67 Questions
What is the maximum duration for an original restraint order for an adult in a hospital setting?
4 hours
Who is responsible for assessing the patient's behavior, orientation to environment, need for restraints, and the appropriate use of restraints?
RN
What must be specified in the provider's order for a restraint?
Circumstances for restraint use
When is it appropriate to use restraints?
If there is a risk of patient injury
What is the maximum consecutive hours that orders for restraint renewal are limited to in hospitals for adults?
24 hours
What is the responsibility of the licensed practical nurse (LPN) regarding restraint use?
Taking the patient out of restraints
What is the required time frame for renewing a provider's order for restraints?
Within specific time frame
What does CMS stand for in the context of assessing restrained patients?
Circulation, Motor, and Sensation
What is the goal concerning the use of restraints?
To discontinue use as soon as possible
What is the responsibility of the nurse regarding assessing restrained patients?
Assess every 2 hours for nonviolent patients and every 15 minutes for violent patients
What is the role of the nurse when instructing assistive personnel about restraints?
Instructing about appropriate restraint use and correct placement of restraint
What type of precautions are needed for patients with influenza, adenovirus, and group A strep?
Airborne precautions
What type of isolation is needed for patients with herpes simplex and varicella zoster (disseminated)?
Contact precautions
Which of the following is a 'never event' as defined in healthcare?
All of the above
What is the recommended method for discarding sharps in a healthcare setting?
In a puncture-resistant container
When is it recommended to use alcohol-based hand rub for hand hygiene?
When hands are not visibly soiled
For which type of isolation do patients need to be placed in a private room or cohort patients, wear gloves and gowns, and have barrier protection?
Protective environment
What is the purpose of standard precautions in healthcare settings?
To protect against the spread of all infections
'Iatrogenic pneumothorax with venous catheterization' is considered a 'never event' because it:
Is entirely preventable and should never occur
'Catheter-associated UTI' is considered a 'never event' because it:
'Manifests as poor glycemic control in patients'
What condition requires positive airflow with >12 air exchanges per hour and HEPA filtration for incoming air?
Protective environment
What precaution is needed for patients who are colonized with multi-drug resistant organisms such as VRE and MRSA?
Contact precautions
When is it necessary to use one-handed scoop method for needle recapping?
When anticipated patient interaction may involve contact with blood or body fluids
Which of the following factors contributes to the increased susceptibility of older adults to infections?
Decreased bone density and osteoporosis
What is an example of an exogenous source of infection?
Microorganisms from outside the individual's body
What is the least invasive fall prevention intervention for older adults?
Consistent rounding by healthcare staff
What does the 'P' in a PES statement refer to?
Problem
In the nursing process, what kind of data includes what the patient says?
Subjective data
What does the term 'endogenous' source of infection refer to?
Altered normal flora causing an overgrowth
Which factor is NOT a contributor to the increased susceptibility of older adults to infections?
Regular exercise routine
What is an example of a nurse-initiated treatment in the implementation stage of the nursing process?
Educating a patient about their condition and treatment plan
Which statement best describes an example of a two-part PES statement?
A diagnostic label related to its etiology
What is the primary risk factor for falls among older adults?
Polypharmacy (use of multiple medications)
Which type of data involves what can be assessed using senses or measured?
Objective data
What does the term 'exogenous' source of infection refer to?
Organisms from outside the individual’s body
Which of the following is NOT a condition considered a 'never event' in hospitals?
Influenza
For which type of isolation do patients need to be placed in a private room or cohort patients, wear gloves and gowns, and have barrier protection?
Contact precautions
What is the recommended method for discarding sharps in a healthcare setting?
Placing them in a puncture-resistant container
What is the primary risk factor for falls among older adults?
Weakness or balance problems
What precaution is needed for patients who are colonized with multi-drug resistant organisms such as VRE and MRSA?
Contact precautions
What does the term 'endogenous' source of infection refer to?
An infection originating from the patient's own microbial flora
'Catheter-associated UTI' is considered a 'never event' because it:
Is preventable with appropriate catheter care and maintenance
'Iatrogenic pneumothorax with venous catheterization' is considered a 'never event' because it:
Is entirely preventable with proper catheter insertion techniques
'Latrogenic pneumothorax with venous catheterization' is an example of:
'Never event' related to medical procedures
What is the purpose of standard precautions in healthcare settings?
To prevent transmission of infectious agents from recognized and unrecognized sources of infection in healthcare setting
What is the primary risk factor for falls among older adults?
Fear of falling
Which type of isolation is needed for patients with herpes simplex and varicella zoster (disseminated)?
Contact precautions
What must be specified in the provider's order for a restraint?
Reason for using the restraint
What is the role of the nurse when instructing assistive personnel about restraints?
To instruct on alternatives to restraint use
When is it appropriate to use restraints?
When managing agitated behavior
What is an example of an exogenous source of infection?
Infection from microorganisms outside the individual
Which factor is NOT a contributor to the increased susceptibility of older adults to infections?
Fear of falling
What does the 'P' in a PES statement refer to?
Problem r/t etiology AEB symptoms
What type of data involves what can be assessed using senses or measured?
Objective data
What is the least invasive fall prevention intervention for older adults?
Consistent rounding
What is the purpose of standard precautions in healthcare settings?
To prevent transmission of bloodborne pathogens and other infectious microorganisms in healthcare settings
What is the maximum duration for an original restraint order for a child under 9 years in a hospital setting?
1 hour
In the context of assessing restrained patients, what does CMS stand for?
Circulation, Motor, Sensation
What is the primary responsibility of the licensed practical nurse (LPN) regarding restraint use?
Taking the patient out of restraints
What must be specified in the provider's order for a restraint?
Specific duration and circumstances for restraint use
When is it necessary to use the one-handed scoop method for needle recapping?
When there is a risk of needlestick injury
What is an example of an exogenous source of infection?
Viruses transmitted through respiratory droplets
What is the goal concerning the use of restraints?
To discontinue use of restraints as soon as possible
When is it recommended to use alcohol-based hand rub for hand hygiene?
Before direct contact with a patient
Which statement best describes the responsibilities of RNs and LPNs and CNAs regarding restraint use?
RN must assess, LPN can take patient out of restraints, CNA cannot take patient out of restraints.
What type of precautions are needed for patients with influenza, adenovirus, and group A strep?
Droplet precautions
What is NOT ordered prn in relation to restraint use?
Renewing orders for restraint duration.
This study guide covers information about restraints, their application, protocols, delegation to licensed and unlicensed individuals, and appropriate usage. It emphasizes the use of least invasive measures first and the necessity of provider orders for restraints.
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