| A | B |
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| Vital signs affect the function of three body processes essential for life. The four vital signs include,________and___. Accuracy is extremely important as even the littlest__ can indicate a change in the persons well being. | Temperature, Pulse, Respirations, Blood Pressure the littlest change |
| Identify the four methods of obtaining a temperature. What is the minimum age for an oral temperature? Which method is the least accurate? If the patient is less than two years of age, what is the best method of obtaining the temperature? Of axiliary, oral and rectal, which provide the most accurate reading? | Oral, rectal, tympanic, axillary. The minimum age for an oral temperature is 4-5 years old. Axillary is least accurate. Rectal is used if the patient is less than two years of age. Rectal is most accurate. |
| When recording the temp. of 98.6F, the CNA records the temp. 98.6F and what other factor? | Which site the temperature was taken from. |
| What position would you place the patient for a rectal temperature? How far is the tip inserted? What if you meet resistance? | Place the patient on his/her side. The tip is inserted 1 inch. Do not force the thermometer into the rectum |
| Axillary temp. Is obtained by placing the bulb end of the thermometer deep into the___ of the___. What is the minimum amount of time for it to be in place? | Middle of the axilla. It must be held in place for 5-8 minutes |
| ___ is the membrane of the ear where temperature can be taken? | Tympanic |
| Identify a minimum of 3 factors that affect a person's temperature. | Illness, external temperature, medication, age, infection, time of day, exercise, emotions |
| On a glass or plastic thermometer each long line indicates an elevation of temperature of ____degree. Each sort line indicates a rise in temperature of___ of a degree. | elevation of temperature of 1 degree. Each sort line indicates a rise in temperature of 2 tenths of a degree. |
| How would you correctly record an oral temp. of 99.6 Fahrenheit? Do you need to always identify where you obtain the temperature from? If so, why? | You should indicate that it was taken orally. It is important to note the site because the temperature will vary depending on where it was taken. |
| When reading a glass/ plastic thermometer it is important to red it at __level for an accurate reading. | Eye level |
| If your patient has just finished a cigarette, a beverage, or eating, how long do you wait to take the temperature? | 15 min. |
| Identify which method of temperature determination should be avoided for the following circumstances? | Answer below |
| Patient for an ear infection | Tympanic |
| A patient with diarrhea | Rectal |
| Patient who is 2 years old | Oral |
| Patient that is vomiting | Axcillary |
| Patient with a fecal impaction | oral |
| A deposal probe__should be used with all thermometers and deposited of after each use. | A disposable probe sheath |
| The pulse is the beat of the heart felt at an____. The lub dub sound counts as__beat? | The pulse is the beat of the heart felt at an artery. The lub dub sound counts as 1 beat? |
| Identify 7 major arteries used to measure pulse rates? | Temporal, carotid, apical, brachial, radial, femoral, popliteal |
| The pulse rate is the number of beats per ___, with a normal range of __to __in adults. Bradycardia is a rate less than __and a tachycardia is a rate greater than ___? | number of beats per minute a normal range of 60 to 100 Bradycardia is a rate less than 60 and a tachycardia is a rate greater than 100 |
| The pulse rhythm should be felt as a regular pattern. When the pulse is very strong it is often called a strong or ___pulse. When it is weak it is called a thready or __ pulse | Strong or bounding pulse. thready or weak pulse. |
| If the pulse is steady and regular you can count for __seconds. | 30 seconds |
| If it is rapid or irregular you will need to count for blank seconds. | 60 seconds |
| When recording a pulse do you need to record if it was regular or irregular? | Yes |
| Apical pulses are always taken for __ seconds using a __. | 60 seconds using a stethoscope |
| What is the correct placement of a stethoscope for an apical pulse reading? | Over the apex of the heart or below the left nipple. |
| Apical and redial pulses should equal each other. Occasionally with some cardiac conditions the two reading will differ. This is called a __. | Pulse deficit |
| Pulse deficit readings are always done with __ staff members, counting at the same time, with one taking the __ reading and the other taking the __ reading, counting for __ seconds. What is done with the two readings to obtain a pulse deficit? | It is with two staff members with one taking the apical reading and the other taking the radial reading. Counting for 60 sec. You subtract the apical minus the radial. |
| Identify the following pulse deficits. | Answer below |
| Apical of 82 radial 70= | Apical of 82 radial 70= pulse deficit of 12. |
