🧠 NURSING PROCESS & SCOPE OF PRACTICERN vs LPN ...
  • Info
    Click 'Save & Edit' to enable all features
    Export
    Study
    Edit
    Manage
Public
Save & Edit
Searching...
Flashcards in this deck (93)

  • What are the primary roles of an RN?

    • Assessments
    • Care plans
    • Most meds
    • Teaching
    nursing roles

  • What does LPN focus on?

    • Focused care
    • Some meds
    nursing roles

  • What tasks does a CNA perform?

    • ADLs
    • Vitals
    • Hygiene
    nursing roles

  • What are the 5 Rights of Delegation?

    • Right task
    • Right circumstance
    • Right person
    • Right direction
    • Right supervision
    nursing delegation

  • Define negligence in nursing.

    Failure to act as a reasonable nurse would.

    nursing legal

  • What is malpractice?

    Professional negligence by a nurse.

    nursing legal

  • What is meant by abandonment in nursing?

    Leaving a patient without proper handoff.

    nursing legal

  • Who explains informed consent?

    The provider, with the nurse only witnessing.

    nursing legal

  • What does ADPIE stand for?

    • Assessment
    • Diagnosis
    • Planning
    • Implementation
    • Evaluation
    nursing process

  • What is the NANDA diagnosis format?

    Problem related to cause.

    nursing diagnosis

  • What makes a goal SMART?

    • Specific
    • Measurable
    • Achievable
    • Relevant
    • Time-bound
    nursing goal-setting

  • What are the 6 links in the chain of infection?

    • Agent
    • Reservoir
    • Portal
    • Mode
    • Entry
    • Host
    infection control

  • Differentiate between medical and surgical asepsis.

    • Medical: Clean
    • Surgical: Sterile
    infection control

  • What do contact precautions require?

    • Gown
    • Gloves
    infection precautions

  • What do droplet precautions require?

    A mask.

    infection precautions

  • What is required for airborne precautions?

    • N95 mask
    • Negative pressure room
    infection precautions

  • What is the best prevention of infection?

    Hand hygiene.

    infection prevention

  • What is required for a C. diff room?

    Use soap & water (not alcohol).

    infection control

  • What is the most common inpatient injury?

    Falls.

    safety injuries

  • What are the 2 patient identifiers?

    • Name
    • DOB
    safety identification

  • When are restraints used?

    As a last resort only.

    safety restraints

  • What do suicide precautions include?

    • 1:1 observation
    • Remove hazards
    safety precautions

  • What is the proper bed position?

    Lowest locked position.

    safety positioning

  • What is the normal SpO₂ range?

    ≥ 95%.

    oxygenation vital-signs

  • What is the minimum SpO₂ for COPD patients?

    ≥ 88%.

    oxygenation copd

  • What are early signs of hypoxia?

    • Restlessness
    • Tachycardia
    • Anxiety
    oxygenation hypoxia

  • What are late signs of hypoxia?

    • Cyanosis
    • Confusion
    • Bradycardia
    oxygenation hypoxia

  • What is the flow rate for nasal cannula?

    1–6 L/min.

    oxygenation flow-rate

  • What is the flow rate for a simple mask?

    6–10 L/min.

    oxygenation flow-rate

  • What is the flow rate for a nonrebreather mask?

    Up to 15 L/min.

    oxygenation flow-rate

  • Differentiate between delirium and dementia.

    • Delirium: Acute
    • Dementia: Chronic
    cognition comparison

  • What is a key sign of delirium?

    Sudden confusion.

    cognition delirium

  • What is priority safety for confused patients?

    Fall prevention.

    safety cognition

  • What are the best aids for sensory loss?

    • Glasses
    • Hearing aids
    • Good lighting
    cognition sensory

  • Differentiate between acute and chronic pain.

    • Acute: Short term
    • Chronic: >3 months
    pain types

  • What is an example of neuropathic pain?

    Diabetic neuropathy.

    pain neuropathic

  • What are some non-pharmacologic pain relief methods?

    • Positioning
    • Heat/cold
    • Relaxation
    pain relief

  • Pain is considered the 5th vital sign.

    True.

    pain vital-signs

  • Therapeutic communication focuses on the patient, not the nurse.

    True.

    communication therapeutic

  • What is an example of an open-ended question?

    How are you feeling?

    communication questions

  • What is an example of a closed-ended question?

    Are you in pain?

    communication questions

  • What is the best practice for an interpreter?

    Speak to the patient, not the interpreter.

    communication best-practice

  • Why should family members be avoided as translators?

    To maintain patient confidentiality.

    communication best-practice

  • What indicates a Stage 1 pressure injury?

    Non-blanchable redness.

    integumentary pressure-injury

  • Describe a Stage 2 pressure injury.

    Partial thickness skin loss.

    integumentary pressure-injury

  • What is a Stage 3 pressure injury?

    Full thickness tissue loss.

    integumentary pressure-injury

  • What is a Stage 4 pressure injury?

    Muscle/bone exposed.

    integumentary pressure-injury

  • How often should patients be turned?

