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NCLEX Blitz Post Assignment (ASSURED A)

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NCLEX Blitz Post Assignment (ASSURED A) 1. List the pertinent information that should be included in a transfer report. ➢ Nurse needs to confirm facility is ready for patient transfer as well as mode of transfer and ...

NCLEX Blitz Post Assignment (ASSURED A) 1. List the pertinent information that should be included in a transfer report. ➢ Nurse needs to confirm facility is ready for patient transfer as well as mode of transfer and time. Transfer documentation includes diagnosis, demographic information, health status, plan of care, vital signs, medications, PRN meds, allergies, active orders, equipment patient needs/uses, code status, family involvement. 2. List four (4) examples of a primary skin lesion including description and example of each. ➢ Macule: nonpalpable, smaller than 1cm looks like a freckle or petechiae ➢ Papule: solid elevation of the skin like nevus, smaller than 1cm ➢ Nodule: palpable, deep, firm, 1-2cm looks like a wart ➢ Vesicle: serous fluid filled, smaller than 1cm, blister, herpes simplex, varicella 3. Provide an example of appropriate documentation of the integumentary system ➢ The patient’s skin is warm to touch with tenting noted. Appropriate skin color for ethnicity/pink skin. Capillary refill should be less than 3 seconds. Even hair distribution. Dry skin. Note pulses and edema if present. 4. A nurse is providing discharge education to a client regarding home wound care. What manifestations of wound infection should the nurse include in this education? ➢ Identify if bleeding, apply pressure. Stabilize the wound do not pick at it. Patient should follow up with provider, notify provider of infection, drainage, redness around the wound, pus, swelling, tenderness, fever. 5. A client has been diagnosed with Varicella. What type of tier transmission precaution is required? What protective equipment will be required for prevention of transmission? ➢ Airborne “My Chicken Hez TB” ➢ Private room with masks for caregivers/visitors ➢ Negative pressure airflow 6. Describe the Tier 2 precautions to implement in the client with suspected Meningitis ➢ (droplet precautions) ➢ Private room ➢ Masks 7. List at least five (5) priority considerations when performing a sterile dressing change. ➢ Initial step is to wash hands to prepare ➢ Sterile field can only touch sterile items ➢ Place field on surface before opening gloves. Open from the corners ➢ Keep sterile field above waist level ➢ Do not reach over sterile items because microbes have the ability to move/travel

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