Airway Management: Discharge Planning for Client Who Has Tracheostomy
1. The dust should be minimized in the clients home, take actions such as not shaking
bedding with client present.
2. The client should receive trach care every 8 hours, including actions such as a fresh
split-gauze tracheostomy dressing.
3. The trach ties should need to be tied a square knot should be used and there should
be one to two finger space between the neck and the tie.
Chp 53 pg 318
Preoperative Nursing Care: Securing Client Belongings
1. The patient will need to remove valuables such as jewelry, dentures, glasses and
prosthetics before surgery.
2. The first option for the patient's valuables is to leave them with family while they are
in surgery.
3. The other option for the patient's valuables is to have the nurse safely store them
before surgery.
Chp 95 pg 640
Managing Client Care: Prioritizing Care for a Group of Clients
1. In prioritizing care for groups of clients, systemic needs should be prioritized over
local.
2. Airway, oxygenation, circulation and potential for disability take priority over other
needs (in that order).
3. Actual problems need to take priority in terms of care for groups of clients over
potential future problems.
Chp 1 pg 5
Managing Client Care: Prioritizing Nursing Care for a Group of Clients
1. Acute problems should take priority over chronic problems.
2. Urgent needs should take priority over non-urgent needs when prioritizing groups of
clients.
3. Unstable findings should take priority over stable findings when prioritizing groups of
clients
Chp 1 pg 6
Professional Responsibilities: Obtaining Informed Consent in an Emergency
1. State laws regulate the guidelines for informed consent in emergency situations.
2. These state laws vary from state to state on how informed consent is obtained in an
emergency.
3. It is the nurse's responsibility to know the state emergency informed consent laws in
the state they practice in.
Chp 3 pg 36
Information Technology: Receiving a Telephone Prescription
1. When receiving a telephone prescription the nurse must repeat the medication's
name, dosage, time or interval, route, and any other pertinent information back to the
provider.
2. The nurse could have another nurse listen to the telephone prescription as a safety
precaution.