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final exam review questions

Terms in this set (55)

What is the correct procedure for putting on sterile gloves?
1.) Prior to performing the procedure, introduce self to client and verify the clients identity. 2 ways.
2.) Explain to client what you are about to do and why its necessary.
3.) Perform hand hygeine.
4.) Provide client privacy.
5.) Open package of sterile gloves. Place package of gloves on a clean, dry surface. If in an inner package of the gloves, open thm as well w/out contaminating the gloves or inner packages.
6.) Put the first glove on the dominant hand. IF the gloves are packaged so that they lie side by side, grasp the glove for the dominant hand by its folded cuffedgew/ thumb and first finger of the nondominant hand. Touch only the inside cuff. If the gloves are packaged one on top of the other, grasp the cuff of the top glove as above, using the opposite hand. Insert the dominant hand into the glove and pull the glove on. Keep the thumb of the inserted hand against the palm of the hand during insertion.
7.) Put the second glove on the nondominant hand. Pick up the other glove with the sterile gloved hand, inserting the gloved fingers under the cuff and holding the gloved thumb close to the gloved palm. Pull on the second glove carefully. Hold the thumb of the gloved first hand as far as possible from the palm.
8.) Remove and dispose of used gloves. There is no technique for removing sterile gloves that is different from nonsterile gloves. if solied w/ secretins remove by turning them inside out.
9.) Perform hand hygeine.
10.) Document that sterile technique was used in the performance of the procedure.
What is the correct procedure for setting up a sterile field?
1.) Make sure package is clean and dry. If wet inside or outside, throw awa becuase it is considered contaminated. Check expiration dates on package and make sure its not been opened.
2.) Introduce self and verify clients indentity. 2 ways. Explain to client the procedure you are about to do and ehy its necessary.
3. Perform hand hygeine and observe other appropiate infection preventipn procedures.
4.) Provide privacy for client.
5.) Open the package. If the package is inside a plastic cover, remove cover.
6.) Establish a sterile field y using a drape. Open package containing drape. With one hand, pluck the corner of the drape that is folded back on the top touching only one side of the drape. Lift the drape out of the cover, and allow it to open freely without touching any objects. with the other hand, carefully pick up another corner of the drape, holding it well away from you and, again, touching only the same side of the drape as the first hand. Lay the drape on a clean and dry surface, placing the bottom farthest from you.
7.) Ass necessary sterile supplies, being careful not to touch the drape with the hands. Place sterile bowl, drape, or other supply on the sterile field by approaching from an angle rather than holding the arm over the field. Discard the wrapper.
8.) Use sterile forceps to handle sterile supplies.
9.) Document that sterile technique was used n the performance of the procedure.
What is the correct procedure for changing a dressing?
1.) Obtain assistance for changing a dressing on a restless or confused client. Assist the client to a comfortable position in which the wound can be readily exposed. Expose only the wound area, using a bath blanket to cover the client, if necessary. Make cuff on the mositure proof bag for disposal of soiled dressings and place bag within reach. Apply a face mask, if required.
2.) Introduce self to client. Verify clients identity and what you are about to do and why its necessary.
3.) Perform hand hygeine and observe other appropiate prevention control procedures.
4.) provide privacy for client.
5.) Remove binders and tape. Remove and dispose of soiled dressings appropiately. Apply clean gloves and remove the outer abdominal dressings or surgipad. Lift the outer dressing so that the undeside is away from the clients face. Place soiled dressings in the moisture proof bag w/out touching the outside of the bag. Remove the underdressings, taking care not to dislodge any drains. If the guaze sticks to the drain, support the drain w/ one hand and remove the guaze with other. Assess the location, type, color, cosistency, odor of wound drainage, and the number of guazes saturated or the diameter of drainage collected ont he dressings. Discard the soiled dressings in the bag mositure proof bag. Perform hand hygeine.
6.) Set up the sterile supplies. Open sterile dressing set, using surgical aseptic technique. Place the sterile drape beside the wound. Open the sterile cleaning solution and pour it over the guaze sponges in the plastic container. Apply sterile gloves.
7.) Clean the wound, if indicated. Clean the wound, using your gloved hands or forceps and guaze swabs moistened with cleaning solution. use a seperate awab for each stroke and discard. dry surrounding skin with dry guaze swabs as required. Dont dry the incision or wound itself.
