Adult Health II Exam 1
What are the 5 rights of delegation?>>> -right task
-right circumstance
-right person
-right direction and communication
-right supervision and evaluation
What can you NOT delegate to a LPN or UAP?>>> -assessments
-patient teaching
-evaluation of care
-admitting a patient
-caring for an unstable patient
What medications + interventions can LPNs perform regarding CKD/in general?>>> -Can: oral meds
-Can: IM/SQ injections
-Other medications depend on hospital policy (ex. some can hang IVF)
-LPN can do dialysis catheter care Q shift
-Cannot: dialysate exchange, intraperitoneal antibiotics, or dialysis catheter care teaching
What does SBAR stand for? What information should be included in each area?>>> S: Situation
-what is happening in the present
-identify self, patient, and room number
-state the problem: what it is, when it started, and the severity
-identify why you are concerned
B: Background
,-what is the background that led up to this situation
-state pertinent background related to the situation: admitting diagnosis, date of admission,
medications, allergies, most recent VS, labs, treatment, and code status
A: Assessment
-explain what you think the problem is
-what is your assessment of the situation
-state changes from prior assessments
-explain if the patient is unstable or worsening
R: Recommendation/ Request
-explain what we should do to correct the problem
What is the RN's role in caring for a patient who uses complementary and alternative therapy?>>> -
know that some herbs interact with over the counter meds and prescriptions (educate about this)
-some herbs can increase clotting time (ex. can bleed out during surgery)
-stop all CAM 2-3 weeks prior to surgery
-obtain a thorough medication list by using open ended question (ex. all herbs, prescriptions, and
supplements)
-educate: take the recommended amount; moisture, sunlight, and heat may change the components of
the herbs; side effects of herbs should be reported to the HCP
A patient treated with antihypertensive medication is planning to start using meditation to promote
relaxation and reduced anxiety. The nurse cautions the patient that
a.meditation can be used successfully only if the patient is responsive to suggestion.
b.the blood pressure should be monitored frequently because the medication might need to be
adjusted.
c.frequent appointments, practice times, and goal setting are necessary for effective use of meditation.
d.meditation can be a good complementary therapy, but medications will always be needed.>>> B
,Rationale: This response ("the blood pressure should be monitored ...") indicates the nurse's acceptance
of the patient's choice while still indicating the possible need for standard drug therapy for
hypertension. The response beginning "meditation can be a good complementary therapy ..." is
incorrect because hypertension can sometimes be controlled by practices such as meditation. The
remaining two responses indicate that the patient may not be successful in practicing meditation and
would discourage the patient from trying this potentially helpful complementary therapy.
The RN is planning the client assignments for the day. Which of the following is the most appropriate
assignment for the nursing assistant?
a.A client requiring a colostomy irrigation
b.A client receiving continuous tube feedings
c.A client who requires urine specimen collection
d.A client with difficulty swallowing food and fluids>>> C
A nursing assistant has the skill to care for the client who requires urine specimen collections. Colostomy
irrigations and tube feeds are not performed by UAP. The client with difficulty swallowing would be at
risk for aspiration.
S/S of a UTI (upper vs. lower)>>> -Upper = systemic s/s like a fever, chills, malaise, flank pain
-Lower: dysuria (painful urination; common), frequency (do not feel like fully emptying; pee less than
every 2 hours), urgency (can become incontinent), supra-pubic discomfort/pressure, hematuria, cloudy
urine, and foul smelling urine
S/S of a UTI for older adults>>> -s/s: non-localized abdominal discomfort and confusion
-do not always have s/s of dysuria, pain, or fever
How to prevent UTIs>>> -regular bladder/bowel emptying
-wipe from front to back (ex. e.coli comes from feces --> wipe incorrectly --> UTI)
-drink 2-3 L of fluid a day (ex. 8 glasses)
, -cranberry juice or tablets
-voids before and after intercourse
-cath care
Define:
-Inflammation of the renal parenchyma/collecting system
-Begins in lower tract and ascends to upper
-Common with the elderly population>>> Pyelonephritis
S/S and Tx for Pyelonephritis>>> S/S
-fatigue
-chills
-fever
-vomiting
-malaise
-flank pain
-lower UTI s/s
-costovertebral angle tenderness
Tx
-antibiotics and fluids
Glomerulonephritis
-define
-s/s>>> Strep throat (antibody induced) --> Inflammation of glomeruli (upper UTI)
S/S
-hematuria (ex. dark colored)!!
