A client is transferred from a long-term care facility to an acute care setting. An indwelling Foley catheter was inserted just prior to her transfer. Which of the following tasks will help prevent the development of a nosocomial infection?
B. Frequently cleaning the client's perineal area and properly caring for the catheter.
A client is in balanced suspension traction following a motor vehicle crash. He is unable to perform his own personal hygiene and must have it performed by the nurse. Which of the following factors will have the most influence on his comfort level.
B. The attitude of the nurse
A client experiences dyspnea and reports feeling tired after completing her morning care. Which of the following should the nurse include in the client's plan of care for the next day?
D. Plan for several rest periods during the morning care
For a client confined to bed, which nursing activity is a part of the routine "hour of sleep" care, but not for 'early morning' care?
A. Providing a back massage
The nurse is preparing to give oral care to an unconscious client. How should the nurse proceed?
A. Lower the head of the bed, place the client in side-laying position
Which intervention is a part of the correct procedure to follow in caring for a client's ears?
A. If unable to loosen cerumen by retracting auricle, irrigate the canal
Which of the following are appropriate teaching measures related to care of the feet for a client with diabetes mellitus? (select all that apply)
a. Inspect feet daily.
b. Use moisturizing lotions on feet.
c. Wash with warm water and let air dry
d. Use over-the-counter products to treat abrasions
e. Check shoes for any foreign objects
a. Inspect feet daily.
b. Use moisturizing lotions on feet.
e. Check shoes for any foreign objects
The nurse is preparing a presentation at a senior citizens center on the
leading cause of accidents in older adults. What topic should the nurse
concentrate on presenting?
Automobile accidents
Accidental medication overdose
Falls
Home fires
falls
An elderly client, hospitalized with a cerebral vascular accident, is unable to ambulate without help. This client becomes disoriented and tries to get out of bed. What safety measure is most appropriate for this client?
Use a bed exit safety monitoring device
Restrain the client in bed
Check the client every 15 minutes
Ask a family member to stay with the client
Use a bed exit safety monitoring device
The nurse assesses a cyanotic appearance and cool temperature in the hand of a client wearing a wrist restraint. The client complains of numbness and tingling in the hand. What should the nurse do first?
remove the restraint and call the physician.
Reapply the restraint in a different area of the wrist.
Leave the restraint in place and notify the physician.
Loosen the restraint and exercise the limb.
Leave the restraint in place and notify the physician.
Which statement by a father indicates understanding of safety measures for his 3-year-old son?
"I shouldn't give him ice cream bars on a stick."
"He knows how to swim, so I usually read a book by the pool."
"I can leave him for a few minutes only when he is asleep."
"He can cross the street by himself to play with his best friend
"I shouldn't give him ice cream bars on a stick."
Which adolescent would be at the highest risk for committing suicide or homicide?
An African-American male
A Caucasian female
A European-American female
An male of French descent
An African-American male
Flexion
decreasing the angle of the joint
Extension
increasing the angle of a joint
Hyperextension
further extension or straightening of a joint
Abduction
movement of the bone away from the midline of the body
Adduction
movement of the bone toward the midline of the body
Rotation
movement of the bone around its central axis
Circumduction
movement of the distal part of the bone in a circle while the proximal end remains fixed
Eversion
turning the sole of the foot outward by moving the ankle joint
Inversion
turning the sole of the foot inward by moving the ankle joint
pronation
moving the bones of the forearm so that the palm of the hand faces downward when held in front of the body
supination
moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body
the extensor muscles or antigravity muscles
carry the major load as they keep the body upright
proprioception
is the term used to describe awareness of posture, movement and changes in equilibrium and the knowledge of position, weight and resistance of objects in relation to the body
A person maintains balance as long as the line of gravity (an imaginary vertical line drawn through the center of gravity) passes through the center of gravity (the point which all of bodys mass is centered) and the base of support ( the foundation on which the body rest).
Intensity
of exercise can be measured by target heart rate ,talk test or borg scale of perceived exertion.
Types of exercise
aerobic- 3 times a week, total of 30 minutes a day, measured by the heart rate, talk test and borg test. Moderate intensity
anaerobic
The flexor muscles are stronger than the extensor muscles so when a person is inactive, the joints are pulled into a flexed (bent) position. The muscle could become permanently shortened and the joint fixed in a flexed position (contracture).
coordinated movement
balanced, smooth, purposeful movement
Three components to coordinated movement (defined as balanced, smooth, purposeful movement).
Cerebral cortex, cerebellum, basal ganglia
One component of coordinated movement is cerebellum
translations instructions, tells which muscle what to do.
