ATI: Chapters 47-49

  1. What percent of all reported hospital accidents do falls account for?
  2. Who is at an increased risk for falls due to decreased strength, impaired mobility and balance, and endurance limitations combined with decreased sensory perception?
    Older adult clients
  3. Besides older adult clients, who are other clients that may be at increased risks for falls?
    • Decreased visual acuity
    • Generalized weakness
    • Urinary frequency
    • Gait and balance problems
    • Cognitive dysfunction
    • Side effects of some medications
  4. The may include sudden onset and violent clonic-tonic movements that result in injury
  5. How do you prevent injury from seizures?
    Implement seizure precautions
  6. What policies need to be understood when using restraints?
    Federal, state laws and facility policies
  7. When should restraints be used?
    • Only as a last resort
    • In consultation with the PCP
    • Only with an order stating why the restraint is necessary and for how long
  8. What are physical restraints?
    Any physical, manual, or mechanical method or device attached to a body to restrict movement
  9. What are chemical restraints?
    Medications used to control behavior
  10. Why are chemical restraints especially dangerous in older adults?
    Because the increased sedation, drowsiness, and/or otherwise impaired cognition may increase the risk of falling
  11. What is use of restraints without an order considered?
    False imprisonment - illegal
  12. How soon must a face-to-face assessment by the PCP be done when a nurse uses restraints in an emergent situation?
    Within 1 hour
  13. What are appropriate nursing diagnoses in relation to falls?
    • Risk for falls
    • Risk for injury
    • Deficient knowledge
  14. What assessment should be done on admission and at regular intervals to prevent falls?
    Fall-risk assessment
  15. What are ways in which to prevent falls?
    • Nonskid footwear
    • Floors free from clutter
    • Adequate lighting
    • Orient client to setting
    • Assistive devices nearby
    • Home safety surveys
    • Education of the client and family of POC
    • Reporting and documenting all incidents in order to prevent them in the future
    • Answer call lights promptly
    • Assign a client at risk for falls to a room close to the nurses' station
    • Keep the bed rails up and the bed in the lowest position
    • Lock wheels on anything that rolls
    • Use chair or bed sensors for clients at risk
  16. To ensure good circulation to the area and allow for full RIM to the limb being restricted, what should be done with the restraints?
    Remove or replace them frequently
  17. Pad bony prominences and do neurosensory checks every __ hours to identify any neurological or circulatory deficits when using restraints
  18. Where should the restraint be tied when the client is in bed?
    The bed frame
  19. How many fingers need to fit between the restraint and the client's body?
  20. How loose should the restraint be?
    Loose enough for range of motion
  21. To help the client and family understand why restraints are being used, what should the nurse do?
    Explain the need and situation
  22. When should restraints be discontinued or limited?
    At the earliest possible time while still ensuring the client's safety
  23. When a client is on restraint orders, can the client be left unattended without the restraint on?
  24. What are four things restraints should do?
    • Never interfere with treatment
    • Restrict movement as little as necessary to ensure safety
    • Fit properly
    • Be easily changed to decrease the chance of injury and to provide for the greatest level of dignity
  25. What does the documentation for restraints include?
    • The behavior that makes the restraint necessary
    • Nursing interventions used prior to the placement of restraints
    • Client's LOC
    • Type of restraint used and location
    • Education/explanations to the client and family
    • Exact time of application and removal
    • Client's behavior while restrained
    • Type and frequency of care
    • Attempts to use alternate restraints with client's response
    • Client's response when the restraint is removed
  26. When developing a plan of care for a client with a history of seizures, what should be assessed?
    • Frequency of seizures
