Card Set Information

2010-05-18 00:16:28

Show Answers:

  1. What should the nurse do with an angry client?
    Use therapeutic communication techniques and as opened ended questions.

    it is good to encourage the patient to verbalize and express their reasons for being angry
  2. What must the nurse do in regards to client confidentiality and how can the nurse protect it?
    HIPAA: do not talk about clients or their families in inappropriate places.

    • Especially in elevators, cafeterias, or anywhere visitors can overhear.
    • (230)
  3. What assessments should the nurse do prior to ambulating a client that is post operative?
    • Level of Consciousness
    • Vital Signs
    • Ability to do ROM
    • Check for orthostatic hypotension
    • Use them walk using their strong side to stabilize them
    • Assess IV tubes and Urine Bags
    • ROM exercises will help them ambulate
  4. The surgeon will most likely write orders for a client going into surgery to include what preoperatively?
    • NPO prior to surgery
    • pre-operative screening test
    • stop anticoagulants the patient is taking
  5. Why would a client be NPO prior to surgery?
    Anesthetics depress (stop) GI functioning and may cause the client to vomit and aspirate
  6. How should the nurse position the wheel chair for the client to transfer into it and why?
    • parallel and as close to the bed as possible.
    • on the patients stronger side.
    • mirror your feet to your patient
    • place the clients strong foot beneath the bed
  7. Describe how the client should use a:
    • - Cane:
    • Hold the cane with the hand on the stronger side of the body.
    • Move the cane forward 1 ft then move the weak leg forward while putting weight on the cane and stronger leg.
    • Move the stronger leg past the cane and weak leg. Repeat.

    - Crutches: The weight of the body should be on the arms rather than armpits.

    • - Walker:
    • Move the walker ahead about 6 inches while body weight is on your legs.
    • Move the right foot up to walker while using walker and left leg as support.
    • Move the left foot up to the right foot while weight is on right leg and both arms.

