NUR 120 EXAM 3 NEWEST ACTUAL EXAM
COMPLETE 400 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH (VERIFIED ANSWERS)
|ALREADY GRADED A+
Factors that affect patient safety - ANSWERDevelopmental characteristics - very young
and elderly need more safety planning
Lifestyle - past and current environments
Mobility - the more mobility the bigger the risk
Sensory perception - altered vision, hearing, smell, etc.
Knowledge - lack of safety awareness, nurse needs to teach pt appropriately
Ability to communicate
Health state - are they on sedating meds? Weak? Consider general health state
Psychosocial state - stress and depression increase risk
Fall risk - history of falls is a warning sign
What patients are at risk for injury? - ANSWERsedated
- altered mental status
- use of ambulatory aids
- elderly
- history of falls
Nursing diagnoses related to safety - ANSWERRisk for injury
- Risk for falls
- Risk for poisoning - will verbalize safe storage of meds
- Ineffective protection - will be free of complications of immobility
- Risk for suffocation - airway patent; wife verbalizes position for airway maintenance
- Risk for suicide - verbalizes plans for future activities and desire to participate
- Risk for trauma - no bruises, skin tears, cuts
- Risk for disuse syndrome (R/T restraints) - uses all extremities during hygiene and
meals
- Impaired home maintenance - home environ free of safety hazards
Teaching fall prevention to family of hospitalized patient - ANSWEROrient to
surroundings, low bed with locked brakes, keep ambulation devices in easy reach, skid
proof footwear, ID furniture with wheels and tell them these are not to be used as
support, tell them purpose or use of equipment or tubing
,Low/Moderate/High risk for falls - ANSWERlow - hourly rounding to check for needs and
provide with safety education
Moderate and high risk - yellow star on door frame, yellow armband, can have any of the
following: 3 side rails up, low bed, call light in reach, mats in use, reorient to
environment, BSC
Define restraint - ANSWERPhysical - Any manual method, device, or material that
immobilizes or reduces patient's ability to move their extremities
Chemical - Medication that restricts a patient's freedom of movement that's not a
standard treatment for their condition/s.
When is it appropriate to use restraints? - ANSWERIf patient is at risk of hurting
themselves or others
If they are trying to pull an IV out or NG tube they might need restrained (counts as
hurting themselves)
Alternatives to restraints - ANSWER-environmental changes (chairs, beds, lighting..)
-behavioral strategies (verbal redirection)
-increasing/decreasing of environmental stimulations (move away from noisy areas, turn
TV on)
-activities geared towards pt.'s cognitive/interest level (provide magazines, puzzles)
Also consider if pt. might need something
see if family can help watch them
use alarms to monitor
move closer to nurses station
provide for extra safety
Physican restraint orders - ANSWERrequired prior to placement, can't be PRN, if need to
be placed immediately get order ASAP
new order needed every 24 hours
if placed for mental health, new order needed every 4 hours
Monitoring a patient in restraints - ANSWERCheck patient at least every hour or sooner
according to patient needs (observe, interact, and directly examine)
Check circulation, hydration needs, elimination needs, level of distress, mental status,
cognitive functioning, skin integrity, if restraints are loose or off
Remove restraints and exercise ROM every 2 hours
RACE - ANSWERRescue persons in danger - remove any people in danger
Activate the fire alarm
Contain the fire - turn on lights, close doors and windows
Evacuate (first evacuate the patients nearest to fire, next ambulatory patients, 3rd non-
ambulatory patients) evacuate to different area on same floor, if not safe move to a lower
floor, if not safe move outside building
PASS - ANSWERpull pin, aim, squeeze, sweep
Types of fire extinguishers - ANSWER-A: wood, paper, trash
-B: Chemical
,-C: Electrical
Why are radiation precautions necessary? - ANSWERTo minimize exposure to
radioactive ions that can damage cells, organs, etc.
To protect patients, staff, and general public from contamination
To comply with state and federal regulations
General precautions for radiation safety - ANSWERIsolating patients treated with nuclear
medicine
Use of shields such as lead aprons or lead lined gloves
Distance - step out of room during active exposure, use of forceps to minimize contact
No one under the age of 18, or who is pregnant is permitted into patient's room
All items leaving room need to be checked for contamination - must stay in room until
checked
Explain time, distance, shielding - ANSWERTime - limit exposure time
Distance - step back
Shielding - wearing a lead apron or gloves
Potential radiation sources - ANSWERDiagnostic nuclear medicine patients
Therapeutic nuclear medicine patients
Portable x-ray unit (portable chest x-ray)
Brachytherapy patients - internal radiation used to treat
Certain lab areas
Teletherapy units - external radiation used to treat
Stationary radiographic or fluoroscopic units
Code Blue - ANSWERcardiopulmonary arrest
dial 1996 at SMMC
equipment includes: AEDs, crash carts, portable suction units
MSD sheets - ANSWERmaterial safety data sheets
provide info on chemical substances used, how to clean, when it is toxic, how to use,
etc.
found on SMMC intranet
Never Events - ANSWERserious, preventable errors that are of concern to the public and
healthcare providers for purpose of public accountability (ex: surgery on wrong part)
Seizure precautions - ANSWERRemove pillow and put side rails up if in bed, if sitting or
standing protect head while guiding to the floor
Do not restrain unless pt in danger
Place on one side and maintain open airway
Loosen constricted clothing
Suction if needed
For status epilepticus: oral airway may need inserted when jaw relaxes between seizures
Provide privacy
Keeping patient records - ANSWERHealth care team communication
Describes orders/plan of care
Serves as legal documentation
, Data for research
Quality review
Statistical info/decision analysis
Educational tools
Reimbursement
Methods of recording - ANSWERPaper vs electronic records
Problem-Oriented medical record - info organized around identified problems
Source records - organized by source of information (lab, radiology, nursing, etc.)
Charting by exception - only chart abnormal values
Case management plan and critical pathways - same diagnosis have the same 'path' in
the hospital, variances are unexpected events that throw people off the path (ex: fever)
Focused charting - uses DAR (data, action, response)
SOAP IER note - ANSWERSubjective - what the patient states (c/o no BM x5 days)
Objective - observable and measurable data (distended abdomen, hard stool)
Assessment - medical or nursing diagnosis (constipation)
Plan - what are you going to do (increase fluids, bran cereal, enema)
Implementation - carry out the plan
Evaluation - see what worked and what didn't
Revision - changes to plan
PIE note - ANSWERused to document problem (P), intervention (I), and evaluation (E)
Advantages and disadvantages of computerized info systems - ANSWERAdvantages -
increased information availability, less reading issues, decreased time on clerical duties,
constant updating, data for quality assurance, increases accuracy, provides decision
support, provides automatic prompts for critical information, and tools for workflow
management
Disadvantages - computer malfunctions make data unavailable, impersonal distance
created by computers, right to privacy and confidentiality may be threatened, may not be
faster
Using medical terminology with patients - ANSWERAdjust vocabulary to fit patient
knowledge, understanding, vocabulary
Review medical abbreviations handout - ANSWERsee abbreviation handout
legal aspects of charting - ANSWERlegal document admissible as evidence
property of the agency
legal action can be taken against someone: concealing info, protecting someone,
deceiving insurance
written consents required for invasive procedures
try to have patient sign AMA if pt leaves without a discharge order
don't complain/criticize
What info should not go on a progress note? - ANSWERRoutine checklist info
info from special forms ex. discharge form
"incident report completed"
vague terms
