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NURSING MISC remediation EXAM Focused review 1. Airway management – considerations when reading oxygen level is less than 90%, nurses should remain with the client and provide emotional support to... decrease anxiety. The expected range is 95% to 100% 2. Home safety- prevention is important because elderly clients can have longer recovery times from injuries and the risk of complications. Place grab bars near the toilet and in the tub or shower, and install a stool risers. RICE Is for a sprain and RACE is for incase of a fire. 3. Adolescents- adolescents have a longer attention span. The CDC recommends adolescents to have varicella, HPV, and seasonal influenza 4. Health promotion and disease prevention- determine risk factors first to determine the client’s need for health promotion and disease prevention What guidelines should the nurse follow when cleaning equipment from the room of a client who is prescribed contact precautions? - Most facilities use disposable thermometer and BP cuffs and have a wall clock for use, if not use a Ziploc bag before entering room. - Pens should be left in the room and clipboards should be kept outside of the room. - Two hampers in the room should be used, one for linens and one for garbage. At the end of the shift the bags should be emptied A nurse is caring for an adolescent client and is reinforcing education related to injury prevention. What information should be included? - Keep firearms in a locked cabinet - Teach proper use of sporting equipment prior to use - Insist on helmet us and pads when roller skating, skateboarding, bicycling and during any other activities that increase injury risk - Avoid trampolines - Beware of changes in mood and monitor for self-harm What is pulse oximetry and what is a normal finding? What could cause an abnormal reading? - Pulse oximetry is a noninvasive measurement of the oxygen saturation of the blood for monitoring respiratory status - A normal finding is 95% to 100% - The cause of an abnormal reading is hypothermia, poor peripheral blood flow, too much light, low hemoglobin levels, jaundice, movement, edema, and nail polish A nurse is caring for a client with a diabetic ulcer which is has a bacterial infection. Identify the lab values the nurse will review to monitor for infection. - Elevated WBC = the expected range is 5,000-10,00 - Elevated ESR = expected range is 15 to 20mm/hr A nurse in the treatment plan of a client with a stage III wound has an order to irrigate the wound site. Identify nursing measures to safely clean and irrigate the wound for this client - clean and/or debride the following, prescribed dressing - surgical intervention - proteolytic enzymes - provide nutritional supplements - administer analgesics - administer antimicrobials To reduce the risk of Hepatitis A transmission identify three (3) measures use to maintain standard precautions. - A private room or a room with other clients who have the same infection - Gloves and gowns worn by the caregivers and visitors - Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag The nurse receives an order to administer enteral tube feedings to a client with dysphagia. The order states- Administer 1500 mLs of enteral feeding over 18 hours via infusion pump. What will the mLs per hour be? Round to the nearest whole number. - 1500/15=83 Name the two (2) preferred sites of an intramuscular injection in an adult client. When is it recommended to use the larger muscle site? - Ventrogluteal and deltoid - It is recommended to use ventrogluteal site when deltoid is not used. A nurse is checking the pulse oximetry of a hospitalized client who is on 2 liters of oxygen by nasal cannula. The finger probe is showing 89% oxygen saturation. Which of the following may produce a low reading? (Select all that apply). - Hypoxemia - Nail polish - Poor peripheral blood flow - Low hemoglobin Describe three (3) special considerations when starting an IV on an older adult client with fragile veins. - Avoid tourniquets - Use a blood pressure cuff instead - Do not slap the extremity to visualize veins - Avoid rigorous friction while cleaning the site The nurse is caring for a client who has a would drainage device in place. Discuss the use and benefits of this drainage system. - Promotes drainage of fluid from the incisional site - Decreases pressure on tissues - Decreases abscess formation - Promotes healing from inside out - Reduces bacterial counts through debridement - Promotes granulation - Stimulates cell growth Focused review funds 2 1. Legal responsibilities- unintentional torts includes malpractice and negligence. An example of negligence is forgetting to put the client’s bed in the lowest position and the patient falls out of bed. It was not intentional but as a nurse it was negligence. An example of malpractice is administering a wrong medication, and the patient becomes affected by it. 2. Delegation and supervision- I learned that CNA can obtain a specimen collection. The five rights of delegation are the right task, right circumstance, right person, right direction and communication, and right supervision and evaluation 3. Older Adults- In older adults there is a decreased sensitivity of tissue cells to insulin. The CDC recommends immunizations against diphtheria, tetanus, pertussis, varicella, influenza, herpes zoster and pneumococcal infections. 