Safety PNC
10 evidence-based recommendations for facilities to implement with the goal of improving client safety
1. prevent infections 2. simplified discharge instructions 3. establish a protocol to prevent hospital acquired venous thrombol embolism (VTE) 4. improve education provided to clients regarding medications 5. limit the amount of continuous time for which a healthcare provider can provide direct client care 6. work with patient safety organization (PSO) to identify potential risks to client safety 7. improve design aspects of the facility that support client safety 8. survey facility personnel to assist the culture of safety 9. create better teams to facilitate communication and improve response times 10. use an evidence-based protocol when performing invasive client procedures
standards of compliance
250 standards but the common ones are medical error prevention, verification of qualifications and competency of healthcare staff procedures, rights and education of clients, infection control management of medications, emergency preparedness
The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?
A face mask
A nurse-manager is auditing the nursing unit's adherence to infection-control practices. Which observation causes the nurse-manager to be most concerned that the clients on the unit are at risk for infection?
A nurse does not wear a gown when caring for a client on contact precautions.
A nurse is showing an older adult client the correct method of self-administering an insulin injection at home. Which statement best describes lipoatrophy and lipohypertrophy to the client?
"Lipoatrophy and lipohypertrophy are conditions of the fatty tissue that can occur from not rotating injection sites."
A nurse is performing discharge teaching for an elderly client diagnosed with osteoporosis. Which statement about home safety should the nurse include?
"Most falls among the elderly occur in the home. These clients should remove throw rugs and install bathroom grab bars."
An emergency department nurse is awaiting the arrival of multiple persons exposed to botulism at the local shopping mall. What should the nurse do?
Activate the facility's emergency disaster plan.
A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first?
Advise the client to discard the drug because it may have undergone chemical changes or become contaminated.
A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?
Airborne and contact precautions
A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?
Allow the client to wear the ring and cover it with tape.
A client in the third trimester of pregnancy has to travel a long distance by car. The client is anxious about the effect the travel may have on her pregnancy. Which instruction should the nurse provide to promote easy and safe travel for the client?
Always wear a three-point seat belt.
The nurse is preparing to administer furosemide to a 3-year-old with a heart defect. After verifying the arm band, which is the most appropriate second identifier for the nurse to use?
Ask the parent the child's name.
Which is a potential complication of a low pressure in the endotracheal tube cuff?
Aspiration pneumonia
The nurse is caring for a client with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which action?
Assess the client for a cough reflex.
Which of the following, if left untreated, can lead to an ischemic stroke?
Atrial fibrillation
For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?
Attaching braces or splints to each foot and leg
The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?
Auscultate lung sounds
When assessing a client's I.V. insertion site, a nurse notes normal color and temperature at the site and no swelling. However, the I.V. solutions haven't infused at the ordered rate; the flow rate is slow even with the roller clamp wide open. When the nurse lowers the I.V. fluid bag, no blood returns to the tubing. What should the nurse do first?
Check the tubing for kinks and reposition the client's wrist and elbow.
A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad?
Client's level of consciousness
The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for the unit's clients during a fire alarm?
Close all of the doors on the unit.
A nurse would anticipate instituting contact precautions for a client with which of the following?
Clostridium difficile infection
The nurse is preparing to administer two IV medications. What is the appropriate nursing action?
Consult a current drug reference book for IV compatibility.
A nurse having difficulty setting up humidified oxygen at 40% per Venturi mask doesn't know how many liters of flow should be used. Which intervention should the nurse perform to ensure that the oxygen is properly administered?
Consult with a respiratory therapist.
What is the priority action by the scrub nurse when the surgeon begins to close the surgical wound?
Count the sponges.
A creatinine clearance test is ordered for a client with possible renal insufficiency. The nurse must collect which serum concentration midway through the 24-hour urine collection?
Creatinine
Which condition is a downward displacement of the bladder toward the vaginal orifice?
Cystocele
Which tube is a nasoenteric feeding tube?
Dobbhoff
A physician orders an I.V. bolus injection of diltiazem hydrochloride for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus?
Gently aspirate the I.V. catheter to check for a blood return.
Which action by the new nurse would alert the charge nurse that more education is needed for the new nurse, after administering an anxiolytic to a client?