With a cerebellum injury, the client movements would become clumsy, unsure, and uncoordinated
One component of coordinated movement is cerebral cortex
sends out a signal and tells us to pick the cup up. It initiates voluntary motor activity
One component of coordinated movement is basal ganglia
maintains posture
Benefits of exercise: Musculoskeletal
decreases muscle atropy, bone density and strength is maintained through weight bearing. The stress between weight bearing and high impact movement maintains a balance between osteoblasts ( bone building cells) and osteoclats ( bone reabsorption and breakdown cells).
Disuse osteoporosis
without the stress of weight bearing activity, the bones demineralize. They are depleted of calcium, which gives the bones strength and density.
Disuse atrophy
unused muscles atrophy ( decrease in size), losing most of their strength and normal functions.
Contractures
irreversible except by surgery, a shortening of the muscle and fixing of the joint.Ex. Foot drop.
Stiffness and pain in the joint
without movement the collagen tissues at the joint becomes permanently immobile (ankylosed)
Cardiovascular system - Diminished cardiac reserve
decreased mobility creates a imbalance in the autonomic nervous system; immobilized person may experience tachycardia with even minimal exertion, edema thrombus formation. Venous vasodilation, and statis
Respiratory
decreased respiratory movement, pooling of respiratory secretions,atelectasis( blocking of a bronchiole), hypostatic pneumonia,
Metabolic system
decreased metabolic rate, negative nitrogen balance(anabolism and catabolism), anorexia (loss of appetite) ,negative calcium balance,
Urinary system- urinary statis
(stopping or slowing down of flow)
Renal calculi
stones
urinary retention
accumulation, urinary incontinence or infection.
Most common organism for UTIs is
Escherichia coli
Psychoneurologic system
Gastrointestinal system and Integumentary system, reduced skin tugor, skin breakdown
Four levels of diagnosing activity:
level 1- walk regular pace, ground level, shortness of breath above normal after climbing a flight of stairs
Level 2-walk one city block, one level ground, indefinitely, climb one flight of stairs slowing without stopping.
Level 3 – walk no more than 50 feet on level ground without stopping, unable to climb one flight of stairs without stopping
lift no more weight than 51 pds,firm mattress, soft pillow, knees slightly higher than hips when sitting; to lift, stand with feet apart , wide base, let legs bear most of the burden.
Fowlers position
head raised 30 to 90 degrees, pillow at head, lumbar, knees may or may not be flexed, feet in plantar position. Position for people who have difficulty breathing
Orthopeneic position
sitting up in bed or on the side of the bed, table across lab, ciliates respiration
Dorsal recumbent position
black lying. Or supine position. head and shoulders slightly elevated. Used to facilitate healing
Prone position
client lies on abdomen, head turned to one side, pillow under abdomen and head. Promotes drainage from the mouth and is esp useful for unconscious clients.Should only be used when the clients back is aligned correctly.
Lateral position
side lying, pillow under head, between knees, and in front of chest. Promotes good back alignment, reduces Lordosis, good for resting and sleeping clients
Sims position
posture halfway between prone and lateral, one arm by pillow and one arm behind and down.towel role for feet. Helps with drainage,
Capillary Blood glucose, Ch 34, pg 805-807
Normal blood sugar is 60-120. For elders who have poor circulation- warm their hands with a warm washcloth for a few minutes.
Active ROM exercises
isotonic exercises in which the client moves each joint in the body through its complete range, maximally stretching all muscle groups within each plane over the joint
Activity tolerance
the type and amount of exercise or daily activities an individual is able to perform
Activity-exercise pattern
refers to a person's pattern of exercise, activity, leisure, and recreation
Aerobic exercise
any activity during which the body takes in more or an equal amount of oxygen than it expends
Ambulation
the act of walking
Anabolism
a process in which simple substances are converted by the body cells into more complex substances (e.g., building tissue, positive nitrogen balance)
Anaerobic exercise
involves activity in which the muscles cannot draw out enough oxygen from the blood stream; used in endurance training
Ankylosed
permanently immobile joints
Anorexia
lack of appetite
Atrophy
wasting away; decrease in size of organ or tissue (e.g., muscle)
Base of support
the area on which an object rests
Bed rest
strict confinement to bed (complete bed rest), or the client may be allowed to use a bedside commode or have bathroom privileges
Calculi
renal stones
Catabolism
a process in which complex substances are broken down into simpler substances (e.g., breakdown of tissue)
Center of gravity
the point at which the mass (weight) of the body is centered
Contracture
permanent shortening of a muscle and subsequent shortening of tendons and ligaments
Crepitation
(1) a dry, crackling sound like that of crumpled cellophane, produced by air in the subcutaneous tissue or by air moving through fluid in the alveoli of the lungs;
(2) a crackling, grating sound produced by bone rubbing against bone
Dorsal position
back-lying position without a pillow
Dorsal recumbent position
a back-lying position with the head and shoulders slightly elevated
Embolus
a blood clot (or a substance such as air) that has moved from its place of origin and is causing obstruction to circulation elsewhere (plural: emboli)
Exercise
a type of physical activity; a planned, structured, and repetitive bodily movement done to improve or maintain one or more components of physical fitness
Flaccid
weak or lax
Fowler's position
a bed sitting position with the head of the bed raised to 45 degrees
Gait
the way a person walks
High Fowler's position
a bed-sitting position in which the head of the bed is elevated 90 degrees
Hypertrophy
enlargement of a muscle or organ
Isokinetic (resistive) exercise
muscle contraction or tension against resistance. Ex weight lifting and body building
Isometric (static or setting) exercise
tensing of a muscle against an immovable outer resistance, which does not change muscle length or produce joint motion Ex. Kegal, quad sets.
Isotonic (dynamic) exercise
exercise in which muscle tension is constant and the muscle shortens to produce muscle contraction and active movement. Ex running, walking,
Lateral position
a side-lying position
Line of gravity
an imaginary vertical line running through the center of gravity
Logrolling
a technique used to turn a client whose body must at all times be kept in straight alignment (like a log)
Lordosis
an exaggerated concavity in the lumbar region of the vertebral column
Low Fowler's position
a bed-sitting position in which the head of the bed is elevated between 15 and 45 degrees, with or without knee flexion
Mobility
ability to move about freely, easily, and purposefully in the environment
Orthopneic position
a sitting position to relieve respiratory difficulty in which the client leans over and is supported by an overbed table across the lap
Pace
number of steps taken per minute or the distance taken in one step when walking
Passive ROM exercises
another person moves each of the client's joints through its complete range of movement, maximally stretching all muscle groups within each plane over each joint
Physical activity
bodily movement produced by skeletal muscles that requires energy expenditure and produces progressive health benefits
Prone position
face-lying position, with or without a small pillow
Range of motion (ROM)
the degree of movement possible for each joint
Semi-Fowler's position
see low Fowler's position
Sims' position
side-lying position with lowermost arm behind the body and uppermost leg flexed
Spastic
describing the sudden, prolonged involuntary muscle contractions of clients with damage to the central nervous system
Supine position
see Dorsal position
Thrombus
a solid mass of blood constituents in the circulatory system; a clot (plural: thrombi)
Tripod (triangle) position
the proper standing position with crutches; crutches are placed about 15 cm (6 in) in front of the feet and out laterally about 15 cm (6 in), creating a wide base of support
Urinary incontinence
a temporary or permanent inability of the external sphincter muscles to control the flow of urine from the bladder
Urinary reflux
backward flow of urine
Urinary retention
the accumulation of urine in the bladder and inability of the bladder to empty itself
Urinary stasis
stagnation of urinary flow
Valsalva maneuver
forceful exhalation against a closed glottis, which increases intrathoracic pressure and thus interferes with venous blood return to the heart
Vital capacity
the maximum amount of air that can be exhaled after a maximum inhalation
Which of the following means freedom from disease-causing microorganisms?
1. Medical asepsis
2. Asepsis
3. Surgical asepsis
4. Sepsis
2. Asepsis
Which of the following consists primarily of nucleic acid and therefore must enter living cells in order to reproduce?
1. Fungi
2. Bacteria
3. Viruses
4. Parasites
3. Viruses
Inflammation is a local and nonspecific defensive response of the tissues to an injurious or infectious agent. Which of the following is NOT a sign of inflammation?
1. Pain
2. Swelling
3. Redness
4. Fatigue
4.Fatigue
Four commonly used methods of sterilization are moist heat, gas, boiling water, and radiation. Which of the following is the most practical and inexpensive method for sterilizing in the home.
1. Gas
2. Moist heat
3. Radiation
4. Boiling water
4. Boiling water
A nurse is evaluating a nursing student's understanding of types of infections. Which of the following statements demonstrates a need for further teaching.
1. A local infection is limited to the specific part of the body where the microorganisms remain.
2. If the microorganisms spread and damage different parts of the body, it is a systemic infection.
3. Acute infections may occur slowly, over a very long period, and may last months or years.
4. Nosocomial infections are classified as infections that are associated with the delivery of health care services in a health care facility.
3. Acute infections may occur slowly, over a very long period, and may last months or years.
A nurse is planning a seminar on the chain of infection. Which of the following is NOT one of the six links?
1. Etiologic agent
2. Reservoir
3. Portal of entry
4. Mode of transmission
3. Portal of entry
An antigen is a:
1. host that produces antibodies in response to natural antigens (e.g., infectious microorganisms) or artificial antigens (e.g., vaccines).
2. substance that induces a state of sensitivity or immune responsiveness (immunity)
3. host that receives natural (e.g., from a nursing mother) or artificial (e.g., from an injection of immune serum) antibodies produced by another source.
4. part of the body's plasma proteins.
2. substance that induces a state of sensitivity or immune responsiveness (immunity)
The CDC recommends antimicrobial hand cleansing agents in all of the following situations EXCEPT:
1. when there are unknown multiple nonresistant bacteria.
2. before invasive procedures.
3. in special care units, such as nurseries and ICU's
4. before caring for severely immunocompromised clients.
1. when there are unknown multiple nonresistant bacteria.
Which of the following statements about disinfectants is incorrect?
1. A disinfectant is a chemical preparation, such as phenol or iodine compounds, used on inanimate objects.
2. Disinfectants are frequently caustic and toxic to tissues.
3. Disinfectants and antiseptics often have similar chemical components, but the disinfectant is a less concentrated solution.
4. A disinfectant is an agent that destroys pathogens other than spores.
3. Disinfectants and antiseptics often have similar chemical components, but the disinfectant is a less concentrated solution.
Which types of precautions are used for clients known or suspected to have serious illnesses transmitted by particle droplets larger than 5 microns?
1. Airborne
2. Droplet
3. Contact
4. Connection
2. Droplet
When planning immediate injury prevention for parents of a toddler, which of the following would NOT be a focus at that time?
1. Burns
2. Suffocation
3. Choking
4. Lead poisoning
4. Lead poisoning
When evaluating a parent's understanding of safety measures for an infant, which of the following statements indicates a need for further teaching?
1. "I will store all household chemicals in the garage."
2. "I will make sure my infant is in his car seat before starting the car."
3. "I will keep small crafting beads locked in the cabinet."
4. "I will keep the trash bags in the kitchen on the bottom shelf by the sink."
4. "I will keep the trash bags in the kitchen on the bottom shelf by the sink."
A nurse planning a safety instruction class for parents of adolescents knows that the focus of the class should be on:
1. teaching adolescents to sleep on a low bed.
2. teaching adolescents about driver safety.
3. teaching adolescents not to ingest lead paint chips.
4. teaching adolescents not to run or ride a tricycle into the street.
2. teaching adolescents about driver safety.
Suicide and homicide are two leading causes of death among teenagers. When planning a workshop on adolescent suicide and homicide, the nurse knows that which of the following is NOT among the most common factors influencing the high suicide and homicide rates?
1. Economic deprivation
2. Stable and fulfilling friendships
3. The availability of firearms
4. Family breakup
2. Stable and fulfilling friendships
A nurse teaching a safety class for parents identifies all of the following as main causes of death for school-age children. Which of the following is NOT one of the leading causes?
1. Broken arms
2. Fires
3. Drownings
4. Firearms
1. Broken arms
When planning a safety inservice program for an independent living community of r older adults, the nurse will include information on which of the following as the leading cause of injury among older adults?
1. Firearms
2. Drownings
3. Suicide
4. Falls
4. Falls
which of the following is an incorrect part of the nursing assessment before applying restraints on a client?
1. Status of skin to which restraint is to be applied
2. Circulatory status proximal to restraints
3. Consideration of other protective measures that may be implemented before applying a restraint
4. Underlying cause of assessed behavior
2. Circulatory status proximal to restraints
When evaluating a parent's understanding of poisoning prevention, which of the following statements indicates a need for further teaching?
1. "we'll store toxic liquids or solids in food containers, such as soft drink bottles, peanut butter jars, or milk a need for further teaching?"
2. "We'll display the phone number of the poison control near or on all telephones in our home so that it is available to babysitters, family, and friends."
3. "We'll teach our children never to eat any part of an unknown plant or mushroom and not to put leaves, stems, bark, seeds, nuts or berries from any plant into their mouths."
4. "We'll not refer to medicine as candy or pretend false enjoyment when taking medications in front of our children."
1. "we'll store toxic liquids or solids in food containers, such as soft drink bottles, peanut butter jars, or milk a need for further teaching?"
A nurse establishing a client's plan of care for implementing seizure precautions should plan to include which of the following?
1. If clients have frequent or recurrent seizures or take anticonvulsant medications, they need to wear a medical identification tag (bracelet or necklace) and carry a card delineating any medications they take.
2. Assist the client in alerting all persons in the community about their seizure disorder.
3. Discuss safety precautions for inside of the home only.
4. Discuss with the client , family, and persons in the community factors that may precipitate a seizure.
/question>
1. If clients have frequent or recurrent seizures or take anticonvulsant medications, they need to wear a medical identification tag (bracelet or necklace) and carry a card delineating any medications they take.
