There are a number of essential measures that should be taken to promote comfort, rest and sleep for clients. For each essential measure listed in the table below, provide two nursing interventions you could perform and a rationale for how these address the essential measure.
No
Essential measure
Nursing interventions
Rationale
a.
Hygiene needs including oral hygiene, dressing and grooming needs
b.
Comfort needs including hygiene, toileting and sleep
c.
Elimination needs including use of incontinence aids
d.
Nutritional and fluid needs
e.
Protection and safety needs
f.
Physiological needs
Describe any three considerations and care interventions you need to apply when working with an immobile client or a client with limited mobility.
List four important steps involved in the care of clients with dentures.
Give two reasons for using alcohol-free mouthwash when or after providing oral care to a client.
Carmel is a post-operative patient who had a total knee replacement done 10 days ago. Carmel has been complaining of constipation since her operation. Now she has called for assistance as she has an urge to use the bathroom. List the steps you will use to help Carmel with the elimination process.
Mr Sands has been admitted to the medical ward where you work as an enrolled nurse. Mr Sands asks you to teach him the correct way of doing deep breathing exercises. Describe five essential steps required for deep breathing exercises.
Mrs Mosby has been admitted to the medical ward post complication of cystic fibrosis. Mrs Mosby needs to be taught coughing exercises to help her loosen mucus effectively. List four essential steps required for coughing exercises.
For each item in the table below, identify two risk prevention strategies.
Item
Risk prevention strategies
Maintaining a safe environment
1.
2.
Preventing fall and falls assessment
1.
2.
Promoting deep breathing and coughing exercise
1.
2.
List six actions you can take to maintain a safe environment for your clients.
Effective clinical handovers that are structured and standardised help bring better outcomes for patients. The ISBAR framework is a common tool used to communicate patient’s details. Outline ISBAR in your own words.
Describe the recording and reporting requirements that must be followed for concerns related to any change in a person’s condition or behaviour, or any situation of risk. Refer to the NSW Health policy directive:
What nursing care/interventions would you provide for a client who is suffering from the following conditions?
Conditions
Potential nursing care/interventions
a) Pain
b) Sleep disturbances
c) Nutritional deficits
d) Cognitive deficits
e) Fluid deficit
List any two relevant risks for episodic care that are created by the following conditions.
Conditions
Two relevant risks
a) Cognitive status
1.
2.
b) DVT, VT, PE
1.
2.
c) Immobility
1.
2.
d) Length of stay
1.
2.
e) Mental health condition
1.
2.
f) Non-compliance
1.
2.
g) Pain
1.
2.
h) Presence of morbidity
1.
2.
i) Age
1.
2.
j) Anaesthesia and surgery
1.
2.
Lily Huang is an 86 year old female who has recently been admitted to an aged care facility. A day before her admission, she underwent surgery for cataract removal. She is hard of hearing and therefore uses hearing aids. Two days after the admission, Lily is found to be confused, restless and disorientated to the place and time.
What are the potential risk factors in this scenario?
List three nursing care actions required for a person like Lily who may have cognitive deficit.
List four nursing care actions required for a person like Lily who may have sensory deficit including use of personal aids and devices.
a) Mr Hunter is an 80-year-old male and has been admitted to the medical ward after two days of breathing difficulties and peripheral cyanosis. He has a history of emphysema and is a chronic smoker. He is complaining of shortness of breath (dyspnoea). Based on Mr Hunter’s underlying medical condition, emphysema, list at least two actual and one potential nursing care action you would provide for Mr Hunter to help him improve his breathing difficulties and peripheral cyanosis.
Actual nursing care actions:
Potential nursing care action:
b) Mr Blake, a 76-year-old male, has been admitted to the medical ward for the management of hypertension. Mr Blake is regularly taking tab Frusemide 40mg BD as ordered by his GP. He complains that he has been non-compliant with his fluid intake and feels thirsty. On assessment, you find that his peripheral extremities are oedematous. List one actual and one potential nursing care measure you could implement to assist Mr Blake.
Actual nursing care measure:
Potential nursing care measure:
According to Standard 10 of the Australian Commission on Safety and Quality in Health Care, people are screened for falls risk at the time of admission and any change in condition is noted.
Explain in your own words why there is a need to screen people for falls risk at the time of admission.
What screening tool is used to assess patients’ falls risk? List at least two strategies to prevent falls in a health care facility.
a) Identify any three contributing factors for skin breakdown.
List one strategy you would use to prevent and manage skin breakdown.
Mr Armstrong has been admitted to the stroke rehabilitation unit. You are looking after him for the morning shift. The doctor has asked you to promote active and passive exercise for him. Identify one risk prevention strategy you would use prior to teaching him these exercises.
Mrs Krushar, an 89-year-old female, has been transferred to the hospital from an aged care facility after a fall in the bathroom. Mrs Krushar has a fracture left hip. In order to prevent skin breakdown for Mrs Krushar, what risk prevention strategies would you use?
In the table below, list the seven essential steps for performing CPR for an unresponsive person as per ARC guidelines, and briefly describe how would you perform each of those steps.
List all emergency codes used in a health care facility and briefly describe the meaning of each code.
While completing your nursing documentation at the the nurses station, one of your patients calls for assistance. As you approach him, he collapses in front of you and is unresponsive. How would you respond to this?
You are working in an aged care facility and looking after a 76 year old female who has been bedridden since the age of 45 as the result of an accident. List one actual and one potential nursing care action she might need during your shift.
Identify any six activities of daily living (ADLs) and explain why it is important to support and assist patients with these?
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