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Nursing Students NCLEX

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[h=4]Interested in studying, reviewing and discussing learned/unlearned material for LPN or RN since it is much of the same information, your welcome to join me.

Study & Support Group it's important to have.[/h][h=4]I am in the state of Florida but anyone can join me.[/h]

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Lets start with Fundamentals and will follow with Medical Surgical which is the bulk of theNCLEX exam.

Unless a special request is made to review a different subject.

Most of the information recorded here is intended for study,review & discussion as mention and will come from facts, online, nursing books or lectures.

Nursing Process:

Nursing assessment is an important step of the whole nursing process and it is used over and over.

Objective of Nursing Process:

Is to help patients alleviate, minimize, or prevent actual or potential health problems. Through effective communication between nurse and patients in any variety of settings this process is being carried out continually.

Assessment: Get as much health information from all sources, exp: patient, family, friends. Includes physiological, psychological, sociocultural, spiritual, economic, and life-style factors as well.

Diagnosis: Is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs.

Planning: Sets measurable and achievable short- and long-range goals.

Implementation: Implement according to the above data collected.

Evaluation: Continuously evaluate the effectiveness and modify the care plan as needed.

*Benjamin Franklin once wrote that failing to have a plan is planning for failure.

"Failing to PLAN is planning to FAIL"

The Nurse is a patient advocate.

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A tort is a civil wrong made against a person or property. Torts may be classified as unintentional or intentional.

Unintentional tort is negligence or malpractice.

Negligence -conduct falls below standard of care i.e. taking a stop sign

Malpractice: is negligence committed by a professional such as a nurse or physician. Exp: Misuse of controlled substances.

Intentional torts are willful acts that violate another's rights. Examples are assault, battery, invasion of privacy and defamation of character.

* Assault -verbal or offensive contact i.e. threaten to give injection w/o consent.

* Battery -any intentional touching w/o consent i.e. actually give injection.

* Publication of private or embarrassing facts

* Defamation of Character -publication of false statements that result on damage to a person's reputation.

* Malice -person knows information is false and still publishes it.

* Slander -if statement is ORAL.

* Libel -if statement is WRITTEN

Who can give consent and what is the nurse's role?

Informed consent: is a process for getting permission before conducting a healthcare intervention on a person.

It should be a collaborative activity between the physician, nurse, and patient. The physician should have obtained consent before the nurse has the patient sign a form.

Nurses can offer what we do best—patient teaching, as we check patient understanding and obtain written consent. Where possible, use the teach-back method, asking the patient to repeat back what he/she understands. However, our teaching cannot take the place of prior physician / patient shared decision-making

Four factors must be verified for a consent to be valid:

* The person giving consent must be mentally and physically competent and be legally an adult (over 18 yrs of age or emancipated).

*The consent must be given voluntarily; no forceful measures may be used to obtain it.

*The person giving the consent must thoroughly understand the procedure, its risks and benefits, and alternative procedures.

*The person giving consent has the right to have all questions answered satisfactorily and confirm his or her understanding of the treatment given.

The nurse's signature witnessing the consent means that the client voluntarily gave consent, that the client's signature is authentic, and that the client appears to be competent to give consent.

Beneficence : refers to taking positive actions to help other.

Nonmaleficience: is the avoidance of harm or hurt, seek to do the least harm if benefits must result in some harm.

What are the nurse's responsibilities and actions after finding a patient injured from a fall?

The nurse completes an incident report, the physician is notified.

The nurse documents only and objective description of what was actually observed, and follow up care that occurred, and does not specify in the medical record that an incident report was prepared. These are the guidelines:

a) The nurse who witnessed the incident or who found the client at the time of the incident files the report.

b) Describe specifically what happened in concise, objective terms.

c) Describe objectively the client's condition when the accident was discovered.

d) Report any measures taken by oneself, other nurses, or physicians at the time of the incident.

e) Do not interpret or attempt to explain the cause of the incident or blame anyone.

f) Submit the report as soon as possible to the appropriate administrator.

g) Keep a written account of the incident report for personal files.

h) Do not photocopy the report since the copy could be subpoenaed in court.

