Download NCLEX Cram

NCLEX Cram – Module I
Safe and Effective Care
Environment
Prepared by
Lori Baker, RN, BSN
2013
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Management of Care (16-22% of NCLEX)
• Consents
• Nurse responsibility
• Obtain consent form and ensure
completed consent forms are on the
chart
• Witness client’s signature
• NOT nurse responsibility
• Obtaining the consent signature
• Explaining the procedure along with
all risks and benefits
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Management of Care
(16-22% of NCLEX)
• Informed Consent
• Consent obtained after the risks and
benefits of having or not having the
procedure or treatment to be performed
are explained by the person performing
the procedure
• Written Consent
• Not required for all medical treatment if
• Client has been fully informed
• Client voluntarily consents
• Immediate treatment is necessary to
save life or limb
• Pregnant minor can sign for herself AND her
fetus
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Management of Care
(16-22% of NCLEX)
• Verbal Consent
• Requires documentation in medical
record
• Describe in detail how and why it was
obtained
• Identify and record the signatures of
two witnesses to the consent who are
not directly related to the treatment or
procedure
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Management of Care
(16-22% of NCLEX)
• Written Consent
• Requires that the person giving
consent, usually the client, be
• Alert, coherent, and an otherwise
competent adult
• Parent or legal guardian
• Loco parentis (person standing in for
parent or legal guardian
(Note: consent of minor client 14 years of age
and older must agree to treatment along with
parent. Competent, emancipated minors can
consent for treatment without the consent of a
parent or guardian)
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Management of Care
(16-22% of NCLEX)
• Surgical Consent
• Obtained prior to any surgical procedure
• Consent must be
• Written
• Explained to the client and parent/guardian by
person performing procedure to include
• Possible complications and
disfigurements
• Removal of any organs or body parts
• Witnessed
• Signed by a competent adult,
emancipated minor, or competent
parent/guardian
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Management of Care
(16-22% of NCLEX)
• Good Samaritan Act
• Protects healthcare practitioner against
malpractice claims for emergency care
provided in “good faith”
• Healthcare personnel are required to
deliver care in a “reasonable and
prudent manner”
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Management of Care
(16-22% of NCLEX)
• Right to Refuse Treatment
• The patient may always do this,
however, it must be WELL
DOCUMENTED that the patient is well
aware of problems that could arise from
refusal of any treatment/procedure
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Management of Care
(16-22% of NCLEX)
• Nursing Responsibilities regarding
Advance Directives
• To deliver nursing care in a way that
meets the needs of the individual
• To deliver care that is consistent with
the goals of the individual with respect
to level of health and quality of life
• To educate and advocate for patients,
ensuring that they are fully aware of all
options and their consequences and
can make informed choices about their
healthcare
Adopted from the ANA
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Management of Care
(16-22% of NCLEX)
• Restraint reminders
• Restrain only under the following
circumstances
• In an emergency
• For a limited time
• For the limited purpose of client
safety or the safety of others
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Management of Care
(16-22% of NCLEX)
• Restraints (cont’d)
• Nursing responsibilities
• Notify healthcare provider immediately
that the client has been restrained and
obtain an order to continue use
• Document facts regarding the rationale
for restraining patient
• Physician must examine patient and write
the order for type and duration of use
• Restraint order must be renewed every
• 24 hours
(Note: restraints of any kind may constitute false
imprisonment if not treated appropriately and the
patient is protected by law)
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Management of Care
(16-22% of NCLEX)
• Legal Terms
• Negligence –
• performing an act that a reasonable
and prudent person would not
perform under similar conditions.
