POD quiz (1-4)

Question 1

What are risk factors/hazards that pose a threat to patient safety?

Answer 1

Cognitive risk factors, ABCCS, Patient position in bed, Bed rails (min 1 & max 3), Bed breaks, Bed in lowest position, Bed/chair alarm on, safety belt on in chair, Environmental risk factors (clutter, sharps, spills)

Question 2

What would you include in a patient and bedside safety check?

Answer 2

ABCCS, bed rails, brakes, bed is in lowest position, call-bell within reach, clutter free

Suction meter testing (suction meter, suction liner, plastic suction canister, tubing, yankauer

Oxygen meter testing (oxygen meter, white nipple), Nasal prongs, simple oxygen mask, suction catheter kit,

Make sure safety equipment bag is located near bed/patient

Question 3

What is cultural safety?

Answer 3

provide care in an appropriate manner through 6 standards: self-evaluation, education, anti-racism, safe environments, relational care, and trauma-informed practice

Question 4

How can you incorporate cultural safety and humility into your clinical practice?

Answer 4

through self-reflection practice, examine your beliefs, values and how they present

Question 5

How can you incorporate anti-racism into your clinical practice?

Answer 5

through anti-racism practice, supporting individuals who have been exposed to racism

Question 6

What are the links in the chain of infection and why is it important for Psychiatric Nurses to understand the infectious process?

Answer 6

Infectious agent (pathogen causing infection)

Reservoir (source for pathogen survive, may or may not multiply)

Portal of exit from reservoir (point of escape)

Mode of transmission (vehicle on or by which microorganism can travel) (direct contact, indirect: vehicle or vector, airborne, droplet)

Portal of entry to host (point of entry into susceptible host)

Susceptible host

Important because want to keep ourselves safe and the patients safe as well

Question 7

What is the difference between medical and surgical asepsis?

Answer 7

Medical asepsis = “clean technique” aimed at controlling microorganisms & used for all clinical patient care activities (reduces # of pathogens)

Surgical asepsis = “sterile technique” aimed at removing all microorganisms and is used for all surgical/sterile procedures (eliminates ALL pathogens)

Question 8

What is hand hygiene?

Answer 8

Most important and basic technique in preventing the transmission of infections, includes using an instant alcohol hand antiseptic before and after providing patient care

Question 9

What are the five key moments for hand hygiene?

Answer 9

Before touching patient, before clean/aseptic procedures, after body fluid exposure, after touching patient, after touching patient surroundings

Question 10

What are the indications for hand washing versus alcohol-based gels/sanitizers?

Answer 10

Handwashing:

Visibly soiled/dirty

Working with patients who have C. diff or norovirus

If hands exposed to blood or body fluids

Question 11

How long should hand washing be carried out?

Answer 11

15 seconds of the actual washing the hands (scrubbing of hands)

40 - 60 seconds total for whole procedure

Question 12

When should non-sterile clean gloves be utilized?

Answer 12

Before aseptic procedure, when anticipating contact with blood or body fluid, non-intact skin, mucous membranes, or equipment or environmental surfaces contaminated with blood or body fluids, when in contact with patient or equipment or environment during additional precautions

Question 13

What are routine practices/standard precautions?

Answer 13

Based on the premise that all patients are potentially infectious, even when asymptomatic, and IPAC routine practices should be used to prevent exposure to blood, body fluids, secretions, excretions, mucous membranes, non-intact skin, or soiled items

Question 14

What are additional/isolation precautions? What is a point of risk assessment?

Answer 14

Point of risk assessment is first step in routine practices, involves assessing the infection risk posed to themselves and others by the patient, a procedure or a situation

Precautions implemented in addition to routine practices for patients with known or suspected to be infected with certain microorganisms, Mode of transmission will direct type of additional precaution

Question 15

After making an unoccupied/occupied bed, what actions would you take to ensure patient safety and comfort?

Answer 15

use of bed rails for support while turning/positioning, call bell in reach, bed proper position, tighten linens, adjust patient often

Question 16

What is the normal range of temperature for a healthy adult?

Answer 16

36-38C

Question 17

What factors can affect the patient’s temperature?

Answer 17

Age, exercise, hormone level, circadian rhythm, stress, environment, fever, hyperthermia, heatstroke, hypothermia,

Question 18

What are the sites used to assess body temperature?

Answer 18

tympanic membrane, oral, axillary, temporal sites

Question 19

How does smoking, chewing gum, and ingesting hot/cold liquids or food affect a patient’s temperature? What are the nursing actions for assessing temperature in relation to these activities?

Answer 19

Effect the oral cavity and give an inaccurate reading

Hot & cold: 20 mins

Gum: 5 mins

Smoking: 2 mins

Question 20

What do the following terms mean: core temperature, fever/pyrexia, and afebrile?

Answer 20

Core temperature: temperature of structures deep within the body

Fever / pyrexia: heat-loss mechanisms unable to keep pace with excess heat production; resulting = body temperature rises to abnormal level

Afebrile: when the fever breaks

Question 21

What is the normal range of heart rate for a healthy adult?

