NURS 200 Exam 1 Terms in this set (298) Identify patients correctly Improve staff communication Use medicines safely Use alarms safely Prevent Infection Identify patient safety risks Prevent mistakes in surgery What are the 2020 Hospital National Safet

NURS 200 Exam 1 Terms in this set (298) Identify patients correctly Improve staff communication Use medicines safely Use alarms safely Prevent Infection Identify patient safety risks Prevent mistakes in surgery What are the 2020 Hospital National Safety Goals? physical and psychosocial factors that influence or affect the life and survival of that patient What is included as the patients enviornment? Oxygen Nutrition Temperature What must be met before physical and psychological safety and security can be addressed? Improper functioning heating system Furnace, fireplace or stove that is not properly vented introduces CO2 What can decrease available oxygen at a patients house? Motor Vehicle Accidents Poison Falls Fire Disasters What are common physical hazards that can result in a person getting injured or killed? Poison Any substance that impairs health or results in death when ingested, inhaled, injected or absorbed into the body. Falls An even that results in a person coming to rest inadvertently on the ground or floor or other lower level. Pathogen Any microorganism capable of producing an illness. By hand What is the most common way to transmit a pathogen? An infection that was not present in the patients at the time of admission but develops NURS 200 Exam 1 Immunizations Reduces, and in some cases, prevents the transmission of disease from person to person. Lifestyle Impaired Mobility Sensory or Communication Impairment Economic Resources Lack of Safety Awareness What are individual risk factors? History of Victimization Disabilities Emotional Problems Substance Abuse Low IQ Low Family Involvement and Low Income Gang Involvement School Failure Transient Lifestyle Diminished Economic Opportunities What are risk factors for violence? Chemical Exposure Falls Patient-Inherent Accidents Procedure Related Accidents Equipment Related Accidents Workplace Safety What are some risks associated with health care agencies? Cognitive status, gait, lower body muscle strength and coordination balance and visual status What should be included in a safety assessment? Assessment Planning Implementation Evaluation What is the nursing care plan? Pull the pin to unlock handle Aim low at the base of the fire Squeeze the handles Sweep the unit form side to side What does the mnemonic PASS? yellow colored wrist band What wrist band indicates a patient is at fall risk? Patients who are confused or agitated or who repeatedly to remove medical devices may temporarily require physical restraints to keep them safe. When would a patient require restraints? Restraint Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move arms, legs, body or head freely. Pressure injuries, pneumonia, constipation, and incontinence, loss of self-esteem, humiliation, agitation, restricted breathing and circulation. What are possible complications associated with restraints? low beds and electronic bed/chair alarms What alternative to restraint would be used for a patient who continues to try to ambulate without assistance? Yes, restraints need a prescription and must be clinically justified and part of the plan of Do restraints need to be prescribed? NURS 200 Exam 1 Must be current (within 24 hours), state the type and location of the restraint and specify the duration and circumstance. What should be included in the provider's order to use restraints? Every 15 minutes for a violent patient and every two hours for a nonviolent patient How often does a nurse have to monitor restraints when applied? Vital signs, skin integrity underneath the restraint, nutrition, hydration, circulation to an extremity, range of motion, hygiene, elimination needs, cognitive functioning, psychological status and need for restraint What must be monitored on a patient who has restraints? Reduce risk of patient injury from falls. Prevent interruption of therapy such as traction, IV infusions, nasogastric tube feeding or Foley catheterization. Prevent patients who are confused or combative from removing life support equipment. Reduce the risk of injury to other by the patient. What are the following objectives that must be met to require the use of restraints? Assign confused or disoriented patients to rooms near nurses' station and observe frequently. What is an alternative to restraint for confused or disoriented patients? Use de-escalation, time out and other verbal intervention techniques when managing aggressive behaviors. What is an alternative to restraint for aggressive behaviors? Camouflage intravenous lines with clothing, stockinette, or Kling gauze dressing. What is an alternative to restraint for patients who mess with their IV? Yes, they are considered a restraint because they increase the risk of falls when patients attempt to get out of bed or crawl over the rail. They can also lead to patient's becoming caught, trapped, entangled or strangled especially in the frail, elderly or confused patients. Are side rails considered a restraint? If so, why? Assessment of patient's mobility and responsiveness to instructions. What determines if side rails are safe to be used on a patient? R - Rescue and remove all patients in immediate danger A - Activate the alarm. C - Confine the fire by closing doors and windows and turning of oxygen and electrical equipment E - Extinguish the fire with an appropriate extinguisher What mnemonic helps set priorities during a fire? What does each letter stand for? Seizure Hyperexcitation and disorderly discharge of neurons in the brain, leading to a sudden, violent, involuntary series of muscle contractions that is episodic, causing loss of consciousness, falling, tonicity and clonicity. tonicity rigidity of muscles clonicity jerking of muscles NURS 200 Exam 1 Aura subjective sensation experience at the onset of a neurological condition, often is