4. Electrolyte imbalances- The expected potassium levels are 3.5 to 5 mEq/L. When potassium levels are decreased monitor for dysrhythmias, such as PVCs, ventricular tachycardia, flattening T waves and ST depression. Focused review: Pharmacology 1. Diabetes Mellitus- Normal blood sugar is 70-110mg/dL. Purpose of insulin is to decrease glucose levels by converting glucose into glycogen and moves potassium into cells. Insulin can be used when requiring treatment of hyperkalemia. Beta blockers and alcohol decrease glucose levels. 2. Immunizations- DTAP is administered in early childhood. Rotavirus is administered at the maximum age of 8 months. Herpes zoster virus A is a one time dose for all adults 60 years or older. 3. Sedative- hypnotics – hypnotics induce sleep (CNS depressant). Barbiturates cause tolerance and dependence. Chlordiazepoxide is a benzodiazepine that does not have the pam at the end. 4. Connective tissue disorder- DMARDs slow the joint degeneration and progression of rheumatoid arthritis. Gluccorticords provide relief of inflammation and pain. A nurse is reinforcing medication teaching to a client being discharged on levothyroxine for hypothyroidism. What information related to adverse effects should be reinforced? - Overmedication can cause anxiety, Tachycardia, palpitations, altered appetite, abdominal cramping, heat intolerance, fever, diaphoresis, weight loss, menstrual irregularities. A client is prescribed metronidazole. What are contraindications for metronidazole? - Pregnancy - Use of disulfiram - Alcohol The nurse is evaluating a client's understanding for why he is taking isoniazid. The nurse knows that the client understands why he is taking the medication when he states . What statement by the client validates he understands the purpose of isoniazid therapy? - This medication is highly specific for mycobacteria. Isoniazid inhibits growth of mycobacteria by preventing synthesis of mycolic acid in the cell wall A client is taking meperidine for post-operative pain. What will you monitor to determine if the client is having an adverse effect to this medication? - Monitor respiratory rate, if it less than 12 breaths/min notify provider - Monitor bladder distention, hypoactive bowel sounds, and I&O, Auscultate lung sounds - Monitor vital signs (bradycardia, orthostatic hypotension) - Biliary colic - Sedation What time of day should zolpidem be taken? What are adverse effects of this medication? - Advise the client to take the medication just before bedtime - The adverse effects are daytime sleepiness and lightheadedness, and headache - Dry mouth - Decreased libido (sexual desire) - Respiratory depression A client has been prescribed disulfiram for the treatment of alcoholism. What client education regarding this medication should the nurse reinforce? - Inform clients of the dangers and potentially fatal reaction of drinking any alcohol - Avoid any products that contain alcohol (cough syrups, sauces, mouthwash, aftershave lotion, colognes, and hand sanitizer) - Wear a medical alert bracelet - Encourage to participate in a 12 step self- help program - Need to wait at least 12 hours after the last drink of alcohol before taking the initial dose of disulfiram Identify two (2) examples of selective serotonin reuptake inhibitors. Identify two (2) therapeutic uses of this class of medication. List three (3) adverse effects of this class of medication. 1. Citalopram examples of SSRIs 2. Paroxetine 1. Obsessive- compulsive disorders Therapeutic use 2. Major depression 1. Decreased libido 2. Inability to sleep, agitation, anxiety ADVERSE EFFECTS 3. Weight loss early in therapy then followed by weight gain with long term treatment A client has been prescribed bisacodyl. What information regarding the use of laxatives should the nurse reinforce with the client? - Do not crush or chew enteric-coated tablets - Discourage clients from daily use of bisacodyl suppositories - monitor for dehydration - encourage adequate fluid intake - chronic use of laxatives can lead to fluid and electrolyte imbalance - exercise - increase daily high fiber foods Name a vaccine that is recommended for clients who are immunocompromised, and/or are over 65 years old. - Pneumococcal polysaccharide vaccine (PPSV23) and pneumococcal conjugate vaccine (PCV13) Identify three (3) adverse reactions the nurse should teach the client about prior to administering the varicella vaccine. - Tenderness and swelling at the injection site, fever, rash - Seizures - Pneumonia, low blood count, severe brain reactions A client was administered diazepam thirty (30) minutes ago and now the client demonstrated respiratory depression. What medication will counteract the adverse effects of diazepam? - Flumazenil A client has been prescribed prednisone for rheumatoid arthritis. Identify three (3) adverse effect of long-term use of this medication. - Infection, osteoporosis, fluid retention, nausea and vomiting, hypotension, hyperglycemia, hypokalemia What is the major risk for a client who is taking Phenelzine and Citalopram? - seizures, death, tachycardia, diaphoresis, muscle rigidity A nurse preparing to administer timolol. What are contraindications for administering this medication? - chronic respiratory disease because the medication can constrict the airway and cause bronchospasm - sinus bradycardia and AV heart block - heart failure List three (3) medications that can cause interactions with Lisinopril? 