PN1 Final Exam Review
Module One & Two:
The nurse is responsible for all tasks that are delegated.
5 rights of delegation:
• Right task: The task is within the UAP's scope of practice and competence.
• Right circumstances: The patient care setting and resources are appropriate for the delegation.
• Right person: The UAP is competent to perform the delegated task or activity.
• Right communication: The nurse provides a clear and concise explanation of the task or activity, including
limits and expectations.
• Right supervision: The nurse appropriately monitors, evaluates, intervenes, and provides feedback on the
delegation process as needed.
Do not delegate what you can EAT: Evaluate Assess Teach
Know the 6 ethical principals that nurses should use and examples of them:
1. Autonomy – self management (person suffers an accident and doesn’t want extra measures)
2. Beneficence – doing good for the patient (nurse & patient decide on post op care together)
3. Nonmaleficence – avoiding things that may cause harm
4. Fidelity – keeping the nurses promise to give care
5. Veracity – telling the truth (telling the truth when one makes an error)
6. Justice – ensuring the equal and fair treatment of all patients (If someone lies about an error)
RESCUE PULL PIN
ALARM AIM HOSE
CONFINE SQUEEZE
EXTINGUISH SWEEP
SBAR Communication: Situation Background Assessment Recommendation
, Team STEPPS
• CUS words: State “I’m concerned; I’m uncomfortable; I don’t feel safe”
• Check backs: Restate what a person said to verify understanding by everyone.
• Call outs: Shout out important information for all team members to hear at one time.
• Two-challenge rule: State a concern twice; if ignored follow facilities chain of command.
Mass Casualty Triage
• RED – Emergent needing immediate attention (Class I)
• YELLOW – Can wait short time for care (Class II)
• GREEN – Non-urgent or “walking wounded” (Class III)
• BLACK – Expected to die or are dead (Class IV)
Common Complications of Decreased Mobility:
Physiological Psychological
Pressure ulcers Depression
Osteoporosis Changes in sleep/wake cycle
Constipation Sensory deprivation
Weight loss/gain
Muscle atrophy
Atelectasis
Osteoarthritis: Disease Process: Risk factors: Diagnostics: ESR labs, Xrays, MRI, CT
Progressive deterioration Affects weight (Primary) Aging, possible Interventions: NSAIDS, Muscle
and loss of cartilage and bearing joints, genetics, weight baring relaxants, opioids (tramadol), rest,
bone in one or more hands, spine joints exercise, hot/cold application, weight
joints Secondary) obesity, control, joint replacement surgery
S&S: pain, trauma, occupation,
*Most common arthritis stiffness, metabolic diseases, blood
and major cause of immobility, disorders
impaired mobility and enlarges nodular
disability
joints,
Gout: a systematic S&S: swollen, Risk factors: Diagnostics: Serum Uric Acid Level
disease in which painful joints (Primary) most common; (above 6.5 indicates gout)
urate crystals deposit purine metabolism errors, X- Interventions:
in the joints, causing linked trait (acute) Colchichine, NSAIDS
inflammation (Secondary) Hyperuricemia; (chronic) Allopurinol, Febuxostat
uric acid in the blood; Low purine diet (meat, shellfish)
caused by another risk Avoid aspirin and diuretics
factor Decrease stress
such as renal failure
Lyme’s Disease: S&S: Risk factors: Diagnostics: ELISA and Western
systemic infectious (stage 1) flu like, Situations where a tick bite blot test
disease caused by bulls’ eye lesion is likely; heavily wooded Interventions: antibiotic therapy;
spirochete borrelia (stage 2) cardiac areas doxycycline or amoxicillin
burgdorferi, results issues, dizziness
from a bite from a deer (stage 3) chronic
tick complications;
arthritis
, Fibromyalgia: chronic S&S: fatigue, sleep Risk factors: Interventions: regular sleep pattern, limit
pain syndrome disturbances, most commonly seen in caffeine and alcohol, anticonvulsants,
numbness/tingling, women ages 30-50 SNRI’s, Tricyclic antidepressants,
