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RACE stands for:
Rescue patients,
sound the Alarm,
Confine the fire,
Extinguish or Evacuate
CDC stands for:
Centers for Disease Control and Prevention
OSHA stands for:
Occupational Safety and Health Administration
PASS stands for:
P—Pull the pin to unlock the handle.
A—Aim low at the base of the fire.
S—Squeeze the handle.
S—Sweep the unit from side to side.
SRD stands for:
Safety reminder device
The older adult tells the nurse that he is having trouble reading the labels on his medication bottles. What is the best strategy that the nurse could suggest to reduce the risk of an accidental medication error?
Recommend that a younger family member assist in handling the pills.
Teach the patient to use a medication organizer to manage the medication.
Tell the patient to have the pharmacist read the label information to him.
Assist the patient to memorize the shape and color of each pill.
Answer 2:
The most practical advice is to teach the patient how to use a medication organizer; suggest using a magnifier to read labels while organizing the pills for the week.
If the patient relies on a family member, this decreases independence.
The pharmacist reviews medication information when the patient picks up the medication.
The shape and color of the pills is only a small part of the information that the patient needs to safely take medication.
In which clinic setting is the nurse most likely to need knowledge of how to apply safety reminder devices (SRDs) and manage the care of these patients?
Pediatric walk-in clinic
Outpatient surgery clinic
Mental health walk-in clinic
Adult ambulatory care clinic
Answer 3:
Patients in mental health settings may require safety reminder devices (SRDs) to prevent harm to self or others; however, all nurses should have a working knowledge of how to safely apply SRDs and how to manage these patients.
A confused patient is yelling at the unlicensed assistive personnel (UAP). As the nurse enters the room, the patient throws the food tray at the UAP. What would the nurse do first?
Ask the UAP to explain what is happening with the patient.
Instruct the UAP to move toward the door and then slowly shut it.
Slowly walk toward the patient and use a gentle touch to soothe him.
Calmly talk to the patient and respectfully address him by name.
Answer 4:
First, the nurse remains calm.
During high levels of anxiety and agitation, it is difficult to process information.
The sound of one’s own name is familiar and may help that person to focus on the nurse’s calm voice.
Touch should not be used in this situation as it may provoke the patient further.
Both the UAP and nurse should protect themselves from injury by standing near the open door.
The nurse is teaching a new group of UAP how to evacuate residents from a long-term care facility in case of a fire or other emergency.
Which item would be needed for the universal carry method?
A blanket
A wheelchair
A stretcher
A mechanical lift
Answer 1:
The universal carry method requires a blanket.
Patient is moved from bed or chair to the blanket; then the patient can be dragged to safety.
The older adult residents in a nursing home must be evacuated because the facility is at risk for flooding and damage due to a hurricane that will pass through the area in several days.
The nurse is assigned to keep a log to document the events.
Which information is the most important to record? Select all that apply.
how each resident was transported
names of residents
where the residents were sent
what personal belongings were sent
who transported each resident
notification of family members and HCPs
Answer 1, 2, 3, 5, 6:
Keeping track of who, how, and where each resident is sent is essential. Recording the notification of family members and providers is also useful so that staff efforts to notify are not duplicated. Keeping track of personal belongings is ideal, but not the priority in an emergency.
In the event of a mercury spill, what is the priority nursing action?
Evacuate everyone from the room.
Close the interior doors and open windows.
Vacuum the mercury and the glass shards.
Mop the floor with hot water and soap.
Answer 1:
Everyone should leave the room where the mercury spill has occurred.
Close interior doors and open windows to increase ventilation to the outside.
The area should not be vacuumed but should be mopped with a mercury-specific cleansing agent.
The nurse should refer to policies and procedures for specific guidelines.
The nurse is caring for a patient who relies on mechanical ventilation. The nurse hears a fire alarm and flames are visible in a back corridor.
What would the nurse do first?
Seek assistance to move the patient and the ventilator to safety.
Turn off the oxygen supply and provide manual respiratory support.
Close the patient's door, call 911, and fight the fire in the corridor.
Delegate the UAP to move ambulatory patients toward the exit.
Answer 4:
By delegating the UAP to move ambulatory patients, the nurse is activating the rescue phase, which is the first action in the mnemonic RACE.
The UAP can rescue the ambulatory patients while the nurse can attend to the next steps.
Next, the nurse would call 911 or activate the alarm.
Closing the door is appropriate because the door will block the smoke and the fire.
The nurse must then attend to the ventilator patient. Oxygen creates a good environment for a hotter and faster fire, so oxygen is turned off.
The nurse now has to manually support respiration by delivering breaths with a bag-valve-mask or a pocket mask.
Both methods will be delivering room air. The nurse is aware that moving the patient and equipment would take minimum of two people and this action would also partially block the hallways; thus, the nurse would use critical thinking to determine when (or if) to move the patient.
The nurse is planning to teach a community group about fire safety in the home. Which information would be included in the presenta-tion? Select all that apply.
No smoking by the patient, family, or visitors in areas where oxygen is used.
Use safety matches to light candles or fireplaces.
Install fire alarms, smoke detectors, and carbon monoxide detectors.
Practice fire escape routes from each room and practice exit drills.
Use one electrical circuit to facilitate monitoring of cords and appliances.
Cover electrical cords with a secure carpet to prevent falls.
Answer 1, 3, 4:
No one should smoke around oxygen.
Fire alarms and other detectors should be properly installed and function should be routinely checked.
Family should have escape routes planned and practiced.
Use of candles should not be encouraged.
Using one electrical circuit creates a potential for overload.
Covering electrical cords may decrease falls, but the carpet will mask frayed cords and offer a fuel source for fires.
An older adult patient in a long-term care facility has been wandering around outside of the room during the late evening hours. The patient has a history of falls. How would the nurse intervene?
Obtain an order for a bed and chair alarm.
Keep the light on and play the television all night.