Includes:
• Lack of skill
• Errors
• Professional misconduct
• Failure to act
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Management of Care
(16-22% of NCLEX)
• Malpractice –
• Equates to professional negligence. The
plaintiff must prove all four of the following
elements to prove malpractice:
• Duty –
• obligation to maintain a nursing standard,
i.e. what a reasonable and prudent nurse
would do (a nurse is expected to anticipate
foreseeable risk
• Breach of duty –
• failure to maintain the nursing standard. A
reasonable and prudent nurse in the same
situation would not have performed this act
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or in this manner. (continued)
Management of Care (16-22% of NCLEX)
• Malpractice (cont’d)
• Injury/damages –
• failure to meet the standard of practice
caused mental or physical injury or
damage to the plaintiff
• Proximate cause – (causation)
• the breach of duty caused the harm
and the nurse’s action or lack of action
caused harm to the plaintiff. A
connection exists between conduct and
the resulting injury referred to as
“proximate cause or remoteness of
damage”
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Management of Care
(16-22% of NCLEX)
• Legal terms (cont’d)
• Assault –
• mental or physical threat to touch
without permission (i.e. forcing a
client to take medication or
treatments)
• Battery –
• touching without permission, with or
without the intent to do harm (i.e.
hitting or striking a client
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Management of Care
(16-22% of NCLEX)
• Five Rights of Delegation
• Right task? Can be delegated by RN or PN
• Right situation? Consider the setting and
available resources, and the appropriateness of
the delegated task
• Right person? Delegation by the proper person
and to the proper person
• Right communication? Provide expectations,
complete instructions, and well-defined limits.
Ensure understanding by the delegate
• Right supervision? Delegatee receives the
proper guidance, evaluation, and follow-up
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Management of Care
(16-22% of NCLEX)
• PN Duties
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•
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•
•
•
•
•
•
Data collection
Focused assessments
Participate in planning nursing care needs
Participate in modifying nursing care plan
Implement care within scope of practice rather than
legal, ethical, and educational parameters
Implement teaching plan for common health
problems and well-defined learning needs
Provide direct basic care to assigned multiple
clients in structured settings
Assist in evaluation of client’s responses and
outcomes to therapeutic interventions
Use a problem-solving approach as the basis for
decision making in practice
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Management of Care
(16-22% of NCLEX)
• RN Duties
•
•
•
•
•
•
Perform initial assessment
Perform comprehensive assessments
Determine nursing diagnoses
Formulate nursing care plan
Implement nursing care
Develop and implement teaching plans rather that
promotion, maintenance, and restoration of health
• Provide for care of multiple clients either through
direct care or assignment and-or delegation of
care to other members of the healthcare team
• Evaluate client’s responses and outcomes to
therapeutic interventions
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Management of Care
(16-22% of NCLEX)
• RN Duties (cont’d)
• Use critical thinking approach to analyze clinical
data and current literature as a basis for
decision making in nursing practice
• Evaluate impact of care
• Make independent decisions
• Communicate and consult with other health
team members
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Management of Care
(16-22% of NCLEX)
• Delegation Do’s and Don'ts
• Do
• Always use the 5 rights of delegation
• Provide adequate supervision of delegated
tasks
• Guidance and direction
• Evaluation and monitoring
• Follow-up
• Understand the qualifications of each
delegatee
• Appropriate education, training,
experience, skills
• Demonstrated and documented
competence
(continued)
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Management of Care
(16-22% of NCLEX)
• Don’t
• Delegate tasks that require nursing
judgment
• Assessment
• Diagnosis
• Planning
• Evaluation
• Delegate invasive or sterile procedures
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Management of Care
(16-22% of NCLEX)
• “Float” Assignments
• Include only those duties and
responsibilities for which competency
has been validated
• Someone familiar with the unit must
oversee all patient care and shall act as
a resource nurse
• Refusing to float is not an option and
may be viewed as insubordination,
subject to discipline
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Management of Care
(16-22% of NCLEX)
• Incident Reports
• These are internal institutional documentation of an
event NOT A PART OF THE CHART
• Never make reference in the nurses notes that an
incident report has been filed – document only the
facts of the event itself
• File an incident any time an incident or event occurs
that is not within institutional guidelines or the
practice of nursing or medicine
• They are NOT for tattling – they are to inform the
facility administrators of incidents that allow the risk
management team to consider changes that might
prevent similar incidents
• They alert administration and the facility insurance
company of potential claims or need for further
investigation
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Infection Control
(8-14% of NCLEX)
• What are transmission-based precautions?
