What type of authority regulates the practice of nursing? Answer- State nurse practice acts
In meeting the safty of needs of the adolescent client, it would be most important for the nurse to focus her teaching on Answer- Drivers education ( most cause of death is because of car accident--- WEAR SEATBELT)
How often should restraints be removed? Answer- at least ever two hours
What is the protocol when removing restraints? Answer- The nurse should stay with the patient when the restraint is removed, offer fluids and assistance with toileting, and check for adverse physiological effects from the restraint.
What can the nurse delegate to the CNA/UAP regarding restraints? Answer- The nurse can delegate the checks and releases to a certified nursing assistant (CNA) or UAP.
What is the CNA/UAP not allowed to do? Answer- The UAP cannot teach, educate, or assess the patient.
Restraints should only be tied to Answer- A moving part of the bed
The 6 factors that contribute to an unsafe patient environment. Answer- 1. Age & ability to understand
2. Impaired mobility
3. Communication
4. Pain & discomfort
5. Delayed assistance
6. Equipment
Why are the elderly more at risk for falls when they are hospitalized? Answer- They may be confused for a variety of reasons including unfamiliar surroundings and medications. When they get up, they may not realize that they are attached to tubes and cords, so they may pull them or trip over them. They may not clearly understand or remember directions from nurses such as not to get up without help.
Answering patients call lights promptly is a safety issue. Defend this statement. Answer- If a patient does not get assistance in a timely manner, he or she may attempt to get up and walk alone when it is not safe to do so. This leads to falls and injuries that could have been prevented.
Discuss the role of nurses in a mass casualty event. Answer- A student nurse's responsibility as a student and as a nurse will be to know and follow his or her facility's disaster plan. A student nurse should expect to be called in to work as an extra if a disaster occurs. It is appropriate for the student nurse to ensure the safety of family first and then assist at his or her place of work. Some facilities have a plan for calling in extra help according to needs, rather than having a barrage of off-duty employees arriving at once.
Researchers have found that, because they are more likely than others to move around in bed or try to get out of bed, the individuals who are at highest risk for entrapment are older, frail adults who experience Answer- Pain, Confusion, Fecal Impaction, Urinary retention
The nurse is caring for a patient who has a history of getting up without assistance, which results in falls. The nurse selects a restraint alternative for this patient. Restraint alternatives include... Answer- Leg Monitors, bed monitors, chair monitors
When an order has been obtained to place restraints on a patient, and the restraints are in place, nursing staff is required by the Health Care Financing Administration (HCFA) and the Joint Commission to follow guidelines, which include Answer- 1. Offering the patient fluids. 2. Assisting the patient with toileting. 3. Changing the patient's position in bed. 4. Removing the restraint every 2 hours. 6. Assessing the patient's extremities for edema, capillary refill, and sensation.
When providing discharge instructions to a patient who has been prescribed home oxygen therapy, the nurse teaches the patient to Answer- 3. Avoid smoking near the
oxygen source. 4. Avoid wearing wool blankets or sweaters.
5. Use extension tubing to move around the house.
When educating a class of nursing students about using good body mechanics and injury prevention, the nursing instructor teaches them to Answer- 1. Plan work carefully.
2. Elevate work to a comfortable level.
3. Hold an object close and bend their elbows when carrying something.
A student nurse is out shopping when he or she hears that a mass casualty event (MCE) has occurred in the area. It is his or her responsibility as a student and as a nurse to Answer- A student nurse should expect to be called in to work as an extra if
a disaster occurs. It is appropriate for the student nurse to ensure the safety of family
first and then assist at his or her place of work. Some facilities have a plan for calling
in extra help according to needs, rather than having a barrage of off-duty employees arriving at once.