NR 224 Final Exam Key Concepts Complete
NOTE: Remember NR 224 requires you to answer exam questions in which you will have to not only understand but
... [Show More] also apply information related to the concepts covered in the course. The intent of this study tool is to outline the major content that will be covered on the exam. Additional content may be included on the exam.
Critical Thinking
Be prepared to prioritize and to consider the
best option when answering exam questions.
What considerations are important when determining the best option?
Whatever decision is best for the patient
When should the nurse delegate vs not delegate?
Delegation: “transferring responsibility for a performance of an activity or task while retaining accountability for an outcome”
• assigning tasks to other healthcare professionals (vitals, labs); UAP (unlicensed assistive personnel),
LPNs
Not delegate: “to do on your own or not share the tasks”
• give meds, change in status, receive new meds, new admission, teaching
What are essential steps the nurse should do prior to performing any skill on a patient?
-AIDET
A-Acknowledge (greet the patient)
I- Introduce yourself
D- duration of assessment
E- explain the procedure
T- thank you
-Hand hygiene and provide privacy
-Identify your patient using name and DOB
-Assess allergies
-Assess pain
-Determine level of consciousness (LOC)
What are principles related to HIPAA?
• Patients’ privacy, who the patient give right to have his information
• Patient information can be used or disclosed by a health plan, provider
• HIPAA enables patients to find out how their information may be used and how it has been disclosed
• gives patients the right to examine and obtain a copy of their own health records and to request corrections.
What is HIPAA?
• Health Insurance Portability and Accountability Act
• Focuses on Patient Health Information
• Stipulates how healthcare workers can share information
A major component of the Health Insurance Portability and Accountability Act (HIPAA), the Privacy Rule, was introduced to promote the use of standard methods of maintaining the privacy of protected health information (PHI) among health care agencies.
Nursing Process
Review the steps in the nursing process. Be prepared to interpret a scenario/situation to determine the corresponding step in the nursing process.
• Assessment: gather all subjective and objective data
• Diagnosis: NANDA, nursing diagnosis for actual problems,
Potential problems, or risk for problems.
• Outcome identification: SMART goals for pt (patient)
• Planning: nurse/pt make a plan to achieve the goal
• Implementation: how the nurse will put the plan into action &
Interventions
• Evaluation: was the goal met and what needs to be adjusted
Consider nursing diagnoses that are applicable to a given situation/scenario.
Infection Prevention and Control What is the difference between clean (aseptic) and sterile technique?
• Clean is the routine hand hygiene, drying and use of nonsterile gloves, it uses for taking blood, examining patients, and feeding patients.
• Sterile techniques used for surgery and invasive procedures with high rates of infection. It involves
surgical hand rub with long actin antiseptic, dry hands with sterile towel, sterile field (gown, mask, gloves, supplies), skin prep, a dedicated room.
• While clean means free from marks and stains, sterile goes even further and is free from bacteria or
microorganisms
• Sterile: No SPORES or microorganisms
What are examples of skills and procedures that should be performed using clean technique? Sterile technique?
1. During procedures that require intentional perforation of the patient’s skin, such as insertion of
peripheral IV catheters or a central intravenous line.
2. when the integrity of the skin is broken as a result of trauma, surgical incision, or burns
3. during procedures that involves invasive procedures such as insertion of a urinary catheter or surgical instruments into sterile body cavities such as insertion of a wound drain
List strategies/interventions that may prevent infection transmission.
• Standard precaution (wash hands, gloves) => apply when contact with blood, body fluid, non-intact skin, and mucous membrane.
• Hand hygiene is the most effective basic technique in preventing and controlling the transmission of infection.
What are principles associated with creating and maintaining a sterile field?
consider the 2.5cm (1 inch) around the sterile gloving contaminated
must be waist level
What is PPE?
PPE: Personal protective equipment for protection against exposure to infectious materials. This includes gloves, mask, goggles, hair net and gown.
Removal: gloves comes off first, then gown, mask, head pieces, and first thing that goes on
Standard precautions: handwashing
What are the different types of isolation precautions and considerations are associated with each type?