8.) Apply dressings to the drain site and incision. Remove and discard gloves. Secure dressings with tape or ties. Perform hand hygeine.
9.) Document the procedure and all nursing assessments.
What is the correct procedure for inserting a urinary catheter into a male and female patient?
1.) Introduce seld and verify clients identity in 2 ways. Explain the procedure you are about to do and why its necessary.
2.) Perform hand hygeine and observe other appropiate infection prevention procedures.
3.) Provide for client privacy.
4.) Place the client in th appropiate position and drape all areas except the perineum.
-Male: Supine, thighs slightly abducted or apart.
-Female: Supine w/ knees flexed, feet about 2 feet apart, and hips slightly externally rotated, if possible.
5.) Establish adequate lightning. Stand on the clients right if you are right-handed, on the clients left if you are left handed.
6.) If using a collecting bag and its not contained w/in the catherization kit, open the drainage package and place the end of the tubing w/in reach.
7.) If agency policy permits, apply clean gloves and inject 10-15ml Xylocaine gel into the urethra of the male client. Wipe the underside of the penile shaft to distribute the gel up the urethra. Wait at least 5 minutes for the gel totake effect before inserting the catheter.
8.) Remove and discard gloves. PErform hand hygeine.
9.) Open the Catherization kit. Place a waterproof drape under the buttocks(female) or penis(male) w/out contaminating the center of the drape w/ your hands.
10.) Apply sterile gloves.
11.) Organize the remaining supplies: Saturate the cleansing balls with the antiseptic solution. Open the lubricant package. Remove the specimen container and place it nearby w/ the lid loosely on top.
12.) Attach the prefilled syringe to the indwelling catheter inflation hub. Apply agency policy and or/ manufacturer recommendation regarding protesting of the balloon.
13.) Lubricate the catheter 2.5-5cm(1-2in.) for females, 15-17cm(6-7in.) for males, and place it with the drainage end inside the collection container.
14.) If desired, place the fenestrated drape over th eperineum, exposing the urinary meatus.
15.) Cleanse the meatus.
-Females: use nondominant hand to spread labia so that the meatus is visible.
-MAles: use your nondominant hand to grasp the penis just below the glans. if necessary, retract the foreskin. Hold the penis firmly upright, with slight tension.
16.) Insert catheter. Grasp teh catheter firmly 5-7.5cm(2-3in.) from the tip. Ask the client to take a slow deep breath and insert the catheter as the client exhales. Slight resistance is expected as the cathter passes via sphicter. advance the catherter 5cm farther after urine begins to flow through it. If the catheter accidently slips into the vagina and labia its considered contaminated. You must discard and redo all over.
17.) Hold the catheter w/ the nondominant hand .
18.) For an indwelling catheter, inflate the retention balloon w/ the designated volume. w/out releasing the catheter, hold the inflation valve between 2 fingers of your nondominant hand while you attacha the syringe and inflate w/ your dominant hand. If the client complains of discomfort, immediately withdraw the instilled fluid, advance the catheter farther, and attempt to inflate the balloon again.
19.) Collect a urine specimen if needed. For a straight catheter, allow 20-30 ml to flow into bottle w/out touching the catheter to the bottle. For an indwelling catheter preattached to a drainage bag , a specimen may be taken from the bag this initial time only.
20.) Allow the straight cathter to continue draining into the urine receptacle.
21.) Examine and measure the urine. In some cases, only 750 to 1000ml of urine are to be drained from the bladder at one time.
22.) Remove the straught catheter when urine flow stops. secure the catheter to patients thigh.
23.) Hang bag below the level of the bladder. no tubing should fall below the top of the bag.
24.) wipe any remaining antiseptic or lubricant from the perineal area. replace teh foreskin if retracted earlier. return the client to a comfortable position. Instruct the client on positioning and moving w/ cathter in place.
25.) discard all used supplies in apporpiate receptacles.
26.) remove and discard gloves. Perform hand hygeine.
27.) Document the catherization procedure including atheter size and results in the client record using forms or checklists supplemented by narrative notes when appropiate.
State the normal ranges of labs associated with fluids and electrolytes.
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Describe each of the 3 levels of prevention and give one specific example of each.
*Primary Prevention-Health promotion and specific protection against disease. Precedes disease. Applies to healthy individuals . Risk assessments