a bright light, smell or taste. Status epilepticus A medical emergency that requires intensive monitoring and treatment, caused when seizures are prolonged or repeated. Position patient, making sure to protect the patients head. Clear surrounding area of furniture and anything else that is hard or sharp. If possible, turn patient onto one side, head tilted slightly forward. Do not restrain patient, hold limbs loosely if they are flailing. Loosing clothing and remove eyeglasses. Do not put anything in the patients mouth and do not force apart a patient's clenched teeth. What are tips for protecting a patient during a seizure? Identify patient's perception of safety needs and risks Identify actual and potential threats to the patient's safety. Determine impact of the underlying illness on the patient's safety. Identify the presence of risks for the patient's developmental stage and patient's environment. Determine medication history and side effects posing safety risks. What is involved during the assessment of the nursing process? Involve patient as a partner in planning care. Select nursing interventions to promote safety according to the patient's developmental and health care needs. Consult with occupational and physical therapists for assistive devices and home modifications of safety hazards. Select interventions that will improve the safety of the patient's home environment. What is involved during the planning of the nursing process? Interventions based on nursing diagnosis What is involved during the implementation of the nursing process. Evaluate if patient's expectations of care are met. Reassess the patient for the presence of physical, social, environmental or developmental risks. Determine if changes in the patient's care resulted in increased threats to safety. What is involved during the evaluation of the nursing process? Age of 85 Bone disorders (osteoporosis, metastasis, i.e.) Coagulation disorders (leukemia, i.e.) Surgery (thoracic and abdominal surgery, i.e) What is the mnemonic that helps to determine whether a patient has a recent history of fall or risks for injury? What does each letter stand for? 2, 4, 5 Which of the following are safe practices to follow in the safe preparation and storage of food? (Select all that apply.) 1. Always use a single cutting board to prepare foods for cooking. 2. Refrigerate leftovers as soon as possible. 3. Always buy vegetables in packages marked "prewashed." 4. Cook meats to the proper temperature. 5. Wash hands thoroughly before food preparation. 3, 4, 5 A nurse enters the hospital room of a patient who had a total knee replacement the day before. Which of the following pose potential safety risks? (Select all that apply.) 1. A current safety inspection sticker is on the IV fluids pump. 2. A walker is positioned near the patient's bedside. 3. The hospital bed is in the high position. 4. There is no gait belt at the bedside. 5. The overbed table with the patients glasses is positioned against the wall opposite the end of the bed. 1, 3, 4 A nurse working on a medicine unit in the hospital hears the fire alarm go off. As the nurse walks down the hallway, there is smoke coming from the family waiting area. Which of the following steps should the nurse take? (Select all that apply.) 1. Immediately phone in to the hospital alert system the exact location of the fire. 2. Direct the nurse technician to place empty stretchers behind the fire doors. 3. Go to each patient room, and direct ambulatory patients to walk themselves to a safe area. 4. Work with the nurse technician to help move patients requiring wheelchairs from their rooms. 5. Close the room doors of patients who cannot get out of bed, and keep them in their rooms. Individual risks Categorize the threat to safety as individual risk or developmental risks: An older adult has limited finances. Developmental risks Categorize the threat to safety as individual risks or developmental risks: A young toddler likes to explore objects by placing them in his mouth. Individual risks Categorize the threat to safety as individual risk or developmental risks: A 55 year old patient has a residual gait change due to a stroke. Developmental risks Categorize the threat to safety as individual risk or developmental risks: A school age child chooses to play ice hockey. Individual risks Categorize the threat to safety as individual risk or developmental risks: A patient newly diagnosed with diabetes has low health literacy. 4 A nurse working on a surgery floor is assigned four patients. The nurse assesses each patient, noting behaviors and physical signs and symptoms. Which of the following patients is more likely to be violent toward the nurse? 1. The first patient maintains eye contact with the nurse, is calm during the nurse's assessment, and asks questions frequently. 2. The second patient is very drowsy, loses attention span when the nurse asks questions, and mumbles when speaking. 3. The third patient moves nervously in bed, swears and grimaces when trying to cough, and speaks in a low volume. 4. The fourth patient speaks in a loud voice and becomes irritable when the nurse arrives to help walk the patient. 2, 3, 5 A nurse working the night shift is assigned a patient who has a history of having fallen in the hospital during a previous admission. The nurse wants to review the admission assessment completed by the nurse on the day shift. Which of the following sections in the assessment are most likely to provide information about the patient's current fall risks? (Select all that apply.) 