Which type of data is this:
Clients description
Use of quotes
Question to gain information: onset, location, duration, frequency, precipitating/aggravating factors
Use their terms in description
Subjective data
Which type of data is this:
What you find: rash, decub ulcer, irregular hert sounds.
Onset, location, description
What you observe and measure
Objective data
When documenting subjective data, document with ____ and ____ when possible.
Parenthesis and exact wording
What is this?
Any event that is not consistent with the routin operations of a health care unit or "routine care" of a client.
Incident
These are an example of what?
Pt fall
needle stick
med errors
omissions of errors
pt/staff injury or risk for
Incident
What is this?
Any adverse outcome for a patient, including an injury or complication directly associated with the care or services provided to a patient.
Ex: rash
Adverse event
What is this?
Any incident resulting in serious harm (loos of life, limb, vital organ). There is a need for immediate investion and response
critical incident
What is this?
An event that could have adverse consequences by did not.
Near miss
The nurse is preparing the information that will be provided to the staff on the next shift. Which of the following should the nurse include in the inter-shift report to the nursing colleagues?
D)
A change-of-shift report should include instructions given in a teaching plan and the client’s response. This should not include detailed content unless staff members ask for clarification. The nurse should relay to staff significant changes in the way therapies are given, but should not describe basic steps of a procedure. The client’s diagnosis-related group is not essential background information to be shared in an inter-shift report. The nurse should not review all routine care procedures or tasks.
The nurse makes a late entry in a client’s record. Which of the following is the best example of how to document this type of situation?
D)
This is the best example of a late entry. The time (2:45 PM) is indicated along with the action and an objective observation. This notation (8:30 AM) is not complete. It does not indicate why the Percodan was given. What was the client’s level of pain? Where was the pain located? The nurse does not need to document about herself; only the client. In this option (12:15 PM), the nurse does not indicate why the morphine was given (client’s level of pain? location of pain?). This entry (8:30 PM) is not complete. It does not state the size of the wound, type of dressing used, or the client’s tolerance of the procedure.
The nurse has made an error and is documenting such on the client’s record and notes. The action that the nurse should take is to:
D)
If a nurse has made an error in documentation, the nurse should draw a single line through the error, write the word error above it, and sign his or her name or initials. Then record the note correctly. The nurse should not erase, apply correction fluid, or scratch out errors made while recording because charting becomes illegible. Also, entries should only be made in ink so they cannot be erased. Using a dark color marker to cover the error is not correct. It may appear as if the nurse was attempting to hide something or deface the record. Footnotes are not used in nursing documentation.
The new staff nurse is having her documentation evaluated by the charge nurse. On review of her charting, the charge nurse notes that there is evidence of appropriate documentation when the new staff nurse:
C)
Each entry should begin with the time and end with the signature and title of the person recording the entry. All entries should be recorded legibly and in black ink because pencil can be erased. The nurse should never erase entries, never use correction fluid, or never use a pencil. The use of correction fluid could make the charting become illegible and it may appear as if the nurse were attempting to hide something or to deface the record. If the physician made an error, the nurse should not document it in the client’s chart. It should be documented in an incident report.
What is the correct response for the licensed practical nurse that answers the phone to respond within the following scenario? The physician calls to leave orders late at night for one of his clients.
C)
A telephone order involves a physician stating a prescribed therapy over the phone to a registered nurse. Saying that an order is unable to be taken and to call back in the morning is not an appropriate response and not in the client’s best interest. It is best to repeat any prescribed orders back to the physician, who can then verify if it is correct or clarify the order. This is not the appropriate response. A registered nurse needs to take the verbal order, but it does not have to be the nursing supervisor.
Which of the following is evaluated as a legally appropriate notation?
D)
Entries should be concise, factual, and accurate. “Verbalized sharp, stabbing pain along the left side of chest” is an example of an objective description of a client’s behavior. The nurse should not document “physician made error.” Instead, the nurse could chart that “Dr. Green was called to clarify order for medication administration.” The nurse should chart only for himself or herself. In this case, nurse Williams should write the charting entry. Only objective descriptions of the client’s behavior should be recorded. For example: Client states, “I don’t want physical therapy! I want to go home
Which of the following nursing notations shows the best understanding regarding the need to document only objective client assessment data?
B)
Do not write personal opinions. Document observable, measurable client-oriented data only. The remaining options either make assumptions regarding observed client behavior or fail to objectively describe the noted client behavior
TO =
telephone order
RN or physician
VO =
Verbal order
Used in emergency situations
T or F:
All TO and VO must be repeated and verified
True
When should MD verify and sign off TO or VO?
Within 24 hours
SOAP notes
Subjective: clients verbalization
Objective: what is measured/observed
Assessment: dx based on data found
Plan: what you are going to do
PIE notes
problem oriented/nursing history
Problem
Intervention
Evaluation
Notes are labeled/numbered according to patients problems. If problem resolved - dropped. Continued problems - addressed daily.
