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answers
The nurse is caring for a patient requiring seizure precautions.
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Which actions may the nurse safely delegate to the non-licensed
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assistive personnel (NAP)? |\ |\
*To administer the IV medication if a seizure occurs
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*To restrain the patient during the seizure
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*To place a tongue blade in the patient's mouth to keep them
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from swallowing their tongue
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*To inform the nurse if seizure activity is observed - CORRECT
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ANSWERS ✔✔To inform the nurse if seizure activity is observed
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Match the following |\ |\
*Airborne precautions (droplet nuclei smaller than 5 microns)
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*Droplet precautions (droplet larger than 5 microns; being within
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3 feet of the patient
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*Contact precautions (direct patient or environmental contact)
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1.) Private room or cohort, gloves, gown
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2.) Private room or cohort patients, mask or respirator
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3.) Private room, mask or respiratory protection device, negative-
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airflow room, N95 respirator depending on the patient condition -
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CORRECT ANSWERS ✔✔-Airborne Precautions: *3
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-Droplet Precautions: *2 |\ |\
-Contact Precautions: *1 |\ |\
,The Centers for Disease Control (CDC) guidelines for preventing
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tuberculosis (TB) transmission include: (select all that apply)
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*Placing the client on contact precautions
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*Requiring health care workers to wear special respirators (N(95)
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when caring for clients with suspected TB
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*Placing the client in a negative pressure airflow room
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*Wearing a N95 mask respirator when planning to come within 3
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feet of the patient - CORRECT ANSWERS ✔✔-Placing the client in
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a private negative-pressure airflow room
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-Wearing a N95 respirator when planning to come within 3 feet of
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the patient
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-Requiring health care workers to wear special respirators (N(95)
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when caring for clients with suspected TB
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-Placing the client on contact precautions
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It is your first day of clinical as a University of South Alabama
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Student Nurse and you are assigned to care for a client requiring
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precautions. You understand: |\ |\ |\
*Protective eyewear is necessary at all times |\ |\ |\ |\ |\ |\
*standard precautions are for use with all clients
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*standard precautions apply only to clients who are HIV positive
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*Gowns, masks, and gloves are required for contact with all
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clients - CORRECT ANSWERS ✔✔Standard precautions are for use
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with all clients
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,Reducing the risk for patient harm is a national health care
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priority. The nurse reduces the risk for patient harm by: (select all
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that apply)
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*Using 2 ways to identify patients
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*Assessing the patient's environment |\ |\ |\
*Using a teach-back method for call button instructions
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*Safely using extremity restraints on all confused patients -
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CORRECT ANSWERS ✔✔-Using 2 ways to identify patients |\ |\ |\ |\ |\ |\ |\
-Assessing the patient's environment |\ |\ |\
-Using a teach-back method for call button instructions
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The student nurse is planning to assist the client with
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ambulation. Which action causes the clinical instructor concern? |\ |\ |\ |\ |\ |\ |\
*Reviews the client's medications |\ |\ |\
*Performs a fall risk assessment prior to ambulation |\ |\ |\ |\ |\ |\ |\
*Plants to use a gait belt |\ |\ |\ |\ |\
*Quickly runs to the nurses station for help when the patient
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starts to fall - CORRECT ANSWERS ✔✔Quickly runs to the nurses
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station for help when the patient starts to fall
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All are "Never Events" with the exception of:
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*ventilator associated pneumonia |\ |\
*IV infiltration
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*Poor blood glucose control
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*Patient death associated with a medication error - CORRECT
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ANSWERS ✔✔IV Infiltration |\ |\
, The nurse has completed the admission assessment on an
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elderly patient. The patient has never been admitted to a
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hospital, takes 5 different medications, and has vision problems.
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The nurse plans priority care to reduce the risk for
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*Disorientation
*Falls
*Fear |\
*Suicide - CORRECT ANSWERS ✔✔Falls |\ |\ |\ |\
Hand hygiene is an important aspect of providing high quality
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care for clients. When is hand hygiene with soap and water
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necessary? (select all that apply) |\ |\ |\ |\
*After removing sterile gloves
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*After using the toilet
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*Before eating |\
*When hands are visibly soiled with bloody or bodily fluids -
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CORRECT ANSWERS ✔✔-Before eating |\ |\ |\
-After using the toilet
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-When hands are visibly soiled with blood or bodily fluids
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The use of restraints has been associated with which adverse
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outcome/s? (select all that apply) |\ |\ |\ |\
*Pressure injury |\
*Constipation
*Early discharge |\