Chapter Thirteen

Question 1

SBARR

Answer 1

Situation
Background
Assessment
Resolution
Response

Question 2

Ambulate

Answer 2

To Walk

Question 3

The Joint Commission

Answer 3

The organization responsible for evaluation and accrediting health-care organizations and programs in the United States

Question 4

Fall Assessment Rating Scales

Answer 4

Forms that when filled out, give a numerical rating for each patients risk for falls

Question 5

Restraints

Answer 5

Vests, Jackets, or Bands that have connected traps that are tied to the bed chair or wheelchair to keep the patient in one place

Question 6

Restraint Alternatives

Answer 6

Less restrictive ways to help patients remember to get up and to tru to walk, or to alert nursing staff that the patient is attempting to do so

Question 7

Restraint Alternative (Monitor devices)

Answer 7

Monitors:
-Chair Monitor
-Bed Monitor
-Position Alarm
-Leg Monitor

Question 8

Hypervigilant

Answer 8

to be on alert

Hyper - excessive (+) Vigilant - attentive to stimuli

Question 9

Restraint Alternative (soft devices)

Answer 9

These can include bolsters that can be placed in the bed on either side of the patient to prevent them from slipping between or through the side rails

Question 10

Restraint Alternative (Strategies)

Answer 10

Strategies:
-Placing patient who is a fall risk by the nurses station so it is easy to see if they attempt/ check on them
-Stay 1on1 with fall risk patients
-Keep bed at the lowest level at all times except if staff is bedside
-Place bedside table across chair to help patient remain seated
-Have high energy fall risks sit in a rocking chair to help relax and use up energy
-Offer regular opportunities to go to bathroom or get snacks or drinks
-Assess fall risks frequently for subjective complaints like nausea, pain, or other discomfort
-Provide back rubs and distractions

Question 11

Restraints

Answer 11

Can be called protective devices or safety reminder devices. Sometimes can be called poseys after the brand name of the first restraints on the market.
Avoid using restraints if possible.

Question 12

If an order for restraints has been placed, what guidelines do you need to follow:

Answer 12

-Check on patient every 30 min, making sure skin has no redness/chaffing and the extremities for warmth and color
-Remove restraint every 2 hours

While Removed do these things:
-Offer fluids
-Assist with toileting as needed
-Change position if in bed
-Assess for edema, cap refill, sensation, and function
-Assess skin over pressure points for integrity and erythema
-Assist the patient to ambulate if that is appropriate
-Stay with patient the entire time restraint is off
-Document all actions on the appropriate flow sheet

Question 13

RACE

Answer 13

-Rescue: Remove patients from immediate danger to a safer area
-Alarm: Sound the fire alarm according to facility policy
-Confine: Confine the fire to one room or area.
-Extinguish: You should only attempt to extinguish a small fire with a fire extinguisher

Question 14

PASS

Answer 14

Pull - the pin
Aim - the nozzle at the base of the flames
Squeeze - the handle together to release the contents
Sweep - side to side at the base of the flames to put it out

Question 15

Types of Extinguishers

Answer 15

A
B
C
D
K

Question 16

Type A

Answer 16

Paper Wood Fabric and Trash

Question 17

Type B

Answer 17

Combustible liquids such as oil, gasoline, and other petroleum-based products and flammable gases

Question 18

Type C

Answer 18

Electrical fires such as short circuits in wires, motor, or equipment

Question 19

Type D

Answer 19

Powders, flakes, or shavings of combustible metals

Question 20

Type K

Answer 20

Kitchen fires caused by combustible cooking fluids like oils and fats

Question 21

Cardiopulmonary Resucitation

Answer 21

CPR
A set of actions used to restart the heart or breathing of an unresponsive victim without a pulse or respirations

Question 22

Heimlich Maneuver

Answer 22

An action to relieve choking by thrusting just below a person’s xiphoid process

Question 23

Rescue Breathing

Answer 23

Breathing for the patient in case of respirator arrest when the pulse still is palpable

Question 24

Code Team

Answer 24

A group of specially trained personnel designated to respond to codes throughout the hospital

Question 25

Mass Casualty Event

Answer 25

MCE
A public health or medical emergency involving thousands of victims

Question 26

Body Mechanics

Answer 26

The movement of muscles of the body for balance and leverage

Question 27

Center of Gravity

Answer 27

The middle point of the body, below the umbilicus and above the pubis, around which the body’s mass is distributed

Question 28

Base of Support

Answer 28

This refers to your feet and lower legs

Question 29

Ataxia

Answer 29

Unsteady Gate

Question 30

Safety Data Sheet

Answer 30

SDS
Facility is required to have on file for every chemical
Contains information about potential harm caused by exposure and directions for what to do if the product gets in your eyes, on skin, or in mouth