NCLEX PN CHEAT SHEETS Study Guide, Exams of Nursing

Download NCLEX PN CHEAT SHEETS Study Guide and more Exams Nursing in PDF only on Docsity! NCLEX-PN CHEAT SHEETS Study Guide Positioning Techniques (F) - ✔ Re-position at least 1-2 hours in bed. Every 20-30 mins in a chair. • Clients who have impaired nervous or musculoskeletal systems benefit from routine therapeutic positioning. - At least every 1 to 2 hr in bed. - Every 20 to 30 min if in a chair to prevent skin breakdown over bony prominences. • Tools for repositioning clients - Pillows, foot boots. - Trochanter rolls, sandbags. - Hand rolls. - Hand-wrist splints. - Trapeze bar. - Side rails • All side rails cannot be up or they will be considered a restraint. - Bed boards. - Wedge pillow (abductor pillow). Positions (F) - ✔ High Fowler's: 90 degrees Fowler's: 45-60 degrees Semi Fowler's: 30-45 degrees Supine: On back with head and shoulders on pillow. Prone: Flat on abdomen with head to the side. Allows dorsiflexion of feet. Lateral: Side-lying. Sims': On side halfway between lateral and prone. Trendelenburg: Entire bed is tilted with the head of the bed lower than the foot of the bed. Promotes venous return. Reverse Trendelenburg: Entire bed is tilted with the foot of the bed lower than the head of the bed. Promotes gastric emptying. Assistive Devices (F) - ✔ Wheelchair. Walker: Take a step, move walker, take another step. Cane: Single leg or quad. Keep cane on stronger side of the body. Move cane, move weak leg, move strong leg. Crutches: 2.3.4-point gaits. When ascending stairs, good food then crutches then bad food. When descending stairs, crutches then bad foot then good foot. Splints and Braces (F) - ✔ Primary Nursing Concern: Assessment and prevention of neurovascular dysfunction or compromise. Assess every hour for the first 24 hrs. Every 2-4 hours afterwards. Elevate immobilized extremity higher than the heart. Apply ice for the first 24-48 hrs prn to reduce edema. Circulatory Care (F) - ✔ Perform a comprehensive appraisal of peripheral circulation: peripheral pulses, edema, capillary refill, color, temperature. Monitor degree of discomfort or pain. Protect the extremity from injury. Place extremity in a dependent position. Peripheral Sensation Management (F) - ✔ Monitor for paresthesia: numbness, tingling, hyperesthesia, hypoesthesia. Monitor the fit of bracing devices, prostheses, shoes, and clothing. Administer analgesics prn. Discuss or identify causes of abnormal sensations or sensation changes. Care after Immobilizer Removal (F) - ✔ Move extremity carefully. Support with pillows or other devices until strength and movement return. Exercise slowly with physical therapist. Wearing support stockings or elastic bandages to prevent swelling for lower extremities. Nutrition: Older Adults (F) - ✔ Need the same nutrients but in differing amounts. Number of calories needed is less. 1500 mg/day of Calcium Smell and taste decline. May add more salt to enhance taste (teach about salt subs). Decrease vision makes food prep more difficult. Foods to Eat for Older Adults (F) - ✔ Foods low in saturated fat. Foods high in fiber, like whole-grain breads and cereals. Fruits and vegetables. Moderate amounts of low-fat dairy products. Protein like poultry, fish, beans, and eggs. Foods to Avoid for Older Adults (F) - ✔ Sweets and other foods high in sugar, fat, and calories should be eaten sparingly. Dysphagia (F) - ✔ Occurs with a stroke or other neurological conditions. Aspiration is the first concern, followed by dehydration and malnutrition. Observe for Observe for aspiration or pocketing of food in the cheeks or other areas of the mouth. Observe for signs of dysphagia, such as coughing, choking, gagging, and drooling of food. Maintain the client in semi-Fowler's position for at least 1 hr after meals. Provide oral hygiene after meals/snacks. • Dysphagia refers to difficulty when swallowing. Bio-terrorism Categories (F) - ✔ Category A: Highest priority agents. Risk to national security. Easily transmitted. High mortality rate. Examples - smallpox, botulism, anthrax, and plague. Category B: Second highest priority. Easily disseminated with moderate morbidity and low mortality rates. Examples - typhus and cholera. Category C: Emerging pathogens that could be engineered in the future for mass dissemination. Easily reproduced and/or high morbidity and mortality rates. Examples - hipha virus and hantavirus. Hazardous Material Incidents (F) - ✔ Take measures to protect self and avoid contact. Attempt to identify the hazardous material. Try to contain the material. Hazardous Material Decontamination (F) - ✔ With few exceptions, water is the universal antidote. For biological hazardous materials, use bleach. Wear gloves, gown, mask, and shoe covers. If clothing is contaminated, remove it carefully and slowly. Cleanse skin with gentle soap and water. Do not use an abrasive scrub or strong detergent. Do not shave hairy areas if there is redness or tenderness. Bomb Threaths (F) - ✔ A. When a phone call is received, prolong the conversation for as long as possible. Be alert for background noises and note distinguishing voice characteristics. Ask where the bomb will explode and what time. B. If what appears to be a bomb is found, do not touch it. Clear the areas. Obtain professional assistance. Try to isolate the object as much as possible by closing doors. Notify authorities and key personnel (Police, Director of nursing, Supervisor) C. Remain calm and try not to alarm clients. Body Mechanics (F) - ✔ The coordinated efforts of musculoskeletal and nervous systems to maintain posture, balance, and body alignment. Body alignment (F) - ✔ The relationship of one body part to another body part along a horizontal or vertical line. Body balance (F) - ✔ Achieved when a relatively low center of gravity is balanced over a wide, stable base of support, and a vertical line falls from the center of gravity through the base of support. Coordinated body movement (F) - ✔ An object that is unbalanced has its center of gravity away from the midline and falls without support. Clients who fail to maintain coordinated body movement are unsteady and at risk for falling. Regulation of movement (F) - ✔ Includes movements of the skeletal, muscular, and nervous systems. Gait (F) - ✔ Manner of walking. Friction (F) - ✔ The effect of rubbing or the resistance that a moving body meets from the surface on which it moves. - When moving clients, reduce friction to decrease the risk of skin shearing which occurs when the skin adheres to the bed and the muscles and bones move, as when the client slides down in the bed. Can tear the skin and puts the client at risk for pressure ulcer development. - Have the client bend his or her knees and cross arms across the chest as you assist with re-positioning to reduce friction. - Better to lift than push or drag a client. - For clients requiring maximum assist, use a draw sheet to reduce muscle strain for the nurse and friction for the client (Large clients. Unconscious clients. Immobile clients.) 