1. Diuretics 2. Antihypertensive potassium supplements and potassium-sparing diuretics increase the risk of hyperkalemia 3. Ace inhibitors can increase levels of lithium 4. NSAIDs decease the antihypertensive effect of ace inhibitors The health care provider has ordered for a 3-year-old client, oral digoxin 0.12mg daily. The bottle contains 0.1 mg of digoxin in 1 ml. How many ml should the nurse administered to a child? - 0.12/0.1=1.2 - 1.2*1=1.2 Pharmacology case study: 1. the right patient, right medication, right dose, right route,right time, right documentation 2. For all of the medications the nurse will need to obtain known allergies, drug history and all vital signs prior to administration. Metoclopramide- assess for nausea. Atenolol- assess for apical pulse and assess blood pressure from lying to standing. 3. Metoclopramide- controls nausea and vomiting by blocking dopamine and serotonin receptors in the CTZ. Atenolol- Beta1 adrenergic blockade in the myocardium and the electrical conduction system of the heart, as a result decreasing heart rate, cause vasodilation and promotes the excretion of sodium and water. Cafazolin- destroy bacterial cell walls causing destruction of micro- organisms. (treat urinary tract infections). Meperidine- depresses pain impulse transmission at the spinal cord level by interacting with opioid receptors. 4. Metoclopramide- restlessness, anxiety, and spasms of the face and neck. Atenolol- hypoglycemia, decreased cardiac output, AV block, orthostatic hypotension, rebound myocardium excitation. Cefazolin- allergy, hypersensitivity, bleeding, kidney insufficiency, pain with IM injection. Meperidine- respiratory depression, constipation, orthostatic hypotension, urinary retention, cough suppression, sedation. 5. 50ml/60min=0.83333 then multiply by 60. 0.83333*60=50ml/hr. - 100ml/hr Focused Review- Pharmacolgy Practice A 1. anxiety and trauma and stressor- related disorders: Paradoxical responses include insomnia, excitation, euphoria, anxiety, and rage. When a patient is on buspirone is that antianxiety effects develop slowly. Initial responses take 1 week and 2 to 6 weeks for it to reach its full effects. 2. Immunizations- seasonal influenza vaccine, annually, beginning at age 6 months. Anaphylactic reaction to a vaccine is a contraindication for further doses of that vaccine. 3. Antibiotics affecting protein synthesis- adverse effects for the medication is tetracycline is GI discomfort, yellow or brown tooth discoloration hypoplasia od tooth enamel. Hepatoxicity, such as lethargy, and jaundice. 4. Antibiotics affecting the bacterial cell wall- Penicillins destroy bacteria by weakening the bacterial cell wall. Do not mix penicillin and aminoglycosides in the same IV solution. Administer penicillins with food. Report any allergic reactions such as dyspnea, skin rash, itching, and hives. Med-surgical: remediation The nurse is reinforcing teaching of foot care with a diabetic client. Identify three (3) teaching points the nurse should reinforce about foot care? - Wash feet daily with mild soap and warm water, Pat feet dry especially between the toes - Use foot powder with cornstarch on sweaty feet - Wear slippers with soles. Do not go barefoot A client with pulmonary concerns is ordered to have a bronchoscopy. Identify three (3) pre-procedure nursing actions. Identify three (3) post-procedure nursing actions. - Pre-procedure: note allergies to anesthetic agents. ensure that a consent form is signed by the client, maintain the client on NPO usually 8 to 12hr, to reduce risk of aspiration the cough reflex is blocked by anesthesia. - Post- procedure: continuously monitor respirations, blood pressure, pulse oximetry, heart rate, and level of consciousness. Monitor for the presence of gag reflex and the ability to swallow before resuming oral intake. Monitor level of consciousness. Identify three (3) interventions to prevent flexion contractures following an amputation. - Avoid elevating the stump on a pillow after the first 24hr - Have a client lie prone, encourage range of motion exercises - Provide firm mattress Identify two (2) reasons gastric lavage may be indicated. - when a nasogastric tube is inserted - for ingested poison Maternity Focused review: 1. Ch.15 nursing care of newborns: The temperature range for newborns should stay at 97.7 to 98.6 fahrenheit. Identification is applied immediately after birth on the ankle, and wrist. All newborns are administered erythromycin to prevent opthalmia neonatorum 2. Ch.3 prenatal care: pelvic measurements determine whether the pelvis will allow for the passage of the fetus at birth. Bladder should be emptied when having transvaginal ultrasound. Administer Rho(D) immune globulin IM around 38 weeks od gestation for clients who are RH- negative. 3. Ch. 1 contraception: Diaphragm and spermicide should be replaced every 2 years and refit for a 20% fluctuation, after every pregnancy, and should stay in place 6 hours after intercourse 4. Ch. 4- Nutrition: clients should gain 1 to 2kg (2.2 to 4.4 lb) during the first trimester. For the last two trimester 0.4kg (1lb) per week should be gained. Folic acid foods include beef liver, leafy vegetables, dried peas, and beans, seeds, and orange juice. Blood glucose range for newborns should be 30 to 60mg/dL Discuss five (5) general safety tips that should be provided to parents before discharge. - parents need to be aware of the importance of well-baby checkups. - Do not feed the newborn every time he cries - Encourage the client to breastfeed at least 15 to 20min per breast to ensure that newborn receives adequate fat