A nurse has a prescription to apply wrist restraints to maintain client safety. What should the nurse do when applying this type of restraint?
Check the site of restraint every 30 mins
Remove the wrist restraint every 2 hours
Ensure they wrist restraint is well padded
Tie the straps of the wrist restraint to the bed frame using a slip knot
What are important steps when transferring a pt from a bed to a chair using a mechanical lift?
Spread the legs of the lift apart before lowering the pt to the chair
Attach the longer straps to the lower grommets on each side of the sling
A client is cognitively impaired is admitted to the hospital for pneumonia. The client has a history of wandering at night. What should the nurse do to meet his needs?
Apply a radio frequency product to the wrist
Restrict fluids several hours before bed
Activate the bed alarm
Eliminate caffeine from the diet
An 87 year old is admitted to the hospital for IV re hydration after a fall. Orders are out of bed ad lib. What should the nurse do before getting the pt out of the bed?
Test the strength of the leg muscles
Which nursing interventions gives the client a sense of control?
Instruct client how to lock the wheels on the wheelchair
Teach the client how to use the call bell
Orient the client to the environment
A nurse in the ER hears a client and family member arguing with each other in the room at the end of the unit. What should the nurse do first?
Get another staff member and go to the room together.
Warm compresses are prescribed to be applied to the insertion site of an IV catheter that has become red and inflamed. What should the nurse explain is the desired outcome of this thearpy?
Circulation to the area will increase which will promote healing
A nurse is caring for a client with a vest restraint. Which action should the nurse implement?
Tie the restraint to the movable part of the bed
Ensure the cross-over of the vest restraint is in the front of the client.
A nurse is caring for a client that is blind. What should the nurse do to facilitate safety?
Walk about 1 foot ahead and have the client grasp your arm
Remain near bye when they are providing self care
Orient the client to the psychical environment
What should the nurse implement when ambulating a client with a gait belt?
Position yourself slightly behind and next to the client when ambulating a client with a gait belt.
Stand on the client's weaker side when ambulating a client gait belt.
Assess for activity intolerance while ambulating a client with a gait belt
Hold the gait belt in the middle of the client's back
A nurse is caring for a client with wrist restraints. Which action should the nurse implement when caring for this client?
Provide additional padding
Offer fluids and bathroom breaks every time restraints are released
Ensure that every 24 hrs the Dr assess the need for them
A nurse is completing an assessment for the purpose of determining factors that place the client at risk for falls. Which factor is the most concern when completing this assessment?
Has a history of falls
A nurse is teaching a class about how to prevent the most common cause of fatal accidents in the home.
Store cleaning products in locked cabinets
Which human response to illness alert the nurse the pt is at risk for aspiration during meals?
Lethargy, Stomatitis ( inflammation of the mucus membranes in the mouth), Dysphagia
Pt has a nasogastric tube for gastric compression. Which nursing intervention takes priority?
Position pt in semi fowler position
Pt was shocked by radio when turning it on. The nurse should do what first?
Take the apical pulse
Which nursing intervention enhances the older adults sensory perception and thereby helps prevent injury when walking from the bed to the bathroom?
Provide adequate lighting
A patient has dysphagia. What nursing action takes priority when feeding the patient?
Checking the mouth for emptying between every bite
Profuse smoke is coming out the heating unit in a pt room. Which should the nurse do first?
Move the patient out of the room
A nurse is planning care for a pt with wrist restraints. How often should a wrist restraint be removed, the area massaged, the joints moved through full ROM?
Every 2 hours
A nurse is preparing a bed to receive a newly admitted pt. Which action is most important?
Ensuring the bed wheels are locked
Which interventions should a nurse implement when assisting a pt to use a bedpan?
Ensure the bed rails are raised once the pt is on the bedpan, encourage the pt to help as much as possible when using bedpan, raise to semi-Fowler position once the pt is placed on bedpan
A pt is delirious and attempting to pull out a urinary catheter. What is important to consider when planning care for this pt?
Reasons for using restraints must be clearly documented
Laws permit the use of restraints when specific guidelines are followed
Which drugs are most often implicated in poisoning deaths among children?
Analgesics, antihistamines, sedatives
Restraint need to knows
Check every 30 mins
2 finger loose
removed every 2 hrs
Have Dr assess every 24 hrs
Vest= crossover infront, prevent choking and slipping, tie to movable part of bed
RACE stands for
Rescue, Alarm, Confine, Extinguish
What is the number one cause of injury for over 65
Also at risk: impaired vision/balance, altered gait, meds, postural hypotension, slowed reaction time, confusion
*perform hourly rounds at night to help prevent
When completing a safety event report, the nurse should include what?
Objectively describe the incident in detail