Nursing 221 Test 1 (With complete solution)

What does RACE stand for? correct answers rescue, alarm, confine, extinguish What does PASS stand for? correct answers pull the pin, aim, squeeze, sweep If seizures occur what do you do? correct answers always stay with the patient, call for help, if standing, guide to the floor and cradle head in lap or place pad under head, provide privacy, turn patient on side if able with head tilted and slightly forward, do not place anything in mouth, note time seizure starts, ends, and the patients behavior, maintain patent airway, suction, and apply oxygen by nasal cannula What is the assessment for falls risk? correct answers poor vision, cognitive dysfunction, impaired mobility, urinary frequency, physical condition, medications, age, history of falls How do you prevent falls? correct answers side rails up when appropriate, bed low position/wheels locked, call bell in reach, glasses, hearing aids, ambulatory aids in use, room clutter free, clean up spills, electrical safety good lighting, provide non-skid footwear for clients What are the 6 p's of rounding? correct answers Pain, potty, position, personal items, plan, place call bell in reach, ask: is there anything else? What things should you orient your patient to? correct answers room, equipment, call bell/emergency bell, telephone, tv/radio, side rails, safety measures, visiting hours, unit routine, including meals What are examples of safe transfers? correct answers from bed to chair, and from bed to stretcher When is it okay to use a restraint? correct answers as a last resort to provide patient safety or safety of others What might chemical restraints do to the elderly? correct answers may cause confusion What are physical restraints? correct answers a physical device attached to the body to restrict movement/activity for safety what do you assess when using restraints? correct answers mental status, pain, education level and understanding of client, therapy needed, determine need for restraint What needs to be determined for a use of a restraint? correct answers if behavior may interrupt therapy, or if there is a threat to self or others what are some safety measures when using restraints? correct answers inspect client for injury per policy, check neurological and circulatory status, ensure restraint is secure but not restrictive loose enough for two fingers to fit between restraint, never tie to bed rails (use quick release