,Contributing factors Fall - CORRECT ANSWERS-Older age
Impaired mobility
Cognitive and/or Sensory impairment
Bowel and bladder dysfuntion
Side effects of medications
History of falls
Nursing interventions Falls - CORRECT ANSWERS-Complete a fall risk assessment
Communicate identified risks with the health care team
Assign clients at risk falls to a room close to nurses' stations and assess frequently
Provide clients with nonskid footwear
Keep the floor free of clutter and maintain an unobstructed path to the bathroom
Orient the client setting (grab bars, call light), including how to use and locate all
necessary items
Maintain bed in low position
Instruct the client who is unsteady to use the call light for assistance before ambulating
Answer call lights promptly to prevent clients who are at risk from trying to ambulate
independently
Provide adequate lighting (nightlight for necessary trips to the bathroom)
Determine the client's ability to use assistive devices (walkers, canes, etc.).
Keep all items within reach
Use chair or bed sensors for client who are at risk
Lock wheels on beds, wheelchairs, and gurneys to prevent rolling during transfers or
stops
Report and document all incidents per the facility policy
Nursing intervention Restraints - CORRECT ANSWERS-Implement nonpharmacologic
measures such as distraction, frequent observation, or diversion activities
Prior to application, review manufacturer's instructions for correct application
Notify the provider immediately when restraints are implemented
Remove the restraints and assess client every 2 hr
Assess neurovascular and neurosensory status every 2 hr
Leave the restraint loose enough to prevent injury
Always tie the restraint to the bed frame (using loose knots that are easily removed)
Reassess the need for continue use
Document
Document Restraints - CORRECT ANSWERS-Behaviors making restraint necessary
Alternatives attempted and the client's response
Type and location of restraint and time applied
Frequency and type of assessment
Restraints should NEVER - CORRECT ANSWERS-Interfere with treatment
Be used because of short-staffing or staff convenience
Not written as PRN orders
,Nursing intervention Seizure precaution - CORRECT ANSWERS-Assess seizure
history, noting frequency, presence of auras, and sequence of events
Identify precipitating factors that may exacerbate or lead to seizure
Review medication history.
If routine lab work is required (Dilantin), when was last level drawn
Place rescue equipment at the bedside, including oxygen, oral airway, and suction
equipment
Establish IV or saline lock access for high risk clients
Inspects the client's environment for items that may cause injury in the event of a
seizure.
Remove any unnecessary items from the immediate environment
At the onset seizure, position the client for safety, and remain with client
If sitting or standing, ease client to floor. Protect the client's head. If client is in bed, raise
the side rails and pad for safety
Roll the client to the side with the head flexed slightly forward
Do not put anything in the client's mouth
Loosen restrictive clothing
Accurately document the event, including timing precipitating behaviors or events, and a
description of the event (movements, loss of consciousness, loss of continence, injuries,
mention of aura, postictal state).
Report seizure to the provider
Fire response - CORRECT ANSWERS-R-Rescue: protect and evacuate clients in
immediate danger
A-Alarm: Activate the alarm and report the fire
C-Contain: Close doors or windows
E-Extinguish: use correct fire extinguisher to exliminate the fire
"RACE"
Type fire extinguisher - CORRECT ANSWERS-Class A
Class B
Class C
Class A - CORRECT ANSWERS-Paper
Wood
Cloth
Trash
Class B - CORRECT ANSWERS-Flammable liquids
Gases
Class C - CORRECT ANSWERS-Electrical fires
Extinguish properly - CORRECT ANSWERS-"PASS"
P-Pull
A-Aim
, S-Squeeze
S-Sweep
Home Health setting - CORRECT ANSWERS-Post "No Smoking" signs
Assess for risk (oxygen therapy, smoking, electrical equipment)
Teach client to develop a plan of action in the event of a fire, including a route of exit
and a location where family members will meet
Instruct client to keep fire extinguisher accessible
Review "Stop, Drop, and Roll"
Nursing interventions on Equipment - CORRECT ANSWERS-Electrial equipment must
be grounded
Do not overcrowd outlets
Do not extension cords on client care areas
Only used equipment for intended purpose
Regularly inspect equipment for frayed cords
Disconnect all equipment prior to cleaning
Nursing interventions on chemical and Radiation - CORRECT ANSWERS-Determine
type and amount of radiation used
Place a sign on door. "Caution Radioactive Material."
Wear monitoring badge to record amount of exposure
Dispose of items removed from the room in appropriate containers
Never handle any type of radioactive agent with bare hands
Nursing interventions on lifting and transfer of clients - CORRECT ANSWERS-Assess
mobility and strength
Instruct client to assist when possible
Use mechanical lift and assistive devices
Avoid twisting the thoracic spine or bending at the waist
Use major muscle groups, and tighten abdominal muscles
Nursing intervention on transferring clients from bed to chair or chair to bed -
CORRECT ANSWERS-Instruct the client how to assist when possible
Lower the bed to the lowest setting
Position the bed or chair so that the client is moving toward the strong side
Assist the client to stand, then pivot
Nursing interventions repositioning clients in bed - CORRECT ANSWERS-Raise the
bed to waist level
Lower side rails
Use slide boards or draw sheets
Have the client fold his arms across his chest while lifting the head
Proceed in one smooth movement
Collaborate with other staff members for assistance
Impaired mobility
Cognitive and/or Sensory impairment
Bowel and bladder dysfuntion
Side effects of medications
History of falls
Nursing interventions Falls - CORRECT ANSWERS-Complete a fall risk assessment
Communicate identified risks with the health care team
Assign clients at risk falls to a room close to nurses' stations and assess frequently
Provide clients with nonskid footwear
Keep the floor free of clutter and maintain an unobstructed path to the bathroom
Orient the client setting (grab bars, call light), including how to use and locate all
necessary items
Maintain bed in low position
Instruct the client who is unsteady to use the call light for assistance before ambulating
Answer call lights promptly to prevent clients who are at risk from trying to ambulate
independently
Provide adequate lighting (nightlight for necessary trips to the bathroom)
Determine the client's ability to use assistive devices (walkers, canes, etc.).