odor sensitivity, Tramadol, NSAIDS, physical and
headaches, jaw pain integrative therapy
Scoliosis: lateral spinal S&S: uneven Diagnostics: Adam’s bending
deformity pant/shirt length, forward test
pain Interventions: Milwaukee Brace, surgery
Kyphosis: posterior S&S: hunchback Interventions: brace, spinal infusion
curvature of the thoracic
spine
Osteoporosis: chronic S&S: back pain, Risk factors: Diagnostics: DEXA
bone loss diseases constipation, heigh Alcohol
decrease, humped Corticosteroid use Interventions: exercise, diet high in
back, fractures Calcium low calcium Vitamin D Fiber and Protein,
Estrogen low avoid alcohol and smoking, avoid fall
Smoking risks, Biphosphates
Sedentary lifestyle *40mg daily for 3 months, EMPTY
stomach with 6-8oz water, no food
30
min after, do not lie down for 30 min
Osteomyelitis: bone S&S: fever, malaise, Risk factors: Diagnostics: bone culture, CBC, needle
infection swelling, purulent Malnourished, elderly, aspiration
drainage, overweight, injection drug Interventions: IV antibiotic
tachycardia use therapy, immobilize body part
Piaget’s Disease: S&S: hip pain, deep Diagnostics: increase in ALP, x ray, bone
increased bone arching, warm to the scan
absorption leading to touch Interventions: limiting complications
compensation by
remodeling, leading to
deformities
Osteomalacia: S&S: generalized Risk factors: low vitamin D, Diagnostics: serum calcium, phosphate,
metabolic disease skeletal pain, malabsorption, biliary vitamin D, BUN
causing poor and delated waddling gait system disease Interventions: sunlight exposure,
mineralization of bone Vitamin D supplements, ergocalciferol
cells
Assessing mobility: Preventing decreased mobility: Interventions for decreased mobility:
- Past medical - AROM exercises every - PROM
history two hours - Turn & reposition every
- Family history - Help pump activites 2 hours
- Current - Adequate fluids - Keep skin clean and dry
medications - Evaluation for need of - Adequate nutrition and
Lifestyle ambulatory aids fluid intake
behaviors/occupation - Ambulate with aides
- Encourage deep breathing
- Educate the patient and
their family
A nurse is performing a neurovascular assessment. What should the nurse include in this assessment?
Module One & Two:
The nurse is responsible for all tasks that are delegated.
5 rights of delegation:
• Right task: The task is within the UAP's scope of practice and competence.
• Right circumstances: The patient care setting and resources are appropriate for the delegation.
• Right person: The UAP is competent to perform the delegated task or activity.
• Right communication: The nurse provides a clear and concise explanation of the task or activity, including
limits and expectations.
• Right supervision: The nurse appropriately monitors, evaluates, intervenes, and provides feedback on the
delegation process as needed.
Do not delegate what you can EAT: Evaluate Assess Teach
Know the 6 ethical principals that nurses should use and examples of them:
1. Autonomy – self management (person suffers an accident and doesn’t want extra measures)
2. Beneficence – doing good for the patient (nurse & patient decide on post op care together)
3. Nonmaleficence – avoiding things that may cause harm
4. Fidelity – keeping the nurses promise to give care
5. Veracity – telling the truth (telling the truth when one makes an error)
6. Justice – ensuring the equal and fair treatment of all patients (If someone lies about an error)
RESCUE PULL PIN
ALARM AIM HOSE
CONFINE SQUEEZE
EXTINGUISH SWEEP
SBAR Communication: Situation Background Assessment Recommendation
, Team STEPPS
• CUS words: State “I’m concerned; I’m uncomfortable; I don’t feel safe”
• Check backs: Restate what a person said to verify understanding by everyone.
• Call outs: Shout out important information for all team members to hear at one time.
• Two-challenge rule: State a concern twice; if ignored follow facilities chain of command.
