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Updated 2026 Questions and Answers | 100% Verified
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,Nursing intervention Restraints Implement nonpharmacologic measures such as distraction, frequent observation,
or diversion activities
Prior to application, review manufacturer's instructions for correct application
Notify the provider immediately when restraints are implemented
Remove the restraints and assess client every 2 hr
Assess neurovascular and neurosensory status every 2 hr
Leave the restraint loose enough to prevent injury
Always tie the restraint to the bed frame (using loose knots that are easily
removed)
Reassess the need for continue use
Document
Document Restraints Behaviors making restraint necessary
Alternatives attempted and the client's response
Type and location of restraint and time applied
Frequency and type of assessment
Restraints should NEVER Interfere with treatment
Be used because of short-staffing or staff convenience
Not written as PRN orders
Nursing intervention Seizure precaution Assess seizure history, noting frequency, presence of auras, and sequence of
events
Identify precipitating factors that may exacerbate or lead to seizure
Review medication history.
If routine lab work is required (Dilantin), when was last level drawn
Place rescue equipment at the bedside, including oxygen, oral airway, and suction
equipment
Establish IV or saline lock access for high risk clients
Inspects the client's environment for items that may cause injury in the event of a
seizure.
Remove any unnecessary items from the immediate environment
At the onset seizure, position the client for safety, and remain with client
If sitting or standing, ease client to floor. Protect the client's head. If client is in
bed, raise the side rails and pad for safety
Roll the client to the side with the head flexed slightly forward
Do not put anything in the client's mouth
Loosen restrictive clothing
Accurately document the event, including timing precipitating behaviors or
events, and a description of the event (movements, loss of consciousness, loss of
continence, injuries, mention of aura, postictal state).
Report seizure to the provider
Fire response R-Rescue: protect and evacuate clients in immediate danger
A-Alarm: Activate the alarm and report the fire
C-Contain: Close doors or windows
E-Extinguish: use correct fire extinguisher to exliminate the fire
"RACE"
Type fire extinguisher Class A
Class B
Class C
,Class A Paper
Wood
Cloth
Trash
Class B Flammable liquids
Gases
Class C Electrical fires
Extinguish properly "PASS"
P-Pull
A-Aim
S-Squeeze
S-Sweep
Home Health setting Post "No Smoking" signs
Assess for risk (oxygen therapy, smoking, electrical equipment)
Teach client to develop a plan of action in the event of a fire, including a route of
exit and a location where family members will meet
Instruct client to keep fire extinguisher accessible
Review "Stop, Drop, and Roll"
Nursing interventions on Equipment Electrial equipment must be grounded
Do not overcrowd outlets
Do not extension cords on client care areas
Only used equipment for intended purpose
Regularly inspect equipment for frayed cords
Disconnect all equipment prior to cleaning
Nursing interventions on chemical and Radiation Determine type and amount of radiation used
Place a sign on door. "Caution Radioactive Material."
Wear monitoring badge to record amount of exposure
Dispose of items removed from the room in appropriate containers
Never handle any type of radioactive agent with bare hands
Nursing interventions on lifting and transfer of clients Assess mobility and strength
Instruct client to assist when possible
Use mechanical lift and assistive devices
Avoid twisting the thoracic spine or bending at the waist
Use major muscle groups, and tighten abdominal muscles
Nursing intervention on transferring clients from bed to Instruct the client how to assist when possible
chair or chair to bed Lower the bed to the lowest setting
Position the bed or chair so that the client is moving toward the strong side
Assist the client to stand, then pivot
, Nursing interventions repositioning clients in bed Raise the bed to waist level
Lower side rails
Use slide boards or draw sheets
Have the client fold his arms across his chest while lifting the head
Proceed in one smooth movement
Collaborate with other staff members for assistance
Semi-Fowler's Head of bed elevated to 30
Indication semi-Fowler's Gastric feeding
Head injury
Postoperative cranial surgery
Respiratory illness with dyspnea
Postoperative cataract removal
Increased intracranial pressure
Fowler's Head of bed elevated to 45
Indication Fowler's Head injury
Postoperative cranial surgery
Postoperative abdominal surgery
Respiratory illness or cardiac problems with dyspnea
Bleeding esophageal varices
Postoperative throidectomy or cataract removal
Increased intracranial pressure
High-Fowler's Head of bed elevated to 90
Indication High-Fowler's Respiratory illness with dyspnea:
empphysema
status asthmaticus
pneumothorax
cardia problem with dyspnea
feeding
meal times
hiatal hernia
during and after meal
Supine Lying on back, head, and shoulders
Slightly elevated with small pillow
Indication Supine Spinal cord injury (no pillow)
Prone Lying on abdomen, legs extended, and head turned to the side
Indication Prone Client who is immobilized or unconscious
Post lumbar puncture 6 to 12 hr
Post myelogram 12 to 24 hr (oil-based dye)
Postoperative tonsillectomy and adenoidectomy