35 Questions
In older adults, age-related functional deterioration in immune system function leads to:
Decreased ability to produce antibodies
Which of the following is a source of infection categorized as endogenous?
Overgrowth of patient’s flora due to altered environment
What is the first step for donning sterile gloves?
Select correct size/type of gloves
Which intervention is considered least invasive for fall prevention in older adults?
Consistent rounding
What is the last step in the nursing process?
Evaluation
What does PES statement in nursing diagnosis stand for?
Problem, Etiology, Symptoms
What does subjective data refer to in nursing assessment?
What the patient says
Which factor contributes to decreased immune response in older adults?
Poor nutrition
What is the primary principle of sterility when donning sterile gloves?
"Open package carefully"
What is the best predictor of risk for falls in older adults?
Past history of falls
What does the nursing diagnosis component 'P' represent in a PES statement?
Problem
Which intervention is considered most invasive for fall prevention in older adults?
Pharmaceutical sedation
Which type of isolation is needed for diseases like influenza, adenovirus, and group A strep?
Airborne precautions
What type of PPE is needed for patients requiring contact precautions?
Gown, mask, goggles, gloves
Which condition is considered a 'never event' in hospitals?
Catheter-associated UTI
When should hand hygiene be performed according to the text?
Before direct contact with patients; between patient contacts; after contact with blood, body fluids, and secretions; immediately after gloves are removed
What type of precautions are needed for diseases like VRE, MRSA, and C. diff?
Contact precautions
What do 'never events' in hospitals refer to?
Serious medical errors that should never occur
Which procedure requires donning PPE in the following order: gown, mask, goggles, gloves?
Respiratory hygiene and cough etiquette
What are the manifestations of poor glycemic control considered as 'never events' in hospitals?
DKA
What is the main purpose of using protective environment for allogenic hematopoietic stem cell transplants?
To minimize the risk of airborne infections
What should be done if needle recapping is necessary according to the text?
Use one-handed scoop method
When should alcohol-based hand rub be used?
After contact with spores
What type of isolation is needed for patients with respiratory syncytial virus (RSV)?
Contact precautions
In hospitals, what is the maximum duration for each original restraint order for adults (18 years +)?
4 hours
What is the responsibility of a registered nurse (RN) regarding assessing patients under restraint?
Assess every 2 hours for violent patients
What is the role of a licensed practical nurse (LPN) in relation to taking patients out of restraints?
Cannot take the patient out of restraints
What is the maximum duration for each original restraint order for children under 9 years in hospitals?
1.5 hours
What is the goal in using restraints on patients?
To prevent interruption of therapy
When are restraints considered appropriate in healthcare settings?
After trying least invasive measures first
What is the responsibility of a healthcare provider if restraints are needed due to violence or self-destructive behavior?
Assess the patient within 60 minutes
What skill related to restraint use and appropriate assessment cannot be delegated to non-RN staff?
Correct placement of restraint
What must a provider specify when ordering restraints?
The location and type of restraint to be used
What is the primary responsibility of a nurse in instructing assistive personnel about restraints?
To instruct about correct placement of restraints and changing position
What must be done if restraints are found to be needed due to violence or self-destructive behavior?
The RN must inform the healthcare provider immediately
This study guide covers information about restraints, their application, protocols, and delegation to licensed and unlicensed individuals. It also discusses the appropriateness of using restraints and emphasizes the importance of using the least invasive measures first.
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