Unit 5 Fundamentals Of Nursing

Question 1

Nursing intervention for falls

Answer 1

Complete fall assessment on admission
Assign in room close to nursing station
Provide nonskid footwear
Keep floor free of clutter
Orient client
Maintain bed low position
Instruct  on call light
Adequate lighting 
Lock wheel chair and beds

Question 2

Restraint interventions

Answer 2

Nonpharmological measures such as distraction
Notify provider immediately when implementing
Remove and monitor client every 2 hours
Loose enough to prevent injury
Tie to bed frame
Provider may renew prescription with max 24 hr

Question 3

Intervention seizures

Answer 3

Collect data for seizure history
Identify factors that may contribute
Place rescue equipment bedside( suction, o2,)
Remove items that cause injury
Sitting or standing ease client to floor
Roll to side head flexed slightly forward
Do not put anything in client mouth

Question 4

RACE

Answer 4

Rescue
Alarm
Contain
Extinguish

Question 5

PASS

Answer 5

Pull
Aim
Squeeze
Sweep

Question 6

Lifting and transferring a client interventions

Answer 6

Collect data on mobility
Tell client to assist when possible
Lower bed to lowest position( getting in and out bed)

Question 7

Position head of bed is at 30 degrees, indicated for gastric feeding, head injury, resp. Illness

Answer 7

Semi fowlers

Question 8

Bed is positioned 45- 60 degrees

Answer 8

Fowlers

Question 9

Bed positioned 90 degrees

Answer 9

High fowlers

Question 10

Laying on back, head and shoulders slightly elevated on pillows

Answer 10

Supine

Question 11

Laying on abdomen, legs extended head turned to side

Answer 11

Prone

Question 12

Crutches should be ___ finger widths between axilla and top of crutch

Answer 12

3