Care Plans
For a patient with Impaired Mobility nursing diagnosis. Which of the following outcomes meets the criteria for being measurable?
-Demonstrate use of walker by time of discharge.
-Utilize assistive devices well.
-Maintain balance by discharge
-Understand the need for the walker by time of discharge.
Demonstrate use of walker by time of discharge
Outcomes must include an action verb, performance criteria, and a targeted timeframe.
What U.S. department is solely responsible for drug enforcement and the handling, disposal and administration of controlled substances?
Drug Enforcement Agency (DEA)
What is a 'sentinel event'?
Give me an example
An unexpected occurrence involving death or serious physical or psychological injury.
Such events are called “sentinel” because they signal the need for immediate investigation and response. Some examples of sentinel events are wrong-side surgery, suicide, and operative and postoperative complications.
Amoxicillin, 625 mg PO, is ordered. It is supplied as a liquid preparation containing 250 mg in 5 mL. How much does the nurse administer?
12.5 ml
Dose ordered/on hand x volume
625mg/250mg x 5ml = 12.5ml
A patient requires 40 units of NPH insulin and 10 units of regular insulin daily subcutaneously. What is the correct sequence when mixing insulins?
'Clear before Cloudy'
Inject 40U air into NPH vial
Inject 10U air into R vial
Draw up 10U regular, Draw up 40 U NPH
Should have total 50 units
A client states, "I would like to quit smoking, I have tried before, but I really think I can do it now"
What is an appropriate nursing dx.?
-Readiness for enhanced health management
-Deficient knowledge
-Risk-prone behavior
-Ineffective role performance
Readiness for enhanced health management.
A person who expresses desire to enhance management of risk factors and to integrate and strengthen a therapeutic regimen into daily living has a health promotion nursing diagnosis.
You enter a patient's room to give medications. The patient is using the bathroom. The patient is alert and oriented and is being discharged today.
Can you leave the medications at the bedside?
No...
Unless you have seen the patient swallow the drug, the drug cannot be recorded as administered. The patient’s health record is a legal record. Medications can be left at the bedside only with a prescriber’s order.
What is a 'Root Cause Analysis'?
investigation into an event to determine why the event occurred, and exploring the circumstances that led to it to determine where improvements can be made
Phenytoin 100 mg PO is prescribed to be given through a nasogastric tube. Phenytoin is available as 30 mg/5 mL. How much would the nurse administer?
16.666---->16.7ml
100mg/30mg x 5ml = 16.7ml
The nurse is administering a medication to a patient via an enteral feeding tube. Which are accurate guidelines related to this procedure?
Check tube placement prior to administering medications.
Give each medication separately and flush with water between each drug and adjust the amount of water used if fluids are restricted.
Enteric-coated medications should not be crushed, the tube should be flushed with 15 to 30 mL of water, and the head of the bed should be elevated to prevent reflux.
Why do you have to do care plans in nursing school?
To learn the 5 steps on the nursing process
Assess
Diagnose
Plan
Implementation
Evaluate
Ms. Hall has an order for hydromorphone, 2 mg, intravenously, q 4 hours PRN pain. The nurse notes that according to Ms. Hall’s chart, she is allergic to hydromorphone. The order for medication was signed by Dr. Long. What would be the correct procedure for the nurse to follow in this situation?
Administer the medication; the doctor is responsible for medication administration.
Call Dr. Long and ask that the medication be changed.
Ask the supervisor to administer the medication.
Ask the pharmacist to provide a medication to take the place of hydromorphone.
Call Dr. Long and ask that the medication be changed.
What is a 'never event'?
Give examples.
Extremely rare medical errors that should never happen to a patient.
Errors such as surgery performed on the wrong body part or on the wrong patient, leaving a foreign object inside a patient after surgery, or discharging an infant to the wrong person.
Methylprednisolone 40 mg IV is prescribed every 8 hours. Methylprednisolone is available 125 mg/2 mL. How many mL would the nurse administer?
40mg/125mg x 2ml = 0.6ml
A nurse is administering phenytoin via a gastric tube to a patient who is receiving tube feedings. This drug cannot be given with food. What would be an appropriate action of the nurse in this situation?
The nurse should discontinue a continuous tube feeding and leave the tube clamped for the required period of time before and after the medication has been given, according to the reference and facility protocol.
A nurse is preparing a clinical outcome for a patient who is an avid runner and who is recovering from a stroke that caused right-sided paresis. What is an example of this type of outcome?
1 Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete.
Functional outcomes describe the person’s ability to function in relation to the desired usual activities.
Quality-of-life outcomes focus on key factors that affect someone’s ability to enjoy life and achieve personal goals.
Affective outcomes describe changes in patient values, beliefs, and attitudes.
A nurse discovers that a medication error occurred. What should be the nurse’s first response?
The nurse’s first responsibility is the patient—careful observation is necessary to assess for any effect of the medication error.
Then call physician, chart the error and complete an incident report.
Review of a patient’s record revealed that no one obtained informed consent for the heart surgery that was performed on the patient. Which intentional tort has been committed?
Assault
Battery
Invasion of privacy
False imprisonment
Assault is a threat or an attempt to make bodily contact with another person without that person’s consent.
Battery is an assault that is carried out.
The nurse is to administer 50-mcg fentanyl. The pharmacy supplies the nurse with an ampule of fentanyl 0.1 mg/2 mL. How much should the nurse administer?
Convert mcg to mg
50mcg = 0.05 mg
0.05mg/0.1mg x 2ml = 1ml
The nurse notes an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action?
3 The nurse should first validate the finding if it is unusual. The nurse should be sure that all data recorded are accurate; all data should be validated before documentation if there are any doubts about accuracy.
A nurse is writing an evaluative statement for a patient who is trying to lower cholesterol through diet and exercise. Which evaluative statement is written correctly?
4 The evaluative statement must contain a date; the words “outcome met,” “outcome partially met,” or “outcome not met”; and the patient data or behaviors that support this decision. The other answer choices are incomplete statements.
A nurse administers a dose of an oral medication for hypertension to a patient who immediately vomits after swallowing the pill. What would be the appropriate initial action of the nurse in this situation?
If a patient vomits immediately after swallowing an oral pill, the nurse should assess the vomit for the pill or fragments of it. The nurse should then notify the primary care provider to see if another dosage should be administered.
A nurse administers the wrong medication to a patient and the patient is harmed. The health care provider who ordered the medication did not read the documentation that the patient was allergic to the drug. Whose responsible?
Nurses are legally responsible for carrying out the orders of the health care provider in charge of a patient unless an order would lead a reasonable person to anticipate injury if it was carried out. If the nurse should have anticipated injury and did not, both the prescribing health care provider and the administering nurse are responsible.
Digoxin 0.125 mg PO daily is ordered. It is available as a liquid in a unit dose container labeled 500 mcg/10 mL. How many mL does the nurse the nurse administer?
First convert mg to mcg
0.125mg = 125mcg
125mcg/500mcg x 10ml =2.5ml
While you are administering an IV medication, the patient begins to complain of pain at the IV site. What should you do?
Stop medication. Assess IV site for any signs of infiltration or phlebitis. Flush the IV with normal saline to check for patency. If the IV site appears within normal limits, resume medication administration at a slower rate.