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Compare and contrast between standard precautions and transmission-based precautions. Be detailed and give examples of when you would use each kind .
- Standard: all clients to prevent spread of microorganisms. Use with contact of body fluids, blood, execretions (except for sweat), mucous membranes and non- intact skin. Gloves and Hand Hygiene
- Transmission: Known or suspected airborne, droplt, contact infections FULL PPE
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Double gloving: take off both and wash hands; use double gloves sparingly in most cases not necessary or useful.
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When a nurse gets a needle stick with a clean needle, not used, what should he/she do? If a client gets a needle stick with the same needle that just stuck them, what does the nurse tell them. What do you do?
- 1. Wash need sticks and cuts with soap and water
- 2. Flush nose, mouth and skin with clean water.
- 3. Irrigate with clean water, saline or sterile irrigants.
- 4. Report and fill out incident report.
- 5. Seek medical Treatment
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In giving a bedbath, do you need gloves to wash the face? How do you wash the face?
No
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What is your FIRST action when you see a needle in the bed of a client?
Don gloves and discard needle in sharps
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Define HIPAA
Health insurance Portability and accountability Act
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What would an L VN do in this situation? Overhearing a staff nurse breaching HIPAA (2 actions in order of priority)
Report to supervisor and fill out incident report
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What are the other two names of the Nurse Practice Act? What IS the NPA?
- Legal Practice acts for professional nursing practice.
- Regulates the practice of nursing in the US and Canada.
- NAMES: Title 22 and Scope of Practice
- COMMON PURPOSE: to protect the public.
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What is the number one fear from nurses receiving medication orders via telephone?
Authenticity of Caller
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What would you say if another nurse drew up medications and asked you to give them for her?
I cannot administer medications that were not drawn up by myself.
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What is normal range of intake and output for an adult?
Intake: 2,500 mL Output: 1,400 to 1,500mL
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What is the best way to force fluids?
Offer what they like every hour
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When a patient is complaining of numbness and tingling in the arms and legs, what should the nurse assess in the labs?
Check for electrolytes (Especially K+)
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If a client has a catheter in place (indwelling) and c/o pain, what is the nurses FIRST action?
Check for kinks in tubing
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If you are catheterizing a client for a C&S, what do you do once you see urine start to flow? FIRST?
Insert 1 inch further
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What is the normal size gauge and balloon for an adult client?
- 14-16 Fr. – Women 30ml Balloon for urine drainage.
- 18Fr. – Men 5mL balloon or greater for hemostasis
- 5-10mL for balloon
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What is the nurses first action for a client with a post-operative fever?
- - TCDB : turn, cough and deep breath - to prevent pneumonia and to get rid of the gunk accumulated during surgery
- - assess lungs
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If neither arm is available for BP reading, what is the next site and how do you apply it to that site (artery)?
- Thigh, palpate the popliteal artery
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What is the best measurement of a patients pain?
Facial expression, pain scale 0-10
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When someone complains of pain, what is the nurse's FIRST response?
- Assess pain using PQRST
- Provocative- What causes it? What makes it better? What makes it worse?
- Quality- How does it feel, look, or sound, and how much of it is there?
- Region- Where is it? Does it spread?
- Severity scale- Does it interfere with activities? How does it rate on a scale of 0-10?
- Timing- When did it begin? How often does it occur? Is it sudden or gradual ?
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What are the five stages of grief and what might a client say in each stage?
Denial, Bargaining, Anger, Depression, Acceptance
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Oxygen saturation-
95-100%
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Blood glucose (fasting) -
normal: 60-99mg/dL diabetic: 70-110
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Potassium (K) -
3.5-5 mEq/L
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Chloride (CL)-
95-105mEq/L
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Sodium (Na)-
134-142 mEq/L
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Magnesium (Mg)-
1.3-2.1mEq/L / 1.5-2.4 / 1.6-2.6
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Hemoglobin (Hgb) -
14-18g/dL (men) ; 12-16g/dL (women)
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White blood cells (WBC)-
5,000 - 10,000/mm3
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