Asepsis
The nurse is preparing to give a bed bath to an immobilized client with tuberculosis (TB). The nurse would plan to wear which items when performing this care?
1. Surgical mask and gloves
2. Particulate respirator, gown, and gloves
3. Particulate respirator and protective eyewear
4. Surgical mask, gown, and protective eyewear
2: Clients with active tuberculosis should have airborne precautions, which include caregivers wearing an individually fitted particulate respirator. The nurse should also wear gloves as per standard precautions. The nurse wears a gown whenever there is a possibility that the clothing could become contaminated, such as when giving a bed bath. Surgical masks are not considered effective as airborne precautions for conditions such as tuberculosis. There is nothing in the question necessitating the use of protective eyewear.
What is the term for a heart rate that is 119 bpm?
Tachycardic- HR should be 60-100. Anything over 100 bpm is considered tachycardic. We should also note the rhythm (regular or irregular) and strength of the pulse if it was palpated. Can you document the strength of the apical pulse?
What position it is called when a patient is lying flat on their back?
Supine
What is the mnemonic to help remember how to operate a fire extinguisher?
PASS
Pull, Aim, Squeeze, Sweep
A patient wakes up with their eyes crusted shut. The nurse must wash the eyes. How should the nurse do this?
Apply a clean, moist wash cloth to the eyes and let sit for a couple of minutes. Then, wipe the eyes from the inner canthus to the out canthus, using a cloth part of the wash cloth with each stroke.
The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which would the nurse include in the preparations? Select all that apply.
1. Use a dry table that is below waist level.
2. Open the distal flap of a sterile package first.
3. Prepare the sterile field just before the planned procedure.
4. Don clean gloves before touching items on the sterile field.
5. Place the sterile field 1 foot behind the working area and out of view of the client.
6. Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.
2, 3, 6: Sterile packages are opened away from the nurse's body, and the distal flap of a sterile package is opened first. This prevents contaminating the pack by reaching over the exposed sterile contents after the other flaps are opened (option 2). To avoid contamination, the sterile field should be prepared just before the planned procedure, and supplies should be used immediately (option 3). The outer 1-inch border of the sterile field must be considered unsterile, and sterile items are not placed within this 1-inch area (option 6). A dry table that is at waist level (not below) is used to set up a sterile field. Moisture will contaminate the sterile field, and anything below waist level is considered contaminated, according to the principles of surgical asepsis. The sterile field must be kept in sight at all times, and the nurse should not turn away from it. If this happens, the nurse cannot be sure that it is still sterile. Sterile gloves, not clean gloves, are used. An unsterile item touching a sterile item contaminates the sterile item.
What is the normal range for the respiratory rate?
Describe how to count a respiratory rate.
12-20.
Observe the chest for chest rise for 30 seconds and multiply that number by 2 unless the patient is having irregular respirations then count for a full minute.
If a patient is at risk for aspiration, how should we keep the bed positioned?
Semi fowlers or higher. Keep the HOB elevated at least 30 degrees.
You suspect a fire in the kitchen which is next to your unit where there are several patients that are unable to ambulate on their own. What should you do first?
Rescue clients and remove clients from immediate danger first.
Activate the fire alarm
Confine the fire
Extinguish the fire (if able)
RACE!
How should you clean a hearing aid?
Use a soft, dry cloth. Do not use water.
The nurse would institute which interventions for a client diagnosed with Clostridium difficile? Select all that apply.
1.) Wear a mask if within 3 feet of the client.
2.) Place a mask on the client when client is outside the room.
3.) Wear gloves and gown while in the room caring for the client.
4.) Use soap and water, not alcohol-based hand rub, for hand hygiene.
5.)Keep the door of the room shut except when entering or exiting the client's room.
3 & 4: Contact precautions are necessary for colonization or infection with a multidrug-resistant organism. This includes enteric infection with Clostridium difficile. Measures used to prevent the spread of C. difficile are wearing gowns and gloves while in the room (not just during care) because the spores are on surfaces in the room. Washing with soap and water for hand hygiene is indicated because alcohol-based sanitizers are ineffective against the spores. The use of a mask by the nurse, or the client when outside the client's room, is unnecessary because C. difficile is not transmitted by the respiratory route. The door does not need to be kept shut.