    • Type and date of last seizure
    • Medication
    • Triggers or trends of the seizures
  27. What rescue equipment needs to be at the bedside of a patient on seizure precautions?
    • Oxygen
    • Oral airway
    • Suction equipment
    • Saline lock for IV access if the client is at high risk for experiencing a generalized seizure
  28. To reduce risk of injury, the client should be assisted in ___________ and ______________
    Ambulation; transfer
  29. What should all caregivers and family be advised to not do in the event of a seizure?
    To not put anything in the client's mouth - except in status epilepticus when an airway is needed
  30. How do you ensure a client's safety in the event of a seizure?
    • Do not restrain him
    • Lower him to the floor or bed
    • Protect his head
    • Remove nearby furniture
    • Provide privacy
    • Put him on his side if possible
    • Loosen clothing to prevent injury
    • Promote dignity of the client
  31. After a seizure what should be done for the client?
    • Explain what happened
    • Provide comfort and understanding
    • Provide a quiet environment for the client to recover
  32. When documenting a seizure, what should be included?
    • Precipitating behaviors
    • Description of the event
    • Report to the PCP
  33. True or false: Use equipment only after a safety inspection and instruction of its use
  34. When is equipment inspected?
    • Regularly by the engineering or maintenance department
    • By the user prior to use
  35. Why is faulty equipment a hazard?
    • It can start a fire
    • Cause a shock
  36. How is electrical equipment grounded and why?
    • Three-pronged plug and grounded outlet
    • To decrease the risk of electrical shock
  37. When should outlet covers be used?
    In environments with individuals at risk for sticking items into them
  38. How should equipment be unplugged?
    Using the plug - not the cord
  39. What should be done with electrical equipment prior to cleaning?
    Unplug it
  40. What does JCAHO require all pumps to have to prevent an overdose of fluids or medications?
    Free-flow protection
  41. Do not overcrowd outlets and use extension cords only when absolutely necessary. If extension cords must be used in an open area, what should be done to the cord?
    Tape the cords to the floor
  42. The first response in the health care setting to fire is:
  43. What does RACE stand for?
    • Rescue - protect and evacuate clients in immediate danger
    • Alarm - report the fire
    • Contain - contain the fire
    • Extinguish - extinguish the fire
  44. What class of fire extinguisher is used for paper, wood, upholstery, rags or other types of trash?
    Class A
  45. What class of fire extinguisher is used for flammable liquids and gases?
    Class B
  46. What class of fire extinguisher is used for electrical fires?
    Class C
  47. What should be taught to the client for home fire safety?
    • "Stop, drop and roll"
    • Correct use and storage of oxygen
    • Emergency numbers near the phone
    • Stairs are well lit with nonslip tread
    • Family exit and meeting plan
    • Fire extinguishers and operable smoke and carbon monoxide detectors
    • In the event of fire, if possible, closing windows and doors, covering the mouth and nose with a damp cloth, and keeping the head as close to the floor as possible
  48. What is the correct use and storage of oxygen in the home?
    • No open flames
    • Storing the container as instructed by the manufacturer
  49. A nurse enters a client's room and discovers flames in the trash can. Identify the sequence of actions in response to a fire in a client care area.
  50. Identify the order of priority for completion of each of the following interventions for a newly admitted client with a history of falls.
    A. Survey the client's belongings
    B. Complete a fall-risk assessment
    C. Complete a physical assessment
    D. Make arrangements for a home safety survey
    E. Educate the family and client on the fall risks
    • A - 3
    • B - 1
    • C - 2
    • D - 5
    • E - 4
  51. When doing an admission, the nurse surveys the personal belongings of an older adult client. The client's belongings include glasses, a hearing aid, cane, and a variety of medications. Identify a priority nursing diagnosis for this client based on this information.