5 Functions of Bones (F) - ✔ Support. Protection. Movement. Mineral storage. Hematopoiesis (blood cell formation). Joints (F) - ✔ Connection between bones. Ligaments (F) - ✔ White, shiny, flexible bands of fibrous tissue. Bind joints; connect bones and cartilage. Aid in joint flexibility and support. Tendons (F) - ✔ White, glistening, fibrous bands of tissue. Connect muscle to bone. Cartilage (F) - ✔ Non-vascular, supporting connective tissue. Flexibility of a firm, plastic material. Muscles (F) - ✔ Facilitate movement. Determine body form and contour. Proprioception (F) - ✔ The awareness of the position of the body and its parts. Balance (F) - ✔ Controlled by the nervous system, including the cerebellum and the inner ear. Principles of Body Mechanics (F) - ✔ The center of gravity is the center of the mass. Weight is acted on by the force of gravity. To lift an object, the weight of the object must be overcome. When upright, the center of gravity is the pelvis. When anyone moves, the center of gravity shifts. The closer the line of gravity to the center of the base of support, the more stable the client/nurse is. Use hips and abdominal muscles when moving an object. Protect your back. Lifting (F) - ✔ Use major muscle groups to prevent back strain. Distribute weight between large muscles of arms and legs to decrease injury. Flex hips, knees, and back. Keep knees bent and back straightened. Use assistance when needed. Pushing and Pulling (F) - ✔ Widen base of support. Pull object toward center of gravity. If pushing, move one foot forward. If pulling, move the rear leg back for stability. Face the direction of movement when moving a client. Avoid twisting or bending the back. Guidelines to Prevent Injury (F) - ✔ Know your facility policy. Use assistive devices when available (Transfer belt. Hydraulic lift. Sliding board.) Plan ahead by asking for help. Rest between heavy activities to decrease fatigue. Maintain good posture. Exercise regularly (Increase strength. Prevent injury.) Use smooth movements to prevent injuries. Avoid repetitive movements. Older Homes (F) - ✔ Encouraged to have inspections for the presence of lead in paint, dust, or soil. Lead also comes from the plumbing fixtures in a home, clients should have water from each faucet tested. Infection (F) - ✔ The invasion of a susceptible host by pathogens or microorganisms, resulting in disease. Colonization (F) - ✔ When a microorganism invades a host, grows, and/or multiplies, but does not cause disease or infection unless it alters normal tissue functioning - If it can be spread from one person to another, it is referred to as communicable. Nosocomial Infection (F) - ✔ A health care facility acquired infection. Handwashing (F) - ✔ No. 1 way to prevent the spread of infection. - Friction. - Water. - Soap. restraints to be used - The treatment must be prescribed by the provider in writing, based on a face-to-face assessment of the client. - The prescription must include the reason for the restraint, the type of restraint, the location of the restraint, how long the restraint may be used, and the type of behaviors demonstrated by the client that warrant use of the restraint. • The prescription and the renewal are limited to 4 hr for an adult, 2 hr for clients ages 9 to 17, and 1 hr for clients younger than 9 years of age. Prescriptions may be renewed, if needed, with a maximum of 24 consecutive hr. Restraints Monitoring and Interventions (F) - ✔ • Restraints should be removed or replaced frequently - Ensure good circulation to the area. - Allow for full range of motion to the limb that has been restricted. • Safety should be checked and documented every 15 to 30 min based on facility policy. • Bony prominences should be padded and neurosensory checks should be performed every 2 hr to identify neurological or circulatory deficits - Loosening or removing the restraint. - Testing temperature, mobility, and capillary refill. The restraint should be tied to a nonmovable part of the bed frame where it will not tighten when the bed is raised or lowered. • The restraint should be secured using a quick release knot that can be easily untied. • The restraint should be left loose enough for range of motion and with enough room to fit two fingers between the device and the client to prevent injury. • Regularly assess the need for continued use of the restraints to allow for discontinuation of the restraint or limiting the restraint at the earliest possible time while ensuring client safety. • The client should not be left unattended without the restraint. Wound Specimen (F) - ✔ Apply gloves and clean the wound with sterile saline before specimen collection. • Use a culture swab to swab the center of the wound site, collecting as much drainage as possible. • Then, insert the swab into the culture tube without touching the outside of the tube. • After securing the tube's top, transfer the tube into a biohazard bag for transport and perform hand hygiene. Stool Specimen (F) - ✔ Wearing gloves, use clean cup with seal top (does not need to be sterile) and tongue blade to collect small amount of stool. • Using the tongue blade, collect needed amount of feces from client's bedpan. • Transfer feces to cup without touching cup's outside surface. • Dispose of tongue blade. • Seal cup and transfer specimen into clean biohazard bag for transport. • Remove gloves and perform hand hygiene. Urine Specimen (F) - ✔ Apply gloves and use sterile cup to collect 5 to 10 ml of urine. • Place cup or tube on clean towel in the client's bathroom. • If the client has a urinary catheter, use a needleless safety syringe to collect specimen from sampling port on the catheter. (see manufacturer's instructions) • Instruct client on how to obtain a clean voided specimen if not catheterized. • Secure the top of the transfer container, label for transport, and place in a biohazard bag. • Remove gloves and perform hand hygiene. Hazardous Materials Incidence (F) - ✔ • Nurses can be exposed to biological, chemical, or radiation incidents or used as weapons - Anthrax, smallpox, Ebola, pesticides, gases. • Protect