exam 7
what are some potential hazards to infants and children
Household cleaners Objects that are small enough to go in the mouth, ears, nose, etc. Pots and pans Heavy objects Sockets and outlets Pools safety Rails of the crib should be u
The older adult residents in a nursing home must be evacuated because the facilities at risk for flooding and damage due to hurricane that will pass through the area in several days the nurse is assigned to keep a log to document the events what information is most important to record .
How each resident was transported, name of residence, where the residence were sent, who transported each resident and , notification of family members and healthcare providers.
A mother brings her alert and playful child to clinic because she found him playing with this empty bottle of baby aspirin what questions is the most important to ask the mother?
How many pills do you think we're in the container
A patient with a latex allergy is exposed to latex which sign or symptom is cause for the greatest concern
laryngeal edema
what should your focus be when it comes to srd ?
to try alternative strategies before turning to use of SRDs
Before the nurse can intervene, the UAP pushes contaminated material into an overfilled sharp container and sustains a puncture wound what should the nurse do first
Assist the UAP to scrub the wound with copious amounts of soap and water
Mercury Spill Cleanup Procedure
1. Evacuate the room except for housekeeping crew (if available) 2. Ventilate the area. Close interior doors and open any outside windows. 3. DO NOT VACUUM THE SPILL! After mercury has been removed: 4.Mop the floor with a mercury-specific cleanser 5.Dispose of collected mercury according to a local environmental safety regulations.
Which new lead made a patient is most likely to need in benefit from individualized explanation of the bathroom facilities
A 65-year-old man who is from April farming region of China
The nurse is teaching a new group of UAP had to evacuate residence for me long-term care facility in case of a fire or other emergency what piece of equipment for the universal carry make it to the nurse need to teach about?
A blanket
The patient tells the nurse he would like to be transferred to hospital X because his cardiologist doesn't come to hospital Y what should the nurse do
Advise the patient that a transfer requires an order from the provider
Which occurrence is most likely to be investigated as a sentinel event
An older patient sustained a broken arm related to the use of an Srd
The patient reports dizziness when standing up too fast which over-the-counter medication is most likely to be contributing to the patients orthostatic hypotension?
Antihistamine
The nurse is giving instructions to a family caregiver of an order patient who will need help after discharge from the hospital the nurse says his tension, resentment, and unwillingness from the caregiver what should the nurse do for us
Assess the caregivers attitude toward the patient and the circumstances
The postoperative patient demonstrates some mild dizziness and mild shortness of breath when moving from sitting to a standing position what action should the nurse perform first
Assist patient to sit back down
The patient is being transferred from the medical surgical unit to a long-term care center what size can be delegated to the UAP
Bathe and incontinent patient, assist to collect personal items, take a final set of vitals signs
A confused patient is yelling at the unlicensed assistive personnel as a nurse enters the room the patient does the food tray at the UAP what should the nurse first do ?
Call me talk to the patient and respectfully address him by name
The nurse is sitting at the front desk at a walk-in clinic patient comes in and reports a fever, malaise, and muscle aches with the rash on the tongue, mouth, and throat. The nurse notes pustules on the patient palms what should the nurse do first
Call the provider to triage the patient
The patient has an old head injury and demonstrates occasional intermittent episodes of belligerence and confusion interspersed with appropriate behavior he is currently angry and wants to leave AMA the nurse is unable to reach the provider what should the nurse do first
Call the supervising RN because the patient now has acute needs
Disaster Manual
Chain of command Callback procedures Assignment procedure Departmental responsibilities Patient evacuation procedures and routes Procedures for the receipt and management of casualties Polies related to overall management of supplies and equipment Must know hospital codes!
Potential Hazards to adults
Changes associated with aging significantly affect the ability of older adults to protect themselves from injury ➢ Unsteadiness in gait causes falls ➢ Vision changes may affect the ability to see the height of stairs ➢ Vertigo may occur due to disease and/or medications
The nurse is admitting a new patient to the diagnostic and surgical Center what should the nurse do first
Check identification band
Accidental Poisoning
Childhood poisoning is one of the major causes of death in children under 5 years of age The older adult is also at risk ➢ Changes associated with aging interfere with the individual's ability to absorb or excrete drugs ➢ The older adult may share drugs with friends ➢ Changes in eyesight may lead to an accidental ingestion 91% of all unintentional poisonings are related to drugs (OTC and prescription) Prevention Poison Control Center: 1-800-222-1222
The nurse is caring for a patient who relies on mechanical ventilation the nurse here's a fire alarm in flames are visible in the back corridor what should the nurse first do ?