    D. risk for falls
  52. What does ergonomics mean?
    The factors or qualities in an object's design and/or use that contribute to comfort, safety, efficiency and ease of use
  53. Prior to attempting to position or move a client, what type of assessment should the nurse do?
    A mobility assessment
  54. What does correct body alignment assist with?
  55. What happens to the body's muscles when the body's center of gravity is stable?
    No strain on the muscles
  56. What happens to the body without correct body alignment?
    • Less control over balance
    • At increased risk for falls
  57. How can you enhance balance?
    Widen the base of support and ensure the center of gravity is within the base of that support
  58. In which position is lateral with no support except for a pillow under the head, with the vertebrae straight without causing discomfort for the client?
  59. When sitting and standing what is the best body alignment?
    • Head erect
    • Vertebral column straight and in S-shape from lateral view
    • Shoulder and hips parallel
  60. In which position is the client lying supine with HOB elevated 45 - 90 degrees, and the knees may be slightly elevated?
    Fowler's position
  61. Which position allows for better chest expansion and ventilation and for better dependent drainage after abdominal surgeries?
    Fowler's position
  62. In which position is the client lying supine with HOB elevated 30 - 40 degrees, and the knees may be slightly elevated?
    Semi-Fowler's position
  63. Which position promotes lung expansion and decreases stress on the abdominal muscles?
    Semi-Fowler's position
  64. In which position is the client lying on his back with his head and shoulders elevated on a pillow?
    Supine or dorsal recumbent position
  65. In which position is the client lying flat on the abdomen with the head to one side?
    Prone position
  66. Which position promotes drainage from the mouth for clients with throat or oral surgery, but inhibits chest expansion?
    Prone position
  67. In which position is the client lying on his side with most of the weight on the dependent hip and shoulder. The arms should be flexed in front of the body with a pillow behind the back and hips to support the client and maintain the position.
    Lateral or side-lying position
  68. Which position is a good sleeping position, but the client must be turned regularly to prevent development of pressure ulcers on the dependent area?
    Lateral or side-lying position
  69. In which position is the client on his side halfway between lateral and prone positions with the lower arm behind the client while the upper arm is in front with the upper leg flexed?
    Sims' or semi-prone position
  70. Which position is a comfortable sleeping position for many clients and promotes oral drainage?
    Sims' or semi-prone position
  71. In which position is the entire bed tilted with the HOB lower than the foot of the bed?
    Trendelenburg position
  72. Which position is used during postural drainage and facilitates venous return?
    Trendelenburg position
  73. In which position is the entire bed tilted with the foot of the bed lower than the HOB?
    Reverse Trendelenburg
  74. Which position promotes gastric emptying and prevents esophageal reflux?
    Reverse Trendelenburg
  75. What needs to be assessed when determining need for transfer assistance and/or use of assistive devices?
    • Assess the client's ability to help with transfers
    • Determine the need for additional personnel or assistive devices
    • Assess and monitor the client's proper use of mobility aids
    • Include assistance or mobility aids needed for safe transfers and ambulation in POC
  76. What are some appropriate nursing diagnoses for client positioning or immobility?
    • Risk for injury
    • Risk for impaired skin integrity
    • Impaired physical mobility
    • Risk for activity intolerance
  77. For an immobile client when should position changes occur?
    Every 1 to 2 hours or per facility/agency protocol or provider's orders
  78. What do you assess to determine if there is an accumulation of secretions in the lungs?
    Respiratory status
  79. What should the nurse encourage the client to do to reduce stasis of secretions in the lungs and fully expand the lungs, which decreases the risk of pneumonia or respiratory complications?
    Turn, cough and deep breathe or do incentive spirometry every 2 hours
  80. What should be assessed regularly to determine increased risk for thrombosis -specifically in the lower extremities?
    Circulatory status
  81. What should the nurse encourage the client to do to promote circulation and prevent stasis?
    • Leg exercise
    • Ambulation
    • Fluids
    • Position changes
  82. How can the risk of orthostatic hypotension be reduced?
    • By ambulating the client as soon as possible to increase venous return
    • Assist with transfers and ambulation to prevent falls
  83. What types of treatments, ordered by the PCP, to decrease venous return and risk of thrombosis?
    • Medications - platelet inhibitors or anticoagulants
    • Intermittent pneumatic compression cuffs (IPCs) or sequential compression devices (SCDs)
    • Therapeutic elastic stockings
  84. What do IPCs or SCDs do?
    Increase venous return through external pressure
  85. What to therapeutic elastic stockings do?
    Exert external pressure on muscles promoting venous return
  86. What is the center of gravity?
    The center of a mass
  87. Where is the body's center of gravity?
    The pelvis
  88. How is the center of gravity lowered?
    Bend the hips and knees
  89. True or false: Twisting the spine or bending at the waist minimizes risk for injury
  90. Which direction should you face when moving a client?
    The direction you are moving
  91. Is it safer to push or pull from the center of gravity?
  92. A client is being admitted to the surgical unit postoperatively with strict orders for no ambulation for 4 days. What assessments should be done to evaluate the risk for complications?
    • Skin
    • Circulatory
    • Respiratory
  93. A postoperative client should be in a Semi-Fowler's position. The nurse determines the position is incorrect because