Having the client walk to the bathroom
Which is the most common cause of acute encephalitis in the United States?
Herpes simplex virus
When checking a client's medication profile, a nurse notes that the client is receiving a drug contraindicated for clients with glaucoma. The nurse knows that this client, who has a history of glaucoma, has been taking the medication for the past 3 days. What should the nurse do first?
Hold the medication and report the information to the physician to ensure client safety.
When administering benazepril with spironolactone, the nurse should be aware that which electrolyte imbalance may occur?
Hyperkalemia
those on the rapid response team
ICU nurse, respiratory therapy provider, and a critical care provider
A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client?
Impaired gas exchange related to ventilator setting adjustments
A client is admitted to the psychiatric emergency department with difficulty sleeping, poor judgment, and incoherent speech. The client reports being a special messenger from the Messiah who needs to be "sacrificed to save the world." Which action should the nurse take first?
Institute suicide precautions.
The nurse is caring for a toddler who is visually impaired. What is the most important action for the nurse to take to ensure the safety of the child?
Maintain a tidy environment around the child.
A woman who gave birth to a healthy baby 6 hours ago is having cramps in her legs. Upon further assessment, the nurse identifies leg pain on dorsiflexion. What action should the nurse take?
Notify the health care provider (HCP).
While changing bed linens the nurse notices a metal object on the bottom sheet of a client with radiation seeds implanted in the bladder. Which action should the nurse take?
Notify the radiation department. Walk away from the item
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?
Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
alarm fatigue
Occurs when nurses become desensitized to patient care alarms and then miss or delay response to an alarm
The nurse teaches a premenopausal female client to perform breast self-examination (BSE) at which interval?
On day 5 to day 7, counting the first day of menses as day 1
PASS
Pull, Aim, Squeeze, Sweep
quality and safety education for nurses
QSEN project for preparing future nurses with the knowledge skills and attitudes necessary to continuously improve the quality and safety of the healthcare systems within which they work
The nurse is caring for a client with a nasogastric tube and in mitt restraints. Which nursing action is required every 1 to 2 hours?
Remove restraints and assess skin and circulation.
When a nurse removes an I.V. from an client with acquired immunodeficiency syndrome (AIDS), blood splashes into the nurse's eyes. What should the nurse do next?
Rinse their eyes with water, report the incident, and go to Employee Health.
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:
Severe headache and early change in level of consciousness
SBAR
Situation Background Assessment Recommendation
The nurse is working with a colleague who has a delayed hypersensitivity (type IV) allergic reaction to latex. Which statement describes the clinical manifestations of this reaction?
Symptoms are localized to the area of exposure, usually the back of the hands.
A client with glaucoma has been given a prescription for a mydriatic drug. What is a priority action of the nurse?
Tell the physician.
A nurse conducting a community education program on hyperthermia determines that the participants understand the information when they identify that the heat index is which of the following?
Temperature sensed when temperature and humidity are combined
A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?
The client lying in a lateral position, with the head of bed flat apparently it is supposed to be Fowlers
The nurse teaches the client with allergies about anaphylaxis, including which statement?
The most common cause of anaphylaxis is penicillin.
Which of the following is a true statement regarding safety during a home visit?
The nurse should never walk into a patient's home uninvited.
Which is a major manifestation of Wiskott-Aldrich syndrome?
Thrombocytopenia
A client is returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside?
Tracheostomy set
A client is receiving radiation therapy and asks the nurse about oral hygiene. What teaching specific to the client's situation should the nurse include?
Use a soft toothbrush and allow it to air dry before storing.
Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
Vitamin B6
A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?
Within 24 hours after exposure
ceiling lift
a device mounted to the ceiling, which also uses a sling
The nurse is checking the client's chart for possible contraindications, before administering meperidine, 50 mg I.M., to a client with pain after an appendectomy. The nurse should hold the meperidine when the nurse sees an order for what type of drug?