*Secondary Prevention-Early detection of disease, prompt intervention, and health maintenance for individuals experiencing health problems

*Tertiary Prevention- Begins after diagnosis. Focus to help rehabilitate patients and restore them to an optimum level of functioning within the constraints of the disability
Discuss types of diabetes (type I, type 2).
*Type I Diabetes-Beta call destruction leading to absolute insulin deficiency. Autoimmune
Immune system fails to recognize normal body cells as "self" and takes destructive actions against them
Idiopathic . Insulin Dependent

*Type II Diabetes- Ranges from insulin resistance with relative insulin deficiency to secretory deficit with insulin resistance. Can develop at any age. Associated with excess weight, physical inactivity, family history of diabetes.The pancreas does not produce enough insulin (insulin deficiency). The cells don't use insulin properly. The insulin can't fully "unlock" the cells to allow glucose to enter (insulin resistance).
Discuss hypoglycemia.
Abnormally low levels of glucose in the blood. <70mg/dl
Common causes related to diabetes:
Too much insulin as it relates to food intake and physical activity
Insulin injected at the wrong time relative to food intake and physical activity
Wrong type of insulin injected at the wrong time
Decreased food intake resulting from missed or delayed meals
Increased insulin sensitivity as a result of regular exercise and weight loss
What is the difference between regular and NPH insulin?
NPH insulin, or Insulin Isophane Suspension, is a transitional form of insulin which has the ability to extend its capacity for a longer time in contrast with regular ones. The regular insulin, or Insulin Injection Regular, is described to be a drug with short-acting effects.

Regular insulin has an appearance of a clear consistency, and the solitary form can be given through intramuscular injections because of its required immediate effects. This type of insulin may also be given via intravenous infusion. On the contrary, NPH is described to have a cloudy appearance and is only administered via subcutaneous injection.

Regular insulin has an effect on a patient in a period of 30 min.-1 hr. while NPH insulin needs one to two hours remaining time to take effect. The onset, peak, and duration of its effectivity also differs with each other. The prescription of these two types has the same goal of reducing the blood sugar levels to a normal range. Moreover, the vital part is that the patient has an adequate amount of knowledge on the prescribed medication given by the physician.
Discuss the preparation of insulin in an insulin syringe
Clean both insulin vial tops. Inject measured AIR into NPH vial. Inject measured AIR into Reg vial. Draw up Reg dose. Draw up NPH dose without adding any Reg into NPH vial. Administer to patient IMMEDIATELY. NPH will begin to settle
Mixing Insulin
Draw regular insulin into syringe first to avoid contamination of regular insulin
Clear to cloudy
Not Ready/Ready Now
Methods of insulin delivery
SubQ (syringe or insulin pen)
IV
Insulin Pump
Mixing Insulin
Diabetic patients may require 2 types of insulin administered at the same time. Regular insulin is CLEAR. NPH insulin is CLOUDY. "Clear before Cloudy"
Describe culturally responsive care.
Centered on client's cultural perspectives
Integrates client's values and beliefs into plan of care
Develops self-awareness of nurse's own culture, attitudes, and beliefs
State at least 4 questions that a nurse could ask to assess a patient's culture.
1. What is your religious preference?
2. What is your native language?
3. Do you practice your religion in your home?
4. Do you belong to a religion instituion?
Describe the goals of the therapeutic relationship.
FACILITATE communication
ASSIST patient with problem solving
HELP patient examine own behaviors
PROMOTE patient's self-care
HELPING RELATIONSHIP (Therapeutic Relationship)
A confidential, interactional relationship between a person with a problem(s) and a skilled helper who facilitates problem solving in a fashion consistent with the person's values.
CHARACTERISTICS OF HELPING RELATIONSHIP:
what it is!
Focus on client's needs
Goal directed
Explicit time frame
Expectation of confidentiality
Relationship created with care, skill, and trust
CHARACTERISTICS OF HELPING RELATIONSHIP:
What it is NOT!
Not nurse-centered
Not based on what the nurse needs to get done
Not un-ended time frame
Not based on whether or not nurse agrees with client
Phases of a Therapeutic Relationship
*Pre-Interaction Phase-
*Orientation Phase
*Working Phase
*Termination Phase
State a specific example of each of the 6 C's of Caring.
*Compassion- Awareness of ones relationship to others, sharing thier toys, sorrows, and accomplishments. Participation in the experience of another.