and protein - Solids are not introduced until 6 months of age - Place the newborn in the supine position for sleeping greatly decreases the risk of SIDs A nurse is reinforcing discharge instructions with a postpartum client. What findings should the client report to the health care provider that could suspect mastitis? - Nipples are cracked, and breastfeeding is painful, fatigue, tender localized area, usually on one breast How is Nagele's rule used to calculate the estimated date of birth? - count 3 months back and add 7 days What are abnormal findings during pregnancy that the client should be instructed to notify their provider about if they occur? - Vaginal bleeding - Premature rupture of membranes - Fetal movement of less than three per hour or cease for 12hr. - Excessive vomiting A nurse is reinforcing discharge information for a client with preeclampsia. What dietary information should be reinforced? - Avoid foods high in sodium - Avoid alcohol, tobacco, and limit caffeine intake - Drink 6- 8 glasses of water per day What are expected cardiovascular changes during pregnancy? - Heart size increases by 5 to 10/min and rotates forward toward the left - blood pressure should stay the same throughout pregnancy - increased cardiac output and blood volume What is preterm labor? What are five (5) risk factors for preterm labor? - Preterm labor is uterine contractions and cervical changes that occur between 20 to 37 weeks of gestation 1. Infections of UTI, vagina, or chrioamnionitis 2. Multifetal pregnancy 3. Excessive amniotic fluid 4. Smoking 5. Substance abuse The nurse is monitoring newborns in the nursery. What two (2) priority complications and the associated findings would the nurse report to the provider upon admission to the nursery? - Hypothermia and bradypnea The nurse is collecting data from a first trimester client with hyperemesis gravidarum. What symptoms would indicate dehydration? - Weight loss - Poor skin turgor and dry mucous membranes A nurse is reinforcing teaching to a client receiving Nifedipine for preterm labor. What are three (3) points the nurse should include? - Slowly change positions from supine to upright and sit until dizziness disappears - Maintain adequate hydration to counter hypotension - Do not administer with magnesium sulfate The nurse is reinforcing teaching to a group of pregnant clients about adverse effects of ferrous sulfate. What would the nurse include the reinforcement of the teaching? - If GI discomfort occurs, take after meals or with food. Do not take within 2 hours of other medication. The nurse is reinforcing teaching about self-administering insulin to a client with gestational diabetes. What are three (3) points the nurse should reinforce with this client. - Insulin is usually given in the upper arm or thigh - Make sure the right dose of insulin is being injected - Prior to administering insulin, daily glucose level checks - Prepare the site with alcohol to clean the skin, then let it dry A pregnant client is preparing for a transvaginal ultrasound. What are two (2) teaching points the nurse will reinforce to the client regarding the purpose for this procedure? - empty the bladder - useful for clients who are obese and those in the first trimester to detect ectopic pregnancy, and identify abnormalities A postpartum client asks the nurse why her baby needs a newborn screen. What teaching should the nurse reinforce regarding why this test is necessary? - To maintain patent airway, monitor vital signs, maintain thermoregulation, monitor elimination patterns, and preventing infections The nurse is caring for a client who had a cesarean section two days ago and is now complaining of gas pain. What are three (3) teaching points the nurse should reinforce to the client to assist in alleviating the discomfort? - Rock back and forth - Drink plenty of fluids - Drink warm liquids each morning Focused Review: Maternal practice A 1. Ch. 12 Nursing Care of the Client During the Postpartum Period: The greatest risks during the postpartum period are hemorrhage, shock, and infection. Fundus after delivery should be at the umbilicus and firm, not soft. 2. Chapter 7 Nutrition Across the Lifespan: 2,000 to 3,000 mL of fluid daily. Women should abstain all alcohol consumption during pregnancy. 3. Ch.14 Newborn Data Collection: Bulb syringe is used for removing excessive mucus from the mouth and nose. Head circumference should be 2 to 3 cm larger than chest circumference. 4. Ch. 13 Complications of the Postpartum Period: management of thrombophlebitis is encourage rest. Facilitate bed rest and elevation of the extremity above the level of the client’s heart. Postpartum hemorrhage is when the fundus is soft, and boggy. Blood clots are larger than a quarter, pads are saturated in 15min or less. Focused review: Nursing Care of children 1. Ch.4- health promotion of Toddlers. Domestic mimicry means playing house. Language increases to about 300 words by the age of 2 years. Autonomy vs. shame and doubt  toddlers use negatism such as saying no to their independence. Maintain routines to provide a sense of comfort. 2. Ch.5- Health promotion of preschoolers (3-6 years). Preschoolers bodies evolve away from unsteady wide stances and protruding abdomens of toddlers into a more graceful alignment. The vocabulary increases more than 2.100 words by the end of the fifth year. 3. Ch.6- health promotion of school-age children (6-12 years) onset of physiologic changes begins around the age of 9 years, particularly in females. Realizes that physical elements do not magically appear and disappear. 