lOMoAR cPSD| 66549320
Lecture 11/25/23 Review Comp 2
Nur 283 Comp 2 exam
1. Negligence-failure to provide adequate care; unintentional tort
a. Failure to communicate concerns about elder client who is confused and is being discharged home is an example of negligence
2. Slander- Spoken remarks that cause harm Gossip
3. Assault – threat by words; intentional; intentional tort
4. Battery- act of harm... “base ball bat”; intentional tort
5. Libel- written “library” remarks of harm; intentional
6. Delegation
a. UAP- medical intake, I & O, remind
i. Intervene SHOULD NOT= assisting client who has paracentesis 2 hours ago to get out of bed for 1st time b.
LPN- medical intake, reinforce teaching
i. Asking LPN to obtain cap blood glucose reading on client who is diaphoretic
ii. Which of the following task should Rn delegate to LPN= collection of past medical hx for client who is admitted for
cellulitis
iii. Delegate to LPN reinforce discharge teaching
7. Interdisciplinary conference/ mandatory reporting
a. Police, social services, DCF
i. Detail interview, physical exam, full hx
1. Child S/S neglect - undernourished, dirty, poorly clothed, untreated dental caries
2. Child S/S- physical abuse- spiral fracture, burns bilateral hands, redden welts on back
3. Elder neglect S/S- poor eye contact, exp meds, broken glasses and hearing aids
4. Elder physical abuse S/S= weight loss , dehydration, malnutrition, pressure ulcer, poor hygiene
a. 72 year old who lives w/ daughter and has several pressure ulcers stage 3
b. Substance abuse mom with child
i. Report suspected abuse MUST BE REPORTED
1. Protect client from immediate harm
2. Separately interview client away from suspected abuser
3. Collect, prepare evidence
4. Safety plan, provide info on shelters, safe house
b. PT= gross motor, walking, crutches , cane
i. 2 year old impaired gross motor and fine motor who was just dx with cerebral palsy
c. OT= fine motor and ADLS, feeding, dressing
i. Occupational therapist referral for client who has Parkinson's disease and having trouble performing
activities of daily
living
d. ST= language, communication , DYSPHAGIA
i. Speech therapist , the client who has COPD and has developed dysphagia e. Hospice
i. Hospice care for Pt with terminal cancer and needs assistance with pain management at home f.
Outside public health agency
i. 27 year old who was admitted with confirmed STI 8.
A fib- rapid firing in Atria= RISK FOR CLOTS can lead to MI, PE, CVA,
DVT;
a. HR over 100, irregular, NO P wave , no PR interval
i. Management- anticoags, HEPRIN DRIP (warfarin), beta blockers, cardiac ablation,
digoxin if HR less 60 HOLD; toxic if 2 or more), cardioversion
ii. Treatment - o2, anti-coags, prepare for cardioversion iii. Teaching- dig ( report signs of
toxicity) , warfarin ( INR)
9. Hepatic encephalopathy (liver = removes ammonia, metabolize rx, stores glycogen, produce clotting factors, albumin, bile)
a. Expected – acetone breath, jaundice, elevated enzymes ALT, AST, pruritus, asterixis, twitching arms and legs, confusion, bizarre
behavior
b. Report to HCP- unresponsive, coma, seizure
i. Report to HCP= client who has developed hepatic encephalopathy . It is important to notify hCP of = pupil size from
7mm to 5mm
c. Med- lactulose- get rid of ammonia, K; NO tylenol
, lOMoAR cPSD| 66549320
i. Management-client w/ end stage cirrhosis of the liver with encephopathy intervention to reduce ammonia level= 1 st
reduce intake of protein , 2nd administer lactulose
10. Meds
a. Med not working ...see patient first !!!!!!; no rush to give insulin unless DKA ( IV);
11. Chronic strep infections
a. Swelling sign of sepsis -!!!!!