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The Five Rights of Medication Administration

​Reduce medication errors and harm is to use the five rights”:

The right patient

The right drug

The right dose

The right route

The right time.

Documentation is important to mention because if not documented it was never done.

Nurses should also know information about the drug and the patient has the right to refuse the drug.

An Original copy of the living will must be present to be accepted.

DNR: Do-not-resuscitate order Allows you to choose whether or not you want CPR before an emergency occurs. It is specific about CPR. It does not provide instructions for other treatments, such as pain medicine, other medicines, or nutrition.

Organ donor patients: next of kin must give permission.

Order of Kin:

Spouse

Adult son or daughter

Mother

Adult brother or sister

Legal guardian

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Delegation: Who can you delegate?

RN to RN, LPN, CNA

RN STILL ACCOUNTABLE - ALWAY FOLLOW UP - PROTECT YOUR LICENSE,

Don't delegate tasks outside the scope of practice.

Be clear when delegating.

CNA report to LPN or RN.

CNA and LPN can NOT Assess,Teach, Delegate or create a care plan.

CNA assist with basic needs, they observe,feed, bathe, dress patients, take patient vital signs,serve meals, make beds and keep rooms clean among other things.

LPN:

  • Giving medication as prescribed by a physician
  • Taking vital signs, such as blood pressure, temperature, and weight
  • Basic wound care including cleaning and bandaging injured areas
  • Giving injections of medication
  • Immunizations
  • Taking medical histories
  • Entering information into computer systems

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Handwashing: Clean Hands Save Lives

NO sharing, change gloves, wash hands before and after care.

Standard: uniform level of caution that should be used in all patients -primary goal = Prevent transmission of nosocomial infection -hand hygiene -gloves -misc barriers (mask, eye protection, face shield, gown)

Contact: Direct skin to skin. (Exp: Diphtheria)

Droplet: Loaded with infectious particles can travel up to 3 feet. ( Exp: Sneeze,cough,exhale)

Airborne: Spread through the air, small droplets of Anthrax (inhalational), Chickenpox,Influenza, Measles, Smallpox, Cryptococcosis, and Tuberculosis.

Cranial Nerves:

I Olfactory Smell

II Optic Central/peripheral vision

III Oculomotor Pupil constriction

IV Trochlear Have pt follow tip of finger

V Trigeminal Jaw strength

VI Abducens 6 cardinal movements of eyes

VII Facial Facial symmetry

VIII Acoustic Ears –hearing

IX Glossopharnygeal Taste, uvula midline, etc

X Vagus Taste, uvula midline, etc.

XI Accessory Neck, shoulder

XII Hypoglossal Midline tongue

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Fire in patients room?

PACE / RACE

P = get patient out / R = Rescue patients

A = activate fire alarm, rescue other patients

C = close door to confine fire

E = extinguish fire

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QUESTIONS:

1. A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the client's vital sign hereafter. What phrase of nursing process is being implemented here by the nurse? 1

  1. Assessment
  2. Diagnosis
  3. Planning
  4. Implementation

2.Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions? 4

  1. Providing a back massage
  2. Feeding a client
  3. Providing hair care
  4. Providing oral hygiene

The first techniques used examining the abdomen of a client is: 4

  1. Palpation
  2. Auscultation
  3. Percussion
  4. Inspection

Resonance is best describe as: 1

  1. Sounds created by air filled lungs
  2. Short, high pitch and thudding
  3. Moderately loud with musical quality
  4. Drum-like

The nurse asked the client to read the Snellen chart. Which of the following is tested: 1

  1. Optic
  2. Olfactory
  3. Oculomotor
  4. Troclear

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DROPLET Precaution:

SPIDERMAN

S- sepsis

9k=S-scarlet fever

S-streptococcal pharyngitis

P-paravovirus B19

P-pertussis

P-pneumonia

I- influenza

D-diphtheria (pharyngeal)

E-epiglottis

R-rubella

M-mumps

M-meningitis

M-mycoplasma or meningeal pneumonia

An-adenovirus

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