Exam (elaborations)
NUR 283 Transition To Registered Nursing Practice Transitions_comp_3_notes__1
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- Galen College Of Nursing
NUR 283 Transition To Registered Nursing Practice
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!!!!WE’RE ALMOST THERE!!!!�� When answering NCLEX questions, remember: ��
a. ADPIE for developing plan of care
i. Always assess first
ii. Is the question asking for an intervention? Or do you need to gather more data first?
b. UNSTABLE > STABLE
i. patient w/ expected findings for their diagnosis are considered stable
c. ACUTE > CHRONIC conditions
d. SYSTEMIC > LOCAL
i. Systemic s/s (fever, hypotension, tachycardia) take priority
e. ABC→ safety→ pain→ education/feelings framework for PRIORITY interventions
i. If CPR is necessary: Compressions FIRST→ Airway SECOND → Breathing LAST
ii. Airway- NPO, gag reflex present, breathing, airway
iii. Breathing- breath sounds, O2 admin, pulse ox, raise the HOB
iv. Circulation- HR, BP, fluid status, diarrhea, IV fluids, central lines, bleeding
v. Pain med admin is rarely a priority
f. Use subjective & objective data when care planning
2. FLU VACCINE GUIDELINES (announcements) Question on vaccine
a. Shot (Inactivated) (via IM)
i. CAN get= children 6m+, pregnant women
ii. CAN’T get= children younger than 6m, prior allergic rx to flu vaccine (gelatin & eggs allergy), hx of Guillain Barre
Syndrome (dystonia), or is feverish
b. Nasal Spray (Live)
i. CONTRAINDICATED= adults >50y, pregnant women, children <2y, immunocompromised (HIV, Cancer)
3. MANTOUX TB SKIN TEST (announcements) Question on what you are giving, how much, syringe, the angle, induration
timeline.
a. Administration (via epidermal)
i. Site is 2-4in below elbow on anterior forearm
ii. Inject 0.1mL w/ a tuberculin syringe (27G) at a FLAT angle (5-15degree) w/ bevel up!
1. If no wheal, must do it again at a site at least 2in away
b. Reading test
i. Within 48-72hrs
ii. Neg = flat
iii. Inspect for induration / thickening of skin (raised, palpable, hardened)... NOT ERYTHEMA
1. >5mm is a false pos+ for HIV/immunocompromised
2. >10mm is pos+ for children
3. >15mm is pos+ for anyone
4. INCIDENT REPORTS (announcements) dentures are missing file incident report
a. EX: risk for injuries (phlebitis), med errors, patient fall/injury/harm, needle sticks, patient loses something (dentures),
visitor injury on premises or a visitor that exhibits symptoms of communicable diseases
i. Should not be placed or mentioned in patients medical record
b. Use objective data & put subjective data in quotation marks
5. STAGES OF GRIEF (announcements)
(going to give ex. on test, have to know which stage the patient is in &
therapeutic communication)
Gives example on test and read through the 5 stages and you have to tell
which one it is.
a. Denial- avoidance, shock, fear
, b. Anger- frustrated, irritable
c. Bargaining- struggling with meaning, reaching out to others
d. Depression- overwhelmed and hopeless, flight
e. Acceptance- what kind of treatment/ what can I do to move on?
6. CHEST TUBES (announcements)
Collection Water Seal Suction Control
Chamber Chamber Chamber
Notify physician if: → 2cm of sterile water is needed Want to see gentle &
→ drainage is >70-100mL/hr → Tidaling w/ patient's breathing= normal continuous bubbling
→ drainage is bright red or increases (UP w/ inhalation, DOWN w/ exhalation)
→ intermittent bubbling= normal for pneumothorax NOT VIGOROUS BUBBLING
suddenly
→ continuous bubbling= air leak (indicates the need to turn
NOTE WHERE LEVEL IS AT BEGINNING OF
→ no bubbling= kink or *lung has re-expanded down suction pressure)
SHIFT
Interventions:
→ when setting up, first connect the chest tube to patient, then connect it to suction & turn on
→ keep below level of chest
→ *ALWAYS keep a clamp & occlusive dressing at bedside
→ keep petroleum gauze against the skin, covered w/ dry gauze (don’t want to see skin through the dressing b/c
it allows air to leak around the tube)
→ avoid kinks / loops ***reposition patient FIRST when assessing for a kink
→ change patient position freq to promote drainage/ventilation
→ encourage TCDB
→ NEVER strip/milk tubing
IF REMOVED / DISCONNECTED:
-insert tube into a sterile bottle of water
-apply occlusive dressing taped on 3 sides over insertion site (allows air to escape)
7. LEGAL TERMS (announcements)
a. Autonomy: individual's right to self-determination. For example, the ability of the patient to refuse treatment, such as
surgery or blood transfusion.