| Apical of 100 radial 94= | Apical of 100 radial 94= pulse deficit of 6 |
| Apical of 98 radial of 76= | Apical of 98 radial of 76=22 |
| Identify a minimum of 5 factors that can have an effect on a person’s pulse rate? Can these also affect the respiratory rate? | Illness, emotions, age, exercise, elevated temperature, gender, position physical training, drugs. These can also affect the respiratory rate |
| Respirations involve breathing and inhalation of __, and the breathing out or exhalation of __inhalation and exhalation count as __ respirations. | Inhalation of oxygen and exhalation of carbon dioxide. Counts as one respiration. |
| The normal adult respiratory range is ___, counted while the person is at ___, and ___ the person knowing. | The normal adult respiratory range is 12-20 breathes per minute counted while the person is at rest, and without the person knowing. |
| Define apnea | A period of no respirations |
| Define Dyspnea | Difficult or labored breathing |
| Regular respirations are counted for ___ seconds, and irregular respirations are counted for ___ | Regular respirations are counted for 30 seconds, and irregular respirations are counted for 60 seconds. |
| Labored, shallow, wet respirations are reported to the nurse when? How are they reported and documented? | Soon as possible, they are documented as shallow, deep, normal, wet, riles and crackles. |
| Blood pressure is the amount of force exerted against the walls of an ___ | artery |
| What are the two phases of blood pressure and what is the heart muscle doing in each phase? Which is the top or first heart sound heard, and which is the bottom or the reading when the heart sound disappears? | Systolic- contraction of the ventricles of the heart. It is the first heart sound heard Diastolic- relaxation of the ventricles of the heart. It is when the heart sound disappears |
| If the BP were 120/80, which is the systolic and which is the diastolic? | 120 is the systolic, 80 is the diastolic |
| What is the normal range for BP’s? What is considered hypertension and what is considered hypotension? | Normal BP is 120/80. hypertension is higher than 140/90. hypotension is systolic pressure less than 100. |
| Identify a minimum of 5 factors that can affect the blood pressure. | Elasticity of arteries, cardiac output, blood viscosity, peripheral resistance, age, activity, emotions, pain, blood volume |
| When measuring the BP, the person should ___ or ___ down, with their arm at the level of the level of their ___, palm side up. Stand close to the patient with the aneroid at ___ level. | When measuring the BP, the person should sit or lie down, with their arm at the level of the level of their heart palm side up. Stand close to the patient with the aneroid at eye level. |
| Place the arrow of the cuff over the ___ artery, wrap the cuff evenly and snuggly around the arm, ___ inch above the elbow or anticubital area. The bladder part of the cuff should measure ___% or 2/3 of the circumference of the patient’s arm. Does the size of the cuff affect the reading? | Place the arrow of the cuff over the brachial artery, wrap the cuff evenly and snuggly around the arm, 1 inch above the elbow or anticubital area. The bladder part of the cuff should measure 66% or 2/3 of the circumference of the patient’s arm. the size of the cuff can affect the reading |
| Identify a minimum of 3 situations that prevent taking a blood pressure using the arm. | Stroke, Iv, paralyses. Fistula. |
| The large lines on the blood pressure gauge are at increments of ___ Hg, and the small lines on the blood pressure gauge indicate ___ intervals. BP readings are always done in ___ numbers | The large lines on the blood pressure gauge are at increments of 10 mmHg, and the small lines on the blood pressure gauge indicate 2 mmHg intervals. BP readings are always done in even numbers |
| When you get an abnormal reading, how long do you wait before rechecking the BP? | 1-2 minutes |
| The difference between the systolic and diastolic readings is called? | Pulse pressure |
| Identify the vital signs that are outside normal Pulse- 104, Resp.- 16, BP- 142/96, Temp. 102°F R, Resp.- 32, BP- 100/60, Temp.- 98.6°F O, Pulse- 68, BP- 88/56, Pulse- 92, Resp.- 8, Temp.- 96°F Ax, BP- 152/98, Resp.- 28 Pulse- 72 | Pulse- 104, BP- 142/96, Temp. 102°F R, Resp.- 32, BP- 88/56, Resp.- 8, BP- 152/98, Resp.- 28 |
| Indentify a minimum of 3 guidelines for obtaining an accurate weight. | Empty bladder, use the same methods as before. Make sure scale is level. |
| Weight is done in lbs or kg. What is the conversion of lbs to kg, and kg to lbs? How many kg would a patient who weighs 80 lbs be? How many lbs would patient who weighs 36kg be? | lbs to kg- divide by 2.2 kg to lbs- multiply by 2.2 80 lbs = 36.4 kg 36 kg = 79.2 lbs |
| Always put the scale weights to ___ before putting the patient on the scale. | zero |
| Height is measured in in or cm. What is the conversion? | 1 inch = 2.54 cm |