Put up the side rails and frequently check on the patient.
Have the family come to check on the patient at night.
Answer 1:
Patient safety would determine the best choice. A bed and chair alarm, although sometimes regarded as SRDs, alert the nursing staff that the patient is getting up, so someone knows to go to assist the patient.
Keeping the light and television on would add to confusion and disorientation.
Side rails are considered a form of restraint and confused patients often attempt to crawl over the rails.
Frequently checking on the patient is always a good idea, but the patient can still wander off between times.
Having family come in every night is unpractical and unrealistic in an extended-care situation.
The nurse applies a gait belt to a male patient of average build who has some weakness on the left side. How does the nurse position herself before assisting the patient to ambulate?
On the patient's left side and holding the weak left arm.
On the patient's right side and holding the front of the gait belt.
On the patient's left side and holding the back of the gait belt.
On the patient's right side and holding one arm around his waist.
Answer 3:
The nurse stands on the weaker side and grasps the gait belt at the back.
This position allows the nurse to provide support and ease the patient to the floor if he begins to fall.
The nurse is considering the use of an SRD to prevent a patient from self-injury. When using an SRD, what would the nurse do? Select all that apply.
Obtain an order from the HCP for the SRD.
Explain the purpose of the SRD to the patient.
Explain the purpose of the SRD to the family.
Obtain consensus of nursing staff for type of SRD.
Exhaust all alternatives before using an SRD.
Answer 1, 2, 3, 5:
The use of safety reminder devices (SRDs) requires an order, explanation to patient and family, and is only used as a last resort after other methods have been tried or considered.
Although a multidisciplinary effort is required to safely manage patients, the entire nursing staff does not have to be consulted about the type of SRD.
Type of SRD depends on provider’s orders, clinical judgment, and ongoing assessment.
The nurse notices smoke coming from the wastebasket in a patient's room. Upon entering the room, the nurse sees a fire that is starting to flare up. What would the nurse do first?
Extinguish the fire.
Remove the patient from the room.
Close the door to the room.
Turn off all electrical equipment.
Answer 2:
The nurse remembers RACE (Rescue, Alarm, Confine, and Extinguish or Evacuate) and first removes the patient from the room.
As they exit the room, the nurse closes the door to confine the fire to that room and then sounds the alarm.
The nurse is not likely to turn off all electrical equipment in this case.
Which occurrence is most likely to be investigated as a "sentinel event"?
Patient leaves the hospital against medical advice because she gets angry with the
nurse.
An older patient sustains a broken arm related to the use of an SRD.
A nurse is 2 hours late administering routine scheduled medications.
During a follow-up phone call, a patient reports that care in the hospital was poor.
Answer 2:
A sentinel event is an occurrence that causes death or serious permanent or temporary harm to a patient.
A broken arm suggests that there may have been improper assessment, application, monitoring, or choice of SRD.
The other events may be subject to an internal review by risk management, hospital administration, or the nurse manager.
The nurse is conducting a fall risk assessment on an older adult patient who is moving into an assisted living center. Which questions would the nurse ask? Select all that apply.
"Have you had any falls in the past year?"
"Are you able to independently get up after a fall?"
"Do you feel unsteady when you stand up?"
"Are you able to independently walk from room to room?"
"What medications are you taking?"
"Do you use a cane or other assistive device?"
Answer 1, 3, 4, 5, 6:
Previous history of falls and unsteadiness increase the risk for falls.
If assistance is required to walk from room to room, the nurse must plan to assist the patient to the bathroom and to meals.
The nurse ensures that all assistive devices are close to the bed or chair. Performing a medication review enables the nurse to determine if the patient is on any medications that might increase the risk for falls.
Asking the patient if he can independently get up after a fall is an assessment of strength and independence, but this also suggests that the patient should independently attempt to get up after a fall.
(Patient should be assessed for injury after a fall and encouraged to regain balance and strength before attempting to get up.)
The nurse is giving instructions to the UAP about patient safety and fall prevention. What would the nurse tell the UAP about helping the older adult patient to go to the bathroom?
"Help the patient whenever she needs help."
"Ask her if she wants to walk or use the bedpan."
"Have her put on her glasses before getting up."
"Help her to the commode chair if she seems weak."
Answer 3:
The nurse gives specific instructions to provide the eyeglasses to allow the older adult to adequately see the environment and so lessen the risk of falls.
“Whenever she needs help” is a vague direction that requires the patient to ask for help and then the UAP must decide if help is appropriate, but there is no guidance about circumstance or execution.
The nurse should assess whether the use of the bedpan is appropriate for the patient.
If the patient is able to get up, walking decreases the complications of immobility.
The UAP should not be expected to make a decision about “if she seems weak.” This decision should be based on nursing assessment.
For the care of a patient who has an SRD in place, which task can be delegated to a UAP?
Observe for circulation distal to the SRD.
Check for respiratory effort and breathing
Change position every 2 hours.
Determine when the SRD can be removed.
Answer 3:
The UAP can be instructed to assist the patient to change position every 2 hours.
Assessment of circulation and respiratory effort should be performed by the nurse.
The RN and the health care provider should be consulted to determine the time for removal of SRDs.
Which instructions would be given to the UAP who is assigned to assist in the care of a patient who is being treated with internal radiation?
"Do not go into the room unless the patient uses the call bell."
"Help children to don a lead shield apron before entering the room."
"Wear a mask, eye shield, and isolation gown when entering the room."
"Wear your personal dosimeter during care or when handling patient items."
Answer 4:
Anyone involved in the care of a patient who is receiving internal radiation should wear their own dosimeter.
This includes while handling items such as linen and trash.
Routine care must continue (e.g., vital signs and hygiene); thus staff will enter the room whenever necessary, but care should be well-organized so that minimal exposure occurs.
Children younger than 18 years should not visit the patient while there is a danger of radiation exposure.
