Basic Nursin Skills Blueprint. Cards with * are the ones she said remember
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| What are some things that make up a person's environment? | Walls, floors, lighting, & climate control
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| What colors promote a soothing effect? | blue, mauve, & light green
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| Where should lighting be placed in a person's room? | over the patient's bed
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| What should you do if the patient is c/o the room being too cold? | adjust the thermostat & get the patient a blanket
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| ***** What are some patients that might need the temperature adjusted? | Infants & older adults might need warmer rooms
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| ***** If your patient is congested what might you see ordered & why? | A humidifier to moisten respiratory passages
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| If the room is not ventilated well what might that cause? | Room will smell
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| What are some things that might cause odor in the hospital? | Bedpans, urinals, wounds, body odor
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| What are some odors that linger? | Cigarette smoke, strong foods (onions & garlic), perspiration
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| ***** List some things you can do for noise control | Avoid talking on the intercom, limit conversations in the halls, speak in lower voices, soft pleasant background noise, adjust t.v. volume
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| The bed being adjustable is a ______ and ______ factor. | comfort & safety
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| What position should the bed remain in unless otherwise needed? | Lowest
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| You have a confused patient, what should you do for this patient? | Bring them to the nurses station or have a family member set with them
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| How thick is an eggcrate that relieves pressure? | 4 inches
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| List some things that pillows are used for. | Supporting body parts, keeping the body in position, and splinting a surgery site
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| List steps you will take before a linen change. | Access what you will need, gather you linens, check the bed for loose articles, wear gloves, raise the bed
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| How do you apply linens? | Top to bottom one side at a time
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| When changing an occupied bed describe how you position the patient. | in the side lying position on the far side of the bed with the side rails raises
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| How would knowing the patient's diagnosis alter how the bed is changed? | the patient may not be able to get up, the head of the bed may not be able to be adjusted, there may be special equipment that can't be moved.
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| What are some things that the overbed table is used for? | Meals are served on it, sterile field is set up on it, activities (writing, reading, applying makeup)
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| What equipment might you find on the bedside stand? | suction equipment, wound supplies, peri wash, any item that may be used on the patient for care or for specific purposes
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| What are some ways that you can protect the patient's safety? | orient them to their room, call light, & hospital environment
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| ****** What has safety guidelines that are required by OSHA to have on each unit? | MSDS (Material Safety Data Sheet)
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| What is the leading cause of death in infant/toddlers and school age children as well as adolescents? | Accidents
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| List some reasons why older adults are at an increased risk for falls. | visual impairment, urinary urgency, reduced coordination, & impaired mobility.
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| What can you do if the patient is c/o being cold and their feet are cold? | provide additional blankets & encourage the used of warm bed socks
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| What does all fire prevention include? | good housekeeping, maintenance, & employee discipline
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| What are the different types of fire extinguishers and what are they used for? | Type A- for wood, paper, cloth
Type B- for flammable liquid fires (grease & anesthetics)
Type C - for electrical fires
Type ABC- for any type of fire
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| Describe what RACE stands for | R- Rescue & remove individuals closest to the fire
A - Activate the alarm
C- Confine the fire by closing windows & doors. Turn of all oxygen & electrical equipment)
E- extinguish the fire using a fire extinguisher
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| When using an extinguisher what does the word PASS refer to? | P-Pull the pin
A-Aim low
S-Squeeze
S-Sweep
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| What is asphyxiation? | The inability to breath
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| What are some causes of asphyxiation? | Food, inhalation of vomit or other liquids, smoke, carbon monoxide, swelling in the throat or mouth
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| What is carbon monoxide? | odorless smokeless gas
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| Individuals that are suffering from carbon monoxide poisoning, their cells are starving for _______. | oxygen
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| What are some of the s/s of carbon monoxide poisoning? | headache, nausea/vomiting, dizziness, weak muscles, confusion, shortening of breath, cherry red skin
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| What is the first intervention when someone is suffering from carbon monoxide poisoning? | get the person into fresh air
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| What is a much more radical treatment for carbon monoxide treatment? | hyperbaric treatment
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| What are some safety precautions that could help prevent drowning? | Never leave a child unattended around water, Enroll in a water safety program, learn to swim, wear water safety devices, Never go into the water alone
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| What is one thing we can do in our home to prevent electrical shock in our home where children are concerned? | Make sure plug covers are in place
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| You have a patient admitted to the hospital that brings their electric razor in with them. What should you do? | Let maintenance check it out for frayed cords or loose plugs
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| ***** What is poison? | any substance (solid, liquid, gas) that even in small amounts causes damage to the body or interferes with the function of it's system?