• As easy as A D C
• A= airborne
• D= droplet
• C= contact
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Infection Control
(8-14% of NCLEX)
• Who goes in airborne precautions?
• My Chicken Haz TB!
• Measles
• Chickenpox
• Herpes Zoster
• Tuberculosis
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Infection Control
(8-14% of NCLEX)
• Private Room for Airborne includes
• Pretty Nasty Ninny Muggins.
• Private room
• Negative pressure
• N95 filtration mask
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Infection Control
• Droplet precautions
– Spiderman
drops from
building
Private room
Mask
(8-14% of NCLEX)
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Sepsis
Scarlet fever
Streptococcal pharyngitis
Parvovirus b19
Pertussis
Pneumonia
Influenza
Diphtheria
Epiglottitis
Rubella
Mumps
Meningitis
Mycoplasma or
meningeal pneumonia
Adenovirus
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Infection Control
(8-14% of NCLEX)
• Contact Precautions – contact Mrs. Wee
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•
•
•
•
•
Multidrug resistant organisms
Respiratory infection (RSV)
Skin infections
Wound infections
Enteric infections (c. diff)
Eye infections
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Infection Control
(8-14% of NCLEX)
• Skin infections requiring contact
precautions
• Vicarious CHIPS
• Varicella zoster
• Cutaneous diphtheria
• Herpes simplex
• Impetigo
• Pediculosis
• Scabies and staph
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Infection Control
•
(8-14% of NCLEX)
Know about Hepatitis A, B, and C
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•
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•
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•
•
Source of infection
Route of infection
Incubation period
Onset
Seasonal variation
Age group
Vaccine
Inoculation
Potential for chronic liver disease
Immunity
• See next slides
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Infection Control
(8-14% of NCLEX)
• Hepatitis A
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•
•
•
•
•
•
•
•
Source of infection–contaminated food/water
Route of infection-oral, fecal, parenteral
Incubation period-2-6 weeks
Onset-abrupt
Seasonal variation-autumn, winter
Age group-children, young adults
Vaccine-yes
Inoculation-yes
Potential for chronic liver disease-no
Immunity-yes
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Infection Control
(8-14% of NCLEX)
• Hepatitis B
• Source of infection-contaminated blood,
needles, or surgical instruments
• Route of infection-parenteral, oral, fecal, direct
contact, breast milk, sexual contact
• Incubation period-6-20 weeks
• Onset-insidious
• Seasonal variation-all year
• Age group-any age
• Vaccine-yes
• Inoculation-yes
• Potential for chronic liver disease-yes
• Immunity-yes
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Infection Control
(8-14% of NCLEX)
• Hepatitis C
• Source of infection-contaminated blood,
needles, IV drug use, dialysis
• Route of infection-parenteral, sexual contact
• Incubation period-average 6-7 weeks
• Onset-insidious
• Seasonal variation-all year
• Age group-any age
• Vaccine-no
• Inoculation-yes
• Potential for chronic liver disease-yes
• Immunity -no
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Infection Control
(8-14% of NCLEX)
• Liver Problems
• Symptoms
• Fatigue, malaise, weakness, anorexia, N/V
• Jaundice, dark urine, clay-colored stool
• Myalgia (muscle aches), joint pain
• Dull headaches, irritability, depression
• Abdominal tenderness in RUQ
• Fever with Hepatitis A
• Elevated liver enzymes (ALT, AST,
alkaline Phosphatase), bilirubin
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Infection Control
(8-14% of NCLEX)
• Liver problems cause high ammonia
levels
• Give Lactulose
• to decrease ammonia levels
• This causes diarrhea – remind the
patient this is an expected side
effect
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Infection Control
(8-14% of NCLEX)
• Tuberculosis
• Symptoms
• Fever with night sweats
• Anorexia, weight loss
• Malaise, fatigue
• Cough, hemoptysis
• Dyspnea, pleuritic chest pain with
inspiration
• Cavitation or calcification as evidenced
on chest x-ray
• Positive sputum culture (AFB)
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Infection Control
(8-14% of NCLEX)
• TB – planning, intervention and patient
teaching
• Take all medications daily for 9-12 months
• Hand hygiene often
• Return to work after 3 (three) negative
sputum cultures
• Respiratory isolation while hospitalizedpersonnel to wear a particulate respirator
mask
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Infection Control
(8-14% of NCLEX)
• Skin Test for TB
• Mantoux test with PPD (tuberculin purified protein
derivative) injected intradermally on the forearm;
standard method for identifying infection with M.