Wearing a mask, eye shield, and isolation gown do not offer sufficient protection against radiation exposure.
A patient begins to have a grand mal seizure.
What is the priority action?
Monitor the patency of the airway.
Protect against falls and other injuries.
Suction the mouth to prevent aspiration.
Gently insert an oral airway between the teeth.
Answer 1:
Checking and monitoring the patency of airway is the priority.
If the patient is having uncontrollable movements during a grand mal seizure, placing soft material around head or extremities may offer some protection against injury.
Extremities should not be restrained.
Inserting an oral airway or oral suction catheter are not done during the seizure but may be done after the seizure is over to keep the tongue from falling backward and to remove excessive secretions.
The nurse is talking to a young mother who has an infant who has just started to crawl.
Based on knowledge of growth and development, which safety issue is currently the most important to discuss with the mother?
What to do when using pots and pans on the stove
How to ensure backyard pool safety
measures
How to manage electrical sockets and cords
Where to obtain safety labels for cleaning products
Answer 3:
For infants who are just learning to crawl, the mother should look at what’s on the floor and within arm’s reach from a crawling position.
This would include electrical sockets and cords.
Pot and pan handles should be turned away from the child’s reach. This becomes relevant when the child begins to stand and walk. Pool safety is more related to toddlers and children.
Children can be taught to recognize dangerous products, but this is for preschoolers who have developed language skills.
Which newly obtained piece of equipment creates the greatest risk for falls for an older adult?
Gait belt
Prescription lenses
Safety bar in shower
Walker
Answer 2: Any new device or equipment has some risks because of the learning curve; however, new prescription lenses frequently cause some distortion in depth perception and they are less likely to be perceived by the patient or the staff as “new” or directly related to safe ambulation.
A safety bar and walker are designed to increase stability.
In addition, the older adult is likely to approach these new items with caution.
It is the responsibility of the person assisting the patient to properly apply and use the gait belt.
The postoperative patient demonstrates some mild dizziness and mild shortness of breath when moving from sitting to standing position.
Which action would the nurse perform first?
Assist the patient to get into bed.
Assist the patient to sit back down.
Check vital signs and assess symptoms.
Call the provider for an order for oxygen.
Answer 2:
For safety, assist the patient to sit back down.
This prevents an uncontrolled fall.
Next, the nurse would take vital signs and perform additional assessment.
Based on the assessment, the nurse may opt to assist the patient back into bed or call the provider.
The patient reports dizziness when standing up too fast. Which over-the-counter medication is most likely to be contributing to the patient's orthostatic hypotension?
Nonaspirin pain reliever
Antihistamine
Vitamin supplement
Medicated cough drop
Answer 2: Antihistamines cause drowsiness and have mild sedative properties, so patients should be cautioned about side effects.
An infant has a wound with a dressing on the left upper arm. He repeatedly attempts to remove the dressing. Which SRD would the nurse select?
Mummy wrap
Wrap jacket
Bilateral wrist SRDs
Right elbow SRD
Answer 4:
The infant is using his right hand to grab at the dressing on the left arm.
If the right elbow is secured in a straight position, he should not be able to reach the dressing.
(Note to student: Sometimes it may be necessary to pin or secure the SRD to the linen/mattress if the child is very determined.)
Mummy wrap is more restrictive and usually used as a temporary restraint during procedures.
Bilateral wrist SRDs are also more restrictive and the infant is likely to have skin damage because he will continuously pull to get free. The wrap jacket allows free arm movement.
A mother brings her alert and playful child to the clinic because she "found him playing with this empty bottle of baby aspirin." Which question is the most important to ask the mother?
"Has he ever done anything like this before?"
"How many times has he vomited since the ingestion?"
"How many pills do you think were in the container?"
"Did you contact poison control before you drove to the clinic?"
Answer 3:
In cases of overdose, it is essential to determine quantity. The mother may need help to remember that the bottle was half full or only had a few pills.
In the case of aspirin, number of times of vomiting is less relevant, because aspirin is readily dissolved and absorbed in the stomach.
The health care team will contact Poison Control regardless of the mother’s report or the first aid given at home.
In addition, Poison Control is likely to have the mother’s call on file.
Asking about previous episodes of poisoning would be relevant after current emergency care is given, if the health care team has reason to suspect child neglect/ abuse.
A patient with a latex allergy is exposed to latex. Which sign or symptom is cause for the greatest concern?
Hives
Laryngeal edema
Runny eyes and nose
Localized swelling
Answer 2:
Laryngeal edema puts the patient at risk for an airway obstruction.
The other signs and symptoms could occur during a type IV hypersensitivity allergic reaction, which is less serious.
Before the nurse can intervene, the UAP pushes contaminated material into an overfilled sharps container and sustains a puncture wound. What would the nurse do first?
Tell the UAP to immediately report to the infection-control nurse.
Assist the UAP to scrub the wound with copious amounts of soap and water.
Report the UAP for improper handling of hazardous material.
Dispose of the sharps container to prevent any additional injuries to others.
Answer 2:
Scrubbing and flushing the wound with soap and water is the best first action to decrease risk of infection.
The UAP should contact the infection-control nurse.
Sharps boxes should never be overfilled but are disposed of before they are full and immediately replaced.
The nurse and the UAP should write an incident report that includes the facts per institutional policy.
The nurse started a new job in a small long-term care facility in a rural area. The back exit hallway is being used as a storage area while a new storage area is being planned. What would the nurse do first?
Report the facility for unsafe conditions.
Express unwillingness to work in unsafe conditions.
Review the facility's policies/ procedures for emergencies.
Check the building for other safety issues.
Answer 3:
The nurse would first review the facility’s emergency/fire policies and procedures to determine if contingency plans have been made for the blocked hallway.
Based on the review of the policies/procedures, the nurse may decide to use the other options.
