Determining the client position for insertion of indwelling catheter, Most important
Orthopnea
Nurse teaching male with multiple sclerosis (MS) how to
... [Show More] empty bladder using creude method. When performing return demonstration pt applies pressure to the umbilical area of his abdomen
Apply downward manual pressure at the suprapubic region
Finding a client sitting on the floor, nurse calls for help from UAP
Get a BP cuff
Correct position for patient walking with cane
30o flexion at the elbow
Teaching a patient about crutch walking
Place weight on arms and hands when using crutch
Patient has active tuberculosis. Action to prevent spread of infection
Wear mask when going to patient’s room
To advance NG tube while inserting what position should patient be in
High fowler’s
Which profession is at greatest risk of developing Hepatitis A
Cook in a restaurant
Handwashing sequence
Palms, between fingers, dry off with paper towel, turn off faucet
Someone with wound vac how to make sure it is effective
Check seal to make sure no leaks
Chest tube becomes disconnected
Get new saline bottle to stick end into until reconnect tube
Patient in ventricular fibrillation
Defib shock once
Chest tube colume 125
Mark container between 100 and 150
Heart sounds audio
S1S2
Patient on bleed precautions Soft bristle toothbrush Electric razor only to shave
Avoid IM injections, use small needles when necessary and hold pressure for 5 minutes No straining with BM
UAP giving complete bath-which patient is more concern
Patient with dyspnea (SOB when lying flat)
Patient receiving Morphine in PCA pump
Make sure the lock is on the machine
Precautions for RSV
Do not put patient with another patient having RSV
Insulin can be kept at room temp
28 days
Drawing insulin
Clear (regular) first then cloudy (NPH)
Know the insulins and their peak/onset (there are several Qs about this in different formats) Rapid-Lispro (Humalog) and Aspart (Novolog) Onset: 5-15 minutes Peak: .75-1.5 hours Short acting- regular (humulin) Onset: 30-60 minutes Peak: 2-3 hours (IV ok) Intermediate acting- NPH Onset: 1-2 hours Peak 6-12 hours
Long acting- Glargine (lantus) Onset 1.1 hour Peak: 14-20 hours (DO NOT MIX)
Assessing placement of NG tube
<4 pH gastric aspiration
Carpal spasm induced by BP cuff and seen in patient with hypocalcemia
Trousseau’s sign
Trousseau's sign
(Trousseau sign of latent tetany, low calcium, holding hand like swan, seen in hypocalcemia before hyperrelexia or tetany) Put bp cuff around arm, inflate, hold in place 3 mins, occuldes brachial, pt, will put hands like shape of swan
Facial spasm after tapping facial nerve and seen in patients with hypocalcemia
Chvostek’s sign
Patient on neutropenic precautions
No flowers or plants in room No fresh veggies-cooked only Avoid crowds and sick people
head of the bed positioning for post-craniotomy patient with infratentorial lesions
FLAT
Supratentorial – elevated
assisting the patient to cough productively
increase fluids to loosen secretions
O2 flow rate be for a patient with COPD
No more than 2 liters by nasal cannula
patient is vomiting and restless, diarrhea, respiration rate of 8 to 10 per minute, shows arrhythmias on the EKG monitor
metabolic alkalosis
preventing hypoxia during suctioning
give 100% oxygen before and after endotracheal suctioning
assessing a patient’s sleep-rest pattern related to respiratory health
Has trouble falling asleep
Awakens abruptly during the night Has to sleep with the head elevated
nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting
The fingernails and their base
caring for a patient with COPD and pneumonia who has an order for arterial blood gases to be drawn
5 Minutes
patient with a recent history of a dry cough has had a chest x-ray that shows presence of nodules
Positron emission tomography (PET)
patient with recurrent shortness of breath just had a bronchoscopy
Monitoring the patient for laryngeal edema
After assisting at the bedside with thoracentesis, the nurse should continue to assess the patient for
Pneumothorax
nurse notices clear nasal drainage in patient newly admitted with facial trauma and a nasal fracture
Test the drainage for the presence of glucose
patient is being discharged from the emergency department after being treated for epistaxis
Apply ice compresses to the nose
Pinch the entire soft lower portion of the nose
Partially insert a small gauze pad into the bleeding nostril
caring for a patient who is 3 hours postoperative laryngectomy, the nurse’s highest priority assessment
Airway patency
teaching a patient the supraglottic swallow following a radical neck dissection with
Cola
nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care facility-allergy
Hypersensitivity to eggs
Which task can the registered nurse (RN) delegate to nursing assistive personnel (NAP) care of a stable patient has a tracheostomy
Suctioning the patient’s oropharynx
Anterior Cruciate Ligament injury
crutches
priority nursing assessment in the care of a patient who has a tracheostomy
Respiratory rate and oxygen saturation
promote airway clearance in a patient with pneumonia
Maintain adequate fluid intake Splint the chest when coughing
Instruct patient to cough at end of exhalation
Soft diet-select
yogurt, chicken soup, cottage cheese
Pneumatic compression devices
used to prevent DVT, improves venous circulation
patient admitted to the hospital with pneumonia, temperature of 101.4° F, productive cough with yellow sputum, and respiratory rate of 20
Hyperthermia related to infectious illness
IV med incompatible
start a new line
physical assessment finding in a patient with a lower respiratory problem best supports diagnosis of ineffective airway clearance
Basilar crackles
Ankle brachial index
ensure that you provide meticulous foot care to client
clinical manifestation expect to find during assessment of a patient admitted with pneumococcal pneumonia
Increased vocal fremitus on palpation
priority nursing intervention in helping a patient expectorate thick lung secretions
Increase fluid intake to 3 L/day if tolerated
NGT Irrigation-assignment
RN must irrigate
discharge teaching for a 65-year-old patient with COPD and pneumonia
Pneumococcal
Vitamin K
Technique 25 gauge, 58-inch needle to administer in either the vastus lateralis
discharge teaching for a patient hospitalized with pneumonia most effective when the patient states
“I should continue to do deep-breathing and coughing exercises for at least 6 weeks” [Show Less]