How do you determine how much to inflate into the cuff prior to taking blood pressure?
Palpate the brachial pulse and inflate the cuff, when you no longer feel the pulse note that number then add 20 mm Hg. You will inflate to that number.
For example: I stop feeling the brachial pulse at 110. So I will inflate the cuff to 130.
You are getting ready to move a patient from the bed to the wheelchair and you uncertain how steady they are. What needs to be done first?
Make sure the wheels are locked on the bed and wheelchair.
Apply a gaitbelt for safe transfer.
A nursing student administers an IM injection into a child's thigh. The nursing student recaps the needle and then places the needle into a red puncture-resistant container. The instructor comments how?
The instructor informs the student to never EVER recap a dirty needle.
A nurse begins to wash the legs of a bed-ridden patient that needs total assistance for bathing. How should the nurse wash the legs?
In long strokes from distal to proximal parts of the leg to aid in blood return. Wash the feet last since they are the dirtiest part.
The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions would the nurse use to perform this procedure? Select all that apply.
1.) Put on a mask
2.) Don gown and gloves
3.) Apply shoe protectors
4.) Wear a pair of protective goggles
5.) Have the client wear a mask and goggles
Contact precautions are in place, which include wearing gloves and a gown while providing care to the client. The mask and goggles are indicated because of the potential of splash contact during the wound irrigation procedure. Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. Shoe protectors are not necessary and are used in operating rooms in the surgical departments. If the client is under airborne or droplet precautions, a mask is worn by the client when going outside of the room. Goggles are not worn by clients.
A cuff that is too small will yield a falsely _________ reading and a cuff that is too large will yield a falsely _______ reading.
too small will cause a falsely high reading
too large will cause a falsely low reading
How should a nurse pick up a heavy box from the ground?
Bend at the knees, keeping the back straight. Hold the box close to the body or center of gravity.
What is the maximum weight a nurse should left solo?
35 lbs
List 5 ways we can help to reduce the incidences of falls in the hospital.
Assess patients for risk of falling and identify them somehow. Morse fall scale. The higher the score, the more likely the patient is to have a fall.
Put at patient at risk for falls near the nurse's station
Instruct the patient to use the call light when they need to get up; if they are confused they should have a bed or chair alarm on
Lock wheels on beds, wheelchairs, stretchers, etc.
Keep personal items within reach
Eliminate clutter, make sure there is a clear (lit) path to the bathroom
A patient with really long toe nails has asked you to trim them. What do you need to know before you can trim the toenails?
Are they diabetic? If they are, we typically send them to a podiatrist to have their nails trimmed.
**remember diabetic patients may have peripheral neuropathy which can decrease their ability to feel sores on their feet. Due to poor circulation from vascular changes with diabetes, the patient has delayed healing.
The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster?
1. A staff member who has never had roseola
2. A staff member who has never had mumps
3. An assistive personnel who has never had German measles
4. An assistive personnel who has never had chickenpox
4: Herpes zoster is caused by a reactivation of the varicella zoster virus, which is the causative virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus are susceptible to chickenpox. Options 1, 2, and 3 are not associated with the herpes zoster virus.
98.2 degree Fahrenheit is how much in degrees Celsius?
36.7
(98.2-32) * 5/9 = 36.7
to convert celsius to fahrenheit= celsius * 9/5+32
If you are moving a sedated patient from one bed to another bed, which bed should be higher to begin the transfer?
The bed the patient is currently one needs to be higher than the bed the patient is moving to.
The nurse applies wrist restraints, prescribed to prevent a patient from pulling out an NG tube. How would the nurse determine that the restraints are not too constrictive?
Place two fingers under the restraint to determine snugness.
You are providing oral care to a patient this is unresponsive. What position should you place this patient in to avoid complications?
Side lying position so secretions run out the side of the mouth.