self from exposure. • Approach scene or client cautiously. • Locate poison control number or MSD (material safety data) if chemical known. • If possible, decontaminate before entering facility. • Wear gloves, mask, water-resistant gown, and shoe covers. • Place all contaminated items into a large plastic container and seal it. Chain of Infection (F) - ✔ • Causative agent - Bacteria, virus. - Fungus, prion, parasite. • Reservoir - Human, animal. - Water, soil, insects. • Portal of exit - Respiratory tract, Gastrointestinal, Genitourinary. - Skin, mucous, blood, body fluids. • Mode of transmission - Contact, droplet, airborne, vector-borne. • Portal of entry - Same as portal of exit. • Susceptible host - Compromised defense mechanisms. Standard Precautions: Tier 1 (F) - ✔ the most important and should be used with all clients • Gloves. • Handwashing Standard Precautions: Tier 2 (F) - ✔ specific, based on medical diagnosis - For example, different precautions will be used for different diseases, depending on how each disease is transmitted • Contact. • Droplet. • Airborne. Barrier Equipment (F) - ✔ • Gloves - Prevents contamination by direct/indirect contact. Single use only. - Gloves go on after gowns and must be pulled over gown sleeves. • Gowns - Barrier protection against contact with infectious body/blood fluids or waste. Fluid resistant. Ripped gowns should be changed. • Masks - Prevents inhalation of droplet nuclei larger than 5 microns. - Become ineffective if moist or wet. Never reuse. • Particulate respirator - Prevents inhalation of droplet nuclei smaller than 5 microns. - Most commonly used for clients who have tuberculosis (TB). • Eyewear/face shields - Glasses or goggles with side shields to prevent contamination of the eyes from splashing/splattering of secretions. Reverse Isolation/Protective Precautions (F) - ✔ • Used to protect the client from health care workers and others. • Most commonly seen in clients who have: - Cancer. - Immunosuppression from autoimmune disorders • Human immunodeficiency virus (HIV). • Acquired immune deficiency syndrome (AIDS). • Strict hand washing for all persons in contact with client. • Avoid fresh fruits and vegetables. • No fresh flowers, plants, or standing water in room. • Restrict visitors who may be ill. Removal of Protective Equipment (F) - ✔ • Remove gloves - Grasp glove and pull inside out. - Tuck finger of ungloved hand inside cuff of gloved hand, and remove inside out. • Remove eyewear - Remove per agency policy. • Remove gown - Untie waist and neck strings of gown. - Remove hands from sleeves without touching outside of gown and fold inside out. • Remove mask - Untie top string and then bottom strings. - Do not touch outside of mask and dispose immediately in garbage. When not to Perform ROM (F) - ✔ • Hypertensive crisis. • Conditions that result in a higher intracranial pressure. • Preeclampsia. • Other conditions in which stimulation worsens the underlying disease/condition. • Degree of immobility. System Impairments: Respiratory System (F) - ✔ Decreased movement results in decreased oxygenation and stasis of secretions, which can result in atelectasis and pneumonia. • Postoperative clients must be instructed in ways to prevent complications - Coughing and deep breathing. - Adequate hydration. - Timely pain management. - How to splint incisions. • Encourage early ambulation and use of incentive spirometry. • Chest physiotherapy can help loosen secretions for expectoration. • Maintain a patent airway - If clients become too weak to cough, suctioning can be needed to keep airway patent and prevent pneumonia. - Monitor clients for green-yellow sputum production, fever, and pain. System Impairments: Cardiovascular System (F) - ✔ • Complications within the cardiovascular system can include - Orthostatic hypotension. - Decreased cardiac output. - Increased risk of thrombus. • Teach the client to avoid the Valsalva maneuver. • Encourage position changes and leg exercises to prevent deep-vein thrombosis (DVT). • Use elastic stocking(s) to promote venous return - Should be removed and reapplied every 8 hr. • Intermittent pneumatic compression or sequential compression devices (SCDs) are plastic sleeves placed on the legs. - The sleeves are then connected to an air pump that alternately inflates and deflates in a rhythmic motion up and down the legs to promote venous return. System Impairments: Musculoskeletal and Integumentary (F) - ✔ • Musculoskeletal changes - Complications • Muscle atrophy. • Foot drop. • Decreased strength and endurance. • Poor balance. - In addition, disuse osteoporosis, a disorder characterized by bone resorption secondary to immobility, can occur • This condition places clients at risk for pathological fractures. • Integument changes - Immobility increases direct pressure on the skin • Can lead to ischemia or lack of blood flow over bony prominences. • This can cause skin breakdown and pressure ulcer formation. System Impairments: Changes in Metabolism of Carbohydrates, Fats, and Proteins (F) - ✔ • Complications - Decreased metabolic rate. - Decreased protein metabolism. - Calcium resorption. • Pancreatic activity decreases, as does the body's ability to tolerate glucose. • Insulin production is not enough to lower serum glucose levels. - This can happen in as little as 3 days. • As protein is metabolized, nitrogen is produced as an end product - Nitrogen balance provides a reliable indicator of protein use by the body. - A negative nitrogen balance exists when the excretion of nitrogen from the breakdown of protein exceeds intake • Can lead to problems with wound healing and tissue growth. • Results in increased percentage of body fat and the loss of lean body mass. • Monitor - Anthropometric measurements • Body measures of height and weight. • Skin-folds. - Intake &Output. - Electrolytes. - Nutritional intake. - Serum protein and albumen levels. • Be aware anorexia can occur - Encourage a balanced diet plan • Carbs, proteins, and fats specific to the client's needs. - Collaboration with a dietitian can be helpful. System Impairments: Elimination and Psychosocial Condition (F) - ✔ • Elimination - Complications • Renal calculi. • Poor perineal care. • Decreased peristalsis leading to constipation. • Fecal impaction. - Assess bowel sounds frequently. - Monitor I&O, characteristics of stool and urine. - Offer hydration and administer stool softeners as prescribed. • Psychosocial condition - Immobile clients are at risk for sensory deprivation, depression, anxiety, sleep/wake pattern