a monoamine oxidase (MAO) inhibitor
class ABC fire extinguisher
a multi-purpose fire extinguisher that contains a dry chemical suitable for use on flammable materials and liquids or electrical equipment
near Miss
a potential error or event or circumstance that could have caused harm, but was caught and avoided
creative thinking
a process involving imagination intuition and spontaneity factors that underpin the art of nursing
clinical reasoning
a specific term usually referring to ways of thinking about patient care issues like determining preventing and managing patient problems for reasoning about other clinical issues like teamwork collaboration and streamlining workflow nurses usually use critical thinking
conditions that call for a rapid response team
a sudden change in vital signs, low oxygen saturation despite efforts to oxygenate, chest pain despite the administration of nitroglycerin, seizures, medical professional has a deep concern about the client's condition, or a sudden variation in the client's mental status
RACE: Alarm
activate the emergency fire alarm the facility policy
a client falls out of bed and sprains a wrist
adverse event
disaster
an emergency event of greater magnitude that requires the response of people outside the involved community
surgical site infection (SSI)
an infection that occurs in the part of the body where surgery occurred
adverse drug events (ADEs)
any undesirable occurrence related to administering or failing to administer a prescribed medication
informatics
as information technology becomes further integrated into medicine common nurses input is an essential part of the design process
nursing process
assessment, diagnosis, planning, implementation, evaluation
RACE: Rescue
assists in removing clients, visitors, and employees who are in immediate danger of the fire
RACE: extinguish
attempt to extinguish small fires the proper extinguisher is available and it is safe to do so
It is important for the nurse to assist a postsurgical client to sit up and turn the head to one side when vomiting in order to
avoid aspiration.
When teaching a client how to prevent low back pain as a result of lifting, the nurse should instruct the client to:
avoid overreaching.
practices to avoid electrical injury
avoid plugging or unplugging a device when hands are wet or standing in a wet area 0 avoid rolling over electrical cords with the client's bed or other healthcare equipment unplug a device by grasping the plug. I'm plugging the equipment by pulling on the cord can cause damage to the equipment or injury to the nurse or patient avoid using extension cords if electrical devices or equipment is not safe, tag and remove the devices from the workspace environment, and notify the clinical engineering department per the facilities policy
nurses need to encourage patients to
be assertive to actively speak up and ask questions about medications therapies test and procedures be knowledgeable about their conditions or illness and have awareness of how to prevent a complications have a support person to assist in those areas and be vigilant about the safety of care practice safe behavior such as washing hands appropriately, asking for help when needed, eating appropriate foods on their prescribed diet and reporting any mistakes noticed to the nurse or another member of the stuff
teamwork and collaboration
because treatment sometimes involves multiple departments in a 24-hour care, teamwork across departments and shifts is necessary for optimal Care
ways a chemical can make it into the body by inhalation
breathing in the fumes or air that has been contaminated by the chemical
safety regarding school age children
car accidents, sports, drowning, and shootings
class B fire extinguisher
carbon dioxide based fire extinguisher for oils, gasoline's, paints, grease, other caustic materials
standards for critical thinking
clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for the purpose), and fair
ISBARR: Situation
client name and age, admitting diagnosis, Chief complaint or urgent need for the rapid response to be called
a patient who is NPO (nothing by mouth) prior to the surgery it's delivered a food tray, which the client consumes. the procedure is delayed
client safety event
vertical evacuation
clients, visitors, and staff who are threatened by fire are relocated to a different floor
lateral evacuation
clients, visitors, and staff who are threatened by fire or moved on the same floor to a safe location
safety precautions during evacuation
close all doors wrap all clients in a blanket, with the face covering with over their face. this step is appropriate for both clients and staff members when moving to the hallways, stay low to the ground, because smoke rises. if necessary crawl on the floor do not run or panic, and do not allow others to do so
personal protective equipment (PPE)
clothes, gowns, mass, face shield, or goggles
four acute changes and conditions that nurses must investigate to determine an intervention or the urgency in responding
cognitive changes, physical changes, functional changes, behavioral changes
handoff reporting
communication of patient information between nursing units, between shifts, other departments, staff, physicians
elements of performance
consistently using two methods of identifying the patient and ensuring that the patients receiving blood transfusions are correctly identified prior to the transfusion
A client is diagnosed with scabies in a long-term care facility. Which type of client care precautions would the nurse institute?
