Assessment
Vital signs such as oxygen, heart rate, and blood pressure are a form of what type of nursing assessment?
Objective
What is 1 step to the clinical judgement nurse model?
One step in the National Council of State Boards of Nursing Clinical Judgment Model (NCSBN-CJM) is Recognize Cues. This initial step involves the nurse identifying and collecting relevant patient information through assessment and observation. It's a crucial part of the clinical judgment process, as it forms the foundation for subsequent decision-making and patient care planning.
To prevent infection, nurses and health care providers may do what?
Nurses and health care providers can prevent infection through several key practices:
Hand hygiene: Proper handwashing is the single most important measure to prevent the spread of infections.
Use of Standard Precautions: Apply these for all patients, regardless of their diagnosis.
Proper use of personal protective equipment (PPE): This includes gloves, gowns, masks, and eye protection when necessary.
Aseptic technique: Maintain sterility during invasive procedures.
Environmental cleanliness: Ensure patient rooms and equipment are properly cleaned and disinfected.
Proper handling of sharps: Use safety devices and dispose of sharps correctly to prevent needlestick injuries.
Patient education: Teach patients and visitors about infection prevention practices.
Isolation precautions: Implement appropriate isolation measures for patients with known infections.
Vaccination: Stay up-to-date with recommended vaccinations.
Device care: Properly maintain and care for medical devices such as catheters and ventilators.
Antibiotic stewardship: Use antibiotics judiciously to prevent antibiotic resistance.
By consistently implementing these practices, healthcare providers can significantly reduce the risk of healthcare-associated infections.
What is HIPAA?
HIPAA stands for the Health Insurance Portability and Accountability Act, enacted in 1996. It is a federal law that:
HIPAA is fundamental in protecting patient privacy and confidentiality in the U.S. healthcare system. It requires healthcare professionals, including nurses, to be vigilant in safeguarding patient information and avoiding discussions about patients in public areas.
What is the last step of the nursing process?
The last step of the nursing process is Evaluation. This step involves:
Evaluation is a crucial, ongoing process that ensures the effectiveness of nursing care and promotes optimal patient outcomes.
True
True or False? The first step for the Nursing Clinical Judgement Model is: Recognize Cues?
True.
The patient has reported sleep disturbances. What are 3 signs of sleep disturbance the nurse should plan to assess throughout the shift?
The nurse should plan to assess the following signs of sleep disturbance throughout the shift:
Additionally, the nurse should observe for any physical conditions or environmental factors that may contribute to sleep disturbances, such as pain, frequent nighttime urination, or disruptive hospital noises.
HIPAA regulations guide nurses' actions in protecting patient confidentiality through several specific requirements:
Limited information sharing: Nurses must only share patient information with those directly involved in the patient's care or those with a "right to know."
Secure communication: Patient information should not be discussed in public areas like hallways, elevators, or cafeterias.
Access control: Nurses should only access patient records necessary for providing care.
Written acknowledgment: Patients must be notified of privacy policies and provide written acknowledgment.
Minimum necessary disclosure: When sharing information, nurses should limit disclosure to only what is required for a particular purpose.
Electronic safeguards: Nurses must follow administrative, physical, and technical safeguards for protecting electronic health information.
Social media restrictions: Patient information should never be posted on social media platforms.
Breach reporting: Any violations of patient confidentiality must be reported to supervisors.
By adhering to these HIPAA-mandated practices, nurses play a crucial role in maintaining patient trust and protecting their right to privacy in healthcare settings.
How does the evaluation step differ when caring for patients with chronic conditions versus acute illnesses? Name at least 1 way.
Chronic Conditions:
Acute Illnesses:
In both cases, evaluation remains an ongoing, dynamic process, but the timeframe, focus, and specific measures differ based on the nature of the condition.
What are at least ways a patient may receive oxygen?
Patients can receive oxygen through various methods:
Low-flow systems:
High-flow systems:
Non-invasive ventilation:
Invasive ventilation:
Specialized methods:
The choice of oxygen delivery method depends on the patient's condition, oxygen requirements, and treatment goals. Continuous monitoring of oxygen saturation (SpO2) is essential to assess the effectiveness of oxygen therapy and adjust as needed.
A patient has fallen out of the hospital. What are 5 NANDA approved nursing diagnoses?
For a patient who has fallen in the hospital, 5 NANDA-approved nursing diagnoses are:
These diagnoses address the immediate and potential consequences of the fall, including the risk of future falls, mobility issues that may have contributed to or resulted from the fall, pain from any injuries sustained, the risk of further injury, and the psychological impact of the incident. Each diagnosis would be followed by appropriate interventions and care planning to ensure patient safety and recovery.
