CFPN D1 (46Q) Individualized Plan of Care Development

Question 1

What is the numerical pain assessment tool used by RNs?

Answer 1

Pain is rated from 0 (no pain) to 10 (the most severe pain imaginable)

This tool is commonly used in clinical settings for pain evaluation.

Question 2

Which pain rating scale combines pictures and numbers for pain ratings for children aged 3 years or older and adults?

Answer 2

Wong-Baker FACES pain rating scale

This scale helps communicate pain levels effectively, especially for those who may have difficulty verbalizing their pain.

Question 3

What does the FLACC scale stand for?

Answer 3

Face, Legs, Activity, Crying, Consolability

This scale is particularly useful for young children and adults who are unable to communicate their pain.

Question 4

True or False: Ratings on a pain scale should be the sole indicator for identifying the severity of pain or the need for medication.

Answer 4

False

Pain ratings should be considered alongside other assessments and clinical judgment.

Question 5

What does the PEG scale measure?

Answer 5

Pain intensity, interference with Enjoyment, interference with General activity

This scale assesses both the intensity of pain and its impact on daily life.

Question 6

The PEG scale provides insight into how the patient is viewing his or her _______

Answer 6

pain.

This reflects the patient’s subjective experience of pain and its effects.

Question 7

What types of liquids are included in clear liquids?

Answer 7

Water, black coffee or tea, carbonated beverages, and fruit juices with no pulp

Alcohol is not included in clear liquids.

Question 8

How long before a procedure can clear liquids be consumed?

Answer 8

Up to 2 hours prior to procedure

Question 9

How long before a procedure can breast milk be consumed?

Answer 9

Up to 4 hours prior to procedure

Question 10

How long before a procedure can infant formula be consumed?

Answer 10

Up to 6 hours prior to procedure

Question 11

How long before a procedure can a light meal be consumed?

Answer 11

Up to 6 hours prior to procedure

Question 12

What types of foods should be avoided at least 8 hours prior to a procedure?

Answer 12

Fried foods, fatty foods, meat

Question 13

What should a thorough patient allergy interview include?

Answer 13

Questions about:
* the type of reaction that occurred
* when the reaction occurred
* how quickly the reaction occurred after exposure
* whether treatment was required
* whether other drugs from the same classification are tolerated
* whether the reaction was life-threatening

This comprehensive approach helps in understanding the patient’s allergy history better.

Question 14

When do most allergic responses occur after exposure?

Answer 14

Within 1 hour of exposure

This timing is crucial for diagnosing and managing allergic reactions.

Question 15

What are examples of non-IgE-mediated allergic reactions?

Answer 15

Gastrointestinal disturbances, drowsiness, and family history of allergic response

These responses do not involve a hyperresponsive immune response.

Question 16

In addition to medications, what else should patients be screened for regarding allergies?

Answer 16

Allergic responses to:
* foods (eg, eggs, bananas, avocado, kiwi)
* antiseptic solutions
* latex

This ensures a comprehensive allergy evaluation.

Question 17

What are culture-specific issues related to substances used in medications?

Answer 17

Substances such as pork and beef that, while not true allergies, should be respected

These issues may affect patient compliance and preferences.

Question 18

What should be done with the results of the allergy history?

Answer 18

Documented and communicated to other health care team members

This ensures coordinated care and awareness among the health care team.

Question 19

Who typically conducts the initial preoperative assessment?

Answer 19

Registered Nurse (RN)

This may be through a face-to-face or phone interview.

Question 20

What is the purpose of the preoperative assessment?

Answer 20

To ensure thorough and accurate evaluation for appropriate nursing diagnoses, patient outcomes, and interventions

This is essential throughout the continuum of care.

Question 21

What key areas should the focus of the preoperative assessment include?

Answer 21

• Medical history, especially comorbidities
• Results of diagnostic and laboratory tests
• Medication history
• Patient’s knowledge of the planned procedure

Question 22

What must be gathered at a minimum during the preoperative assessment?

Answer 22

Essential details including medical history, diagnostic results, medication history, and patient knowledge

This list is not all-inclusive; additional information may be required.

Question 23

What is perioperative care?

Answer 23

Care provided to a patient undergoing an operative or invasive procedure, including preoperative, intraoperative, and postoperative phases.

