exam 4 Flashcards
(127 cards)
1
Q
What is the definition of delegation?
A
transferring responsibility for the performance of an activity or task while retaining accountability for the outcome
2
Q
who wrote the definition for delegation?
A
ANA
3
Q
What are questions the nurse should ask themselves before delegating a task to someone else?
A
Is it safe for patient and staff? Have they been trained to do it? Who is the safest person for the skill?
4
Q
what are advantages to delegation?
A
improved efficiency, productivity, and job enrichment
5
Q
What are the 5 rights of delegation?
A
right task, right circumstances, right person, right direction/ communication, right supervision
6
Q
What does right task mean when referring to delegation
A
nothing is done out of scope
7
Q
What does right circumstance mean when referring to delegation
A
safety for staff and patient
8
Q
What is closed-loop communication?
A
feedback from our team once we delegate them a task
9
Q
What is direct delegation/
A
assigning a task
10
Q
What is indirect delegation
A
approved list of activities or tasks for someone else
11
Q
Example of indirect delegation
A
CNA’s taking vital signs q 4 hours as apart of their scope
12
Q
If a CNA takes a blood pressure and forgets to tell the nurse it is very low, whose responsibility is this?>
A
the nurses
13
Q
What can we delegate to unlicensed assistive personnel>
A
vital signs, bathing, feeding, ambulation
14
Q
What can we delegate to licensed practical nurse?
A
for exam, we are the same
15
Q
What can we delegate to ancillary personnel/
A
answering calls, bringing juice (remember they cannot touch the patient)
16
Q
are ancillary personnel allowed to touch patients
A
NO
17
Q
What can we delegate with other registered nurses
A
checking insulin, verifying meds, wasting meds
18
Q
If our patient is a two max assist, can we send UAP alone?
A
no
19
Q
If someone is combative, should we enter their room alone
A
NO
20
Q
Is pain objective or subjective?
A
subjective always
21
Q
T or F? Clients who abuse substances overreact to discomforts
A
false
22
Q
T or F? Administering analgesics regularly leads to drug addiction?
A
F
23
Q
T or F: the amount of tissue damage in an injury accurately indicates pain intensity?
A
False
24
Q
Health care personnel are the best authorities on the nature of a clients pain. T or F?
A
false (best authority is the patient followed by their families)
25
Chronic pain is all psychological. T or F?
false
26
Clients who cannot speak cannot feel pain. T or F
false
27
What is onset and duration of pain?
when it started/reoccurs and how long it lasts
28
What is location of pain?
where pain is occuring
29
What are intensity of pain examples?
if pain is mild/severe/moderate
30
What are quantity of pain examples?
0/10 (numeric)scale, Faces scale, FLACC scale
31
Can intensity and quantity of pain be used interchangeably?
yes
32
What are quality of pain examples?
aching, burning, shooting, stabbing, etc
33
What are patterns of pain examples?
comes and goes, constant, during certain movements
34
What is meant by relief factors of pain?
makes pain subside
35
What is meant by aggravating factors of pain?
makes it worse
36
What is the Wong-Baker faces assessment scale?
set of faces 0-10 to help determine pain
37
Who would benefit from using the Wong-baker faces assessment scale?
children aged 3 and older ; communicating with those who have a language barrier/nonverbal
38
What is the numeric pain scale?
patient ranks their pain on a scale from 0-10
39
What is FLACC pain rating scale?
pain scale used for unconscious patients
40
what does FLACC Stand for?
face, legs, activity, cry, consolability
41
What does A stand for in ABCDE of pain management?
A = ask about pain regularly ; assess systemically
42
What does B stand for in ABCDE of pain management?
B = believe the client and family about pain and what relieves it
43
What is C stand for in ABCDE of pain management
choose pain control options appropriate
44
What does D stand for in ABCDE of pain management ?
delivery interventions in a timely, logical and coordinated fashion
45
What does E stand for in ABCDE of pain management>
empower clients and families, enable them to control their course
46
What is drug tolerance?
body builds up tolerance, need higher dose
47
What is drug addiction
seeking out med/drug regardless of wellbeing or safety. Continues even with the negative impacts to their life.
48
What is drug dependence
getting physical symptoms of abruptly stopping/ withdrawing (ex include being sick/having headaches)
49
If someone experiences dependence and withdrawal, does this always mean they are addicted?
NO
50
What is breakthrough pain?
flare of pain that may happen even during chronic treatment of pain
51
How is breakthrough pain treated?
short - acting opioid treatment
52
What is the reversal agent for opioid overdose?
Narcan/naloxone
53
What is the reversal agent for benzodiazepines?
Romazican/flumazenil
54
How to recognize benzodiazepines?
end in -lam and -pam
55
If our client has a basal dose of 2mg/h and a bolus dose of 0.5 mg q 15 minutes (assume they use it), how many MG would they receive over an hour?
4 mg
56
If our client has a basal dose of 2mg/hr, a bolus dose of 1mg q 10 minutes, and a lockout of 3/hr, how much would they receive over one hour? (assume they use bolus dose as prescribed)
5 mg
57
Examples of major surgeries
open heart and brain
58
Example of a minor surgery
cataracts
59
What are elective surgeries? Give examples
life enhancing, not sustaining ; joint replacement, plastic surgery
60
What are urgent surgeries? Give examples
fix before it gets worse ; appendectomy
61
What are emergency surgeries? Give examples
have to be performed right this second ; ruptured appendix/spleen removal,hemorrhages
62
What are diagnostic surgeries
used to do biopsies and figure things ut
63
What are ablative surgeries?
cutting and removing
64
What are palliative surgeries?
not used to cure but will improve quality of life
65
What are reconstructive / restorative surgeries?
used to reconstruct body parts
66
What are organ procurement / transplant surgeries?
used in organ replacements
67
What are cosmetic surgeries?
used to enhance appearance
68
What are the requirements for someone to be able to sign an informed consent?
over 18, not under influence of drugs are alcohol, not in a coma, do not have Alzheimers or dementia
69
If our patient speaks a different language, can they sign an informed consent?