tuberculosis
• Must be given INTRADERMALLY
• If given subcutaneously, the test is invalidated
• The common cold is NOT a contraindication for
immunization
• Tine test (OT, Old Tuberculin),
• consists of four prongs pressed into the forearm;
these multiple puncture tests are unreliable and
should not be used to determine the presence of a
TB infection
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Infection Control
(8-14% of NCLEX)
• Skin Test for TB (cont’d)
• A positive reaction represents exposure to M.
tuberculosis
• Screening can be initiated at 12 months of age
• Read at 48 to 72 hours (10cm induration is
positive – or 5 cm if the client is
Immunocompromised)
• Anyone who has received a BCG vaccine
(vaccine against TB) will have a positive skin
test and must be evaluated using a chest x-ray
• Once positive, always positive – they must
always get a chest x-ray instead of the skin test
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Infection Control
(8-14% of NCLEX)
• TB Therapy points
• Rifampin• reduces effectiveness of oral
contraceptives; should use other
birth control methods during
treatment
• Gives body fluids orange tinge
• stains
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Infection Control
(8-14% of NCLEX)
• TB Therapy points ( cont’d)
• Isoniazid (INH)
• Increases Dilantin levels
• Ethambutol
• Vision check before starting therapy and
monthly
• May have to take 1-2 years longer
Note: the rationale for combination drug
therapy is to increase compliance.
Resistance develops more slowly if several
anti-TB drugs are given, instead of just one
drug at a time
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Infection Control
(8-14% of NCLEX)
• HIV/AIDS
• Risk groups
• Homosexual or bisexual males
• IV drug abusers or those who have had tattoos or
acupuncture
• Heterosexual partner of a risk group member
• Recipients of blood products prior to blood product
screening (~1985)
• Those taking medications such as steroids or
other agents that cause immunosuppression
• Infants born to infected mothers
• Breastfeeding infants of infected mothers
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Infection Control
(8-14% of NCLEX)
• HIV/AIDS (cont’d)
• Lab testing
• Positive ELISA (enzyme-linked
immunosorbent assay); can be false
positive
• Confirmation is by the Western Blot
test
• Uses electrophoreses and
evaluates virus specific bands
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Infection Control
(8-14% of NCLEX)
Stage of HIV
•
Primary – CD4 T- cell counts of at
least 800 cells/mm3
Description/Symptoms
•
•
•
•
HIV-Asymptomatic (CDC Category A)
– CD4 T-cell counts more than 500
cells/mm3
•
•
•
Flu-like symptoms, fever, malaise
Mononucleosis-like illness,
lymphadenopathy, rash
Symptoms usually occur within 3
weeks of initial exposure to HIV, afterwhich the person becomes
asymptomatic
No clinical problems
Characterized by continuous viral
replication
Can last for many years (10 years or
longer
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Infection Control
(8-14% of NCLEX)
Stage of HIV
Description/Symptoms
•
•
HIV symptomatic (CDC Category B)
– CD4 T-cell counts between 200499 cells/mm3
•
•
•
•
•
•
•
Persistent generalized
lymphadenopathy
Persistent fever
Weight loss, diarrhea
Peripheral neuropathy
Herpes zoster
Candidiasis
Cervical dysplasia
Hairy leukoplakia, oral
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Infection Control
(8-14% of NCLEX)
Stages of HIV
Description/Symptoms
•
•
AIDS (CDC Category C) - CD4 T-cell
counts less than 200 cells/mm3
•
Occurs when a variety of bacteria,
parasites, or viruses overwhelm the
body’s immune system
Once classified as category C, the
client remains classified as category C;
this provides eligibility for entitlements
such as health benefits, housing, food
stamps, etc. (if certain financial
requirements exist)
CDC Categories of HIV
• A - Mildly symptomatic
• B - Moderately symptomatic
• C - Severely symptomatic
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Infection Control
(8-14% of NCLEX)
Treatment
STD/Symptoms
• Syphilis
•
Primary (local); up to 90 days post
exposure
• Chancre (red, painless lesions
with indurated border)
• Highly infectious
•
Secondary (systemic); 6 weeks to
6 months post exposure
• Influenza type symptoms
• Generalized rash that affects
palms of hands and soles of feet
• Lesions are contagious
•
Tertiary; 10-30 years post
exposure
•
Penicillin G given IM usually 2.4 to 4.8
million units
Any STD in infants and
children usually indicate
sexual abuse and should be
reported. The nurse is legally
responsible to report
suspected cases of child
abuse.
