Podcast
Questions and Answers
What should be done if a client answers 'yes' during the initial screening regarding fall risks?
What should be done if a client answers 'yes' during the initial screening regarding fall risks?
- Document the response and monitor the client closely.
- Conduct further assessment using a fall risk assessment tool. (correct)
- Inform the client that no action is necessary.
- Initiate immediate medications to prevent falls.
Which of the following is NOT a recognized mechanism for preventing falls in hospitalized clients?
Which of the following is NOT a recognized mechanism for preventing falls in hospitalized clients?
- Maintaining a clutter-free environment
- Keeping hospital bed brakes locked
- Using non-skid footwear
- Providing sedative medications as needed (correct)
What should nursing staff do to enhance client safety regarding falls according to best practices?
What should nursing staff do to enhance client safety regarding falls according to best practices?
- Conduct fall screenings every day without considering facility policy.
- Ensure that clients have adequate lighting and personal items within reach. (correct)
- Increase client movement and encourage unassisted mobility.
- Limit the use of call lights to reduce distractions for nursing staff.
How does hourly rounding by nursing staff affect client falls?
How does hourly rounding by nursing staff affect client falls?
Which of the following actions would be least effective in the overall fall prevention strategy for hospitalized clients?
Which of the following actions would be least effective in the overall fall prevention strategy for hospitalized clients?
What is the primary assessment technique for diagnosing orthostatic hypotension?
What is the primary assessment technique for diagnosing orthostatic hypotension?
Which statement accurately describes orthostatic hypotension?
Which statement accurately describes orthostatic hypotension?
What vital sign changes are indicative of orthostatic hypotension?
What vital sign changes are indicative of orthostatic hypotension?
Which patient-related factor increases the risk of developing orthostatic hypotension?
Which patient-related factor increases the risk of developing orthostatic hypotension?
In which situation should orthostatic hypotension symptoms be evaluated?
In which situation should orthostatic hypotension symptoms be evaluated?
What should be recorded when documenting orthostatic blood pressure measurements?
What should be recorded when documenting orthostatic blood pressure measurements?
Which medication category is commonly associated with orthostatic hypotension?
Which medication category is commonly associated with orthostatic hypotension?
What is an effective way to monitor for symptoms of orthostatic hypotension?
What is an effective way to monitor for symptoms of orthostatic hypotension?
Which of the following is NOT a symptom of orthostatic hypotension?
Which of the following is NOT a symptom of orthostatic hypotension?
Why is orthostatic hypotension considered a risk factor for falls in elderly patients?
Why is orthostatic hypotension considered a risk factor for falls in elderly patients?
What is the primary purpose of using antiembolism stockings in a clinical setting?
What is the primary purpose of using antiembolism stockings in a clinical setting?
What assessment finding might indicate a possible deep vein thrombosis (DVT)?
What assessment finding might indicate a possible deep vein thrombosis (DVT)?
When assessing a walking patient using an assistive device, where should the caregiver stand?
When assessing a walking patient using an assistive device, where should the caregiver stand?
What symptoms may a patient with DVT experience?
What symptoms may a patient with DVT experience?
What is the significance of measuring bilateral calf circumference daily?
What is the significance of measuring bilateral calf circumference daily?
Which group of patients is at increased risk for developing deep vein thrombosis?
Which group of patients is at increased risk for developing deep vein thrombosis?
Which medication may be prescribed prophylactically to prevent DVT?
Which medication may be prescribed prophylactically to prevent DVT?
What should a caregiver do if a patient becomes weak or dizzy while walking?
What should a caregiver do if a patient becomes weak or dizzy while walking?
What possible condition should be reported if a patient experiences orthostatic hypotension?
What possible condition should be reported if a patient experiences orthostatic hypotension?
For assessment of DVT in patients with a previous history, which body part should also be monitored regularly?
For assessment of DVT in patients with a previous history, which body part should also be monitored regularly?
What should be done if a patient in restraint shows signs of cyanosis?
What should be done if a patient in restraint shows signs of cyanosis?
Which of the following is an appropriate action when caring for a patient requiring NPPV?
Which of the following is an appropriate action when caring for a patient requiring NPPV?
What type of gloves should be used for a patient with a known sensitivity to latex?
What type of gloves should be used for a patient with a known sensitivity to latex?
What should be monitored when using restraints on a patient?
What should be monitored when using restraints on a patient?
In what scenario is it essential to wear respiratory protection, such as an N95 respirator?