| If the patient is unable to stand for the height measurement, what other means can you implement to obtain this reading? | Use a measuring tape, mark the patient's height on the sheet they are lying on with a marker and measure that |
| Before weighing the person on a wheelchair scale, you must first weigh the ___. | Wheelchair |
| When using a bed scale, the person’s body must completely ___ the bed before a reading is taken. | off |
| Your patient, Mr. Graham needs VS. His pulse is irregular, and his respirations are labored. His BP reading is 156/95. He needs a height and weight but is on bed rest. His IV is in his left arm. | Answer below |
| How long should you take to obtain his pulse? How is it recorded? | 60 seconds, recorded as irregular |
| How long will you take to obtain his resp.? How will you get his height? | 60 seconds. Use a tape measure |
| Which arm will you use for his BP? | Right arm |
| When are abnormal vital signs reported? Is it ok wait until the end of your shift? | Report them right after recording them. Do not wait to the end of your shift |
| The three goals of rehabilitation healthcare include: Focus on improving ___. Promote function to the highest level of ___. Prevent a ___ in functioning or ability. | Focus on improving physical abilities. Promote function to the highest level of ___. Prevent a relapse in functioning or ability. |
| The two goals of restorative care are: Maintain the ___ level of functioning. Prevent an unnecessary ___ in functioning. | Maintain the current level of functioning. Prevent an unnecessary complication in functioning. |
| The similarity between restorative and rehabilitation care is that they both have a whole person approach, and stress what the person ___ do, not what the person ___ do. | And stress what the person can do, not what the person can't do. |
| Fill in the common goals shared by both rehab, and restorative care: | Answer below |
| Increase the person’s physical____ | ability |
| Prevent___such as pressure ulcers | complications |
| Maintain the person’s current | mmmmmmmmmm |
| Help the person adopt to___imposed by disability. | limitations |
| Increase the person’s__of life | mmmmmmm |
| Both consider the ___ person psychological, spiritual, physical aspects of rehab. Care (i.e. self care, use of mobility devices). | whole |
| A patient who cannot complete any or all of the ADL’s independently is said to have a self care___. | Deficit |
| Identify a minimum of 4 activities that are included in the task of daily living. | Bathing, dressing, eating, toileting, mobility |
| Identify a minimum of 3 social and psychological aspects commonly seen with disabilities. | Depression, disorientation, irritability |
| How do you approach the patient based on these findings (i.e. be understanding)? | Stress the patient's ability, not disabilities |
| Are the person’s unique cultural needs or spiritual needs considered in rehab process? Or is the focus solely on promoting physical abilities? | The person’s unique cultural needs or spiritual needs are considered in rehab process. |
| What is empathy? Do we empathize or sympathize with rehab. Patient? Is it appropriate to say, “I know what you are going through”? | Empathy is understanding, no |
| People with disabilities may be unable to move at will, resulting in numerous complications that result from immobility. Identify a minimum of one complication immobility can cause for the following: | Answer below |
| Musculoskeletal | Muscles become weak and atrophy |
| integumentary | Muscles become weak and atrophy |
| Cardiovascular | The heart takes longer to a normal pace after activity |
| Respiratory | Lungs do not expand as fully as they did when the person was active |
| Gastrointestinal | Appetite decreases, causing weight loss |
| Urinary | The bladder does not empty completely |
| nervous | Weakness and limited mobility |
| Indentify a minimum of 4 members of the rehab team. Identify one responsibility for each: | Answer below |
| Nursing | Bowel and bladder management, prevention of pressure ulcers and other complications. |
| Doctors | mmmmmmmmmmmm |
| Physical therapy | Learn how to walk again |
| Speech therapy | Learn new communication or swallowing methods |
| Occupational therapy | Relearn the activities of daily living |
| Dietician | Dietitians: help residents to learn new dietary restrictions, and to plan and prepare meals. |
| Social services | Plan for the impending discharge. |
| Psychologist | Provide emotional support assistant the person in adapting to sudden changes brought by the patient’s condition. |
| The role of the CNA is to promote all aspects of care for the patient as ordered by the various disciplines. The patient is unable to __ unless we encourage as much____ or self help as possible from the patient. Offer verbal___ for any and all accomplishments made by the patient. | Progress, independence, reassurance or praise. |
