Basic Nursing Principles Exam Questions Guide
Eye Charts - Answers 1. Snellen
- Stand 20 ft away
2. Rosenbaum
- Stand 14 inches away
SAFTEY IS BIG ON THIS ATI!
Factors that affect the patient's ability to protect themselves - Answers - Age
- Mobility
- Cognitive and sensory awareness
- Emotional state
- Ability to communicate
- Lifestyle
- Safety Awareness
Fall Risk - Answers - Decreased visual acuity
- Generalized weakness
- Urinary frequency
- Gait and balance problems (Cerebral palsy, MS, Parkinsons)
- Cognitive dysfunction
- Medication side effects
Seizure precautions - Answers - Have oxygen, suction, oral airway at bedside
- Padded side rails
- Saline locked IV for immediate access (High risk patients)
- Rapid intervention to maintain airway patency.
- Clutter free environment
,- Make sure everyone (family too) knows that if pt. has a seizure, to not put anything in their mouth
during seizure. *Only thing that would go in mouth during seizure is airway for status epilepticus.
- During seizure do not restrain pt. Lower pt. to floor or bed and protect pt. head. Remove nearby
furniture. Put patient on side with head flexed slightly forward if possible and loosen his clothing.
How would you help prevent falls for a patient with orthostatic hypotension? - Answers - Avoid getting
up to quickly
- Sit on the side of the bed for a few seconds prior to standing
- Stand at the side of the bed a few seconds prior to walking
Seclusion and Restraints - Answers - When everything else fails (orientation to environment, family
member, sitter, diversional activities, electronic devices) is when you use restraints.
- Provider must prescribe after seeing the patient face to face
Provider prescription for restraints must include what? - Answers - Reason for restraints
- Type of restraints
- Location of restraints
- How long to use restraints
- Type of behavior that warrants restraints
- *Prescription only last 4 hours for an adult. Providers may renew these prescriptions with a maximum
of 24 consecutive hours.*
Restraints in an emergency situation - Answers - When there is an immediate risk to the patient or
others, nurses may place restraints on patient.
- The nurse must then obtain a prescription from the provider ASAP, usually within 1 hour.
Nursing Responsibilities for patients in restraints - Answers - Explain the need for restraints to pt. and
family. They are for safety and are temporary.
- Ask pt. or guardian to sign consent form.
,- Assess skin integrity and provide skin care according to hospital protocol, usually Q2.
- Offer fluid and food.
- Provide means for hygiene and elimination.
- Monitor Vitals
- Offer range of motion exercises of extremities.
- Pad bony prominences to prevent skin breakdown.
- Use quick release knot to tie the restraints to the bed frame where they will not tighten when raising
or lowering the bed.
- Fit 2 fingers b/w restraints and patient.
- Remove or replace restraints frequently to ensure good circulation to the area and allow for full range
of motion to the limbs.
- Never leave pt. alone without restraints.
Fire Response - RACE - Answers R - *Rescue* and protect patients close to fire by moving them to a safer
location. Let patients who can walk, walk.
A - *Alarm* Activate alarm
, C - *Contain* the fire by closing doors and windows and turning off any sources of oxygen and electrical
devices. Vent. pts. who are on life support with a BVM.
E - *Extinguish* fire
How to use fire extinguisher - PASS - Answers P - *Pull* the pin
A - *Aim* at base of fire
S - *Squeeze* handle
S - *Sweep* extinguisher from side to side.
State licensing boards - Answers Ensure that health care providers and agencies comply with state
regulations.
The Joint Commission - Answers Sets quality standards for accreditation of health care facilities.
Medicare - Answers For patients older than 65 or those with permanent disabilities.
Medicaid - Answers For patients who have low income.
Preventative health care - Answers Educates and equips patients to reduce and control risk factors for
disease.
Examples
- Programs that promote immunizations
- Stress management
- Occupational health programs
- Seat belt use
Primary Health care - Answers Emphasizes health promotion and includes prenatal and well-baby care,
family planning, nutrition counseling, disease control.