*competence Having the "knowledge, judgement, skills, energy, experience and motivation required to respond adequately to the demands of ones professional responsibilities"

*confidence- Comfort with self, client, and others that allows one to build trusting relationships

*coscience- Morals, ethics and an informed sense of right and wrong. Awareness of personal responsibility

*commitment-The deliberate choice to act in accordance with ones desires as well as obligations, resulting in investment of self in a task or cause.

*comportment-Appropiate bearing, demeanor, dress, and language that are in harmony with caring presence. Presenting oneself as someone who respects others and demands respect.
The Six C's of Caring
Compassion
Competence
Confidence
Conscience
Commitment
Comportment
Give one specific example of each Facilitating Communication Techniques and Barrier Communication Techniques.
***Facilitating Communication Techniques Using Silence, Accepting, Giving Recognition, Offering self, Giving broad opening, Offering general self, Placing the event in time or sequence, Making observations, Encouraging description of perceptions, Encouraging compassion, Restating , Focusing, Exploring, Giving, information, Clarifying or verbalizing the implied, Presenting reality, Suggesting collaboration, Summarizing

***Barrier Communication Techniques Reassuring (Unwarranted),Failing to listen,Rejecting, Approval/Disapproval, Giving common advice, Agreeing/Disagreeing, Probing, Challenging, Testing, Defensive responses, Making stereotyping responses, Using denial
Using silence
Allowing a time when no verbalizations are made
Example:
Client: I'm all alone...
Nurse: says nothing, perhaps takes client's hand
Client: I hate being alone in this room all day
Accepting
Making a nonjudgmental response
Example:
Client: If there is a God, I wouldn't be sick. I don't believe in God anymore
Nurse: nods head
Give specific examples of how a nurse can improve communication with patients with special needs
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Patients with Special Needs
Adapt communication techniques to the clients unique needs
Do not assume, generalize, or stereotype clients
Requires the nurse to be especially respectful and sensitive
Keep focus on the client, not the "task"
Be respectful of other cultural values
Validate the client's understanding according to their unique special needs
Patients with Special Needs: Difficulty Hearing
Interact directly with the patient
Position yourself in front of the patient
Be sure that the patient sees you approach
Gain the patient's attention before you speak
Speak clearly, in a normal tone of voice, just a little louder, and at a moderately slow pace
Pause between phrases
Avoid having anything in your mouth
Maintain eye contact with the patient
Minimize the use of medical terminology
Include non-verbal communication
Do not talk over your shoulder or from an unobservable area
Minimize background noise as much as possible
Write the message if appropriate
Supplement the conversation with visual aids
Be patient
Which are important nursing actions when speaking with an older adult with hearing impairment? Select all that apply
Limit background noise
Stand directly in front of the patient when speaking
Patients with Special Needs: Difficulty Seeing
Greet the patient
Speak directly to the patient
Tell the patient that you will be touching them before you do so
Explain to the patient what you are doing as you are doing it
Be verbally descriptive
Tell the patient when you leaving the area
Never touch or distract a patient's service dog
When walking with a patient using a service dog, walk on the opposite side of the service dog
Patients with Special Needs: Cognitive Impairment
Expect an increase in confusion when the patient wakes up or in evening ("Sundowning")
Approach the patient from the front and call the patient by name
Respect the patient's personal space
Avoid sudden movements that may startle or irritate the patient
Speak slowly and distinctly in a low-pitched voice
Ask one question at a time
Give one-step directions
Be mindful of your non-verbal messages
Do not disagree or argue with the patient
Dealing with Angry Persons
Be aware of how you are responding to the angry patient
Keep reminding yourself not to take anger personally
Recognize anger and anxiety are normal feelings when facing adversity
Encourage the patient to express feelings verbally yet appropriately
Listen instead of defending
Do not take responsibility for the patient's anger
Remain calm
Help the patient identify what is causing the anger and try to meet those needs
Be alert to your own and to the patient's safety needs
What are at least 5 concepts of effective communication between health care professionals?
Simplicity
Clarity
Timing & Relevance
Adaptability
Credibility
Describe informed consent.
Consent must be given voluntarily
Consent must be given by a patient or individual with the capacity and competence to understand
Patient or individual must be given enough information to be the ultimate decision maker
Describe how HIPAA applies to documentation of patient information.
*HIPAA- According to HIPAA patients have a right to:
See and copy their health record
Update their health record
Get a list of the disclosures a healthcare institution has made independent of disclosures made for the purpose of treatment, payment, and healthcare operations
Request a restriction on certain uses or disclosures
Choose how to receive health information
Describe the components of a health history.
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Describe the general survey
H-Help
E-Environment&Equipment
L- look
P- People

