Complete Solutions
stable patients (could be complex also) and tasks that are routine, simple,
repetitive, everyday activities that don't require nursing judgment such as
feeding, hygiene, ambulation - Answer-what tasks can NAP be assigned
Weakness - supervise/assist with balance/gait
Incontinence - provide aids/management and ensure hydration so other issues
don't arise
Environment - ensure no hazards, ensure light, glasses and walk aids
Medication - pharmacist review, assess side effects
Confusion - have staff known to pt, reorientate
Impaired mental status - assess underlying causes, Ax1 with ADLs
Ambulation - Ax1/supervise
IVT - Ax1, get to buzz when needing to go somewhere
Visually impaired - Glasses, increase light - Answer-Risks for Falls
-blood/body fluids
-toxic chemicals
-electrical hazards
-fire
-workplace violence
-injury to self and patients - Answer-safety risks
,1st Level = Airway, Breathing, Cardiac/Circulation (ABCs). Require immediate
intervention.
2nd Level = Pain, urinary elimination, mental status change, untreated medical
problems, lab value changes, risk of infection, safety, security. Attended to
immediately after first level priorities are met.
3rd Level = Problems that are important to the patient's health, but can be
addressed after more urgent health problems are tended to. - Answer-Priorities in
nursing
result from an electrical hazard or malfunction, disrepair, or misuse of equipment
- Answer-equipment-related accidents
Determine patient's strong and weak sides
Always position the patient so that he or she transfers toward the strong side
Lock wheelchair locks and move footrests out of the way - Answer-Wheelchair
Transfers
Handwashing before and after patient care, sanitizing reusable equipment -
Answer-Preventing the spread of infection
hand hygiene, sterile technique, sanitizing equipment - Answer-ways to decrease
healthcare-associated infections
an area that is set up for certain procedures and is free from all organisms -
Answer-sterile field
sterile - Answer-sterile touching sterile remains
, contaminated - Answer-sterile touching clean becomes
contaminated - Answer-sterile touching contaminated becomes
sterile objects - Answer-only ___________ ___________ may be placed on a
sterile field
you find a tear or break in the covering of a sterile object - Answer-sterile state is
questionable when
contaminated - Answer-a sterile object or field out of the range of vision or an
object held below a person's waist is:
contaminated - Answer-the edges of a sterile field are considered
Alcohol hand sanitizer - Answer-you may use this for hand hygiene when hands
are not visibly soiled
needlestick injury - Answer-an accidental puncture wound caused by a used
hypodermic needle, potentially transmitting an infection
Sitting position - Answer-Position used during much of the physical examination
including examination of the head, neck, lungs, chest, back, breast, axilla, heart,
vital signs, and upper extremities