Accountability Correct Answer Cannot be delegated
ANA Scope and Standards of Practice Correct Answer NOT
laws, but influence policy development
Be familiar with Continuous Passive Motion (CPM) Machine
Correct Answer pg 304-305
Be familiar with elastic stockings and Sequential Compression
Devices (SCD): rationale for use, application, assessment and
care, and safety measure related to use. Correct Answer pg
305-308
Be familiar with The Joint Commision (TJC) Patients' Rights
Standard. Correct Answer pg 15, box 2.3
C = comparison with the intervention Correct Answer Does a
comparison intervention exist? Which standard of care or
current intervention do you usually now use in practice?
Core measures Correct Answer national standards of care and
treatment processes for common conditions; proven to reduce
complications and lead to better patient outcomes
Dorsal recumbent Correct Answer lying on back, knees bent
Explain how to use a fire extinguisher Correct Answer P =
pull pin
A = aim
,S = squeeze handle
S = sweep
Explain restraint application and quick release tie Correct
Answer - Use least restrictive restraint
- Attach restraint straps to a part of the bed frame that moves
with the patient; NEVER the side rail
- Secure restraints on bed frame with quick release tie/buckle;
NEVER a knot
- Ensure restraint is not too tight
- Assess for circulation, sensation, color of restrained body part
- Assess every 15 min for signs of injury
- Released restraints at least every 2 hrs and assess needs for
toileting, food, fluids, mobility
Explain the restraint free goal Correct Answer Serious, often
fatal complications can result from restraints; restraint free is the
goal for all patients; restraints can be chemical or physical
Fall precautions Correct Answer pg 342 and table 14.1
Familiarize yourself with the USA College of Nursing Dress
Code. Correct Answer refer to uniform policy
Fowler's Correct Answer HOB inclined at 45 degrees
High Fowler's Correct Answer HOB inclined at 60-90 degrees
How do you provide oral hygiene to an unconscious patient?
Correct Answer - Sims position (lying on left side with knee
up), head of bed elevated to at least 30 degrees
, How do you provide perineal care to female patients? Correct
Answer Place in dorsal recumbent position (laying on back
with knees up), wipe front to back (perineum to rectum), use
different sections of wash cloth for each front to back stroke
How do you provide perineal care to male patients? Correct
Answer Place in supine position, if patient has erection stop
and come back
How do you provide ROM exercises to patients? Correct
Answer Incorporate active ROM in patient's ALDs; incorporate
passive ROM in bathing/feeding; put patient in comfortable
position, sitting or lying down
- support joint by holding distal and proximal areas adjacent to
joint
- support joint by cradling distal part of extremity
- use cupped hand to support joint
How do you reduce orthostatic hypotension associated injury?
Correct Answer - Allow patient to sit on side of bed for a
minute
- Dangle legs, move back and forth
- Allow legs to touch floor
- If dizziness persists for more than 60 seconds, lay patient down
How do you remove a gown from a patient with an IV? Correct
Answer - If snaps are present simply use those to remove the
gown