What are the 5 rights of delegation?>>> -right task
-right circumstance
-right person
-right direction and communication
-right supervision and evaluation
What can you NOT delegate to a LPN or UAP?>>> -assessments
-patient teaching
-evaluation of care
-admitting a patient
-caring for an unstable patient
What medications + interventions can LPNs perform regarding CKD/in general?>>> -Can: oral meds
-Can: IM/SQ injections
-Other medications depend on hospital policy (ex. some can hang IVF)
-LPN can do dialysis catheter care Q shift
-Cannot: dialysate exchange, intraperitoneal antibiotics, or dialysis catheter care teaching
What does SBAR stand for? What information should be included in each area?>>> S: Situation
-what is happening in the present
-identify self, patient, and room number
-state the problem: what it is, when it started, and the severity
-identify why you are concerned
B: Background
,-what is the background that led up to this situation
-state pertinent background related to the situation: admitting diagnosis, date of admission,
medications, allergies, most recent VS, labs, treatment, and code status
A: Assessment
-explain what you think the problem is
-what is your assessment of the situation
-state changes from prior assessments
-explain if the patient is unstable or worsening
R: Recommendation/ Request
-explain what we should do to correct the problem
What is the RN's role in caring for a patient who uses complementary and alternative therapy?>>> -
know that some herbs interact with over the counter meds and prescriptions (educate about this)
-some herbs can increase clotting time (ex. can bleed out during surgery)
-stop all CAM 2-3 weeks prior to surgery
-obtain a thorough medication list by using open ended question (ex. all herbs, prescriptions, and
supplements)
-educate: take the recommended amount; moisture, sunlight, and heat may change the components of
the herbs; side effects of herbs should be reported to the HCP
A patient treated with antihypertensive medication is planning to start using meditation to promote
relaxation and reduced anxiety. The nurse cautions the patient that
a.meditation can be used successfully only if the patient is responsive to suggestion.
b.the blood pressure should be monitored frequently because the medication might need to be
adjusted.
c.frequent appointments, practice times, and goal setting are necessary for effective use of meditation.
d.meditation can be a good complementary therapy, but medications will always be needed.>>> B
,Rationale: This response ("the blood pressure should be monitored ...") indicates the nurse's acceptance
of the patient's choice while still indicating the possible need for standard drug therapy for
hypertension. The response beginning "meditation can be a good complementary therapy ..." is
incorrect because hypertension can sometimes be controlled by practices such as meditation. The
remaining two responses indicate that the patient may not be successful in practicing meditation and
would discourage the patient from trying this potentially helpful complementary therapy.
The RN is planning the client assignments for the day. Which of the following is the most appropriate
assignment for the nursing assistant?
a.A client requiring a colostomy irrigation
b.A client receiving continuous tube feedings
c.A client who requires urine specimen collection
d.A client with difficulty swallowing food and fluids>>> C
A nursing assistant has the skill to care for the client who requires urine specimen collections. Colostomy
irrigations and tube feeds are not performed by UAP. The client with difficulty swallowing would be at
risk for aspiration.
S/S of a UTI (upper vs. lower)>>> -Upper = systemic s/s like a fever, chills, malaise, flank pain
-Lower: dysuria (painful urination; common), frequency (do not feel like fully emptying; pee less than
every 2 hours), urgency (can become incontinent), supra-pubic discomfort/pressure, hematuria, cloudy
urine, and foul smelling urine
S/S of a UTI for older adults>>> -s/s: non-localized abdominal discomfort and confusion
-do not always have s/s of dysuria, pain, or fever
How to prevent UTIs>>> -regular bladder/bowel emptying
-wipe from front to back (ex. e.coli comes from feces --> wipe incorrectly --> UTI)
-drink 2-3 L of fluid a day (ex. 8 glasses)
, -cranberry juice or tablets
-voids before and after intercourse
-cath care
Define:
-Inflammation of the renal parenchyma/collecting system
-Begins in lower tract and ascends to upper
-Common with the elderly population>>> Pyelonephritis
S/S and Tx for Pyelonephritis>>> S/S
-fatigue
-chills
-fever
-vomiting
-malaise
-flank pain
-lower UTI s/s
-costovertebral angle tenderness
Tx
-antibiotics and fluids
Glomerulonephritis
-define
-s/s>>> Strep throat (antibody induced) --> Inflammation of glomeruli (upper UTI)
S/S
-hematuria (ex. dark colored)!!
