Hip arthroplasty
The nurse should implement foam wedge between legs to prevent dislocation
Because the muscle surrounding the hip joint has been cut to expose and replace the diseased joint
clients are at risk for hip dislocation
Proper body alignment after total hip arth
Venous thromboembolism
Wearing elastic stockings or a sequential compression device (SCD) will help prevent another complication, venous thromboembolism
To prevent venous thromboembolism, the nurse should also teach leg exercises; encourage fluid intake; observe for redness, sw
Monitor for shortening of the affected leg with Hip arthoplasty
Monitoring for shortening of the affected leg is a nursing action that identifies dislocation
Signs of dislocation include shortening of the extremity
pain and external rotation of the extremity
These findings should be reported immediately
The nurse shou
A major complication of total hip replacement
A major complication of total hip replacement is subluxation (partial dislocation) or total dislocation
In addition to preventing adduction, the client should avoid flexing the hips more than 90�, not 60�
The nurse should use diagrams or demonstrate corre
continuous quality improvement (CQI) program
to review the events leading up to each medication administration error
The purpose of CQI is to evaluate outcomes of care based on standards of practice
In CQI, once a problem is identified, data collection and analysis should take place before interveni
Remove an NG tube
( always very order before removal of the NG tube)
- Discontinuing a NG tube requires a provider order Therefore, confirmation of an order would be a priority before removal of the tubeNasogastric tubes can be used to provide enteral nutrition, to administer medication, and to provide gastric decompressio
sanguineous
Sanguineous drainage is bright red and indicates active bleeding
serosanguineous
Serosanguineous drainage is pink (light red), watery, and a mixture of serum and blood
Iron
Food sources of iron fall into two categories:
1- heme iron (from lean red meat, poultry, and fish)
2- nonheme iron (from fruit, vegetables, grains, and dried peas and beans)
The body more easily absorbs heme iron
Example:
A nurse is teaching a client who is at risk for iron-deficiency anemia about optimizing her dietary intake of iron. The nurse should explain that which of the following sources of iron is easiest for the body to absorb?
Chicken
Soy Milk
Soy milk is the best choice for this client because soy milk is lactose-free.
The responsibility for the delivery of quality care rests with the staff member who directly provides the care
Individuals have the greatest impact on the perceived quality of care provided to a specific client in any health care organization
The responsibility for the delivery of quality care rests with the staff member who directly provides the care
Individuals have the greatest impact on the perceived quality of care provided to a specific client in any health care organization
The client is considered to be a primary source of information
Information obtained directly from the client (client concern) is the most accurate and provides the best information available to the nurse
The client is considered to be a primary source of information.
NG Tube
Prior to administering an intermittent gastric tube feeding, the stomach should be checked for residual volume
When gastric residual exceeds 100 mL (10 mL for intestinal placement), the nurse should do the following:
- Withhold the feeding
- Notify the pr
NG Tube
It is appropriate to flush the tubing with tap water
The stomach is not considered sterile, so tap water is acceptable
Typically, the tubing is flushed with 30 to 60 mL of tap water (or as prescribed) following each feeding and after administering medicat
Intermittent feeding NG Tube feeding
Intermittent feeding may be done by using a large barrel syringe or feeding bag
The steps in administering intermittent NG tube feedings include the following:
1- Have the formula and a 60-mL syringe prepared
2- Remove the plunger from the syringe
3- Hold
Positioning with Ng feeding
The head of the bed should be positioned at a minimum of 30� elevation to prevent aspiration from reflux during feedings
The greatest risk to a client receiving enteral feedings is injury from aspiration
Therefore, the priority nursing action before initi
acute pancreatitis
After addressing the pain the nurse should:
rest the pancreas and reduce secretion of pancreatic enzymes, oral fluids and food are withheld during the acute phase of pancreatitis
The most effective way to recognize someone's abilities and contributions is through direct, immediate feedback. Direct communication of both positive and negative feedback fosters teamwork
The most effective way to recognize someone's abilities and contributions is through direct, immediate feedback. Direct communication of both positive and negative feedback fosters teamwork
Treatment for alcohol withdrawal
Illusions present the greatest safety risk to the client and are therefore the priority finding
Findings:
- Increased heart rate is a finding that can occur during alcohol withdrawal
- Diaphoresis is a finding that can occur during alcohol withdrawal
- Vi
when nurse sees a change in a client's behavior such as
- Meaningless phrases, worry
A mixture of words or phrases that lack meaning are characterized by loose association in clients who have schizophrenia
It is an indication of disorientation, disorganization, and an alteration in mental cognition
This should
Diminished facial affect
Affect is the outward representation of a person's internal state of being and is an objective finding
A diminished affect could indicate depression, or be seen in clients who have schizophrenia
This should be reported, but it is not the priority
first-degree ankle sprain
A first-degree sprain requires rest, ice, compression, and elevation (RICE)
-The client should rest the ankle, but immobilization is not necessary for a first-degree sprain
Initially, the client may need to avoid weight bearing
-Elevate ankle above the le
first-degree ankle sprain
If the client reports throbbing, discomfort, or the wrap is too tight, the nurse should remove and rewrap the bandage with less stretch
The nurse should begin from the distal point of the extremity (toes) and move toward the proximal point (up the leg) in
Third-degree sprains
Immobilization is indicated for 4 to 6 weeks in
or when severe ligament damage occurs
As a result of a third-degree sprain, arthroscopic surgery may be necessary
Negligence
The nurse's conduct displayed negligence, which is providing client care below the standard of care and placing the client at risk for harm.
