NURS 495 comprehensive study guide
1. ABCs (Airway, Breathing, Circulation)
2. When in distress DO NOT ASSESS! Unless 2nd hand information is received.
3. Scenario
• Expected outcome with Disease Process : Continue to monitor & Document finding
• Unexpected finding with Disease Process...
1. ABCs (Airway, Breathing, Circulation)
2. When in distress DO NOT ASSESS! Unless 2nd hand information is received.
3.Scenario
Expected outcome with Disease Process : Continue to monitor &
Document finding
Unexpected finding with Disease Process : Nursing intervention that
must make a difference & Call HCP
4. Mini Maslow’s
1) ABCs (& Pain unrelieved by meds)
2) Safety
3) Comfort (Pain)
4) Psychological
5) Social
6) Spiritual
5. STAT words → Pick the answer that failing to do so will kill or cause great
harm
● Highest Priority
● Most Important
● Immediate Action
6.*Least Invasive First*
7. Secondhand Info → Any time you have 2nd hand info, the right answer is
ASSESS
∙ UAP ∙ Family
∙ Labs ∙ EMR
∙ EKG ∙ BP machine
8. Never ever take away the coping mechanism a patient uses during a
crisis, except if the mechanism puts the patient or others @ risk
9. Eliminate answer choices & DNR
10.Never withhold Tx! If you’re left with two answer choices and the
options are to Tx, or watch the patient, Pick Tx!
11.Anytime there’s a reversal from the norm, you must
worry! Ex: rebound tenderness (pain after you
relieve pressure)
12.Assign Stable Patients to:
∙ UAP ∙ LPN ∙ New nurse
∙ Graduate Nurse∙ Float Nurse ∙ Travel
nurse
13.Anytime you see excessive findings, That’s not normal!
,14.Always empower your patient
15.If a question has “ ”, pick an answer that has what they’re feeling &
not what they’re saying
16.3 R’s of Psych
1) Reality – Functional psych patient
2)Reassure – pt with Delirium
3)Redirect – pt with Dementia
, Automatic Correct Answers
1. Give meds either 1 hour before meal or 2 hours after meal
2. Give antacids 1 hour before med or 4 hours after med
3.When in doubt pick K (potassium)
4. 2 – 3 L of fluids
5.When in doubt pick answer that has you stay with patient
6. Anytime you see restless & ↓ level of consciousness = early sign -
PICK
7. Head of Bead → 30-45 degrees for any neuro patient
8. Elderly with acute onset confusion → UTI
9. Secretions will turn Orange/Red for meds
10.Anytime you have GI problem/exacerbation = NPO
11. All surgeries RISK:
1st 24 hrs –
bleeding
48 hrs – infection
12.Check daily weights if it’s a fluid problem
13.Lateral position for maternity
14.Remove answer choices that are ‘absolutes’
Rules for Delegation
RN ASSIGNMENT == Do not delegate what you can E A T: Evaluate
Assess Teach
● Cannot delegate assessment, teaching, or nursing
judgement LPN/LVN ASSIGNMENT
● Assign stable with expected
outcomes UAP ASSIGNMENT
● Delegate standard, unchanging procedures
Five Rights of Delegation
RIGHT TASK – scope of practice, stable client
RIGHT CIRCUMSTANCES – workload
RIGHT PERSON – scope of practice
RIGHT COMMUNICATION – specific task to be performed, expected
results, follow- up communication
, RIGHT SUPERVISION – clear directions, intervene if necessary
Therapeutic Communication Tips
DO: DO NOT:
Do respond to feeling ● Do not ask ‘why’ questions - NEVER pick WHY
tone Do provide
● Do not ask ‘yes/no’ questions, except in the
information case of possible self-harm
Do focus on the
● Do not focus on the nurse
client Do use
● Do not explore
silence ● Do not say, “Don’t worry!”
Do use presence
Who Do You See First?
Consider:
∙ Unstable vs. Stable∙ Acute vs. Chronic
∙ Unexpected vs. Expected ∙ Actual vs.
Potential
∙ABCs
Common
Traps
∙ Do not ask “Why?” ∙ Do not ‘do
nothing.’
∙ Do not leave the client. ∙ Do not
read into the question
∙ Do not persuade the client. ∙ Do
not pass the buck.
∙ Do not say, “Don’t worry!”
Strategies
● Only use textbook nursing – textbook knowledge
● Pain is psychosocial, unless, it’s severe, acute, & unrelenting
● If it’s a position question, is it going to prevent or promote something –
position, prevent, promote
● Teaching/learning – use T/F on each answer – same strategy for SATA
questions
● Risk Questions – use Risk Factors
● If the answers have an absolute in them, do not pick them
● Question that have the phrase ‘And Then’ – did they miss something
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