100% satisfaction guarantee Immediately available after payment Both online and in PDF No strings attached 4.6 TrustPilot
logo-home
Exam (elaborations)

NURSE 420 EXAM 2 LEADERSHIP.| VERIFIED SOLUTION

Rating
-
Sold
-
Pages
23
Grade
A+
Uploaded on
23-02-2024
Written in
2023/2024

NURSE 420 EXAM 2 LEADERSHIP.| VERIFIED SOLUTION 1. A client states: “ I do not want to be awakened for breakfast-I didn’t sleep at all last night.” What is the first action for the RN to take? a. Notify the client’s provider b. Talk with the client to work out a mutual plan c. Consult with the patient’s family to get suggestions d. Contact the dietitian 2. An elderly client who has a documented history of dementia is intermittently alert and can currently tell you her name. Who should sign the client’s informed consent for an invasive diagnostic procedure? a. The client’s husband, who is blind b. The client herself, who has an advance directive c. The client’s friend who has durable power of attorney for health care for the client d. The client’s daughter, who is competent and visiting her mother from out of state 3. Nursing staff members are in the lounge on their morning break. A nursing assistant thinks that a unit secretary has acquired HIV and then tells the staff that the secretary probably caught it from her husband who is a drug addict. Which legal tort has she violated? a. Libel b. Slander c. Assault d. negligence 4. When referring to the standard of care, which phrase best describes the meaning of a nursing standard of care? a. The belief that nurses will always behave in a wise/prudent manner. b. The directive that ensures all nurses will always act in ways that help patients get better c. The ethical principle that states that a nurse shall do no harm d. The minimal level of nursing care and expertise that is expected to be delivered to a patient. 5. Which one of the following characteristics describes a “reasonable and prudent RN? a. At least 5 years of applicable RN experience b. Specialized RN skills for the assigned nursing area c. Average RN judgment and skill level in delivering patient care d. A BSN degree 6. An RN witnesses an assistive personnel (AP) under her supervision reprimand an elderly client for spilling urine form his urinal on the bed sheets. The AP verbally threatens to put a diaper on the client if he does use the urinal more carefully next time. Which one of the following wrong doings is the AP committing? a. False imprisonment b. Assault c. Invasion of Privacy d. slander 7. An RN accidentally sticks her hand with the syringe needle after administering an IM injection to a client. Which one of the following should the nurse do first? a. Notify the charge nurse of the incident b. Go to employee health services

Show more Read less
Institution
Course

Content preview

INACE, CNA Practice Exam 4, CNA practice
test 2, CNA Practice Test 1, Complete Verified
Solution
Reporting & Recording
-Check current documentation of resident status & care.
-Observe & report resident data (verbal).
-Record objective & subjective resident data (written)
Communicate need for changes in care plan.
- Report unsafe conditions.
-Place & receive phone calls
Objective Data
Things you can see, hear, feel, smell, or measure: Vital signs, weight, open sore on
arm, reddened area on hip, swollen knee, wheezing, skin cold clammy, foul smelling
urine, etc.
-Subjective Data
Things a resident tells you that cannot be observed through senses: Complaints of pain
(headache, chest pain, stomach ache), nausea, numbness & tingling of fingers, no
appetite, etc
At the Nurse's Station:
1 st ring. • Identify unit, give name & title. • Take message. • Do NOT give confidential
information. Refer caller to nurse
The Resident's Personal Phone:
Assist resident to answer. • Answer w/ consent. • If resident is unavailable, answer
bedside phone (not cell phone) & take a message; do NOT provide any confidential
info. Do NOT give your name or title, the name of the unit or facility
Answer call signal:
Used to signal for help.
- Bed, bathroom.
- Keep w/in reach.
-Strong side.
-Instruct on use.
-Remind to use when help needed.
- Answer promptly - Everyone responsible! Adaptations if limited mobility.
4. Reinforce instructions from other health professionals to resident & family
- Not responsible for teaching but for knowing & reinforcing/assisting resident
Inventory & label personal property
Upon admission, as acquired.
Instruct resident in use of body mechanics.
Keep body in good alignment; have good posture. Have a wide base of support (feet
shoulder-width apart).
-Use strongest & largest muscles (shoulders, upper arms, hips, thighs).
- Keep objects close to body.
- Avoid unnecessary bending & reaching.

