Final Exam

• Nurse Practice Act


  • LVN responsibility
  • Under supervision of RN/MD
  • We should assist in continuing education
  • We should always use the nursing process to attend the needs of our patients
  • All the obligations and the duties associated to an LVN
• Signs and symptoms of infection

  • WBC increase (Range: 4500-11000)
  • Elevated temp 101.4 must be reported
  • Warmth
  • Redness
  • Nosocomial: Infection that you get from the hospital, sets in 3 days or 72 hours after the procedure – Catheter insertion, wound treatment, IV insertion infections, any invasive
• Most effective prevention of infections

  Hand hygiene
• PPE for Contact Precaution

  • gloves and gown
  • MRSA (Chlorhexidine)
  • C DIFF (soap & water)
  • Make sure patients have delegated equipments
• When touching linens with fecal matter

  Wear gloves
• Mask for patient with TB (Tuberculosis)


  Pre Fitted N95, no hair on the face when using
• Patients with low immune system

  • Immunocompromised patients
  • No fresh fruits/plants or flowers – only canned fruits
• Where to put used needles

  • Put puncture safe and/or sharp disposal containers
  • Never recap any needles
• After a needle puncture accident

  1. Wash with soap & water if ever punctured

  2. Allow some bleeding on the site, do not squeeze too much

  3. Report after & Hep B/TB - start prophylaxis med

  4. If the patient has HIV, the facility will administer a medication for you right away (prophylaxis)
• Suffix -itis


  Inflammation – sign of infection
• Maslow's Hierarchy


  • Self-actualization: full use of individual talents
  • Esteem: self-respect, self-confidence, feelings of self-worth
  • Love and belongingness: affection, acceptance by peers and community
  • Safety and security: stability, protection, security, freedom from fear and anxiety
  • Physiologic: nutrition, elimination, oxygenation, sexuality
• PPE sequence


  1. Donning: Gowns, Mask, Goggles, Gloves

  2. Doffing: Gloves, Goggles, Gown, Mask
• MRSA


  Methicillin-Resistant Staphylococcus Aureus
• Subjective and Objective data

  • Subjective data: information that the patient provides
  • Objective data: what we see, smell, and feel
• Nursing care plan


  Interventions are placed in the Planning stage
• Incident report


  Document any event not consistent with the routine operation of a health care unit or the routine care of a patient
• When to use an incident report

  When there is an unplanned occurrence within a health care facility
• Do not mention incident report in nurses notes
• SBAR


  • Situation: what is the current situation?
  • Background: relevant background information on the patient
  • Assessment: what do you think the problem is?
  • Recommendation: How would you correct it?
• Steps when a patient has a fall

  1. Obtain vitals

  2. Assist pt to bed if no injury

  3. Notify MD and the supervisor

  4. Complete incident report
• Apical pulse


  Checked in the 5th intercostal space
• Priority for admission of patient with vision problems

  1. Describe room

  2. No clutter

  3. Call light within reach

  4. Teach how to use controls
• Checking patient's bowel sounds

  1. Listen with stethoscope first before percussing

  2. Listen before touching abdomen to not alter the sound
• Checking patient's lungs for crackles

  1. Place stethoscope on left posterior base of lungs

  2. Ask patient to take deep breaths and cough
• Ways to obtain temperature

  • Oral
  • Rectal
• Cautions for obtaining oral temperature

  Ask if patient has had hot/cold drinks, smoked, or had oral trauma within 30 minutes
• Cautions for obtaining rectal temperature

  Check for hemorrhoids, trauma, redness and pain - use red thermometer
• How patients get their medical record

  Written request
• Intervention when patient complains about medication


  Double check order in the patient/physician's chart
• We document because the facility is getting federal funding for the patient
• Requirements to access electronic records

  User ID and password - only you should know
• Examples of objective and subjective data

  • Subjective: Information that the patient has provided
  • Objective: What we assess and observe
• AMA


  Against Medical Advice
• Rules for AMA


  1. Notify the Dr, remove all the lines, have pt sign the form - if pt refuses, have 2 nurses sign the form with date and time

  2. Do not get transportation for the pt
• Sociocultural background for nonverbal communication

  Example: Pt bowing their head when talking may mean respect
• Eye contact when communicating with patient

  Direct eye contact, eye level with 2-6 seconds
• Type of listening when communicating with patient

  Active listening
• When doing treatments and ADLs, you provide the patient with privacy
• Position for unresponsive patient

  Side lying position to prevent aspiration
• Providing personal hygiene for immobilized patient

  1. Check linen, no wrinkles

  2. Check personal items

  3. Check temperature when giving shower

  4. Shave hair in direction of growth

  5. Remove gown from strong side, put back on weak side first