Capston Exam 1| Home safety summary
Home safety: Planning care for a client who has vision loss -: a.Remove throw rugs, loose carpets.
b. Electrical cord/ extension against the wall behind the furniture
c. Monitor gait
d.Steps/ sidewalks are in good repair
e. Grab bar near toilet/tub, stool riser
f. Non skid mat in tub.shower
g. Shower chair and Bedside commode
h. Proper lightning
Cystic Fibrosis: Priority Assessment for a Group of children -: Assess lung sounds and respiratory status.
12 yr old child has difficulty swallowing secretion
Infection Control: Infectious Diseases to -: Report any communicable diseases (TB, STI, communicable
disease)
Legal Responsibilities: Documenting Admission Data -: Fall risk data, advance directives (living will, POA)
Disorders of the Eye: Evaluating a Client's Understanding of Cataract Removal -: Provider will remove
lens and use replacement lense, sand grains in the eye is normal, wear sunglasses, increase light in room,
prevent IOP, prevent infection, provide pain relief, fall prevention
Crisis Management: Crisis Intervention for Intimate Partner Abuse -: Safety first. Precautions of
safeguard on the client
Delegation and Supervision: Scope of Practice of Registered Nurses -: a. Provide supervision, either
directly or indirectly (assigning supervision to
another licensed nurse)
b. Monitor performance. Intervene if necessary (for unsafe clinical practice).
,c. Provide feedback
d. Evaluate the client and determine the client's outcome status.
e. Evaluate task performance and identify needs for performance-improvement
activities and additional resources.
Facility Protocols: Discovering a Medication Errors -: a. 1st assess client
b. then call hcp
c. Then do an incident report within 24 hrs (AVOID telling client or place in client's chart)
d. Submit to risk manager
Managing Client Care: Evaluating an Assistive Personnel Performance -: a, Assist with breakfast with
client who has vision loss
b. AP can do ADL, feeding without swallow precaution, positioning, routine task, i/o, specimen
collection, vitals (if client is stable)
Continuity of Care: Interventions Promoting Independence -: ● home health nurse: nursing home,
traditional home, assisted living
● -work as part of team, holistic care. nurses, pt, OT, home health aids, social workers and dieticians part
of the care
● -provide skilled assessment, wound care, lab draws, med education, parenteral nutrition, IV fluids &
meds, central line care, urinary catheter insertion and maintenance, coordination of other participants in
health
● -evaluate living environment for safety - older adults= increase fall risk
● -ask about food in home, help with household activities, living alone, support system, set up and
dispense of medications, access to health care
● -encourage clients to be independent and involved
, Legal and Ethical Issues: Respecting Clients Rights -: a. Veracity- honest, justice- being fair, fidelity- loyal/
faithful, beneficence- doing good, nonmaleficence- no harm
b. A voluntarily admitted client has the right to apply for release at any time. This client is considered
competent, and so has the right to refuse medication and treatment.
Managing Client Care: Planning an Audit of Quality Control -: a. Structure audits evaluate the influence
of elements that exist separate from or outside of the client-staff interaction.
b. Process audits review how care was provided and assume a relationship exists between nurses and
the quality of care provided.
c. Outcome audits determine what results, if any, occurred as a result of the nursing care provided.
d. Retrospective audits occur after the client receives care.
e. Concurrent audits occur while the client is receiving care.
f. Prospective audits predict how future client care will be affected by current level of services.
Cancers Disorders: Planning discharge Teaching for a client who is postoperative following a modified
radical mastectomy -: a. D/c teaching includes incision care and drainage tubes. (Drains are usually left
in for 1 to 3 weeks.)
b. AVOID placing her arm in a dependent position.
c. Encourage early arm and hand exercises (squeezing a rubber ball, elbow flexion and extension, and
hand-wall climbing) to prevent lymphedema and to regain full range of motion.
d. AVOID tight clothing.
e. Teach BSE.
f. Report numbness, pain, heaviness, or impaired motor function of the affected arm to the surgeon.
g. Encourage discuss breast reconstruction alternatives with the surgeon (Reconstruction can begin
during the original breast removal procedure or after some healing has occurred, Nipple reconstruction
from labia, abdomen, or inner thigh)
h. Genetic counseling for BRCA 1 and 2
i. Recommendation of bilateral mastectomy, oophorectomy to prevent cancer occurrence. Clients who
do not choose this option should have early, frequent, thorough screening for breast and ovarian cancer.
