· Cultural and spiritual nursing care: effective communication when caring for a client who speaks different language than the nurse
- Providing
... [Show More] language assistance to clients who has communication needs
- Direct the questions to the client, not the interpreter
- Do not interrupt the client through the conversation
- Allow time to the interpreter to and the family to be introduced
· Ethical responsibilities: responding to a client's need for information about the treatment
- State the ethical dilemma, including all the surrounding issues.
- List and analyze all possible options for resolving the dilemma
- Apply the decision to the dilemma and evaluate the outcomes
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· Client education: discharge planning for a client who has diabetes mellitus
- Adults learn well by building on prior information and life experiences
- Adults' learning abilities can be influenced by life factor.
- Learning for adults is enhanced when the nurse work with the client setting mutual goals.
· Action to take when receiving a telephone prescription
- Have a second nurse listen to a telephone prescription
- Repeat it back and question any prescription that seems inappropriate for the client
- Make sure the provider signs the prescription in person within the facility time frame.
· Older adults: teaching about manifestations of delirium
- Acute, temporary
- Have a physiologic source or related to a change in surroundings
- Delirium is the fist manifestation of infection in older adults
· Urinary elimination: teaching about Kegel exercises
- Tighten pelvic muscles for a count of 10, relax slowly of count of 10, and repeat it in sequences of 15
- Can be lying down, sitting or in a standing position
- Perform bladder compression techniques to help manage reflex incontinence
· Health promotion and disease prevention: stages of health behavior change
- Identify client's readiness to receive and apply health information
- Identify acceptable interventions
- Help motivate change by setting realistic timelines
- Reinforce steps toward changes à encourage clients to maintain change
· Integumentary and peripheral vascular systems: findings to report from a skin assessment
- Primary lesions arise for healthy tissue: macule (nonpalpable), papule (palpable), vesicle, tumor (solid mass), atrophy
- Secondary lesion occur from change in primary lesion: erosion (loss of epidermis), fissure, crust (pus), ulcer
- Check lesions using the ABCDE system to detect possible skin cancer
· Thorax, heart, abdomen: steps to take when performing an abdominal assessment
- Auscultate just after the inspection because percussion and palpation can alter bowel sound
- Have the client to lie supine with arms at both sides and knees slightly bent
- The most appropriate time to auscultate abdomen is between meals.
- Percussion: expect dullness over liver and a distended bladder.
· Client safety: implementing seizure precautions
- Make sure rescue equipment is at the bedside including oxygen, oral airway, suction equipment, and patting for the side rails.
- Inspect the client's environment for items that could cause injury during seizure.
- Advise all caregivers and families not to restrain the client during a seizure but to lower the client to the floor or bed, protect their head, and provide privacy.
· Medical and surgical asepsis: planning care for a patient who has a latex allergy.
- The team must use latex free gloves, equipment, and supplies.
- Use non-latex nitrile gloves
- It is the health care team's responsibility to identify latex allergies and use items that are latex free
Safe medication administration and error reduction: client identification
- Before administering the medication the nurse should obtain:
- Age, health problems and the current reason for seeking for care.
- The name, dose, route, and frequency of each medication
- Client's understanding of the purpose of the medication
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· Medical and surgical asepsis: preparing a sterile field
- Pour sterile solutions: place the bottle cap up on a clean field
- Hold the bottle with the label in the palm of the hand so the solution do not run down the label
- After setting up everything, put the sterile gloves.
· Home safety: evaluating client understanding of home safety teaching
- Remove items that could cause the client to trip
- Monitor gait and balance, and provide aids as needed.
- Place grab bars near the toilet and the shower, and install a stool riser
- Ensure lighting is adequate
- Place electrical and extension cords against the wall
· Client safety: proper use of wrist restrains
- Use of restrains for shortest duration necessary and only if less restrictive measures are not sufficient. They are for physical protection to the client and the other clients.
- In emergency situation, nurses can place restrains in clients by obtaining a prescription of the provider.
- The prescriptions allow only 4 hr of restrain for an adult.
- Assess for skin integrity
· Therapeutic communication: Responding to a client concerns prior to surgery
- Elicit and attend to client's thoughts, feelings, concerns, and needs.
- Obtain information and provide feedback about patient's status
- Active listening, asking questions, restating, reflection, paraphrasing
· Airway management: performing chest physiotherapy
- Involves the use of chest percussion, vibration, and postural drainage to help mobilize secretions.
- For postural drainage, one or more positions allow gravity to assist with the removal of secretions from specifics areas of the lung.
- Early morning postural drainage mobilizes secretion that have accumulated through the night
· Vital signs: caring for a patient who has high fever
- Provide fluids and rest. Minimize activity. Provide a cooling blanket.
- Monitor WBC and electrolytes.
- Prevent shivering at this increase energy demand
- Provide antipyretics
· Mobility and immobility: preventing thrombus formation
- ROM exercises while awake
- Use elastic stocking
- Clients who are immobile should perform leg exercises, increase their fluid intake, and change positions frequently.
· Preparing an injectable medication from a vial
- Scrub the self-sealing tops on both the diluent and powdered medication vials with the antimicrobial swab and allow to dry.
- Draw up the appropriate amount of diluent into the syringe.
- Insert the needle or blunt cannula through the center of the self-sealing stopper on the powdered medication vial.
- Inject the diluent into the powdered medication vial.
- Remove the needle or blunt cannula from the vial and replace cap.
- Gently agitate the vial to mix the powdered medication and the diluent completely. Do not shake the vial.
- Draw up the prescribed amount of medication while holding the syringe vertically and at eye level.
- After the correct dose is withdrawn, remove the needle from the vial and carefully replace the cap over the needle. Some facilities require changing the needle, if one was used to withdraw the medication, before administering the medication.
· Urinary elimination: selecting a coude catheter
- Commonly prescribe if patient have enlarged prostate
- The catheter tip is designed to get past that tight spot
- For intermittent urinary catheterization [Show Less]