NU 301 EXAM 1
When a patient is having a seizure the nurse should always... -
ANSWERS-time it
Physical and chemical restraints restrict... - ANSWERS-a patient's
physical activity or normal access to the body.
What is a physical restraint? - ANSWERS-A physical restraint is any
manual method, physical or mechanical device, material, or
equipment that immobilizes or reduces the ability of a patient to move
his or her arms, legs, body, or head freely
What are some chemical restraints? - ANSWERS-sedatives and
anxiolytics
What are some types of physical restraints? - ANSWERS--posey /
vest
-belt
-mittens
What are some complications of restraints? (6) - ANSWERS--
Pressure ulcers,
-pneumonia,
-constipation,
,-incontinence,
-loss of dignity,
-restricted circulation or breathing.
Restraints must meet at least one out of four criteria. What are the
four criteria? - ANSWERS--Reduce the risk of patient injury from
falls.
-Prevent interruption of therapy.
-Prevent a confused or combative patient from removing life support
equipment.
-Reduce the risk of injury to others by the patient.
In order for a restraint to be ordered the risk of the restraint must... -
ANSWERS-outweigh the risk the client poses to themselves or to
others
What must a restraint order include? - ANSWERS-reason, type, how
long it will be in effect
Can restraints be ordered on a PRN basis? - ANSWERS-NO
What is the time limit of a restraint on an adult patient? - ANSWERS-
four hours
Can side rails be considered restraints? - ANSWERS-YES!
Never have all 4 up at once!!
,What should nurses consider when working with a restrained patient?
- ANSWERS-Assess skin integrity every 2 hours.
Offer fluids, food and provide hygiene.
Monitor vital signs.
Offer ROM exercises.
Pad bony prominences,
Remove and replace restraints frequently to ensure circulation.
Use quick release knots to bed frame-no side rails.
Verify restraints loose enough for two fingers to fit between device
and client.
Never leave patient unattended.
Document, document, document.
What are some alternatives to restraints? - ANSWERS--family
involvement
-put patient in a room near the nurses station
-evaluate if the behavior is caused by medication
-constantly assess patient
What should you do in the event of a fire? - ANSWERS-Rescue
Activate Alarm
Confine Fire
Extinguish
RACE*
, In a standard hospital what does code blue mean?
Red?
Grey?
Black?
Pink?
Yellow?
White?
Orange? - ANSWERS-Blue: Cardia/ Respiratory arrest
Red: Fire
Grey: Severe Weather
Black: Bomb threat
Pink: Child abduction
Yellow: Disaster (Mass Casualty)
White: Security Alert (Violence/Hostage)
Orange: Hazardous Material Spill
What is hygiene?
What does it contribute to? - ANSWERS--Hygiene describes
activities involved in maintaining personal cleanliness and grooming.
-Personal hygiene contributes to physical and psychological well-
being.
What are some ADLs related to hygiene?
When a patient is having a seizure the nurse should always... -
ANSWERS-time it
Physical and chemical restraints restrict... - ANSWERS-a patient's
physical activity or normal access to the body.
What is a physical restraint? - ANSWERS-A physical restraint is any
manual method, physical or mechanical device, material, or
equipment that immobilizes or reduces the ability of a patient to move
his or her arms, legs, body, or head freely
What are some chemical restraints? - ANSWERS-sedatives and
anxiolytics
What are some types of physical restraints? - ANSWERS--posey /
vest
-belt
-mittens
What are some complications of restraints? (6) - ANSWERS--
Pressure ulcers,
-pneumonia,
-constipation,
,-incontinence,
-loss of dignity,
-restricted circulation or breathing.
Restraints must meet at least one out of four criteria. What are the
four criteria? - ANSWERS--Reduce the risk of patient injury from
falls.
-Prevent interruption of therapy.
-Prevent a confused or combative patient from removing life support
equipment.
-Reduce the risk of injury to others by the patient.
In order for a restraint to be ordered the risk of the restraint must... -
ANSWERS-outweigh the risk the client poses to themselves or to
others
What must a restraint order include? - ANSWERS-reason, type, how
long it will be in effect
Can restraints be ordered on a PRN basis? - ANSWERS-NO
What is the time limit of a restraint on an adult patient? - ANSWERS-
four hours
Can side rails be considered restraints? - ANSWERS-YES!
Never have all 4 up at once!!
,What should nurses consider when working with a restrained patient?
- ANSWERS-Assess skin integrity every 2 hours.
Offer fluids, food and provide hygiene.
Monitor vital signs.
Offer ROM exercises.
Pad bony prominences,
Remove and replace restraints frequently to ensure circulation.
Use quick release knots to bed frame-no side rails.
Verify restraints loose enough for two fingers to fit between device
and client.
Never leave patient unattended.
Document, document, document.
What are some alternatives to restraints? - ANSWERS--family
involvement
-put patient in a room near the nurses station
-evaluate if the behavior is caused by medication
-constantly assess patient
What should you do in the event of a fire? - ANSWERS-Rescue
Activate Alarm
Confine Fire
Extinguish
RACE*
, In a standard hospital what does code blue mean?
Red?
Grey?
Black?
Pink?
Yellow?
White?
Orange? - ANSWERS-Blue: Cardia/ Respiratory arrest
Red: Fire
Grey: Severe Weather
Black: Bomb threat
Pink: Child abduction
Yellow: Disaster (Mass Casualty)
White: Security Alert (Violence/Hostage)
Orange: Hazardous Material Spill
What is hygiene?
What does it contribute to? - ANSWERS--Hygiene describes
activities involved in maintaining personal cleanliness and grooming.
-Personal hygiene contributes to physical and psychological well-
being.
What are some ADLs related to hygiene?