    Every 2 hours.

    integumentary care

  • What scale predicts pressure injury?

    Braden scale.

    integumentary assessment

  • What is the normal urine output per day?

    1200–1500 mL.

    elimination output

  • What is the definition of oliguria?

    < 400 mL/day.

    elimination output

  • What are common causes of constipation?

    • Low fiber
    • Immobility
    • Opioids
    elimination constipation

  • What is a sign of urinary retention?

    Bladder distention.

    elimination retention

  • What are signs of Fluid Volume Deficit (FVD)?

    • Dry mucosa
    • Hypotension
    • Dark urine
    fluid-volume deficit

  • What causes FVD?

    • Vomiting
    • Diarrhea
    • Diuretics
    • Burns
    fluid-volume deficit

  • What are signs of Fluid Volume Excess (FVE)?

    • Edema
    • Crackles
    • JVD
    • Weight gain
    fluid-volume excess

  • What are common causes of FVE?

    • Heart failure
    • Kidney failure
    • Excess IV fluids
    fluid-volume excess

  • How much fluid does 1 kg weight change equal?

    1 liter.

    fluid-volume weight

  • What is the normal range for sodium?

    135–145.

    electrolytes sodium

  • What is the normal range for potassium?

    3.5–5.0.

    electrolytes potassium

  • What is the normal range for calcium?

    8.6–10.5.

    electrolytes calcium

  • What are signs of hyponatremia?

    • Confusion
    • Weakness
    • Seizures
    electrolytes hyponatremia

  • What are signs of hypernatremia?

    • Thirst
    • Dry mouth
    • Restlessness
    electrolytes hypernatremia

  • What EKG change is associated with hypokalemia?

    Flat T wave.

    electrolytes hypokalemia

  • What EKG change is associated with hyperkalemia?

    Tall peaked T wave.

    electrolytes hyperkalemia

  • What are signs of hypocalcemia?

    • Tingling
    • Tetany
    • Chvostek sign
    electrolytes hypocalcemia

  • What are signs of hypercalcemia?

    • Kidney stones
    • Constipation
    • Weakness
    electrolytes hypercalcemia

  • What is the primary energy source in nutrition?

    Carbohydrates.

    nutrition energy

  • What is the function of protein?

    Growth and tissue repair.

    nutrition protein

  • What BMI indicates underweight?

    < 18.5

    health bmi

  • What BMI indicates obesity?

    <blockquote>

    30

    </blockquote>

    health bmi

  • What is the normal range of albumin?

    3.4–5.4 g/dL

    health albumin

  • What is the best technique for aspiration prevention?

    Chin-tuck position

    health aspiration

  • A sign of dysphagia is?

    Coughing while eating

    health dysphagia

  • What does NREM sleep support?

    Tissue repair, immune support

    sleep nrem

  • What is the main purpose of REM sleep?

    Dreaming, brain activity

    sleep rem

  • How many hours of sleep do adults need?

    7–9 hours

    sleep adults

  • What is the definition of insomnia?

    Inability to fall or stay asleep

    sleep insomnia

  • What is narcolepsy?

    Sudden uncontrollable sleep attacks

    sleep narcolepsy

  • What defines sleep apnea?

    Breathing stops during sleep

    sleep apnea

  • What is considered the best sleep hygiene habit?

    Consistent bedtime

    sleep hygiene

  • Define anticipatory grief.

    Grief before death occurs

    grief loss

  • What is disenfranchised grief?

    Grief not socially accepted

    grief loss

  • What constitutes complicated grief?

    Prolonged, maladaptive grief

    grief loss

  • List the Kubler-Ross stages of grief.

    • Denial
    • Anger
    • Bargaining
    • Depression
    • Acceptance
    grief loss

  • What is an end-of-life breathing pattern?

    Cheyne-Stokes

    grief loss

  • What is the last sense to disappear?

    Hearing

    grief senses

  • What does DNR stand for?

    Do Not Resuscitate

    grief medical

  • Define ethnocentrism.

    Belief that one’s culture is superior

    culture diversity

  • What is stereotyping?

    Generalizing without proof

    culture diversity

  • What does cultural competence entail?

    Respectful, responsive care to beliefs

    culture diversity

  • What is culture shock?

    Disorientation in unfamiliar culture

    culture diversity

  • Before providing care, you should ask about?

    Beliefs

    culture patient_care
Study Notes

Nursing Process & Scope of Practice

Roles of Nurses

  • RN: Conducts assessments, develops care plans, administers medications, provides education.
  • LPN: Focuses on patient care and administers some medications.
  • CNA: Assists with activities of daily living (ADLs), takes vital signs, ensures hygiene.

Key Legal Concepts

  • Negligence: Failing to act as a reasonable nurse would.
  • Malpractice: Professional negligence exhibited by a nurse.
  • Abandonment: Leaving a patient without a proper handoff.
  • Battery in Healthcare: Unauthorized touching.
  • Informed Consent: Explained by the provider; nurses witness.

Nursing Process Steps

  • ADPIE:
  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation

Goal Setting

  • SMART Goals: Specific, Measurable, Achievable, Relevant, Time-bound.

