*NURSING > NCLEX > NCLEX UWorld (1823 Questions with 100% Correct Answers) complete solution guide (All)

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NCLEX UWorld (1823 Questions with 100% Correct Answers) complete solution guide

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When do *advanced directives* go into effect? - ✔✔when person is *unable to speak for him/herself* due to either: 1. *Mental Incapacity* - *coma *(GCS score ≤ 7) 2. *Aphasia* (≠as soon as ... signed; directives can always be changed later by person) SBAR Communication Framekwork Components - ✔✔1. *S* = Situation - what *prompted* the communication (eg *what* changes occurred) 2. *B* = Background - *pertinent information, relevant history, vital signs* 3. *A* = Assessment - nurse's assessment of the situation (*when* & *what changes* occurred) 4. *R* = Recommendation - *request* for *prescription* or *action* from HCP Appropriate order of actions when client found on floor - ✔✔1. *Assessment* of *physiological stability* (ABCs) 2. *Assessment* of *injuries* 3. *Moving client* 4. *Notifications* 5. *Documentation* Conditions of being *ineligible to leave AMA* - ✔✔1 *danger to self or others* 2. *lack of consciousness* 3. *Altered consciousness* 4. *Mental illness* 5. Being under *chemical influence* 6. *Court decision*Effective handoff communication components - ✔✔Nurse should: 1. Provide *identifying information* (eg client's name and room number) 2. Note *care priorities* and upcoming or outstanding tasks (eg time to replace medication infusion bag, need to perform delayed wound care and cause of delay) 3. Provide *exact, pertinent information* (eg medication dose, time, measurable outcomes) 4. Include *multidisciplinary plans* (eg radiology examinations, family meetings, physical therapy) 5. Relay significant client changes in a clear manner [Show More]

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