MILESTONE FULL EXAM 2024/2025 |VERIFIED |ACCURATE ANSWERS
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Course
Milestone
Institution
Milestone
Eye drop admin - ACCURATE ANSWER-Administer medication safely and appropriately,
-Avoid cornea,
-Never touch eye or eye lid with administration device,
-Pressure to lacrimal duct after giving medications,
-Inner to outer canthus
Enema Patient Preparation - ACCURATE ANSWER-Explain the purp...
MILESTONE FULL EXAM 2024/2025
|VERIFIED |ACCURATE ANSWERS
Eye drop admin - ACCURATE ANSWER✅✅-Administer medication safely and
appropriately,
-Avoid cornea,
-Never touch eye or eye lid with administration device,
-Pressure to lacrimal duct after giving medications,
-Inner to outer canthus
Enema Patient Preparation - ACCURATE ANSWER✅✅-Explain the purpose
-A reclining position for enema administration
-Specifically left side-lying with the upper thigh pulled toward the abdomen if
possible, or the knee-chest position
-If the patient has a respiratory disorder or is having difficulty breathing, elevate
the head of the bed slightly.
-Avoid Fowler's position because the solution will remain in the rectum and
expulsion will occur rapidly, resulting in minimal cleansing.
-Some patients think the solution should be expelled as soon as possible. Reinforce
the need to retain the solution to achieve the desired results.
Residual Urine - ACCURATE ANSWER✅✅urine that remains in the bladder
after voiding
Ambulation Tolerance - ACCURATE ANSWER✅✅The ability to the act, action,
or an instance of moving about or walking
,Wheelchair Transfer CVA - ACCURATE ANSWER✅✅Bedside to Wheelchair
1) Support pt.'s weakest side
2) Turn pt. to a decubitus position
3) Place one arm under neck & other over the legs
4) "Swoop" pt. into sitting position
5) Straddle pt.'s legs
6) Put hands on pt.'s hips
7) Lift & pivot into the wheelchair
Wheelchair Safety - ACCURATE ANSWER✅✅-Check wheel locks;
-Check for flat or loose tires; Check wheel spokes;
-Be sure casters point forward for balance and stability;
- Be sure person's feet are on footplates before pushing or repositioning (feet
cannot touch or drag on floor);
-Push chair forward when transporting person, going backward ONLY through a
doorway;
-Lock both wheels before you transfer person to or from the wheelchair;
- Follow care plan for keeping wheels locked when not mving wheelchair (locking
would keep person from moving or getting out of chair is so desired);
-DO NOT let person stand on footplates;
-DO NOT let footplates fall back onto person's legs;
-Make sure person has needed safety belt, pouch, tray, lapboard or cushions;
-Remove armrests (if able) when transferring person to bed, toilet, commode, tub,
or car;
-Swing front rigging out of way to transfer to & from wheelchair (some detach);
- Clean wheelchair according to agency policy;
,-Ask nurse or PT to show you how to propel wheelchair up steps, ramps, and over
curbs; ---Follow measure to prevent equipment accidents
Droplet precautions - ACCURATE ANSWER✅✅-Use a private room, if
available. Door may remain open.
-Wear PPE upon entry into the room for all interactions that may involve contact
with the patient and potentially contaminated areas in the patient's environment.
-Transport patient out of room only when necessary and place a surgical mask on
the patient if possible.
-Keep visitors three ft from the infected person.
Droplet Precautions - ACCURATE ANSWER✅✅-Flu
-Meningitis
-Mumps
-Pneumonia
Restraints - ACCURATE ANSWER✅✅-are devices that limit the patient's
movement and are used to prevent the client from injury
-RN is to protect and promote the patient's rights while in them
-Need MD order and frequent monitoring by RN
-Every 15 minutes (q15m) for the first hour, then every 30 minutes (q30m) to
ensure proper circulation.
-Removed every 2 hours (q2h) for range of motion, toileting, and offer of fluids.
-Written order by provider based on exam before applied, no PRN orders,
minimum q4 hour assessment for adults, MD assessment face-to-face q 24 hours,
Reportable if death during use w/I 24 hours
, Side Rails Restraints - ACCURATE ANSWER✅✅-not considered a restraint if
the patient requests that it be raised to be able to get in and out of bed.
-They have to be able to demonstrate that they can raise and lower the side rail by
themselves
-Usually in the hospital setting 4 side rails is considered a restraint
-can pose serious risks for a confused or agitated patient. Entanglement or injury,
asphyxiation and can be fatal.
Saline Flush - ACCURATE ANSWER✅✅prefilled syringe with 10 mL 0.9%
sodium chloride (NS)
Braden Scale - ACCURATE ANSWER✅✅-Sensory perception, moisture,
activity, mobility, nutrition, friction and shear
-The higher the number the greater the risk
Fats - ACCURATE ANSWER✅✅9 cals per gram
Alchohol - ACCURATE ANSWER✅✅7 cals per gram
Protein - ACCURATE ANSWER✅✅4 cals per gram
Carbs/Starch - ACCURATE ANSWER✅✅4 cals per gram
Sugars - ACCURATE ANSWER✅✅4 cals per gram
Nutrition Assessment Calorie counts - ACCURATE ANSWER✅✅Records
portion size patient consumes - RN; Does not rely on memory
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