alterations, and ineffective coping. - Provide diversional activities and one-on-one interaction. - Maintain call light within reach. - Encourage family visits. Pain (F) - ✔ • Thought of as the fifth vital sign. • It is a nurse's responsibility to evaluate for pain regularly - Review vital signs. - Evaluate effectiveness of all pain interventions. - Premedicate before starting painful procedures or therapy. • The client's report of pain is the most reliable diagnostic measure Evaluating Pain (F) - ✔ Ask • PQRSTU - P: Palliative or provocative factors • What makes it better or worse? - Q: Quality • How do you describe your pain? - R: Region or radiation • Where does it hurt? Does it spread somewhere else? - S: Severity • How bad is your pain now? (0--10, FACES) - T: Timing • Is your pain consistent, intermittent? - U: Effect of pain • Does it prevent you from doing what you would like to do? Non-pharmacological Pain Relief Interventions (F) - ✔ • Biofeedback - Helps change perception of pain, alter pain, and provide a sense of control. - Is completed with help from a licensed specialist. • Chiropractic • Acupuncture and Acupressure - Vibration or electrical stimulation via tiny needles inserted into the skin and subcutaneous tissues at specific points. • Guided imagery - Focusing on a pleasant thought to divert. • Relaxation/guided imagery - Includes meditation, yoga, and progressive muscle relaxation. • Distraction - Includes ambulation, deep breathing, visitors, television, and music. • Massage. • Therapeutic touch. • Cutaneous stimulation - TENS unit. - Interruption of pain pathways. - Cold for inflammation. - Heat to increase blood flow and to reduce stiffness. • Aromatherapy. Palliative Care (F) - ✔ A management approach for end-of-life issues that prevents, relieves, and eases symptoms without compromising medical interventions. • Recognize that requests for tissue and organ donations must be made by specially trained personnel. Factors Influencing Heat and Cold Tolerance (F) - ✔ • Duration of application (should not exceed 15 to 20 min). • Body part. • Damage to body surface. • Prior skin temperature. • Body surface area. • Age and physical condition. • Temperature of therapy. • Type of application - Moist. - Dry. Heat and Cold Client Education and Safety (F) - ✔ • Use cautiously in: - Older adults. - Clients who have sensory impairment. - Clients who are immobile. - Clients who have diabetes mellitus. - Clients who have nerve damage. • Bony prominences are more sensitive and should be monitored frequently. • No heat application to the abdomen of a pregnant woman. • Cold applications not appropriate for clients who have vascular insufficiency. • Assess site every 5 to 10 min - Redness. - Pain. - Numbness. - Shivering. - Blisters. - Cyanosis. - Pallor. • Discontinue the application if any of the above occur, or remove the application at the predetermined time (usually 15 to 20 min). Applying Heat and Cold Therapy (F) - ✔ The nurse should make sure the provider has written a prescription that includes the following: - Location. - Duration and frequency. - Specific type (moist or dry). - Temperature to use. Heat Therapy (F) - ✔ • Vasodilation - Improves blood flow. • Analgesic effect - Reduces muscle tension. - Eases joint stiffness and pain. • Reduces blood viscosity - Promotes delivery of nutrients and removal of waste. • Increases cell metabolism - Increases nutrients and white blood cells (WBCs) to site. Cold Therapy (F) - ✔ • Vasoconstriction - Reduces blood flow and warmth. • Local anesthetic effect - Reduces blood flow, preventing edema. • Increases blood viscosity - Promotes coagulation. - Decreases bleeding. • Decreases cell metabolism - Reduces inflammation. Moist Heat Therapy (F) - ✔ • Warm moist compress - Improves circulation. - Relieves edema. - Promotes concentration of pus and drainage. - Because heat evaporates quickly, change compress frequently. • Warm soak - Increases circulation. - Lessens edema. - Increases muscle relaxation. - Can be applied with a medicated solution. • Sitz bath - For clients who had rectal surgery, episiotomy during child birth, painful hemorrhoids, or vaginal inflammation. - Only the perineal area is immersed in a warm fluid. - Disposable basin contains an attachment that resembles an enema bag and allows for gradual introduction of warmer water. Moist Cold Therapy (F) - ✔ • Cold moist compresses - Should be applied for 20 min to relieve inflammation and swelling. - Observe for adverse reactions • Burning or numbness. • Mottling of skin. • Redness. • Paleness. • Bluish skin discoloration. • Cold soaks - Decrease inflammation and swelling by submerging affected body part in cold water. Dry Heat Therapy (F) - ✔ • Aquathermia (water-flow) pads - Useful for treating: • Muscle sprains. • Areas of mild edema or inflammation. - Unit consists of a machine filled with distilled water that has a temperature gauge. - Machine connects to a pad that fills with distilled water. • Either hot or cold depending on the temperature setting. - To prevent burning of the skin, cover pad with a pillowcase. - An application should last 15 to 20 min. Dry Cold Therapy (F) - ✔ • Ice bag or collar - Prevent edema formation. - Control bleeding. - Anesthetize a body part. Nail Care (F) - ✔ Nails should be filed straight across to avoid ingrown nails and to prevent nicking the skin - Breaks in skin integrity can lead to infection. - The edges of the nail should be filed. - Inspect nail for fungus, size, shape, and condition. - Extra care should be provided for clients who have diabetes and other conditions that affect circulation Back Massage (F) - ✔ Redness can be a sign of capillary damage and a stage I pressure ulcer - Vigorous rubbing can further break down capillaries and lead to decreased blood flow. - Apply lotion gently to avoid further damage. - Do not rub reddened area. - Reposition client off the red area, document, and monitor. Bed Baths (F) - ✔ Nurses should move from head to toe, moving from least personal to most personal body area (head and face first and perineal care last) - Each body part should move from clean to dirty (arm from wrist to armpit, leg from ankle to groin, perineal area: females front to back and males in a circular motion away from urinary meatus). Complete Bed Baths (F) - ✔ Water should be changed when water becomes too cold or too dirty, or when otherwise needed - The water should be changed before providing perineal care to reduce the risk of urinary tract infection. Care of Older Adults (F) - ✔ Older adult clients have less