front 1 Cultural and Spiritual Nursing Care: Using a Medical Interpreter
Chapter 35
Advocacy | back 1 - Use only a facility-approved medical interpreter. Do not use
the client's family or friends or a nondesignated employee.
- Inform the interpreter about the reason for and the type of
questions that will be asked.
- Allow time for the
interpreter and the family to be introduced and become
acquainted.
- Ask one question at a time.
- Use lay
terminology if possible, knowing that some words may not have an
equivalent word in the client's language.
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front 2 Legal Responsibilities: Continuity of Care
Chapter 4
Concepts of Management | back 2 - Nurses should use the formal chain of command to verbalize
concerns related to assignment in light of current legal scope of
practice, job description, and area of competence.
- Nurses
should refuse to practice beyond the legal scope of practice.
- Nurses must ensure the clients understand their rights and
protect their client's rights.
- Nurses are accountable for
protecting the rights of clients.
- Nurses must ensure the
clients understand their rights and protect their client's
rights.
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front 3 Admissions, Transfers, and Discharge: Initiating Discharge Planning
Chapter 9
Continuity of Care | back 3 - Discharge planning should begin on admission - unless it is
long-term care.
- Assess whether or not the client will be
able to return to his previous residence.
- Determine whether
or not the client will need to have someone to assist him at home,
and if he has that person.
- Assess the residence to see if
the client will need adaptations or specific equipment.
- A
client who is legally competent has the right to leave the facility
at any time.
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front 4 Information Technology: Correct Documentation
Chapter 5
Continuity of Care | back 4 - Subjective data can be documented as direct quotes, within
quotation marks, or summarized and identified as the information of
the client's statement.
- Objective data should be
descriptive and should include what the nurse sees, hears, feels,
and smells.
- Information and facts should be documents
precisely - only abbreviations and symbols approved by the Joint
Commission.
- Never pre-chart an assessment, intervention, or
evaluation.
- Communicate documented information in a logical
sequence.
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front 5 Information Technology: End of Shift Report
Chapter 5
Continuity of Care | back 5 - Formats include face-to-face, audiotaping, or presentation
during walking rounds in each client's room.
- A report
should include significant objective information about the client's
health problem.
- It should proceed in a logical
sequence.
- There should be no gossip or personal
opinions.
- Changes in medications, treatments, procedures, and
discharge plans should be related.
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front 6 Safe Medication Administration and Error Reduction: Documentation
Chapter 47
Reporting of Incident/Event/Irregular Occurrence/Variance | back 6 - Do not use od, qd, qod, or qhs. Write out words.
- So
not write subq, write subcut.
- Do not write IN or IJ.
- Write out greater than or less than.
- Do not use / to
indicate per, write out per.
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front 7 Pharmacokinetics and Routes of Administration: Instructing Client to
Self-Administer Insulin
Chapter 46
Safe Use of Equipment | back 7 - When drawing up regular and NPH insulin, inject air into NPH,
inject air into regular, draw up regular, draw up NPH.
- Insulin is injected subcutaneously (also heparin).
- Inject into adequate fat bad (abdomen, upper hip, lateral upper
arms, thighs).
- Clear insulin must be drawn up before cloudy
insulin.
- Roll insulin between hands prior to
administering.
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front 8 Infection Control: Caring for a Client with Methicillin-Resistant
Staphylococcus Aureus
Chapter 11
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis | back 8 - Use a respirator for clients with TB.
- Rinse equipment
first in running cold water, then in warm water with soap.
- Masks, eye protection, and face shields are required when care
may cause splashing or spraying of body fluids.
- Avoid
overuse of antimicrobials.
- Teach client about infection
control measures at home, self-administration of medications, and
any complications that need immediate attention.
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front 9 Medical and Surgical Asepsis: Preparing a Sterile Field
Chapter 10
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis | back 9 - Prolonged exposure to airborne micro-organisms can make sterile
items nonsterile.
- Only sterile items may be in a sterile
field.
- Consider any items held below waist or above the chest
to be nonsterile.
- Outer wrappings and 1-inch edges of
packaging that contains sterile items are not sterile.
- Do
not reach across or turn your back on a sterile field.
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front 10 Mobility and Immobility: Steps for Transferring a Client
Chapter 40
Mobility/Immobility | back 10 - First, determine how capable a client is of participating in
the transfer.
- Explain the transfer process so the patient
understands what will happen.
- Ensure all equipment is ready
and functioning properly before beginning to move the patient.
- Maintain correct posture, use appropriate body mechanics and
lifting techniques, and use assistive devices whenever
possible.
- When moving patients from a bed to a wheelchair or
a gurney, put all brakes in the locked position to prevent falls and
injuries.
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front 11 Pharmacokinetics and Routes of Administration: IM Injections
Chapter 46
Medication Administration | back 11 - Sites with high blood perfusion have rapid absorbtion. IM has
risk for infection, though.
- IM injections are appropriate
for irritating medications, solutions in oils, and aqeous
suspensions.
- Use a needle size 18 to 27 gauge (usually 22 to
25), length 1 to 1.5 inches long, and injected at 90 degree
angle.
- Volume injected is usually 1-3 ml; if a greater amount
is required, it should be divided into two syringes.
- Most
common sites include ventrogluteal, deltoid, and vastus lateralis
(pediatric). Dorsogluteal is contraindicated.
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front 12 Specimen Collection for Glucose Monitoring: Using Correct Technique
Chapter 52
Diagnostic Tests | back 12 - Outer edge of the fingertip is the most common site.
- Rotate sites to avoid ongoing tenderness.
- Cleanse the
site with warm water and soap or antiseptic swab (not alcohol).
- Wipe away the first drop of blood.
- Hold finger in
dependent position.
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front 13 IV Therapy: Interventions to Promote Infusion
Chapter 49
Potential for Complications of Diagnostic Tests/Treatments/Procedures | back 13 - Infiltration - pallor, local swelling, decreased skin
temperature, damp dressing, slowed rate of infusion. Stop infusion
and remove catheter, elevate, restart infusion proximal to the
site.
- Phlebitis - edema, throbbing, burning, increased skin
temperature, red line up arm. Discontinue and remove catheter, apply
warm compress, culture site.
- Fluid overload - JVD,
increased BP, tachycardia, SOB, crackles, edema. Stop infusion and
raise head of bed.
- Cellulitis - pain, warmth, edema,
induration, red streaking, fever, malaise, chills. Discontinue and
remove, elevate and apply warm compress, obtain specimen.
- Embolus - missing catheter tip, severe pain at side with
migration. Place tourniquet high on extremity to limit venous flow,
save the catheter, prepare for removal.
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front 14 Fluid and Electrolyte Imbalances: Findings to Report
Chapter 57
Fluid and Electrolyte Imbalances | back 14 - Hyponatremia - coma, seizures, respiratory arrest.
Hypernatremia - serious neuro, endocrine, and cardiac
disturbances.
- Hypokalemia - PVCs, hyperthermia, hypotension,
muscle weakness and cramping, parasthesias. Hyperkalemia - Cardiac
arrhythmias and cardiac arrest.
- Hypocalcemia - painful
muscle spasms, parasthesias, Chvosteks sign (facial twitching) and
Trousseaus sign (blood pressure cuff). Hypercalcemia - decreased
reflexes, bone pain, flank pain (renal calculi).
- Hypomagnesemia - hyperactive DTR, C and T signs, increased
cardiovascular symptoms. Hypermagnesemia - diminished DTR, muscle
paralysis, decreased cardiovascular signs.
- Dehydration
indicates increased protein, BUN, electrolytes, and glucose.
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