    - Wheel chair: Use arms to turn wheel. (756)
  8. What are the safety precautions to use when transporting a client via the wheel chair?
    Apply breaks to the wheelchair. Use a transfer belt to help move the patient. Have the patient sit far back in the chair so that it does not topple over. Practice of body mechanics will reduce risk of injury to patient and yourself. (781)
  9. How would you position a wheelchair for a client with IV tubing attached to the client or a Foley catheter?
    Make sure the IV tubing or catheter bag are out of the way.
  10. Describe the location where you would attach the Foley urine collection bag to the bed.
    Secure the drainage bag to the bed frame using the hook or strap provided. Suspend the bag off the floor, but keep it below the level of the patient's bladder. (593)
  11. Describe how you would take an orthostatic B/P and why.
    Knowing a patient is hypotensive can prevent falls. Place patient in a supine position for 2-3 minutes to stabilize pressure and pulse in this position. Record the patient's pulse and blood pressure. Assist the patient to sit or stand slowly supporting client in case of faintness. After 1 minute in the upright position, recheck the patient's pulse and blood pressure in the same sites as previously. (389)
  12. What type of exams would a client be put into the lithotomy position and what type of client would most likely be put into this position?
    Papsmear (also known as speculum exam or pelvic exam), child birth, internal examination. It is a common position for surgical procedures and medical examinations involving the pelvis and lower abdomen. Women are most likely to be the patients put in this position.
  13. Describe how to set up a sterile field and what precautions must be taken when setting up a sterile field.
    Open packages by holding the edges. Do not reach over the sterile field. If the sterile field contacts a non-sterile surface, it is considered contaminated. Keep hands above the waist. (171)
  14. Define dysphagia.
    Dysphagia is difficulty swallowing.
  15. What do you need to do for a dysphagic client in order for them to drink and eat?
    Dysphagic patients require special attention to the texture of their food. A soft diet may be easier for the patient to swallow. The use of Thickenup reduces chance of aspiration and allows the patient to slowly swallow liquids. Environment should be free of noise and distractions so the patient can concentrate on eating. Either hot or cold foods, not tepid are thought to trigger swallowing. Patient should be placed in high fowlers.
  16. What are the different types of enemas? What is the end result that needs to be accomplished with each?
    • Cleansing enema: Removes feces to prevent the escape of feces during surgery or prepare for certain diagnostic tests such as colonoscopies. It also removes feces when there is constipation or impaction.
    • Retention enema: Introduces oil into the rectum and sigmoid colon. Oil is retained for 1-3h to soften feces and lubricate the rectum.
    • Return flow enemas: (Harris flush) is used to expel flatus. Alternating flow of 100-200mL 5-6 times. (612)
  17. What should the stool look like from a cleansing enema?
    If patient was constipated, the feces will be impacted. Otherwise, feces would look like normal, just flushed out. Eventually the water will be clear after multiple enemas.
  18. How does the nurse count respirations of a client?
    Choose a suitable time to assess respirations (not after extensive activity). Place hand against patient's chest to feel chest movements or place patient's arm across the chest or abdomen while appearing to take their radial pulse. Patients will often change their breathing pattern if they know their respirations are being watched. Do this for 1 minute or 30 seconds and multiply by two. (399)
  19. Describe the 2 step method for taking a B/P.
    Prepare and position the client appropriately. First find the brachial pulse. Second, wrap the deflated cuff evenly around the upper arm. Position the stethoscope over the brachial pulse. Inflate the cuff. Release the valve on the cuff carefully at the rate of 2-3 mm Hg per second while identifying the manometer reading at each of the 5 phases. Remove the cuff. Document and report pertinent assessment data (401)
  20. Describe how to take a pulse.
    Locate one of the 9 common pulse sites. Using 2-3 finger tips, palpate and count the pulse 1 minute for a baseline. Note any irregular beats. Document and report pertinent information. (396)
  21. Describe how to take an apical pulse and how long do you count it for?
    Position the patient to a supine or sitting position. Babies should be supine. Locate the apical impulse (point of maximal impulse). Using the sternum as reference, find the apical impulse to the left of the patient's sternum around the fifth intercostal space, midclavicular. Ausculate and count heartbeats for 60 seconds. Assess the rhythm and strength of the heartbeat. (398)
  22. When performing CPR, what is the first action you must take?
    Check for responsiveness by shaking the person gently. See if the person moves or makes a noise. Shout, "Are you OK? (817)
  23. What is a pressure ulcer?
    Lesions caused by unrelieved pressure that results in damage to underlying tissue. They are caused by a deficiency of blood supply to the tissue (ischemia). Friction can also cause shearing of the skin. For instance a sheet may remove superficial layers of the skin making it more prone to breakdown. Factors that can contribute are immobility, inadequate nutrition, edema, fecal or urinary incontinence (maceration causes softening of tissue by prolonged wetting, fecal matter contains enzymes that may break down the skin), excessive body heat (increases the body's metabolic rate, increasing the need for cellular oxygen), and advanced age (decrease pain sensation of pressure and skin integrity)(482)
  24. What are the stages of decubitus/pressure ulcers and what do they look like?