Eye Charts - Answers 1. Snellen
- Stand 20 ft away
2. Rosenbaum
- Stand 14 inches away
SAFTEY IS BIG ON THIS ATI!
Factors that affect the patient's ability to protect themselves - Answers - Age
- Mobility
- Cognitive and sensory awareness
- Emotional state
- Ability to communicate
- Lifestyle
- Safety Awareness
Fall Risk - Answers - Decreased visual acuity
- Generalized weakness
- Urinary frequency
- Gait and balance problems (Cerebral palsy, MS, Parkinsons)
- Cognitive dysfunction
- Medication side effects
Seizure precautions - Answers - Have oxygen, suction, oral airway at bedside
- Padded side rails
- Saline locked IV for immediate access (High risk patients)
- Rapid intervention to maintain airway patency.
- Clutter free environment
,- Make sure everyone (family too) knows that if pt. has a seizure, to not put anything in their mouth
during seizure. *Only thing that would go in mouth during seizure is airway for status epilepticus.
- During seizure do not restrain pt. Lower pt. to floor or bed and protect pt. head. Remove nearby
furniture. Put patient on side with head flexed slightly forward if possible and loosen his clothing.
How would you help prevent falls for a patient with orthostatic hypotension? - Answers - Avoid getting
up to quickly
- Sit on the side of the bed for a few seconds prior to standing
- Stand at the side of the bed a few seconds prior to walking
Seclusion and Restraints - Answers - When everything else fails (orientation to environment, family
member, sitter, diversional activities, electronic devices) is when you use restraints.
- Provider must prescribe after seeing the patient face to face
Provider prescription for restraints must include what? - Answers - Reason for restraints
- Type of restraints
- Location of restraints
- How long to use restraints
- Type of behavior that warrants restraints
- *Prescription only last 4 hours for an adult. Providers may renew these prescriptions with a maximum
of 24 consecutive hours.*
Restraints in an emergency situation - Answers - When there is an immediate risk to the patient or
others, nurses may place restraints on patient.
- The nurse must then obtain a prescription from the provider ASAP, usually within 1 hour.
Nursing Responsibilities for patients in restraints - Answers - Explain the need for restraints to pt. and
family. They are for safety and are temporary.
- Ask pt. or guardian to sign consent form.
,- Assess skin integrity and provide skin care according to hospital protocol, usually Q2.
- Offer fluid and food.
- Provide means for hygiene and elimination.
- Monitor Vitals
- Offer range of motion exercises of extremities.
- Pad bony prominences to prevent skin breakdown.
- Use quick release knot to tie the restraints to the bed frame where they will not tighten when raising
or lowering the bed.
- Fit 2 fingers b/w restraints and patient.
- Remove or replace restraints frequently to ensure good circulation to the area and allow for full range
of motion to the limbs.
- Never leave pt. alone without restraints.
Fire Response - RACE - Answers R - *Rescue* and protect patients close to fire by moving them to a safer
location. Let patients who can walk, walk.
A - *Alarm* Activate alarm
, C - *Contain* the fire by closing doors and windows and turning off any sources of oxygen and electrical
devices. Vent. pts. who are on life support with a BVM.
E - *Extinguish* fire
How to use fire extinguisher - PASS - Answers P - *Pull* the pin
A - *Aim* at base of fire
S - *Squeeze* handle
S - *Sweep* extinguisher from side to side.
State licensing boards - Answers Ensure that health care providers and agencies comply with state
regulations.
The Joint Commission - Answers Sets quality standards for accreditation of health care facilities.
Medicare - Answers For patients older than 65 or those with permanent disabilities.
Medicaid - Answers For patients who have low income.
Preventative health care - Answers Educates and equips patients to reduce and control risk factors for
disease.
Examples
- Programs that promote immunizations
- Stress management
- Occupational health programs
- Seat belt use
Primary Health care - Answers Emphasizes health promotion and includes prenatal and well-baby care,
family planning, nutrition counseling, disease control.