i. Nurse should assess first=15 year old who has acute post strep glomernephritis and has crackles in the lungs and neck
vein distention
12. IM z- track
a. Ztrack
i. IM- 22-25 length 0.5-1inches; 90 degrees, 1-2mL (in deltoid)= ventral gluteal, Dorso gluteal, deltoid; infants 012months
vastus lateralis; Z track
ii. Max 1ml in deltoid
iii. Hold skin taut with z track method
13. Insertion of IV
a. Correct care = placing cloth between clients skin and tourniquet of older adult
14. Removal of IV
a. Correct care = use of clean gloves to discontinue client IV infusion
15. Blood transfusion procedure
a. Ensure 18-19 gauge IV
b. Inspect blood exp, bubbles ect
c. 2 RN verify blood order patient name
d. VS before and during every 15mins
e. Prime y tubing ; saline 0.9%
f. Prime y tubing with blood
g. Stay at bedside for 15mins take vs every 15mins
i. Nurse is administering unit of packed RBCs what should nurse plant to take = administer over 3 hours
ii. Client develops chills, flushing skin and reports back pain. The newly hired nurse stops the infusion and implements
the following action. Which action requires INTERVENTION (incorrect)= Disposing of blood transfusion bag and tubing
in biohazard bag
16. Clean and sterile specimen collection
a. Sterile
i. Clean gloves open outer wrapping,
ii. Sterile gloves open inner liner,
iii. Maintain 1in border iv. Open flap away from body
v. Maintain waiste level or above, never back to field
vi. Hands never below waist
b. Clean catch specimen
i. “since I am right handed I will use my left hand to spread labia open.”
17. Client 10 rights- know info while in hospital, refuse, know who is managing care, knowledge of alternative treatments
a. “Can I refuse the ECT tomorrow?” You have the right to refused even though you have signed the consent
18. Pediculosis Capitis – LICE= common in children
a. Management - permethrin NIX; pets do NOT need treatment!!!!
b. Education - wash with hot water; seal non washable items in air-tight bags, no sharing combs scarfs ect, vacuum carpets
discard vacuum bag
i. Home instruction =Seal non washable items (toys) in airtight plastic bag for 14 days
19. Dementia - progressive (forgetful)
a. Management- acknowledge & discuss feelings, DO NOT present reality or rationalize, Redirect with activities Least
b. invasive to most invasive- chair alarms, bed alarms first, last use restraints
20. Medication error process
a. First assess patient, second tell DR.( need antidote);Last incident report
i. Which situation requires nurse to complete an incident report = a client has developed phlebitis from IV cath and is
now receiving antibiotics
21. Mass Casuality black , red, yellow , green
a. Black= 60% burns, grey matter exposed, fixed dilated pupils, not breathing
Lecture 11/25/23 Review Comp 2
Nur 283 Comp 2 exam
1. Negligence-failure to provide adequate care; unintentional tort
a. Failure to communicate concerns about elder client who is confused and is being discharged home is an example of negligence
2. Slander- Spoken remarks that cause harm Gossip
3. Assault – threat by words; intentional; intentional tort
4. Battery- act of harm... “base ball bat”; intentional tort
5. Libel- written “library” remarks of harm; intentional
6. Delegation
a. UAP- medical intake, I & O, remind
i. Intervene SHOULD NOT= assisting client who has paracentesis 2 hours ago to get out of bed for 1st time b.
LPN- medical intake, reinforce teaching
i. Asking LPN to obtain cap blood glucose reading on client who is diaphoretic
ii. Which of the following task should Rn delegate to LPN= collection of past medical hx for client who is admitted for
cellulitis
iii. Delegate to LPN reinforce discharge teaching
7. Interdisciplinary conference/ mandatory reporting
a. Police, social services, DCF
i. Detail interview, physical exam, full hx
1. Child S/S neglect - undernourished, dirty, poorly clothed, untreated dental caries
2. Child S/S- physical abuse- spiral fracture, burns bilateral hands, redden welts on back
3. Elder neglect S/S- poor eye contact, exp meds, broken glasses and hearing aids
4. Elder physical abuse S/S= weight loss , dehydration, malnutrition, pressure ulcer, poor hygiene
a. 72 year old who lives w/ daughter and has several pressure ulcers stage 3
b. Substance abuse mom with child
i. Report suspected abuse MUST BE REPORTED
1. Protect client from immediate harm
2. Separately interview client away from suspected abuser
3. Collect, prepare evidence
4. Safety plan, provide info on shelters, safe house
b. PT= gross motor, walking, crutches , cane
i. 2 year old impaired gross motor and fine motor who was just dx with cerebral palsy
c. OT= fine motor and ADLS, feeding, dressing
i. Occupational therapist referral for client who has Parkinson's disease and having trouble performing
activities of daily
living
d. ST= language, communication , DYSPHAGIA
i. Speech therapist , the client who has COPD and has developed dysphagia e. Hospice
i. Hospice care for Pt with terminal cancer and needs assistance with pain management at home f.