Deligate UAP to move ambulatory patients towards the exit
In the event of a mercury spell what is the priority nursing action
Evacuate everyone from room
fire safety
Fires in health care facilities are often related to smoking in bed or faulty electrical equipment An established fire safety program is mandatory for all health care facilities Fire prevention includes good housekeeping, maintenance, and employee discipline All employees should know the telephone number and procedure for reporting a fire, as well as the location of the nearest firefighting equipment Health care workers must know their roles in the overall evacuation plan
The nurse is giving instructions to the UAP about patient safety and fall prevention what should the nurse tell the UAP about helping the patient to go to the bathroom?
Have her sit up slowly and dangle her legs before standing
The nurse is conducting a fall risk assessment on an older patient who's moving into an assisted living center . which question should the nurse ask
Have you had any falls in the past year, do you feel unsteady when you stand up, are you able to independently walk from the room to room, have you ever lost conscious before or after a fall, and do you use a cane or other assistive devices.
The nurse is talking to a young mother who has an infant who has just started to crawl based on knowledge of growth and development which safety issues is currently the most important to discuss with the mother
How to manage electrical sockets and chords
what are some complications of Safety Reminder Devices (SRDs)
Immobility Dehydration Incontinence Psychologic Skin impairments Circulation issues Loss of function
The nurse is working in the local health department and there has been an unusually large number of phone calls about food borne illnesses which question is the nurse most likely to ask callers to differentiate the possible involvement of the bioterrorist agent that causes botulism isn't from other common causes a food borne illnesses.
In addition to gastrointestinal symptoms have you been dropping eyelids or difficulty swallowing or speaking
Which patient is likely to have the most complex discharge plan
It's 73-year-old man with chronic disease who has no family in the area
Mercury spill
Know who to call if there is a mercury spill ➢ This will vary from facility to facility Mercury can enter the body through skin and inhalation Mercury is not frequently used in health care facilities; however, you need to be prepared if you were presented with a safety issue
discharging Patient
Many hospitals have a form with written instructions and teaching documentation for the patient to sign and acknowledge understanding of the instructions ➢ These instructions serve as a guide for the patient to use at home
In which clinic setting is the nurse most likely to need knowledge of how to apply safety reminders devices and manage the care of these patients ?
Mental health walk in clinic
A patient begins to have a grand mal seizure what is the priority action
Monitor the patency of the airway
what are some safety reminder devices
Must have an order Make sure to assess need for SRD Appropriately apply SRD➢ Please review each in the skills section➢ DO NOT APPLY RESTRAINT TO THE SIDE RAIL➢ Allow for movement, about 1-2 inches➢ Must be able to have palpable pulses➢ Use a quick release knot, do not double knot restraints Document! Monitor the client closely!➢ Assess pulses, skin at least every 30 minutes ➢ Remove one SRD every 2 hours for 5 minutes
what should you never use
Never use frayed or damaged electrical supplies
The nurse is planning to teach a community group about fire safety in the home what information should be included in the presentation?
No smoking by the patient, family, or visitors in areas where oxygen is used, install fire alarms, smoke detectors, and carbon monoxide detectors. Practice fire escape route from each room and practice exit drills.
A rational patient wishes to leave the hospital against medical advice ( AMA )despite the nurses best attempt at therapeutic communication what is the nurse first responsibility
Notify the provider
What to implement prior to applying SRD
Orient client to environment Encourage family and friends to stay with patient Place confused/disoriented pt's close to nurses station Provide appropriate visual and auditory stimuli Use relaxation techniques Exercise and ambulation schedules Diversional activities Toileting routines Bed alarms, chair alarms PT/OT Assess medication side effects
The nurse is considering the use of an SRd to prevent a patient from self injury when using an SRd what should the nurse do?
Obtain a providers order for the SRD , Explain the purpose of the SRD to the patient, explain the purpose of the SRD to the family, exhaust all ultra notice before using an SRd
An older adult patient in a long-term care facility has been wandering around outside of the room during the late evening hours the patient has a history of falls how should the nurse intervene
Obtain an order for a bed and chair alarm
Which task related to a meeting a new patient can be delegated to the UAP
Obtain personal care items such as water pitcher or pack cleansing cloths, position the bed for transfer from stretcher or wheelchair, assisted patient to range desired items such as eyeglasses within reach
During the admission of a patient to a healthcare facility what are the responsibilities of the admission department representative
Octane identifying information, giving information on health insurance for portability and accountability act, placed in the correct identification been on the patient's wrist, obtaining an emergency contact information, and gathering insurance information
The nurse is trying to explain the bed controls in the car button and other related to hospitalizations but the older adult patient keeps telling the nurse to wait for my son to get here what should the nurse do first
Offer comfort measures and ensure patient safety
if patient is on restraint what should you offer ?