i. Jehovah witness refuse blood transfusions
b. Nonmaleficence: this means you have the obligation to do no harm to the patient. It is the nurse's job to make sure
they don't ever hurt their patient. If you have trouble remembering what this means, remember "non" means no or
against. And with "maleficence" recall the Disney movie, Sleeping Beauty. The evil queen was called Maleficent, which
means producing evil or mischief.
c. Beneficence: is the opposite of nonmaleficence. It means doing good. "Bene" means good. Think of something that
benefits someone or is beneficial.
d. Veracity: means telling the truth. It comes from the Latin word, "vericitas" which means truth.
e. Fidelity: means doing what you say. Think of someone being faithful. That's the etymology of this word. Think of the
Marines. Their slogan is Semper Fi--always faithful (from the Latin words "semper" which means "always" and
"fidelis"which means "faithful."
f. Negligence: "mistake". like forgetting to turn the oxygen back on your patient after walking them to the bathroom
and they suffer respiratory problems because of it. You didn't intend to harm the patient. You made a mistake, but
harm still came to the patient.
g. Malpractice: requires intent. It doesn't mean that you wanted to hurt the patient but you failed to do something you
know you should have done. For example, a Foley catheter insertion and you know you broke a sterile field and the
Foley gets contaminated, but you insert it anyway because you are too lazy to go get a new kit and start over. The
patient then gets a CAUTI because of your actions. You knew you should have gotten a new kit and failed to do so.
That's not a mistake. That was an intentional failure to perform the required duty.
h. Defamation: false communication against someone that causes damage to their reputation
i. spoken (slander)
, ii. written (libel).
i. Assault: is a verbal threat or physical stance that puts someone in fear
j. Battery: is when you follow through on your threat and actually make physical contact.
k. Nurses can witness a surgical & blood consent, but NOT AN ADVANCE DIRECTIVE
l. DNR- must be defined clearly, signed, and physically in front of you or in the chart to be active...otherwise the patient
will remain a full code.
i. If patients health status changes then it needs to be re evaluated
8. DELEGATION (announcements)
a. Delegate the RIGHT: Task, Person, Circumstance, Communication, Supervision & Eval
RN LPN UAP
-Perform initial assessments or (SOME invasive tasks) (noninvasive tasks: skin care, ROM,
status change assessments STABLE & PREDICTABLE Patients ambulation, grooming, hygiene)
-Develop care plans -Monitor patients -Baths
-Educate or teaching -Taking vitals/histories -Abulating (only AFTER an RN has assessed)
-Admin IV meds & blood transfusions -Performing routine assessments -Empty foley & ostomy bags (1/3 full), & toileting
-Dressing changes -Report I/O
-Inserting IV -Feeding
-Urinary catheterization -Changing linens
-NG tube
-Trach care/Suctioning
-admin meds (PO, SUBQ, IM)
9. SICKLE CELL DISEASE (announcements) Question on a condition that causes the flare up
a. Autosomal recessive disorder from inheriting two Hb S genes causes a mutation of RBC to sickle (like grim reaper) and
obstructs small blood vessels → ischemia! Primarily African Americans
b. Crises (vaso-occlusive):
i. Causes= reduced oxygen conditions (acidosis, hypoxia, temp changes, dehydration, infections)
ii. Extremely painful
iii. Acute exacerbations, followed by remission
c. S/S: severe pain & fever
d. Treatment:
i. Treat infections (infections precipitate crisis= medical emergency)
ii. Hydrate
iii. Supplemental O2
iv. Pain meds (no meperidine b/c of RF seizures)
v. Hydroxyurea (reduces crisis events)
vi. Folic Acid supplements- high protein diet with supplements
e. Education:
i. Immunocompromised = avoid infections, fresh fruit, standing drinks, UTD w/ vaccinations
ii. Avoid high altitudes (low O2)
iii. Maintain fluid intake (prevent dehydration)
f. Systemic effects: ALL OVER FROM HEAD DOWN
i. Hepatosplenomegaly, stroke, MI, HF, avascular necrosis of joints, retinopathy & hemorrhage
10. PEDS GI (announcements)
a. Gastroesophageal Reflux (chalasia)
i. "Spitting up" VS. vomiting/projectile vomiting
ii. TX- feed w/ head elevated 30-45 degrees
b. Esophageal Atresia w/ Tracheoesophageal Fistula
i. Have difficulty handling their secretions (frothy sputum & drooling)
ii. 3C’s= Coughing, choking, cyanosis
c. Pyloric Stenosis (AGAIN)
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