Focus charting
Narrative form
Use of DAR notes
Data
Action/nursing intervention
Response of client/evaluation
A different approach not designed for just problems includes clients concerns, not just problem area
Which notes are labeled/numbered according to patients problems?
PIE notes
Which appraoch is not deisgned for just problems. but also includes clients conerns?
Focus charting
What is infiltration?
Tip of catehter has poked out of vein and into surrounding tissue
What does infiltration cause?
Swelling
Pale color
Cool to touch
Pain
Bruised-like skin
How do you tell the difference between infiltration and phlebits?
Phlebitis - red area
Infiltration - pale area
What interventions should you use if IV site if infiltrated?
1. Discontinue infusions.
2. Insert new IV into another extremity
3. To redue pain, raise arm to promote venous drainage an decrease edema
4. Heat therapy - wrap arm in warm moist towel for 20 min to promote venous return, increase circulation, and reduce pain/edema.
What is phlebitis?
Inflammed vein
You see a red streak tracking upstream from IV site. What is this?
Phlebitis
What does phlebitis cause?
Increase temp in vein
redness
pain
edema
What are some nursing interventions for phlebitis?
1. Discontinue IV
2. insert a new line in a nother vein
3. warm moist heat redeuces pain
With phlebitis, how often whould ou rotate periiheral venous cannulas and sites?
Evrey 72 hours
Diffusion/osmosis is from ___ to ___ concentration
High and low
Which solution does not promote the shift of fluids into or out of the cells, causing them shrink or swell?
Isotonic solutions
Which solution has the same number of particles as plasma?
Isotonic solution
Which solution doesn't cause edema?
Isotonic
Normal saline, D5W, and lactated ringers solution are two of the most commonly used ________
Isotonic solutions
The location of ostomies determines _______
stool consistency
When the ileostomy bypasses the large intestine, stools will be _____
liquid and frequent
Colostomy is within the _____
colon
If colostomy is within transverse colon, stools will be _____
solid and formed
If colostomy is within sigmoid, stools will be _____
near normal
A loop colostomy is for:
medical emergency
temporary
An end colostomy is a _______
surgical type of colorectal cancer.
often rectum is removed
Dr. Smith has determined that the client with hepatitis has contracted the infection form contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis?
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis D
a. Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.
A female client being seen in a physician’s office has just been scheduled for a barium swallow the next day. The nurse writes down which instruction for the client to follow before the test?
a. Fast for 8 hours before the test
b. Eat a regular supper and breakfast
c. Continue to take all oral medications as scheduled
d. Monitor own bowel movement pattern for constipation
a. A barium swallow is an x-ray study that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal tract. The client should fast for 8 to 12 hours before the test, depending on physician instructions. Most oral medications also are withheld before the test. After the procedure, the nurse must monitor for constipation, which can occur as a result of the presence of barium in the gastrointestinal tract.
Polyethylene glycol-electrlyte solution (GoLYTELY) is prescribed for the female client scheduled for a colonoscopy. The client begins to experience diarrhea following administration of the solution. What action by the nurse is appropriate?
a. Start an IV infusion
b. Administer an enema
c. Cancel the diagnostic test
d. Explain that diarrhea is expected
d. *KNOW!* The solution GoLYTELY is a bowel evacuant used to prepare a client for a colonoscopy by cleansing the bowel. The solution is expected to cause a mild diarrhea and will clear the bowel in 4 to 5 hours. Options A, B, and C are inappropriate actions.
The nurse is caring for a hospitalized female client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician?
a. Hypotension
b. Bloody diarrhea
c. Rebound tenderness
d. A hemoglobin level of 12 mg/dL
c. Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the physician.
The nurse is caring for a male client postoperatively following creation of a colostomy. Which nursing diagnosis should the nurse include in the plan of care?
d. Nutrition: more than body requirements, imbalanced
C. Body image, disturbed relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). No data in the question support options A and C. ****Nutrition: less than body requirements, imbalanced is the more likely nursing diagnosis.****
In isotonic solutions, cells do not ____ or _____ water
gain or lose water
Isotonic solutions have no effect on the ________
surrounding cells
Which solution is often used for electrolyte replacement, those suffering from dehydration, excessive vomitting, and for perioperative fluid adminstration?
Isotonic
What is the most common type of IV fluid
isotonic solutions
Water quickly shifts out of the vascular ebd and into the cells, by way of osmosis in which solution?
Hypotonic
Which solution is frequently given to correct cellular dehydration and hpernatremia?
Hypotonic solution
Which solution is routinely used in hospitals to keep patients hydrated?
hypotonic
Which type of solution is rapidly absorbed by the body and eliminated by the renal system?
hypotonic
Sports drinks that contain salts/electrolytes are also called ___________
hypotonic solutions
Which solution hydrates the cells by moving fluids out of the blood system and into the cells?
hypotonic solution
Which type of solution has more particles than the body's water?
hypertonic
Which solution pulls water back into circulation from the cells and interstitial spaces, shrinking the cells?