4. Ch.34- immunizations. The action of vaccines is to stimulate the immune system to produce antibodies against a specific disease. Provide distraction, apply a topical anesthetic prior to injection. Encourage breastfeeding during immunization 2 min prior, during and 3 min after administration. A nurse is reinforcing discharge instructions to parents of a child with an acute respiratory infection. Identify three (3) strategies to include in discharge instructions to decrease the spread of infection. - Stay away from people who have colds, viruses, and infections - Perform hand hygiene - Limit contact with others annual flu immunization A nurse is caring for a child who is 10-years-old. What are some findings that may suggest that the child is experiencing delays in development? - Does not realize that physical elements do not magically appear and disappear - Does not develop an awareness of the connection between things and ideas - Does not acquire the ability to read The nurse is planning activities for toddlers who are hospitalized. What activities would be appropriate for this age group? Identify three (3) appropriate activities - Cloth books, puzzles with large pieces - Large crayons and paper - Push-and-pull toys, balls - Tricycles - Educational media programs When reinforcing education regarding immunizations, the nurse should include information on contraindications/precautions. Identify three (3) complications/contraindications that can be noted after administration of an immunization. - severe allergic reaction, such as anaphylaxis - do not administer live virus vaccines to children who is severely immunocompromised - Hib vaccine should not be administered to ages younger than 6 weeks The nurse is evaluating the effectiveness of sleep teaching to a group of parents. Identify two things that the parents have done at home to promote effective sleep patterns in their preschooler. - keep a consistent bedtime routine - use a nightlight in the room - provide child with a favorite toy - discourage sleeping with parents The nurse is caring for a preschool aged child. The provider has ordered a diagnostic test for this client. What interventions should the nurse provide to this client about teaching the child about the diagnostic test? - Discus with the child and family what to expect during the hospitalization - Encourage independence and choices - Explain treatments, procedures, and cares to the child A nurse is caring for a client who may have Leukemia. What diagnostic tests would confirm the diagnosis? - bone marrow aspiration or biopsy analysis A 4-year-old client is admitted with a diagnosis of rotovirus. Identify three (3) age appropriate toys or activities for the preschooler to have available while hospitalized. - Playing with a ball - Hand puppets - Musical toys A parent of a 2-year-old client complains that their child is a picky eater. Discuss the nutritional requirements of a toddler - Should consume 24 to 28oz milk per day, and can switch from drinking whole milk to low fat milk after 2 years of age - Juice consumption should be limited to 4-6 oz per day. - Toddlers prefer finger food - Snacks or deserts that are high in sugar, fat, or sodium should be avoided A 7-year-old client is newly diagnosed with diabetes mellitus and is terrified to perform glucose monitoring. Identify two (2) points the nurse should reinforce with the client to minimize pain. - Do not lie to the child and say that it won’t hurt - Use distractions Focused review: Nursing Care of children B 1. Ch.12- acute neurological disorders Viral (aseptic) meningitis usually requires only supportive care for recovery. Bacterial (septic) meningitis is a contagious infection, and prognosis depends on how quickly care is initiated. Lumbar puncture is the definitive diagnostic test for meningitis 2. CH. 11- infection control. Virulence is the ability of a pathogen to invade and injure a host. A nurse should assess each client for the risks of infection specific to the client, the disease or injury, and the environment. The stages of infection are incubation stage, prodromal stage, illness stage, and convalescence stage. 3. Ch.10- Hospitalization, Illness, and Play. Separation anxiety manifests in three behavioral responses. Discuss with the child and family what to expect during hospitalization. Encourage family members to stay with the child during the hospital experience to reduce the stress. 4. Ch.4- Health Promotion of Toddlers (1-3 years). At 30 months of age, toddlers should weigh four times their birth weight. Toddlers grow about 7.5cm (3in) per year. Head circumference are usually equal 1 to 2 years of age. Mental Health Remediation: A nurse is caring for a client under suspicion of abuse by her partner. What are common risk factors for intimate partner abuse? - People who have mental illness are 2.5 times more likely to be victims of abuse than those who have no mental illness. A nurse is reinforcing teaching in a community health class on depression. What are some risk factors for developing depression that should be include in this educational session? - depression can be the primary disorder or it can be a response to another physical or mental health disorder. Family history, female, age over 65 years, stressful life events, medical illness, postpartum period, poor social network, substance use disorder. A client with psychosis