SATA
You are caring for a patient in the ICU who has pulled out his own IV line. You tried restraint alternatives already, which of the following would you assess for appropriateness/reason to physically restrain the patient?
1: health care provider's order
2: patients' current behavior
3: current medications
4: health literacy
5: presence of a fever
6: serum electrolytes
7: age
1,2,3,5,6
The nurse is administering a drug that has been ordered as follows "give 10 mg on odd numbered days and 5 mg on even numbered days" when the date changes from May 31 to June 1, what should the nurse do
1: give 1o mg because june 1 is a odd numbered day
2: hold the dose until the next odd numbered day
3: change the order to read "give 10 mg on even numbered days and give 5 mg on odd numbered days"
4: consult the prescriber to verify that the note should alter each day no matter if its even or odd numbered
4
list the Maslow's hierarchy of needs top to bottom
self actualization
self esteem
love and belonging
physical safety and psychological security
physiological needs
How to apply physical restraints:
step 1: adjust bed to proper height and lower side rail on side of patient contact. Be sure that patient is comfortable and in proper body alignment
step 2: inspect area where restraint is to be placed. Note if there is any nearby tubing or device, assess condition of skin, sensation, adequacy of circulation, and rand of joint motion
step 3: pad skin and bony prominences (as necessary) that will be under restraint
step 4: apply proper size restraint
A nurse finds 68-year-old women wandering in the hallway and exhibiting confusion. the patient says she is looking for the bathroom. which interventions are appropriate for this patient?
1: Ask the health care provider to order a restraint
2: recommend insertion of a urinary catheter
3: provide scheduled toileting rounds every 2-3 hours
4: institute a routine exercise program for the patient
5: keep the bed in a high position with the side rails down
6: keep the pathway from the bed to the bathroom clear
3,4,6
The nursing student realizes that she has given a client a double dose of an antihypertensive medication. The tablet was supposed to be cut in half. but the student forgot and administered the entire tablet. The clients blood pressure just before the dose was 146/98, what should the student nurse do first?
1: notify the clients physician
2: notify the clinical faculty
3: take the clients blood pressure
4: continue to monitor the client
2
what are the 5 types of restraints and what are they?
1: physical- manual holding or immobilization
2: mechanical- use of material or straps for restriction
3: chemical- medications
4: barrier- lapboard and four side rails
5: seclusion- placing client alone
What are the steps in the design of a restraint free environment?
orient and re- orient
compansionship/sitters
activites
near nurses' station
relaxation techniques
exercise/walking
toileting schedule
pain control
bed and chair alarms
which type of PPE should the nurse wear when caring for a pediatric patient who is placed on airborne precautions for confirmed chickenpox/herpes zoster?
1: disposable
2: N95 respirator mask
3: face shield or goggles
4: disposable mask
5: gloves
1,2,5
a newly admitted patient was found wandering the hallways for the past two nights. the most appropriate nursing interventions to prevent a fall for this patient would include:
1: lower the patients bed and raise all four side rails when its dark
2: use an electronic bed monitoring device
3: place the patient in a room close to the nursing station
4: use a loose-fitting vest type jacket restraint
2
What are some seizure precautions?
Protect client from harm, protect airway, put client on their side, clear the environment, padded side rails, do not restrain them, note the start time, duration, quality, record and report, post seizure assessment
What does RACE stand for when talking about fire precautions
rescue/remove
activate alarm
confine
extinguish
the infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. which of the following actions on the nurses part would contribute to reducing HAI?
1: teaching correct handwashing to assigned patients
2: using correct procedures in starting and caring for an intravenous infusion
3: providing perineal care to a patient with an indwelling urinary catheter
4: isolating a patient on antibiotics who has been having loose stool for 24 hours
5: decreasing a patient's environmental stimuli to decrease nausea
1.2.3
a nurse floats to a busy surgical unit and administers a wrong medication to a patient. this error can be classified as
1: a poisoning accident
2: an equipment related accident
3: a procedure related accident
4: an accident related to time management
3
What patients would need swallow precautions?
stroke patients, drowsy, drooling, inability to sit upright, slurred speech, compromised respiratory system (concern w/aspiration), inability to cough or clean throat frequently
When any type of error occurs, what is always the first priority?
client safety