Offer food ,water ,toilet
And experience LVN is working on a medical surgical unit the LV insist that a new RN has not completed the admission assessment on a patient who arrived 20 hours ago what should the LVN do first?
Offered to collect data so the new nurse can complete the admission assessment
The nurse supplies a gate belt to email patient of average build who has some weakness on the left side how does the nurse position herself before assisting the patient ambulate down the hall?
On the patient's left side hole in the back of the gate belt
The nurse is reviewing the disaster preparedness plan for a small nursing home what should be included in this plan
Possible admission to a hospital or transfer to a temporary shelter, log to document residents names and locations, system to notify families and providers, and matter of a patient identification such as bracelet or picture ID
Which newly obtain piece of equipment creates the greatest risk for fall for an older adult
Prescription lenses
the mnemonic PASS:
Pull the pin ➢ Aim low➢ Squeeze handle ➢ Sweep the unit
proper fire extinguisher
Type A: paper, wood, and cloth fires Type B: flammable liquid fires (grease, anesthetics) Type C: electrical fires If marked ABC it is appropriate for all fires
The nurse notices smoke coming from the wastebasket in a patient room upon entering the room the nurse is a fire that is starting to flare up what should the nurse do first
Remove the patient from the room
What is memonic race
Rescue patients➢ Sound the Alarm➢ Confine the fire➢ Extinguish or Evacuate
It is suspected that a patient has been exposed to a cyanide gas the nurses alert for which symptom
Respiratory distress
The nurse started a new job in a small long-term facility in the Royal area the back exit hallway is being used as a storage area while a new storage areas being planned what should the nurse to first
Review the facilities policies/procedures for emergencies
An infant has a wound with a dressing on the left upper arm he repeatedly attempts .to remove the dressing which srd would the nurse select
Right elbow SRD
Discharging planning
Systematic process of planning for patient care after discharge from the hospital Although discharge from a health care facility is usually considered routine, effective discharge requires careful planning and continuing assessment of the patient's needs during hospitalization Risk factors should be identified Discharge planning involves multidisciplinary action with participation by all members of the health care team, the patient, and the patient's family Referrals for health care services are considered Discharge planning should begin shortly after admission
The older adults is the nurse that he is having trouble reading the labels on his medication bottles. What is the best strategy that the nurse considers to reduce the risk of an accident medication error?
Teach the patient to use a medication organizer to manage the medication.
what is included in discharge planning teaching
Teaching Disease signs and symptoms medications Proper use of equipment Schedules Ordered exercises ➢ Referrals (should be initiated prior to discharge) ➢ Communicating dietary and activity instructions ➢ When to call the provider➢ Community resources
An older adult patient is post operative for hip surgery he is transferred by ambulance from the hospital to rehabilitation unit one after one hour after he is assisted into bed at the rehab unit he dies in his sleep which documentation provides the best legal protection for the transferring nursing staff
The discharge assessment that was performed just before the patient left the hospital
The nurses place in an interpretation been on a patient who was admitted to the emergency department what is best to say as the band is applied
The primary purpose of the band is to maintain safety
Factors that Affect Disaster Response
Time of day Scope and duration of the triggering event Readiness of health care facility, personnel, and equipment Preparations for appropriate procedures Extent to which the various community agencies and institutions communicate
A patient with Alzheimer's disease is being transferred from a long-term care facility to an acute care hospital for possible sepsis and change in mental status which question is the most important as the nurse was given the report
What is the patient's baseline mental status and behavior
The patient is newly in newly admitted and seems anxious but appears very hesitant to ask questions which statement by the nurse best demonstrates empathy
You seem a little uncertain do you have some questions
For the care of a patient who has an SRD in place where which task can be delegated to the UAP
change position every two hours
how often should the srd order be renewed
every 24 hours
how often should you check wrist restraints
every 30 min
what kind of knot should you use
quick realize knot
Which instruction should be given to a UAP who is assigned to assist in the care of a patient who is being treated with internal radiation
wear your personal dosimeter during care or when handling patient items