The nurse is sitting at the front desk at a walk-in clinic. A patient comes in and reports fever, malaise, and muscle aches with a rash on the tongue, mouth, and throat. The nurse notes pustules on the patient's palms. What would the nurse do first?
Notify the public health department.
Isolate the patient.
Put on personal protective equipment
(PPE).
Call the HCP to triage the patient.
Answer 2:
With suspicion of potential unknown communicable disease or exposure to biological or chemical agents, the first action would be to isolate the patient from other staff and patients in the waiting area.
The clinic should have a specified negative pressure room to put such patients, which is later cleaned per protocol as appropriate to the diagnosis that is made.
With an unusual clinical presentation, the HCP should be notified to evaluate the patient, and personal protective equipment should be donned prior to patient evaluation.
The public health department also needs to be notified as soon as possible.
It is suspected that a patient has been exposed to cyanide gas. The nurse is alert for which symptom?
Erratic behavior
Nausea and vomiting
Respiratory distress
Vesicle formation
Answer 3: Severe respiratory distress is the most prominent symptom of cyanide gas exposure.
The nurse is reviewing the disaster preparedness plan for a small nursing home. What would be included in the plan? Select all that apply.
Emergency treatment for the most critically injured
Possible admission to a hospital or transfer to a temporary shelter
Log to document residents' names and locations
System to notify families and providers
Designation of an area for decontamination
Method of patient identification, such as a bracelet or picture ID
Answer 2, 3, 4, 6:
For nursing homes or long term care facilities, the plan must include ways to keep track of residents and notification of families and providers.
The goal would be to provide a safe environment, which may include moving residents to another location.
Providing emergency treatment for critically injured patients or initiating decontamination would be included in hospital disaster plans.
The nurse is working in a local health department and has noted an unusually large number of phone calls about food-borne illness. Which question is the nurse most likely to ask callers to differentiate the possible involvement of the bioterrorist agent that causes botulism from other more common causes of food-borne illness?
In addition to gastrointestinal symptoms, have you had drooping eyelids or difficulty swallowing or speaking?
Have you experienced a low-grade fever, sweating, fatigue, and a nonproductive cough?
How soon after eating did the abdominal cramping, vomiting, and diarrhea start?
Have you had fever, malaise, and muscle aches with a rash on the tongue, mouth, throat, and palms?
Answer 1:
Botulism presents with gastrointestinal symptoms, followed by neurologic symptoms; there is no fever, or change in mental status or sensory perception.
Many disorders will present with flulike symptoms: low-grade fever, diaphoresis, fatigue, and a nonproductive cough.
Abdominal cramping, vomiting, and diarrhea after eating are typical with most food-borne illnesses.
Fever, malaise, and muscle aches with a rash on the tongue, mouth, throat, and palms are seen in smallpox.
The nurse is preparing to give an intramuscular injection to a patient. What factors would increase the risk of needlestick injury to the nurse? Select all that apply.
Using a needleless device
Disposing the needle device in the needle disposal container
Applying a Band-Aid to the injection site immediately after administering injection
Using a new type of safety device injection system
Recapping the needle after the injection
Cleansing the skin with an alcohol swab after uncapping the needle
Answer 3, 4, 5, 6:
After administering an injection, the first action would be to utilize the needle safety device to cover the needle.
This should be done prior to applying a Band-Aid, to avoid setting the exposed needle down where it could become lost in bed linens.
Using an unfamiliar type of needle safety device increases the risk of needlestick.
The nurse must become familiar with each new type of needle safety device prior to using it.
Recapping a needle increases the risk of needlestick as does uncapping the needle prior to actually administering the injection.
A needleless device cannot be used for an intramuscular injection.
Placing a used needle device in a safety container box immediately after use is recommended.
The patient with mild cognitive impairment is being discharged from the hospital with several new medications. Which action by the nurse would be most effective in reducing the risk of accidental poisoning by medication misuse?
Teach the patient the names, doses, potential side effects, and indication for use for each medication.
Request that the patient have their adult son come to safely set up the medications each day.
Teach the patient how to use a medication box and reminders.
Teach the patient how to organize the medications on the day of discharge.
Answer 3:
A simple medication box can help the patient organize his medication for safe use.
Teaching the names, doses, and side effects of each medication may be too much information for the patient with mild cognitive impairment to retain.
Written material with this information can be provided for later reference.
It may not be realistic for the patient to have a family member come to the house each day to set up medications.
Discharge teaching regarding medications should begin as soon as possible in the hospitalization to enable the nurse to assess the ability of the patient to safely manage his medications at home.
Beginning at the time of discharge would not allow enough time for the patient to learn and demonstrate his abilities.
Even if the final prescriptions are not issued until the day of discharge, the nurse can have the patient demonstrate use of a medication box in the preceding days to assess the patient’s ability to handle the task.
Assessment of the patient’s ability to safely manage medications is an important nursing function.
The hospitalized patient is confused and has a history of falls. Which actions would the nurse take to help avoid the use of SRDs? Select all that apply.
Review the patient's medication list.
Assign the patient to a quiet room far from the nurses' station.
Use a sitter if needed if family members are not available.
Use a bed alarm.
Restrict visitors because the patient becomes upset when they leave.
Use relaxation techniques such as massage or music to create a calm atmosphere for the patient.
Answer 1, 3, 4, 6:
The nurse would review the medication list to determine if any of the medications could be increasing the patient’s confusion or risk for falls.
The nurse could also review the list with the admitting HCP to be sure all of the medications are therapeutic for the patient at this time.
A family member or sitter at the bedside can help monitor the patient.
A bed alarm would alert the staff that the patient is leaving his bed.
Utilization of relaxation techniques can create an atmosphere where a patient might feel less agitated and restless.
The nurse would want to assign a patient with these issues closer to the nursing station for enhanced monitoring.
Rather than restricting visitors, the nurse could work to utilize visitors if they are willing to help monitor the patient and ask them to notify the nurse when they are leaving so the nurse can help the patient accept the transition.