contact
weighs a chemical can make it into the skin or eyes
contact with skin or eyes
national patient safety goals
created by The joint commission goals that focus on client safety, safe and effective delivery of healthcare, and recommendations to avoid adverse outcomes
national patient safety goals (NSPG)
created by The joint commission to help accredited organization deal with specific topics on patient safety
sentinel event (near event)
critical, unexpected adverse event that caused severe physical or psychological harm to a client, including death, dismemberment, permanent injury, and severe or temporary injury expected occurrences related to a client's illness such as death are not these events
suicide
death results in himself interest behaviors performed with the intent to die also known as suicidal intention
safety considerations involving adolescents
drowning, fires, sports, guns, and cars also risk related to peers that may increase the risk of suicide
class C fire extinguisher
dry chemical based fire extinguisher specific for electrical fires, including those involving wiring, fuse box, computers common other electrical devices
The physician suspects tracheoesophageal fistula in a 1-day-old neonate. Which nursing intervention is most appropriate for this child?
elevating the neonate's head and giving nothing by mouth
fetal mortality
ensure uterine death of a fetus at any gestational age
A nurse notices that a client admitted for treatment of major depression is pacing, agitated, and becoming verbally aggressive toward other clients. What is the immediate care priority?
ensuring the safety of this client and other clients on the unit
chemical emergency
event caused by the release of a chemical compound that has the potential for harming People's health
critical thinking indicators
evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice
clinical alarm systems
examples include bed and chair alarms as well as alarms on feeding and IV infusion pumps, heart monitors, and ventilators
guidelines following critical results
facilities definition of a critical result a defined time frame from when the results are available to when they are reported to the provider written documentation of the notification of results to the provider AKA who received the results and who communicated them
Poison control center
facility that handles poison exposure and provides poison prevention teaching to the general population
safety record regarding the older adults
falls, frailty, ability to fight diseases,
class D fire extinguisher
fire extinguisher for fires involving metals or flammable metal shavings from elements such as titanium, magnesium, potassium, and sodium
class K fire extinguisher
fire extinguisher specific for kitchen fires involving flammable oils and fats
The nurse is caring for a child with leukemia. Which nursing intervention would be the highest priority for this child?
following guidelines for reverse isolation
two common patient identifiers
full name and date of birth
ISBARR: Assessment
general client impression and significant findings through assessment, diagnostic test, lab work, and vital signs
safety culture
general feeling of shared attitudes, values, practices, beliefs that result in behaviors and feelings of responsibility for safety in all daily routines
traditional work practices that have been implemented to assist nurses and increasing their time with patients at the bedside
hourly rounding, hand off communication
A client in her first trimester of pregnancy comes to the prenatal clinic and states, "I feel nauseous and I'm vomiting all the time. I can't even keep down water." This client should be evaluated for what condition?
hyperemesis gravidarum
A nurse is monitoring a client receiving tranylcypromine sulfate. Which serious adverse reaction can occur with high dosages of this monoamine oxidase (MAO) inhibitor?
hypertensive crisis
ISBARR
identity, situation, background, assessment, recommendations, read back
behavioral changes
inappropriate movements, disorientation to time and place, hallucinating, depression, and wandering
hospital acquired infections
infections that are acquired during a client's hospital stay
chemicals.can enter the body in four ways
inhalation, skin her eyes, ingestion, or injection
concept mapping
instructional strategy that requires Learners to identify graphically display and Link key concepts
elder abuse
intentional actor failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult includes physical abuse, sexual abuse/contact, emotional/psychological abuse, neglect, and financial abuse/exploitation
nuclear terrorism
intentional dispersal of radioactive materials into the environment for the purpose of causing injury and death
ISBARR: identify
introduce yourself and where you are calling from
chemical restraint
involves the administration of medications to a patient to reduce the patient's movement or control behavior
nurse practice act
law established to regulate nursing practice
The nurse needs to pick up a large object that is sitting on the floor in a client's room. Which action most increases the nurse's risk of a back injury?
leaning forward toward the object
alpha radiation
least amount of risk does not penetrate clothing and it travels only if you centimeters possibility of health hazards from exposure of this radiation is minor
A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client's chart (shown above), into which position would the nurse assist the client?