Libel
The nurse who is libel uses untrue written communication
Slander
The nurse who slanders uses the spoken word to harm another professional's reputation
Battery
The nurse who uses battery touches a client without permission, which may cause embarrassment or injury
Precipitous labor
Precipitous labor is defined as labor that lasts less than 3 hr from the onset of contractions to the time of birth
Precipitous labor may result from hypertonic uterine contractions, which may increase the risk for placenta abruption
precipitous labor include ( rapid labor)
The most important intervention is preventing injury to the infant during the delivery
Fetal complications from precipitous labor include hypoxia caused by decreased periods of uterine relaxation between contraction
A change in pressure from a rapid deliv
Maternal complications
Maternal complications associated with a precipitous labor can include:
uterine rupture, lacerations of the birth canal, and postpartum hemorrhage
Applying perineal pressure as the fetal head is crowning may decrease maternal tearing and injury
placental
If a precipitous labor results in emergency birth without the provider attending, the placenta can be left in place until the provider arrives
The nurse should never tug on the cord
Signs of placental separation include a slight gush of dark blood, length
Risk for injury when working with clients who have a history of anger and aggression
Avoid wearing necklaces during client care is correct
Know the layout of the facility is
Provide immediate verbal feedback for escalating behavior
Providing immediate verbal feedback for escalating behavior is an effective de-escalation technique
client who is experiencing a seizure
1- Note time and call for help:
2- Calling for help will initiate additional team members to assist and is essential for client safety
3- Position client safely
4- Loosen restrictive clothing
5- Reorient and reassure client
6- Determining precipitating tr
client who is experiencing a seizure
1- Note time and call for help:
2- Calling for help will initiate additional team members to assist and is essential for client safety
3- Position client safely:
4- Loosen restrictive clothing
5- Reorient and reassure
1- Note time and call for help:
When a client experiences a seizure, noting the time is essential because it allows for accurate documentation that may aid the provider in caring for the client
2- Calling for help will initiate additional team members to
client who is experiencing a seizure
Provide client privacy during this time
4- Loosen restrictive clothing
5- Reorient and reassure client
Continue to monitor the seizure (type of seizure; parts of body affected; loss of consciousness; presence of lip smacking, mastication, or grimacing; ro
client who is experiencing a seizure
Seizure precautions include placing the bed in the lowest position, ensuring oxygen and suctioning equipment are available, and placing a saline lock (especially if the client is at risk for a generalized tonic-clonic seizure)
The practice of padding the
The nurses conflicting among themselves to make a client care decision is an example of intrapersonal conflict
Example:
Nurses on the day and night shift are conflicting regarding who should do client daily weights.
The nurses throughout an organization conflicting about length of shifts is an example of intergroup conflict
Example:
Nurses throughout the hospital disagree on having 8-hour shifts or 12-hour shifts
The individual nurse is struggling to make a personal or professional decision, which is an example of intrapersonal conflict
Example:
Nurse Jones is deciding between going to a professional meeting or attending a play
The nurse who is threatened by another nurse may be experiencing bullying, this is an example of interpersonal conflict
Interpersonal conflict arises from differing goals and value system
Example:
Nurse Lee is professionally threatened by Nurse Doe
Change Agent
A change agent organizes and prepare available resources when change is going to occur and informs the staff nurse of the change and education needed, this statement is characteristic of a change agent
A change agent plans ahead for education when a major
Early symptoms of hypoglycemia
Early symptoms of hypoglycemia include sweating, irritability, anxiety, tachycardia, and hunger
Late symptoms include weakness, fatigue, confusion, and seizures. TIRED is an acronym for early signs: tachycardia, irritability, restlessness, extreme hunger,
Acute glomerulonephritis
Acute glomerulonephritis is an inflammation of the glomerular capillaries
The expected symptoms include hematuria, decreased urine output, and proteinuria
Clients should consume a diet low in sodium and restrict fluid intake
Cellulitis
Cellulitis is a generalized infection in deep connective tissue with staphylococcus or streptococcus
It is usually a localized inflammation that may enlarge rapidly if not treated
Expected findings include redness, warmth, edema, tenderness, and pain
This
Predetermined
Predetermined is used to distinguish the characteristic for implementing a new standard of care
Delegation involves
responsibility: an obligation to accomplish a task
accountability: accepting ownership for the results or lack of
authority: right to act or empower over others
Remember the steps in the Nursing Process - A Delicious PIE
Remember the steps in the Nursing Process - A Delicious PIE
A = Assessment
D = Diagnosis
P = Planning
I = Implementation
E = Evaluation
RNs cannot delegate the following activities to unlicensed assistive personnel (UAP)
assessment of clients
evaluation of client data
nursing judgment
client/family education/counseling and evaluation
nursing diagnosis/nursing care planning
Licensed Practical or Vocational Nurses (LPN/VN)
assist in implementing a defined plan of care and to perform procedures according to protocol
assessment skills involve collecting data and are directed at differentiating normal from abnormal
may reinforce information that has been given to the client by
Unlicensed Assistive Personnel (UAP)
because they are unlicensed, they have no scope of practice
in general, nursing tasks that may be delegated include non-invasive and non-sterile treatments
assist in a variety of direct client care activities or tasks, e.g., bathing, transferring, ambulat
Five Rights of Delegation
?Right Task
?Right Circumstances
?Right Person
?Right Direction/Communication
?Right Supervision/Evaluation