Quiz 3 Flashcards
any manual method or physical or mechanical device ( such as fill set of side rails)
Materials, or equipment that immobilizes or reduces the ability of a patient to move his arms, legs, nod, or head freely
physical restraint
medications such as anxiolytics and sedatives used to manage a patient’s behavior and are not a
Standard treatment or dosage for patients conditions.
chemical restraint
What is the mnemonic to set priorities in case of fire include?
R: rescue and remove all patients in immediate danger
A: activate the alarm. Always do this before attempting to extinguish even a minor fire
C: confine the fire by closing doors and windows and turning off oxygen and electrical equipment
E: extinguish the fire with an appropriate extinguisher
What is the mnemonic when using a fire extinguisher?
P: pull pin
A: Aim at base of fire
S: squeeze handles
S: sweep from side to side to coat area evenly
A nurse observes smoke coming from under the door of the staff’s lounge. Which of the following actions is the nurse’s priority? A. extinguish the fire. B. activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit.
C
A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply.)
A. family members who smoke must be at least 10 ft from the client when oxygen is in use.
B. Nail polish should not be used near a client who is receiving oxygen.
C. a “No Smoking” sign should be placed on the front door.
D. Cotton bedding and clothing should be replaced with items made from wool.
E. a fire extinguisher should be readily available in the home.
B, C, E
The use of restraints associated with complications resulting in..?
immobilization such as pressure ulcers, pneumonia, constipation, and incontinence
Who is at risk for falls?
elderly, visually impaired, generalized weakness, urinary frequency, balance issues such as cerebral palsy, multiple sclerosis, side effects of meds
A nurse is caring for a client who fell at a nursing home. the client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.)
A. Place a belt restraint on the client when he is sitting on the bedside commode.
B. Keep the bed in its lowest position with all side rails up.
C. Make sure that the client’s call light is within reach.
D. Provide the client with non skid footwear.
E. Complete a fall‐risk assessment.
C, D, E
A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse’s priority?
A. Complete a fall‐risk assessment.
B. educate the client and family about fall risks.
C. eliminate safety hazards from the client’s environment.
D. Make sure the client uses assistive aids in his possession
A
A charge nurse is assigning rooms for the clients to be admitted to the unit. to prevent falls, which of the following clients should the nurse assign to the room closest to the nurses’ station?
A. a middle adult who is postoperative following a laparoscopic cholecystectomy
B. a middle adult who requires telemetry for a possible myocardial infarction
C. a young adult who is postoperative following an open reduction internal fixation of the ankle
D. an older adult who is postoperative following a below‐the‐knee amputation
D
a sudden surge of electrical activity in the brain. it can occur at any time due to epilepsy, fever, or a variety of medical problems
seizure
What should you as a nurse do when a client is having a seizure?
- stay with client, call for help
- maintain airway patency and suction PRN
- administer meds
- note duration, sequence, and type of movement
- after, determine mental status and measure O2 sat and vitals
seizure due to electrical surges in one part of the brain
partial seizure
seizure that involves the entire brain
generalized seizure