left lateral
quality
level of performance consistent with current evidence that increases efficiency and effectiveness for desired safety outcomes
healthcare facilities that can support safety
make necessary resources available include all levels of employees and committees making decisions about initiatives celebrate improvements when quality programs are implemented do management walk around to support staff offer periodic safety training serious successes and improve patient outcomes and safety goals attained
ISBARR: Background
medical history including current medications and advanced directives if any
evidence-based practice
medicine is evolving and changing every day, and thus current medical findings must be monitored for the possibility of improved care
multi drug resistant organisms (MDRO)
microorganism often bacterial that causes infection in his resistant or unaffected by the various intramicrobial medications used to treat and destroy the pathogen
beta radiation
middle level of risk travels a small distance, specialized clothing is needed to prevent exposure
Hoyer lift
mobile (ground) lift lifting device with locking wheels and a sling to cradle clients
person-centered care
model of patient care based on holistic roots in which the nurse or other caregiver uses every clinical encounter to assess how the person is doing and to communicate respect, compassion, and care
caring
moral imperative that guides nursing practices like education practice and research action and competencies that aim towards the goal and welfare of others
safety regarding adults
more lifestyle choices like alcohol consumption and smoking mental disorders, and obesity workplace accidents as well as leisure activities
Gamma radiation
most serious can travel in great distance penetrating through clothing and body tissue protection from exposure requires leading possibility of health hazards from exposure of this radiation is high including skin burns and internal issue or organ injuries
critical results
must be immediately reported to a licensed care provider patient safety issue
raise a chemical can make it into the body by a injection
needle stick injury
quality and safety education for nurses (QSEN)
nursing competencies that would better prepare nursing students with practical experience and providing safer more effective care defined with specific knowledge, skills, and attitudes necessary to provide better quality and safety in healthcare settings
Central line-associated bloodstream infection (CLABSI)
occurs when pathogens enter the bloodstream via a central line, which access is a large vein in the body and can remain in place for long periods of time
catheter associated urinary tract infection (CAUTI)
occurs when pathogens into the urinary system via catheter inserted through the urethra into the bladder best way to prevent this one is to avoid placing a catheter and if a catheter has to be inserted then getting it out as soon as possible
reflective practice
occurs when the caregiver has a profound awareness of self, and one's own biases, prejudgments, prejudices, and assumptions, and understands how these may affect the therapeutic relationship
culture of safety
organizational environment where core values and behaviors resulting from the collective and sustained commitment by organizational leaders management and workers emphasize safety over competing goals
patient center Care
patients are partners and their care, and the perspectives, police, and culture need to be taken into consideration during their care
time out
pause and all personal activities within the operating or procedure room that take place before each surgery allows for the confirmation of the correct client, site, and procedure to be performed
communication disability
persons and ability to interact with others in ways that staff will understand and can involve challenges in the sending common receiving, or processing on messages maybe found in patients who have a hearing impairment, autism, or aphasia secondary to a stroke or other neurological conditions or have dementia or Alzheimer's disease making them intellectually impaired
ventilator associated pneumonia (VAP)
pneumonia that develops in hospitalized patients who are on a ventilator
a nurse is educating a newly licensed nurse about the joint commission's national patient safety goals. which of the following goals does the nurse include when providing the education? preventing diabetes preventing surgical site infections preventing myocardial infarctions preventing cerebrovascular accidents
preventing surgical site infections
screening test
procedures used to detect the possible presence of health considerations before symptoms are apparent
decision-making skills
purposeful goal-directed effort applied in a systematic way to make a choice among alternatives
attributes of safety
qualities or properties of remaining safe
ISBARR: Read back
read back the message or prescription from the provider which allows for clarification of any miscommunication
the three major principles that must be followed to assure safety from radiology
reduce the time spent around the radiation increase the distance from the source of radiation use shielding when handling the source of radiation
functional decline
reduction in the quality of our ability for physical or cognitive function
individuals with special needs
refers to individuals with mental, emotional, or physical disabilities who may require special care or assistance to communicate, ambulate, perform self-care activities, or make decisions
0 clinical judgment
refers to the results or outcome of critical thinking or clinical reasoning the conclusion decision or opinion a nurse makes
therapeutic relationship
relationship between the caregiver and patient that is focused on promoting or restoring health and well-being of the patient
After an infant undergoes surgical repair of a cleft lip, the physician orders elbow restraints. For this infant, the postoperative care plan should include which nursing action?
