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NUR170 Exam 2 - Class Notes: Complete Study Guide
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NUR170 Exam 2 - Class Notes: Complete Study Guide
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NUR170 Exam 2 - Class Notes: Complete Study GuideEnvironment of Care Right Ans - Making sure the environment we provide
care is safe.
Ex. Ensuring there is no clutter, bed in lowest position, call light and
possessions in reach, handrails and bars for stairs and in bathroom, non-slip
surfaces and footwear, PPE, etc.
Effective Communication: SBAR Right Ans - Situation
Background
Assessment
Recommendations
Situation: Right Ans - Patient name, age, location, code status, current vital
signs/O2 saturation, current status, etc.
Background: Right Ans - Admitting date/diagnosis, allergies, diagnostic
tests pending, patient physical/mental status, oxygen in use or not, etc.
Assessment: Right Ans - Lungs/heart/neurologic status, IV
sites/fluids/rates, diet and intake/output, active precautions, isolation
precautions, special care-tubes, wounds, etc.
Recommendations: Right Ans - Suggestions for diagnostic tests, treatments,
transfer to critical care, come to see patient, etc.
Proper Hand Washing Right Ans - 20 seconds, it's the friction and motion
of bubbles that breakdown spores; does not need to be antibacterial. Wash
INTO sink, not down so it doesn't run down your arm
Material Safety Data Sheet Right Ans - Specific to your workplace. Informs
you about a specific chemical, how to treat exposure to the chemical
Ticket to Ride Right Ans - Ensuring communication between people to
ensure patients have what they need to be transferred (any isolations, heart
monitors, if they need a stretcher or wheelchair, any lines or tanks, etc.)
,When giving report... Right Ans - Ensure clear, concise information and
ensure that it is organized
Adverse Drug Event Right Ans - Something you were not expecting to
happen to the patient (allergic reaction, Steven Johnson's syndrome from
Tylenol, etc.) It CAN happen, but it is not expected for normal patients.
NOTE: side effects that occur that are dangerous.
Ex. Respiratory depression and sedation from opioids
Side Effect Right Ans - Side effects of a drug that are anticipated that it MAY
happen
NOTE: Everything has side effects. Through testing we have found that you
might get. These are expected. NOT a crisis.
Ex. Constipation from opioids. Side effects are managed
Safe Medication Administration Right Ans - Right patient: 2 patient
identifiers
Right drug
Right dose
Right time
Right route
Right assessment: Does the patient need this drug?
Right documentation: Document AFTER patient took medication, not before
Also, check to see if the drug is expired or tampered with
Fall Scores Right Ans - Evaluate a patient's risks for falls. Constantly need
to be assessed
Seizure Precautions Right Ans - Suction at bedside, side rails are padded,
protect head, track duration of seizure,
In order to BE ABLE to put on a restraint... Right Ans - You MUST have a
physician's order or it is battery. If an emergency, ensure you get a physician's
order within an hour
, What do you do PRIOR to resorting to a restraint? Right Ans - Less
restrictive actions FIRST.
Ex. sit with patient, companion, family with them, distraction, bed close to
nurses' station, address their needs, etc.
What do you do every 2 hours when a patient is in restraints? Right Ans -
ROM exercises, capillary refill checks, allow them to use restroom, check pulse
and for skin integrity
*(ATI pg. 61)*
Who are the most at risk for safety? Right Ans - Very old and very young
RACE for fires Right Ans - Rescue, alarm, confine, extinguish
PASS for fire extinguisher Right Ans - P-pull pin
A-aim at base of fire
S-squeeze handle to release
S-sweep side to side
How do you protect YOURSELF? Right Ans - Proper body mechanics,
practice within scope of practice, manage mental stress, de-escalation tactics,
wellness checks prior to entering hospital setting, etc.
*(pg. 73-74 ATI)*
Culture of Safety Right Ans - They do everything in their power to foster a
safe environment and helps employees to be transparent if there is an
incident
What do you do if you have a patient in restraints CONSTANTLY? Right Ans
- Reassess the need for restraints
Being an Advocate for Safety Right Ans - Be aware and know how many
steps into home if being released to HHC to ensure patient is ready to go home
and SAFE when she gets home. Know if a bathroom is on the top floor, or
temperature controls, etc.
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