| Identify what a pressure area is and why this is a concern in the elderly. | Its anywhere on the body that is prone to pressure sore development. It’s a concern because elderly have thinning of skin and are not as mobile. |
| How does shearing and friction contribute to skin breakdown? | Answer below |
| Friction | Friction it contributes to pressure ulcer formation. |
| Shearing | Shearing causes blood vessels to be twisted and stretched, which causes the tissues to lose oxygen and nutrients. |
| How does moisture contribute to skin breakdown? What care measures would you implement for a depended patient, on bed rest, and incontinent of urine and stool ( i.e. liens, peri-care, turning)? | Yes, I would clean the sheets, cloth bath the patient and report any findings. |
| Your patient is lying in a supine position. I identify a minimum of 3 pressure areas. | Toes, heals, lateral knee, buttocks, coccyx, elbow, shoulder, rim of ears, and back of head. |
| Prolonged pressure prevents the circulation of nutrients to issues. Tissue death can occur in as little as__minutes, but usually occurs in__ hours | 90 minutes or 6-8 hours. |
| What is the skin appearance when there is prolonged pressure over a boney area? How would this appear in a darker skinned person? | Red, darker skinned person dryer or dark blue or black. |
| Identify a minimum of 4 patients at risk of pressure ulcer formation: | Older people, people who re ver thin, obese patients , immovable patients, malnourished, disorientated, dehydrated, |
| Identify the skin or tissue appearance for each of the 4 stages of pressure ulcers. | Answer below |
| Stage 1 | Red or blue gray |
| Stage 2 | The skin is red and there are abrasions, blisters, or shallow carter. |
| Stage 3 | Deep carter with all layers of skin destroyed |
| Stage 4 | The destruction goes past the skin to bone muslce and other structures. |
| An indication of stage one pressure ulcer occurs when the pressure is relived, but the discoloration remains for ___minutes or more. | 30 mins. |
| It is much easier to ____ a pressure through good nursing care, than to cure one. | To prevent a pressure ulcer |
| Identify a minimum of 5 assistive devices *i.e. elbow protectors) and nursing measures ( i.e. turn q2h) to prevent ulcer formation. | Answer below |
| Assistive devices | Sheep skin pads, foam pads, pillows and overlays, bed cradles, air mattresses |
| Nursing measures | Change the patient's position every 2 hours. Encourage sitting patients to raise them selfs every 15 mins. Encourage proper nutrition and fluid intake. Remove feces and urine from skin. Inspect areas where pressure ulcers are commonly formed. Keep skin clean and dry. |
| Define range of motion | The maximum extension of a joint. |
| Identify a minimum of 3 benefits of ROM. | To prevent changes in the structure of joints. To improve circulation of the involved body part and indirectly to the entire body. To maintain normal range of motion. To retain muscle strength. To develop control and coordination. |
| The cardinal rule of range of motion exercises is never to push the joint past the point of___ or__ __. | Beyond its present range of motion or force the joint to the point of pain. |
| Identify the difference between active, passive, and assistive ROM. | Answer below |
| Active ROM | Exercises done during activities of daily living. |
| Passive ROM | Exercises performed for patients when independent movement is impossible. |
| Active assistive | The resident some of the ROM while the caregiver assists. |
| Abduction | Movement away from midline or center. |
| Adduction | Moving toward the midline. |
| Flexion | Decreasing the angle between two bones. |
| Hyperextension | Excessive straighten of the body part. |
| Dorsiflexion | Toes pointed up |
| Internal rotation | Turning the joint inward. |
| External rotation | Turning the joint outward. |
| Pronation | Hands palm down. |
| supination | Hands palm up. |
| Mrs. Smith is new admission to your unit. She has had stroke leaving her with left sided paralysis. She is placed on bed rest until her condition stabilizes. | Answer below |
| When does Mrs. Smith's rehabilitation process begin? | Right away or as directed by doctor |
| What nursing measures will prevent complications from her immobility? | ROM turning every 2 hours, active assistance and the right side. |
| Mrs. Smith is able to use her right side to do some of her care, but asks you to bath and dress her. What is your response? | Yes help her ask for if she can help. |
| While providing ROM and abducting her left arm out to the side, she complains of pain. What is the appropriate action? | Stop and notify the nurse. |
| You provided peri-care, clean linens, and turned and positioned Mrs. Smith. Before leaving the room she is incontinent of urine. She is on a q2h turning schedule. What is the appropriate action? | Change and clean her up and return to the same position. |
