STUDY GUIDE FINAL EXAM NR 224
Hello class,
What to Review:
THINK SAFETY FIRST (ALWAYS) AND SEQUENCE
HIPAA
o Provides rights to patients and protects employees
o It protects employees from losing their health insurance when changing jobs by providing
portability
o In the privacy section
o Creates patient right to consent to the use and disclosure of their protected health
information to inspect and copy one’s medical record, and to amend mistaken or
incomplete information
o Limits who can access patient records
o Avoid discussing pt information in public hallways and provide reasonable levels
of privacy when communicating with and about patients in any manner
Delegation
Don’t delegate a task to the LPN or UAP if the task requires TAPE!!
o Teaching
o Assessment
o Planning
o Evaluating
Duties that can be delegated
o Ambulating, turning, bathing, mouth care, linen changes, feeding, vital signs,
weights
Five rights of delegation
o Right task
o Right circumstance
o Right person
o Right direction and communication
o Right supervision and evaluation
Documentation
, Vital Sign Parameters
Expected Temperature Ranges
Oral temperature: 96.8 to 100.4 F average is 98.6 F
Rectal temp: usually 0.9 F higher than oral and tympanic temp
Axillary: temp is usually 0.9 F lower than oral and tympanic
Temporal: are close to rectal, but nearly 1 F higher than oral and 2 F higher than axillary
temp
Hyperthermia:
Abnormally elevated body temperature
Nursing interventions
o Obtain specimens for blood, urine, sputum, or wound cultures
o Assess/monitor WBC counts, sedimentation rates and electrolyte
o Administer antibiotics
o Provide fluids and rest. Minimize activity. Use cooling blanket
o Children and older adults are at particular risk for fluid volume deficit
o Provide antipyretics (aspirin, acetaminophen, ibuprofen) not for kids and
adolescents who have viral illness due to risk of Reyes syndrome
o Prevent shivering as this increases energy demand
o Offer blankets during chills and remove when client feel warms
o Provide oral hygiene
Hypothermia
Less than 95 F
Nursing interventions
o Provide a warm environmental temperature, heated humidified oxygen, warming
blanket, and/or warmed oral or IV fluids
o Keep the head covered
o Provide continuous cardiac monitoring
Hello class,
What to Review:
THINK SAFETY FIRST (ALWAYS) AND SEQUENCE
HIPAA
o Provides rights to patients and protects employees
o It protects employees from losing their health insurance when changing jobs by providing
portability
o In the privacy section
o Creates patient right to consent to the use and disclosure of their protected health
information to inspect and copy one’s medical record, and to amend mistaken or
incomplete information
o Limits who can access patient records
o Avoid discussing pt information in public hallways and provide reasonable levels
of privacy when communicating with and about patients in any manner
Delegation
Don’t delegate a task to the LPN or UAP if the task requires TAPE!!
o Teaching
o Assessment
o Planning
o Evaluating
Duties that can be delegated
o Ambulating, turning, bathing, mouth care, linen changes, feeding, vital signs,
weights
Five rights of delegation
o Right task
o Right circumstance
o Right person
o Right direction and communication
o Right supervision and evaluation
Documentation
, Vital Sign Parameters
Expected Temperature Ranges
Oral temperature: 96.8 to 100.4 F average is 98.6 F
Rectal temp: usually 0.9 F higher than oral and tympanic temp
Axillary: temp is usually 0.9 F lower than oral and tympanic
Temporal: are close to rectal, but nearly 1 F higher than oral and 2 F higher than axillary
temp
Hyperthermia:
Abnormally elevated body temperature
Nursing interventions
o Obtain specimens for blood, urine, sputum, or wound cultures
o Assess/monitor WBC counts, sedimentation rates and electrolyte
o Administer antibiotics
o Provide fluids and rest. Minimize activity. Use cooling blanket
o Children and older adults are at particular risk for fluid volume deficit
o Provide antipyretics (aspirin, acetaminophen, ibuprofen) not for kids and
adolescents who have viral illness due to risk of Reyes syndrome
o Prevent shivering as this increases energy demand
o Offer blankets during chills and remove when client feel warms
o Provide oral hygiene
Hypothermia
Less than 95 F
Nursing interventions
o Provide a warm environmental temperature, heated humidified oxygen, warming
blanket, and/or warmed oral or IV fluids
o Keep the head covered
o Provide continuous cardiac monitoring
