Isolation Practices
These precautions are designed for all clients in the hospital.
What is Standard Precautions?
This hand hygiene product is not effective for C-diff.
What is alcohol-based rubs?
How often is skin integrity assessed when a client wears wrist restraints?
What is every 2 hours?
per agency policy
This assistive device is held on the stronger side of the body when walking.
What is a cane?
You have stuck yourself accidentally with a dirty needle, what do you do first, second & third?
1. Encourage bleeding from the wound
2. Wash with soap and water thoroughly
3. Report incident immediately to nursing supervisor
Name the precautions that are implemented for a client that has an open oozing leg wound with MRSA.
What is contact precautions?
This intervention only takes 20 seconds and it reduces the spread of infection.
What is proper handwashing.
The nurse splashes her eyes with fluid from emptying a JP drain. She rinses her eyes thoroughly for 5-10 minutes with copious amounts of water.
What is the initial action after splashing her mucous membranes (eyes) with body fluids?
Applying proper body mechanics when caring for patients, list 1 principle.
1. Establish a wide base of support, feet should not be close together. 2. Use equipment and others to help. 3. Avoid movements that cause pain, bending at waist, stooping and lifting with straight legs. 4. When lifting keep items/pts. close to you.
Pain Scale 0 - 10:
Mild - list the number range
Moderate - list the number range
Severe - list the number range
What is mild - 1 - 3
moderate - 4 - 6
severe - 7 - 10
Transport of a client with TB outside of the room for essential purposes, such as X-ray, the patient must be wearing this.
What is surgical mask?
What is a normal WBC?
What is 4500 - 11,000/mm?
The new graduate nurse is places her 75 year-old female client in a rocking chair near the nurses station, her patient is fidgety, and increasingly confused after her dinner meal.
What is a nursing intervention that is an alternative to restraints?
Another person moves each of the client's joints through its complete range of movement.
What is passive ROM exercise?
You are the nurse and you are admitting a new client, 10 y/o female with right lower quadrant pain and fever, she hasn't eaten today. What should you as the nurse do first? Your CNA has gotten your vital signs.
What is assess the pain using a pain scale?
The nurse is wearing an N95 mask to care for a patient on this type of transmission based precautions.
What is airborne precautions?
Sterile field is not longer considered sterile when?
What is when sterile objects touch unsterile objects: sterile objects are out of site or below the waist; > 2 inches above the elbow; when health care persons reach over sterile field; sterile field is set up ahead of time; 1 inch margin at each edge of an open drape is considered unsterile?
Obtain one within 24 hours after applying a restraint.
What is a physician order?
Move the walker and the weak leg ahead together about 6 inches while your weight is borne on the stronger leg. Then move the stronger leg ahead while your weight is borne by the affected leg and both arms.
What is the proper teaching for use of a walker if one leg is weaker than the other leg?
Compare acute and chronic pain. List 2 signs and symptoms each. p. 1088
Acute - increased pulse, resp. BP, diaphoresis, dilated pupils. Pain resolves when injury is healed, Restless, anxious, cry, rub area, hold area, client reports pain
Chronic - VS WNL: dry, warm skin; pupils normal or dilated; Pain cont. beyond healing; depressed, withdrawn; doesn't mention pain unless asked; pain behavior often absent.
Precautions for Measles outbreak.
What is airborne precautions
A patient whose head of bed is raised 30 degrees is said to be in this position?
What is Semi-Fowlers?
Proper way of securing of soft wrist restraints and where should they be placed?
What is using a quick release knot and securing to bed frame?
When using crutches if continued pressure is placed on the axilla can injure the radial nerve resulting in.
What is the cause of crutch palsy?
The nurse is preparing to instruct a client on nonpharmacologic interventions that target the body (not the mind or spirit) for pain control - list 1.
What are: massage, applying heat or ice, TENS unit, Acupressure, positioning, diet - nutritional supplements,exercise, pacing invasive interventions, sleep p. 1116?