subcutaneous tissue, are less mobile, and perspire less - They should bathe approximately 3 times per week. - When bathing older client, dry skin is an issue so use bag baths if available instead of soap and water. - You can still use soap and water for dirtier areas. • Position client. • Drape client. • Prepare sterile field - Male • If client not circumcised, retract foreskin. • Clean in circular motion from urethral meatus down to glans three times. - Female • Expose meatus. • Begin cleaning from front to back from far, near, and then over the meatus. • Place catheter - Male • Insert 7 to 9 inches. • If you feel resistance, do not force. • Once you see urine, advance catheter another 1 to 2 inches. • Inflate bulb. • Reduce foreskin if uncircumcised. - Female • Insert 3 inches or until urine begins to return. • Then insert another 1 to 2 inches. • Inflate bulb as recommended by manufacturer. • Secure catheter to leg of client. • Make sure the catheter bag/system is at a level below the client's bladder to avoid reflux. Hygiene and Skin Care for Elimination Devices: Nursing Interventions (F) - ✔ • Wash at the insertion site including the urinary catheter tubing with soap and warm water every shift and after defecation - No vigorous rubbing or alcohol. • Assess skin around device for redness, breakdown, drainage, and odor. • Change tubing and device per provider order or facility policy. • Empty device every 8 hr and as needed. Complications of urinary catheterization (F) - ✔ • The most common complication of urinary catheterization is UTI. • Strategies to prevent UTI - Never lift catheter bag above the level of bladder without clamping tubing. - Use strict sterile technique with catheter insertion. - Cleanse perineal area front to back or away from the urinary meatus. - Direct client to drink 1 to 2 L of fluid per day. - Avoid kinks in the tubing. Catheter Irrigation (F) - ✔ • To maintain the patency of indwelling urinary catheters, it sometimes becomes necessary to irrigate or flush a catheter. • Blood, pus, or sediment can collect within the tubing and result in bladder distension and the buildup of stagnant urine. • When irrigation is performed, sterile aseptic technique should be followed. • Catheter irrigation cannot be delegated. Closed Catheter Irrigation (F) - ✔ - Prepare prescribed sterile solution in sterile graduated cup • Avoid cold solution, which can result in bladder spasms or discomfort. - Clamp indwelling retention catheter just below the specimen port. - Draw sterile solution into syringe using aseptic technique. - Apply gloves, and cleanse injection port with antiseptic swab. - Insert hub of syringe through port at a 30° angle toward bladder. - Slowly inject fluid into catheter and bladder. - Use slow pressure when injecting fluid • Too much pressure can traumatize the urethral or bladder wall. - Withdraw syringe, remove clamp, and allow solution to remain in bladder for ordered time. Urinalysis: Random Nonsterile Specimen (F) - ✔ • Explain the procedure to the client. • Ask the client to urinate. • Put on gloves. • Pour urine into the specimen container. • Label the container with the client's identifying information. • Place container in biohazard bag. • Remove gloves and perform hand hygiene. • Transport or send the specimen to the laboratory. Clean-Catch Midstream for Culture and Sensitivity (C&S) (F) - ✔ • Teach the client the technique for obtaining the specimen. • The urine sample is "caught" midstream after thorough cleansing of the urethral meatus. • The client voids some urine into a commode, bedpan, or urinal; stops, then urinates into a sterile cup. • The client must not place his fingers in the cup or touch the lid. Catheter Urine Specimen for C&S (F) - ✔ • This requires a sterile specimen from a straight or indwelling catheter obtained using surgical asepsis (sterile technique). • Drain the catheter's tubing of urine. • Clamp the catheter's tubing below the port for 20 min. • Use surgical asepsis while withdrawing the required amount from the port with a syringe. • Unclamp the catheter. Timed Urine Specimens (F) - ✔ • These are usually collected for 24 hr but can be ordered for varying times. • Discard the first voiding. • Collect all other voidings in a container placed on ice. • If the client urinates and discards the urine, timing of the specimen must begin again with the next voiding. Factors Affecting Bowel Elimination (F) - ✔ • Age - Decrease in peristalsis. - Esophageal emptying slows. • Diet - Regular daily food intake helps maintain a regular patter of peristalsis in the colon. - Fiber provides the bulk of fecal material. • Fluid intake - Inadequate fluid intake or disturbances resulting in fluid loss (such as vomiting) affect the character of feces. • Physical activity - Physical activity promotes peristalsis. - Immobilization decreases peristalsis. • Personal habits - Most clients benefit from being able to use their own toilet facilities at a time that is most effective and convenient for them. - Chronically ill and hospitalized clients are not always able to maintain privacy during defecation, which can lead to the client ignoring the urge to defecate, thus becoming constipated and uncomfortable. • Psychosocial - Depression decreases peristalsis. • Surgery and anesthesia - General anesthetic agents used during surgery cause temporary cessation of peristalsis. - If client remains inactive or is unable to eat after surgery, return of normal bowel function is further delayed. • Medications - Some medications have expected actions on the bowel • Medications to promote defecation or control diarrhea. - Medications for acute and chronic conditions often have secondary effects on bowel elimination pattern. • Positioning - Immobilized client • Bed bound. • Difficulty defecating. • Pain - Discomfort from surgery. - Constipation. • Pregnancy - Fetus presses on intestine. Constipation (F) - ✔ • Constipation is a symptom, not a disease. • Maintain the client's privacy during bowel elimination - The call light and a supply of toilet paper need to be within easy reach. Bowel Training (F) - ✔ • A client who is incontinent is unable to maintain bowel control. • A bowel training program helps some clients to defecate normally,especially those who still have some neuromuscular control. • The training program involves setting up a daily routine. • By attempting to defecate at the same time each day and using measures that promote defecation, the client gains control of bowel reflexes. • The provider determines the client's physical readiness and ability