Perioperative care begins before the patient is brought to the operating room.

Question 24

How many steps are in the nursing process?

Answer 24

Six steps.

The nursing process is a systematic approach to patient care.

Question 25

What is the focus of the nursing process?

Answer 25

Viewing each patient as an individual with unique care needs. ## Footnote This focus is essential for achieving optimal patient outcomes.

Question 26

What is included in the baseline preoperative assessment?

Answer 26

A comprehensive evaluation of the patient's health status and unique needs. ## Footnote This assessment guides the perioperative care plan.

Question 27

What is the importance of reassessing the patient throughout the perioperative experience?

Answer 27

To ensure that care needs are continuously met and to adapt to any changes in the patient's condition. ## Footnote Ongoing assessment is vital for patient safety and effective care.

Question 28

What is Black cohosh commonly associated with?

Answer 28

May cause premature labor or miscarriage. ## Footnote Avoid use in pregnant women.

Question 29

What potential effect do Feverfew, Garlic, Ginger, Ginkgo Biloba, Ginseng, and Vitamin E have?

Answer 29

May increase bleeding. ## Footnote Avoid preoperative use. Have hemostatic supplies available.

Question 30

What are the benefits of Goldenseal?

Answer 30

Aids digestion and regulates menses. ## Footnote May exacerbate hypertension or edema.

Question 31

What serious effects can Goldenseal have?

Answer 31

May potentiate effects of insulin, cause electrolyte imbalances, seizures, respiratory paralysis. ## Footnote Avoid preoperative use.

Question 32

What is a notable effect of Kava kava?

Answer 32

Has sedative effect on motor reflexes and judgment. ## Footnote Potentiates sedatives and hypnotics.

Question 33

When should Kava kava be discontinued?

Answer 33

At least 24 hours preoperatively.

Question 34

What adverse effects can Valerian cause?

Answer 34

May cause headaches, excitability, nausea, and visual disturbance. ## Footnote Long-term use may increase anesthesia tolerance.

Question 35

What may happen if Valerian is suddenly discontinued?

Answer 35

May cause withdrawal symptoms. ## Footnote Taper dose over 1 to 2 weeks preoperatively.

Question 36

What are the two minimum identifiers required for accurate patient identification?

Answer 36

Patient’s name and date of birth ## Footnote These identifiers are essential for ensuring the correct identification of the patient prior to any medical procedures.

Question 37

What should a registered nurse (RN) do to identify a patient?

Answer 37

Introduce themselves and ask the patient to state their name and date of birth ## Footnote This process is crucial for confirming the patient's identity.

Question 38

What individualized patient characteristics may impact completing an assessment?

Answer 38

Patient's age, serious illness, language barrier, cognitive deficit ## Footnote These factors may prevent the patient from being able to respond to identification questions.

Question 39

How can an RN identify a patient who cannot respond themselves?

Answer 39

By using a parent, legal guardian, or matching information on the patient’s identification band ## Footnote This ensures that identification can still be accurately confirmed in challenging situations.

Question 40

What components does the Universal Protocol include for verification?

Answer 40

* The procedure * Informed consent * The operative site * Side or site marking ## Footnote These components are critical to prevent surgical errors.

Question 41

What should the RN do to verify the procedure being performed?

Answer 41

Ask the patient or their legal representative to state the procedure ## Footnote This information is then cross-checked with the surgical schedule and consent form.

Question 42

What additional consent forms should the nurse verify?

Answer 42

* Consent for anesthesia * Administration of blood products * Intraoperative photography * Presence of ancillary persons in the OR ## Footnote Ensuring all relevant consents are in place is vital for patient safety.

Question 43

What is the role of the RN regarding site marking?

Answer 43

Verify that the surgical site has been marked correctly ## Footnote The site mark must correspond with the consent form and the patient's statement about the proposed procedure.

Question 44

Who typically marks the operative site, and how?

Answer 44

The surgeon marks it with their initials using indelible ink ## Footnote This marking is crucial for ensuring that the correct site is operated on.

Question 45

Accurate identification of the patient is a priority during the _______

Answer 45

during all phases of perioperative care. ## Footnote This emphasizes the importance of patient identification in the surgical process.

Question 46

The normal hematocrit for a patient aged 10 years ranges from

Answer 46

34% to 40%.