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NURS 713 Fundamentals of Nursing > Exam 1 > Flashcards

Exam 1 Flashcards

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1
Q

What are the risk factors that influence patient safety?

A

Developmental Stage
Cognitive function
Mobility
Sensory Function
Communication
Lifestyle
Safety Knowledge/Awareness
Environment

Hospital-Specific:
Medical Errors/Never Events
Near Misses
Hospital Setting and Enviroment

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2
Q

What are the Joint Commission 2023 National Patient Safety goals?

A

ID patients correctly with 2 forms
Improve Staff Communication
Use medicine labels safely
Use Alarms Safely
Prevent Healthcare Associated Infections
ID Patient Safety Risks
Prevent Mistakes in Surgery

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3
Q

What are Serious Reportable Events aka ‘never events’

A

Surgical or invasive procedure events
Product or device events
Patient protection events
Care management events
Environmental events
Radiologic Events
Potiential criminal evens

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4
Q

An example of a Never event:
Surgical or invasive procedure event

A

Wrong patient, wrong site, wrong procedure, retained object

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5
Q

An example of a Never event:
Patient protection event

A

Suicide or attempted suicide, self inflicted injury, elopement, discharge to unauthorized individual

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6
Q

An example of a Never event:
Care management events

A

Med error, blood product incompatibility, falls, Stage 3, 4 or unstageable pressure injuries aquired during hospitalization, failure to communicate or follow-up test results

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7
Q

What are CMS hospital acquired conditions (HACs)?

A

Foreign object retained after surgery
air embolism
blood incompatibility
Stage 3 and 4 pressure injuries
Falls and Trauma
Manifestations of Poor Glycemic control
Catheter-associated urinary tract infections
Vascular Catheter-Associsted infections
DVT s/p orthopedic procedures
Iatrogenic pneumothorax with venous cath

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8
Q

What do you do when an injury occurs?

A

Get patient and you to safety
Call for help if needed
Assess patient
Notify provider
Report

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9
Q

What do you report when an injury occurs?

A

Medication errors
Hospital acquired pressure injuries
falls
equipment failure of malfunction
sentienel events, near misses, never events
Anything posing an actual or potenial threat to patient/staff safety

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10
Q

Team Member Safety:
Sticks

A

Never recap a used needle
Use safety needles, sharps boxes, and needless ports
Know what to do if you get stuck with a dirty needle

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11
Q

Team Member Safety:
Splashes

A

Wear appropriate PPE always
If in doubt, wear it

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12
Q

Team Member Safety:
Ergonomics/body mechanics

A

Use a wide base of support and maintain body alignment

Keep center of gravity low and close to your core

Side step or pivot, no twisting

Squat don’t bend

Use lifting assist devices

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13
Q

Team Member Safety:
Falls

A

Assess risk using validated assessment tool-Morse Fall Scale

Consider risk factors

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14
Q

What are the risk factors for falls?

A

Lighting
Room assignment, orientation and clutter
Location of belongings
Assistive devices and footwear
Bed position, brakes, side rail position
Response time to call light
Elimination needs
Medication side effects
Knowledge of risks and prevention strategies

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15
Q

What are the high alerts for enhanced fall risk?

A

History of Falls
Confusion
Age over 65
Impaired judgement
Sensory deficit
Unable to ambulate correctly
Decrease level of cooperation
Increase anxiety/emotional liability
Incontinence or urgency
Co-morbidity
Postural hypotension and vertigo
Monitoring and therapeutic devices

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16
Q

What are the cateogories in the Morse Fall scale?

A

History of Falling

Secondary Diagnosis

Ambulatory Aid

IV or IV access

Gait: weak/Impairment

Mental Status

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17
Q

Fire: What does RACE stand for?

A

RACE

Rescue and remove patients (horizontal before vertical
Activate alarm and report details
Contain/confine first (close doors)
Extinguish fire if possible

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18
Q

Fire: What does PASS stand for?

A

PASS

Pull the pin
Aim at base of fire
Squeeze the handles
Sweep from side to side

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19
Q

Restraints: *****

What are the reasons for using restraints?

A

Medical Necessity (non-behavorial)
Behavioral/mental health (imminenet danger)

Meant to be temporary for saftey

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20
Q

Restraints: *****
What should you do before using restrants?

A

Use all least restrictive alternatives first

Have a provider order that had a face to face assessment within 1 hour of application

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21
Q

Restraints: *****

The reassessment frequency depends on?

A

Medical : Q 2 hours
Behavioral: Q 15 minutes

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22
Q

Restraints: *****
What are the different types of restraints?

A

Physical:
Manual method, physical, or mechanical device (full set of side rails)

Chemical:
Medications such as anxiolytics and sedatives

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23
Q

Restraints: *****
What is the last choice of restraint methods?

A

chemical

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24
Q

Restraints: *****

What should you be reassessing for?

A

-VS, circulation and perfusion
-Hydration and elimination needs
-ROM, skin integrity, tightness of restraint
-Mental status, level of agitation/distress, cognitive
-need for continued use

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25
Q

Restraints: *****
What should you document?

A

-Ongoing assessment required
-Include behavior that necessitated need, procedure used, condition of body part, client response

26
Q

Restraints: *****

Things to consider when using bilateral wrist restraints

A

-Renewel requirements
-Provider order w/in time limit
-Remove/replace every 2 hrs
-Pad boney prominences
-Perform re-assessment every 2 hrs
-Tie to bed frame not side rail with quick release knot
-‘Two finger’ looseness
Assess for continued need
Thorough documentation
Delegation: UAP can check restraints to see if they have loosened or become tighter

27
Q

Restraints: *****

Things to consider when using side rails

A

Many hospital policies state that 4 out of 4 side rails up is restraint, however 4 can be up for transport and not be considered restraint

28
Q

Restraints: *****
Which one of these are restraint?

