NR 452 Capstone Exit
Reviewer (NR452) Exam
(Elaborations)
,Managing Client Care: Action Requiring Intervention During Tracheostomy Suctioning
- Suction 10-15 seconds maximum
- Wait one minute in-between
- When using suction catheter it shouldn’t exceed half of the internal diameter of the
et tube to prevent hypoxia
- Hyperoxygenation
- Have extra tach kit at bedside
- Don’t untie trach collar before tying new ones.
Coordinating Client Care: Planning Care for a Client Following a Stroke
- Immediately obtain a CT – to determine type of stroke
- NPO until Swallow test by ST
- Ischemic : most common, results from a clot blocking or impairing blood flow...deprives
the brain of o2 and nutrients. Alteplase
- Hemorrhagic : increased icp decreased loc , leakage of blood in brain.
Multiple Sclerosis: Priority Referral for a Client Who Has Amyotrophic Lateral Sclerosis
- ALS is a disease of the upper and lower motor neurons characterized
by muscle weakness progressing to muscle atrophy and eventually
paralysis and death. ALS does not involve autonomic changes,
sensory alterations, or cognitive changes.
- Death usually occurs due to respiratory failure within 3 to 5 years
of the initial manifestations. The cause of ALS is unknown, and
there is no cure.
- Maintain a patent airway, and suction and/or intubate as needed.
- Monitor ABGs, and administer oxygen, intermittent positive pressure
ventilation, bilevel positive airway pressure, or mechanical ventilation
as needed.
- Keep the head of the bed at 45°; turn, cough, and deep breathe
every 2 hr; and conduct incentive spirometry/chest physiotherapy.
- Facilitate effective communication (dysarthria) with the use of a
communication board or a speech language therapist referral.
- Assess coping and depression.
- Assess swallow reflex and ensure safety with oral intake. Thicken
fluids as needed.
- Meet nutritional needs for calories, fiber, and fluids. When no
longer able to swallow, provide enteral nutrition as prescribed.
- Use energy conservation measures.
- Address the client's interest in the establishment of advance
directives/living wills.
- PRIORITY RT,PT,OT
,Practice Settings and Nursing Roles in the Community: Identifying the Sequence of Steps
Required for a Home Visit
1. Pre planning – review referral, call pt, plan activities, bring forms, stock bags
2. Initiation- confirm visit, state name hospital that inhibit referral, establish rapport
3. Implementation- vitals, assessment, teaching, hazards, confront client problem
4. Termination – leave contact info, made contract, plan second visit, charting, plan next
5. Post home visit- leave, consult / collab with I team, make referral for family,
stay connected, document.
Legal and Ethical Issues: Caring for a Client Who Is Experiencing Acute Mania and Is in
Restraints
- explain reason/use to family and patient
- assess q2 and check vitals, offer food/fluid, toilet, ROM (offer q 15-30 min)
- pad bony prominences
- use quick-release knot
- must fit 1-2 fingers between body and restraint
- conduct eval and regularly determine if the restraint use needs to
continue or if it can be stopped
-provider must assess the patient within one hour of application
Mobility and Immobility: Evaluating Client Understanding of Crutch Safety
- Begin your step as if you were going to use the injured foot or leg, but
shift your weight to the crutches instead of the injured foot. Your body
swings forward between the crutches. Finish the step normally with
your non-injured leg. When the non-injured leg is on the ground, move
your crutches ahead in preparation for the next step.
- Up with the good, down with the bad food first.
Crutch Instructions
• Do not alter crutch after fitting, Follow the Prescribes crutch gait.
• Support bodyweight at the hand grips with elbows, Flexed at 20
degree to 30 degree.
