Falls
The PRIORITY action when the nurse discovers a patient who has fallen is to __________.
ASSESS the patient
A restraint should never bed attached to _____.
side rails of bed
Identify patients using at least ____ patient identifiers, including ______ and _________.
2
name, DOB, MRN
The nurse's _________ is a component of the legal medical record.
documentation
The use of standardized terminology increases the effectiveness of ______ within the healthcare team.
communication
Wet floors unmarked, failure to use patient lift, and alarms not properly functioning are examples of __.
risks for injury/falls
Restraints should be removed at least every ____ hour(s).
two
If patient is agitated or noncompliant, remove one restraint at a time, and/or have staff assistance.
The nurse should use _______ Precautions with all patients to minimize spread of infection.
Standard
Nurses must practice within their scope. This can by found by accessing the Board of Nursing's ______________.
Nurse Practice Act
Nurses should never administer medications they did not ______.
prepare
...don't give a medication your colleague drew up!
A patient may be taken off Fall Risk when they are ______.
discharged from the hospital
Name three types of physical restraint.
elbow, soft wrist, belt/body, mitten, side rails that prevent patient from freely exiting bed
Anesthetic gases, cleaning solutions, chemotherapy, and disinfectants are examples of environmental health risks in health care agencies. Nurses should refer to the __________ for detailed information about the chemical, precautions, safe handling, health hazards, etc.
MSDS (Material Safety Data Sheets)
HIPAA stands for:
List three ways nurses can help reduce procedure related accidents.
minimize distraction/interruption, refer to policy and procedure manual, take a time out, reflect before on what is to be done, review knowledge, use safe patient-handling techniques, use medical devices appropriately,
A patient taking a sedating medication is at _____ risk for falls.
increased
Orders for restraints must be renewed at least this often.
every 24 hours
every 2 hours for children/adolescents, every 4 hours for adults with violent or self destructive behavior
A patient in the hospital has a purple armband, which indicates ______.
DNR order is in effect
Failure to document is an example of unintentional nursing _______.
malpractice
Example: The nurse did not document a dose of medication, so when a second phone call was made to the health care provider, a second dose of medication was prescribed because no documentation was noted of the first dose. The patient subsequently coded after the overdose.
When the nurse does not understand a verbal order, they should _______ the order.
clarify
The nurse is admitting a patient who is a fall risk. The patient's room should be located ________.
near the nurse's station
A patient in an ankle restraint is found to have toes that are blue in color. The nurse should first ______ the restraint.
Remove
An adult patient is treated in the emergency department for hypothermia. This socioeconomic factor should be assessed.
Homelessness/Economic resources
When a CNA (assistive personnel) documents abnormal vital signs, it is the responsibility of _______ to interpret and follow up as necessary.
the nurse
Name the rights of medication administration.
Original five:
+Five expanded rights: