Ch 27 Flashcards
Summary
• Clinical judgment is complex when promoting safety because it requires understanding a patient’s perspective of safety as well as the risks posed by any physical conditions.
• Vulnerable populations (e.g., infants, children, older adults, per- sons with chronic disease) are especially at risk for alterations in safety because of reduced access to health care, fewer resources, and increased morbidity.
• Common environmental hazards to safety include vehicle accidents, poisonings, conditions causing falls, and fire hazards.
• A nurse’s role in managing environmental hazards is to educate patients about the common hazards in the home and at work, teaching them how to prevent injury and emphasizing the hazards to which patients are the most vulnerable.
• A patient’s developmental stage can create threats to safety because of lifestyle choices, cognitive and mobility status, sensory impairments, and safety awareness.
• Use the Banner Mobility Assessment Tool (BMAT) or Timed Up and Go (TUG) test to determine a patient’s ability to walk, need for assistance, and progress of balance, sit to stand, and walking.
• Conduct a fall risk assessment in a hospital by using a validated tool containing major risk categories such as age, fall history, elimina- tion habits, high-risk medications, mobility, and cognition. At a minimum, conduct the assessment on admission, following a change in a patient’s condition, after a fall, and when the patient is transferred to a new health care setting.
• A procedure-related accident is less likely to occur when you strictly follow policies and procedures or standards of nursing practice, and when you minimize distractions and interruptions.
• An assessment of psychosocial factors that influence patient safety must include a review of a patient’s health literacy, cultural background, and perception of health and safety.
• Patients with actual or potential risks to safety require you to make clinical judgments necessary in selecting the patient- centered interventions that prevent and minimize the specific threats to safety.
• It is important to learn a patient’s routines and willingness to make changes in the environment, because decisions on ways to change the environment require the patient’s full participation.
• Evidence-based alternatives to physical restraints include offering diversional activities, using de-escalation techniques, providing visual and auditory stimuli, and promoting relaxation techniques.
• Before applying restraints, review the medical record for underly- ing cause(s) of agitation and cognitive impairment, assess whether the patient has a history of dementia or depression, and review medications and current laboratory values.
• When a patient is in a physical restraint, assess the placement of the restraint, and note skin integrity, pulses, skin temperature and color, and sensation of the restrained body part.
You are caring for a patient in an intensive care unit (ICU) who has pulled out his own IV line. You have tried restraint alternatives.Which of the following would you assess to determine appropriateness or reason to physically restrain the patient? (Select all that apply.)
1. Health care provider’s order
2. Patient’s current behavior
3. Current medications
4. Health literacy
5. Presence of fever
6. Serum electrolytes
7. Age
1.,2.,3.,5.,6.,
You complete a fall risk assessment on your assigned patient, who is 45 years old and has a history of cocaine use and liver failure. His laboratory results show an elevated prothrombin time. You determine that the patient is at high risk for falling. Which of the following measures are targeted to his fall risk status? (Select all that apply.)
1. Using skid-proof footwear
2. Scheduling any oral medications at least 2 hours before bedtime
3. Placing a low bed in room
4. Placing the nurse call system within patient’s reach
5. Using a bed exit alarm
6. Providing patient with a protective head helmet when in chair
or walking
2.,.3.,5.,6.,
During a home health visit a nurse observes a patient preparing
lunch. Which of the following are safe practices to follow in the safe preparation and storage of food? (Select all that apply.)
1. Always use a single cutting board to prepare foods for cooking.
2. Refrigerate leftovers as soon as possible.
3. Always buy vegetables in packages marked “prewashed.”
4. Cook meats to the proper temperature.
5. Wash hands thoroughly before food preparation.
2.,4.,5.,
A nurse enters the hospital room of a patient who had a total knee replacement the day before and is sitting in a chair. The nurse is preparing to return the patient to bed. Which of the following pose potential safety risks? (Select all that apply.)
1. A current safety inspection sticker is on the IV fluid pump.
2. A walker is positioned near the patient’s bedside.
3. The hospital bed is in the high position.
4. There is no gait belt at the bedside.
5. The overbed table with the patient’s glasses is positioned against the wall opposite the end of the bed.
3.,4.,5.,
Match the patient fall risks on the left with the correct risk factor category on the right.
___1. A 42-year-old patient who is recovering from anesthesia
refuses assistance with walking to
the bathroom.
___2. A 60-year-old patient with a
history of falling in the last
6 months.
___3. A patient’s walking path has
spilled fruit juice on the floor.
___4. A 68-year-old patient recovering
from a colon resection uses an IV
pole to walk.
___5. Patient is unable to identify own
fall risks.
___6. The physical therapist has not yet
fitted a 62-year-old patient for a prescribed walker.
A. Intrinsic risk
B. Extrinsic risk
A.,a.,b.,b.,a.,b.,
A nurse working on a surgery floor is assigned four patients. The nurse assesses each patient, noting behaviors and physical signs and symptoms. Which of the following patients is more likely to be violent toward the nurse?
1. The first patient maintains eye contact with the nurse, is calm during the nurse’s assessment, and asks questions frequently.
2. The second patient is very drowsy, loses attention when the
nurse asks questions, and mumbles when speaking.
3. The third patient moves nervously in bed, swears and grimaces
when trying to cough, and speaks in a low volume.
4. The fourth patient speaks in a loud voice and becomes irritable
when the nurse arrives to help walk the patient.
4
Match the intervention for promoting child safety on the left with the correct developmental stage on the right.
1. Teach children proper bicycle and skateboard safety.
2. Teach children how to cross streets and walk in parking lots.
3. Teach children proper techniques for specific sports.
4. Teach children not to operate electric toothbrushes while unsupervised.
5. Teach children not to talk to or go with a stranger.
6. Teach children not to eat items found in the grass.
A. School-age children
B. Preschooler
A.,a.,a.,b.,b.,b.,
The nurse finds a 68-year-old woman wandering in the hallway and exhibiting confusion. The patient says she is looking for the bathroom. Which interventions are appropriate for this patient? (Select all that apply.)
1. Ask the health care provider to order a restraint.
2. Recommend insertion of a urinary catheter.
3. Provide scheduled toileting rounds every 2 to 3 hours.
4. Institute a routine exercise program for the patient.
5. Keep the bed in high position with side rails down.
6. Keep the pathway from the bed to the bathroom clear.
3.,4.,6.,
Place the following steps for applying a wrist restraint in the correct
order:
1. Pad the skin overlying the wrist.
2. Insert two fingers under the secured restraint to be sure that it
is not too tight.
3. Be sure that the patient is comfortable and in correct anatomical
alignment.
4. Secure restraint straps to bedframe with quick-release buckle.
5. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly.
3.,1.,5.,2.,4.,
Match the fall prevention intervention on the left with the scientific rationale on the right.
___1. Prioritize nurse call system responses to patients at high risk.
___2. Place patient in a wheelchair with
wedge cushion.
___3. Establish elimination schedule with bedside commode.
___4. Use a low bed for patient.
__5. Provide a hip protector.
___6. Place nonskid floor mat on floor next to bed.
A. Maintains comfort and makes exit difficult
B. Makes it difficult for patients with lower extremity weakness to stand
C. Reduces slipping when walking
D. Reduces fall impact
E. Ensures rapid response for help
D. Reduces chance of patient trying to get out of bed on own
E.,a.,f.,b.,d.,c.,
