Safety
The steps a nurse takes when responding to a fire & how to use a fire extinguisher (pneumonics)
What is RACE- Rescue, alarm, confine, extinguish/evacuate
PASS- pull, aim, squeeze, sweep
The #1 way to prevent the spread of infection
What is: Hand washing
What is: HIPAA
Three tasks that can be delegated to the UAP/CNA/AP
What is/are:
Hygiene care
collection of vital signs
ambulation assistance
transport
intake/output & documentation
assistance with feeding
Removal/ delivery of supplies
Oral Care
Activities of daily living
etc.
The order in which assessments are typically performed, and the one exception to this rule.
What is-
inspect, palpate, percuss, auscultate.
This is different for the abdomen-
Inspect, auscultate, percuss, palpate (order of percuss & palpate arguable, auscultate first is key)
Two key elements of proper ergonomics and what do to if a client falls
What is:
feet shoulder width apart (widen base of support)
use adaptive equipment
hold objects close to core when lifting
use major muscle groups
Don't twist spine: turn entire body
use multiple staff members
sliding, rolling, and pushing > lifting
For a fall: lower client to the floor- slide down- don't use your back/ arms to break their fall
The type of precautions that are used for a client who has influenza.
What is droplet.
1 subjective sign of pain, 1 objective sign of pain, 1 sign of pain relief
What is-
objective: grimacing, guarding, wincing, moaning, restlessness, agitation, hypertension, tachycardia, contracted/stiff muscles, crying
subjective: stating pain (most reliable)
signs of relief: return to normal VS, slumping of shoulders, relaxation of muscles
What is the order in which interventions are prioritized?
What is the A,B,Cs- Airway, breathing, circulation
Three assessment findings associated with long-term immobility.
What are -
Contractures
Pressure ulcers
Pneumonia
Atelectasis
Fluid retention
constipation
signs of a DVT
foot drop
etc
What is-
Locking the bed/chair/wheelchair/ etc.
Educating the client to call for help
Using bed alarms
Removing clutter
having the appropriate number of people
following the "assist"
using assistive devices like gait belts/ walkers
Ensuring the appropriate length of oxygen tubing
Educating on throw rug use
Using grab bars
Eliminating small animals/ trip hazards
Using grippy socks/ good shoes
etc.
How to exit a client's room who has tested positive for clostridium dificile.
What is remove gloves, remove gown, perform hand washing with antimicrobial soap.
Interventions/ education (at least 3) for a client with type 1 stool on the bristol stool chart
What is- Increase fluid intake, increase fiber intake, increase ambulation, take stool softeners/laxatives as prescribed, don't strain, drink prune juice, administer enemas as prescribed
List 3 expected signs of aging & 3 findings in an older adult that require follow up (abnormal findings)
What is-
Normal: decreased hair pigmentation, hair loss, slightly increased blood pressure, osteoporosis, kyphosis, wrinkled skin, mild vision/hearing loss, changes to sleep patterns/appetite
Abnormal: Anything that demonstrates instability- stroke, severely decreased or increased VS, anaphylaxis, confusion, dementia, delirium, MI, seizures, full vision loss, etc.
The names of the five locations auscultated when assessing heart sounds
What is- Aortic, pulmonic, erb's point, tricuspid, mitral
Preventing injury/harm during a seizure: 3 interventions
What is
Turn on their side
Loosen restrictive clothing
remove jewelry
suction as needed
clear the area
assess oxygen saturation/ vital signs
call for help
The type of precautions a client is placed on when they have a productive cough & night sweats.
What is airborne (N95+other PPE with a negative pressure room)
Describe a wound dehiscence and evisceration & required interventions (at least 2).
What is-
when the edges of a surgical wound pull apart/ separate (when organs protrude through the separation)
Lie flat, cover with moist sterile dressing (NS), contact provider, prepare for emergency surgery, assess, eventually administer an antibiotic because of infection risk
The pneumonic used for general delegation rules, especially in regards to the vocational nurse (and what it stands for)
TAPE
Teach, Assess, Plan, Evaluate
One way to assess the function of cranial nerve IX.
What is -
check the gag reflex
conduct a swallow evaluation
or
Check perception of sweet and sour tastes (back of the tongue)
(glossopharyngeal)
4 important rules/ steps to take when using restraints
secure using a quick release tie
attach to a non-movable part of the bed
Perform frequent assessments and range of motion exercises (remove q2h)
Ensure two fingers fit under restraints
Renew order every 24 hours
The type of PPE worn when a client has MRSA
What is a gown & gloves (contact precautions)
Normal range of potassium & 3 high potassium foods
What is:
3.5-5
potatoes, bananas, prunes, salmon, spinach, white beans, etc.
The nurse accidentally administers a double dose of a client's prescribed warfarin (Coumadin), a blood thinner. They contact the provider and request-
What is Vitamin K
What is: Redness, swelling (unilateral), pain, homan's sign
- pulmonary embolism, stroke, myocardial infarction