    B. the HOB is at 50 degrees
  94. Place the following steps in a mobility assessment in the correct sequence.
    - Exercise tolerance
    - Moving from supine to sitting on the side of the bed
    - Gait
    - Range of motion
    • Range of motion
    • Moving from supine to sitting on the side of the bed
    • Gait
    • Exercise tolerance
  95. Which of the following positions promotes drainage from the mouth for clients with throat or oral surgery but inhibits chest expansion?

    C. Prone position
  96. What is asepsis?
    The absence of illness-producing microorganisms
  97. How is asepsis maintained?
    Through the use of aspetic technique
  98. What is the primary behavior associated with aseptic technique?
    Hand hygiene
  99. The use of precise practices to reduce the number, growth, and spread of microorganisms from an object or area. It is also know as "clean technique". What type of asepsis is this?
    Medical asepsis
  100. When is medical asepsis used?
    • Oral medication administration
    • Nasogastric tube management
    • Providing personal hygiene
  101. The use of precise practices to eliminate all microorganisms from an object or area. Also known as "sterile technique". What type of asepsis is this?
    Surgical asepsis
  102. When is surgical asepsis used?
    • Parenteral medication administration
    • Insertion of urinary catheters
    • Surgical procedures
  103. What is the number one measure to reduce the growth and transmission of infectious agents?
    Good hand washing
  104. What are the three essential components of good hand washing?
    • Soap or a chemical that contains an antimicrobial agent
    • Water
    • Friction
  105. When are healthcare workers required to wash their hands?
    • Before and after every client contact
    • After removing gloves
    • After contact with body fluids
    • When hands are visibly soiled
    • After using the restroom
  106. How long does the CDC recommend the handwashing time should be?
    • 10 - 15 seconds to remove transient flora
    • Up to 2 min when hands are more soiled or in contact with high risk areas
  107. What are additional examples of practices that reduce the growth and spread of microorganisms?
    • Changing linens daily
    • Cleaning floors and the client's bedside stand
    • Separating clean linen from contaminated materials into different areas
  108. What helps control the contact and spread of microorganisms to both the PCP and the client?
    The use of masks, gloves, gowns and protective eyewear
  109. Why should items never be placed on the floor in the client environment, even soiled laundry?
    Because the floor is considered grossly contaminated
  110. Why should linens not be shaken out in the client environment?
    To avoid raising dust which can be irritating to those in the environment
  111. When a soiled item is moist, what type of bag should it be put in?
    A plastic bag
  112. What are things a PCP should do to prevent spread of microorganisms?
    • Follow facility/agency protocols for isolation and protection
    • Wash hair frequently and keep it short or pulled back to prevent contamination of the care area or client
    • Not wear artificial nails and keep the nails short and clean
    • Use hand lotion to prevent drying, chapping, and lesions on the hands
    • Not wear rings with grooves or stones that are difficult to clean
  113. What are practices that maintain a sterile field?
    • Avoid coughing, sneezing or talking directly over a sterile field
    • Air movement should be controlled by special ventilation
    • Only sterile items may be in the sterile field
    • Do not reach across or above a sterile field
    • Items to be added to a sterile field must be held a minimum of 6 inches above the field
    • Keep all surfaces dry
    • Discard any sterile packages that become wet
  114. What area of the sterile field is actually considered unsterile?
    The outer wrappings and 1-inch edge of the packaging
  115. What are the steps to opening a sterile package?
    • 1. open the farthest edge away from you
    • 2. open the side flaps
    • 3. open the edge closest to you
  116. How should sterile solutions be poured?
    • 1. remove the bottle cap
    • 2. place the bottle cap face up on the surface
    • 3. hold the bottle with the label in the palm of the hand so that the solution does not run down the label
    • 4. pour a small amount of the solution into an available receptacle (1 to 2 ml)
    • 5. pour the solution onto the dressing or site without touching the bottle to the site
  117. When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it's important that the nurse

    B. place a mask on the client to limit the spread of microorganisms into the surgical wound
  118. A nurse is teaching a group of personal care assistants that the most effective way to decrease the spread of infection by

    D. basic handwashing
  119. While wearing sterile gloves, a nurse can touch any

    A. object on the sterile field
  120. Match each of the following practices to the best example.
    A. medical asepsis practice
    B. standard precautions
    C. sterile field maintenance
    D. contamination

    1. a nurse wears gloves when emptying a bedpan each time
    2. a nurse drops a sterile dressing on the floor
    3. a nurse keeps her sterile hands above her waist
    4. a nurse wipes off the client's bedside table
    • A - 4
    • B - 1
    • C - 3
    • D - 2
  121. Which of the following statements are true of surgical asepsis and a sterile field? (select all that apply)
    - The nurse should turn her back on the sterile field if she needs to cough
    - The 1 inch edge around a sterile field is considered sterile
    - A sterile item can touch another sterile item without contaminating it
    - Sterile items must remain above the waist
    - Surgical asepsis is also called "sterile technique"
    • - A sterile item can touch another sterile item without contaminating it
    • - Sterile items must remain above the waist
    • - Surgical asepsis is also called "sterile technique"
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ATI: Chapters 47-49
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