removing the restraints every 2 hours
RACE
rescue, alarm, contain, extinguish
functional changes
respiratory distress, change in mobility, on set of slurred speech, weakness of extremities, numbness of extremities, and acute functional deficit
barrier restraint
restraints the class moving within a setting through the use of barriers to the movement movement such as a concave mattress or lap board that are attached to chairs
patient rights regarding medication
right assessment right drug right dose right patient right route right time right documentation TRAMPED
What would be considered a "right" of drug administration?
right drug right client right dose right documentation
active shooter priority actions
run, hide, fight
a client has signed an operative consent for a lumpectomy of the right breast that receives a mastectomy of the left breast
sentinel event
occurrence or incident report
serves as a data base for further investigation and alerts risk management to a potential claim
adverse event
situation or circumstance that causes unexpected harm to the client
PolyGlide sheet
smaller version of the slide sheet for movement of body parts such as an obese client's extremities
asphyxiation
stoppage of breathing or the lack of air reaching the lungs synonym for suffocation
A client has been diagnosed with a muscle strain. What does the physician mean with the term "strain"?
stretched or pulled beyond its capacity
ways to measure safety cultures
surveys like ahrq patient safety culture surveys and safety attitudes questionnaire
scoop method
technique of threading the needle within the cap without touching the cap itself
thoughtful practice
the care of a patient by a clinician who utilizes clinical reasoning and reflective practice to guide thoughtful actions and person-centered processes of care
client identifiers
the client's name, date of birth, designated hospital number, telephone number, or alternative client specific documentation
deep vein thrombosis (DVT)
the condition results from a blood clot inside a deep vein, usually in the leg, though it may present in an arm as well. clients who sustain a DVT within 3 to 6 months of a hospitalization are 50% to 60% having acquired a DVT as a result of hospitalization makes it a hospital acquired condition
critical thinking
thought that is disciplined, comprehensive, based on intellectual standards comment and as a result well reasoned systematic way to form and shape one's thinking that functions purposefully and exactly
ISBARR: Recommendation
treatment provided in the client's response to the treatment
0 seclusion
type of environmental restraint that involves placing the client alone in a securely locked room without their consent less common in impatient psychiatric facilities for clients who are combative and pose a risk to other clients and staff
client safety event
unexpected event or circumstance that occurred with or without injury to the client, but that had the potential to cause harm to the client
class A fire extinguisher
water-based extinguisher for general combustible material such as paper, wood, plastic, rubber, and cloth
chemical safety
when chemicals used can cause burns or are poisonous if absorbed through the skin
A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse?
"Although the required position may not be comfortable, it will make the procedure safer and easier to perform."
A client arrives at the emergency department and is experiencing a severe allergic reaction to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed?
"Brightly colored clothes help to ward off bees."
A client asks the nurse why his residual limb cannot be elevated on a pillow. What is the best response by the nurse?
"Elevating the leg might lead to a flexion contracture."
A client taking disulfiram during alcohol rehabilitation therapy reports to the nurse that they have a mild cold and plan to use a cough medicine. Which statement made by the client indicates understanding of the nurse's teaching?
"I may experience vomiting and an upset stomach if I take cough medicine while taking this medicine."
A client in early labor is connected to an external fetal monitor. The physician hasn't noted any restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and that her partner can help her. How should the nurse respond?
"Please press the call button. I'll disconnect you from the monitor so you can get out of bed."
The nurse is providing teaching to the mother of a 4-year-old girl about bike safety. Which statement by the mother indicates a need for further teaching?
"She can ride on the street if I am riding with her."
The nurse is assessing a 1-year-old baby. The mother states, "I'm not sure if he has a fever. I have such a hard time with my glass thermometer. It's so hard to read." The nurse's best response would be:
"There is some danger in using a glass thermometer and the mercury it contains. You might consider buying a new type of device."
The nurse is caring for a client who had a permanent pacemaker surgically placed and is now ready for discharge. What statement made by the client indicates the need for more education?
"We will be getting rid of our microwave oven so it will not affect my pacemaker."
physical restraint
0 coding or immobilizing the patient using physical strength only appropriate for short-term situation or procedure such as an injection bruises and fractures can come from this
RACE: contain
0 contain the fire by closing doors and windows, which decreases the source of oxygen for the fire
The label of a drug package reads "meperidine hydrochloride, 50 mg/ml." How many milliliters should a nurse give a client for a 30-mg dose?
