Falls Prevention
What assessment tool do nurses use to identify adult patients’ falls risk on admission to the unit?
Morse Falls Risk Scale
What two things do you document at the beginning and end of your shift?
Transfer of Accountability &
Corporate Patient Safety Check
How often do you complete the Braden Scale score for each patient?
A. Every 12 hours
B. Every 24 hours
C. Every 48 hours
D. Every 72 hours
C. Every 48 hours
If a patient is at risk for aspiration what will you do before feeding them?
• Elevate head of the bed to at least 30-45 degrees
This progressive disease affects memory, thinking and behaviour.
• Dementia
Which one below is NOT a falls prevention strategy on the unit?
A.Set patient’s bed at lowest or locked position
B.Perform assessments with Braden scale
C.Bring patients with high falls risk to rooms near the nursing station
D.Use Falls Injury Prevention floor mats
B .Perform assessments with Braden scale
When do you complete and document Physical Assessment?
• On Admission to 30 days
• Q30 days after admission
• QWED & PRN post initial 30 days
• On Discharge
A patient is at risk of developing pressure injuries if their Braden Scale score is ___ or less.
18
What nursing interventions would apply if your patient is hypotensive?
• Recheck BP
• Push fluids
• Check for medications
• Reassess after intervention
• Notify NP/MRP
GPA emphasizes this type of approach instead of using physical restraints
• De-escalation & Redirection
How often do nurses reassess patients’ falls risk?
• Every 24hrs and prn (for moderate and high falls risk, and post-procedure/post-operative)
• Every Monday and prn (for low falls risk)
• On transfer from one unit to another throughout the hospital
• With any changes in patient status (e.g., behavior change, decreased mobility)
What does ISBAR stand for?
• Identify
• Situation
• Background
• Assessment
• Recommendation
In order to prevent pressure injuries, you should maximize the linen layers on the patient’s bed.
A. True
B. False
False, you should minimize their linen layers to optimize the effect of the pressure redistribution surfaces.
What are the steps you will take if your patient is coughing while drinking thin liquids?
• Downgrade patient to thickened fluids
• Put in an interprofessional order for SLP referral
• Notify TL/NP/MRP AND send an email to RCC Dietary/Call and inform them
• Update TOA
What part of the brain is responsible for reasoning and judgement and is often affected first in dementia?
A. Occipital Lobe
B. Temporal Lobe
C. Frontal Lobe
D. Parietal Lobe
A. Frontal Lobe
The Room Sign Monitor outside the patient’s room will display a red standing man icon to indicate the patient’s falls risk.
A. True
B. False
False, it's supposed to be a yellow falling man icon.
Where can you edit the Primary/Secondary diagnoses on a patient chart in Meditech?
A. Patient Care
B. Summary of Visits
C. Clinical Data
D. Plan of Care
C. Clinical Data
This stage of a pressure injury is characterized by full-thickness skin loss, where fat may be visible, but bones, muscles and tendons are not exposed.
Stage 3
Your patient presents with fever (38C) and new onset cough. What nursing interventions will you apply?
• Place patient on droplet/contact precautions
• Give PRN medication to treat the fever
• Obtain a full set of vital signs and f/u on effectiveness of PRN medication for fever
• Notify NP/MRP to obtain any orders (ex. COVID/RSV/INFL A&B)
• Notify IPAC
• DOCUMENT!
Vital Signs
Nursing note
Corporate patient safety check
When a patient exhibits a behavior, what is the nurse’s primary responsibility?
A) Redirect the patient without considering the cause of the behavior
B) Understand what the behavior is communicating and adjust the approach to care
C) Ignore the behavior if it is not harming anyone
D) Use a strict and authoritative approach to correct the behavior
B) Understand what the behavior is communicating and adjust the approach to care
This reinforces the importance of assessing why a behavior is occurring and adapting care strategies to support the patient effectively.
Describe the system HRH has in place to keep track of falls.
• Staff complete QRM notification in Meditech for each patient fall
• Risk Management tracks the number, severity and contributing factors from these notifications
• Falls Risk and Prevention Committee evaluates falls statistics. Unit leaders are invited to participate.
• Monthly & Quarterly reports of these results are available to the unit leadership team to share with their staff
When a patient is on head injury routine post fall, how often are Neuro Vital Signs charted on?
Q15 minutes X 1 hour
Q1H X 4 hours
Q4H X 24 hours
For what stage(s) of a pressure injury does a Wound & Skin referral get initiated?
• Stage 3
• Stage 4
• Unstageable
What interventions will you take if your patient has a deteriorating pressure injury with signs of infection?
• Complete/document Pressure Injury assessment (note the size, appearance and any discharge)
• Notify NP/MRP of deteriorating wound for new wound order and potential swab for assessment of presence of bacteria
• Put in a new dietician referral as interprofessional order for deteriorating wound
A patient with altered perception says, “There are snakes in the hallway!” What is the best nursing intervention?
A) Validate their distress and reassure them they are safe
B) Argue with the patient and prove that there are no snakes
C) Lock the patient in their room to prevent further distress
D) Tell the patient to stop being dramatic
A) Validate their distress and reassure them they are safe