Which of the following would NOT be a preventive measure for an older client with poor vision?
1. Ensure eyeglasses are functional.
2. Ensure appropriate lighting.
3. Mark doorways only.
4. Keep the environment tidy.
3. Mark doorways only.
9 Factors Affecting Safety
Age & development
lifestyle
mobility & health status
sensory-perceptual alternations
cognitive awareness
emotional state
ability to communicate
safety awareness
environmental factors
Age & Development
This is the most common. Very young children have to learn that a stove is hot.
As an adult ages their sensory acuity diminishes so they are at an increased risk for falls.
Lifestyle
What they come in contact with throughout the day (work, safety equipment for work, do they participate in risk taking behaviors such as not wearing a seatbelt or not wearing a helmet on a motorcycle)
Mobility & Health Status
Are they able to move (Do they have full range of motion, do they have arthritis, do they have an injury such as a broken leg with a leg cast)
Sensory Perceptual Alterations
If any of the senses are impaired they are at an increased risk for injury.
Cognitive Awareness
If they loose the ability to perceive or respond to stimuli then they are at increased risk for injury
Emotional State
If their emotions are extreme or they have increased stress then they have a decreased ability to concentrate and their judgment will be impaired.
Ability to communicate
If they can’t convey or receive information they are at increased risk (such as language barriers, unable to read, etc.)
Safety Awareness
The more info you know, the safer you will be. Orient them to their environment (where the restroom is, how to push their call light, etc.)
Environmental Factors- There are 3 areas
-Home- (for elderly) no rugs, nonskid surface in the shower, smoke alarms, lighting (visual acuity decreases with age-let the sunlight shine in)
-Work
-Community
Assessing Safely (5)
1. Document age and how they perceive their general health to be.
2. Document any restricted ROM, any arthritis pain (where it is, is it worse at certain times such as in the morning), encourage them to increase their mobility (weight bearing exercise increases bone density).
3. Document any sensory-perceptual deficits and how extensive the deficit is (legally blind but can see shadows).
4. Document altered thought process such as confusion. Even if they are oriented x3 there could be confusion.
5. Accident and Injury History- If they have fallen once then they are at an increased risk to fall again.
Risk Assessment Tools
these are usually used to assess risks in homes and usually focuses on preventing falls.
Home Hazard Appraisal
focuses on falls, fires, poisoning, and suffocation.
4 reasons for Diagnosing
-Risk for injury, poisoning, suffocation, latex allergy response, aspiration, disuse syndrome. (Unless they already have the injury then the diagnosis will be “risk for”)
-Latex allergy-latex gloves, name badges, stethoscope covers, foley catheters, tourniquets, IV cath lines, mattress covers (cover beds completely), IV controllers, all cords, etc.
-Knowledge Deficit- educate the pt on accident prevention (elderly pt-teach about rugs and low tables, parents of young children-teach about locking meds and poisonous materials, wearing helmets on bike, etc)
-The overall main goal is to prevent the injury and part of setting interventions is to identify hazards in the home or community.
Implementation
4 ways to promote safety
1. Education-this is individualized for each person.
2. Observation-lack of observation is the # 1 cause of newborn and infant deaths. Be sure to teach parents about the amt of observation needed to be appropriate to their child’s age.
3. Accident proofing/preventing- take all the steps necessary to prevent injury. This mainly focuses on toddlers and the elderly. (baby proof you home-lock meds and chemicals even if its out of reach, remove and lead paint, etc.)(Elderly-remove rugs, have hand rails in the restroom, ramps to get into the house, etc.)
4. Awareness-make people aware of all their potential dangers.
Implementing for Different Age Groups
·Newborns/Infants-leading cause of death is due to lack of observation by parents/caregivers. Parents need to be taught amt of observation needed of child
·Toddlers-they are fascinated by potential dangers. Toddler proofing the home is very important (turn pot handles inward on the stove)
·Preschoolers- they are active and very clumsy. Be sure to keep hazards out of reach and keep safety measures up. When you tell them no you need to enforce it. Also keep poison control # readily available.
·School age- vehicle accidents are # 1 cause of death (usually because they weren’t riding in an appropriate seat or riding in the front seat-child should not sit in front seat if younger than 13). The next leading cause of deaths is drowning, fire, and firearms. They often act before thinking (jump into a pool before thinking that they can’t swim) and they imitate parents or superheros.
Newborns/Infants
leading cause of death is due to lack of observation by parents/caregivers. Parents need to be taught amt of observation needed of child
Toddlers
they are fascinated by potential dangers. Toddler proofing the home is very important (turn pot handles inward on the stove)
Preschoolers
they are active and very clumsy. Be sure to keep hazards out of reach and keep safety measures up. When you tell them no you need to enforce it. Also keep poison control # readily available.
