Principles of Nursing Exam 1 Study Guide
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Questions and Answers

The Joint Commission National Patient Safety Goals (NPSGs) aim to enhance patient safety by reducing risks of harm to patients and staff in all healthcare settings.

True (A)

Which of these contribute to a culture of safety? (Select all that apply)

  • Holding yourself accountable. (correct)
  • Using ISBARR to communicate with other healthcare providers. (correct)
  • Reporting errors that could reach the patient. (correct)
  • Reporting errors that don't reach the patient. (correct)

    • A ______ event is a patient safety incident that results in harm, injury, or death to the patient.

    Sentinel

    List three common risk factors for a patient falling.

    <p>Age, medications, and a history of falls.</p> Signup and view all the answers

    Match the following interventions with their corresponding purpose in preventing patient falls:

    <p>Bringing the patient closer to the nurse's station = Increased visibility and quicker response time Using 2-3 bed rails = Prevent the patient from rolling out of bed Placing belongings and call light within reach = Promote independence and reduce need to get out of bed Keeping the bed at the lowest position = Reduce the distance to fall if a patient gets out of bed</p> Signup and view all the answers

    Which of the following interventions can help prevent blood clots in an immobile patient?

    <p>All of the above (D)</p> Signup and view all the answers

    Which of the following are alternative methods to using restraints for a patient who is agitated?

    <p>Communicating with the patient (A), Distracting the patient (B), Placing the patient with a sitter (C), Putting the patient near the nurses station (D)</p> Signup and view all the answers

    A rectal temperature measures a surface temperature.

    <p>False (B)</p> Signup and view all the answers

    While applying restraints, the nurse must ensure that the patient's skin integrity is assessed every 12 hours.

    <p>False (B)</p> Signup and view all the answers

    What is a common assistive device used to help patients ambulate safely in the hall?

    <p>Gait belt</p> Signup and view all the answers

    What are the essential nursing responsibilities while a patient has restraints applied?

    <p>Assess skin integrity, provide skin care, offer food and fluids, provide hygiene and elimination care, monitor vital signs, and offer range of motion exercises.</p> Signup and view all the answers

    To prevent pressure ulcers, a patient should be repositioned every ______ hours.

    <p>2</p> Signup and view all the answers

    When applying restraints, the nurse must ensure that ____ fingers can fit comfortably underneath the restraint.

    <p>two</p> Signup and view all the answers

    Match the following immobility-related risks with their corresponding body systems:

    <p>Heart and Blood Vessels = Blood clots, orthostatic hypotension, and decreased cardiac output Skin = Pressure ulcers, skin breakdown Gastrointestinal = Constipation, weight loss, and decreased appetite Urinary = Incontinence, increased risk of UTIs Psychological = Depression, social isolation, and anxiety</p> Signup and view all the answers

    Match the type of ROM with its definition:

    <p>Active ROM = The patient can move their limbs Passive ROM = The nurse moves the patient's limbs Full ROM = The patient can move all of their limbs without any support</p> Signup and view all the answers

    If a patient starts to fall while ambulating, the nurse should try to catch them to prevent injury.

    <p>False (B)</p> Signup and view all the answers

    Which of the following nursing actions promotes good body mechanics?

    <p>Squatting to lift (D)</p> Signup and view all the answers

    Which of the following interventions can help prevent constipation in an immobile patient?

    <p>All of the above (D)</p> Signup and view all the answers

    Describe a situation where passive ROM exercises would be beneficial for a patient.

    <p>A patient who has suffered from a head injury that immobilizes them would benefit from passive ROM exercises. This would help prevent muscle atrophy and joint stiffness.</p> Signup and view all the answers

    Immobility can contribute to decreased lung expansion and increase the risk of pneumonia.

    <p>True (A)</p> Signup and view all the answers

    What are two measures that can help reduce the risk of urinary tract infections (UTIs) in an immobile patient?

    <p>Encourage plenty of fluids, ensure proper perineal hygiene</p> Signup and view all the answers

    Which type of heat exchange occurs when a warm object transfers heat to a cooler object through direct contact?

    <p>Conduction (D)</p> Signup and view all the answers

    Hypoxemia is caused by an excessive supply of oxygen to the body's tissues.

    <p>False (B)</p> Signup and view all the answers

    What are three signs or symptoms that might indicate a patient is experiencing hypotension?