Hypertonic
Which solution supressess inflammation and sometimes is used to prevent edema/intracranial hypertension when using IV fluids to treat horrhagic shock?
Hypertonic solutions
A client experiences a loss of intracellular fluid. The nurse anticipates that the intravenous (IV) therapy that will be used to replace this type of loss is:
C. The client will need a hypotonic solution, such as 0.45% NS. A hypotonic solution has an osmolality that is less than body fluids, so the cells will draw the fluid in, which is the desired effect when the client has experienced a loss of intracellular fluid. Dextrose 5% in NS, 10% dextrose, and 5% dextrose in lactated Ringer’s are all hypertonic solutions that will draw fluid into the vascular space by osmosis. The client needs a hypotonic solution to rehydrate the cells.
The health care provider orders 1000 mL of D5LR with 20 mEq KCl to run for 8 hours. Using an infusion set with a drop factor of 15 gtt/mL, the nurse calculates the flow rate to be:
A. 1000 mL ÷ 8 hr = 125 mL/hr; (15 gtt/mL ÷ 60 min) x 124 mL = 32 gtt/min.
The nurse will be starting a new intravenous infusion and needs to select the site for the insertion. In selection of a site, the nurse should:
D. The nurse should avoid veins in an extremity with compromised circulation, such as a dialysis graft. The nurse should use the most distal site in the nondominant arm, if possible, and should avoid hardened cordlike veins.
A client has intravenous therapy for the administration of antibiotics and is stating that the “IV site hurts and is swollen.” Which of the following information assessed on the client indicates the presence of phlebitis, as opposed to infiltration?
B. ***KNOW*** Signs of phlebitis may include increased temperature over the vein, erythema, pain, and edema. With phlebitis, the area is warm to the touch; with infiltration, the area is cool to the touch. The intensity of pain is not a differentiating factor between phlebitis and infiltration. Pain may occur with both. The amount of subcutaneous edema is not a differentiating factor between phlebitis and infiltration. Edema may occur with both. Skin discoloration of a bruised nature is not the best way to differentiate phlebitis from infiltration. With phlebitis, the area is typically reddened. With infiltration, the area is typically pale.
For a client with a nursing diagnosis of excess fluid volume, the nurse is alert to which one of the following signs and symptoms?
C. ***KNOW*** Hypertension is a symptom of fluid volume excess. A weak, thready pulse is associated with fluid volume deficit. A bounding pulse is a symptom of fluid volume excess. Dry mucous membranes and flushed skin are both symptomatic of fluid volume deficit, not excess.
An IV solution of 125 mL is to be infused over a 1-hour period. A microdrip infusion set will be used. The nurse calculates the infusion rate as:
a. 32 gtt/min
b. 60 gtt/min
c. 125 gtt/min
d. 250 gtt/min
ANS: 3(60 gtt/mL ÷ 60 min) x 125 mL = 125 gtt/min.
A client is prescribed 0.9% sodium chloride (normal saline), which is an isotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to:
B. Isotonic solutions such as normal saline, 0.9% sodium chloride, expand the body’s fluid volume without causing a fluid shift from one compartment to another. The remaining options describe the function of other types of fluids.
A client is prescribed 3% sodium chloride, which is a hypertonic solution. The nurse recognizes the primary goal of such intravenous therapy is to:
C. A hypertonic solution (a solution of higher osmotic pressure), such as 3% sodium chloride, pulls fluid from cells, causing them to shrink. The remaining options describe the function of other types of fluids.
What are 5 complications of eneteral tube feeding?
Aspiration
Diarrhea
Constipation
Tube occlusion
Tube displacement
Liquid nutritional supplements/feedings if unable to swallow food is _______
enteral feeding
Internall app of pressure through inflated balloon to prevent hemorrhage is _________
compression
irrigation of stomach for active bleeding, poisoning, gastric dilation is ________
lavage
Levin tube
lumen
most commonly used
one lumen NG tube
useful in instilling material into/suctioning material out of stomach
Salem-sump tube
two lumen
drainage lumen and secondary tube open to air
major advantage - can be used for continuous suction
white and blue ends
Miller-Abbott tube
two lumen
rubber ballon, and tube with holes
one tube is used for suction, the other is used for doctor to inflate balloon
Sengstaken-Blakemore tube
tripe lumen
inflatable esophagus ballon
stomach balloon
gastric suction lumen
used to treat bleeding ulcers and cirrhosis
Dobhoff tube
used for long term feeding
placement must be verified by xray
takes 24 hours for tube to pass from stomach into small intestines
patient lays on RIGHT side to facilitate passage of tube
What is the best way to verify placement of an NG tube?
