NR 446 Funds Post Assessment Review

NR 446 Funds Post Assessment Review Latest 2023 / 2024

• List the pertinent information that should be included in a transfer report.
• Medical dx, care providers, demographics, overview of health status, plan of

care, & recent progress, alterations that may precipitate an immediate concern, notification of assessment or care essentials w/i next few hours, most recent vitals, medications, diet, and activity orders, allergies, specific equipment or adaptive devices, advanced directives, emergency code status, family involvement in care, and health proxy if applicable.

2. *Please describe the five rights of delegation including an example of each:

• Right person
• Right task
• Right circumstance
• Right direction and communication
• Right supervision and evaluation
• What are three (3) of the provider’s responsibility for obtaining an informed consent?
• Provides pt. with reason of treatment/procedure
• Teach pt. how treatment will benefit client
• Teach about risk involved
• List three (3) actions to take during the analysis or data collection step.
• Recognize patterns or trends,
• Compare the data with expected standards or reference ranges
• Arrive at the conclusions to guide nursing care
• The nurse discovers a fire on the unit. After following the proper steps included in

RACE, the nurse begins to extinguish the fire. What is RACE? What are the proper steps for using a fire extinguisher?

• R- rescue, A- activate alarm, C- contain fire, E- extinguish and evacuate
• P- pull pin, A- aim at base of fire, S- squeeze handle, S- sweep extinguisher from

side to side

• A nurse is caring for an older adult client with dementia. What preventative measures

should the nurse institute to reduce the risk of falls?

• Fall risk assessment
• Call light and personal belongings within reach
• Adequate lighting
• Orient to setting
• Room near nurses station
• Nonskid footwear
• No clutter, CLEAN room
• Assistive devices if needed
• Bed in low position
• A nurse is providing discharge education to a client regarding home wound care. What

manifestations of wound infection should the nurse include in this education?

• Fever, chills, foul odor, purulent drainage, redness, swelling
• List at least five (5) priority considerations when performing a sterile dressing change.
• Avoid coughing, sneezing, and talking directly over sterile field 1 / 2

• Only dry, sterile items touch the field (1-inch border is non-sterile)
• Keep all objects above waist and within vision (do not turn back on field)
• Wash hands and don sterile gloves
• Hold items to add to sterile field at a min. of 6 inches above field
• Identify three (3) priority-teaching points to include when educating a client to use a

cane.

• Maintain two points of support on the ground at all times
• Keep cane on stronger side
• Move came forward then weaker leg
• A nurse is caring for a client receiving oxygen therapy. What is the expected reference

range when obtaining oxygen saturation level? Identify four (4) reasons the reference range may be lower.

• 95%-10%
• Increased work of breathing

ii. Coughing iii. Wheezing iv. Cyanosis

• Describe tertiary prevention measures and provide one (1) example
• Aims to prevent long term consequences of chronic illness/disability and to

support optimal functioning

i. Ex: Referral to support group, rehab, pressure ulcer prevention measures,

diabetic foot care

• Describe the motor, cognitive and psychosocial development during infancy.
• Motor: gross and fine motor skills develop month by month within the first 12

months from infant demonstrating head lag (gross), and strong grasp reflex (fine) to being able to sit down from standing (gross), and build two block towers (fine) [Chp. 18, pg. 91, 18.1]

b. Cognitive: Piaget sensorimotor (birth to 24 months)

• Separation is the sense of being distinct from other objects in the

environment ii. Object permanence develops at nine months iii. Mental representation in the recognition of symbols

iv. Language development: respond to noises, vocalizes “oohs” “aahs”,

laughs, squeals, turns head to sound of rattle, comprehend simple commands, pronounce single syllable words

c. Psychosocial: Erikson (trust vs. mistrust)

• Infant trusts that their needs will be fulfilled

ii. Attachment with parental bonding develops iii. Separation anxiety develops between 4-8 months iv. Stranger anxiety evident at 6-8 months

• A 36-year-old client is in the psychosocial development phase of generativity vs.

stagnation. Identify four (4) psychosocial development tasks specific to the middle- aged adult.

• Use life as an opportunity for creativity and productivity

b. Moral development: religious maturity

• Self concept development: menopause, sexuality, depression
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