| After turning Mrs. Smith, you notice a reddened area on her hip. 30 minutes later the redness is still apparent. What stage of pressure ulcer does this indicate? Is it reversible at this stage? What care measures can you implement to prevent its progression? | Stage 1 yes, turn her every two hours, do not put her on the tender side. Watch out for skin break outs. |
| Who is primarily responsible for explaining all aspects of surgery experience? Who is responsible for getting the consent signed? | Physician or RN |
| Your patient has questions about the surgery and what to expect. What is your role? | Refer specific questions to the nurse |
| Can you assist the RN with pre-op teaching? What does this involve? | Yes assist as recommended by the nurse. What, when, were, when to do the jobs. |
| Patients expecting surgery are always ___ after midnight. | On an NPO diet |
| Can the patient wear light make up, hair pins, jewelry during surgery? What about nail polish? | No, and No |
| What information do you need before preparing the skin of the operative site for surgery? | Keep the skin clean, know the shape. |
| How often are vital signs measured for your post op. patient? | Answer below |
| 1 hour | 15 |
| 2nd hour | 30 |
| Every hour for___ hours | 4 |
| Every___hours there after | 4 |
| When is a change in vital signs, bleeding from the incision, disorientation, nausea, vomiting pain ect. Reported? | As soon as possible |
| Your post op patient is requesting ginger ale. What must you do prior to providing a beverage and or food? | Ask nurse or doctor |
| Urinary retention is common with the post operative patient. Is it important to notify the nurse if the patient has not void by the end of your shift. The patient needs to void within__hours of surgery. | 8 |
| Is it important to keep an ___ basin at eh bedside as nausea and vomiting are common after surgery. | Emeses |
| How often is the person’s position changed? Alone with changing the position, what is done to prevent respiratory complications? What can you do to lessen pain while encouraging coughing and assisting with positioning? | 2 ask patient to hold a pillow |
| What nursing measures promote circulation and prevent clot formation? | Leg exercises and sequential socks, ted hose, compressive devices. |
| Ted hose and sequential stockings are to assist with circulation. How is Ted hose applied? When are they removed? Where is the opening in the ted hose placed and why? How often is sequential compression removed for skin inspection? | Extended from ankle to toe. Check for circulation near the toe and, reduction in blood flow. Be for e bathing and clothing. |
| Pain is common after surgery. Reposition all complaints of pain at once and remember, pain is what the __ says it is! | Patient |
| Post op patients are commonly have IV fluids. In the IV fluids part of the intake? What are you assessing when you are with the patient? Can you adjust the flow? When are amoralities (not dripping reddened insertion site, etc.) reported? | Check Iv, and any sites for abnormalities, check time tape, no, report as soon as possible. |
| At times post operative patients as well as other patients have a drop in oxygen levels at the cellular level. What is the first sign of hypoxia? How would you position the patient? | Restlessness, fowlers, Sims position, orthapictic every 2 hours. |
| Turning coughing, and deep breathing prevents respiration complications. What other device can be used as an incentive to encourage the patient to deep breath and expands the lungs? | Incentive spiromotry |
| Disease, injury, and surgery can interfere with breathing resulting in the needs for O2 therapy. Who orders oxygen? Who starts and maintains it? What is your role? | The doctor, the nurse assist the nurse. |
| It is especially important in home care to place a __ __sign is in place when oxygen is in use. The patient in home care uses on oxygen tank. As the care provider you will need to make sure there is sufficient ___ in the tank by reading the ___. | No smoking, O2, gage |
| Identify a minimum of 4 care measures for a patient with a fresh plaster cast. | Elevate the lime on pillows, do not cover cast. Support cast with palm. Do not let the person insert anything in it. Do not place the cast on a hard surface. Keep dry when giving peri-care. Use fracture pan. |
| Identify a minimum of 4 nursing measures when caring for the patient on traction. | Good alignment. Do not remove traction. Check for frays. Keep weights off floor, fracture pan, do not add or remove weights, position as directed. |
| Identify a minimum of 4 nursing care measures when caring for a patient with a hip fracture. | Skin care. Encourage deep breathing and coughing. Turn the person in a position as directed. Do not let the person stand or operate on the affected area. Leg should be abduction position. Elevate HOB at no more than 45 %. Do not have them cross their legs. Use additional staff. Place chair of the effected side. |
| Define urinary incontinence | Loss of bladder control |