to benefit from bowel training. Components of a Successful Bowel Training Program (F) - ✔ • Determining the normal elimination pattern and recording times when the client is incontinent. • Choosing a time in the client's pattern to initiate defecation control measures. • Giving stool softeners orally ever day or a cathartic suppository at least half an hour before the selected defecation time. Bowel Training Nursing Actions (F) - ✔ • Offering a hot drink (i.e., hot tea) or fruit juice before the defecation time. • Assisting the client to the toilet at the dedicated time. • Avoiding medications, such as analgesics, that increase constipation. • Providing privacy and setting a time limit for defecation (15 to 20 min). Bowel Training: Reinforcing Client Education (F) - ✔ • Instruct the client to learn forward at the hips while sitting on the toilet, to apply manual pressure with the hands over the abdomen, and to bear down but not strain to stimulate colon emptying. • Do not criticize or convey frustration if the client is unable to defecate. • Maintain normal exercise within the client's physical ability. Bowel Training: Older Adults (F) - ✔ • Constipation is a common complaint in older clients. • Coarse bran rather than refined fiber is more effective in increasing stool weight. • Fruit juices increase fiber content and as intake. • A minimum of 1,500 ml/day of fluid reduces the risk of constipation - Increased fluid needs during summer months and for clients who are on diuretics with stable cardiovascular status. • Encourage regular exercise - Even maintaining an erect posture in a client who is immobilized reduces the risk of constipation. • Clients need to feel at ease during elimination. • Lack of privacy leads the client to ignore the urge to defecate. • Use of behavioral intervention, such as habit training, provides relief of constipation. • Have clients sit on the toilet about 30 min after a meal, whether or not they feel the urge to defecate. Sleep Cycle (F) - ✔ • The sleep cycle consists of nonrapid eye movement (NREM) sleep and rapid eye movement (REM) sleep. • Typically, after a person experiences stage 1 of NREM sleep, he cycles four to six times through other stages of sleep during the night. Insomnia (F) - ✔ - Difficulty falling asleep or the inability to receive restorative sleep. - More common in women than men. - Causes include stress, illness, and work-related issues. Questions to Ask • How easily do you fall asleep? • Do you fall asleep and have difficulty staying asleep? How many times do you awaken? • What do you do to prepare for sleep? • How often do you have trouble speaking? Sleep apnea (F) - ✔ - A disorder caused by lack of airflow to the nose and mouth for greater than 10 s or longer during sleep. - Caused by a single disorder or a mixture of central nervous dysfunction or obstructive disorders. Questions to Ask • Do you snore loudly? • Has anyone ever told you that you often stop breathing for short periods during sleep? • Do you experience headaches after awakening? • Do you have difficulty staying awake during the day? Narcolepsy (F) - ✔ - A disorder of the sleep--wake mechanism. - The person may lose the ability to stay awake. - Often happens at inappropriate times. - Can put clients at risk for injury. Questions to Ask • Do you fall asleep at inopportune times? • Do you have episodes of losing muscle control or falling to the floor? • Have you ever had the feeling of being unable to move or talk just before walking or falling asleep? • Do you have vivid, lifelike dreams when going to sleep or waking up? Sleep Symptoms to Report (F) - ✔ • If a client has a sleep problem, a more detailed history should be conducted. • To begin, the nurse should understand: - Nature of the sleep problem. - Manifestations. - Onset and duration. - Severity. - Predisposing factors or causes. - Overall effect on the client. Sleep Assessment (F) - ✔ • Ask the client about sleep pattern, history, and if changes have occurred. • Use a linear scale or visual with "best night sleep" on one end and "worst night sleep" on the opposite end - Also, the nurse could ask the client to rate sleep on a 0 to 10 scale. • Assess for common factors the interfere with sleep - Illness. - Current life events. - Emotional or mental illness. - Medications. - Diet. - Exercise. Nursing Interventions to Promote Sleep and Rest (F) - ✔ • Assist the client in establishing and following a bedtime routine. • Attempt to minimize the number of times a client is awakened during the night when hospitalized. • Offer to assist the client with personal hygiene needs and/or a back rub prior to sleep to increase comfort. • Keep nursing unit quiet during night time for optimal rest. Client Education to Promote Sleep and Rest (F) - ✔ • Exercise regularly at least 2 hr before bedtime. • Arrange the sleep environment to what is comfortable. • Limit alcohol, caffeine, and nicotine in the late afternoon and evening. • Limit fluids 2 to 4 hr before bedtime. • Engage in muscle relaxation if anxious or stressed. Sleep and rest: Promoting Safety (F) - ✔ • Clients who have obstructive sleep apnea are at risk for complications while in the hospital. • Postoperatively, these clients reach deep levels of REM sleep - This deep sleep results in muscle relaxation that leads to obstructive sleep apnea. • The nurse should monitor the client frequently after surgery: - Airway. - Respiratory rate, depth. - Breath sounds. Walkers (F) - ✔ • Walkers are extremely light, movable devices. • The client holds the hand-grips on the upper bars, takes a step, moves the walker forward, and takes another step. • A walker requires a client to lift the device up and forward. • Client should hold the handgrips evenly on each side. • Take a step forward. • Move the walker forward. • Take another step. Bed-to-Stretcher Transfer (F) - ✔ • Assess whether the client can assist with the transfer. • Use a friction-reducing device for clients who weigh less than 200 lb. • If a client weighs 200 lb or more, use a friction-reducing device (such as a slide board) and three caregivers. • Use caution when moving a client with suspected spinal cord trauma - If you have to move the client, place a transfer board under the client to maintain spinal alignment. Slings and Mechanical Lifts (F) - ✔ • Toileting slings are available for toileting. • Mesh slings are available for bathing. • Mechanical lifts may be used with a full-body sling to transfer clients who are uncooperative but can bear partial weight or a client who cannot bear weight and is either