• Cardiac and neurologic
destruction
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Infection Control
(8-14% of NCLEX)
STD/Symptoms
Treatment
• Gonorrhea
•
•
Females; majority are
asymptomatic
Males; dysuria, yellowish-green
urethral discharge, urinary
frequency
•
•
Ceftriaxone sodium plus doxycycline
hyclate
Spectinomycin HCL plus doxycycline
hyclate
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Infection Control
(8-14% of NCLEX)
STD/Symptoms
Treatment
• Chlamydia
•
•
Females; many asymptomatic, but
may exhibit dysuria, urgency,
vaginal discharge
Males; leading cause of
nongonococcal urethritis
•
Doxycycline hyclate or Tetracycline
HCL
Chlamydia is the most
reported communicable
disease in the United States
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Infection Control
(8-14% of NCLEX)
STD/Symptoms
Treatment
• Trichomoniasis
•
•
Females; green, yellow, or white
frothy foul-smelling vaginal
discharge with itching
Males; asymptomatic
•
•
Metronidazole (Flagyl)
Male partners treated regardless of
symptoms to prevent reinfection
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Infection Control
(8-14% of NCLEX)
STD/Symptoms
Treatment
• Herpes simplex type 2
•
•
•
Vesicles in clusters that rupture
and leave painful erosions that
cause painful urination
Characterized by remissions and
exacerbations
May be contagious even when
asymptomatic
•
•
Acyclovir (Zovirax) partially controls
symptoms
Palliative care
• Viscous lidocaine topically to ease
pain
• Keep lesions clean and dry
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Infection Control
(8-14% of NCLEX)
STD/Symptoms
Treatment
• HPV (Human papillomavirus)
•
•
•
•
Multiple strains (>70), some of
which are implicated in cervical
cancer
Alarming rate increase in
adolescent population
Lesions may be small, wart-like or
clustered
May be flat or raised
•
•
•
•
Applied medications such as
podophyllin (contraindicated in
pregnancy)
Trichloroacetic acid (TCA)
Laser
Cryotherapy
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Infection Control
(8-14% of NCLEX)
• Disaster/Bioterrorism
• Triage categories
• Red
• Most urgent, first priority, lifethreatening injuries, cannot delay
treatment
• Yellow
• Urgent, second priority, injuries with
systemic effects and complications,
may delay treatment 30-60 minutes
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Infection Control
(8-14% of NCLEX)
• Triage (cont’d)
• Green
• Third priority
• Minimal injuries with no systemic
complications
• May wait several hours for treatment
• Black
• Dying or dead
• Catastrophic injuries
• No hope for survival even with
treatment
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Infection Control
(8-14% of NCLEX)
• Bioterrorism
• Possible agents
• Anthrax
• Pneumonic plague
• Botulism
• Smallpox
• Inhalation tularemia
• Viral hemorrhagic fever
• Biotoxin agents (Ricin)
• Nerve agents (Sarin)
• Radiation
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End of Module I
• Please keep in mind, this is a very brief
overview and should not be used as your
sole source of NCLEX study.
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