0.6 ml
A physician orders preoperative medications to be administered to a client by the I.M. route: meperidine, 50 mg; hydroxyzine pamoate, 25 mg; and glycopyrrolate, 0.3 mg. The medications are dispensed this way: meperidine, 100 mg/ml; hydroxyzine pamoate, 100 mg/2 ml; and glycopyrrolate, 0.2 mg/ml. How many milliliters in total should the nurse administer?
2.5 ml (i got 1.7mL)
A client with common variable immunodeficiency (CVID) who is also deficient in IgA is being treated with IV immunoglobulin (IV Ig) in the hospital. For which sign/symptom should the nurse closely monitor the client during treatment?
Anaphylaxis
How should the nurse position the head of the bed for a client receiving epidural opioids?
Elevated 30 degrees
A nurse is caring for a client with a percutaneous feeding tube. The client has a prescription for 325 mg enteric coated aspirin to be given via the feeding tube once daily. How should the nurse give this medication?
Request an alternate formulation
Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client reports feeling chilled. Which of the following actions by the nurse would be inappropriate?
Restrict oral fluids.
Upon examination, the nurse practitioner notes a backward positioning of the client's uterus. How would the nurse document this finding?
Retroversion
When teaching a group of nursing students about rheumatic disorders, a nurse emphasizes which important differences when caring for the older adult?
Risk for falls
A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?
Risk for injury
conditions that a client may suffer while in a healthcare facility
SSIs CAUTIs CLABSIs burn or electrical shock blood transfusion incompatibility injury related to falls or trauma an effective and unsafe insulin usage deep vein thrombosis pressure injuries
Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?
Tensilon test
common safety risk assessment data from the patient or family member during an interview
ability to communicate ability to provide self care cognitive ability memory deficiencies bowel and bladder elimination and control susceptibility to falls or any other safety risks visual or other sensory deficiencies mobility deficiencies use of assistive devices presence of Foley catheter, peg tube, colostomy, or tracheostomy skin integrity vulnerability to injury nutritional status developmental considerations
birth defects
abnormalities present at birth that cause physical or mental disability or death
examples of an unexpected event that must be documented in an occurrence report
accident or injury of a client, staff member, or visitor like a fall unexpected vaccine reaction 0 unexpected drug reaction administration the wrong vaccine or drug to a client incorrect administration of a drug or vaccine to a client property damage or lost items exposure to blood, body fluid, or other infectious material on the skin, eyes, or mucous membranes a typical behaviors, actions, and events that go against the facilities policy or procedures; client injury may occur as a result
I'm sorry I'm just not used to you asking about someone as well injuries involving involving infants and preschoolers
accidental poisonings and chokings, drowning, burns
safety
activities such as knowledge sharing and error reporting must be taken seriously to improve
workplace violence
acts of verbal abuse, threats, physical assault, or homicide that occur at work
quality improvement
adverse events must be monitored and reported so that they can be tools for Learning and similar situations in the future and catalyst for improvements and quality and safety
A client with major depression is taking tranylcypromine sulfate, a monoamine oxidase (MAO) inhibitor. The nurse understands that additional teaching is needed when the client reports eating which food?
aged cheese
A nurse is caring for a confused client and develops a plan of care based on a least restraint policy. Which intervention would be most appropriate for the nurse to implement based on this policy?
alarm-activating wrist bracelet
A client with a recent history of rectal bleeding is being prepared for a colonoscopy. The nurse knows that positioning the client lying on the left side with the knees bent is an appropriate intervention. The nurse recognizes that this position will
allow proper visualization of the large intestine.
physical changes
changes in vital signs, change in oxygen saturation, changing skin color, change and appearance of an incision, on set of diaphoresis, seizure activity, and an onset of pain
electrical safety
check for faulty electrical equipment check for ground fault circuit interrupters receptacle damage use safe work practices
hourly rounding consists of
check on clients every hour to address their needs such as toileting, positioning, pain management, and safety checks of side row and bed position or proximity of the call light to the patient
A pregnant client comes to the facility for her first prenatal visit. When providing teaching, the nurse should be sure to cover which topic?
