Nursing 221 Test 1
What does RACE stand for? - correct answer rescue, alarm, confine, extinguish
What does PASS stand for? - correct answer pull the pin, aim, squeeze, sweep
If seizures occur what do you do? - correct answer always stay with the patient, call for help, if standing, guide to the floor and cradle head in lap or place pad under head, provide privacy, turn patient on side if able with head tilted and slightly forward, do not place anything in mouth, note time seizure starts, ends,
and the patients behavior, maintain patent airway, suction, and apply oxygen by nasal cannula
What is the assessment for falls risk? - correct answer poor vision, cognitive dysfunction, impaired mobility, urinary frequency, physical condition, medications, age, history of falls
How do you prevent falls? - correct answer side rails up when appropriate, bed low position/wheels locked, call bell in reach, glasses, hearing aids, ambulatory aids in use, room clutter free, clean up spills, electrical safety good lighting, provide non-skid footwear for clients
What are the 6 p's of rounding? - correct answer Pain, potty, position, personal items, plan, place call bell
in reach, ask: is there anything else?
What things should you orient your patient to? - correct answer room, equipment, call bell/emergency bell, telephone, tv/radio, side rails, safety measures, visiting hours, unit routine, including meals
What are examples of safe transfers? - correct answer from bed to chair, and from bed to stretcher
When is it okay to use a restraint? - correct answer as a last resort to provide patient safety or safety of others
What might chemical restraints do to the elderly? - correct answer may cause confusion What are physical restraints? - correct answer a physical device attached to the body to restrict movement/activity for safety
what do you assess when using restraints? - correct answer mental status, pain, education level and understanding of client, therapy needed, determine need for restraint
What needs to be determined for a use of a restraint? - correct answer if behavior may interrupt therapy,
or if there is a threat to self or others
what are some safety measures when using restraints? - correct answer inspect client for injury per policy, check neurological and circulatory status, ensure restraint is secure but not restrictive loose enough for two fingers to fit between restraint, never tie to bed rails (use quick release knot), explain need for restraint to client and family, never leave client alone if restraint is removed temporarily, orders are required, reassess for q 24 hours.
When can a order be obtained after a restraint is applied? - correct answer in emergency situations like ER or ICU
What must you document when using restraints? - correct answer what behavior required restraint, type
of restraint applied, education provided to family/client, clients consent if required policy, times of application and removal, assessment of client, limb, ROM, assessment of therapy, review physician order
for changes/updates
Does 4 side rails up equal a physical restraint? - correct answer no
What does body mechanics and alignment also refer to? - correct answer posture, coordinated efforts of the musculoskeletal and nervous systems, sitting, standing, or lying
What is the nature of infection? - correct answer infection is the invasion of a susceptible host by pathogens or microorganisms, resulting in disease; entry and multiplication of organisms result in disease; colonization occurs when a microorganism invades the host but does not cause infection; communicable disease is the infectious process transmitted from one person to another; if pathogens multiply and cause clinical signs and symptoms, the infection is symptomatic; if clinical signs and symptoms are not present, the illness is termed asymptomatic; hand hygiene is the most important technique to use in preventing and controlling transmission of infection what is the cycle of infection? - correct answer infectious agent or pathogen, reservoir or source for pathogen growth, portal of exit, mode of transmission, portal of entry, susceptible host
what are the stages of infection? - correct answer incubation, prodromal stage, illness stage, convalescence
incubation - correct answer interval between the pathogen entering the body and presentation of the first symptom
prodromal stage - correct answer interval from onset of general symptoms to more distinct symptoms. during this time the pathogen is multiplying
illness stage - correct answer interval when symptoms specific to the infection occur
convalescence - correct answer interval when acute symptoms disappear. total recovery could take days to months
How do you prevent infection? - correct answer separate personal care items, handling solid and fluid waste, wound cleaning, and patient education
What is proper cough etiquette? - correct answer cover your nose/mouth, place a surgical mask on a patient if does not compromise respiratory function or is applicable; perform hand hygiene after contact with contaminated respiratory secretions, maintain spatial separation greater than 3 feet from persons with respiratory infections
What is isolation? - correct answer the separation and restriction of movement of ill persons with contagious diseases; standard precaution, and isolation precautions
What are isolation precautions? - correct answer airborne, droplet, contact, and protective environment
