NCLEX PN (MARCH EXAM)

How to reduce Falls in the home?
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Terms in this set (24)
How to reduce Falls in the home?
Removal of all area RUGS and

Installation of GRAB BARS in the bathroom
Shingles (HERPES ZOSTER)
- Contact Precaution

- Airborne Precautions
Nosocomial Infection
Nosocomial infection occurs in hospital or other health care setting and is not the reason for the client admission. Many Nosocomial Infections are caused by multi-drug resistant organisms. These infection occur 48 hours or more after admission or up to 90 days after discharge.
Which clients are at greater risk for Nosocomial Infection?
YOUNG CHILDREN, The ELDERLY and those with compromised immune systems. Other risk factors include hospital stays, being in the intensive care unit. The use of the indwelling catheters, failure of health care workers to wash their hands, and the overuse of antibiotics.
What is the most common NOSOCOMIAL INFECTION?
Urinary Tract Infection (UTI) followed by surgical site infections, pneumonia, and blood stream infections
Full Weight Bearing
- No Assistance Required
- 1 person STANDBY ASSISSTANCE or OBSERVATION FOR CLIENTS WHO ARE UNCOOPERATIVE or AT HIGH RISK FOR FALLS
Partial Weight Bearing
- 1 Person Assist stant & Pivot transfer with gait belt or motorized assist device if cooperative
- 2 person Assist with Full Body Sling if Client is uncooperative
None Weight Bearing
- Motorized Assist device if client is cooperative & has upper Body Strength
- 2 Person Assist with Full body Sling if client is uncooperative &/or has no upper Body Strength
How to reduce the incidence of catheter-related infections from peripheral IV catheters
- The nurse should clip excessive hair if needed
- clean the site with Chlorhexidine in a back and forth motion using friction, and allow it to dry completely.
- Catheter hub should be secured with sterile tape, and access ports should be cleaned with 70% alcohol prior to use.
First Priority when violence occur?
SAFETY IS THE FIRST PRIORITY. People should leave the area and call security immediately.
Client indetifier to ensure "the right client"Acceptable identifier are First and Last Name, Medical Record number, and Birth Date.C-Diff Contact precautionsDisposable Gown Clean GlovesC-diff requires contact Based precautions- Private isolation Room - Disposable gown - Nitrile Gloves C-Diff requires the use of soap and water to prevent transmissionGeneral AnesthesiaThe goal is to make and keep a person completely unconscious (or "asleep") during the operation, with no awareness or memory of the surgery. General anesthesia can be given through an IV (which requires sticking a needle into a vein, usually in the arm) or by inhaling gases or vapors by breathing into a mask or tube.Regional anesthesia.An anesthetic drug is injected near a cluster of nerves, numbing a larger area of the body (such as below the waist, like epidurals given to women in labor). Regional anesthesia is generally used to make a person more comfortable during and after the surgical procedure. Regional and general anesthesia are often combined.Local anesthesia.An anesthetic drug (which can be given as a shot, spray, or ointment) numbs only a small, specific area of the body (for example, a foot, hand, or patch of skin). With local anesthesia, a person is awake or sedated, depending on what is needed. Local anesthesia lasts for a short period of time and is often used for minor outpatient procedures (when patients come in for surgery and can go home that same day). For someone having outpatient surgery in a clinic or doctor's office (such as the dentist or dermatologist), this is probably the type of anesthetic used. The medicine used can numb the area during the procedure and for a short time afterwards to help control post-surgery discomfort.How to remove PPE?1. GLOVES 2. GOGGLES or FACESHIELD 3. GOWN 4. MASK or RESPIRATORHow to put on PPE?Hand Hygiene 1. GOWN 2. MASK or RESPIRATOR 3. GOOGLES OR FACE SHIELD 4. GLOVESEBOLAEbola is an extremely contagious viral disease with a high mortality rate. Infected client require extensive infectious precautions, including an AIRBORNE ISOLATION ROOM, STRICT PERSONAL PROTECTIVE EQUIPMENT USE, RESTRICTION OF VISITORS, and a LOG OF INDIVIDUALS WHO ENTER AND EXIT THE ROOMWho is at higher risk for hospital acquired MRSA?Older Adults and those with suppressed immunity, long history of antibiotic use, or invasive tubes or lines. Clients in the intensive care unit (ICU) are especially at risk for MRSADuring an Emergency, The clients immediate family member refuses to leave the room. How should the nurse handle this situation?If the family members are not causing a disruption in care of the client, they should be allowed to stay in the room with a staff member assigned to explain the intervention being implemented. A staff member should be assigned to stay with the family member to explain the interventions taking place.AIRBORNE PRECAUTIONSN95 and handwashingLithium TherapyOften used in the treatment of bipolar Disorder Dehydration and sodium loss from vomiting and diarrhea can lead to toxic lithium levels in clients receiving lithium therapy.What is ISOTRETINOIN?An oral acne medication derived from vitamin A