front 1 A nurse has a prescription to apply wrist restraints to maintain client safety. What should the nurse do when applying this type of restraint? | back 1 Check the site of restraint every 30 mins Remove the wrist restraint every 2 hours Ensure they wrist restraint is well padded Tie the straps of the wrist restraint to the bed frame using a slip knot |
front 2 What are important steps when transferring a pt from a bed to a chair using a mechanical lift? | back 2 Spread the legs of the lift apart before lowering the pt to the chair Attach the longer straps to the lower grommets on each side of the sling |
front 3 A client is cognitively impaired is admitted to the hospital for pneumonia. The client has a history of wandering at night. What should the nurse do to meet his needs? | back 3 Apply a radio frequency product to the wrist Restrict fluids several hours before bed Activate the bed alarm Eliminate caffeine from the diet |
front 4 An 87 year old is admitted to the hospital for IV re hydration after a fall. Orders are out of bed ad lib. What should the nurse do before getting the pt out of the bed? | back 4 Test the strength of the leg muscles |
front 5 Which nursing interventions gives the client a sense of control? | back 5 Instruct client how to lock the wheels on the wheelchair Teach the client how to use the call bell Orient the client to the environment |
front 6 A nurse in the ER hears a client and family member arguing with each other in the room at the end of the unit. What should the nurse do first? | back 6 Get another staff member and go to the room together. |
front 7 Warm compresses are prescribed to be applied to the insertion site of an IV catheter that has become red and inflamed. What should the nurse explain is the desired outcome of this thearpy? | back 7 Circulation to the area will increase which will promote healing |
front 8 A nurse is caring for a client with a vest restraint. Which action should the nurse implement? | back 8 Tie the restraint to the movable part of the bed Ensure the cross-over of the vest restraint is in the front of the client. |
front 9 A nurse is caring for a client that is blind. What should the nurse do to facilitate safety? | back 9 Walk about 1 foot ahead and have the client grasp your arm Remain near bye when they are providing self care Orient the client to the psychical environment |
front 10 What should the nurse implement when ambulating a client with a gait belt? | back 10 Position yourself slightly behind and next to the client when ambulating a client with a gait belt. Stand on the client's weaker side when ambulating a client gait belt. Assess for activity intolerance while ambulating a client with a gait belt Hold the gait belt in the middle of the client's back |
front 11 A nurse is caring for a client with wrist restraints. Which action should the nurse implement when caring for this client? | back 11 Provide additional padding Offer fluids and bathroom breaks every time restraints are released Ensure that every 24 hrs the Dr assess the need for them |
front 12 A nurse is completing an assessment for the purpose of determining factors that place the client at risk for falls. Which factor is the most concern when completing this assessment? | back 12 Has a history of falls |
front 13 A nurse is teaching a class about how to prevent the most common cause of fatal accidents in the home. | back 13 Store cleaning products in locked cabinets |
front 14 Which human response to illness alert the nurse the pt is at risk for aspiration during meals? | back 14 Lethargy, Stomatitis ( inflammation of the mucus membranes in the mouth), Dysphagia |
front 15 Pt has a nasogastric tube for gastric compression. Which nursing intervention takes priority? | back 15 Position pt in semi fowler position |
front 16 Pt was shocked by radio when turning it on. The nurse should do what first? | back 16 Take the apical pulse |
front 17 Which nursing intervention enhances the older adults sensory perception and thereby helps prevent injury when walking from the bed to the bathroom? | back 17 Provide adequate lighting |
front 18 A patient has dysphagia. What nursing action takes priority when feeding the patient? | back 18 Checking the mouth for emptying between every bite |
front 19 Profuse smoke is coming out the heating unit in a pt room. Which should the nurse do first? | back 19 Move the patient out of the room |
front 20 A nurse is planning care for a pt with wrist restraints. How often should a wrist restraint be removed, the area massaged, the joints moved through full ROM? | back 20 Every 2 hours |
front 21 A nurse is preparing a bed to receive a newly admitted pt. Which action is most important? | back 21 Ensuring the bed wheels are locked |
front 22 Which interventions should a nurse implement when assisting a pt to use a bedpan? | back 22 Ensure the bed rails are raised once the pt is on the bedpan, encourage the pt to help as much as possible when using bedpan, raise to semi-Fowler position once the pt is placed on bedpan |
front 23 A pt is delirious and attempting to pull out a urinary catheter. What is important to consider when planning care for this pt? | back 23 Reasons for using restraints must be clearly documented Laws permit the use of restraints when specific guidelines are followed |
front 24 Which drugs are most often implicated in poisoning deaths among children? | back 24 Analgesics, antihistamines, sedatives |
front 25 Restraint need to knows | back 25 Check every 30 mins 2 finger loose removed every 2 hrs Have Dr assess every 24 hrs Vest= crossover infront, prevent choking and slipping, tie to movable part of bed |
front 26 RACE stands for | back 26 Rescue, Alarm, Confine, Extinguish |
front 27 What is the number one cause of injury for over 65 | back 27 falls Also at risk: impaired vision/balance, altered gait, meds, postural hypotension, slowed reaction time, confusion *perform hourly rounds at night to help prevent |
front 28 When completing a safety event report, the nurse should include what? | back 28 Objectively describe the incident in detail |