a nurse is assessing a client who has required bed rest for the past month

Posted on October 8th, 2020

Emboli, secondary to total parenteral nutrition occur when air is permitted to enter this closed system during tubing changes and when a new bottle or bag of hyperalimentation is hung. Jean Watson’s Jean Watson developed the Human Caring Theory which states that caring is the essence of nursing. You would recommend a skin sealant, including products like Bard’s Protective Barrier and Convatec’s Allkare, which are a fast drying polymer transparent film that can be applied relatively simply with a wipe or a spray. For example, when the first day of the last menstrual period is 10/20/2016 you would: You should explain that fetal station is the level of the fetus’ presenting part in relationship to the mother’s ischial spines. The nurse must maintain a 1/2 inch border around the sterile field that is not sterile. A sentinel event is an event or occurrence, incident or accident that has led to or may have possibly led to client harm. The stages of conflict and conflict resolution in the correct sequential order are frustration, conceptualization, and taking action. Which of the following, Administer the medication with the needle at a 45 degree angle. The right competency is not one of these basic Five Rights, but instead, competency is considered and validated as part of the combination of matching the right task and the right person; the right education and training are functions of the right task and the right person who is able to competently perform the task; the right scope of practice, the right environment and the right client condition are functions of the legal match of the person and the task; and the setting of care which is not a Right of Delegation and the matching of the right person, task and circumstances. You would document the size of this wound as 24 cm.

Optic Cranial Nerve: This sensory nerve transmits the sense of vision from the retina to the brain.

Cognitive models of disability focus on the importance of affected client’s ability to remain as independent as possible and ways that the empowered client can exercise their own self-determination, confidence, self efficacy, and control. Ask the clients how often they use the stress management techniques that they have learned during this educational series. provider as a possible indication of a skin malignancy. The appearance of petechiae is a sign of thrombocytopenia which is a low platelet count. If there is a danger that anyone may cough or sneeze over the field, the professional staff and/or the client should don a mask to prevent contamination. The next thing that you would do is assess the client to determine their physical status and to provide necessary emergency measures, including CPR, if it is indicated. The goal of this environment is to facilitate the client’s coping and recovery without the need to cope with these extraneous and avoidable stressors. The Patient Self Determination Act, which was passed by the US Congress in 1990, gives Americans the right to make healthcare decisions and to have these decisions protected and communicated to others when they are no longer competent to do so. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. For this reason, nurses must refer to a compatibility or incompatibility chart before they mix medications or medications and solutions. The NCLEX-RN Test Plan is organized into four major Client Needs categories. Disinfect the client’s finger with an alcohol swab.

Assessing the Client's Need for Sleep and Rest and Intervening As Needed How much sleep is needed depends upon the individual, their age and their level of wellness. The normal partial pressure of oxygen (PaO2) is from 75 to 100 mm Hg. Secondary intention healing, also referred to as healing by second intention, is done for contaminated wounds in order to prevent infections, to prevent the formation of abscesses and to promote healing from the bottom up to the outer surface of the skin so that any potential infection is not closed in at the bottom of the wound. Hemolysis can be prevented by typing and cross matching the blood and checking for ABO compatibility prior to administration. They also follow-up with patients who have gotten a prosthesis to check and adjust it in terms of proper fit, patient comfort and functioning. 1 hour  =  The ordered mL per hour 125 mLs
Validate the nurse’s competency in terms of the application of body mechanics principles during a transfer. The Mental Health Parity Act passed in 2008, mandates insurance coverage for mental health and psychiatric health services in a manner similar to medical and surgical insurance coverage. Click on the section names below to jump to a particular section of the RegisteredNursing.org NCLEX-RN Practice Exam. This is how to determine the client’s total daily dosage when the doctor has ordered has ordered 5 mg/kg/day: This is how to determine the client’s dose for each of the two divided doses: 109.05/2 = 54.53 mg which is rounded off to 55 mg for each of two divided doses. Questions are rarely asked. The most complete and accurate definition of a physical restraint is any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body and is NOT a safety devices that is routinely used for certain procedures, according to the Centers for Medicare and Medicaid Services. Your client may be experiencing a fluid overload. For example, genetics, age and gender are NOT modifiable risks, but the risks associated with life style choices are modifiable, correctable and able to be eliminated when the person changes their behavior in reference to these risky behaviors.