In what scenario is it essential to wear respiratory protection, such as an N95 respirator?
What is the primary purpose of proper use and disposal of PPE?
What is the primary purpose of proper use and disposal of PPE?
What is the correct procedure for hand hygiene after removing gloves?
What is the correct procedure for hand hygiene after removing gloves?
What is an essential requirement for placing patients requiring airborne isolation?
What is an essential requirement for placing patients requiring airborne isolation?
If a patient shows signs of discomfort in a restrained extremity, what action should be taken?
If a patient shows signs of discomfort in a restrained extremity, what action should be taken?
Which precaution should be taken when dealing with blood or bodily fluids?
Which precaution should be taken when dealing with blood or bodily fluids?
Why is it important to keep your hands lower than your elbows during hand washing?
Why is it important to keep your hands lower than your elbows during hand washing?
What is the minimum duration recommended for washing hands thoroughly?
What is the minimum duration recommended for washing hands thoroughly?
What should be used to clean under the fingernails during hand washing?
What should be used to clean under the fingernails during hand washing?
Which step is critical after washing hands to avoid recontaminating them?
Which step is critical after washing hands to avoid recontaminating them?
What should you do if you find a cut or lesion on your hands before applying gloves?
What should you do if you find a cut or lesion on your hands before applying gloves?
When should extra sterile gloves be placed in the procedure room?
When should extra sterile gloves be placed in the procedure room?
What is a critical action to take when inspecting gloves before use?
What is a critical action to take when inspecting gloves before use?
What should be done first when preparing to apply gloves?
What should be done first when preparing to apply gloves?
Flashcards are hidden until you start studying
Study Notes
Hand Hygiene
- Keep hands lower than elbows to prevent water from running down to the hands after washing.
- Wash hands for a minimum of 15 to 20 seconds, ensuring thorough cleaning.
- Clean back of fingers, between fingers, and under fingernails during handwashing.
- Use a nail file or orangewood stick to clean under fingernails, particularly in the morning or after heavy soiling.
- Rinse wrists, hands, and fingers well, allowing water to flow from wrists to fingertips.
- Dry hands and wrists thoroughly with clean, dry paper towels, patting dry starting from fingertips.
- Turn off faucets with clean paper towel to avoid contamination, discarding the used towel in a wastebasket.
Use of Gloves
- Choose latex-free or synthetic gloves for patients with latex allergies or sensitivities.
- Ensure glove packages are intact, dry, and not expired before use.
- Perform surgical hand antisepsis using manufacturer-recommended methods before putting on gloves.
- Inspect hands for cuts or lesions; cover any open lesions with sterile, transparent dressings.
- Apply gloves carefully, taking care not to contaminate them during the process.
Assessing Subjective Patient Cues
- Gather health history and reports from family, caregivers, and healthcare team members.
- Example subjective cues include: "I have been nauseated for a week" or "My mom has been confused and forgetful."
Orthostatic Hypotension
- Defined as a significant drop in blood pressure upon changing position (lying to sitting to standing).
- Diagnosed when systolic pressure falls by at least 20 mm Hg or diastolic by 10 mm Hg within 2 to 5 minutes of standing.
- Commonly occurs in patients who are dehydrated, anemic, or have experienced recent blood loss.
- Symptoms include light-headedness, dizziness, or fainting, increasing fall risk in older adults with hypertension.
- Assess by measuring blood pressure and pulse in supine, sitting, and standing positions within a 3-minute interval.
Deep Vein Thrombosis (DVT)
- DVT occurs when blood clots form in the veins, mainly in the legs, usually due to pooled blood.
- Symptoms may include swelling, warm or cyanotic skin, pain, and tenderness in the affected area.
- Daily measurement of calf circumference can help detect early signs of DVT.
- Patients at risk include those with limited mobility, especially postoperative patients.
- Preventive measures include anticoagulation therapy and use of antiembolism stockings or sequential compression devices.
Fall Prevention Measures
- Implement non-skid footwear and maintain beds in low positions to reduce fall risk.
- Lock wheelchair brakes and keep a clutter-free environment with adequate lighting.
- Position call lights and personal belongings within reach of patients.
- Educate patients on fall prevention and familiarize them with the hospital environment.
- Utilize hourly rounding by nursing staff and promptly respond to call lights to further decrease fall incidence.
- Maintain sturdy handrails and ensure hospital beds are correctly adjusted during patient transfers.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