danger signs during pregnancy
using medication safely
decrease errors associated with anticoagulant medications reconcile the client's medication
cognitive changes
decrease the level of consciousness not, change in memory common change in mood, difficulty thinking, and acute confusion
safety
decreasing risks of dangers or hazard to prevent accidents, injuries, mistakes, and harm
pressure injury
decubitus ulcer or bed sore condition results from sustained pressure on the skin and tissue beneath the skin. if the pressure injury occurs during hospitalization it is considered a hospital and acquired injury
rapid response team
dedicated interdisciplinary group who's responsibilities to proactively bring their critical Care knowledge and skills to the client's bedside
The nurse is caring for a client who has just returned to the postpartum unit after a cesarean birth. Which action is a priority for the nurse to teach the client to perform over the next 24 hours to prevent complications?
deep breathing and coughing exercises every 2 hours
A client who is 24 weeks pregnant has sickle cell anemia. When preparing the care plan, the nurse should identify which factor as a potential trigger for a sickle cell crisis during pregnancy?
dehydration
An x-ray demonstrates a fracture in which the fragments of bone are driven inward. This type of fracture is referred to as
depressed
Which action is the priority when assessing a suicidal client who has ingested a handful of unknown pills?
determining if the client's physical condition is life-threatening
restraint
device used to limit movement or immobilize a patient
sit-to-stand lift
device used to move a client from a sitting position to a standing position has locking brakes for safety
ways a chemical can make it into the body by ingestion
direct or indirect direct is following of the chemical and indirect is contamination of the hands, which then contact the food or liquid that is consumed
intuitive problem solving
direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible
Colles fracture occurs in which area?
distal radius
safety event report
documentation describing any injury or potential for injury suffered by a patient in a healthcare facility
intimate partner violence
domestic violence or battery between two people and a close relationship
standard precautions
guidelines previously referred to as universal precautions and body substance isolation includes the use of proper hand hygiene, productive equipment, and safe injection practices and the effective management of potentially contaminated surfaces or equipment
mechanical restraint
materials, straps, fabric, and leather devices that can be fastened around the wrist or ankles least restrictive restraint is the handmitten effective in preventing the client from removing or dissecting tubes lines and medical devices Mr elbow restraint on one or more extremities is the next least restrictive restraint and can achieve similar results belt or vest restraints are used to prevent a client from falling out of the bed or chair four point extremity restraints are the most restrictive and are usually recommended for clients who are aggressive and behaving dangerously these restraints should never be tied to the side rail
A nurse is caring for a client undergoing opiate withdrawal, which causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:
methadone.
examples of MDROs
methicillin staff resistant staphylococcus aureus (MRSA) vancomycin resistant enterococci (VRE) clostridium difficile (C. diff) other gram negative bacteria organisms are often seen
trial and error problem solving
method of problem solving that involves testing any number of solutions until one is found that works for that particular problem
nurses performing medication reconciliation and notes that the client who return routinely takes celebrex (a nonsteroidal anti-inflammatory drug) at home is prescribed celexa (antidepressant) instead. the client does not have a history of depression
near Miss event
After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed?
near the client's hip, with legs shoulder width apart and one foot near the head of the bed
bullying
negative, often repetitive, destructive behavior also referred to as horizontal violence, lateral violence and professional incivility
A 3-month-old infant just had a cleft lip and palate repair. To prevent trauma to the operative site, the nurse should:
place the infant's arms in soft elbow restraints.
example of a setinel event
surgical and post surgical errors and complications, client suicide, infant and abduction, and falls with serious injury most common in the US are performing a surgical procedure on the wrong body part, complications of surgery or during surgery or postoperative and clients committing suicide within the facility
scientific problem solving
systematic problem-solving process that involves (1) problem identification, (2) data collection, (3) hypothesis formulation, (4) plan of action, (5) hypothesis testing, (6) interpretation of results, and (7) evaluation resulting in conclusion or revision of the study
bio-terrorism
the deliberate spread of pathogenic organisms into a community to cause widespread illness, fear, and panic
blended competencies
the set of intellectual, interpersonal, technical, and ethical/legal capacities needed to practice professional nursing
cyber terror
the use of high-tech means to disable or delete critical electronic infrastructure data or information
safety checks before a surgery/invasive procedure
use two client identifiers to establish the client's identity Mark the surgical site if possible perform a timeout in the operating/procedure room