School age
vehicle accidents are # 1 cause of death (usually because they weren’t riding in an appropriate seat or riding in the front seat-child should not sit in front seat if younger than 13). The next leading cause of deaths is drowning, fire, and firearms. They often act before thinking (jump into a pool before thinking that they can’t swim) and they imitate parents or superheros.
Adolescents
When they have their drivers license be sure to inform them of the dangers of texting while driving and driving too fast. Need to assess their level of responsibility. Greater risk for sports injuries because coordination is still developing. The leading cause of deaths are homicide and suicide usually having to do with gangs. The male suicide rate is higher than female.
Young Adults
vehicle accidents are the leading cause of death. Suicide is also another leading cause (usually doesn’t leave a note so that it will appear to be an accident). The major safety hazard is natural radiation with can later cause melanoma (be careful of sunburns and tanning bed burns).
Middle Age Adults
There is an increased risk for occupational accidents (in factory settings-hearing loss or hands caught in machinery). Vehicle accidents are sill the leading cause of death.
Older Adults
The key is preventing accidents. There is an increased suicide rate in the elderly because of loosing spouses or children. They usually can’t bear to alone or they don’t want to be a burden.
Implementing Preventions: Scalds/burns
scald is exposure to hot liquid but a burn is exposures to thermal, chemical, electrical, or radioactive agents. This can be due to an impaired sense of touch and you will need to assess how they will protect themselves from burns (use thermometer to check bath water or meats after they’ve cooked).
Implementing Preventions: Falls
Get Up And Go (have pt sit then assess them stand and walk from point A to point B)
Implementing Preventions: Seizures
Implement seizure precautions-pad the side rails of the bed, have some type of airway for after the seizure is over, and have some kind of suction to remove excess fluid and allow them to breath, oxygen, have all four side rails up.
Implementing Preventions: Poisoning
Usually because of inadequate supervision. Always call poison control (they will ask you “what kind and how much of the substance did you take and what is your age and symptoms”. Keep on side or have head between knees). Carbon Minoxide and lead to unconsciousness or even death (don’t start the car with garage door closed.
Implementing Preventions: Choking/suffocation
When choking use the Heimlich maneuver and when suffocating remove whatever is blocking the airway.
Implementing Preventions: Excessive Noise
Make sure radios are not too loud, use protective equipment or earplugs at work. It only takes a very small increase in decibals to damage hearing (85 and below is normal)
Implementing Preventions: Electrical hazards
Don’t touch someone that is being electrocuted(shut off power). Make sure your equipment is grounded and there is no faulty equipment.
Implementing Preventions: Firearms Safety
teach responsibilities associated with this.
Implementing Preventions: Radiation
Teach about limiting sun exposure, don’t go out between 10 am and 2 pm, should have an spf of 15 or more and should reapply ever 2 hours, do not use tanning beds, and wear hat , long pants, long sleeves.
Fire Safety
-RACE-acronym used for fire safety.
·R- Remove the patients in immediate danger
·A- Activate the alarm
·C- Contain the fire (if it is safe for you to do so)
·E- Extinguish the fire (if it is safe for you to do so)
-Acronym for Extinguisher
·P-Pull
·A-Aim
·S-Squeeze
·S-Sweep from side to side
-Types of extinguishers (there are some that encompass all three)
1. Class A-Paper, wood, upholstery, rags, rubbish
2. Class B- Flammable liquid and gas
3.Class C-Electrical
-When evacuation is necessary then there is an order for evacuation
1.Remove the ambulatory patients first
2.Remove patients with wheelchairs or assistive devices
3.Remove bedridden patients last because you can’t use elevators
Home Fire Safety
-Focus on teaching fire safety
·Keep numbers near the phone
·Make sure smoke alarms are working
·Family fire drills (encourage children not to hide)
·Fire extinguishers available and working
·Close all windows and doors in a fire and cover mouth/nose with a damp cloth when exiting home to prevent smoke inhalation. Also crawl on the floor to avoid smoke.