has been prescribed fluphenazine. What education regarding management of anticholinergic effects and postural hypotension should the nurse reinforce to this client? - Keep maintenance doses low, and give at bedtime - The effects occur in 1 to 2 days but can take up 2 to 4 weeks to reach full effect - Rise from different position slowly Identify three (3) adverse effects associate with valproic acid. - Nausea, vomiting, indigestion - Hepatotoxicity - Pancreatitis - Thrombocytopenia Identify a therapeutic lithium level and three (3) signs of lithium toxicity noted in a client. - Lithium level is 0.4 to 1.3 mEq/L - Lithium levels increase if sodium levels decrease - Excessive loss of salt and fluids from vomiting, diarrhea, and sweating can increase lithium levels. - hand tremors, persistent GI upset, slurred speech, and muscle weakness, muscle irritability, and changes on a EEG Management Remediation: A client is admitted with Vancomycin-Resistant Enterocci. What guidelines regarding the handling of infectious material and equipment should the nurse consider when caring for this client? - The patient should be on contact precautions and the barrier equipment used is private room, gloves, gowns, and standard precautions. A client is scheduled for a closed amputation of the left lower leg. Provide one (1) example of how the nurse can evaluate the client’s understanding of this scheduled procedure. - The client understands the procedure explanation from the provider, and signs the consent form with all questions asked. A nurse has been assigned a client diagnosed with group A streptococcal pneumonia. The nurse can expect to use what type of precautions when caring for this client? - This patient should be put on droplet precautions. The barrier equipment is a private room, a mask, and standard precautions. A nurse enters a client’s room to administer scheduled medications and finds the client on the floor. The nurse knows a client fall requires an incident report. What is the procedure for completing an incident report? - All nursing action should follow facility policies - Notification of a provider - Incident reports should not be shared with the client, not placed in the client’s chart or mentioned in the medical record. It should be handled by the risk manager and should be completed within 24 hour of the incident. - Client’s name and hospital number, or visitor’s name and address. • Date, time, and location of incident. • Factual description, and injuries, treatments if necessary. • Names of any witnesses to incident. • Corrective actions taken, including notification of provider or referrals. • Name and dose of any medication or identification of equipment involved in incident. Focused review Fundamentals: 1. Ch.10 Medical and Surgical Asepsis: medical asepsis is the practice to reduce the number, growth and the spread of micro-organisms, which is also called the clean technique. Surgical asepsis is the practice to eliminate all micro-organisms which is called the sterile technique. Sterile technique is used on parenteral medication administration, insertion of urinary catheters, surgical procedures, and sterile dressing changes. 2. Ch.43- Bowel elimination: Fiber requirement is 25 to 30g/day. Lactose intolerance is when individuals have difficulty digesting milk products. Fluid requirement should be 2,000 to 3,000mL/ day. Physical activity stimulates intestinal activity. 3. Ch.55 Pressure Ulcers, Wounds, and Wound management: wounds are a result of injury to the skin. Another name for pressure ulcer is decubitis ulcer. Factors that affect wound healing is increased age, loss of skin turgor, skin fragility and many more. 4. Ch. 31- musculoskeletal and neurosensory systems: to assess the musculoskeletal system is gait, alignment, symmetry and muscle mass, muscle tone, range of motion, any involuntary movements, indications of inflammation, and gross deformities. A neurological screening examinations would include assessing the mental status, cranial nerves, motor function to test cerebellar function, sensory function, sensory and reflexes. Focused Review: Nursing care of children 1. Ch.37- HIV/AIDs: encourage a balanced diet that is high in calories and protein. Administer total parental nutrition if indicated by the child’s nutritional status. Administer to all infants who are born to infected mothers until HIV infection is excluded. IV gamma globulin to prevent recurrent or serious bacterial infections. 2. Ch, 5 Health Promotion of Preschoolers (3 to 6 years): preschoolers begin to recognize differences in appearances and identify what is considered acceptable and inacceptable. Preschoolers have slight decrease in the number of calories required per unit of body weight. 3. Ch. 55- Menstrual Disorders and menopause: The average age of menarche is 12.4 years but can occur from 9 to 17 years. Menstrual cycles are typically 28 days long, with a range 23 to 35 days. 4. Ch.34-immunizations: administration of a vaccine stimulates the immune system to produce antibodies against a specific disease. The purpose is to decrease or eliminate certain infectious diseases in society. The common cold and other minor illnesses are not contraindications to immunization Focused Review: Maternal Newborn 1. Ch.15 Health Promotion of Infants (2 days to 1 year): head circumference averages 33 to 35cm. Newborns lose up to 10% of their birth weight by 3 to 4 days of age. This is due to fluid shifts, loss of meconium, and limited intake, especially in infants who are breastfed. 