    <p>Cold to the touch, clammy skin, and a weak and rapid pulse are all signs of hypotension.</p> Signup and view all the answers

    The transfer of heat from a warm surface to another without direct contact is called ______.

    <p>radiation</p> Signup and view all the answers

    Match the following heat exchange processes with their descriptions:

    <p>Radiation = The transfer of heat from a warm surface to another without direct contact Convection = The transfer of heat through direct contact between objects of different temperatures Evaporation = The conversion of a liquid to a vapor Conduction = The heat loss from one surface to another without direct contact</p> Signup and view all the answers

    An apical pulse is typically taken to assess heart rate when a peripheral pulse is difficult to obtain or abnormal.

    <p>True (A)</p> Signup and view all the answers

    Which of these is NOT a potential sign or symptom of hypoxemia?

    <p>Increased alertness (C)</p> Signup and view all the answers

    What nursing interventions can be implemented for a patient experiencing dyspnea and an oxygen saturation of 88%?

    <p>Place the patient in a Fowler's position, encourage deep breaths, and administer supplemental oxygen.</p> Signup and view all the answers

    What is the purpose of the Joint Commission National Patient Safety Goals?

    <p>To reduce the risk of harm to self and others in all healthcare settings.</p> Signup and view all the answers

    Which of the following are examples of NPSGs for 2021?

    <p>Reduce risk for health care-associated infections (B), Improve accuracy of patient identification (C), Improve effectiveness of communication among caregivers (D)</p> Signup and view all the answers

    How do each of the following contribute to a culture of safety? (Select all that apply)

    <p>Reporting errors that don't reach the patient. (A), Using ISBARR to communicate with other healthcare providers. (B), Reporting errors that could reach the patient. (C), Holding yourself accountable. (D)</p> Signup and view all the answers

    What is a Sentinel Event?

    <p>A patient safety incident that causes harm, injury, or death.</p> Signup and view all the answers

    Which of the following are examples of sentinel events?

    <p>Performing surgery on the wrong patient, or wrong body part (A), Patient on suicide watch commits suicide (B), An infant is discharged to the wrong family (C)</p> Signup and view all the answers

    What are some common risk factors for falling? (Select all that apply)

    <p>Mental status (A), Age (B), Environment (C), The need to use the washroom (D), Medications (E), The patient has a past history of falling (F)</p> Signup and view all the answers

    If a client is confirmed to be a high fall risk, what interventions are you implementing as a nurse?

    <p>Bring the patient closer to you, place them on a bed alarm, use 2-3 bed rails, place their belongings and call light within reach, keep the bed at the lowest position, and identify the patient as a fall risk.</p> Signup and view all the answers

    When is it appropriate to place a patient in restraints?

    <p>When they are at risk of injuring themselves or others, or disrupting therapy.</p> Signup and view all the answers

    What are the different types of restraints?

    <p>Mechanical device (A), Chemical (B), Physical (C)</p> Signup and view all the answers

    What can you do to avoid using restraints?

    <p>Distract the patient, place them with a sitter, communicate with them, and put them near the nurses station</p> Signup and view all the answers

    Deborah has soft wrist restraints ordered and applied correctly. She remains agitated towards the staff. What are your responsibilities and assessments while the restraints are in place?

    <p>Assess Deborah's skin integrity and provide skin care per protocol, usually every 2 hours. Offer food and fluid to Deborah. Provide hygiene and elimination needs. Monitor her vital signs. Offer range of motion exercises to Deborah.</p> Signup and view all the answers

    What must you do after the nursing assistive personnel (NAP) applies the restraints?

    <p>Ensure two fingers fit underneath the restraint, make sure they are not tied to the bed rails, and the correct size restraints are placed on the patient.</p> Signup and view all the answers

    How can the nurse practice good body mechanics?

    <p>Squat to lift (A), Raise the bed to your waist level when working with a patient (B), Ask for help from others (C), Have a wide base of support (D), Lift with your legs not your back (E), Use assistive devices (F)</p> Signup and view all the answers

    What is the difference between active, passive, and full ROM?

    <p>Active ROM - The patient can move their limbs (A), Passive ROM - The nurse moves the patient's limbs (B), Full ROM - The patient can move all of their limbs without any support (C)</p> Signup and view all the answers

    Provide examples of patient illnesses and injuries that would benefit from passive ROM exercises?