You notice upon assessment there is a break/an opening in the patient's skin. What goals should the nurse include in the care plan?
The nurse should include the following goals in the care plan for a patient with a break/opening in the skin:
These goals align with the principles of wound care and aim to support optimal healing while preventing further complications.
What are at least 3 functions of white blood cells?
White blood cells (WBCs), also known as leukocytes, play a crucial role in the body's immune system and defense against pathogens. Their main functions include:
What are key safety practices a nurse may employ/implement to evaluate?
The nurse can evaluate patient safety through several methods:
Key safety practices to evaluate include:
The nurse should also consider:
Continuous reassessment and adjustment of safety measures based on the patient's changing condition and environment are crucial for maintaining optimal safety.
What are 7 assessment findings for a patient with a wound?
Odor, exudate, size, pain, redness, location, medication, wound care regimen
A patient has Cdiff. What are 7 nursing diagnoses to include the related to and as evidenced by parts?
Diarrhea related to Clostridioides difficile infection as evidenced by frequent watery stools and abdominal cramping
Risk for Infection Transmission related to highly contagious C. difficile spores as evidenced by potential for environmental contamination
Imbalanced Nutrition: Less than Body Requirements related to increased gastrointestinal motility as evidenced by weight loss and decreased appetite
Risk for Electrolyte Imbalance related to excessive fluid loss through diarrhea as evidenced by abnormal electrolyte levels
Acute Pain related to intestinal inflammation as evidenced by patient reports of abdominal discomfort and grimacing
Anxiety related to diagnosis and isolation precautions as evidenced by expressed concerns and increased restlessness
Impaired Skin Integrity related to frequent liquid stools as evidenced by perianal skin irritation and breakdown
Increased protein in the diet may be prescribed for patients with what conditions? Name at least 7 conditions.
Increased protein may be prescribed for patients with:
Proper protein intake is crucial for tissue repair, wound healing, maintaining immune function, and supporting overall recovery in these conditions.
A nurse is monitoring the patient for infection. The nurse understands that there are different types of white blood cells with specialized functions. What are the 5 different types of white blood cells along with their specialized function?
Different types of white blood cells have specialized functions:
What are 3 methods a nurse may use to evaluate patient safety? In other words: the nurse can evaluate patient safety through several methods:
What are the 3 MAR checks and rights of medication administration?
The 3 MAR (Medication Administration Record) checks are performed:
These checks are part of the broader "Nine Rights" of medication administration, which include:
A patient's ex husband wants information about the patient but the patient does not want him to have the information. What nursing diagnoses relate to the ethical considerations in this matter?
The key nursing diagnoses related to the ethical considerations in this situation are:
Risk for Impaired Rights related to potential breach of confidentiality as evidenced by ex-husband's request for patient information without consent
Decisional Conflict related to patient's right to privacy versus ex-husband's desire for information as evidenced by patient's explicit refusal to share information
Anxiety related to concerns about privacy violation as evidenced by patient's expressed desire to withhold information from ex-husband
Compromised Family Coping related to communication barriers and relationship dynamics as evidenced by ex-husband seeking information outside proper channels
Risk for Ineffective Health Management related to potential breakdown in trust between patient and healthcare providers as evidenced by concerns over information security
These diagnoses reflect the ethical principles of patient autonomy, confidentiality, and the nurse's duty to protect patient privacy as mandated by HIPAA regulations. The nurse must prioritize the patient's right to determine who has access to their personal health information while maintaining professional boundaries and legal compliance.
A nurse has to insert a foley catheter. What are the nursing steps for foley catheter insertion?
The nursing steps for Foley catheter insertion are:
Remember to maintain aseptic technique throughout the procedure to minimize the risk of catheter-associated urinary tract infections (CAUTIs).
What clinical conditions or lab values might indicate an abnormal white blood cell count?
An abnormal white blood cell (WBC) count can be indicated by various clinical conditions and lab values:
Elevated WBC count (Leukocytosis):
Extremely high WBC count:
25,000/μL
Low WBC count (Leukopenia):
Abnormal differential count:
Clinical signs:
It's important to interpret WBC counts in conjunction with other clinical findings and the patient's overall condition.
A patient is admitted for chest pain. The patient has inadequate perfusion. How may the nurse evaluate for adequate perfusion during the shift? Name at least 7 ways.
To evaluate adequate perfusion during the shift for a patient admitted with chest pain and inadequate perfusion, the nurse should monitor:
Vital signs:
Skin assessment:
Peripheral pulses:
Mental status:
Urine output:
Hemodynamic parameters (if available):
Gastrointestinal function:
Lab values:
Continuous cardiac monitoring:
Patient symptoms:
The nurse should document these findings regularly, report significant changes promptly, and adjust interventions as needed to improve perfusion status.