NCLEX: Safety: Restraints, Fall Risk, Seizures, Po
NCLEX: safety: restraints, fall risk, seizures, po
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NCLEX: safety: restraints, fall risk, seizures, postmortem care Exam Questions & Answers
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NCLEX: safety: restraints, fall risk, seizures, po
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NCLEX: Safety: Restraints, Fall Risk, Seizures, Po
NCLEX: safety: restraints, fall risk, seizures, postmortem care
precautions for a pt who is blind - Answer- - offer elbow and walk slightly ahead
- announce room entry and exit to orient
- describe location of items using clock face orientation
- use cane with dominant hand and sweep areas in...
NCLEX: safety: restraints, fall risk,
seizures, postmortem care
precautions for a pt who is blind - Answer- - offer elbow and walk slightly ahead
- announce room entry and exit to orient
- describe location of items using clock face orientation
- use cane with dominant hand and sweep areas in front from side to side to orient
if a pt has restraints how often should the RN assess skin integrity and
neuromuscular status and near status - Answer- q2hrs
if a pt has restraints how often should the RN offer liquids, nutrition, and toileting -
Answer- q2hours
prevent dehiscense of an abdominal wound of a pt with impaired wound healing -
Answer- - use an abdominal binder
-give docusate
-give ondansetron
-tight glucose control
what type of IV solution is given IMMEDIATELY to a pt with hypovolemic shock? -
Answer- isotonic (.9)
pt NEWLY returned after knee surgery wants help going to the chair. what is nurses
FIRST action? - Answer- verify activity prescription
-the nurse should be present when the pt begins ambulating
legally blind pt ambulating 1 day after appendectomy. most appropriate action by
RN: - Answer- use the sighted-guide technique by walking slightly ahead with pt
holding onto nurses elbow.
-after evaluation by nurse, pt can ambulate around unit with cane
postmortem care - Answer- - maintain standard or isolation precautions
- gently close the pt's eyes
-remove tubes and dressings ((UNLESS AUTOPSY/ORGAN HARVEST is pending))
-straighten and wash the body and change linen
- replace dentures so face maintains its shape
-place pad under perineum
- raise HOB
-allow family member to assist with care
which patients can NOT sign out AMA - Answer- - impaired by alcohol or drugs
- pt who hears voices (homicidal/suicidal)
-those not in touch with reality (ex. pt insists he is the embodiment of jesus christ
, post cagb: incision care - Answer- - wash incision daily with soap and water in
shower and pat dry
- AVOID tub baths
- do NOT apply powders or lotions
- REPORT any redness, swelling, and increased drainage
- itching, tingling, and numbness may be present for several weeks after due to
damage of local nerves
the valsalva maneuver is contraindicated with which diagnosis - Answer- -IICP
-Stroke
-head injury
-heart disease
-glaucoma
-eye surgery
-abd surgery
-liver cirrhosis
with a new sudden onset of restlessness/agitation first think: - Answer- oxygenation
then blood glucose
wrist restraints: protecting th pt from injury - Answer- - tie to MOVABLE part on the
bed frame
- use quick release tie
-side-lying or semi fowlers positioning
- release restraints q2hrs to perform skin care, assess for pressure injury and for
continued need
-place gauze pads under restraint to avoid excessive pressure
pt is beginning a tonic-clonic seizure during ambulation. what should be done
immediately? - Answer- -guide pt to floor and cradle the head
- move objects that may cause injury
-position left lateral
-remain with pt, observe and record seizure activity
what should NOT be done during a seizure - Answer- - do not place a tongue blade
in pt's mouth
- do not retrain limbs or torso
which peripheral IV site should be chosen to reduce the risk of catheter related
bloodstream infections? - Answer- dorsal surface of hand or forearm
how to reduce catheter related infections from peripheral IV lines - Answer- -select
sit on upper extremity (hand or forearm)
-clip excessive hair (NO SHAVE)
-clean site with chlorhexidine in back and forward motion and allow to dry completely
-change site q3days
-access ports should be cleaned with 70%alcohol prior
which pt's are at an increased risk for falls? - Answer- -age >65-75
-hx of falls
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