A long-term care facility resident is in hospice care and end of life is imminent. The primary health care provider (HCP) orders IV fluids.
The hospice nurse objects and the nurses are not sure what to do. Who should mediate this situation?
Director of nursing services for the facility
Family member who has power of attorney
Medical director of the core interdisciplinary team
Supervisor of the hospice nurse
Answer 3:
The medical director of the core interdisciplinary team does not take the place of the primary HCP but acts as a mediator between the hospice team and the primary HCP.
The family of an older adult is struggling with financing long-term care versus loss of income if someone quits work to provide full-time care. Which member of the core interdisciplinary team would be most helpful in advising the family?
Social worker
Nurse coordinator
Medical director
Admissions nurse
Answer 2:
The social worker can assist the family to locate and review resources, such as insurance, assets, or community resources.
The nurse coordinator may also have advice about how other families have funded care.
Which outcome statement best indicates that the goal of bereavement counseling has been met?
Widow reports that family missed her dead husband during the holidays, but he was fondly remembered.
Older widow appreciates bereavement counselor and a deep personal relationship develops.
Widow calls bereavement counselor several times a month for several years after the death of a spouse.
Bereavement counselor sends cards and messages, but never hears from the widow of the deceased.
Answer 1:
The goal of bereavement care is to help survivors transition to life without the deceased person. A widow who spends holiday time with family in fond remembrance demonstrates the best adjustment.
Which assessment is the nurse most likely to perform to evaluate efficacy of hypodermoclysis?
Assess for bowel sounds and abdominal distention.
Assess mucous membranes and skin turgor.
Assess for relief of local pain and general discomfort.
Assess for nausea and frequency of vomiting.
Answer 2:
Hypodermoclysis is used to relieve dehydration.
It involves the subcutaneous administration of fluids.
Assessment of hydration status includes observing the condition of mucous membranes and checking skin turgor.
Which factors contribute to constipation in terminally ill patients? Select all that apply.
Poor dietary intake
Poor fluid intake
Hyperglycemia
Hyponatremia
Opioids for pain control
Decreased activity
Answer 1, 2, 4, 5, 6:
Factors that contribute to constipation are poor dietary intake, poor fluid intake, hypercalcemia, hyponatremia, tumor compression of the bowel, use of opioids for pain control, and decrease in physical activity.
In which circumstance would the nurse need to know whether a patient has agreed to Do Not Resuscitate DNR?
Patient has terminal illness and refuses to eat.
Patient is having chest pain with trouble breathing.
Patient has no pulse and is not breathing.
Patient is difficult to arouse with faint pulse.
Answer 3:
If the patient is pulseless and not breathing, then no actions are taken to revive the patient under DNR (do not resuscitate) orders.
POLST (physician orders for life-sustaining treatment) has the option for DNR, but the patient and caregiver may also select other options for life-sustaining treatments.
DNR orders do not apply in the circumstances where the patient still has a pulse and is breathing, such as refusal to eat, chest pain, or decreased consciousness.
Which patient best meets the criteria for admission to hospice?
The patient is in poor health, homeless, and prognosis is uncertain; no family caregivers are available for support.
The patient is undergoing cancer treat-ments, but pain and symptoms are difficult for the family to manage.
The patient has less than 6 months to live and family is willing to participate in the planning of care.
The patient wants around-the-clock skilled nursing care and emergency life support as needed.
Answer 3:
Hospice care should be available without discrimination; however, there are criteria related to prognosis (6 months or less to live), certification of prognosis by physicians, and patient and caregiver’s willingness to participate.
Cancer is the most common diagnosis in hospice, but any terminal conditions could be included.
Comfort is the goal, rather than life support or curative treatments.
The family of a dying patient is feeling physically and emotionally exhausted while taking around-the-clock shifts to care for their loved one. Which hospice service would be the best benefit for the family?
Respite care service
Palliative care consultation
Bereavement counseling
Hospice ethics committee
Answer 1:
Respite care is a period of relief from responsibilities of caring for a patient.
A palliative care consultant gives advice about relief of the patient’s pain or symptoms.
Bereavement counseling assists family/caregiver after the patient has died.
The hospital ethics committee advises about ethical issues such as discontinuation of feeding.
The HCP orders oral opioid medication for the terminally ill patient for pain control. What other types of medications would the nurse expect the HCP to order? Select all that apply.
Anticholinergics
Anticonvulsants
Anticoagulants
Antiemetics
Antihypertensives
Anxiolytics
Answer 1, 2, 4, 6:
Anticholinergics help to manage excessive secretions.
Anticonvulsants are prescribed for neuropathic pain.
Antiemetics are for nausea and vomiting.
Anxiolytics are for anxiety and reduced anxiety helps to decrease the subjective experience of pain.
Anticoagulants and antihypertensives could be prescribed for selected medical conditions but are less emphasized in hospice care.
The hospice nurse performs a pain assessment and gives different amounts of pain medication to the patient rather than the same dose each time. What is the best rationale for this practice?
Determining the right dose of medication is difficult, so different amounts are tried to determine a safe dose.
As a person is dying, the organs begin to shut down and absorption and metabolism of medication decreases.
Every patient is different in how he or she responds to the medication, so it is administered by trial and error.
The dosage is titrated to manage pain while keeping the patient alert enough to interact with the family.
Answer 4:
Managing pain and keeping the patient alert are goals of pain medication therapy.
Which nursing intervention would help the patient / family to meet the hospice goals?
Encourage the family to consider putting the patient into long-term care.
Remind the cancer patient that hoping for remission is therapeutic and beneficial.
Reassure the primary caregiver that going out to a movie is not being selfish.
Reinforce that eating and drinking as much as possible facilitates healing and recovery.
Answer 3:
Primary caregiver and patient are encouraged to live and enjoy life; thus, going to an occasional movie or taking a break would be advisable.
