NUR 337 Exam 1 Questions With Correct
Answers
Identify |safety |concerns |in |the |clinical |setting.
Aspiration
falls
injuries
seizures
Suicide/Self |Harm
Pressure |Injury-
Infection |risks
Identify |patient |specific |risks |(ex. |Falls, |Pressure |Injuries, |Aspiration) |and |determine |
interventions |and |precautions.
falls/injuries: |at |risk= |ABCS,
a=age |over |85 |y/o-B=bone |health, |fracture |risk |or |history |of |osteoporosis, |steroid |use, |etc. |)-
C= |coagulation |(anticoagulants)-S= |surgery: |wishing |the |last |14 |days
-Failure |to |communicate |changes |in |assessments/interventions
-Failure |to |implement |and |document |prevention |interventionsUnclear/incomplete |
handoffsInsufficient/unclear |safety |instructions
-Pt |or |family |confusion |related |to |nurse's |teaching
,-Assuming |its |only |important |to |teach |patient
-Education |that |fails |to |be |individualized
-Pressure |injuries: |Immobility, |lack |of |sensory |perception, |poor |nutrition |and |hydration, |
medical |conditions |affecting |blood |flow, |diabetes
-Preventions: |turn |pt. |every |2 |hours, |do |not |use |lotion |in |high-risk |areas, |do |skin |assessments |
frequently, |promote |adequate |hydration |and |nutrition, |keep |pressure |points |off |of |mattress
Aspiration: |Older |adult, |stroke, |ineffective |airway |clearance, |dementia, |impaired |mental |status,
|seizures, |dental |problems
Prevention: |avoid |distractions, |make |sure |foods |are |small |and |easy |to |chew, |eat |and |drink |
slowly, |sit |up |straight |when |eating |or |drinking |if |possible
Identify |precautions |to |prevent |the |transmission |of |infections |agents: |
*Standard |precautions |= |(hand |hygiene, |gloves)
•– |Contact |= |(Gown, |gloves) |ex. |C-Diff
Transmission-based |precautions:
,– |Droplet |= |( |Mask) |ex. |Meningitis, |influenza, |COVID-19 |(Note: |Influenza |and |COVID-19 |can
become |airborne |during |some |procedures)
– |Airborne |(N95 |mask) |ex. |TB
Analyze |an |inpatient |unit |RN's |responsibility |and |priorities |when |receiving |a |patient |from |the |
emergency |department.
-Understand |patho |behind |admitting |diagnosis |and |evaluate |accordingly
-Review |assessment |for |appropriate |admission |to |the |unit
-Clarify |issues |that |are |unclear
-Welcome |and |communicate |with |the |patient
-Begin |admission |procedures
--assessment, |history, |safety |screening
-orientation |to |the |room |and |unit, |assessment |of |IV |access |and |meds |running
Analyze |the |assessment |of |risk |for |injurious |falls |and |ways |to |minimize |risk |of |injury |related |to
|falls.
ABCS!
•–A=Age |> |85 |y/o
– |B |= |Bone |health |(Fx |risk |or |history |– |osteopororsis, |bone |mets, |steroid |use)
, – |C |= |Coagulation |(coagulopathy |or |on |anticoagulant |medications)
– |S |= |Surgery |(within |14 |days)
------
RISKS |= |
-Failure |to |communicate |changes |in |assessments/interventions
-Failure |to |implement |and |document |prevention |interventions
-Unclear/incomplete |handoffsInsufficient |or |unclear |safety |instructionsPt |or |family |confusion |
related |to |nurse’s |teaching |
-Assuming |it |is |only |important |to |teach |patient |Education |that |fails |to |be |individualized
Use |effective |hand-off |communication |in |the |patient |care |setting.
The |transfer |of |information |during |transitions |in |care |across |the |continuum
nIncludes |an |opportunity |to |ask |questions, |clarify, |and |confirm
Answers
Identify |safety |concerns |in |the |clinical |setting.
Aspiration
falls
injuries
seizures
Suicide/Self |Harm
Pressure |Injury-
Infection |risks
Identify |patient |specific |risks |(ex. |Falls, |Pressure |Injuries, |Aspiration) |and |determine |
interventions |and |precautions.
falls/injuries: |at |risk= |ABCS,
a=age |over |85 |y/o-B=bone |health, |fracture |risk |or |history |of |osteoporosis, |steroid |use, |etc. |)-
C= |coagulation |(anticoagulants)-S= |surgery: |wishing |the |last |14 |days
-Failure |to |communicate |changes |in |assessments/interventions
-Failure |to |implement |and |document |prevention |interventionsUnclear/incomplete |
handoffsInsufficient/unclear |safety |instructions
-Pt |or |family |confusion |related |to |nurse's |teaching
,-Assuming |its |only |important |to |teach |patient
-Education |that |fails |to |be |individualized
-Pressure |injuries: |Immobility, |lack |of |sensory |perception, |poor |nutrition |and |hydration, |
medical |conditions |affecting |blood |flow, |diabetes
-Preventions: |turn |pt. |every |2 |hours, |do |not |use |lotion |in |high-risk |areas, |do |skin |assessments |
frequently, |promote |adequate |hydration |and |nutrition, |keep |pressure |points |off |of |mattress
Aspiration: |Older |adult, |stroke, |ineffective |airway |clearance, |dementia, |impaired |mental |status,
|seizures, |dental |problems
Prevention: |avoid |distractions, |make |sure |foods |are |small |and |easy |to |chew, |eat |and |drink |
slowly, |sit |up |straight |when |eating |or |drinking |if |possible
Identify |precautions |to |prevent |the |transmission |of |infections |agents: |
*Standard |precautions |= |(hand |hygiene, |gloves)
•– |Contact |= |(Gown, |gloves) |ex. |C-Diff
Transmission-based |precautions:
,– |Droplet |= |( |Mask) |ex. |Meningitis, |influenza, |COVID-19 |(Note: |Influenza |and |COVID-19 |can
become |airborne |during |some |procedures)
– |Airborne |(N95 |mask) |ex. |TB
Analyze |an |inpatient |unit |RN's |responsibility |and |priorities |when |receiving |a |patient |from |the |
emergency |department.
-Understand |patho |behind |admitting |diagnosis |and |evaluate |accordingly
-Review |assessment |for |appropriate |admission |to |the |unit
-Clarify |issues |that |are |unclear
-Welcome |and |communicate |with |the |patient
-Begin |admission |procedures
--assessment, |history, |safety |screening
-orientation |to |the |room |and |unit, |assessment |of |IV |access |and |meds |running
Analyze |the |assessment |of |risk |for |injurious |falls |and |ways |to |minimize |risk |of |injury |related |to
|falls.
ABCS!
•–A=Age |> |85 |y/o
– |B |= |Bone |health |(Fx |risk |or |history |– |osteopororsis, |bone |mets, |steroid |use)
, – |C |= |Coagulation |(coagulopathy |or |on |anticoagulant |medications)
– |S |= |Surgery |(within |14 |days)
------
RISKS |= |
-Failure |to |communicate |changes |in |assessments/interventions
-Failure |to |implement |and |document |prevention |interventions
-Unclear/incomplete |handoffsInsufficient |or |unclear |safety |instructionsPt |or |family |confusion |
related |to |nurse’s |teaching |
-Assuming |it |is |only |important |to |teach |patient |Education |that |fails |to |be |individualized
Use |effective |hand-off |communication |in |the |patient |care |setting.
The |transfer |of |information |during |transitions |in |care |across |the |continuum
nIncludes |an |opportunity |to |ask |questions, |clarify, |and |confirm