1. Allergy history 2. Medication history 3. Patient age 4. Patient's occupation 5. Physical exam of neuromuscular function School-age child Determine if the intervention for promoting child safety is meant for the developmental stage school-age child or preschooler: Teach children proper bicycle and skate board safety. School-age child Determine if the intervention for promoting child safety is meant for the developmental stage school-age child or preschooler: Teach children how to cross streets and walk in parking lot. School-age child Determine if the intervention for promoting child safety is meant for the developmental stage school-age child or preschooler: Teach children proper techniques for specific sports. Preschooler Determine if the intervention for promoting child safety is meant for the developmental stage school-age child or preschooler: Teach children not to operate electric toothbrushes while unsupervised. Preschooler Determine if the intervention for promoting child safety is meant for the developmental stage school-age child or preschooler: Teach children not to talk to or go with a stranger. Preschooler Determine if the intervention for promoting child safety is meant for the developmental stage school-age child or preschooler: Teach children not to eat items found in the grass. 3, 4, 6 The nurse finds a 68 year old woman wandering in the hallway and exhibiting confusion. The patients says she is looking for the bathroom. Which interventions are appropriate for this patient? (Select all that apply.) 1. Ask the health care provider to order a restraint 2. Recommend insertion of a urinary catheter 3. Provide scheduled toileting rounds every 2 to 3 hours 4. Institute a routine exercise program for the patient. 5. Keep the bed in high position with side rails down. 6. Keep the pathway from the bed to the bathroom clear Be sure that the patient is comfortable and in correct anatomical alignment. Pad the skin overlying the wrist. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly. Insert two fingers under the secured restraint to be sure that it is not too tight. Secure restraint straps to bedframe with quick-release buckle. What are the steps for applying a wrist restraint in the correct order? Ensures rapid response for help. Explain the rationale for the following fall prevention: Prioritize nurse call system responses to patients at high risk. Maintains comfort and makes exit difficult. Explain the rationale for the following fall prevention: Place patient in a wheel-chair with wedge cushion. Reduces chance of patient trying to get out of bed on their own. Explain the rationale for the following fall prevention: Establish elimination schedule with bedside commode. Makes it difficult for patients with lower extremity weakness to stand. Explain the rationale for the following fall prevention: Use a low bed for patient. Reduces fall impact. Explain the rationale for the following fall prevention: Provide a hip protector. Reduces slipping when walking. Explain the rationale for the following fall prevention: Place nonskid floor mat on floor next to bed. Infection Results when a pathogen invades tissue and begins growing within a host. Colonization The presence and growth of microorganisms with a host but without tissue invasion or damage. True T or F: Disease and infection only occurs if pathogens multiply and alter normal tissue function. Communicable disease A disease that is spread from one person to another. An infectious agent or pathogen A reservoir or source for pathogen growth A port of exit from the reservoir A mode of transmission A port of entry to a host A susceptible host What is the chain of infection? Virulence The ability to produce disease. Immunocompromised Having an impaired immune system. Reservoir A place where microorganisms survive multiply and await transfer to a susceptible host. food, oxygen, water, temperature, pH and light What is involved in the proper environment for an organism to thrive? Skin and mucous membranes Respiratory tract Urinary tract Gastrointestinal Tract Reproductive Tract Blood What are examples of a portal of exit? Unwashed hands of the health care worker. What is the major route of transmission for pathogens identified in the health care setting? True T or F: Organisms enter the body through the same routes they use for exiting. pain, tenderness, warmths and redness at the wound site What are the symptoms a patient will normally experience if their infection is localized? systemic infection An infection that affects the entire body instead of just a part or single organ. Direct, indirect, droplet, airborne, vehicles and vector What are the modes of transmission? Personal contact of susceptible host with a contaminated inanimate object. Describe the indirect mode of transmission. Person to person (fecal, oral) physical contact between source and susceptible Describe the direct mode of transmission. An infectious person coughs or sneezes, carrying germs a short distance within 6 feet. Describe the droplet mode of transmission. Organisms are carried in droplet nuclei or residue or evaporated droplets suspended in the air during coughing or sneezing. Describe the airborne mode of transmission. Contaminated items, water, drugs, solutions, blood, food Describe the vehicle mode of transmission. External mechanical transfer, Internal transmission as parasitic conditions between vector and host (mosquito, loose, flea, tick). Describe the vector mode of transmission. Incubation period Prodromal stage illness stage convalescence What is the course of infection by stage? Incubation period interval between initial infection and first signs and symptoms Prodromal stage person is most infectious, vague and nonspecific signs of disease Illness stage interval when patient manifests signs and symptoms specific to type of infection Convalescence interval when acute symptoms of infection disappear Age, nutritional status, stress, sex, and disease process What are factors influencing infection prevention and control? Asepsis Absence of pathogenic microorganisms. Cleaning Removal of organic material or inorganic material. Disinfection Describes a process that eliminates many or all microorganisms with the exception of bacterial spores from inanimate objects. Standard precautions Precautions designed to be used for the care of all patients in all settings regardless of risk or presumed infection status. Contact precautions Precautions used for direct and indirect contact with patients and their environment.