uncooperative or does not have upper body strength. - Two caregivers are necessary for this type of transfer. - Hoyer lift. Feeding Devices (F) - ✔ • Clients who have had a stroke or weakness from a disease can need assistance with feeding. • Occupational therapy may be involved in providing specialized devices to ensure more independence for the client. • The nurse's role is to ensure these devices are set up and accessible to the client. Communication Devices (F) - ✔ • Communication devices can assist clients of any age in communicating their needs. - Special needs population. - Client who had a stroke. - Client on a ventilator. • There are two main types - Electronic • DynaVox. • Tango. • iPad. - Nonelectronic • Picture system. • Speech therapy can assist in choosing which is the best for the client - Helping client use the device. - Making it accessible. - Evaluating effectiveness. Warning Signs of Dysphagia (F) - ✔ • Cough during eating. • Change in voice tone or quality after swallowing. • Abnormal movements of the mouth, tongue, or lips. • Slow, weak, imprecise, or uncoordinated speech. • Abnormal gag. • Delayed swallowing. • Incomplete oral clearance or pocketing. • Regurgitation. • Pharyngeal pooling. • Delayed or absent trigger of swallow. • Inability to swallow. Silent Aspiration (F) - ✔ • Clients who have dysphagia often do not show overt signs, such as coughing, when food enters the airway. • Silent aspiration occurs without a cough and occurs in clients who have neurological problems that lead to decreased sensation. • Silent aspiration accounts for most of the 40% to 70% of aspiration in clients who have dysphagia following a stroke. Risk for Aspiration (F) - ✔ • The assessment of a client's risk for aspiration and determination of positioning cannot be delegated. • Nursing assistive personnel may feed clients after receiving instructions in aspiration precautions. Screening for Aspiration (F) - ✔ • Early screening with a formal dysphagia screening protocol significantly decreases the risk for aspiration pneumonia in clients. • Clients at high risk for aspiration are those who have: - Decreased level of alertness. - Decreased gag and/or cough reflexes. - Difficulty managing saliva. Clients who have dysphagia are at risk for aspiration and need more assistance with feeding and swallowing. A speech pathologist identifies clients at risk and provides recommendations for therapy. Dysphagia Nursing Interventions (F) - ✔ • Clients who have dysphagia should be provided a 30-min rest period before eating. • The client should be positioned in an upright, seated position in a chair, or the head of bed should be raised to 90°. • Ask the client to slightly flex the head to a chin-down position to help prevent aspiration. • If the client has unilateral weakness, teach the client and caregiver to place food in the stronger side of the mouth. • Determine the viscosity of foods that the client tolerates best through the use of trials of different consistencies of foods and fluids - Thicker foods are generally easier to swallow. • There are four levels of diet - Dysphagia puree. - Dysphagia mechanically altered. - Dysphagia advanced. - Regular. • Feed the client who has dysphagia slowly, providing smaller size bites, and allow the client to chew thoroughly and swallow the bite before taking another. - More frequently chewing and swallowing assessments throughout the meal are necessary. • Allow the client time to empty the mouth after each spoonful, matching the speed of feeding to the client's readiness. • If the client begins to cough or choke, remove the food immediately. • Provide opportunities for clients to direct the order in which they want to eat the food items, as well as how fast they wish to eat. • If the client requests the food to be warmer or colder, try to meet this need. Sources of Nutrition (F) - ✔ • Nutrition impacts the health of the body. • Essential nutrients cannot be made by the body. • Components - Carbohydrates/fiber. - Protein. - Lipids. - Vitamins. - Water. Carbohydrates (F) - ✔ • Provide energy for the body. • Types - Monosaccharides. - Disaccharides. - Polysaccharides (take longer to break down). Proteins (F) - ✔ • Building and repair in the body. • Complete - 9 essential amino acids • Animal sources. • Incomplete - Do not have all essential amino acids • Grains. • Nuts. • Legumes. • Vegetables. • Complementary - A combination of sources that when eaten together complete all essential amino acids. Lipids (F) - ✔ • Energy to the body secondary to carbohydrates. • Helps with hormone production and cell wall strength. • Pads vital organs and provides insulation to the body. • Covers nerve fibers and helps with absorption of fat-soluble vitamins. • Triglycerides - Sweets and other foods high in sugar, fat, and calories should be eaten sparingly. Calcium Consumption for Adults (F) - ✔ • The National Institutes of Health advises that adults older than 65 years of age consume about 1,500 mg/day of calcium. • It is sometimes difficult to meet that amount through diet alone. A supplement may be recommended. How Sensory Alterations Affect Nutritional Intake (F) - ✔ • Smell - Ability to smell and taste candecline gradually with age. This can make food less appetizing, resulting in poor habits. • Taste - Older adults sometimes add more salt to food products to enhance taste • Can lead to - High blood pressure. - Cardiovascular disease. - Older adults should be taught about salt substitutes and seasoning of foods to enhance taste without increasing salt. • Vision - Decreased vision makes food preparation more difficult. Foods that Decrease the Risk of Constipation (F) - ✔ • Constipation can be a chronic problem for older adults. • Older adults should be encouraged to consume enough fiber and the proper amount of fluids. • Being physically active also helps to increase peristalsis, aiding in bowel elimination. • Foods that should be recommended are whole-grain breads and cereals, legumes, vegetables, and fruits. • Fiber gives bulk to stools. Fluids help keep stools softer, making them easier to eliminate. Dental Health for Nutrition (F) - ✔ • Tooth loss or mouth pain can be an obstacle to good eating. • Poor-fitting dentures can make chewing harder and less efficient. • Dentures should be adjusted for a proper fit. • Softer foods are easier to chew. • Drinking plenty of water or other fluids with meals can make swallowing easier. • Good dental care (brushing, flossing, regular check-ups) will help keep teeth and gums healthy. Socialization Factors that Affect an