• Hold the crutches in one hand and grasp the arms of the chair
with the hand for balance while sitting and rising from a chair
• The tripod position is the basic crutch stance, The client should
place the crutches 15 cm(6inches) in front of the 15 cm (6 in) to
the side of each foot to provided a wide base of support
• Crutch gait: Client alternates weight from one leg to the other as
well as on the crutches
• The clients should stand with a straight back, hips, head and neck
and should not place any weight on the axillae
Cane Instructions
, • Maintain two points of support on the ground at all times
• Keep the cane on the stronger side of the body
• Support body weight on both legs
• Move the cane forward 15 to 25 cm ( 6 to 10 inches)
• Next, move the weaker leg forward toward the cane
• Finally, advance the stronger leg past the cane
Musculoskeletal Trauma: Discharge Teaching Following Surgery for Carpal Tunnel Syndrome
- Cant remove wrist band, must have provider order
- warn the patient that it may take up to 4 weeks after surgery to regain full strength
to accomplish tasks.
- Refer to PT / OT
- Cover surgical incision when showering
- Don’t use ointments
- Don’t rub skin
- Ice therapy may be used
Nursing Care and Discharge Teaching: Teaching About Newborn Safety
- Car seat safety : -position newborn rear-facing until 2 years of age
-secure the car seat with the vehicle seat belt
-place the car seat at a 45 degree angle to prevent slumping and subsequent airway
obstruction in the newborn
-retainer clip should be at armpit level
- Crib slats should be no more than 2 and 1/4 in. apart
- Infants should be back to sleep , supine
- Sleep with pacifier to prevent sids.
- Infants should consume 1 to 2 ounces ever 2 – 3 hrs. 8-12 times a day
- 6-8 wet diapers a day
- Bathe clean to dirty, cover body parts not being bathed
Burns: Priority Action to Reduce the Risk of Infection
- The client may need 5,000 calories per day.
- Increase caloric intake to meet increased metabolic demands and prevent hypoglycemia.
- Increase protein intake to prevent tissue breakdown and to promote healing
- Enteral therapy or total parenteral nutrition (TPN) may be necessary due to
decreased gastrointestinal motility and increased caloric needs.
Reviewer (NR452) Exam
(Elaborations)
,Managing Client Care: Action Requiring Intervention During Tracheostomy Suctioning
- Suction 10-15 seconds maximum
- Wait one minute in-between
- When using suction catheter it shouldn’t exceed half of the internal diameter of the
et tube to prevent hypoxia
- Hyperoxygenation
- Have extra tach kit at bedside
- Don’t untie trach collar before tying new ones.
Coordinating Client Care: Planning Care for a Client Following a Stroke
- Immediately obtain a CT – to determine type of stroke
- NPO until Swallow test by ST
- Ischemic : most common, results from a clot blocking or impairing blood flow...deprives
the brain of o2 and nutrients. Alteplase
- Hemorrhagic : increased icp decreased loc , leakage of blood in brain.
Multiple Sclerosis: Priority Referral for a Client Who Has Amyotrophic Lateral Sclerosis
- ALS is a disease of the upper and lower motor neurons characterized
by muscle weakness progressing to muscle atrophy and eventually
paralysis and death. ALS does not involve autonomic changes,
sensory alterations, or cognitive changes.
- Death usually occurs due to respiratory failure within 3 to 5 years
of the initial manifestations. The cause of ALS is unknown, and
there is no cure.
- Maintain a patent airway, and suction and/or intubate as needed.
- Monitor ABGs, and administer oxygen, intermittent positive pressure
ventilation, bilevel positive airway pressure, or mechanical ventilation
as needed.
- Keep the head of the bed at 45°; turn, cough, and deep breathe
every 2 hr; and conduct incentive spirometry/chest physiotherapy.
- Facilitate effective communication (dysarthria) with the use of a
communication board or a speech language therapist referral.
- Assess coping and depression.
- Assess swallow reflex and ensure safety with oral intake. Thicken
fluids as needed.
- Meet nutritional needs for calories, fiber, and fluids. When no
longer able to swallow, provide enteral nutrition as prescribed.
