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what is the nurse’s job in informed consent - witness the informed consent ensure provider gave client all info ensure client understand notify provider of client has more questions document client
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ATI EXAMS what is the providers responsibility in the informed consent process- explain purpose of procedure
describe procedure
description of potential side effects
options for other treatment
option to refuse and consequences of doing so
what is the nurse’s job in informed consent - witness the informed
consent
ensure provider gave client all info
ensure client understand
notify provider of client has more questions
document client questions
what are the nursing actions for a client who requires home oxygen -
wear cotton to prevent static electricity
ensure all electrical devices are working properly
educate on hazards of smoking while using
nursing interventions for a client with dysphagia and feeding -
position in high Fowler or in chair
support upper back, neck and head
tuck their chin while swallowing
avoid use of straw
keep client in semi-flowers for at least one hour after feeding
provide oral hygiene after meals and snacks
information included in a transfer report - medical diagnosis and
care providers
demographics
overview of health status, plan of care and recent progress
any immediate concerns care needed in next few hours
VS
allergies
special equipment
AD
family involvement
first aid for external bleeding - ID sources of external bleeding and
apply direct pressure
do not remove impaled objects
practices that maintain a sterile field - prolonged exposure to
airborne mi organisms can make sterile items non-sterile
only sterile items can be in the sterile field (outer wrapping and 1-
inch edges not sterile)
do not reach or turn your back on sterile field
any sterile, no waterproof wrapper that comes in contact with
moisture becomes non-sterile
instructions on cane use - maintain two points of support on ground
at all times
cane on stronger side of body
support weight on both legs
move cane 6-10 inches forward
next move weaker leg towards cane
then stronger leg
identifying cultural variables during assessment - use of space
use of silence
use of the body
use of touch
facial expressions
eye movement
tone of voice assessing pain in a client who has dementia and difficulty
communicating - facial expressions
moaning, crying
decreased attention span
BP, RR, HR increase
expected findings for dehydration - hypo or hyperthermia
tachycardia
thready pulse
hypotension
hypoxia
dizziness
confusion
thirst
dry mucous membranes
oliguria
lab findings for fluid volume overload - decreased Hct and Hgb
decreased blood osmolarity
decreased urine sodium
decreased BUN
Normal Hct values - Male: 40-54%
Female: 37-47%
Normal Hgb levels - Men: 14-18
Women: 12-16
Normal BUN levels - 10-20 mg/dL
actions to take if a client refuses a medication - respect the clients
right to refuse, explain the consequences, notify provider and
document
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