NURS 345- CH 22 Clinical Nursing Care Radford University Exam Questions and Answers 2024;full solution pack

Safety alert-1 - Cords, tablecloths, plastic bags, bottles, and cans are tempting, potentially dangerous objects that caregivers must strive to keep out of reach of infants Safety alert-2 - In both environments, parents should be taught to place their infants on their backs when sleeping to prevent sudden infant death syndrome (SIDS) Safety alert-3 - Outside the home, toddlers and preschoolers need supervision With caregiver guidance, they will learn about playing away from automobile traffic and avoiding strange animals. In addition, car seats are necessary for travel in motor vehicles. Safety alert-4 - Children should wear properly fitted helmets when cycling, riding, or playing contact sports and life jackets when sailing or boating Safety alert-5 - It becomes important that healthcare providers educate patients to refrain from driving while under the influence of substances that alter ability to drive or when sleep deprived. Safety alert-6 - never place rear-facing car seats in the front seats of cars with passenger-side airbags Safety alert-7 - knots should not be used; rather, restraints should have quick-release connectors so that healthcare providers can release quickly in an emergency Poison prevention - ∅remind adult caregivers to store medications, including over-the-counter products, in childproof containers out of children's reach ∅store household cleansers and other potentially toxic products in childproofed or locked cupboards or on shelves out of children's reach ∅keep household products in their original containers with warning labels and emergency information intact ∅keep poisonous houseplants out of young children's reach and supervise children outdoorsAt change-of-shift report, you are told that Mr. Rau was acutely confused during the night shift and that wrist restraints were applied to prevent him from pulling out his IV. When you make rounds, you find Mr. Rau very agitated, pulling hard against the restraints. His fingers are slightly blue and appear swollen. What is the best way to maintain safety for this patient? - Answer: restraints are not always the best way to maintain a client's safety. In acute care agencies, restraints may be applied but a physician's order must be obtained withing 24 hours. Protocols should be in place for the appropriate use and monitoring of restraints to prevent injury. Assess circulatory other options, such as having a family member sit with the client or using a sitter if a family member is unavailable. Make an effort to detect the cause of Mr. Rau's acute confusion to direct treatment at resolving the underlying cause. Mr. Ames, age 84, has just been admitted to the hospital for the treatment of pneumonia. In addition to this diagnosis, Mr. Ames also has stage II Alzheimer's disease and is disoriented to place and time. As the night has progressed, he has become increasingly agitated, pulling out his intravenous catheter and wandering throughout the unit. He has become more agitated as the nurses have attempted to reorient and redirect him. Which intervention should the nurses perform? a) Position Mr. Ames' bed closer to the nurses' station and perform an assessment. b) Apply a restraint vest to Mr. Ames once he has been returned to bed. c) Call a "code gray" in order to call hospital security to deal with Mr. Ames. d) Resettle Mr. Ames in his bed and raise the side rails. - Answer: Position Mr. Ames' bed closer to the nurses' station and perform an assessment. Explanation: *It is important to rule out causes of agitation by performing an assessment* and to attempt alternatives to restraints or calling a "code gray." Side rails may pose an increased risk to Mr. Ames in his confused state. Restraint - a restraint is any physical or chemical means of (1) stopping a patient from being free to move (2) prevent injury to patients but are not risk-free devices there is little evidence that restraints prevent injury, particularly from falls, and they have many unintended negative consequences restraints may be necessary to limit a patient's physical activity, such as pulling out an IV line or mechanical ventilator tubing, or to prevent movement that would disrupt therapy.Restraints often ↑ agitation restraints may not preserve dignity Types of Restraints - JACKET OR VEST restraint worn on the chest and attached to the bed frame or legs of a chair A BELT RESTRAINT on stretchers or wheelchairs used in transporting MITT or HAND RESTRAINT that prevent confused patients from using their hands, wrist, or ankle restraints that immobilize one or more limbs MUMMY RESTRAINTS that wrap around a child's body to prevent movement during a procedure SIDE RAILS remind patients (a) not to roll too far to the side, and (b) they provide bars that assist patients when they turn to the side. CHEMICAL RESTRAINTS a medication used to control behavior or to restrict a person's freedom of movement that is not a standard of treatment for the person's medical or psychiatric conditions NONVIOLENT/self-destructive RESTRAINT use of restraint when patient's behavior interferes with treatment VIOLENT/self-destructive RESTRAINT use of restraint when patient is demonstrating aggressive or violent behavior that presents an immediate serious danger to self or others SECLUSION involuntary confinement of an individual in a room alone for any period of time from which the person is prevented from leaving A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan?a) Fire safety b) Gun safety c) Smoking cessation d) Childproofing the house - Answer: Fire safety Correct Explanation: Although all these topics are beneficial for most age groups, the preschooler, developmentally, is able to understand fire safety measures. Childproofing the house would be an appropriate topic for parents of toddlers. Smoking cessation should be taught to pregnant women, and gun safety is an appropriate topic for adolescents. Nurses provide many interventions to prevent falls in health care settings. What would be an appropriate intervention to prevent falls? a) Lock wheels on beds and wheelchairs. b) Keep bed in the high position. c) Keep side rails up at all times. d) Apply restraints to all confused clients. - Answer: Lock wheels on beds and wheelchairs. Correct Explanation: Locking wheels on beds and wheelchairs prevents them from rolling and precipitating a fall. Beds should be kept in low positions with the side rails down in most situations; restraints should be applied only as a last resort. A nurse is preparing to provide care to a client who is receiving radiation therapy for cancer; the radiation source will be kept in the client's room. Which action would be most important for the nurse to do? a) Ensure client is admitted to a semi-private room. b) Dispose of linens immediately upon exposure. c) Limit own exposure to radiation to the minimum time.d) Wear an apron made of thick cotton material. - Answer: Limit own exposure to radiation to the minimum time. Explanation: The nurse should be aware that ionizing radiation can adversely affect the health. Consequently, *the time of exposure should be minimized. Linens should be kept in the room until the radiation source is removed. They require special labeling and disposal. Nurses should use a lead apron, not one made of thick cotton. The client should be admitted to a private room with a private bath, not to a general unit, in order to prevent exposure to other clients*. Radiation safety - an international symbol marks areas where radioactive substances are used. 3 cardinal rules for radiation protection: 1) minimize time of exposure to the source 2) maximize distance from the source, and 3) use appropriate shielding≈ use lead shields or lead aprons ; -wear gloves -encourage patients to do as much of their own care as possible - private room with a private bath - keep linens in the room until the radioactive source is removed -special labeling and disposal of soiled linens, excreta, and other wastes