Clinical Procedures & Protocols Flashcards

A parish nurse discovers an unresponsive adult in the church hallway. After calling for help, what is the correct first action in the CPR sequence per current AHA guidelines?

Answer: Begin 30 chest compressions

Current AHA BLS guidelines use the C-A-B sequence; compressions are started first (30 compressions) before opening the airway and giving breaths.

When documenting a client interaction in a parish nurse health log, which practice best protects client confidentiality?

Answer: Use initials instead of full names and store records in a locked cabinet

Using initials and storing records in a locked, secure location protects client confidentiality consistent with HIPAA principles applicable to health ministry.

A parish nurse is assessing a client's respiratory rate. Which technique is most accurate?

Answer: Count breaths for 30 seconds and multiply by 2 while the client is unaware

Counting respirations for 30 seconds and multiplying by 2 without alerting the client is most accurate because awareness of monitoring causes people to alter their breathing.

A parish nurse notices a child at a church event has a suspected allergic reaction with hives and throat tightness. The caregiver has an epinephrine auto-injector. Where should it be administered?

Answer: Anterolateral thigh

Epinephrine auto-injectors are designed to be administered into the anterolateral thigh because it provides rapid absorption due to high muscle mass and vascularity.

A parish nurse is educating a family about preventing pressure injuries in a bedridden church member. Which intervention is most effective?

Answer: Reposition the individual every 2 hours and use pressure-relieving surfaces

Repositioning every 2 hours and using pressure-relieving mattresses or cushions are the cornerstone interventions for preventing pressure injuries in immobile clients.

A parish nurse is assessing a client's medication adherence and finds the client cuts their extended-release metoprolol tablets in half to make them last longer. The nurse should explain that:

Answer: Extended-release tablets must not be crushed or cut as it destroys the time-release mechanism

Extended-release formulations must never be cut, crushed, or chewed because doing so destroys the controlled-release mechanism, leading to dose dumping and toxicity.

During a home visit, a parish nurse observes a client self-administering insulin. The client reuses the same syringe multiple times without recapping. The nurse should advise:

Answer: Needles should not be reused as the tip dulls and sterility cannot be guaranteed after first use

Although some guidelines historically allowed limited reuse by the same patient, current best practice discourages needle reuse as it dulls the tip, causes micro-trauma, and compromises sterility.