Keep all items within reach
Use chair or bed sensors for client who are at risk
Lock wheels on beds, wheelchairs, and gurneys to prevent rolling during transfers or
stops
Report and document all incidents per the facility policy
Nursing intervention Restraints - CORRECT ANSWERS-Implement nonpharmacologic
measures such as distraction, frequent observation, or diversion activities
Prior to application, review manufacturer's instructions for correct application
Notify the provider immediately when restraints are implemented
Remove the restraints and assess client every 2 hr
Assess neurovascular and neurosensory status every 2 hr
Leave the restraint loose enough to prevent injury
Always tie the restraint to the bed frame (using loose knots that are easily removed)
Reassess the need for continue use
Document
Document Restraints - CORRECT ANSWERS-Behaviors making restraint necessary
Alternatives attempted and the client's response
Type and location of restraint and time applied
Frequency and type of assessment
Restraints should NEVER - CORRECT ANSWERS-Interfere with treatment
Be used because of short-staffing or staff convenience
Not written as PRN orders
,Nursing intervention Seizure precaution - CORRECT ANSWERS-Assess seizure
history, noting frequency, presence of auras, and sequence of events
Identify precipitating factors that may exacerbate or lead to seizure
Review medication history.
If routine lab work is required (Dilantin), when was last level drawn
Place rescue equipment at the bedside, including oxygen, oral airway, and suction
equipment
Establish IV or saline lock access for high risk clients
Inspects the client's environment for items that may cause injury in the event of a
seizure.
Remove any unnecessary items from the immediate environment
At the onset seizure, position the client for safety, and remain with client
If sitting or standing, ease client to floor. Protect the client's head. If client is in bed, raise
the side rails and pad for safety
Roll the client to the side with the head flexed slightly forward
Do not put anything in the client's mouth
Loosen restrictive clothing
Accurately document the event, including timing precipitating behaviors or events, and a
description of the event (movements, loss of consciousness, loss of continence, injuries,
mention of aura, postictal state).
Report seizure to the provider
Fire response - CORRECT ANSWERS-R-Rescue: protect and evacuate clients in
immediate danger
A-Alarm: Activate the alarm and report the fire
C-Contain: Close doors or windows
E-Extinguish: use correct fire extinguisher to exliminate the fire
"RACE"
Type fire extinguisher - CORRECT ANSWERS-Class A
Class B
Class C
Class A - CORRECT ANSWERS-Paper
Wood
Cloth
Trash
Class B - CORRECT ANSWERS-Flammable liquids
Gases
Class C - CORRECT ANSWERS-Electrical fires
Extinguish properly - CORRECT ANSWERS-"PASS"
P-Pull
A-Aim
, S-Squeeze
S-Sweep
Home Health setting - CORRECT ANSWERS-Post "No Smoking" signs
Assess for risk (oxygen therapy, smoking, electrical equipment)
Teach client to develop a plan of action in the event of a fire, including a route of exit
and a location where family members will meet
Instruct client to keep fire extinguisher accessible
Review "Stop, Drop, and Roll"
Nursing interventions on Equipment - CORRECT ANSWERS-Electrial equipment must
be grounded
Do not overcrowd outlets
Do not extension cords on client care areas
Only used equipment for intended purpose
Regularly inspect equipment for frayed cords
Disconnect all equipment prior to cleaning
Nursing interventions on chemical and Radiation - CORRECT ANSWERS-Determine
type and amount of radiation used
Place a sign on door. "Caution Radioactive Material."
Wear monitoring badge to record amount of exposure
Dispose of items removed from the room in appropriate containers
Never handle any type of radioactive agent with bare hands
Nursing interventions on lifting and transfer of clients - CORRECT ANSWERS-Assess
mobility and strength
Instruct client to assist when possible
Use mechanical lift and assistive devices
Avoid twisting the thoracic spine or bending at the waist
Use major muscle groups, and tighten abdominal muscles
Nursing intervention on transferring clients from bed to chair or chair to bed -
CORRECT ANSWERS-Instruct the client how to assist when possible
Lower the bed to the lowest setting
Position the bed or chair so that the client is moving toward the strong side
Assist the client to stand, then pivot
Nursing interventions repositioning clients in bed - CORRECT ANSWERS-Raise the
bed to waist level
Lower side rails
Use slide boards or draw sheets
Have the client fold his arms across his chest while lifting the head
Proceed in one smooth movement
Collaborate with other staff members for assistance