Mass Casualty Triage
• RED – Emergent needing immediate attention (Class I)
• YELLOW – Can wait short time for care (Class II)
• GREEN – Non-urgent or “walking wounded” (Class III)
• BLACK – Expected to die or are dead (Class IV)
Common Complications of Decreased Mobility:
Physiological Psychological
Pressure ulcers Depression
Osteoporosis Changes in sleep/wake cycle
Constipation Sensory deprivation
Weight loss/gain
Muscle atrophy
Atelectasis
Osteoarthritis: Disease Process: Risk factors: Diagnostics: ESR labs, Xrays, MRI, CT
Progressive deterioration Affects weight (Primary) Aging, possible Interventions: NSAIDS, Muscle
and loss of cartilage and bearing joints, genetics, weight baring relaxants, opioids (tramadol), rest,
bone in one or more hands, spine joints exercise, hot/cold application, weight
joints Secondary) obesity, control, joint replacement surgery
S&S: pain, trauma, occupation,
*Most common arthritis stiffness, metabolic diseases, blood
and major cause of immobility, disorders
impaired mobility and enlarges nodular
disability
joints,
Gout: a systematic S&S: swollen, Risk factors: Diagnostics: Serum Uric Acid Level
disease in which painful joints (Primary) most common; (above 6.5 indicates gout)
urate crystals deposit purine metabolism errors, X- Interventions:
in the joints, causing linked trait (acute) Colchichine, NSAIDS
inflammation (Secondary) Hyperuricemia; (chronic) Allopurinol, Febuxostat
uric acid in the blood; Low purine diet (meat, shellfish)
caused by another risk Avoid aspirin and diuretics
factor Decrease stress
such as renal failure
Lyme’s Disease: S&S: Risk factors: Diagnostics: ELISA and Western
systemic infectious (stage 1) flu like, Situations where a tick bite blot test
disease caused by bulls’ eye lesion is likely; heavily wooded Interventions: antibiotic therapy;
spirochete borrelia (stage 2) cardiac areas doxycycline or amoxicillin
burgdorferi, results issues, dizziness
from a bite from a deer (stage 3) chronic
tick complications;
arthritis
, Fibromyalgia: chronic S&S: fatigue, sleep Risk factors: Interventions: regular sleep pattern, limit
pain syndrome disturbances, most commonly seen in caffeine and alcohol, anticonvulsants,
numbness/tingling, women ages 30-50 SNRI’s, Tricyclic antidepressants,
odor sensitivity, Tramadol, NSAIDS, physical and
headaches, jaw pain integrative therapy
Scoliosis: lateral spinal S&S: uneven Diagnostics: Adam’s bending
deformity pant/shirt length, forward test
pain Interventions: Milwaukee Brace, surgery
Kyphosis: posterior S&S: hunchback Interventions: brace, spinal infusion
curvature of the thoracic
spine
Osteoporosis: chronic S&S: back pain, Risk factors: Diagnostics: DEXA
bone loss diseases constipation, heigh Alcohol
decrease, humped Corticosteroid use Interventions: exercise, diet high in
back, fractures Calcium low calcium Vitamin D Fiber and Protein,
Estrogen low avoid alcohol and smoking, avoid fall
Smoking risks, Biphosphates
Sedentary lifestyle *40mg daily for 3 months, EMPTY
stomach with 6-8oz water, no food
30
min after, do not lie down for 30 min
Osteomyelitis: bone S&S: fever, malaise, Risk factors: Diagnostics: bone culture, CBC, needle
infection swelling, purulent Malnourished, elderly, aspiration
drainage, overweight, injection drug Interventions: IV antibiotic
tachycardia use therapy, immobilize body part
Piaget’s Disease: S&S: hip pain, deep Diagnostics: increase in ALP, x ray, bone
increased bone arching, warm to the scan
absorption leading to touch Interventions: limiting complications
compensation by
remodeling, leading to
deformities
Osteomalacia: S&S: generalized Risk factors: low vitamin D, Diagnostics: serum calcium, phosphate,
metabolic disease skeletal pain, malabsorption, biliary vitamin D, BUN
causing poor and delated waddling gait system disease Interventions: sunlight exposure,
mineralization of bone Vitamin D supplements, ergocalciferol
cells
Assessing mobility: Preventing decreased mobility: Interventions for decreased mobility:
- Past medical - AROM exercises every - PROM
history two hours - Turn & reposition every
- Family history - Help pump activites 2 hours
- Current - Adequate fluids - Keep skin clean and dry
medications - Evaluation for need of - Adequate nutrition and
Lifestyle ambulatory aids fluid intake
behaviors/occupation - Ambulate with aides
- Encourage deep breathing
- Educate the patient and
their family
A nurse is performing a neurovascular assessment. What should the nurse include in this assessment?