Older Adult's Nutritional Intake (F) - ✔ • In general, people eat less when they eat alone or are only preparing meals for one. • Older adults should be encouraged to plan meals ahead of time and to freeze extra portions for easy access in the future. • Encourage socialization and interaction with family and friends, as well as participation in community activities. Interventions to Promote Safety in the Kitchen (F) - ✔ • Wear flat, rubber-soled shoes in the kitchen. • Wipe up spills immediately to prevent slipping. • Remove throw rugs to prevent falls. • Sit while working at the table. • Use a stable stool when working at the stove or counter. • Use a loud timer to avoid overcooking and potential fires, especially if the client has hearing loss or tends to be forgetful. • Organize the kitchen so everything is within reach. - Keep appliances on the counter. - Store heavy pans on lower shelves. - Use a rolling tea cart to move food and dishes from kitchen to table. • Keep a magnifying glass handy to read the small print on packages or recipes. • Keep the cordless phone nearby while cooking for safety and convenience. - If the client falls or has an emergency, she can call for help. Adaptive Devices (F) - ✔ • Check with the provider, medical supply store, or occupational therapy for adaptive kitchen devices - Utensils with specially designed handles. - All-in-one fork and spoon. - Cutting boards with spike to hold foods in place. - Can make food preparation and eating easier for people who have arthritis or other physical limitations. Hydration Facts (F) - ✔ • An estimated 24% to 34% of older adults in health care facilities are dehydrated. • Dehydration increases mortality rates by an estimated 45% to 48%. Types of Dehydration (F) - ✔ • Hypotonic dehydration is when sodium loss is greater than water loss, such as in overuse of diuretics. • Isotonic dehydration is when water loss equals salt loss such as a result of diarrhea, vomiting, or complete fasting. • Hypertonic dehydration is when sodium loss is less than water loss, such as in fluid deprivation or fever. Risk Factors for Dehydration (F) - ✔ • Risk factors include those who are - Acutely ill. - Febrile. - Older adults. - Nothing By Mouth (NPO). • The greatest risk of dehydration has been found to be in older adults who are assumed to be ingesting adequate fluids but actually are not. Dehydration Nursing Interventions (F) - ✔ Monitor for clinical manifestations of dehydration - Dry tongue. - Dry mucous membranes. - Sunken eyes. - Confusion. - Upper body weakness. Clinical Management of Oral Hydration (F) - ✔ • Measure accurate intake and output for clients who are at risk for dehydration - Know volumes of containers to accurately calculate intake. - Check urine specific gravity. • Check daily weights each day - At the same time. - After voiding. - While wearing the same type of clothes. • Monitor for flat neck veins. • Monitor for tachycardia. • Monitor skin turgor. • Offer fluids frequently if allowed. • Two 8-ounce glasses of fluid a.m., p.m., and more if client can tolerate. • Provide fresh drinking water. • Ask the client about beverage preferences as allowed. Progressive Diets (F) - ✔ • Used for clients who have gastrointestinal (GI) problems. • Can be used to treat disease, stress, or after surgery. • Typical progression of diet begins with a clear liquid diet, then a full liquid diet, then finally a soft diet or regular diet. Clear Liquids (F) - ✔ • Requires minimum digestion • Uses - Maintain positive fluid and electrolyte balance. - Spare body protein from digestion. - Stimulate GI tract. - Contains no fiber, therefore will see a decrease in amount of stools. • Usual contents - Water. - Sugar. - Small amount of water-soluble vitamins • Fruit juices, such as apple juice. • Some clients are allowed hard candies. • Usual clear liquid tray includes apple juice, tea, gelatin, and broth. • Used commonly as first meal postoperatively. Full Liquid (F) - ✔ • Possible to have adequate nutrition with this diet with minimal "work" of food ingestion - No chewing necessary, therefore little energy expended. - Decreased chance of gagging. - Small food particles are quickly digested. • Do not use injection sites that are edematous, inflamed, or have moles, birthmarks, or scars. • Discard all sharps (broken ampule bottles, needle) in designated containers. Containers should be leak- and puncture-proof. Intradermal Route (F) - ✔ • Most often used for - Tuberculin skin testing. - Allergy testing. • Given under the epidermal layer of the skin. • Monitor for presence of wheal after administering to indicate correct technique. Subcutaneous Route (F) - ✔ • Most often used for - Heparin. - Insulin. - Lovenox. • Rotate sites with each injection. Intramuscular Landmark Identification (F) - ✔ • Deltoid: Three finger widths below acromion process and draw line across arm at axilla. • Ventrogluteal: Heel of nondominant hand over lateral aspect of greater trochanter, index finger toward the anterosuperior iliac spine, middle finger towards the iliac crest, and thumb toward the groin. Recommended site for adults when deltoid is not used. • Vastus Lateralis: One hand width below the greater trochanter and one hand width above the knee. Recommended site for children less than 2 years of age. Dorsogluteal: Located above the diagonal line drawn from great trochanter and posterior superior iliac spine and in the upper outer quadrant when you divide the buttock into four quadrants. Do not use for intramuscular injections. Alternate Method for Injection (F) - ✔ • Z-Track Method: Pull skin to one side, hold taut while aspirating and injecting medication for 10 seconds. Release skin after withdrawing needle. • Recommended for administering irritating intramuscular (IM) injections. Standard Conversion Factors (F) - ✔ • 1 ounce = 30 ml • 1 teaspoon = 5 ml • 1 tablespoon = 15 ml • 1 kg = 2.2 lb • 1 cup = 240 ml (a standard measuring cup) • 1 quart = 1,000 ml General Rounding Guidelines (F) - ✔ • If the number to the right is equal to or greater than 5, round up by adding 1 to the number to the left. • If the number to the right is less than 5, round down by subtracting 1 from the number on the left. • For dosages less than 1.0, round to the nearest hundredth. • For example: The calculated dose is 0.746 ml. Look at the number in the thousandths place (6). Six is greater than 5. To round to hundredths, add 1 to 4 and drop the 6. The rounded dose is 0.75 ml. • For dosages greater than 1.0, round to the nearest tenth. Temperature Conversions - ✔ (Math Review)