1) Trying to keep pt from voluntarily getting up
2)Trying to prevent PT from inadvertently falling
3)If pt lack capacity to get out of bed
4)Trying to keep pt from exiting bed

A

1) restraint
2)not restraint
3)not restraint
4)restraint

29
Q

What is the chain of infection?

A

Infectious agent->reservoir->portal of exit->mode of transmission->portal of entry->host->

30
Q

What does the SAFETY Framework for infection control stand for?

A

S-System Specific Assessments
A-Analysis of Concept
F-First do Priority Interventions
E-Evaluation of Expected Outcomes
T-Trend for Potential complications
Y-You manage risk to RN and patient

31
Q

S: system specific assessments means to?

A

Look for any signs of infection

Symptoms, cues, manifestations supporting the identified problem.

32
Q

A-Analysis of concept means?

A

Infection control, pain.

Identifies the patients problem from the concept perspective

33
Q

F: First-do Priority interventions means?

A

Identifies the priority nursing interventions to address the problem and by doing them, moves closer to resolving the problem and achieving the outcome.

34
Q

The difference between Medical and Surgical asepsis is?

A

Medical-Reduce the # of organisms and prevent spread

Surgical-Eliminate all organisms including spores

35
Q

What are the 7 principles of surgical asepsis?

A

1) A sterile object only remains sterile when touched by another sterile object
2)Only sterile objects can be placed in a sterile field
3)A sterile object or field out of the range of vision or below the waist is contaminated
4)A sterile object becomes contaminated by prolonged exposure to air
5)If a sterile object comes in contact with a wet contaminated object, the object or field becomes contaminated
6)Fluid flows in the direction of gravity
7) The edges of a sterile field are considered contaminated

36
Q

When would you use contact precautions?

A

If the mode of transmission is direct or indirect.

EX: MRSA, VRE, Scabies, cdiff

37
Q

What are contact precaution PPE?

A

gown and gloves

38
Q

When would you use droplet precautions?

A

If the mode of transmission is respiratory droplets traveling short distances (~3 to 6 ft)

EX: Flu, meningitis, pertussis, RSv

39
Q

Droplet precautions require what PPE?

A

a surgical mask

40
Q

When could you use airborne precautions?

A

When the mode of transmission is aerozolized smaller particles traveling longer distances (>6ft)

EX: TB, Varicella, Measeles, COVID

41
Q

What PPE is required for Airborne Precautions?

A

N95 respiratory, Gown, gloves and eye protection

42
Q

What is the sequence for donning PPE?

A

Gown, mask, Eyewear, gloves

43
Q

What is the sequence for doffing PPE?**

A

Gloves, eyewear, gown, mask

44
Q

What does E: Evaluation of expected outcomes mean?

A

Has the patient responded to the priorites and is the patient getting better

Identify the specific outcome criteria which if met, represents resolution of the concept/problem that is specific and measurable

45
Q

What does T: Trend for potiential complictions mean?

A

Is the client getting worse?

Identify what could indicate development of a potiential complication

46
Q

What does Y: You manage risk to RN and Patient

A

Protect yourself and your patient by following proper safety protocol by following RISK

47
Q

What is the protocol for oral hygiene if your patient is unconcious or immobile?

A

-Position to prevent aspiration
-Keep muscosa moist Q1-2 hrs
-Diligent oral care ! 8-12 hrs
-Chloehexidine swaps per policy

48
Q

What is the protocol for oral hygiene if your patient is elderly?

A

-don’t place dentures on meal tray
-dentures should fit correctly
-increased moisture needs from dry mucous membranes and meds

49
Q

What is the protocol for oral hygiene if patient has NG tube or immunocompromised?

A

Watch for Stomatitis, thrush or pain
-no flossing
-NS rinse
-no smoking

50
Q

Foot care:
Patients with diabetes should have what specialized foot care?

A

Do not soak feet
Do not cut nails
Do not apply lotion between toes
Always inspect both skin and sensation during foot care

51
Q

What are the steps in the nursing process?

A

Assessment/Data Collection
Analysis
Planning
Implementation
Evaluation

52
Q

Nursing Process:

Assessment

A

Systematic collection of information and data-interpreting and validating

53
Q

Nursing Process:
Diagnosis (analysis)

A

Form a nursing diagnosis: a clinical judgement to describe a patient’s response or vunerability to a health condition or life event that RN is licensed to treat

Problem-focused, risk, or health promotion

54
Q

Nursing Process:
Planning

A

Establish priorities and optimal outcomes, as new info. and responses to care evolves you will continue to establish priorites and optimal outcomes

55
Q

Nursing Process:

Implementation

A

Based on evidence based rationale, and licensed to perform w/in scope of practice the nurse anticipates and prevents complications and responds to changing conditions and unplanned events

56
Q

Nursing Process:

Evaluation

A

Evaluate pts response to interventions and form clinical judgements about the extent that goals have been met. Continue, discontinue or revise

57
Q

What does RISK stand for?

A

-Recognition of limitation of staff
-Infection control
-Safemed Administration
-Keep client and environment safe

58
Q

What do the ABC’s stand for?

A

Airway: open and patent
Breathing: respiratory rate and effort
Circulation: HR, BP for perfusion, hemorrage

59
Q

What are the steps in risk assessment?

A

Safety risk to client
Greatest risk to client
Significance of risk compared to other risks

60
Q

Acute means?

A

Higher threat

NURS 713 Fundamentals of Nursing (4 decks)

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