2. Ch. 3 Prenatal Care: during data collection nurse should assess abuse history or risk: check all clients for all forms including physical, sexual, or psychological abuse, because the risk increases during pregnancy. 3. Ch. 13- complications of the postpartum period: postpartum disorders are unexpected events or occurrences that can happen during the postpartum period. Provide thigh-thigh antiembolism stockings for the client at risk for venous insufficiency. Oxytocin is used to contract the uterus, if hemorrhage begins with a bogy fundus. 4. Ch.7- Infections: TORCH is a group of infections that can negatively affect a client who is pregnant. These infections cross the placenta and have teratogenic effects on the fetus. TORCH does not include all the major infections that present risks to the mother and fetus. Focused Review: Pharmacology 1. Ch. 10- Urinary Tract Infections: Sulfonamides, trimethroprim and urinary tract antiseptics are medications that treat UTIs. These medications inhibit bacterial growth by preventing the synthesis of a folic acid derivative for the replication bacteria. Do not administer trimethoprim-sulfamethoxazole to clients who have allergies to the following sulfonamides (sulfa), thiazide diuretics loop diuretics 2. Ch.7 depressive disorders: Fluoxetine (SSRI) are used to treat major depression, OCD, bulimia nervosa, panic disorder and more. May cause sexual dysfunction. Possible adverse effects and to notify the provider if intolerable. 3. Ch.41- Mycobacterial, fungal, and parasitic Infections: Mycobacterium is a slow-growing pathogen that necessitaties long-term treatment. Isoniazid is a mediation that is highly specific for mycobacteria. Indicated for active and latent tuberculosis. 4. Ch.31- Opioid Agonists and Antagonists: Opioids analgesics treat moderate to severe pain. Morphine is one type of opiod that have side affects of respiratory depression, constipation, orthostatic hypotension, urinary retention, cough suppression, sedation, biliary colic, nausea, and vomiting. Focused Review: Fundamentals Re-evaluation Assessment 1. Ch.27 Vital signs- the rectum, tympanic membrane, and urinary bladder are core temperature. 96.9 to 100.4 is the range for oral temperature. The regularity at which each impulse is felt. A premature or late heartbeat can result in an irregular interval in which impulses are felt or heard and can indicate abnormal electrical activity of the heart. Typically, an impulse should be sensed at regular intervals. 2. Ch.11- Infection control- signs and symptoms of infection is fever, increased pulse and respiratory rate, malaise, anorexia, nausea, and/ or vomiting. Enlarged lymph nodes. Use frequent and effective hand hygiene before and after care is given. 3. Ch.8 Critical Thinking and Clinical Judgement- Nursing practice requires the application of knowledge from biological, social, and physical sciences; knowledge of pathophysiology; and knowledge of nursing procedures and skills. Consequently, nurses must use multiple thinking skills, including critical thinking skills such as interpretation, analysis, evaluation, inference, and explanation, to make clinical judgments about problems posed in nursing practice. 4. Ch.41 Pain Management – effective pain management includes the use of pharmacological and nonpharmacological pain management therapies. Perception or awareness of pain occurs in various areas of the brain and is influenced by thought and emotional processes. Focused Review: Nursing Care of children Re-evaluation Assessment 1. Ch.37- HIV/AIDs: encourage a balanced diet that is high in calories and protein. Administer total parental nutrition if indicated by the child’s nutritional status. Administer to all infants who are born to infected mothers until HIV infection is excluded. IV gamma globulin to prevent recurrent or serious bacterial infections. 2. Ch, 5 Health Promotion of Preschoolers (3 to 6 years): preschoolers begin to recognize differences in appearances and identify what is considered acceptable and inacceptable. Preschoolers have slight decrease in the number of calories required per unit of body weight. 3. Ch. 55- Menstrual Disorders and menopause: The average age of menarche is 12.4 years but can occur from 9 to 17 years. Menstrual cycles are typically 28 days long, with a range 23 to 35 days. 4. Ch.34-immunizations: administration of a vaccine stimulates the immune system to produce antibodies against a specific disease. The purpose is to decrease or eliminate certain infectious diseases in society. The common cold and other minor illnesses are not contraindications to immunization Exit: A nurse is caring for a client for a client with schizophrenia that is experiencing hallucinations. What data should be collected regarding the client's hallucinations? - Hearing voices or sounds, seeing persons or objects, smelling odors, experiencing tastes, feeling sensations. A nurse is caring for a client with a psychotic disorder who is exhibiting alterations in speech. Define the following alterations in speech: Flight of ideas, neologisms, echolalia, clang association, word salad. - Flight of ideas: associative looseness. The client might say sentence after sentence, but each sentence can relate to a different topic, and the listener is unable to follow the client’s thoughts. Neologisms: made up words that have meaning only to the client. Echolalia: the client repeats the words spoken to him. Clang