Hygiene/Patient Safety 1
Name at least one fire safety measure to have in the home
•Check batteries in smoke detectors regularly to make sure they are working
•Keep a fire extinguisher in the kitchen and handy
•Don’t smoke inside. Only smoke outside of home
Which of the following interventions by the student nurse requires follow up from the nurse regarding visibly soiled hand hygiene?
A. Washing hands between fingertips, nails, and wrists
B. Using friction motions
C. Scrubbing in circular motions for at least 15 seconds
D. Keeping watches and bracelets on
D. Keeping watches and bracelets on
Which of the following is an example of an open-ended question?
A. Does your head hurt?
B. Are you worried about your new diagnosis?
C. Tell me about how your abdominal pain started
D. Are you experiencing any pain?
C. Tell me about how your abdominal pain started
Which of the following is an example of the first step in the nursing process?
A. Analyzing urine color and odor
B. Assigning a nursing diagnosis
C. Setting up a goal with the patient
D. Ambulating patient after meals
A. Analyzing urine color and odor
Which of the following are examples of objective data?
A. "I have a fever"
B. "I am short of breath"
C. Vital signs, HR: 120, BP: 110/65
D. Constipation for 2 days
C. Vital signs, HR: 120, BP: 110/65
Which of the following is correct regarding restraints?
A. You do not need an order from the physician
B. Keep padded portion of restraint against the wrist for wrist restraints
C. Tie restraint to side rail
D. Apply restraint as tight as possible
B. Keep padded portion of restraint against the wrist for wrist restraints
What is the correct order of Maslow's Hierarchy of needs starting at the bottom of the pyramid?
Physiological, Safety, Social, Self-esteem, Self-actualization
Put the following components of a NANDA nursing diagnosis in the correct order: etiology, defining characteristics, and problem
1. Problem (diagnostic label)
2. Etiology (related factors)
3. Defining characteristics
True or false:
NANDA’s are used by nurses to formulate nursing diagnosis to analyze data, identify health problems/risks/strengths, and formulate diagnosis statements
TRUE
Which of the following would be a priority concern for a patient?
A. low self-esteem
B. disturbed body image
C. poor hygiene
D. safety of patient
D. safety of patient
Name at least two risk factors for falls
•Poor Vision
•Cognitive Dysfunction
•Mobility restrictions
•Orthostatic Hypotension
•Urinary frequency
Which of the following is true regarding poison prevention?
A. Keep harmful agents close to children
B. Don’t store harmful agents in different containers or remove labels
C. There is not a need to read product labels
D. You can refer to medicine as candy to children
B. Don’t store harmful agents in different containers or remove labels
Which phase of the nursing process describes this statement "drawing conclusions about the problem status, comparing the data with the desired outcomes, and seeing if goals were met or not
Evaluation
Which of the following is an example of a NANDA nursing diagnosis?
A. risk for falls
B. pneumonia
C. hypertension stage 1
D. bronchitis
A. risk for falls
Which of the following would occur in the planning phase of the nursing process?
A. Patient will gain 0.5-1 pound per week by the time of discharge
B. Patient will eat more vegetables and fruits
C. Patients family will bring food from home
D. Patient will verbalize understanding of healthier eating
A. Patient will gain 0.5-1 pound per week by the time of discharge
A patient is partially bearing weight and is transferring from the bed to a chair. Which of the following can be helpful in the transfer?
A. Stand back and watch patient try to move on their own
B. Have the family members assist
C. Use a assistive lift device
D. Ask another staff member to help carry the patient
C. Use a assistive lift device
What does RACE stand for?
Rescue, Alarm, Contain, Extinguish
What part of the nursing process would the following be included in. "The patients goal is to ambulate in the hallway three times a day prior to discharge"
Planning phase
Which of the following occurs in the assessment phase of the nursing process?
A. Obtaining vital signs and a health history
B. setting measurable goals
C. formulating the nursing diagnosis
D. planning a discharge date
A. Obtaining vital signs and a health history
Which of the following patients should be seen first?
A. A patient who is confused asking where his daughter went
B. A patient who has been waiting 15 minutes to receive pain medication
C. A post-op patient who is complaining of chest tightness
D. A patient waiting discharge instructions
C. A post-op patient who is complaining of chest tightness
Name at least 2 seizure precautions
•Remain with client & call for assistance
•Do not restrain client
•If not in bed lower the client to the floor and pad surroundings for safety
•Turn the client to the lateral position if able
•Move items in environment to ensure there is no injury
•Loosen any restrictive clothing
•Do not put anything in the client’s mouth
•Provide O2 & suction as needed
•Prepare seizure medications
•Time and record movements of the seizure to report to MD
•Document the seizure in a timely manner after it occurs
True or False:
The patient with a cane will move the cane and the weak leg forward at the same time.
Which of the following is an appropriately stated goal for the nursing diagnosis of impaired skin integrity related to immobility aeb skin tearing
A. Patients family will use lotion on skin
B. Patients skin will remain intact and patient will be turned q2
C. Daily baths will be performed
D. Patient will be turned q12
B. Patients skin will remain intact and patient will be turned q2
Which of the following is a correctly written nursing diagnosis?
A. hypertension r/t high blood pressure aeb stroke
B. sinus infection r/t headache
C. constipation r/t surgery aeb recent surgery
D. deficient fluid volume r/t prolonged vomiting aeb poor skin turgor
D. deficient fluid volume r/t prolonged vomiting aeb poor skin turgor
Describe a three point gait with crutches
The patient moves both crutches and the weak foot forward at the same time