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| ***** What information do you need when you call a poison control center? | weight & age of the patient, substance ingested, inhaled, or injected, how much, when taken, if other drugs were taken, and by what route, status of the patient at the present time.
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| You have a patient that ARS (Acute Radiation Sickness) what is one thing you may have to limit? | the amount of time you are in the room (limit you exposure to radiation)
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| What is the most common route of poisoning? | by mouth
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| ***** What is the first step you should do when poisoning has occurred? | Assess the patient, obtain a history, call poison control
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| What should you do first when a patient comes in with suspected poisoning? | Assess the patient & obtain a history
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| What are some things that we can do to prevent accidental poisoning? | Don't keep medicine in your purse, Don't call medicine candy, keep chemicals in their original container, keep toxins stored & clearly labeled, check carbon monoxide detectors to make sure they are working
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| When would you not induce vomiting on a patient suffering from poisoning? | if the victim is having a seizure, if they are semiconscious or unconscious, if nurse suspects caustic or corrosive substance, serious heart condition, later stage of pregnancy, or under 9 months old
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| What is the most frequent cause of injury in the hospital? | Falls
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| What type of patients are at an increase risk for falls and what can you do to reduce the chances of this occurring? | confused, taking narcotics, weak. You should assess them often & remind them to get help when up.
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| If a fall occurs for one of your patients what would you do first? | Check the condition of the patient
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| What is the principle behind using protective devices? | Use the least amount of immobilization as needed for the situation
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| ***** What are the 2 types of restraints? | physical & chemical
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| What is the purpose of a restraint? | To prevent the patient from injuring themselves or others
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| You have a confused patient, what do you need to do before applying a restraint? | talk with the patient and determine the cause of the problem
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| What are some of the problems that may occur when restraints are used? | more confusion, chronic constipation, incontinence, upper respiratory infection, pressure ulcers, UTI
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| What is OBRA and what does it define? | Omnibus Budget Reconciliation Act - it defines the rights & choices of clients & also states acceptable reasons for the use of physical restraints
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| What are some of the restraint regulations according to OBRA? | Only as a last resort, only applied under a Dr.'s order that specifies why & for how long, the patient agrees, the patient be free of physical restraints not required to treat their medical symptoms
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| You as the nurse can't _____ delegate responsibility to the family to monitor the patient. | legally
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| When are some times when a restraint might be necessary? | protecting the patient from falls, protect a body part, keep the patient from interfering with therapies (pulling out tubes, disconnecting IV's, removing wound coverings, reduce risk to others)
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| If unable to obtain a doctor's order prior to applying restraints how soon do you need to get an order & how often does it need to be renewed? | 24 hours, 24 hours
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| How often do you monitor a patient in restraints? | Frequently
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| When using restraints what are some things you would assess? | vital signs, circulation, skin condition, behavior
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| What are some general things you would document concerning the use of restraints? | behavior that made restraints necessary, type of restraint, explanation given to the client & support person, client's consent, time restraint was applied & removed, client's behavior, frequency of care, circulation, ROM, notification of Dr., reevaluation
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| What are 2 things that you need to assess when using restraints? | circulation & ROM
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| What are some things that you can do before using restraints? | Assign nurses in pairs, place patient close to supervision, prepare patient for a move, stay w/ patient, monitor meds, lower bed, use rocking chairs, wedge pillows/pads, lap tray, warm drink, soft lights, back rub, walk, environmental restraints, etc.
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| What are some possible causes of wandering disorientation & combativeness? | poor hearing, poor eyesight, pain, frustration
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| List some reasons why you wouldn't use restraints. | patient constantly calling for assistance, short handed, patient getting up & you don't have time to watch them
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| What must you do to bony prominences when applying restraints? | pad them
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| How often does the restraint need to be removed? | Every 2 hours
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| Describe how you would apply a w/c restraint. | under the w/c to the back, tie the straps in a 1/2 bow knot
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| Describe how you would secure a wrist or posey restraint. | Tie it to the movable part of the bed frame
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| If using a posey vest, besides v/s, circulation, and performing ROM, what else do you need to assess? | agitation
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| What type of restraints might you use for a patient that is pulling at their IV's, dressing, or scratching a wound? | Mitten restraints or Wrist restraints
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| If wrist restraints are used what would you need to evaluate to assess circulation of an extremity? | color, warmth, pulse distal to the device
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| During your assessment you notice the s/s that indicate impaired circulation. What would you do? | Release restrain & notify the Dr.
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| How would you make sure that a vest restraint is not applied too tight? | place you hands under the vest
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| If you apply a restraint and the patient becomes more confused what should you do? | remove the device, stay with the patient, talk to them to calm them down
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Created by:
Jacksonville VNE
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