Podcast
Questions and Answers
- A nurse is caring for a female
patient who has been hospitalized for a right-side dcerebrovascular accident (CVA). The patient is impulsive and confused. She has weakness on the left side of her body and requires assistance when ambulating. What is the nurse’s highest priority when caring for this patient?
- A nurse is caring for a female patient who has been hospitalized for a right-side dcerebrovascular accident (CVA). The patient is impulsive and confused. She has weakness on the left side of her body and requires assistance when ambulating. What is the nurse’s highest priority when caring for this patient?
A nurse manager is working on methods to decrease patient falls on the nursing unit.Which nursing action would lead to decreased falls?
A nurse manager is working on methods to decrease patient falls on the nursing unit.Which nursing action would lead to decreased falls?
A nursing instructor supervises a student nurse who is caring for a patient who is on fall precautions.The nursing instructor would intervene if the student nurse is observed doing what?
A nursing instructor supervises a student nurse who is caring for a patient who is on fall precautions.The nursing instructor would intervene if the student nurse is observed doing what?
A nurse is admitting a 65-year-old patient with a diagnosis of transient ischemic attack. The patient is alert and responds appropriately to questions. Based on this information, what type of intervention should the nurse take to maintain patient safety?
A nurse is admitting a 65-year-old patient with a diagnosis of transient ischemic attack. The patient is alert and responds appropriately to questions. Based on this information, what type of intervention should the nurse take to maintain patient safety?
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A fire breaks out on the nursing unit and the fire doors close. A family member tries to open the doors. What is the best response by the nurse based on the RACE protocol?
A fire breaks out on the nursing unit and the fire doors close. A family member tries to open the doors. What is the best response by the nurse based on the RACE protocol?
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A nursing student is reviewing the PASS acronym. Which action is consistent with following this protocol?
A nursing student is reviewing the PASS acronym. Which action is consistent with following this protocol?
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A charge nurse supervises an unlicensed assistive personnel(UAP)while providing care to a patient at risk for falls. The patient repeatedly attempts to get out of bed without assistance. The charge nurse intervenes when observing which action by the UAP?
A charge nurse supervises an unlicensed assistive personnel(UAP)while providing care to a patient at risk for falls. The patient repeatedly attempts to get out of bed without assistance. The charge nurse intervenes when observing which action by the UAP?
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8.A nurse is completing documentation on a chart outside the patient’s room and hears a loud thud coming from the room. What is the priority nursing action?
8.A nurse is completing documentation on a chart outside the patient’s room and hears a loud thud coming from the room. What is the priority nursing action?
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When caring for a patient with bilateral wrist restraints,a nurse can delegate which of the following to a certified nursing assistant (CNA)?
When caring for a patient with bilateral wrist restraints,a nurse can delegate which of the following to a certified nursing assistant (CNA)?
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A nurse is working on a nursing unit and moving a patient up in the bed.Which observation by the nurse manager warrants immediate intervention?
A nurse is working on a nursing unit and moving a patient up in the bed.Which observation by the nurse manager warrants immediate intervention?
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A nurse is extinguishing a fire that has broken out in the work place.Which is the first step the nurse should take?
A nurse is extinguishing a fire that has broken out in the work place.Which is the first step the nurse should take?
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A nurse is monitoring a chemotherapy patient and finds a moderate amount off fluid on the floor in the patient’s room. The nurse is not sure about what the fluid is. What is the priority nursing action?
A nurse is monitoring a chemotherapy patient and finds a moderate amount off fluid on the floor in the patient’s room. The nurse is not sure about what the fluid is. What is the priority nursing action?
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A student nurse encounters an unresponsive patient in a waiting room.The patient is not breathing and has no pulse or respirations. What is the first step the student nurse should take?
A student nurse encounters an unresponsive patient in a waiting room.The patient is not breathing and has no pulse or respirations. What is the first step the student nurse should take?
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A member of the hospital maintenance staff is mopping the floor when patients begin to complain about watery eyes and irritated throats. Which priority action should the nurse take?
A member of the hospital maintenance staff is mopping the floor when patients begin to complain about watery eyes and irritated throats. Which priority action should the nurse take?
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A patient who is a fall risk is sitting in the chair with the call bell in reach after being assisted by the certified nursing assistant (CNA). The patient’s bed alarm continues to go off. What is the first action that the nurse should take upon going into the patient’s room?
A patient who is a fall risk is sitting in the chair with the call bell in reach after being assisted by the certified nursing assistant (CNA). The patient’s bed alarm continues to go off. What is the first action that the nurse should take upon going into the patient’s room?
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Which of the following items increase a patient’s risk for falling,according to the Morse Fall Scale?Select all that apply.