Acute and Infectious Respiratory Illness: Prioritizing Care for a Group of Children -: PRIORITY s a child
that's drooling, sitting upright with tongue out, stridor (croup can be fatal)
Home safety: Planning care for a client who has vision loss -: a.Remove throw rugs, loose carpets.
b. Electrical cord/ extension against the wall behind the furniture
c. Monitor gait
d.Steps/ sidewalks are in good repair
e. Grab bar near toilet/tub, stool riser
f. Non skid mat in tub.shower
g. Shower chair and Bedside commode
h. Proper lightning
Cystic Fibrosis: Priority Assessment for a Group of children -: Assess lung sounds and respiratory status.
12 yr old child has difficulty swallowing secretion
Infection Control: Infectious Diseases to -: Report any communicable diseases (TB, STI, communicable
disease)
Legal Responsibilities: Documenting Admission Data -: Fall risk data, advance directives (living will, POA)
Disorders of the Eye: Evaluating a Client's Understanding of Cataract Removal -: Provider will remove
lens and use replacement lense, sand grains in the eye is normal, wear sunglasses, increase light in room,
prevent IOP, prevent infection, provide pain relief, fall prevention
Crisis Management: Crisis Intervention for Intimate Partner Abuse -: Safety first. Precautions of
safeguard on the client
Delegation and Supervision: Scope of Practice of Registered Nurses -: a. Provide supervision, either
directly or indirectly (assigning supervision to
another licensed nurse)
b. Monitor performance. Intervene if necessary (for unsafe clinical practice).
,c. Provide feedback
d. Evaluate the client and determine the client's outcome status.
e. Evaluate task performance and identify needs for performance-improvement
activities and additional resources.
Facility Protocols: Discovering a Medication Errors -: a. 1st assess client
b. then call hcp
c. Then do an incident report within 24 hrs (AVOID telling client or place in client's chart)
d. Submit to risk manager
Managing Client Care: Evaluating an Assistive Personnel Performance -: a, Assist with breakfast with
client who has vision loss
b. AP can do ADL, feeding without swallow precaution, positioning, routine task, i/o, specimen
collection, vitals (if client is stable)
Continuity of Care: Interventions Promoting Independence -: ● home health nurse: nursing home,
traditional home, assisted living
● -work as part of team, holistic care. nurses, pt, OT, home health aids, social workers and dieticians part
of the care
● -provide skilled assessment, wound care, lab draws, med education, parenteral nutrition, IV fluids &
meds, central line care, urinary catheter insertion and maintenance, coordination of other participants in
health
● -evaluate living environment for safety - older adults= increase fall risk
● -ask about food in home, help with household activities, living alone, support system, set up and
dispense of medications, access to health care
● -encourage clients to be independent and involved
, Legal and Ethical Issues: Respecting Clients Rights -: a. Veracity- honest, justice- being fair, fidelity- loyal/
faithful, beneficence- doing good, nonmaleficence- no harm
b. A voluntarily admitted client has the right to apply for release at any time. This client is considered
competent, and so has the right to refuse medication and treatment.
Managing Client Care: Planning an Audit of Quality Control -: a. Structure audits evaluate the influence
of elements that exist separate from or outside of the client-staff interaction.
b. Process audits review how care was provided and assume a relationship exists between nurses and
the quality of care provided.
c. Outcome audits determine what results, if any, occurred as a result of the nursing care provided.
d. Retrospective audits occur after the client receives care.
e. Concurrent audits occur while the client is receiving care.
f. Prospective audits predict how future client care will be affected by current level of services.
Cancers Disorders: Planning discharge Teaching for a client who is postoperative following a modified
radical mastectomy -: a. D/c teaching includes incision care and drainage tubes. (Drains are usually left
in for 1 to 3 weeks.)
b. AVOID placing her arm in a dependent position.
c. Encourage early arm and hand exercises (squeezing a rubber ball, elbow flexion and extension, and
hand-wall climbing) to prevent lymphedema and to regain full range of motion.
d. AVOID tight clothing.
e. Teach BSE.
f. Report numbness, pain, heaviness, or impaired motor function of the affected arm to the surgeon.
g. Encourage discuss breast reconstruction alternatives with the surgeon (Reconstruction can begin
during the original breast removal procedure or after some healing has occurred, Nipple reconstruction
from labia, abdomen, or inner thigh)
h. Genetic counseling for BRCA 1 and 2
i. Recommendation of bilateral mastectomy, oophorectomy to prevent cancer occurrence. Clients who
do not choose this option should have early, frequent, thorough screening for breast and ovarian cancer.
Acute and Infectious Respiratory Illness: Prioritizing Care for a Group of Children -: PRIORITY s a child
that's drooling, sitting upright with tongue out, stridor (croup can be fatal)