- Use energy conservation measures.
- Address the client's interest in the establishment of advance
directives/living wills.
- PRIORITY RT,PT,OT
,Practice Settings and Nursing Roles in the Community: Identifying the Sequence of Steps
Required for a Home Visit
1. Pre planning – review referral, call pt, plan activities, bring forms, stock bags
2. Initiation- confirm visit, state name hospital that inhibit referral, establish rapport
3. Implementation- vitals, assessment, teaching, hazards, confront client problem
4. Termination – leave contact info, made contract, plan second visit, charting, plan next
5. Post home visit- leave, consult / collab with I team, make referral for family,
stay connected, document.
Legal and Ethical Issues: Caring for a Client Who Is Experiencing Acute Mania and Is in
Restraints
- explain reason/use to family and patient
- assess q2 and check vitals, offer food/fluid, toilet, ROM (offer q 15-30 min)
- pad bony prominences
- use quick-release knot
- must fit 1-2 fingers between body and restraint
- conduct eval and regularly determine if the restraint use needs to
continue or if it can be stopped
-provider must assess the patient within one hour of application
Mobility and Immobility: Evaluating Client Understanding of Crutch Safety
- Begin your step as if you were going to use the injured foot or leg, but
shift your weight to the crutches instead of the injured foot. Your body
swings forward between the crutches. Finish the step normally with
your non-injured leg. When the non-injured leg is on the ground, move
your crutches ahead in preparation for the next step.
- Up with the good, down with the bad food first.
Crutch Instructions
• Do not alter crutch after fitting, Follow the Prescribes crutch gait.
• Support bodyweight at the hand grips with elbows, Flexed at 20
degree to 30 degree.
• Hold the crutches in one hand and grasp the arms of the chair
with the hand for balance while sitting and rising from a chair
• The tripod position is the basic crutch stance, The client should
place the crutches 15 cm(6inches) in front of the 15 cm (6 in) to
the side of each foot to provided a wide base of support
• Crutch gait: Client alternates weight from one leg to the other as
well as on the crutches
• The clients should stand with a straight back, hips, head and neck
and should not place any weight on the axillae
Cane Instructions
, • Maintain two points of support on the ground at all times
• Keep the cane on the stronger side of the body
• Support body weight on both legs
• Move the cane forward 15 to 25 cm ( 6 to 10 inches)
• Next, move the weaker leg forward toward the cane
• Finally, advance the stronger leg past the cane
Musculoskeletal Trauma: Discharge Teaching Following Surgery for Carpal Tunnel Syndrome
- Cant remove wrist band, must have provider order
- warn the patient that it may take up to 4 weeks after surgery to regain full strength
to accomplish tasks.
- Refer to PT / OT
- Cover surgical incision when showering
- Don’t use ointments
- Don’t rub skin
- Ice therapy may be used
Nursing Care and Discharge Teaching: Teaching About Newborn Safety
- Car seat safety : -position newborn rear-facing until 2 years of age
-secure the car seat with the vehicle seat belt
-place the car seat at a 45 degree angle to prevent slumping and subsequent airway
obstruction in the newborn
-retainer clip should be at armpit level
- Crib slats should be no more than 2 and 1/4 in. apart
- Infants should be back to sleep , supine
- Sleep with pacifier to prevent sids.
- Infants should consume 1 to 2 ounces ever 2 – 3 hrs. 8-12 times a day
- 6-8 wet diapers a day
- Bathe clean to dirty, cover body parts not being bathed
Burns: Priority Action to Reduce the Risk of Infection
- The client may need 5,000 calories per day.
- Increase caloric intake to meet increased metabolic demands and prevent hypoglycemia.
- Increase protein intake to prevent tissue breakdown and to promote healing
- Enteral therapy or total parenteral nutrition (TPN) may be necessary due to
decreased gastrointestinal motility and increased caloric needs.