Infection Control

Chain of Infection

  • 6 Links: Agent, Reservoir, Portal of Exit, Mode of Transmission, Portal of Entry, Host.

Asepsis

  • Medical Asepsis: Clean technique.
  • Surgical Asepsis: Sterile technique.

Precautions

  • Contact Precautions: Gown + gloves required.
  • Droplet Precautions: Mask required.
  • Airborne Precautions: N95 mask + negative pressure room.

Best Practices

  • Infection Prevention: Hand hygiene is key.
  • C. difficile precautions: Requires soap & water, not alcohol.

Safety

Patient Safety

  • Common Injury: Falls are the most frequent inpatient injury.
  • Patient Identification: Use 2 identifiers (Name + DOB).
  • Restraints: Used as a last resort only.
  • Suicide Precautions: 1:1 observation; remove hazards.
  • Bed Position: Maintain in the lowest locked position.

Oxygenation

Oxygen Saturation

  • Normal SpO₂: ≥ 95%.
  • COPD Minimum SpO₂: ≥ 88%.
  • Signs of Hypoxia:
  • Early: Restlessness, tachycardia, anxiety.
  • Late: Cyanosis, confusion, bradycardia.

Oxygen Delivery

  • Nasal Cannula: 1–6 L/min.
  • Simple Mask: 6–10 L/min.
  • Nonrebreather: Up to 15 L/min.

Cognitive & Sensory

Delirium vs Dementia

  • Delirium: Acute confusion; sudden onset.
  • Dementia: Chronic cognitive decline.

Safety for Confused Patients

  • Priority: Fall prevention.

Aids for Sensory Loss

  • Glasses, hearing aids, and appropriate lighting.

Comfort & Pain

Types of Pain

  • Acute Pain: Short-term.
  • Chronic Pain: Lasts longer than 3 months.

Pain Management

  • Neuropathic Pain: Example: diabetic neuropathy.
  • Non-Pharmacologic Relief: Positioning, heat/cold therapy, relaxation.
  • Pain as a Vital Sign: Considered the 5th vital sign.

Communication

Effective Communication

  • Therapeutic Communication: Focuses on the patient, not the nurse.
  • Open-ended Questions: Example: "How are you feeling?"
  • Closed-ended Questions: Example: "Are you in pain?"
  • Interpreter Protocol: Speak to the patient directly, avoid relying on family members.

Integumentary

Pressure Injury Stages

  • Stage 1: Non-blanchable redness.
  • Stage 2: Partial thickness skin loss.
  • Stage 3: Full thickness tissue loss.
  • Stage 4: Muscle or bone exposed.

Prevention

  • Turning Patients: Every 2 hours.
  • Pressure Injury Risk: Assessed using the Braden Scale.

Elimination

Urinary Output

  • Normal: 1200–1500 mL/day.
  • Oliguria: Defined as < 400 mL/day.

Constipation Causes

  • Low fiber intake, immobility, opioid use.
  • Urinary Retention: Signs include bladder distention.

Fluid Volume

Fluid Volume Deficits vs Excess

  • FVD Signs: Dry mucosa, hypotension, dark urine.
  • FVE Signs: Edema, crackles, JVD, weight gain.

Weight Change

  • 1 kg equals 1 liter of fluid.

Electrolytes

Normal Ranges

  • Sodium: 135–145 mEq/L.
  • Potassium: 3.5–5.0 mEq/L.
  • Calcium: 8.6–10.5 mg/dL.

Electrolyte Imbalances

  • Hyponatremia: Signs include confusion and seizures.
  • Hyperkalemia: Tall peaked T waves on EKG.
  • Hypocalcemia: Signs of tingling and Chvostek sign.

Nutrition

Nutritional Fundamentals

  • Primary Energy Source: Carbohydrates.
  • Protein Role: Growth and tissue repair.
  • BMI Definitions:
  • Underweight: < 18.5
  • Obese: > 30.

Aspiration Prevention

  • Best Technique: Chin-tuck position.
  • Dysphagia Indicator: Coughing while eating.

Sleep & Rest

Sleep Needs

  • Normal Adult Requirement: 7–9 hours.
  • NREM Sleep: Responsible for tissue repair.
  • REM Sleep: Involves dreaming and brain activity.

Sleep Disorders

  • Insomnia: Difficulty falling/staying asleep.
  • Narcolepsy: Uncontrolled sleep attacks.

Grief & Loss

Types of Grief

  • Anticipatory Grief: Grief before death occurs.
  • Disenfranchised Grief: Not socially accepted grief.
  • Complicated Grief: Prolonged, maladaptive grieving.

Kubler-Ross Stages

  • Stages of grief: Denial, Anger, Bargaining, Depression, Acceptance.

Diversity & Culture

Cultural Concepts

  • Ethnocentrism: Belief of cultural superiority.
  • Stereotyping: Generalizing without evidence.
  • Cultural Competence: Respectful, responsive patient care.

Cultural Interaction

  • Cultural Shock: Disorientation when encountering a new culture.
  • Pre-Care Assessment: Always inquire about cultural beliefs.