association: meaningless rhyming of words, often forceful, such as, Oh fox, box, and lox. Word salad: words jumbled together with little meaning or significance to the listener, such as, “Hip hooray, the flip is cast and wide- sprinting in the forest. A nurse is reinforcing teaching to a client who had an episiotomy. What non- pharmacological pain relief measures would the nurse suggest? - Use ice packs, sitz baths, and frequent perineal hygiene A nurse is reinforcing teaching about post-procedural care of open-angle glaucoma to a client. Identify five (5) activities the client should avoid after this surgical intervention. - Bending over at the waist - Sneezing - Straining - Head hyperflexion - Restrictive clothing, such as tight shirt collars - Sexual intercourse A nurse is caring for a client with severe burns. The nurse monitors laboratory findings for this client. Which client presentation(s) with review of labs can be expected with a client with significant burns? Select all that apply. - Hyponatremia, hypokalemia, anemia Disorders of the eyes that are caused by the aging process including macular degeneration, cataracts, and glaucoma. Identify for each eye disorder, two (2) risk factors, and two (2) expected findings related to each disorder. - Macular degeneration: risk factors- smoking, diabetes mellitus, hypertension, female, short body structure, family history, diet lacking carotene and vitamin E. Expected findings lack of depth perception, objects appear distorted, dark spot in the center of vision, blurred vision, loss of central vision, blindness - Cataracts: risk factors advanced age, diabetes, heredity, smoking, eye trauma, alcohol consumption greater than four drinks/day for males and three drinks/day for females, excessive exposure to the sun, chronic corticosteroid use. Expected findings decreased visual acuity, blurred vision, diplopia, photophobia, progressive and painless loss of vision, absent red reflex, increased nearsightedness. - Glaucoma: risk factors age, infection, tumors, diabetes mellitus, genetic predisposition, hypertension, eye trauma, African American ethnicity. Expected Findings painless, gradual reduction of peripheral vision, decreased accommodation, halos seen around lights, elevated IOP Identify two (2) examples of appropriate snacks for a 2-year-old client. - Chicken tenders, cut in bite sizes. Soft cooked vegetables Describe three (3) postoperative nursing care modifications needed for the older adult associated with age-related changes. - Changing positions, cough and deep breath, early ambulation The nurse is reviewing newborn feeding options with the parents. What are three (3) teaching points to reinforce about bottle feeding? - Preparing formula bottles - How to store open formula - Hold and love the baby - Correct amount of formula - Do not prop bottle - Bottle mouth syndrome The nurse is working with parents of a newborn about circumcision care. What are three (3) teaching points that should be reviewed about post circumcision care? - Keep the area clean - Change the newborn’s diaper at least every 4 hr. - Clean the penis with warm water with each diaper change - Clamp procedure- apply petroleum jelly with each diaper change for at least 24hr after the circumcision - Notify provider id there is any redness, discharge, swelling, odor, tenderness, decrease in urination, or excessive crying. Describe how to elicit the Moro Reflex on a newborn. - By allowing the head and trunk of an infant in a semi-sitting position to fall backward to an angle of at least 30 degree. A nurse is caring for an adolescent who has been admitted for suicidal ideation. What priority questions should be asked while collecting data? - are you thinking about killing yourself Culturally respectful communication is necessary in all forms of communication, including client education on nutrition. List three (3) cultural diets with examples of their traditional foods or traditional methods of preparation and their impact on health. - Soy, dried beans, legumes, omega-3 fatty acids, B-6, vitamin E, fruits, and vegetables prevent cardiovascular disease. - Clients who have lactose intolerance should avoid milk and dairy products. - Dietary restrictions for clients with kidney failure is meat, fish, seafood, eggs, and dairy products Describe how to communicate with a client who has Alzheimer’s Disease. - Reminisce with the client about the past. Use memory techniques Focused Review: 1. Ch. 6- Delegation and supervision: Practical nurses monitor findings as input to the RNs. Reinforce client teaching from a standard care plan. CNAs perform bathing, grooming, dressing, toileting, ambulating. 2. Ch.19- eating disorders- There is a direct loss of potassium due to purging(vomiting) and starvation. Dehydration stimulates increased aldosterone production, which leads to sodium and water retention and potassium excretion. 3. Ch.3 Professional Responsibilities: The Patient Self-Determination Act (PSDA) stipulates that on admission to a health care facility, all clients must be informed of their right to accept or refuse care. Competent adults have the right to refuse treatment, including the right to leave a health care facility without a prescription for discharge from the provider. 4. Ch.4- legal responsibilities: A living will is a legal document that expresses the client’s wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues. [Show More]

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