Question the order because Benadryl is an antihistamine and not a sleeping medication. Pelvic inflammatory disease is most often caused by the Neisseria gonorrhoeae and Chlamydia trachomatis pathogens; and it most often occurs as the result of untreated salpingitis, pelvic peritonitis, a tubo ovarian abscess and/or endometritis. A 76 year old female client who has a history of alcohol abuse. A root cause is a factor that has led to a sentinel event; and there is no such thing as a healthcare acquired event. Prep the top of the shorter acting insulin with an alcohol swab. Physical therapists are licensed healthcare professionals who assess, plan, implement and evaluate interventions including those related to the patient’s functional abilities in terms of their gait, strength, mobility, balance, coordination, and joint range of motion. Both nurses document this wasting. Question the order because Benadryl is contraindicated when the client has a sleep inducement disorder. This therapy is not conducted by registered nurses but, instead, by experienced psychotherapists. Validate the nurse’s competency in terms of the application of ergonomics principles during a transfer.

The need for a targeted assessment is based on the application of the nurse’s knowledge of pathophysiology and the presenting symptoms. The second dose of penicillin can lead to distributive shock. Computer data deletion does not always destroy all evidence of the data; data remains. The signs and symptoms of septic shock include the classical signs of infection in addition to hypotension, confusion, metabolic acidosis, respiratory alkalosis, abnormal breath sounds like crackles and rales, a widened pulse pressure, and decreased cardiac output. Another way to perform this longitudinal evaluation is to look at the staff member’s use of over time, like the last six months, when the unit was adequately staffed. The Norton Scale measures the client’s risk for the impairment of skin integrity. You should be aware of the fact that about 20% of the population has an allergy to both penicillin and latex. A 64 year old male client who has a history of impaired oxygen transport. Based on this client’s signs and symptoms and the fact that the client is expected to die in a day or two, the appropriate client outcome for this client is that the client will remain free of pain and distress. This problem is calculated as shown below. Finally, the data in this question does not indicate that the client is constipated and in need of a laxative. The olfactory cranial nerve is a sensory nerve that transmits the sense of smell to the olfactory foramina of the nose; the optic cranial nerve is also a sensory nerve and it transmits the sense of vision from the retina to the brain. The Five Rights of Delegation include the right task, the right circumstances, the right person, the right direction or communication, and the right supervision or feedback. The member of the multidisciplinary team that you would most likely collaborate with when the client can benefit from the use of adaptive devices for eating is the occupational therapist. Root cause analysis activities ask “Why”, rather than “Who”, which would place blame on a person or group of people: and What? finding should the nurse identify as a potential indication of abuse? The verification of the doctor’s order for a medication is to confirm the right paint, medication, dose, route and time or frequency, it, in itself, is not one of the “10 Rights”.

Tornados, cyclones, hurricanes and other severe weather emergencies can be both an internal disaster when they affect the healthcare facility and also an external disaster when they impact on the lives of those living in the community.

Avoidance of the conflict, withdrawing in addition to other passivity, competition, and accommodating others are not effective and healthy conflict resolution techniques. Non REM sleep is sleep that is not accompanied with rapid eye movements (REM).

Prep the top of the longer acting insulin vial with an alcohol swab.
A client interview, a significant other interview, a general survey and a complete physical assessment. Deontology: The school of ethical of thought that requires that only the end goal must be ethical. Mormonism: Baptism for the newborn, last rites at the time of death, communion, and burials of the dead. A gait or transfer belt and slide boards are assistive devices that can be used to assist with transfers and lifting however, they are not appropriate for this client as based on your assessment. The fact that drugs classified as categories A, B and C are contraindicated for women who are pregnant. Behavioral psychotherapy is particularly useful among clients who are adversely affected with phobias, substance related disorders, and other addictive disorders. Circadian rhythms are sometimes referred to as our body clock. Mediterranean ethnicity for cystic fibrosis. In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills pf rest and sleep in order to: Some of the terms and terminology that you should be familiar with in terms of rest and sleep are described below. They remain liable. Fetal position is the relationship of the fetus’ presenting part to the anterior, posterior, right or left side of the mother’s pelvis. Some of these standardized pediatric pain scales, in addition to the CRIES scale, include the FACES Pain Scale, the Toddler Preschooler Postoperative Pain Scale (TPPPS), the Neonatal Infant Pain Scale (NIPS), the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), the Faces Legs Activity Cry Consolability Pain Scale (FLACC), the Visual Analog Scale (VASobs) the Observation Scale of Behavioral Distress (OSBD), the COMFORT Pain Scale and the Pre-Verbal Early Verbal Pediatric Pain Scale (PEPPS) that is used with toddlers. Intramuscular injection sites are determined by using boney landmarks and not by palpating the muscle. (Select all that apply.) A 76 year old female client who has a history of diabetes.

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