Answer 21

60 - 100 beats per min

Question 22

What factors can affect the patient’s heart rate?

Answer 22

Exercise, temperature, emotions, pain, medications, hemorrhage, postural changes, pulmonary conditions

Question 23

What do the terms rate, rhythm (irregular/regular), and quality (strength) mean in relation to assessing the pulse?

Answer 23

Rate: number of pulsing sensations occurring in 1 min

Irregular rhythm: abnormality of heart’s rhythm

Regular rhythm: normal sinus rhythm = 60 – 100 b/min

Quality (strength): strength in regard to blood volume and heart contraction

Question 24

What do the terms tachycardia and bradycardia mean?

Answer 24

Tachycardia: abnormally fast heart rate = > 100 b/min

Bradycardia: slow heart rate, < 60 b/min

Question 25

What are the two common pulse sites used to assess the heart rate?

Answer 25

Radial (thumb side of forearm at wrist) & apical (4th-5th intercostal space at left mid-clavicular line)

Question 26

What is the normal respiratory rate range of a healthy adult?

Answer 26

12 - 20 breaths / min inhalation & exhalation is one breath

Question 27

What factors affect the patient’s respiratory rate? (8)

Answer 27

Exercise, acute pain, anxiety, smoking, body position, medications, neurological injury, hemoglobin function

Question 28

How does the psychiatric nurse assess the respiratory rate?

Answer 28

Right after measuring the pulse while hand remains on patient’s wrist as it rests over abdomen or chest

Observation respirations for 30 seconds and multiply by 2

Full minute if irregular

Question 29

What do the terms rate, rhythm, and depth mean in relation to respiration? What characteristics does the psychiatric nurse assess when observing respirations?

Answer 29

Rate: carbon dioxide exits the lungs at the same rate that the body produces it

Rhythm: determined by observing the chest or abdomen, diaphragmatic breathing results from contraction & relaxation of diaphragm & best observed by watching abdomen (men & children) & women use thoracic muscles to breathe = best observation is upper chest

Depth: assessed by observing degree of excursion or movement of the chest wall, deep = full expansion of the lungs with full exhalation

Question 30

What do the following terms mean: tachypnea, bradypnea, dyspnea, apnea, and orthopnea?

Answer 30

Tachypnea: rate of breathing is regular but abnormally rapid (> 20 breaths/min)

Bradypnea: rate of breathing is regular but abnormally slow (< 12 breaths/min)

Dyspnea: uncomfortable abnormal awareness of breathing (shortness of breath)

Apnea: respirations cease for several seconds then resume, persistent cessation results in respiratory arrest

Orthopnea: sensation of breathlessness in the recumbent (laying down) positions relieved by sitting or standing

Question 31

What is a pulse oximeter? How does the pulse oximeter measure oxygen saturation?

Answer 31

detects the amount of hemoglobin in arterial blood that is saturated with oxygen

Sites to take = finger, toe, nose, & earlobe

Question 32

How does the psychiatric nurse select an appropriate pulse oximeter site?

Answer 32

Assessing capillary refill and skin condition

Question 33

What factors affect oxygen saturation readings?

Answer 33

Anemia, impaired circulation, activity, jaundice, nail polish/artifical nails, dark pigmentation, carbon monoxide poisoning

Question 34

What is the normal range for oxygen saturation of a healthy adult? A patient experiencing COPD? A patient experiencing co-morbidities or an acute health challenge?

Answer 34

95 - 100%

88 - 92%

> 92%

SpO2 > 92% (as presented in lecture due to being in hospital setting)

What is the SpO2 percentage of someone in hospital… > 92%

Question 35

What does blood pressure represent?

Answer 35

Force exerted on the walls of an artery by the pulsing blood under pressure from the heart

Question 36

What is the normal range for the blood pressure of a healthy adult?

Answer 36

Systolic: 100 - 139 mmHg

Diastolic: 60 - 89 mmHg

Question 37

What do the following terms mean: systolic, diastolic, pulse pressure, hypotension, hypertension, sphygmomanometer

Answer 37

Systolic: maximum pressure when ejection occurs

Diastolic: ventricles relax, the blood remaining in arteries – minimal pressure exerted against arterial walls

Pulse pressure: difference between systolic & diastolic

Hypotension: blood pressure lower than 100/60 be specific during exam - give number

Hypertension: blood pressure higher than or equal to 140/90

Sphygmomanometer: instrument for measuring blood pressure

Question 38

what are Korotkoff sounds?

Answer 38

1st: clear rhythmical tapping that corresponds to pulse rate & gradually increases in intensity systolic

2nd: blowing or swishing sound occurs as the cuff continues to deflate (as artery distends, blood flow becomes turbulent)

3rd: crisper and more intense tapping

4th: muffled and low-pitched as the cuff is further deflated diastolic

5th: disappearance of sound

Question 39

What are common mistakes in blood pressure assessment?