Falling Safety
1.Orient pt to surroundings
2.Assess pt for risk
3.Encourage pt to call for assistance
4.Keep personal items within reach
5.Keep the bed in a low position and always lock the wheels
6.Encourage pt to use handrails
7.Use nonskid shoes/mats
8.Keep their environment tidy (be sure to have all cords out of the way)
Safety Institutions
·National Institute for Occupational Safety and Health
·Occupational Safety and Health Administration (OSHA)
·Centers for Disease Control and Prevention (CDC)
Safety Issues
·Encourage people to walk (children like to run in the hallways)
·Keep hallways clear of clutter (everything on one side)
·Lock wheels on stretcher and keep side rails up
·When transporting in an elevator, make sure they keep their hands inside, keep all 4 side rails up, keep any tubes inside the bed
Workplace Safety
·Lighting-very important (if you can’t see what you’re doing you will hurt yourself)
·Floor Surfaces-wear non skid shoes
·Electrical Appliances-make sure cords are intact
·Sharps-needles and glass go in the sharps container
·Dangerous substances or chemicals (every floor of the hospital has a MSDS book-tells how to clean up any chemical)
Safety in Patient Rooms
·Lighting
·Floor surface
·Oxygen (it is in every room of the hospital-remind pt if smoking it is dangerous)
·Furniture-have it pushed up against the wall
·Doors-make sure they latch appropriately and function properly
Protecting the Dependent Adult
·Keep bed low position
·Bed check system (usually have an alarm on bed)
·Use all 3 side rails and bedside table where 4th rail goes
2.Chemical-uses a chemical injection to limit pt movement
MAIN GOAL OF RESTRAINTS
·To keep pt from harming themselves or others (keep them from pulling IVs out)
·Use this as a last resort (have family member sit with them or take them up to nurses station, etc)
·Restraints interfere with established patient rights so there are laws to ensure that restraint are used only when necessary (Medicare & Medicaid)
RESTRAINT: Acute Medical Surgical Care Standard
temorarily immobilize pt for a procedure. This permits that you have up to 12 hours to receive a physicians order and the physician has 12 hours to see the patient from the time the restraint is applied. The physicians order has to be renewed every 24 hours and it has to be a written order that is dated and signed.
RESTRAINT: Behavior Management
They are going to cause harm to themselves or others. Physician have 1 hour to evaluate the patient in person after the restraint is applied. The written order is only good for 4 hours then the patient has to be reassessed. The maximum amt of time to leave on is 5 hours. If they have to continue to need restraints then there needs to be continual audio and visual monitoring (have somebody in there with them all the time). The physicians order needs to state the reason for the restraint and the time period for which the restraint can be used (restricts PRN restraints)
Types of physical restraints for adults (5)
1. Geri Chairs (can be considered a restraint because there is a tray that prevents them from getting up)
2. Belt
3. Vest
4. Mitt/hand
5. Wrist/ankle
3 Types of physical restraints for kids
1. Mummy (like swaddling but arms are inside blanket)
2. Elbow (board on back of elbow so they can’t bend it)
3. Crib (prevents them from going anywhere)
RESTRAINT REQUIREMENTS
·Use the least restrictive type of restraint
·Choose a restraint that does not interfere with pt treatment/health
·Needs to be readily changeable
·Needs to be safe for pt
·Need to choose restraint that is the least obvious to others
·Pt can request to have a restraint put on-Don’t have to have a physicians order, just document that pt requested restraint and why.
·Make sure to be able to get 2 fingers in between the pt and the restraint
·Assess pulses every 2 hours, assess ROM, offer BRP, food, & drinks.
·Usually require assistance with food and drinks (even if they don’t need assistance the nurse needs to stay in there with them during meal time-remove restraints during meal times)
·Need to have a quick release knot
Documenting Restraint Use
·Have a consent form and notify the family of restraint use
·Physicians order has to be less than 24 hours old
·Document type and location of restraint use
·Document time and reason for restraint use
·Document condition of skin, circulation, and ROM
·Removing/reapplying restraints has to be preformed every 2 hours
3 Restraint Hazards
·Emotional-Even if they are confused they will still usually realize that they have a restraint on. It can be very emotionally draining and traumatizing for them.
·Immobility- They won’t be able to move
·Death- If restraints are applied inappropriately the pt can get restraint around neck and suffocate.
Evaluation of understanding - further education needed?
·Nurses role is largely related to the clients knowledge of behaviors that incorporate safety practices and skills to perform in event of certain emergencies and to prevent certain hazards
·Examples of desired outcomes
1.The client will describe methods to prevent specific hazards (name hazards and time frame)
2.The client will alter home environment to decrease risk of falls/injuries (list time frame)
The clinic is a carrier of infection. TO prevent the spread of the infection to other clients of health care providers, the nurse emphasizes the interventions that so which of the following?
eliminate the reservoir
block the portal of entry into the host
block the portal of exit from the reservoir
decrease the susceptibility
block the portal of exit from the reservoir
The most effective nursing action controlling the spread of infection includes which of the following?
Thorough hand cleansing
wearing gloves and mask when providing direct client care
implementing appropriate isolation precautions
administering broad spectrum prophylactic antibiotics
Thorough hand cleansing
In caring for a client on contact precautions for a draining infected foot ulcer, the nurse should perform which of the following?
