should implement to best reduce the risk of falls for this patient?
What is place the call light within reach, orient patient to surroundings, encourage non-slip shoes/socks, provide a night light, keep floors dry and free of clutter, utilize bed and chair monitoring devices, educate family and patient about fall prevention strategies?
What is the primary reason for providing frequent oral care to an unconscious patient, especially those receiving oxygen or with a nasogastric tube?
What is To prevent dry mucous membranes and promote oral comfort?
What is the ideal position for administering an enema or perineal procedure?
What is Sims position?
Before performing a planned nursing intervention, what is one essential step a nurse should take to prepare the patient and promote their cooperation?
What is the nurse should explain the procedure, including what will happen and what the patient may feel, to alleviate anxiety, ensure understanding, and foster trust?
Which of the following actions should be avoided to maintain the sterility of gloves when performing the open method of donning sterile gloves?
A) Ensuring the glove package is unopened and intact before use.
B) Allowing gloves to touch any nonsterile surfaces, such as the floor or your body.
C) Keeping the gloves and your hands above waist level while donning them.
D) Adjusting the gloves by touching the outer surface with your bare hand after they are on.
E) It does not matter, since sterility is not real
What is... B, D, E
A nurse is assisting a patient who is choking and unable to breathe. The nurse remembers that the American Red Cross recommends alternating back blows and abdominal thrusts. How many back blows should the nurse administer before performing abdominal thrusts?
What is 5 back blows, followed by 5 abdominal thrusts?
Why should the battery compartment of a hearing aid be opened and the battery removed when the device is not in use for a week or more?
What is Removing the battery prevents leakage of battery acid, which can damage the hearing aid, and helps preserve the battery by preventing it from draining when not in use?
What are the 4 types of exercise? (extra points if you can give examples of each one)
What is Isometric (hand against a wall), Isotonic (weight training with free weights), Aerobic (jogging, cycling, brisk walking), Anaerobic (rapid, intense exercises like sprinting and lifting heavy objects)?