NCLEX Fundamentals of Nursing
Study online at https://quizlet.com/_440jme
1. Client safety
Falls: Contributing factors:
-older age, impaired mobility, cognitive/ sensory impairment, bowel and bladder
dysfunction, side effects of meds, history of falls
Interventions:
-Fall risk assessment on admission and update as needed
-Communicate identified risks w/ health care team
-Assign client at risk to room close to nurse station
-Provide non-skid footwear
-Keep floor clutter free/ unobstructed path
-Orient client to setting (grab bars, call light)
-Bed in lowest position
-Use call light for assistance b/f ambulating
-Answer call light promptly
-Provide adequate lighting
-Determine ability to use assistive devices- keep within reach
-Use chair or bed sensors for clients at risk
-Lock wheels on bed, wheelchairs etc
-Report and document incidents per policy
2. Safety
Restraints: Safety standards:
-Type/ technique must be least restrictive intervention that will be effective to protect
the client or staff from harm
Definition:
-Human, mechanical, chemical or physical devices that restrict freedom of move-
ment or diminish client's assess to parts of the body
Interventions:
-Implement nonpharmacologic measures- distraction, observation, diversion activi-
ties
-Review instructions for correct application
-Notify provider immediately when implemented
-Remove and assess every 2 hr
-Assess neurovascular and neurosensory status every 2 hr
-Leave restraint loose enough to prevent injury
-Always tie restraint to bed frame
-Reassess need for continued use
, NCLEX Fundamentals of Nursing
Study online at https://quizlet.com/_440jme
-Document: behaviors making restraint necessary, alternatives attempted & re-
sponse, type & location of restraint and time applied, frequency and type of assess-
ments
-Restraints should never: interfere with tx, be used b/c of short staffing or staff
convenience
3. Safety
Seizure precautions: Interventions:
-Assess seizure hx, noting frequency, presence of auras, and sequence of events
-Identify precipitating factors that may exacerbate
-Review med hx; if routine lab work is required, when was last level drawn
-Place rescue equipment at bedside- O2, oral airway, suction
-Establish IV or saline lock access for high-risk clients
-Inspect environment for items that may cause injury - remove unnecessary items
from immediate environment
-At onset of seizure, position for safety and stay w/ client
-Ease client to the floor- protect head; if in bed- raise side rails and pad for safety
-Roll client to side w/ head flexed slightly forward
-Don't put anything in client's mouth
-Loosen restrictive clothing
-Accurately document event, including timing, precipitating behaviors or events, and
description of event (movements, loss of consciousness, loss of continence, injuries,
mention of aura, postictal state)
-Report to provider
4. Safety
Environment
Fire: Interventions
-Know facility's fire drill and evacuation plan
-Keep emergency numbers near or on phone
-Know location of all fire alarams, extinguishers and exits including O2 shut off valves
-RACE:
>Rescue: protect and evacuate
>Alarm: activate and report fire
>Contain: close doors or windows
>Extinguish: use correct extinguisher to eliminate fire
-->Class A: paper, wood, cloth, trash
-->Class B: flammable liquids and gases
-->Class C: electrical fires
-Extinguish properly (PASS): Pull Alarm Squeeze Sweep
Study online at https://quizlet.com/_440jme
1. Client safety
Falls: Contributing factors:
-older age, impaired mobility, cognitive/ sensory impairment, bowel and bladder
dysfunction, side effects of meds, history of falls
Interventions:
-Fall risk assessment on admission and update as needed
-Communicate identified risks w/ health care team
-Assign client at risk to room close to nurse station
-Provide non-skid footwear
-Keep floor clutter free/ unobstructed path
-Orient client to setting (grab bars, call light)
-Bed in lowest position
-Use call light for assistance b/f ambulating
-Answer call light promptly
-Provide adequate lighting
-Determine ability to use assistive devices- keep within reach
-Use chair or bed sensors for clients at risk
-Lock wheels on bed, wheelchairs etc
-Report and document incidents per policy
2. Safety
Restraints: Safety standards:
-Type/ technique must be least restrictive intervention that will be effective to protect
the client or staff from harm
Definition:
-Human, mechanical, chemical or physical devices that restrict freedom of move-
ment or diminish client's assess to parts of the body
Interventions:
-Implement nonpharmacologic measures- distraction, observation, diversion activi-
ties
-Review instructions for correct application
-Notify provider immediately when implemented
-Remove and assess every 2 hr
-Assess neurovascular and neurosensory status every 2 hr
-Leave restraint loose enough to prevent injury
-Always tie restraint to bed frame
-Reassess need for continued use
, NCLEX Fundamentals of Nursing
Study online at https://quizlet.com/_440jme
-Document: behaviors making restraint necessary, alternatives attempted & re-
sponse, type & location of restraint and time applied, frequency and type of assess-
ments
-Restraints should never: interfere with tx, be used b/c of short staffing or staff
convenience
3. Safety
Seizure precautions: Interventions:
-Assess seizure hx, noting frequency, presence of auras, and sequence of events
-Identify precipitating factors that may exacerbate
-Review med hx; if routine lab work is required, when was last level drawn
-Place rescue equipment at bedside- O2, oral airway, suction
-Establish IV or saline lock access for high-risk clients
-Inspect environment for items that may cause injury - remove unnecessary items
from immediate environment
-At onset of seizure, position for safety and stay w/ client
-Ease client to the floor- protect head; if in bed- raise side rails and pad for safety
-Roll client to side w/ head flexed slightly forward
-Don't put anything in client's mouth
-Loosen restrictive clothing
-Accurately document event, including timing, precipitating behaviors or events, and
description of event (movements, loss of consciousness, loss of continence, injuries,
mention of aura, postictal state)
-Report to provider
4. Safety
Environment
Fire: Interventions
-Know facility's fire drill and evacuation plan
-Keep emergency numbers near or on phone
-Know location of all fire alarams, extinguishers and exits including O2 shut off valves
-RACE:
>Rescue: protect and evacuate
>Alarm: activate and report fire
>Contain: close doors or windows
>Extinguish: use correct extinguisher to eliminate fire
-->Class A: paper, wood, cloth, trash
-->Class B: flammable liquids and gases
-->Class C: electrical fires
-Extinguish properly (PASS): Pull Alarm Squeeze Sweep