,- Bend knees & squat. Don't bend your back!
-Get help from co-worker.
-Use proper equipment.
- Position feet & body in direction you are moving
-Avoid sudden & jerky movements. Count 1-2-3.
- Turn whole body when changing direction. Pivot, do NOT twist your back!
Calculate, report, & record
Food intake (solids): 0%, 25%, 50%, 75%, 100%
Fluid intake:
All oral fluids.
-Foods that melt at room temp.
- IV fluids & tube feedings.
- CNA only responsible for fluids by mouth.
Fluid output:
Urine, vomit, diarrhea - CNA only responsible.
- Wound drainage, hemorrhage - Nurse responsible.
Intake & Output
Intake: 1 oz = 30 ml
Output: urinals, graduates, bedpans, specimen containers
each line on urine container increases by 25 mL
Communicate w/ limited English proficient resident.
Utilize tools provided by facility
Assist w/ unit discharge procedure
Collect belongings, compare w/ personal belongings list.
- Assist w/ packing.
-Transport as indicated.
-Wish well.
- Return to room; strip bed, straighten, remove wastes & linens. If any additional
equipment, take to soiled utility room
Measure & Record VS & Weight
All VS:
Lying or sitting.
-At rest for 10-20 min.
-Obtain all VS of a resident (TPR & BP) before reporting any abnormal to nurse.
Temperature:
98.6 + 1⁰ (97.6⁰ - 99.6⁰ )
Elderly on lower end of range ≈ 97.6⁰
- Do not eat, drink, smoke for 15 min
Pulse
60 - 100 beats/min.
- Tachycardia > 100
- Bradycardia < 60
-Count for 30 sec & multiply by 2. If irregular, must count for full min
Respirations
12-20/min
Do not let know you are counting.

, Dyspnea
= difficulty breathing
Blood pressure
90/60 - 120/80
Systolic - top #
- Diastolic - bottom #
- Hypertension - high BP
Wait 1 min before retaking BP
Weight
SAME Scale
- SAME Time of Day (does NOT matter when!)
SAME Amount of Clothing (do NOT need to remove)
Routine urine specimen
anytime, earliest possible time
24-hour urine specimen
Keep chilled.
-Start w/ empty bladder.
-Start over if urine missed or stool/tissue present
Clean-catch urine specimen
Testing for UTI.
-Special cleansing wipes needed, sterile container. -
Start to urinate, stop, start again & collect.
Sputum specimen
Secretions from respiratory system.
-May rinse w/ clear water.
-Take 2-3 deep breaths, cough, expel.
stool specimen
Collect about 2 tbsp. Include anything unusual.
Collect specimens
Assist in preparation of specimen for transfer to laboratory
- Follow Standard Precautions!
- Place in clear biohazard specimen bag.
- Take to appropriate location according to facility policy:
- Specimen refrigerator, lab, etc.
standard percautions
Apply to care of ALL residents.
- Presume EVERYONE is INFECTED!
Presume ALL may contain germs:
Body fluids (blood, urine, saliva, wound drainage, vomit, etc.)
Body substances (stool)
Open skin
Mucous membranes (mouth, eyes, nose, perineum)
standard precautions guidelines
Wash your hands!
#1 in preventing spread of infection.
Using FRICTION most important aspect of handwashing.

Written for

Course

Document information

Uploaded on
February 23, 2024
Number of pages
23
Written in
2023/2024
Type
Exam (elaborations)
Contains
Questions & answers

Subjects

Get to know the seller

Seller avatar
Reputation scores are based on the amount of documents a seller has sold for a fee and the reviews they have received for those documents. There are three levels: Bronze, Silver and Gold. The better the reputation, the more your can rely on the quality of the sellers work.
LectDan Teachme2-tutor
Follow You need to be logged in order to follow users or courses
Sold
220
Member since
3 year
Number of followers
158
Documents
7954
Last sold
4 days ago

4.0

47 reviews

5
25
4
12
3
2
2
3
1
5

Trending documents

Recently viewed by you

Why students choose Stuvia

Created by fellow students, verified by reviews

Quality you can trust: written by students who passed their tests and reviewed by others who've used these notes.

Didn't get what you expected? Choose another document

No worries! You can instantly pick a different document that better fits what you're looking for.

Pay as you like, start learning right away

No subscription, no commitments. Pay the way you're used to via credit card and download your PDF document instantly.

Student with book image

“Bought, downloaded, and aced it. It really can be that simple.”

Alisha Student

Frequently asked questions