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NU 311 Alabama Clinical Nursing Skills Exam 1 Verified 2024
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NU 311 Alabama Clinical Nursing Skills Exam 1 Verified 2024
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NU 311 Alabama Clinical Nursing SkillsExam 1 Verified 2024
- Seizure Precautions & (generalized vs. partial seizure)** & 3 phases to a seizure &
status epilepticcus - ANSWER-a.-Seizures are sudden, abnormal, electrical discharges
in the brain causing alterations in behavior, sensation, or consciousness. Protect the
patient, but avoid restraining & forcing something in the mouth during the seizure. Don't
leave the patient alone; call for help. Remember, dignity.
b.-(Additional- Observe seizure characteristics and duration
c.-Medicate as indicated)
d.-Seizures that appear to begin everywhere in the brain at once are classified as
generalized seizures, whereas seizures beginning in one location of the brain are
classified as partial seizures. There are three phases to a seizure:
e. STAGES-
•Aura—the start of a partial seizure. If the aura is the only phase a patient experiences,
the patient has had a simple partial seizure. If the seizure spreads and affects
consciousness, it is a complex partial seizure. If the seizure spreads to the rest of the
brain, it becomes a generalized seizure.
•Ictus—meaning attack. Ictus is another word for the physical seizure involving a series
of muscle contractions, called tonic and clonic contractions.
•Postictal —meaning after the attack. Postictal refers to the aftereffects of a seizure
(e.g., arm numbness, altered consciousness, partial paralysis).
f.• Status epilepticcus involves 5 minutes or more of either continuous clinical or
electrographic (shown on an electroencephalogram [EEG]) seizure activity or recurrent
seizure activity without recovery between seizures. It is a medical emergency. Status
epilepticus can be convulsive (rhythmic jerking of)
-Centers for Disease Control and Prevention Isolation Guidelines
Standard Precautions (Tier One) for Use With All Patients Cough etiquette (Box 9.2) -
ANSWER-a. Standard precautions apply to blood, blood products, all body fluids,
secretions, excretions (except sweat), non-intact skin, and mucous membranes.
b. Perform hand hygiene before, after, and between direct contact with patients.
(Examples of between-contact activities are cleaning hands after a patient care activity,
moving to a non-patient care activity, and cleaning hands again before returning to
perform patient contact.)
c. Perform hand hygiene after contact with blood, body fluids, mucous membranes,
nonintact skin, secretions, excretions, or wound dressings; after contact with inanimate
surfaces or articles in a patient room; and immediately after gloves are removed.
d. When hands are visibly soiled or contaminated with blood or body fluids, wash them
with either a non-antimicrobial soap or an antimicrobial soap and water.
e. When hands are not visibly soiled or contaminated with blood or body fluids, use an
alcohol-based hand rub to perform hand hygiene.
f. Wash hands with non-antimicrobial soap and water if contact with spores (e.g.,
Clostridium difficile) is likely to have occurred.
,g. Do not wear artificial fingernails or extenders if duties include direct contact with
patients at high risk for infection and associated adverse outcomes.
h. Wear gloves when touching blood, body fluids, secretions, excretions, non-intact skin,
mucous membranes, or contaminated items or surfaces is likely. Remove gloves and
perform hand hygiene between patient care encounters and when going from a
contaminated to a clean body site.
i. Wear personal protective equipment (PPE) when the anticipated patient interaction
indicates that contact with blood or body fluids may occur.
j. A private room is unnecessary unless the patient's hygiene is unacceptable (e.g.,
unconfined secretions, excretions, or wound drainage).
k. Discard all
-Droplet precautions cont... (plus standard precautions) - ANSWER-a. Visitors- Report
to Nurses station before entering room
b. Private room- cohorting possible
c. Masks- wear mask within 3 ft. of patient
d. Essential movement/transport only
e. Mask on patient during transport
-Other source of fire that poses a risk in a health care setting? - ANSWER-Although
smoking is not allowed in health care facilities, smoking-related fires still pose a
significant risk because of unauthorized smoking in beds or bathrooms. In the home
setting, oxygen-related fires are a risk for patients requiring continuous oxygen therapy.
-Biomedical devices must have a safety inspection sticker with an expiration date, and
all electrical equipment should have a three-prong plug for grounding.
-Hospital engineers should inspect any electrical devices a patient brings to the hospital;
discourage patients from bringing nonessential devices.
-If a fire occurs, health care personnel report the exact location of the fire, contain it, and
extinguish it only if it is safe and possible. All personnel are then mobilized to evacuate
patients if needed.
-Most agencies have fire doors that are held open by magnets and close automatically
when a fire alarm sounds. Fire doors should never be blocked.
-Chemicals in many medications, anesthetic gases, cleaning solutions, and
disinfectants are potentially toxic. They injure the body after skin or mucous membrane
contact, ingestion, or vapor inhalation.
-A Safety Data Sheet (SDS) form contains information about the properties of the
particular chemical and information for handling the substance in a safe manner.
-Seizure Precautions (rolling patient on side)** & status epilepticcus guidelines con -
ANSWER-a.• Traditionally patients who have a seizure are immediately placed in the
side-lying position to prevent aspiration of oral secretions. This is still a standard of
practice. However, the patient should be rolled gently into this position and only if
possible without injuring any body part. Refer to your agency policy for positioning
guidelines.
b.• The current practice guidelines for patients with status epilepticus include the
following:
, c.• Within first 2 minutes establish and protect the airway when patient loses
consciousness.
d.• Provide noninvasive airway protection and gas exchange with head positioning,
keeping the airway patent and administering oxygen.
e.• Measure vital signs: oxygen saturation, blood pressure, and heart rate immediately
and every 2 minutes.
f.• Establish an intravenous (IV) route for emergency medications.
g.• When seizure begins to subside, intubation (insertion of an artificial airway) should
be attempted only if gas exchange is compromised or if patient is believed to have
increased intracranial pressure
•continue to steps.
-Standard precautions (Tier 1)- - ANSWER-a. used for all patients, regardless of risk or
presumed infection statue.
b. Apply to blood, blood products, all bodily fluids, secretions, excretions (except sweat),
nonintact skin, & mucous membranes
-Transmission precautions (contact, droplet, & airborne) - ANSWER-a. Use for care of
patients who are known or suspected to be infected, or colonized, with microorganisms
transmitted by the contact, droplet, or airborne route.
b. The three types of transmission-based precautions—airborne, droplet, and contact—
may be combined for diseases that have multiple routes of transmission (e.g.,
chickenpox). When used either singly or in combination, you use them in addition to
standard precautions.
Airborne Precaution - ANSWER-a. Airborne pathogens are smaller than 5 microns &
can travel longer distances than droplets (larger particles).
b. Examples are Chicken Pox & Tuberculosis (TB).
c. Require negative pressure rooms.
d. Require N-95 respirator masks that filter smaller particles.
Alternatives - ANSWER-Common strategies to manage wandering include
environmental adaptations, use of signaling tags...
-Distraction
-Social interaction
-Regular exercise
-Circular design of a patient care unit
-More frequent observation of patients
-Involvement of family during visitation
-Frequent reorientation
Employ strategies to prevent accident removal of medical devices such as IVs or
nasogastric tubes.
(Provide for patient needs and keep them comfortable)
What to do for hourly rounding: (The 5 P's): Pain, potty, possessions, pathway, & pumps
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