* ABC, LOC, Orientation to person, place, time, and situation
Assessment Health History
Identifies health status, strengths, health problems, health risks, need for nursing school
HELP
help, environment & equipment, look, people
List the correct procedure for head-to-toe assessment
*General Survey
*Vital Signs
*Head- hair,scalp, face, eyes, and vision, ears and hearing, nose, mouth and oropharynx
*Neck- muscles, lymph nodes, thyroid gland, carotid arteries, neck veins
*Upper Extremities-skin and nails, muscle strength and tone, joint ROM, brachial and radial pulses, sensation
*Chest and back-skin, thorax shape and size, lungs, heart, spinal column, breasts and axillae
*Abdomen-skin, abdominal sounds, femoral pulses
*External genitals
*Anus
*Lower extremities-skin and toenails, gait and balance, joint ROM, popliteal, posterior tibial, and dorsalis pedia pulses.
Assessments should be:
Purposeful, prioritized, complete, systematic, accurate, relevant, recorded, and documented
Crackles
caused by random, sudden reinflation of groups of alveoli, or disruptive passages or air through small airways, an can be described as fine, medium, or coarse.
Rhonchi
low pitched, continuous sounds caused by muscular spasm, fluid, or mucus in larger airways
Wheezes
high pitched continuous musical sounds, like a squeak heard continuously during inspiration or expiration. They usually are louder on expiration and often are heard in asthma
Adventitious Sounds of Thorax & Lungs
Crackles, Rhonchi, Wheezes, Pleural friction rub
Auscultation of Thorax & Lungs
Assesses movement of air through the tracheobronchial tree and detects mucus or obstructed airways. Normally air flows through the airways in an unobstructed pattern. Recognizing the sounds created by normal airflow.
Thorax and Lungs
Auscultation and Adventitious sounds
Absorption
Passage of drug from site of administration into bloodstream
Speed and amount of absorption critical to overall action of drug
Drug form effects absorption (SL, PO, IM, SC)
Distribution
Movement or transport of drugs to the body cells or spaces between cells

Depends on specific drug and intended cell or tissue (target cell or target tissue)
Biotransformation
Normal body process by which substances are chemically broken down into a form the body can excrete
"metabolism"
Usually takes place in the liver
Some drugs are not active until biotransformed
Half-Life
Excretion
Removal of waste substances from the body

Elderly usually have ________% kidney function making excretion slower
drug effect
Curative
Palliative
Supportive
Substitutive
Chemotherapeutic
Restorative
drug action
process absorption, distribution, biotransformation, excretion
3 Checks in Medication Administration
First read MAR and remove meds from patients drawer. Verify the patients name and room number to match MAR
Second while preparing the meds look at the med label and check against the MAR
Third recheck the med label before returning to the storage place
Check med label against the MAR before opening the package at the bedside
Medication Reconciliation
Process of creating the most accurate list possible of all medications a patient is taking, including drug name, dosage, frequency, and rout, and comparing that list against the physicians' admission, transfer, and/or discharge orders, with the goal of proving correct medications to the patient at all transition points within the hospital
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