    • Stage I: Nonblanchable erythema of intact skin. Skin is flush due to vasodilatation.
    • Stage II: Partial-thickness skin loss involving epidermis, dermis, or both. Ulcer is superficial. Looks like an abrasion or shallow crater.
    • Stage III: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue. Deep crater.
    • Stage IV: Full thickness of skin loss with extensive destruction, tissue necrosis, damage to muscle, bone, or supporting structures such as tendon or joint capsule. Undermining and sinus tracts may also be associated with stage IV pressure ulcers. (483)
  25. When documenting a pressure ulcer, what information has to be included?
    Document the size, color, and any discharge. Can also complete a risk assessment tool such as the Braden or the Norton scale. (485)
  26. What are the normal levels of oxygen saturations?
    Normal saturation levels are 95-100% (504)
  27. What is a TENS unit and how does it work?
    Transcutaneous electrical nerve stimulation is a physical intervention for pain management and promotes healing. (413)
  28. Clean Catch or Midstream Specimen
    • : The perineal is cleaned first. Clean-catch kit is used to catch urine
    • midstream after the distal urethra is cleared of bacteria. Collect 30-60
    • mL of urin in the container. Cap the container tightly only touching
    • the outside of the container. Label specimen and transport it to the
    • laboratory. Bacterial cultures must be started immediately before any
    • contaminating organisms can grow, multiply and produce false results. It
    • identifies microorganisms that cause UTIs.
  29. -Urine Clean Voided Specimen:
    • 1. 120ml
    • 2. free of fecal contamination
    • 3. tighten lid to prevent spillageand contamination
    • 4. labeled time date patient and nurses intials
    • 5. send with lab. requisition
    • 6. delievered to lab within 15 minutes
  30. Describe how you would store, transport, and how soon would it need to be transported for:
    • - Urine Clean Voided Specimen: About 120 mL of urine is required. Specimen should be free of fecal contamination and toilet paper. Tighten the lid on the container to prevent spillage and contamination of other objects. Specimen should be labeled with an attached laboratory requisition. Urine samples should be delivered to the lab within 15 minutes.
    • - Clean Catch or Midstream Specimen: The perineal is cleaned first. Clean-catch kit is used to catch urine midstream after the distal urethra is cleared of bacteria. Collect 30-60 mL of urin in the container. Cap the container tightly only touching the outside of the container. Label specimen and transport it to the laboratory. Bacterial cultures must be started immediately before any contaminating organisms can grow, multiply and produce false results. It identifies microorganisms that cause UTIs. (585)
    • - 24 hour urine: A timed urine specimen collects all urine produced over a period of time. At the end of the collection period, patient is instructed to empty the bladder as part of the specimen. Please the urine jar on top of a basin full of ice.
    • - Indwelling Cather Specimen Sterile (specimen collected from Foley Catheter): If no urine is in the catheter, clamp the drainage tube for 30 minutes. Insert the needle of the syringe into the access port of the tubing at a 30-45 degree angle. Withdraw 3 mL for a urine culture or 30 mL for a routine urinalysis. Transfer the urine to the specimen container. Cap the container. (574-575)
    • - Stool Specimens: follow medical aseptic technique. Collect 1 inch of formed stool or 15-30 mL of liquid stool. Include visible pus, mucus or blood in sample. Send specimen to the laboratory immediately. Fresh specimens provide the most accurate results. In some instances, refrigeration is indicated because bacteriologic changes take place in stool specimens at room temperature. (607)
    • - Sputum: Offer mouth care so that specimen will not be contaminated with microorganisms from the mouth. Ask the client to breathe deeply and then cough up 15-30 mL of sputum. Ask the patient to spit out the sputum into the specimen container. Document amount of sputum collected, color, odor, consistency, and presence of hemoptysis (blood in sputum). (506)
  31. Describe when starting a 24 hour urine specimen what you need to do and what does the patient have to do?
    Instruct the patient, staff, and other personnel to keep all urine. Before starting, the patient must completely void and discard the urine. The time starts on an empty bladder. Save all urine produced in the container, refrigerating or placing container on ice. At the end of the period, instruct the patient to completely void the bladder and saving this urine. (575)
  32. What assessments does the nurse need to do for a client that is restrained? (q30 min)
    Assess the patient is safe and the restraint is not too tight by checking for cyanosis, coldness of skin, patient complains, tingling or pain. Also check if the restraint is still necessary. (137)
  33. How would the nurse ambulate a client that needs assistants both one and two nurse?
    Use a gait belt to help in supporting patient. Nurse would grasp the belt of the client's back and walk behind and slightly to one side of the client. Interlock forearms with the patient and walk on the patient's weaker side. Encourage the patient to press the forearm against your hip for stability. With two nurses, one nurse on each side, grasp the inferior aspect of the client's upper arm with your nearest hand and the client's lower arm or hand with your other hand. Walk in unison with the client. If the client starts to fall each nurse slips an arm under the client's axillae and grasps the patient's hands and slowly lower to the floor. (786)
  34. Describe how to give a bed bath to a client and what areas have to be given special attention to.