Wear a mask during dressing changes
Provide disposable meal trays and silverware
Follow standard precautions in all interactions with the client
Use surgical aseptic technical for all direct contact with the client
Follow standard precautions in all interactions with the client
When caring for a single client during one shift, it is appropriate for the nurse to reuse which of the following protective equipment?
Goggles
gown
surgical masks
clean gloves
goggles
While donning sterile gloves ( open method) , the cuff of the first glove rolls under itself about 1/4 inch. The best action for the nurse is to?
Remove the glove and start over with a new pair
wait until the second glove is in place and then unroll the cuff with the other sterile hand
ask a colleague to assist by unrolling the cuff
leave the cuff rolled under
wait until the second glove is in place and then unroll the cuff with the other sterile hand
after evaluating the clients chart, the nurse concludes that a 65 year old clients immunizations are current. What evidence supports this conclusion?
Last tetanus booster was at age 50
receives a flu shot every year
has not received the hepatitis B vaccine
has not received the hepatitis A vaccine
receives a flu shot every year
A client with poor nutrition enters the hospital for treatment of a puncture wound. A appropriate nursing diagnosis would be:
Risk of infection.
After teaching a client and family strategies to prevent infection prevention, which statement by the client would indicate effective learning has occurred.
We will use antimicrobial soap and hot water to wash our hands at least three times a day.
We must wash or peel all raw vegetables before eating
A wound or sore is not infected unless we see it draining pus
we should not share toothbrushes but it is ok to share towels and washcloths.
We must wash or peel all raw vegetables before eating
Which of the numbered areas is considered sterile on a person in the operating room ?
front of the gown
The nurse determines that a field remains sterile if which of the following conditions exist?
Tips of wet forceps are held upward when held in ungloved hands.
The field was set up one hour before the procedure
sterile items are 2 inches from the edge of the field
the nurse reaches over the field rather than around the edges
sterile items are 2 inches from the edge of the field
Place the following nursing priorities in correct sequence if a fire occurs in a health setting?
report the fire
extinguish the fire
protect the client
contain the fire
protect the client, report the fire, contain the fire, extinguish the fire
What is the leading cause of accidents in young and middle class adults?
Automobile crashes
drowning and firearms
falls
suicide and homicide
Automobile crashes
Because a hospitalized elderly female client, who ambulates with a walker, is receiving diuretics which results in frequent trips to the bathroom at night, the nurse should perform which of the following?
Leave the bathroom lights on
Withhold the clients medication
provide a bedside commode
Keep the side rails up
provide a bedside commode
Which NANDA nursing diagnosis is most applicable for toddlers?
Risk for suffocation
Risk for injury
Risk for poisoning
Risk for disuse syndrome
Risk for injury
A 75 year old client, hospitalized with a cerebral vascular accident ( stroke) , becomes disoriented at times and tries to get out of bed but is unable to ambulate without help. What is the most appropriate safety measure ?
Restrain the client in bed
Ask a family member to stay with the client
Check the client every 15 minutes
Use a bed exit safety monitoring device
Use a bed exit safety monitoring device
A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning clients nursing care, which of the following measures is most essential at this time of admission? Select all that apply,.
Place a padded tongue depressor at the head of the bed
Pad the bed with blankets
Inform the client about the importance of wearing a medical identification tag
Teach the client about epilepsy
Test oral suction equipment
Test oral suction equipment
Which of the following nursing interventions is the highest priority for a client at risk for falls in the hospital settings.
Keep all the side rails
Review prescribed medications
Complete the �get up and go � test
Place the bed in the lowest position
Place the bed in the lowest position
Medication errors can place the client at significant risk. Which of the following practices will help decrease the possibility of errors? Select all that apply.
Hire only competent nurses.
Improve the nurse�s ability to multitask.
Establish a reporting system for �near misses�
Communicate effectively
Create a culture of trust
Establish a reporting system for �near misses�
Communicate effectively
Create a culture of trust
When planning to teach health care topics to a group of male adolescents, the nurse should consider which of the following topics a priority?
Sports contribute to an adolescents self esteem
Sunbathing and tanning beds can be dangerous
Guns are the most frequently used weapon for adolescent suicide
A driver�s education course is mandatory for safety.
Guns are the most frequently used weapon for adolescent suicide
The nurse, at change of shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and has pulled out the IV line which was subsequently reinserted. Which of the following actions by the nurse is appropriate? Select all that apply.
Document the behaviors that require continued use of the restraints
Ensure that the restraints are tied to the side rails
Provide range of motion exercises when the restraints are removed
Orient the client
Assess the tightness of the restraints
Document the behaviors that require continued use of the restraints
Provide range of motion exercises when the restraints are removed
Orient the client
Assess the tightness of the restraints
Author
debgray3
ID
37446
Card Set
merged study guide for exam 2_for flash cards_dg.txt
