Restraints and Protocols in Healthcare Exam 1 Study Guide

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Questions and Answers

Which type of isolation is needed for diseases such as influenza and respiratory syncytial virus?

Airborne precautions

What is the appropriate PPE for dealing with patients at high risk for infection and adverse outcomes?

Mask, gloves, and gown

Under which condition should hands be washed with either nonantimicrobial soap or antimicrobial soap and water?

When hands are visibly soiled or contaminated with blood or body fluids

What are the 'never events' in hospitals according to Box 27-4?

Air embolism, pressure injury stages 3 or 4 Signup and view all the answers

What is the appropriate sequence for donning PPE?

Mask, gloves, gown, goggles Signup and view all the answers

When should respiratory hygiene and cough etiquette be practiced?

In standard precautions Signup and view all the answers

Which type of isolation is needed for conditions such as multi-drug resistant infections and herpes simplex?

Contact precautions Signup and view all the answers

What type of room is required for patients undergoing allogenic hematopoietic stem cell transplants?

Private room with positive airflow Signup and view all the answers

When should hand hygiene be performed as per standard precautions?

Before direct contact with patients and after glove removal Signup and view all the answers

What are some examples of manifestations of poor glycemic control according to 'never events'?

DKA (diabetic ketoacidosis), nonketotic hyperosmolar coma Signup and view all the answers

What type of isolation is needed for diseases such as Neisseria meningitides and rubella?

Airborne precautions Signup and view all the answers

What is the appropriate PPE for dealing with patients undergoing allogenic hematopoietic stem cell transplants?

Mask, gloves, and gown Signup and view all the answers

What is a characteristic of endogenous sources of infection?

They are part of the patient's flora that becomes altered and leads to an overgrowth Signup and view all the answers

What intervention is recommended for older adults to address age-related functional deterioration in the immune system function?

Proper hand hygiene and vaccination Signup and view all the answers

What is the least invasive intervention for fall prevention according to age-related considerations and interventions?

Consistent rounding and fall risk sign on door/chart Signup and view all the answers

What should be the first step in donning sterile gloves?

Select the correct size/type of gloves Signup and view all the answers

Which step of the nursing process involves setting priorities, goals, and interventions?

Planning Signup and view all the answers

What is included in the assessment phase of the nursing process?

Review of systems and travel history Signup and view all the answers

What is the purpose of a PES statement in nursing diagnosis?

To formulate a three-part statement indicating problem, etiology, and symptoms Signup and view all the answers

What distinguishes subjective data from objective data in the nursing assessment?

Subjective data are what the patient says, while objective data are what can be assessed using senses. Signup and view all the answers

What type of isolation is needed for diseases such as influenza and respiratory syncytial virus?

Standard precautions Signup and view all the answers

What is a critical consideration for older adults in relation to fall risk?

Decreased balance and osteoporosis Signup and view all the answers

Which type of room is required for patients undergoing allogenic hematopoietic stem cell transplants?

Protective environment room with positive air pressure Signup and view all the answers

What intervention is recommended for endogenous sources of infection?

Proper hand hygiene and vaccination Signup and view all the answers

What is the maximum duration for an original restraint order for adults (18 years +) in a hospital?

4 hours Signup and view all the answers

Who is responsible for assessing a nonviolent patient's condition every 2 hours while under restraint?

Registered Nurse (RN) Signup and view all the answers

What is the first step to be taken before considering the use of restraints?

Educating and communicating with the patient Signup and view all the answers

What is the role of the licensed practical nurse (LPN) in the context of restraint use?

Taking the patient out of restraints Signup and view all the answers

What is the time frame for renewing an original restraint order in a hospital?

24 hours Signup and view all the answers

Which professional is responsible for specifying the type, location, duration, and circumstances of a restraint order?

Attending Physician Signup and view all the answers

What must be done if a restraint is needed due to violence or self-destructive behavior?

The healthcare provider must assess the patient within 60 minutes Signup and view all the answers

According to CMS guidelines, what does 'CMS' stand for in the context of restraint use assessment?

Circulation, Motor, Sensation Signup and view all the answers

What is the goal regarding the use of restraints?

To discontinue the use of restraints as soon as possible Signup and view all the answers

Which action related to restraint use cannot be delegated to another staff member?

Applying restraints as ordered by the physician Signup and view all the answers

Study Notes

Infection Control and Isolation

Airborne precautions are necessary for diseases such as influenza and respiratory syncytial virus
Contact precautions are necessary for diseases such as multi-drug resistant infections and herpes simplex
Droplet precautions are necessary for diseases such as Neisseria meningitides and rubella

Personal Protective Equipment (PPE)

Appropriate PPE for dealing with patients at high risk for infection and adverse outcomes includes gloves, gowns, masks, and eye protection
Appropriate PPE for dealing with patients undergoing allogenic hematopoietic stem cell transplants includes gowns, gloves, and masks

Hand Hygiene

Hands should be washed with either nonantimicrobial soap or antimicrobial soap and water when leaving a patient's room or after touching a patient
Hand hygiene should be performed as per standard precautions before and after patient contact

Patient Safety and Fall Prevention

"Never events" in hospitals include patient falls, surgical errors, and medication errors
Respiratory hygiene and cough etiquette should be practiced to prevent the spread of infection
The least invasive intervention for fall prevention is to encourage patients to ask for help when getting out of bed

Nursing Process

The planning phase of the nursing process involves setting priorities, goals, and interventions
The assessment phase of the nursing process involves gathering subjective and objective data about the patient
A PES statement in nursing diagnosis includes the problem, etiology, and signs and symptoms
Subjective data includes the patient's perceptions and feelings, while objective data includes measurable signs and symptoms

Restraint Use

The maximum duration for an original restraint order for adults (18 years +) in a hospital is 4 hours
The licensed practical nurse (LPN) can assist with implementing restraints under the supervision of a registered nurse (RN)
The registered nurse (RN) is responsible for assessing a nonviolent patient's condition every 2 hours while under restraint
The goal regarding the use of restraints is to minimize their use and ensure patient safety
The physician is responsible for specifying the type, location, duration, and circumstances of a restraint order
CMS guidelines emphasize the importance of assessing a patient's condition before using restraints

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