Which of the following items increase a patient’s risk for falling,according to the Morse Fall Scale?Select all that apply.
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A nurse is caring for a patient who has been placed in restraints.Which statements made to the patient by the nurse indicate an understanding of following restraint guidelines of the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission? Select all that apply.
A nurse is caring for a patient who has been placed in restraints.Which statements made to the patient by the nurse indicate an understanding of following restraint guidelines of the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission? Select all that apply.
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A nurse is assessing a patient using the Morse Fall Scale and documents a modified risk levelII.Which findings best support this assessment? Select all that apply.
A nurse is assessing a patient using the Morse Fall Scale and documents a modified risk levelII.Which findings best support this assessment? Select all that apply.
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A nurse is monitoring a patient who continually attempts to scratch an area of the body. Which priority actions should the nurse take to minimize this patient action? Select all that apply.
A nurse is monitoring a patient who continually attempts to scratch an area of the body. Which priority actions should the nurse take to minimize this patient action? Select all that apply.
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A nurse is monitoring a patient who has received implanted radiation therapy.What are the best nursing actions related to taking care of this type of patient?
A nurse is monitoring a patient who has received implanted radiation therapy.What are the best nursing actions related to taking care of this type of patient?
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A group of student nurses are reviewing what to do should a mass casualty event (MCE) occur while they are in the clinical environment. Which actions should the student nurses be expected to perform? Select all that apply.
A group of student nurses are reviewing what to do should a mass casualty event (MCE) occur while they are in the clinical environment. Which actions should the student nurses be expected to perform? Select all that apply.
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A nurse is working on a medical unit where restraint shave been routinely used on patient stop even them from injury. For which situations would the use of restraints be indicated? Select all that apply.
A nurse is working on a medical unit where restraint shave been routinely used on patient stop even them from injury. For which situations would the use of restraints be indicated? Select all that apply.
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A nurse is documenting the Morse Fall Scale for a patient who is admitted for urinary sepsis, has no other comorbidities, uses a walker, is receiving IV antibiotics, has a weak gait, and is oriented to time and place. What information should the nurse document? Select all that apply.
A nurse is documenting the Morse Fall Scale for a patient who is admitted for urinary sepsis, has no other comorbidities, uses a walker, is receiving IV antibiotics, has a weak gait, and is oriented to time and place. What information should the nurse document? Select all that apply.
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A nurse applie swrist restraints to a patient.Which actions indicate appropriate technique?Select all that apply.
A nurse applie swrist restraints to a patient.Which actions indicate appropriate technique?Select all that apply.
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Study Notes
Patient Safety and Fall Precautions
- Prioritize safety for patients with CVA, focusing on preventing falls, especially for those with weakness on one side of the body.
- Develop strategies to reduce patient falls in nursing units, such as regular assessments and environmental modifications.
- Observe student nurses during fall precautions; intervene if they are not adhering to established protocols.
Emergency Protocols
- In case of a fire, utilize the RACE protocol: Rescue, Alarm, Contain, Extinguish.
- Adhere to the PASS acronym for using fire extinguishers: Pull, Aim, Squeeze, Sweep.
- When responding to a loud noise, check on the patient immediately to assess for injuries.
Restraints and Patient Monitoring
- Restraints should only be used when necessary to prevent harm; understanding CMS and The Joint Commission guidelines is essential.
- Delegate monitoring tasks related to restraints to CNAs, ensuring safety and compliance.
- Assess patients on the Morse Fall Scale for falls risk, documenting relevant findings like mobility status and orientation.
Clinical Interventions in Emergencies
- For an unresponsive patient, initiate CPR immediately if no pulse or respiration is detected.
- When encountering potential chemical exposure (e.g., cleaning agents causing irritation), prioritize patient safety by removing them from the area and seeking fresh air.
- Address the cause of alarms promptly, especially for fall-risk patients, to ensure their safety and comfort.
Special Patient Considerations
- In cases of implanted radiation therapy, practice strict safety measures to protect both the patient and staff from exposure.
- For patients attempting to scratch an area, employ strategies to minimize and monitor their actions to prevent skin damage.
Mass Casualty Events (MCE) Preparedness
- During an MCE, student nurses should be prepared to triage patients, provide immediate care, and assist with overall emergency response efforts.
Restraint Usage Guidelines
- Document clear indications for restraint use including specific behaviors that necessitate restraint for safety reasons.
- Employ proper techniques when applying restraints to ensure comfort and safety of the patient.
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Description
A nurse is caring for a patient who has been hospitalized for a right-side cerebrovascular accident. The patient is impulsive and confused. The nurse must prioritize care for this patient.
