RN comprehensive predictor ATI
Organ donation considerations
- provide support and education to families, ask in a private area
-Be sensitive to cultural and religious considerations
-Maintain life support for vital organ retrieval.
how to promote safety and risk reduction:
1) look for a safety risk ex: hemorrhage
2) Ask what risk it holds to the patient
3)give priority to the risk that poses the most danger to the patient
What are some things that make a patient more at risk for falls?
- older adult, decreased visual acuity, weakness, urinary frequency and gait disturbances,
cognitive dysfunctions such as confusion and certain use of medications such as opioids.
What are ways to decrease falls risk in a client's household?
- remove throw rugs
- keep walking pathways clear
- ensure stairways are light and have handrails
- paint the edge of steps or install a ramp at the end
What is included in standard precautions?
- hand hygiene between all patients
- use gloves when the possibility of touchi
ng bodily fluids
-properly clean all equipment between patient use (some may be one-time use and disposal)
How do you bathe a newborn baby>
- never leave newborn alone in the tub or the sink
- make sure hot water is set at 49 C or less and at least 38C
- avoid drafts or chilling of the newborn by covering with a towel etc
- clean eyes first
- clean rest of the body
- wrap them in a towel and swaddle and wash the babies hair and dry the hair
Healthy people 2020 lifestyle behavior recommendations:
- use stress management techniques
- get adequate sleep and rest
- eat a nutritious diet and maintain a healthy weight
- avoid sat fats
- regular exercise
-while outdoors wear sunscreen between 10am and 4pm
-wear safety gear
- avoid tobacco, illegal drugs and alcohol
-practice safe sex
- seek medical care when needed, get routine screens etc.
, What height should the table be set at for sterile procedures?
It should be waist level
What is the border of a sterile kit?
The inner kit is sterile including the drape except for the one inch border around the
edges (non sterile). When you have sterile gloves on be sure to only touch the sterile field
(not the one inch border).
What are some infectious diseases that must be reported?
anthrax, gonorrhea, hepatitis, HIV infection, lymes, malaria, mumps, meningococcal,
pertussis, rabies, rubella, smallpox, TB, typhoid fever, Syphilis
Communicable diseases nursing actions The nurse most report to the proper agency and
maintain proper precautions
.
Nursing care for clients in restraints
: - explain the need for restraints to family and pt
- pad boney prominences
- secure restraints to moveable part of the bed frame
- make sure you can slip 2 fingers between the restraint
- conduct ongoing assessment of VS, skin, circulation, and need for restraints
- offer the patient food and water
- never leave the client alone with the restraints.
Nursing interventions for hypothermia in a newborn.
- Monitor the axillary temperature (normal: 36.5-37.5 C)
- if the temperature is unstable place the infant in a radiant warmer or skin to skin with a
parent
- reassess temp Q hour until stable
How should the nurse document subjective and objective information?
Nurses should document subjective data in quotes or summarize as a patient
statement. Objective data should be descriptive, and includes what the nurse sees, smells,
hears and feels. Document actions that describe behaviors not adjectives. Make sure charting
is accurate, concise, complete, current and organized.
What is sublimination?
This is a defense mechanism for anxiety where an individual unconsciously
substitutes unacceptable feelings or impulses into acceptable forms of expression.
Nursing interventions for a bipolar patient in acute mania?
- provide a safe environment
- Assess for suicidal thoughts and escalating behavior
- decrease stimulation
- follow agency protocols for protection (restraints, seclusion, etc)
- implement frequent rest periods
- provide outlets for physical activity
Organ donation considerations
- provide support and education to families, ask in a private area
-Be sensitive to cultural and religious considerations
-Maintain life support for vital organ retrieval.
how to promote safety and risk reduction:
1) look for a safety risk ex: hemorrhage
2) Ask what risk it holds to the patient
3)give priority to the risk that poses the most danger to the patient
What are some things that make a patient more at risk for falls?
- older adult, decreased visual acuity, weakness, urinary frequency and gait disturbances,
cognitive dysfunctions such as confusion and certain use of medications such as opioids.
What are ways to decrease falls risk in a client's household?
- remove throw rugs
- keep walking pathways clear
- ensure stairways are light and have handrails
- paint the edge of steps or install a ramp at the end
What is included in standard precautions?
- hand hygiene between all patients
- use gloves when the possibility of touchi
ng bodily fluids
-properly clean all equipment between patient use (some may be one-time use and disposal)
How do you bathe a newborn baby>
- never leave newborn alone in the tub or the sink
- make sure hot water is set at 49 C or less and at least 38C
- avoid drafts or chilling of the newborn by covering with a towel etc
- clean eyes first
- clean rest of the body
- wrap them in a towel and swaddle and wash the babies hair and dry the hair
Healthy people 2020 lifestyle behavior recommendations:
- use stress management techniques
- get adequate sleep and rest
- eat a nutritious diet and maintain a healthy weight
- avoid sat fats
- regular exercise
-while outdoors wear sunscreen between 10am and 4pm
-wear safety gear
- avoid tobacco, illegal drugs and alcohol
-practice safe sex
- seek medical care when needed, get routine screens etc.
, What height should the table be set at for sterile procedures?
It should be waist level
What is the border of a sterile kit?
The inner kit is sterile including the drape except for the one inch border around the
edges (non sterile). When you have sterile gloves on be sure to only touch the sterile field
(not the one inch border).
What are some infectious diseases that must be reported?
anthrax, gonorrhea, hepatitis, HIV infection, lymes, malaria, mumps, meningococcal,
pertussis, rabies, rubella, smallpox, TB, typhoid fever, Syphilis
Communicable diseases nursing actions The nurse most report to the proper agency and
maintain proper precautions
.
Nursing care for clients in restraints
: - explain the need for restraints to family and pt
- pad boney prominences
- secure restraints to moveable part of the bed frame
- make sure you can slip 2 fingers between the restraint
- conduct ongoing assessment of VS, skin, circulation, and need for restraints
- offer the patient food and water
- never leave the client alone with the restraints.
Nursing interventions for hypothermia in a newborn.
- Monitor the axillary temperature (normal: 36.5-37.5 C)
- if the temperature is unstable place the infant in a radiant warmer or skin to skin with a
parent
- reassess temp Q hour until stable
How should the nurse document subjective and objective information?
Nurses should document subjective data in quotes or summarize as a patient
statement. Objective data should be descriptive, and includes what the nurse sees, smells,
hears and feels. Document actions that describe behaviors not adjectives. Make sure charting
is accurate, concise, complete, current and organized.
What is sublimination?
This is a defense mechanism for anxiety where an individual unconsciously
substitutes unacceptable feelings or impulses into acceptable forms of expression.
Nursing interventions for a bipolar patient in acute mania?
- provide a safe environment
- Assess for suicidal thoughts and escalating behavior
- decrease stimulation
- follow agency protocols for protection (restraints, seclusion, etc)
- implement frequent rest periods
- provide outlets for physical activity
