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Exam (elaborations)

NUR 2101_Safety Questions With Complete Solutions

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NUR 2101_Safety Questions With Complete Solutions

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NUR 2101_Safety Questions With Complete Solutions

2015 National Patient Safety Goals Correct Answers




Assessing clients at risk for accidents and injury involves
Correct Answers (a) noting pertinent indicators in the nursing
history and physical examination, (b) using specifically
developed risk assessment tools, and (c) evaluating the client's
environment.

Assessment tool for fall risk Correct Answers Get up and go
test video

UP and GO test (aka get up and go)

Test to identify possible weaknesses, balance problems, loss of
flexibility problems that contribute to falls in older adults

,Before selecting a restraint, nurses need to understand its
purpose clearly and measure it against the following five
criteria: Correct Answers ^ It restricts the client's movement as
little as possible. If a client needs to have one arm restrained, do
not restrain the entire body.

^ It does not interfere with the client's treatment or health
problem. If a client has poor blood circulation to the hands,
apply a restraint that will not aggravate that circulatory problem.

^ It is readily changeable. Restraints need to be changed
frequently, especially if they become soiled. Keeping other
guidelines in mind, choose a restraint that can be changed with
minimal disturbance to the client.

^ It is safe for the particular client. Choose a restraint with which
the client cannot self-inflict injury. For example, a physically
restrained person could be injured trying to climb out of bed if
one wrist is tied to the bed frame. A jacket restraint would
restrain the person more safely.

^ It is the least obvious to others. Both clients and visitors are
often embarrassed by a restraint, even though they understand
why it is being used. The less obvious the restraint, the more
comfortable people feel.

Behavior Management Standard Correct Answers * Nurse
may apply restraints but the physician or other licensed
independent practitioner must see the client within 1 hour for
evaluation

, * Written restraint order for an adult, following evaluation, valid
for only 4 hours ( most hospitals have their own procedure but
24 hours is the usual time for restraint order expiration)
* Must be continual visual and audio monitoring if client
restrained and secluded

~ In the case of the behavior management standard, the nurse
may apply restraints but the primary care provider or other
licensed independent practitioner must see the client within 1
hour for evaluation. A written restraint order for an adult,
following evaluation, is valid for only 4 hours. If the client must
be restrained and secluded, there must be continual visual and
audio monitoring of the client's status. The medical-surgical care
standard permits up to 12 hours for obtaining the primary care
provider's written order for the restraints. All orders must be
renewed daily.

~ Standards require that a primary care provider's order for
restraints state the reason and time period. The use of a prn order
for restraints is prohibited. In all cases, restraints should be used
only after every other possible means of ensuring safety have
been unsuccessful and documented. See alternatives to the use
of restraints in Box 21-3. Restrained clients often become more
restless and anxious as a result of the loss of self-control. Nurses
must document that the need for the restraint was made clear
both to the client and family.

Being late or in a hurry Correct Answers cutting corners may
put patient safety in peri

Chasing Zero Correct Answers * Chasing Zero Trailer

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