2025
measures to maintain a safe environment for patients - correct answer•Lighting
•Obstacles
•Bathroom hazards
•Be sure bed is low, appropriate side rails are up, wheels on bed are locked, and call
light is within reach.
•Non-skid socks
**Safety rounds should be performed by the nurse at every nurse-client interaction.
Physical and chemical restraints restrict... - correct answera patient's physical activity or
normal access to the body.
What is a physical restraint? - correct answerA 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
Restraints must meet at least one out of four criteria. What are the four criteria? -
correct answer-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.
What must a restraint order include? - correct answerreason, type, how long it will be in
effect
can restraints be ordered on a PRN basis? - correct answerNOOO!
What should nurses consider when working with a restrained patient? - correct answer-
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? - correct answer-family involvement
-put patient in a room near the nurses station
-evaluate if the behavior is caused by medication
-constantly assess patient
, NU 301 Final Review graded A Latest
2025
general safety - correct answer•Keep bed in low position.
•Keep bed locked.
•Keep a light on.
•Two side rails up.
•Use assistive devices.
•Call light within reach of patient.
•No-slip socks or shoes.
•Avoid clutter.
•Good ergonomics(body mechanics)
•Prevent needle sticks.
•Keep cords and fluids off floor.
•Fire Safety Education
•Keep meds and sharps out of reach.
Correct BP cuff size - correct answer¨Widthof bladder will cover 2/3 length of upper arm.
¤Or
¨Cuff width is 40% of arm circumference
¨Length of bladder encircles 80% of arm.
¨Place above antecubital.
what will the following do to a BP reading?
1. too narrow
2. too wide - correct answer1. high reading
2. low reading
ranges of HR throughout life
1. infant
2. toddler
3. preschooler
4. school-age child
5. adolescent
6. adult - correct answer1. infant: 120-160
2. toddler: 90-140
3. preschooler: 80-110
4. school-age child: 75-100
5. adolescent: 60-90