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if a patient is confused and/or disoriented, and is incontinent,
what is the right course of action? - ANSWER -begin a toileting
program to take the patient to the bathroom approx. every 2
hours (or so) and prevent incontinence
what do you need to administer restraints - ANSWER -reason
and doctors orders ; combative, confused/disoriented, danger
to self or others (WHY do they need restraints, find underlying
cause)
if you make a medication error, what should you do first? -
ANSWER -assess
the patient, then notify the provider with the assessment
of the patient,
document with an incident report, do not put it
in the MAR
what nutritional elements can help maintain skin integrity -
ANSWER -protein
,and
fluids
what nutritional elements can help decrease risk of
infection - ANSWER -
vitamins, minerals, adequate
nutritional elements
what can nurses delegate? - ANSWER -ambulating, bathing,
turning/repositioning, blood glucometer, vital signs for stable
patients (must be double checked if irregular), mouth care,
monitoring/calculate input and output (not IV or stomas) ,
feeding (not NG tubes, aspiration risk), linen changes, weight
measurements, basic care!
what cannot be delegated?
(ask self, does this task require TAPE?) - ANSWER -TAPE;
Teaching
Assessment, Planning, Evaluation
hypoventilation - ANSWER ->12 with labored breathing; add
supplemental
oxygen (with order), CPAP; can be caused
by narcotics
what is SaO2? - ANSWER -amount of hemoglobin bound with
oxygen in arteries
, bed rest - ANSWER -limits activity (even ambulating for
bathroom)
water soluble vitamins - ANSWER -A, D, E, K
basal metabolic rate - ANSWER -how much energy cells
need to perform
functions at
rest
what main vitamin is good for skin health/maintaining skin
integrity? - ANSWER -
vitamin
c
what vitamins are good for bone health? - ANSWER -calcium
and vitamin d
what do healthy muscles need? - ANSWER -protein and calories
what vitamin is good for energy? - ANSWER -vitamin b
with immobility, what happens to the heart? - ANSWER -
decreased activity puts increases stress on the heart because
other body systems are not helping maintain circulation; this
can leading to pooling and DVT; the workload is increased but
the output is decreased