• Standard precautions should be used in all settings and it includes hand washing, when hands are visibly soiled used antibacterial soap and water, when not visibly soiled use hand
sanitizer or hand rub and it must be 60% and above alcohol
• Airborne - smaller than 5 microns. Negative air pressure, 6-12 exchanges using HEPA filter, N95 respirator, mask, private room. Measles, Tuberculosis and
Varicella (chicken pox)(MTV)
• droplets - larger than 5 microns. private room or cohort, mask or respirator
• contact - must have gloves and gown, private room or cohort patients.
• PPE - positive air pressure, private room, 12 and above air exchanges using HEPA filter, mask worn by the patients
Remove gloves, eyewear, gown, then mask (top first then bottom), Removing = Gloves, eyewear, gown and mask.
Why? gloves could be visibly or non-visibly soiled, so get rid of it first, then eye wear or goggles, gown to avoid the contaminants from spreading then mask
Sterile field
● Sterile object remains sterile if touched by another sterile object
● Only objects that are sterile must be placed on a sterile field
● Sterile object is assumed contaminated if it is out of field of vision or below the waist
● A sterile object of field becomes contaminated by prolonged exposure to air. It becomes contaminated with in time
● Sterile surface come in contact with wet surface it becomes contaminated by capillary action
● Fluid flows in the direction of gravity
● The edges of a sterile field or container are considered contaminated
○ (Think of the edges when opening the sterile gloves in lab)
What item should be removed first? Why?
Vital Signs
What are the normal ranges associated with each vital sign?
● Temperature (normal): thermometer (15 min drink/smoke)
○ Body: 36-38 C/ 96.8-100.4 F
○ Oral: 37 C
○ Rectal: 37.5 C (red probe)
○ Axillary: 36.5 C
Core vs. surface (core slightly higher and more accurate)
● Alterations:
Hyperthermia (>39C/102.2F) - Factors: fever, infection, ingesting warm substances, recent smoking, stress, metabolism increases, physical exercise.
Hypothermia (<35C/95F) : Factors: ingesting cold substances, advanced aged and young infants,
● Pulse - number of times a heartbeat is auscultated or a pulsation is palpated in one minute.
○ Assess rate, rhythm, strength (amplitude), equality
○ Sites for pulse assessment
■ Apical
○ 60-100 bpm, regular
● Pulse ox:
○ 95% +
● Respirations
○ 12-20, regular and deep
○ No accessory muscles
○ Hyperventilation: Anxiousness, meds (narcotics), sleep
● BP
Temperature
• Axillary or armpit is 97.7
• Oral temperature is 98.6
• rectal temperature is 99.5
• normal core body temperature range is 98.6 to 100.4
Oxygen Saturation above 95%-100%
Respiration is between 12-20 for adults
Blood Pressure is 120/80 bpm normal range but can vary depending on the individual
Pulse Rate is 60-100 beats 3+ full bounding
2+ normal
1+ weak or thready
0+ nonexistent needs doppler technique Rhythm should always be regular
What are the principles and techniques for measuring each vital sign?
Temperature is done using a thermometer and a location in the body
Oxygen Saturation is done using a pulse oximetry
Respiration is done through inspection of the patients chest movements during inhalation and exhalation
Blood Pressure is done using a BP cuff, inspection to see the needle move, palpation for the radial or brachial pulse and auscultation to listen to the sounds
○ Systolic: < 120
○ Diastolic: < 80
○ PP: 30-50
○ Causes: age (up), exercise, stress, pain
● Capnography
○ 35-45
Pulse Rate is done using palpation using 2 fingers and auscultation to listen to the apical pulse -5th intercostal space to the left
Activity and Exercise
What should the nurse include in a teaching session to a client who is using a gait belt/cane/walker/crutches for the first time?
Crutch fitting
● Have patient stand upright, shoulders relaxed, shoes on.
● Adjust the length of crutch and handle
○ Crutch pads: 2-3 finger lengths from axilla [Show Less]