Yes if they meet all other qualifications and we MUST get an interpreter
70
If our patient cannot read or write, can they sign an informed consent?
yes, we must meet them at their needs
71
If our patient has Alzheimers or dementia, can they sign an informed consent
NO
72
Can a client revoke their signature for informed consent?
Yes
73
If our patient backs out last second from surgery after signing consent, what should the nurse do?
inform the surgeon so he can go talk to her
74
What is general anesthesia?
loss of all sensations and consciousness
75
Do patients control their own airway under general anesthesia?
No
76
What is regional anesthesia?
loss of sensation in a certain body area (ex. epidural)
77
What is local anesthesia?
smallest area affected; loss of sensation at a site
78
Examples of when local anesthesia may be needed?
tooth filling, receiving stitches
79
What is conscious/ moderate sedation?
used for procedures not requiring complete anesthesia. Patient controls own airway
80
Which anesthesia has the lowest risk of reaction
local
81
What anesthesia has the highest risk of complications
conscious sedation
82
What should we keep next to our patient on moderate sedation
crash cart
83
How do we monitor our client receiving conscious sedation?
make sure they are maintaining their own airway
84
What do we do if our client on conscious sedation begins to go too far under?
administer O2 and create an airway (will require a breathing tube)
85
What is paralytic ileus?
we are having no peristalsis; complication of surgery
86
Nursing interventions for paralytic ileus?
listen to bowel sounds, ask "When was your last bowel movement" "did you pass gas?"
87
How can we prevent DVTs after surgery?
administer lovanox and apply SCDs / compression stockings
88
How can we prevent post -op PNA
IS, coughing, deep breathing,early ambulation
89
What is the role of the circulating RN?
maintaining safety of the client by monitoring sterile fields, making sure everyone is on the same page, and watching monitors
90
How many counts must be done before closing a patient?
minimum of 3
91
What is malignant hyperthermia?
occurs during or after surgery. Patient gets hot, tachycardia, shake uncontrollably
92
What can we give to treat malignant hyperthermia?
dantrolene (muscle relaxer)
93
a patient is having knee arthroplasty. Their vital signs are 86/40 after receiving midazolam (versed). What does the nurse suspect to be administered?
500 ML NS bolus
94
What is delirium
short term and reversible confusion
95
What is dementia
long term confusion, diagnosis before going into OR
96
What is the most dangerous adverse effect of inhaled anesthesia?
malignant hyperthermia
97
common opioids used during surgery>
morphine, fentanyl
98
Common anesthetic used during srugery
propofol (diprivan)
99
Common benzodiazepines used during surgery?
versed, valium, lorazepam
100
A score of ____ on the aldrete tool will allow discharge from the PACU?
8
101
What is considered as hypotension?
90/60
102
What is within normal range for blood pressure?
120/80 and less
103
What is considered hypertension?
less than 180/100
104
What is hypertensive crisis?
over 180/100
105
Patient education for someone on lisinopril (or other HTN meds)
take at same time q day, do not stop taking, do not skip doses (even if levels are normal)
106
What food education should we provide our clients on HTN medication
avoid high processed foods, fresh and frozen vegetables are better, potassium depending on what type of diuretic it is
107
If they are taking thiazides and loop diuretics, what should recommend our patient take?
potassium supplement or eat high potassium foods
108
Example of loop diuretic?
furosemide
109
Example of thiazide diuretic?
HCTZ (hydrochlorothiazide)
110
Example of potassium sparing diuretic/
spironolactone, amiloride
111
What are potassium rich foods we should encourage our client to eat on potassium wasting diuretics?
potatoes, bananas
112
Those taking spironolactone or amiloride for HTN should avoid?
potassium rich foods,potassium salt substitutes
113
IF our patient drinks wine at night, what time should they take their BP meds
in the morning
114
What are reversible/modifiable risk factors/
diet, exercise, alcohol consumption, smoking, lifestyle
115
What are irreversible/non-modifiable risk factors
gender, age, genetics, family history
116
What are lifestyle changes we can encourage our client with HTN to change?
amount of stress, low sodium, smoking cessation
117
What is sensory overload?
when too much is happening around our patients
118
What can cause sensory overload?
monitors, lights, people coming in and out, monitors, sounds
119
How can we prevent sensory overload?
turn off lights, turn down monitors, cluster care, limit visitors
120
What is sensory deprivation
not enough stimulation
121
How can we prevent sensory deprivation?
clocks, paintings, TV, pet therapy
122
What symptoms can occur from sensory deprivation?
depression, hallucinations
123
What symptoms can occur from sensory overload?
lack of sleep
124
If our client has impaired vision, what should we implement?
clock method for meal tray, declutter floor and lines
125
If we make changes to our patients room to accommodate them, we should
make them aware of the changes and tell them when we move it back
126
If our patient is hard of hearing/ has hearing loss, we should
face them, get on their level, do not scream (talk normally)
127
If our patient is deaf, we should?
find out their best means of communication; have interpreter ready and face them in case they read lips