The patient and family may decide that a long-term care facility is a good choice, but this is just one of many options that should be presented to the whole family.
Hoping for remission would not be a hospice goal; however, hope for realistic goals would be encouraged (e.g., hope to see the birth of a grandbaby).
The patient should be offered food and fluids, but the emphasis is not on healing and recovery.
Emphasis is on helping the patient’s symptoms (e.g., taking some fluid will help relieve dry mouth and eating prevents hypoglycemia symptoms).
The patient and family are from a culture that differs from the nurse's. The family is performing rituals that are making the patient physically and emotionally uncomfortable. What would the nurse do first?
Graciously respect the patient's and family's cultural beliefs and allow them to continue.
Politely ask the patient if he wants to continue or if he would like the family to stop.
Humbly attempt to understand the benefit of the rituals from a cultural point of view.
Respectfully inquire if there is a way to modify the rituals to make them less traumatic.
Answer 2:
The nurse is first and foremost a patient advocate.
Giving the patient the opportunity to continue or stop is way of showing respect and giving the patient control.
The other options could also be considered once the nurse knows that the patient desires to have the rituals continue.
The hospice volunteer says, "I might quit. I like the patient, but the wife expects me to do yard-work, errands, cooking, housework, and pet care. Now she wants the house painted." What would the nurse do?
Talk to the wife and explain the role and responsibilities of the volunteer.
Call the volunteer coordinator and ask for additional help to paint the house.
Ask the patient how he has been getting along with the volunteer.
Instruct the volunteer to explain the situation to the volunteer coordinator.
Answer 4:
The volunteer coordinator’s responsibility is to assess the patient and family’s needs and to train the volunteers and match them with the patient and family; thus, the situation needs to be reassessed, the volunteer needs to be retrained (part of the training should include how volunteers establish boundaries of service), and possibly a different volunteer should be assigned to this family.
The patient and hospice aide frequently talk, joke, and have a close relationship. The nurse suspects that the patient is disclosing more concerns to the aide than he is to the rest of the staff. What is the most important action for the nurse to take?
Praise the hospice aide for having a supportive rapport with the patient.
Have frequent contact with the aide to get updates on the patient's concerns.
Remind the aide about scope of practice and staff-patient boundaries.
Try to spend more time with the patient to develop a better rapport and trust.
Answer 2:
The nurse recognizes that the aide spends a lot of time with the patient, so it is natural for them to develop a rapport.
Frequent reports from the aide will be valuable to the entire team.
The nurse may also decide to use the other options.
Praising reinforces desirable behavior. Reminding about scope of practice may be appropriate if the aide starts giving the patient advice about personal or health problems.
Having rapport and trust with a patient is always desirable.
The patient is a large man who needs assistance to move and transfer to a wheelchair. His wife, the caregiver, is a relatively small woman.
Which team member can best assist the wife with this issue?
Physiatrist
Hospice aide
Physical therapist
Nurse coordinator
Answer 3:
The physical therapist would assess the wife’s abilities and teach her how to do the transfer skills.
Physical therapist may also recommend equipment such as a lift or support bars.
The Edmonton Symptom Assessment System
(ESAS) was used when the patient was first admitted into hospice. Which current assessment findings could be compared to the baseline established by ESAS?
Patient's satisfaction with plan of care and recommendations for improvement
Patient's subjective feeling of pain, tired-ness, and overall feeling of well-being
Patient's cognitive, intellectual, and perceptual status and ability to make judgments
Patient's ability to perform activities of daily living (ADLs) and home maintenance
Answer 2:
Edmonton Symptom Assessment System addresses the areas of pain, tiredness (lack of energy), drowsiness, nausea, appetite, shortness of breath, depression (feeling sad), anxiety or nervousness, and the patient’s overall feeling of well-being.
The patient is having significant pain, but refuses to take oral morphine. "Because it makes me feel confused and I hallucinate." What would the nurse do first?
Encourage taking the medication for now, but promise to call the HCP.
Offer a prescribed nonopioid drug and try several nopharmacologic options.
Call the pharmacist to see if alternative routes of administration cause fewer side effects.
Give the patient a lower dose and observe for confusion or other side effects.
Answer 2:
The nurse would try a prescribed nonopioid medication and nonpharmaceutical options and observe for relief of pain.
The nurse should not encourage a patient to take a medication after the patient reports ill effects.
The nurse should contact the HCP and report the patient’s reluctance to take opioids and the response to nonopioid medication.
Changing to alternative routes or lowering the dose without an HCP’s prescription is outside the scope of nursing practice.
Patient has nausea to related anxiety and to obstruction caused by growth of a tumor. Which medication, if prescribed, would the nurse question?
Promethazine: suppository 30 minutes before meals
Prochlorperazine: oral dose as needed for nausea
Lorazepam: oral dose as needed every 6-8 hours for anxiety
Senna: oral dose two times per day
Answer 4:
Senna is a laxative and laxatives are generally not given if bowel obstruction is suspected.
The other medications could be prescribed for nausea.
The patient is having nausea and vomiting, so the nurse gives the patient an antiemetic and the vomiting subsides. What would the nurse offer the patient first?
Diluted bouillon
Plain white rice
Vanilla pudding
Favorite food
Answer 1:
Replace fluids first; very mild salt solutions may be better tolerated than sweet tastes; however, if the patient prefers sweet, clear liquids, those are acceptable.
Rice and pudding are okay if the patient is tolerating liquids.
Favorite foods should be held until patient feels well enough to enjoy them.
The patient has not had a bowel movement.
What is the initial nursing action?
Advise to increase fiber and fluids in the diet.
Assess the amount and frequency of opioid usage.
Explain that decreased oral intake decreases the amount of stool.
Assess discomfort, bowel sounds, and firmness of the abdomen.
Answer 4:
Assess discomfort and bowel function (bowel sounds, passing flatus).