Answer 39

Bladder or cuff too wide, bladder or cuff too narrow or too short, cuff wrapped too loosely or unevenly, deflating cuff too slowly, deflating cuff to quickly, arm below heart level, arm above heart level, arm not supported, stethoscope fits poorly or impairment of the examiner’s hearing, causing sounds to be muffled, stethoscope applied too firmly against antecubital fossa, cuff inflating too slowly, repeating assessments too quickly, inadequate inflation level, multiple examiners using different korotkoff sounds for diastolic readings

Question 40

What does orthostatic/postural hypotension mean? How does the psychiatric nurse measure blood pressure to detect postural/orthostatic hypotension?

Answer 40

Normotensive person (person with normal blood pressure) develops symptoms of low blood pressure when rising to an upright position developing symptoms like dizziness,

Blood pressure and pulse are obtained with the patient supine, sitting, and standing (readings obtained 1 to 3 minutes after patient changes positions)

Question 41

Why are proper body mechanics important in psychiatric nursing?

Answer 41

reduces risk of injury, prevents unnecessary strains, maintains body alignment/balance/posture, and reduces fatigue of muscles

Question 42

What are the key principles relevant to body mechanics?

Answer 42

Wide base of support

Low center of gravity

Face direction of movement

Prevent abnormal twisting

Avoid lifting (roll, turn, or pivot instead)

Question 43

What five bed positions are used when performing activities of daily living?

Answer 43

Fowler’s (sitting) (45-60 degrees)

Semi-fowler’s (35-45 degrees)

high fowler (60-90 degrees)

Trendelenburg’s (laying on back, head below feet – diagonal)

Reverse trendelenburg’s

Flat

Question 44

What is the purpose of performing mouth care? 

Answer 44

maintains healthy state of mouth, decreased gum disease, removes food/plaque/bacteria. decreased risk of aspiration pneumonia

Asses the condition of teeth, gums, lips, tongue & buccal mucosa

Question 45

What equipment would the nurse need to provide mouth care to the dependent patient? What equipment would the nurse need to provide mouth care to an independent patient?

Answer 45

Dependent: use foam toothette swabs, tongue blade, mouth wash/chlorhexidine solution

Independent: do themselves with toothbrush, toothpaste, floss

Question 46

How do you insert and remove dentures? What are important nursing considerations when caring for dentures?

Answer 46

Grasp upper plate at front with thumb & index finger and pull downwards, lift lower denture from jaw and rotate one side downward to remove, moisten upper denture and press firmly to seal

clean dentures, remove at night, soak in tepid water, keep in closed container (labelled)

Question 47

What are important nursing considerations regarding a patient’s personal and cultural preferences related to hygiene/activities of daily living?

Answer 47

Be careful of intruding in someone’s personal space and touch, ask what would make the patient feel most comfortable, for hygiene, patient may not want it done, be understanding and try to work out a compromise with patient as hygiene is important to prevent infection and skin breakdown

Question 48

What are the key purposes of bathing?

Answer 48

Clean and deodorize skin, stimulate circulation, promote sense of well-being, and promote relaxation/comfort

Question 49

How does the psychiatric nurse perform a complete bed bath? What is a partial bed bath?

Answer 49

washing all body parts including perineum (dependent)

Partial: bathing only those parts that would cause discomfort or odour if not cleaned – including perineal care and areas hard to reach

Question 50

While performing a bed bath, what areas of the skin could you assess on your patient?

Answer 50

skin folds and creases, bony prominences (ears, shoulders, hips, outer knees, between knees, between ankles, outer ankles), wounds

Question 51

Why does the psychiatric nurse wash extremities from distal to proximal?

Answer 51

Stimulates venous blood flow which prevents venous stasis

Question 52

What is meant by the term peri-care or perineal care?

Answer 52

Perineal care: washing the genital and rectal areas of body especially for someone who is more susceptible to infection like someone with in-dwelling catheters, recovering from rectal or genital surgery or childbirth, uncircumcised males

Question 53

How does the psychiatric nurse provide perineal care for female and male patients?

Answer 53

Female: wash labia majora – wiping from perineum to rectum, separate labia exposing urethral meatus & vaginal orifice, wash downward from pubic area toward rectum in one smooth stroke, cleanse thoroughly around labia minora, clitoris, and vaginal orifice, assist patient back into comfortable position

Male: gently raise penis & place bath towel underneath, gently grasp shaft of penis (patient uncircumcised, retract the foreskin), wash tip at urethral meatus first (using circular motion, clean outward), wash shaft with gentle but firm downward strokes, gently clean scrotum (making sure to wash underlying skin folds), assist back to comfortable position

Question 54

bed making ensuring medical asepsis/standards

Answer 54

inspection of linens - clean/dry/wrinkle free, keep soiled linens away from uniform, and placed into hamper, do not shake or put on floor