ANSWERS SURE A+
✔✔Protective environment - ✔✔Private room; positive airflow; mask to be worn by
patient when out of room during times of construction in area (kidney transplant)
✔✔A patient who has been placed on Contact Precautions for Clostridium difficile (C.
difficile) asks you to explain what he should 464know about this organism. What is the
most appropriate information to include in patient teaching? - ✔✔-The organism is
usually transmitted through the fecal-oral route.
-Hands should always be cleaned with soap and water versus alcohol-based hand
sanitizer.
-Everyone coming into the room must be wearing a gown and gloves.
✔✔A patient is diagnosed with meningitis. Which type of isolation precaution is most
appropriate for this patient? - ✔✔droplet precautions
✔✔A patient is placed on Airborne Precautions for pulmonary tuberculosis. The nurse
notes that the patient seems to be angry, but he knows that this is a normal response to
isolation. What is the best intervention? - ✔✔Explain the reasons for isolation
procedures and provide meaningful stimulation.
✔✔removal of PPE order - ✔✔1. remove/dispose of gloves
2. remove eyewear
3. Untie waist and neck strings of gown. Remove gown
4. Untie top and then bottom mask strings and remove from face
5. perform hand hygiene
✔✔A patient is experiencing some problems with joint stability in the right leg. The
doctor has prescribed crutches for the patient to use while being allowed to bear weight
only on the left leg. Which of the following gaits should the patient be taught to use? -
✔✔three point
✔✔RACE (fire safety) - ✔✔rescue, alarm, confine, extinguish
✔✔PASS (Fire Safety) - ✔✔Pull, Aim, Squeeze, Sweep
✔✔Discuss the importance of proper positioning and movement for promoting client
comfort. - ✔✔-Safety is first priority
-Ask patient to help as much as possible
-Determine if patient comprehends
-Ask their comfort level
-Determine if you need assistance
, -Proper positioning allows patients to be comfortable and allows their body to work
efficiently
-Without movement, the body starts to have negative effects
✔✔Discuss considerations for the safe application of restraints. - ✔✔-Restraints must
be the intervention of last resort.
-need Dr. order
-Include the patient's family in the decision
-Explain the purpose of them, expected care while in them, and remind them they are
temporary and protective
-Monitor the patient every 2 hours (15 minutes for violent patients) to inspect vital signs,
skin integrity, nutrition, hydration, circulation, range of motion, hygiene, elimination
needs, cognitive functioning, psychological status, and need for restraint
✔✔Trochanter roll - ✔✔Rolled towel support placed against the hips and upper leg to
prevent external rotation of the legs.
✔✔Hand roll - ✔✔maintain thumb in slight adduction and in opposite fingers
✔✔trapeze bar - ✔✔-Triangular device hanging down from a secure overhead bar
attached to the bedframe
-Allows patient to pull with upper extremities to raise trunk off the bed, assist in transfer,
or perform upper arm exercises
-Increases independence, maintains body strength, and decreasing shearing action
from sliding on bed
✔✔Fowler's position - ✔✔head of the bed is raised 45-90 degrees with foot of bed
slightly raised; used while patient is eating, for nasogastric tube insertion, promotes lung
expansion, eases difficulty breathing
✔✔Semi Fowler's - ✔✔head of the bed is 30-45 degrees with knees slightly elevated
without pressure; promotes lung expansion, used during oral care to reduce aspiration
✔✔Trendelenburg position - ✔✔lying on back with body tilted so that the head is lower
than the feet; used for postural drainage
✔✔flat position - ✔✔bed is parallel with floor; used for patients with vertebral injuries,
hypotensive patients, and sleeping
✔✔Sims position - ✔✔lying on LEFT side with right knee drawn up and with left arm
drawn behind, parallel to the back
✔✔side lying - ✔✔weight on hip and shoulder