Abnormal findings (e.g., absent bowel sounds, abdominal distention, pain, rigidity) should be reported to HCP.
The nurse could also use the other options.
The nurse notes that the patient is weak and emaciated and determines that stomatitis is contributing to the problem. Which intervention would be the most helpful?
Administer an antiemetic medication 30 minutes before meals.
Weigh the patient after meals and point out small improvements.
Assist with oral hygiene and use water-soaked swabs before and after meals.
Have family bring in meals, rather than cook at home.
Answer 3:
Stomatitis is an inflammation of the tissues in the mouth. It is uncomfortable to eat; therefore, hygiene and swabbing the mouth help relieve the discomfort.
Antiemetics are given to decrease nausea and vomiting.
Weighing the patient is not recommended, because the patient will feel depressed about weight loss and weight gain is unlikely.
Bring meals in, if cooking smells seem to be affecting the patient.
The HCP has informed the hospice patient, family, and nurse that there is an invasive untreatable tumor that is contributing to the patient's anorexia. Which intervention is the best for the patient?
Emotional support
Artificial hydration
Total parental nutrition
Tube feedings
Answer 1: The patient and family need emotional support in understanding and experiencing this untreatable condition.
The other options are possible, but rarely considered at this stage.
The nurse gets a phone call from the caregiver who reports hearing the "death rattle." Which instructions would the nurse give to the caregiver?
"I will get an order for a bronchodilator medication and bring it to the house."
"Apply oxygen and stay with him. I will come to the house right now."
"Sit the patient upright in bed, apply oxy-gen, and call 911 "
"This is expected: mucus and fluids will pool in the back of his throat."
Answer 2:
Applying oxygen is an action that empowers the caregiver while the nurse is on the way.
The “death rattle” is often heard 24-48 hours before death, so the nurse should go to the house, support the caregiver, explain the death rattle, and help the caregiver prepare for imminent death.
Bronchodilators can be used for dyspnea and air hunger when appropriate. Calling 911 is not appropriate.
Pooling of mucus and fluids is the cause of the noise, and is somewhat expected; however, explaining this over the phone is insufficient.
The caregiver needs support.
The patient is having difficulty with excessive secretions which cause coughing and choking, especially at night. He is unable to independently sit upright. Which intervention is best?
Teach the patient to cough and deep-breathe.
Obtain an order for droperidol.
Teach the caregiver to perform oral-tracheal suctioning.
Obtain an order for transdermal scopolamine.
Answer 4:
Transdermal scopolamine will help control the excess secretions.
Assess the patient’s ability to successfully use coughing and deep-breathing.
This could be a useful intervention, but it is likely that weakness will prevent successful production of secretions.
Droperidol is an antiemetic medication.
Suctioning is usually not done because it is uncomfortable for the patient and the caregiver would have to wake frequently during the night.
The hospice aide was devastated when the patient died and the nurse discovers that the aide has been visiting the caregiver on daily basis for the past 12 months. What would the nurse do?
Assess the caregiver's feelings about the frequent visits from the aide.
Report the hospice aide's behavior to the nurse coordinator.
Assess the hospice aide's feelings and motivations for behavior.
Suggest that the hospice aide contact the bereavement counselor.
Answer 2:
This is serious and complex issue, so the nurse should go up the chain of command.
While it is normal for the staff to grieve, the aide’s behavior is excessive and potentially burdensome to the caregiver.
The nurse coordinator should investigate the aide’s behavior, the caregiver’s response, and the need for counseling.
The outcomes could impact the caregiver’s grieving and the aide’s future participation as a team member.
The caregiver is normally calm and eager to participate. Today she is frustrated and angrily says, "Nothing is working and I can't go on like this!" What would the nurse do first?
Contact the interdisciplinary team so that the plan can be reevaluated.
Call the nurse coordinator to come and assess the situation.
Check the patient for changes in physical, emotional, or behavioral status.
Use therapeutic communication and encourage the caregiver to express concerns.
Answer 4:
The caregiver is stressed, so the nurse would listen to the caregiver and assess the situation.
Contacting the team is premature.
The nurse coordinator would be contacted after the nurse assesses and determines that the plan needs revision.
If the caregiver had demonstrated fear, anxiety, or had indicated that something was wrong with the patient, the nurse would check the patient’s status first.
Anger and frustration suggest that the patient’s health status is not the problem; the caregiver’s feelings of helplessness are the issue.
The hospice patient has an increased risk for pressure injuries in the last stages of end of life.
He is weak and spends most of the time reclining and dozing. Which instructions will the nurse give to the hospice aide? Select all that apply.
Determine the need for heel and elbow protectors.
Report redness or skin breakdown.
Monitor for poor nutrition, decreased circulation, and immobility.
Use mild soap for bathing and hygiene.
Keep linens clean, dry, and free of food or other debris.
Answer 2, 4, 5: The hospice aide is helpful in assisting with hygiene and comfort care, and can report signs of skin breakdown.
The aide could apply the protectors, but the nurse is responsible for determining the need.
The nurse would assess the skin, nutrition, circulation, and mobility.
Which question would the nurse ask to evaluate the efficacy of droperidol?
"When was your last bowel movement?"
"On a scale of 1 to 10, what number is your pain?"
"Has the medication helped to reduce the nausea?"
"Did the medication help to reduce your anxiety?"
Answer 3:
Droperidol is used to reduce nausea.
Senna is used to prevent constipation.
Lorazepam is used to reduce anxiety.
Morphine or fentanyl are used for severe pain.
In which circumstance is it most important for the nurse to perform an abdominal assessment?
Patient is having side effects after taking the prescribed dose of prochlorperazine.
Patient's extremities are cool and the underside of the body becomes darker.
Patient is refusing to eat or drink as much as he typically would for breakfast.
Patient has no bowel movements despite drinking fluid and taking senna as prescribed.
Answer 4:
Fluids and laxatives should stimulate bowel movements.