    <p>A patient that has suffered from a head injury that immobilizes them would benefit from passive ROM exercises. A patient who undergoes knee replacement surgery may be prescribed a passive motion machine that continuously flexes and extends the patient's knee while lying in bed.</p> Signup and view all the answers

    How can immobility affect the musculoskeletal system? (Select all that apply)

    <p>Joint stiffness (B), Muscle atrophy (C), Contractures (D)</p> Signup and view all the answers

    How can immobility affect the lungs? (Select all that apply)

    <p>Decreased lung expansion (B), Increased risk of pneumonia (C)</p> Signup and view all the answers

    How can immobility affect the heart and blood vessels? (Select all that apply)

    <p>Orthostatic hypotension (A), Decreased cardiac output (B), Increased risk of blood clots (D)</p> Signup and view all the answers

    How can immobility affect the gastrointestinal system? (Select all that apply)

    <p>Weight loss (A), Decreased appetite (C), Constipation (D)</p> Signup and view all the answers

    How can immobility affect the urinary system? (Select all that apply)

    <p>Incontinence (A), Increased risk of UTIs (B)</p> Signup and view all the answers

    How can immobility affect the psychological system? (Select all that apply)

    <p>Anxiety (B), Depression (C), Social isolation (D)</p> Signup and view all the answers

    What are specific interventions for preventing pressure ulcers? (Select all that apply)

    <p>Use proper padding under the patient's bony prominences (A), Assess for early stages of pressure ulcers (C), Reposition the patient every 2 hours, if immobile (D)</p> Signup and view all the answers

    What assistive devices can the nurse use to safely ambulate with clients in the hall? (Select all that apply)

    <p>Crutches (A), Cane (B), Gait belt (C), Walker (D)</p> Signup and view all the answers

    What should you do if a patient begins to feel dizzy while ambulating or transferring?

    <p>Assist them to sit on a chair or on the floor to avoid a fall. Make sure to protect their head as much as possible! If the patient begins to fall, do not try to stop the fall or catch the patient. Try to control their fall by lowering them to the floor.</p> Signup and view all the answers

    Where can you measure a surface temperature? (Select all that apply)

    <p>Armpit (axillary) (A), Orally (B), Forehead (temporal artery) (D), Ear (tympanic) (E)</p> Signup and view all the answers

    How is heat exchanged in each of these processes? (Select all that apply)

    <p>Conduction - The transfer of heat from a warm object (the patient) to a cooler object (the cooling blanket) during direct contact. (A), Radiation - The heat loss from one surface to another without direct contact. (B), Evaporation - The conversion of a liquid to a vapor, such as when perspiration (sweat) evaporates. (C), Convection - The loss of heat from cool air flowing over a warm body. (D)</p> Signup and view all the answers

    What would you do if the nursing assistive personnel (NAP) calls to report a BP of 170/100 on a client. They have consistently had an average BP of 120/70 for the last 3 days?

    <p>Reassess the patient's vitals. Ask the patient if they're experiencing any pain, stress, or just got done exercising. If the patient's blood pressure remains as high as before, I would contact their PCP.</p> Signup and view all the answers

    What are some reasons a client might experience hypoxemia? (Select all that apply)

    <p>Heart disease (B), COPD (D)</p> Signup and view all the answers

    What signs and symptoms can you expect from someone with an oxygen saturation of 88% who reports dyspnea? (Select all that apply)

    <p>Restlessness (A), Apprehension (feeling of impending doom) (B), Dizziness (C), Blue skin (cyanosis) (D), Confusion (E), Fatigue (F), Lack of consciousness (G)</p> Signup and view all the answers

    What nursing interventions can you perform for a patient with low oxygen saturation?

    <p>Put them in a Fowler's position, tell them to take deep breaths, and put them on supplemental oxygen.</p> Signup and view all the answers

    What signs and symptoms can you expect from a hypotensive patient with a BP of 102/58? (Select all that apply)

    <p>Cold to the touch (A), Fast and shallow breathing (B), Clammy skin (C), Weak and rapid pulse (D), Confusion (E)</p> Signup and view all the answers

    When would you want to obtain an apical pulse over a peripheral pulse?

    <p>When the patient's pulse is abnormal.</p> Signup and view all the answers

    Study Notes

    Patient Safety

    • Joint Commission National Patient Safety Goals (NPSGs) were created to reduce harm to patients and other healthcare providers.
    • 2021 NPSGs focus on improving patient identification accuracy, caregiver communication effectiveness, and reducing health care-associated infections.
    • NPSGs aim to enhance safety practices in all healthcare settings.