    Cover patient with a bath towel. Remove the patient's gown. Start by cleaning the eyes by wiping with a clean cloth from the inner canthus to the outer. Use separate corners to prevent transmitting microorganisms from one eye to the other. Wash the face, neck, and ears and pat dry. Place a towel under the arm. Wash and dry the arms and hands including the armpits. Wash the chest and abdomen. Wash the legs and feet. Wash the back and the perineum with a front to back motion. Be sure to pay attention to under the breasts and armpits because the environment is very conducive to bacteria growth. (448)
  35. When washing the client's face, do you need to wear gloves?
  36. What is the first part of the face you wash first and how?
    The eyes from the inner to the outer canthus using a clean portion of the cloth for each wipe to prevent infection between eyes. (448)
  37. Describe how the nurse should wash their hands and for how long.
    • 1. remove jewlery
    • 2. check for broken skin
    • 3. use warm water
    • 4. wet from arms to fingertips
    • 5. 2-4 ml of liquid soap
    • 6. firm fiction
    • 7. wash for minimum of 10-15 seconds
    • 8. dry thoroughly
    • 9 discard paper towel and use new one to shut of water
  38. When should hands be washed?
    Hands should be washed between patients. It is to be washed when hands are visibly soiled. When not visibly soiled, alcohol-based foams and gels are to be used. (165)
  39. What precautions should a nurse take for a client with C-Diff?
    A nurse should use standard precautions and at the very least don gloves. If diarrhea is explosive, PPE may be needed.
  40. What can a nurse teach a client with constipation to do to relieve it?
    • 1. increase fluid intake (2000-3000 ml per day)
    • 2. hot liquid and fruit juices (prune juice)
    • 3. fiber rich food (prunes, raw fruit, bran products, whole grains)
  41. What type of diet should a client with diarrhea be on and why?
    • 1. increased fluid intake
    • 2. bland foods (more easily absorbed)
    • 3. avoid spiced foods and high fiber (aggravates stomach)
    • 4. food with sodium and potassium (potassium and sodium are lost during
    • diarrhea)
    • 5. BRAT diet (bananas, rice, apples, tea)
    • 6. decrease insoluble fiber, increase soluble fiber
    • 7. limit fatty food.
    • 8. foods that normal cause constipation
    • 9. reestablish normal bowel flora by eating fermented dairy products
    • like yogurt after diarrhea stops
  42. What is a valsalva response and what can cause it?
    The pressure created when straining while holding the breath.
  43. Constipation and pain while doing ROM can cause it.
    it can be a problem for clients with brain injuries, heart, and or respiratory disease
  44. Describe how to put a Foley catheter in and what position should be used for a male and a female?
    • 1. SUPINE with knees flexed and (female)thighs externally rotated (male) thighs slightly apart
    • 2. cleanse perineal with warm water and soap
    • 3. rinse and dry
    • 4. prep equipment and set up sterile field.
    • 5. test balloon inflation and deflation.
    • 6. clean meatus
    • 7. lube tip of catheter and put in urthra until urine flows
    • 8. flat balloon to hold in place
    • 9. tap tube to thigh of patient and bag below patients bladder on bed frame
  45. Describe how to administer an enema. What is the level that enema bag should at, how much time should elapse before the client defecates, and when should an enema be stopped?
    • 1. Left Lateral/ Left Sims
    • 2. Lube 2 inches of rectal tube
    • 3. Remove air in tube by running solution.
    • 4. insert tube 2-3 inches
    • 5. slowly adminster enema by opening clamp and raising solution
    • 6. stop flow for 30 seconds ad restart at a slower rate if patient complains of pain or fullness
    • 7. Hold enema 12-18 inches about the rectum
    • 8. have patient retain enema by laying down for 5-10 for cleansing enema or at least 30 for oil retention enema
    • 9. assist patient to defeccate
  46. Describe what can happen if the sterile field is broken while inserting a Foley catheter.
    • Microorganisms that cause UTI can come through the urethra
    • Bladder Infection
  47. What causes decubitus/pressure ulcers?
    • 1. ISCHEMIA: Unrelieved pressure that causes a deficiency of blood supply to the
    • tissue
    • 2. Friction (sheets remove superficial layers of skin making it more
    • prone to break down)
    • 3. Immobility
    • 4. inadequate nutrition
    • 5. edema
    • 6. fecal or urinary incontinence (leads to maceration)
    • 7. excessive body heat (bumps up metabolic rate which increase need for
    • cellular oxygen. oxygen it cannot get because blood is unable to reach
    • tisse becuase of unrelieve pressure)
    • 8. advanced age (less pain sensation of pressure and lower skin
    • integrity)
  48. Why does the nurse need to protect the bony prominences of the client's body?
    It is where pressure ulcers usually occur. The bones increase the pressure. (482)
  49. Hypertonic Enema Solution
    1. solution and amount
    2. what it does
    3. amount of time retained
    • 1. (90-120mL e.g. sodium phosphate)
    • 2. draws water into the colon.
    • 3. 5-10 min
  50. Hypotonic Enema Solution
    1. solution and amount
    2. what it does
    3. amount of time retained
    • 1. (500-1000 mL of tap water)
    • 2. distends colon and stimulates peristalsis.
    • 3. 15-20 min
  51. Isotonic Enema Solution
    1. solution and amount
    2. what it does
    3. amount of time retained
    • 1. (9mL NaCl sodium chloride to 1,000 mL water)
    • 2. distends colon, stimulates peristalsis.
    • 3. 15-20 min
  52. Soapsuds Enema Solution
    1. solution and amount
    2. what it does
    3. amount of time retained
    • 1.(3-5 mL soap to 1,000 mL water)
    • 2.irritates mucosa, distends colon.
    • 3.10-15 min
  53. Oil Enema Solution
    1. solution and amount
    2. what it does
    3. amount of time retained
    • 1.(mineral, olive, cottonseed 90-120 mL)
    • 2.lubricates the feces and the colonic mucosa.
    • 3.30-60 min (612)