| Many situations of incontinence can be avoided by answering the ___ is essential to prevent skin break down. | Call bell |
| At times the patient may have a catheter in place. Identify the following types of catheters: | Answer below |
| Straight | Drainage in bladder and is removed. |
| In dwelling/ Retention/foley | Remains in bladder |
| Suprapublic | Applied never penis that has a tube at the end. |
| The darning bag is kept__ the level of the bladder, attached to the bed___ never the side__. | It is kept below the level of the bladder and attached to the bed frame. Never the side rail. |
| To prevent pulling or dislodging the catheter, the tube is fastened to the patient’s___, usually with nylon tape, with tubing coiled on the____ and a plastic clip fastened to the bed lien. | Fastened to the patient’s leg. With tube coiled on bed. |
| Every time catheter tubing is opened, there is an increased chance of ___ | Infection. |
| What is use d to measure output from a catheter bag? Can you use the measurement provided on the bag itself? | Graduate and no but estimate but not a good idea. |
| What nursing measures do you take after finding a drainage bag disconnected from the tubing? | Report to nurse first and then wash hands. Put gloves on. Disaffect with alcohol wipes and do not touch the ends. Wipe end of catheter. Connect tubes and catheter. |
| How often is peri-care provided for a patient with an indwelling catheter? Is the tubing cleaned? If so in what direction and how much of the tubing is cleaned? | Daily usually twice a day. 4 inches of tube is cleaned down ward away from patient. |
| A change in the color and consistency stool can result from a change in the persons well being. Identify 6-8 observations to make before discarding a patients stool. | Color, amount, order, blood, mucus, particles, food particles, other than corn or raisins. |
| What factors can affect normal elimination. | Bed rest, not being active for a long time, lack of fluids. Stress change in diet an environment. Not enough fiber. |
| Identify the difference between constipation and fecal impaction. | Answer below |
| Constipation: | Difficulty in pooping. |
| Fecal Impaction: | Stool is retained in rectum becomes dry and inability to poop and is the most serious in of constipation. |
| Suppositories and enemas assist with elimination. How fare is a suppository inserted? How long does it take to melt? | 5-20 minutes and 2 inches. |
| What is the correct temperature for enema solution? How far is the tubing inserted? How far above the rectum in the bag held? How far above the bed? Enema solution is given fast/slow? What do you do if the person experiences pain? | 105, 2-4 inches, the bag is held at 12 inches above the rectum. 8 inches above the bed. Enema solution is given slowly. Clamp the tube and wait until pain goes away. And then restart the process. |
| Stool is very irritating to the skin. How is the skin protected with an ostomy? | The skin is protected by skin barriers lubricants, and medicated cream. |
| Your patient Mr. Rodriguez has returned from surgery. He has an abdominal dressing covering an abdominal incision, an IV a foley catheter. He is normally independently ambulatory, but currently sleep and will receive pain medications as needed. He has a history of smoking and COP, but not on oxygen. | Clinical situation |
| Can Mr. Rodriguez get OOB alone? | NO |
| What position are the side rails in? | Up |
| How often are VS taken the first hour? | 15 minutes |
| When are abnormal findings reported? | As soon as possible. |
| Besides VS what other assessments will you make when you are in the room? | Other assessments would be wound drainage, undressing around the incision, and pain. CEMT. |
| His IV is half full but not dripping. What is your reaction to this situation? | Alert the nurse immediately. |
| How would you obtain an accurate output record of his urine? | Use a graduate. |
| Where is the Foley catheter collection bag hung? | Bed frame |
| How often will he be turned and positioned? | Every 2 hours |
| How will you limit incision pain during the turning procedure? | 2 hours. Use a 2 person tea, role to side keep off incision |
| When you take his VS, you also ask if he is in pain. Your objective assessment identifies him resting and without nonverbal signs of pain. His subjective response is the pain is throbbing and rates it as an 8 on the scale of 1-10 how is this reported? | A whole lot tell nurse. |
| What other measures can you implement to prevent respiratory complications and development of clot formation (blood pooling). | Incentive spiraotomtry, sit up and encourage coughing and deep breathing. |
| Mr. Rodriguez puts his call light on. When you enter the room he is restless and pale color. Mr. Rodriguez was given pain medication 45 minutes prior. Restlessness may be an indication of what? When is this reported to the RN? | ASAP, hypoxia |
| If oxygen is needed who will administer the O2? What is your role? | The RN and my role is to help nurse with whatever is needed. |
