Exam (elaborations) RN Comprehensive Predictor 2019 Remediation

Exam (elaborations) RN Comprehensive Predictor 2019 Remediation 1) Ensures the client has the information they need to make decisions about healthcare 2) Advocate even when they disagree with the client’s decision 3) Advocate when clients are unable to speak or act for themselves Managing Client Care: Action Requiring Intervention during Tracheostomy Suctioning 1) An open airway is necessary for breathing so it is the highest priority 2) Breathing is necessary for oxygenation of the blood to occur 3) Circulation is necessary for oxygenated blood to reach the body’s tissues Managing Client Care: Effective Time Management 1) Taking time to plan care and taking priorities into consideration 2) Making repeated trips to the supply room 3) Completing one task before beginning another task for equipment Coordinating Client Care: Planning Care for a Client Following a Stroke 1) Initiation revision and evaluations of the plan of care 2) Facilitating referrals and the use of community resources 3) Facility to another, such as from an acute care facility to a skilled facility RN Comprehensive Predictor 2019 Remediation Coordinating Client Care: Information to Report to Occupational Therapist 1) Client medical diagnosis and care providers 2) Overview of health status, plan of care, and recent progress 3) Most recent vital signs and medications Multiple Sclerosis: Priority Referral for a Client who has Amyotrophic Lateral Sclerosis 1) Plan for disease progression 2) Consider referral to occupational and physical therapy for home environment assessment to determine safety and ease of mobility. 3) Refer to speech language therapist for dysarthria and dysphagia. Information Technology: Using Correct Documentation 1) Begin each entry with the date and time 2) Record entries legibly, in nonerasable black ink, and do not leave blank spaces in the nurses’ notes 3) Sign all documentation as the facility requires, generally with name and title Professional Responsibilities: Priority Action When Obtaining a Signature on an Informed Consent Form 1) For an invasive procedure or surgery, the client is required to provide written consent 2) State laws regulate who is able to give informed consent 3) The nurse must verify that consent is informed and witness the client sign the consent form Communicable Diseases, Disasters, and Bioterrorism: Reportable Infectious Diseases 1) Tuberculosis 2) Hepatitis A 3) Hepatitis C Cultural and Spiritual Nursing Care: Communicating with a client who speaks a language different from the nurse 1) Nurses should accommodate each client’s cultural beliefs and values whenever possible, unless they are in direct conflict with essential health practices 2) Study the client and their environment for examples of cultural relevance 3) Use only a facility-approved medical interpreter Professional Responsibilities: Understanding Regulations for Nursing Scope of Practice 1) Nurses should refuse to practice beyond the legal scope of practice and/or outside of their areas of competence regardless of reason 2) Nurses should use the formal chain of command to verbalize concerns related to assignment in light of current legal scope of practice, job description, and area of competence 3) Standards of care guide, define, and direct the level of care that should be given by practicing nurses Medications Affecting Urinary Output: Teaching About Furosemide 1) Monitor blood pressure 2) Monitor electrolytes and weight 3) Report urine output less than 30 Ml/hr Musculoskeletal Trauma: Discharge Teaching Following Surgery for Carpal Tunnel Syndrome 1) Ensure the client is aware of application protocol regarding full-time or part-time use 2) Instruct the client to observe for skin breakdown at pressure points 3) Do not remove unless instructed to do so Cancer Treatment Options: Caring for a Client Who Has a Radiation implant 1) Place the client in a private room away from other clients when possible 2) Keep the door closed as much as possible 3) Place a sign on the door warning of the radiation source Medical and Surgical Asepsis: Maintaining Aseptic Technique 1) Perform hand hygiene before and after every client contact, and after removing gloves 2) Use protective clothing such as masks, gloves, gowns, and protective eyewear 3) Avoid coughing, sneezing, and talking directly over a sterile field Newborn Assessment: Expected Findings 1) Blood pressure should be 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic 2) Normal heart rate ranges from 110 to 160/min with brief fluctuations above and below this range depending on activity level 3) Respiratory rate varies from 30 to 60 breaths/min with short periods of apnea occurring most frequently during the rapid eye movement sleep cycle Client Education: Creating Written Teaching Materials 1) Assess/monitor learning needs 2) Evaluate the learning environment 3) Identify learning style Health Promotion and Disease Prevention: Evaluating Understanding of Genetic Risks 1) Use stress management strategies 2) Get adequate sleep and rest 3) Avoid saturated fats Sources of Nutrition: Teaching About Food Sources of Calcium 1) Dairy 2) Kale 3) Egg Yolks Care of Specific Populations: Evaluating Health Risks of Migrant Farm workers 1) Climate caused illnesses 2) Communicable diseases 3) Bladder and kidney disorders Medications for Substance Use Disorders: Evaluating Teaching about Disulfram 1) Daily oral medication that is a type of aversion (behavioral therapy) 2) Wear medical adult bracelet 3) Used concurrently with alcohol will cause acetaldehyde syndrome Anxiety Disorders: Action for a client who is Experiencing a Panic Level of Anxiety 1) Structured environment for physical safety 2) Monitor for, and protection from, self-harm 3) Open-ended questions, to help the client express feelings of anxiety Anxiety Disorders: Planning Care for a client Who Has Obssessive-Compulsive Disorder 1) SSRI antidepressant, such as sertraline or paroxetine 2) Assess client risk for self-harm 3) Ensure client is provided with a safe environment Cultural, Ethnic, and Religious Influence: Food Selections for a Client Who Follows a Kosher Diet 1) Tuna 2) Herring 3) Salmon Effective Communication: Responding to a Client Who is Obese and Crying 1) Interactive, purposeful communication skills 2) Express empathy and genuine concern 3) Elicit and attend to a client’s thoughts, feelings, concerns, and need Psychotic Disorders: Caring for a Client who has Auditory Hallucinations 1) Ask directly about hallucinations 2) Should not argue or agree with the client’s view of the situation 3) Provide for safety, due to the increased risk for harm to self or others Sedative-Hypnotics: Identifying Antidote to Diazepam 1) Administer by oral route 2) Instruct clients to take medication 30 min prior to bedtime 3) Instruct clients to take medication on an empty stomach and to avoid high-fat foods before taking Substance Use and Addictive Disorders: Identifying Manifestations of Opiod Withdrawal 1) Diarhea 2) Insomnia 3) Pupil Dilation Effective Communication: Responding to a Client Who Has