PCA Test Questions & Answers Accurate 100%

5 rights of delegation - Answer 1. Task 2. Person 3. direction/communication 4. circumstance 5. supervison codes: Red black blue - Answer red- fire black- bomb blue- medical emergency what not to chart? - Answer assumptions opinions false info negative comments ac - Answer before meals c. diff- - Answer spore for microorganism (can remain in environment for months) -need bleach to clean -clean hands with soap and water one oz= ____ ml - Answer 30 ml how much urine should you excrete an hour? - Answer 30 ml` when to take virtual VS? - Answer q4hr for 3 days (72 hours) (output) 6am, 2pm & 10 pm Approach the patient from the front and call by name? true or false: - Answer true assist the patient with hygiene, eating, drinking, toileting, ambulating and positioning how often? - Answer q 2 hours or as needed ways one can assist with orientating the patient to his or her surroundings? - Answer 1. glasses 2. clocks 3. reassurance 4. touch hands validation therapy - Answer any confused person: talk to them as if they were in reality at the particular time ( go along with their story even if its not reality) 4 co-worker safety tips regarding doing a one to one: - Answer 1. face the patient 2. sit by door 3. stay alert (no sleeping) 4. a pulse oximeter measures what? - Answer oxygen saturation and pulse Vital signs = - Answer BP, respirations, pulse, temperature, pulse oximeter 6 Factors that could have an affect on a persons vital signs: - Answer Infection Fever Stress Pain Strong emotions Weight age injury meds exercise Blood pressure ranges: systolic & diastolic - Answer 120/80 systolic (90-140) diastolic (60-90) Temperature ranges: - Answer 96.5-100.4 oral temperature - Answer 97-99.5 axillary temperature - Answer 96.6-98.6 rectal and temporal temperature: - Answer 98.6-100.6 tympanic temperature - Answer 95.9-99.5 pulse range - Answer 60-100 respiration range - Answer 12-20 pulse oximeter - Answer 95%-100% You report vital sign measurements immediately to the nurse if they are abnormally what? - Answer high or low besides the rate when taking a pulse, what do you need to be aware of? - Answer rhythm, strength and regularity tachycardia: - Answer heart rate over 100 pbm bradycardia: - Answer heart rate under 60 bpm hypotension - Answer low blood pressure hypertension - Answer high blood pressure orthostatic hypotension - Answer low blood pressure when standing up or sitting up communicable infection - Answer it can spread from one person to another what type of environment does pathogens live in? - Answer warm, moist, dark and has oxygen to grow is the skin a defense mechanism? - Answer yes, for infection easiest thing to do to prevent infection? - Answer hand washing c-diff, how do you do hand hygiene? - Answer wash hands with soap and water use bleach to clean everything but hands nosocomial infection - Answer acquired during the hospital stay if you cant get to soap to wash your hands, what should you do? - Answer use alcohol foam to wash hands what does wearing gloves do to help? - Answer it is a barrier from the pathogens reaching your skin Risk factors for infection include: - Answer very young or very old age, poor general health, stress, fatigue and indwelling medical devices (such as catheters, feeding tubes and IV's) Signs and symptoms of infections that need to reported to the nurse: - Answer 1. swelling 2. redness/rash 3. drainage 4. diarrhea 5. N/V 6. fever 7. sores on mucous membranes medical asepsis - Answer clean technique -practice to remove/destroy pathogens and prevent the spread surgical asepsis - Answer sterile technique -no bacteria or microorganisms how long should you wash your hands with soap, water and friction? - Answer 20 seconds how much alcohol foam should you use to wash your hands if not visibly soiled? - Answer 1 quarter what items are considered PPE? - Answer gown, gloves, goggles and mask name specific times you should wash your hands: - Answer -when soiled -using restroom -before & after preparing food -entering/leaving patients room -after coughing -sneezing or blowing nose -touching contaminated objects when measuring a patients nutrition, record what? - Answer record the % of food and nutritious liquids the patient consumes solid food that melts at room temperature are considered _________- ex: ice cream & jello - Answer liquids output is body fluid that can be _________- - Answer measured what doesn't count as nutrition? - Answer soda, coffee, tea, ice & water For I & O, use a _____________ to measure fluid output - Answer graduated cylinder Measuring I & O is critical especially for patients with _______ & ________- disease - Answer cardiac and renal disease CALCULATIONS!! - Answer # 10 Nutrition and fluid??? - Answer edema - Answer too much fluid in the tissues of the body dehydration - Answer too little fluid in the body emesis - Answer vomiting NPO - Answer nothing by mouth whose responsibility is it to make sure the preoperative check list is complete? - Answer nurses a patient is going to surgery, they need to be prepared how? - Answer emotionally and physically when will a patients vital signs be taken more often? - Answer postop SCD's or pneumatic compression devices - Answer inflate and deflate to prevent DVT's, prevent cardiovascular problems -improves blood flow TED's - Answer anti-embolism stockings to prevent DVT's, clots in legs IS - Answer incentive spirometer, needed to open lungs with deep breathing what can you do to prepare for a patient returning from surgery? - Answer -have O2, TED's, IS and SCD's ready -have drains prepared -have emesis container prepared -water pitcher -VS machine -bedside commode -specimen hat -blankets, klenex intraoperative phase - Answer time during surgery can a pressure ulcer be fatal? - Answer yes a pressure ulcer usually starts how? - Answer with a reddened area on a patient that doesn't return to normal color once the pressure to the area is relieved pressure to an area over a length of time - Answer can be the cause of a pressure ulcer heals should be floated off the bed to prevent what? - Answer them from getting boggy pressure ulcer is the result of: - Answer tissue not receiving the proper nutrition and oxygen supply can pressure ulcers be caused by friction? - Answer yes can a patient develop pressure ulcers anywhere else but a bed? - Answer yes, chairs 4 risk factors a patient may have in developing a pressure ulcer - Answer moisture elderly inability to feel response to pressure poor nutrition How can PCA prevent pressure ulcers? - Answer support surfaces initiate turning and repositioning moisture and incontience preventing proper nutrition warning signs ear and device skin protection grand mal seizure - Answer A type of seizure that involves a loss of consciousness and violent muscle contractions. holism - Answer whole person reaction to stress? - Answer headache illness fear? - Answer -disability, financial hardships, not returning home unconscious - Answer unaware of surroundings what do we do when a dementia patient wanders from their room? - Answer redirect them back to their room types of weights done upon admission? - Answer balanced scale, electronic and bed scale best time to do daily weights? - Answer before breakfast what days are everyone weighed? - Answer wednesday do we transfer anyone home? - Answer no, we discharge them AMA - Answer leaving without doctors order safety checks how often for high fall vs. low fall risk? - Answer high- q 2 hrs low- q 4 hrs