    Culture of Safety

    • A culture of safety relies on teamwork, open communication, transparency, and accountability.
    • Reporting errors, even those not reaching the patient, builds accountability.
    • Using ISBARR (identification, situation, background, assessment, recommendation, and response) effectively communicates with other healthcare providers.

    Sentinel Events

    • Sentinel events are serious patient safety incidents causing harm, injury, or death.
    • Examples include wrong-patient surgeries, patient suicide while under watch, and discharging infants to incorrect families.
    • Sentinel events directly impact patient safety and require immediate investigation.

    Fall Risk Factors

    • Environmental factors, age related issues, mental status, medications, and a history of previous falls are common risk factors for falls.
    • Patients with a history of falls, or who need assistance with toileting, are particularly at risk.

    Fall Risk Interventions

    • High-risk fall patients require interventions like placing them closer to the nurse, using bed alarms, two to three bedrails (not four), and keeping belongings/call lights within reach.
    • Fall risk should be communicated and identified.
    • Identifying patients as at-risk is crucial.

    Restraint Use

    • Restraints are used as a last resort to prevent patient harm or injury, to others, or to therapy disruption.
    • They can increase the risk of fall-related injuries.
    • Chemical, physical, and mechanical restraints are types of restraints.
    • Avoiding restraints whenever possible, and using them only with appropriate justification, is paramount to patient well-being.

    Restraint Avoidance Strategies

    • Distracting patients, providing a sitter, establishing clear communication, and positioning near the nurse station can avoid restraint use.
    • Identifying and addressing underlying issues that might lead to a need for restraint should be prioritised.

    Restraint Monitoring

    • Staff members need to regularly assess skin integrity for patients in restraints and provide appropriate care to prevent complications.
    • Frequent repositioning and skin assessment are key.
    • Staff should offer food and fluids every two hours.
    • Skin care and monitoring are essential to prevent pressure sores.

    Body Mechanics

    • Using proper body mechanics, like squatting to lift, keeping a wide base of support, and raising beds to waist height, reduces the risk of injury to the caregiver.

    Range of Motion Exercises

    • Active, passive, and full ROM exercises differ based on patient ability.
    • Passive ROM involves the nurse moving the patient's limbs, whereas active includes patient participation.
    • Full ROM requires no assistance.
    • ROM exercises are essential for maintaining joint mobility.

    Immobility Effects

    • Immobility can impact musculoskeletal systems, lungs, cardiovascular systems, skin integrity, gastrointestinal health, urinary function, and psychological well-being.
    • Addressing immobility involves various interventions like promoting exercise, preventing complications like blood clots, and maintaining good hygiene.
    • Early intervention is key.

    Interventions for Preventing Pressure Ulcers

    • Frequent repositioning, use of proper padding when transferring or positioning, and skin monitoring are crucial for preventing pressure ulcers, particularly during immobility.
    • Early detection and intervention for pressure sore development is crucial.

    Vital Sign Measurement Locations

    • Surface temperature measurements can be collected from the forehead (temporal artery), ear (tympanic), armpit (axillary), or mouth (oral).
    • Rectal temperature is the most accurate for core temperature.
    • Correct measurement protocols are critical.

    Heat Exchange Processes

    • Radiation, convection, evaporation, and conduction are ways heat is lost or gained by a body.
    • Understanding these processes is vital for patient care.

    Hypertension

    • Blood pressure of 170/100 is considered high and warrants a detailed assessment by the nurse.
    • Immediate action may be needed.

    Hypoxemia

    • Low oxygen saturation (hypoxemia) can manifest through a range of symptoms (e.g., bluish skin (cyanosis), difficulty breathing, and confusion).
    • Immediate intervention should be considered if a patient shows signs of low oxygen levels.

    Hypotension

    • Hypotensive patients (low blood pressure) can exhibit symptoms like cold or clammy skin, rapid breathing, a weak pulse, and confusion.
    • Addressing the underlying cause is crucial.

    Apical Pulse

    • Obtaining an apical pulse—a measurement taken at the heart—is often more reliable than a peripheral pulse (taken at the wrist or another location) in abnormal situations.
    • Accurate assessment is crucial.

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    Exam 1 Study Guide PDF

    Description

    This quiz covers essential topics related to patient safety and fall prevention in healthcare settings, focusing on interventions, risk factors, and best practices. It will test your knowledge of safety goals, the nursing responsibilities for patient care, and strategies to enhance patient safety.

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