Outside public health agency
i. 27 year old who was admitted with confirmed STI 8.
A fib- rapid firing in Atria= RISK FOR CLOTS can lead to MI, PE, CVA,
DVT;
a. HR over 100, irregular, NO P wave , no PR interval
i. Management- anticoags, HEPRIN DRIP (warfarin), beta blockers, cardiac ablation,
digoxin if HR less 60 HOLD; toxic if 2 or more), cardioversion
ii. Treatment - o2, anti-coags, prepare for cardioversion iii. Teaching- dig ( report signs of
toxicity) , warfarin ( INR)
9. Hepatic encephalopathy (liver = removes ammonia, metabolize rx, stores glycogen, produce clotting factors, albumin, bile)
a. Expected – acetone breath, jaundice, elevated enzymes ALT, AST, pruritus, asterixis, twitching arms and legs, confusion, bizarre
behavior
b. Report to HCP- unresponsive, coma, seizure
i. Report to HCP= client who has developed hepatic encephalopathy . It is important to notify hCP of = pupil size from
7mm to 5mm
c. Med- lactulose- get rid of ammonia, K; NO tylenol
, lOMoAR cPSD| 66549320
i. Management-client w/ end stage cirrhosis of the liver with encephopathy intervention to reduce ammonia level= 1 st
reduce intake of protein , 2nd administer lactulose
10. Meds
a. Med not working ...see patient first !!!!!!; no rush to give insulin unless DKA ( IV);
11. Chronic strep infections
a. Swelling sign of sepsis -!!!!!
i. Nurse should assess first=15 year old who has acute post strep glomernephritis and has crackles in the lungs and neck
vein distention
12. IM z- track
a. Ztrack
i. IM- 22-25 length 0.5-1inches; 90 degrees, 1-2mL (in deltoid)= ventral gluteal, Dorso gluteal, deltoid; infants 012months
vastus lateralis; Z track
ii. Max 1ml in deltoid
iii. Hold skin taut with z track method
13. Insertion of IV
a. Correct care = placing cloth between clients skin and tourniquet of older adult
14. Removal of IV
a. Correct care = use of clean gloves to discontinue client IV infusion
15. Blood transfusion procedure
a. Ensure 18-19 gauge IV
b. Inspect blood exp, bubbles ect
c. 2 RN verify blood order patient name
d. VS before and during every 15mins
e. Prime y tubing ; saline 0.9%
f. Prime y tubing with blood
g. Stay at bedside for 15mins take vs every 15mins
i. Nurse is administering unit of packed RBCs what should nurse plant to take = administer over 3 hours
ii. Client develops chills, flushing skin and reports back pain. The newly hired nurse stops the infusion and implements
the following action. Which action requires INTERVENTION (incorrect)= Disposing of blood transfusion bag and tubing
in biohazard bag
16. Clean and sterile specimen collection
a. Sterile
i. Clean gloves open outer wrapping,
ii. Sterile gloves open inner liner,
iii. Maintain 1in border iv. Open flap away from body
v. Maintain waiste level or above, never back to field
vi. Hands never below waist
b. Clean catch specimen
i. “since I am right handed I will use my left hand to spread labia open.”
17. Client 10 rights- know info while in hospital, refuse, know who is managing care, knowledge of alternative treatments
a. “Can I refuse the ECT tomorrow?” You have the right to refused even though you have signed the consent
18. Pediculosis Capitis – LICE= common in children
a. Management - permethrin NIX; pets do NOT need treatment!!!!
b. Education - wash with hot water; seal non washable items in air-tight bags, no sharing combs scarfs ect, vacuum carpets
discard vacuum bag
i. Home instruction =Seal non washable items (toys) in airtight plastic bag for 14 days
19. Dementia - progressive (forgetful)
a. Management- acknowledge & discuss feelings, DO NOT present reality or rationalize, Redirect with activities Least
b. invasive to most invasive- chair alarms, bed alarms first, last use restraints
20. Medication error process
a. First assess patient, second tell DR.( need antidote);Last incident report
i. Which situation requires nurse to complete an incident report = a client has developed phlebitis from IV cath and is
now receiving antibiotics
21. Mass Casuality black , red, yellow , green
a. Black= 60% burns, grey matter exposed, fixed dilated pupils, not breathing