The nurse would assess for discomfort, bowel sounds, and firmness of abdomen.
Prochlorperazine is prescribed for nausea.
Side effects include extrapyramidal symptoms, dry mouth, and depression.
Decreased perfusion and circulation lead to cooling of the extremities and darkness on the underside of the body.
The nurse would ask the patient about refusal to eat or drink.
Decreased appetite and fluid intake may be caused by nausea, vomiting, constipation, dysphagia, stomatitis, tumor invasion, general deterioration of the body, depression, or infections.
Which outcome statement best indicates that the goal of palliative care has been met?
Patient finalizes his will and empowers son to be medical power of attorney.
Patient's pain is controlled, and he enjoys a visit with the grandchildren.
Patient independently completes morning hygiene and dresses himself.
Patient and family acknowledge that curing the illness is not possible.
Answer 2:
The goal of palliative care is to control pain and other distressing symptoms.
The goal of pain control is to titrate the dose to alleviate pain and allow the patient to remain alert enough to participate in activities.
Acknowledgment that palliative care is not curative helps the family and patient manage expectations.
Patient may have personal goals to achieve, such as maintaining independence and finalizing affairs.
The family of a patient with terminal cancer has requested information about hospice care. The patient has severe pain and potential curative treatments have been exhausted.
How would the nurse assess the patient's pain?
Pain assessment includes presence of pain, location, intensity (use of scale), variation in intensity, subjective description, treatments being used, rating of relief with current treatment, factors that precipitate or aggravate the pain, and its effect on ADLs
The family of a patient with terminal cancer has requested information about hospice care. The patient has severe pain and potential curative treatments have been exhausted.
Identify the types of medications that may be used to relieve or reduce mild to moderate pain:
Mild to moderate pain is usually controlled by nonsteroidal anti-inflammatory drugs.
The family of a patient with terminal cancer has requested information about hospice care. The patient has severe pain and potential curative treatments have been exhausted.
Identify the types of medications that may be used to relieve or reduce severe pain:
Severe pain is usually treated with opioids.
The family of a patient with terminal cancer has requested information about hospice care. The patient has severe pain and potential curative treatments have been exhausted.
Identify the types of medications that may be used to relieve or reduce pain for long-lasting results:
Long-lasting results are achieved with morphine sulfate, oxycodone, and fentanyl patches.
The family of a patient with terminal cancer has requested information about hospice care. The patient has severe pain and potential curative treatments have been exhausted.
What nonpharmacologic measures may also be implemented to relieve or reduce pain?
Additional measures for pain relief include application of hot or cold packs, repositioning, music therapy, relaxation techniques, transcutaneous electrical nerve stimulation, and acupuncture.
Summarize safety precautions to help prevent falls:
be ready to assist pts w/ ambulation if they’ve had surgery, narcotics, extended bed-rest, or have an unsteady gait
demonstrate proper use of call buttons/cords
encourage pts to wear non-slip shoes/slippers when ambulating
encourage pts to use handrails
if possible, set alarms for restless, disoriented pt
keep beds in lowest position whenever possible
keep environment free of clutter or stuff that could cause pt to trip and fall
lock wheels on stuff that has wheels
orient pt to environment
provide adequate lighting
frequently used items are to be easily accessible
learn facility’s fall precaution protocols if applicable
wipe wet floors fast and be aware of signs to warn slippery floors
When delegating safety measures of fall prevention, be sure to stress the following:
the pt’s mobility limitations and possible fall precautions
environmental safety precautions (locked wheels, bed is at lowest, non-slip shoes, etc.)
what to do if pt falls, starts to fall, etc.
Safety considerations and needs of infants and children:
All household cleaning items and chemicals are poisonous and must be kept out of reach (most children don’t understand warning labels, teach them to stay away).
Educate parents that infants put everything in their mouths, and when they crawl, electrical cords and sockets are especially dangerous.
Prevent dangerous kitchen appliances from spilling (leaving things at the edge, hot pot handles, knives, etc.).
Water safety should be emphasized, they are a severe drown risk and their temp regulation is less efficient.
Higher risk to fall and suffer severe injuries (keep sides rails up, keep 1 hand on infants when giving care).
Safety considerations and needs of older adults:
Aging affects ability to protect self from injury. (unsteady gait, vision changes, medication side effects)
Ensure pt has assistive devices. (glasses, hearing aids, devices for ambulating)
Be aware of physical/sensory limitations pt has. (when appropriate, increased lighting and clear walkways; increased volume or warnings needed for auditory warning cues)
Prevent sensory overload, multi-tasking and ability to respond is much slower.
Changes in cardiovascular system increase risk of syncope and falls.
Changes in peripheral vascular system might cause loss of sensitivity to temp, higher risk for skin breakdown.
Be aware of polypharmacy and the side effects they may be causing pt.
Keep usage of SRDs or any restraints to minimum.
Accidental poisoning is a huge concern. (use medication organizers, differentiate via shape and color, and assess for usage of OTC meds and other supplements)
Describe safe and appropriate methods for the usage of SRDs
be cautious of correct placement
monitor for circulation constriction, skin integrity, adequate breathing
be aware of when and how to change positions
restraining limbs— usually mental health setting
prevent displacement of IV lines— usually PICU/NICU setting
pulling out medical devices— usually ICU setting
bed/chair alarms and wander guards— usually for disoriented/confused pts
explain rationale to pt, family members. (include info about SRD and period for usage)
Nursing interventions when using SRDs and how/why to aim for restraint-free
Focus is on attempting alternative strategies before using SRD, only for pt safety and safety of others.
Usage tends to increase restlessness, disorientation, agitation, anxiety, feelings of powerlessness.
Contributes to pt immobility and associated problems. (dehydration, HAIs, incontinence, increases disability, increased pt weakness and unsteadiness)
Be aware of facility policy.
Most require HCP order. (usually needs renewal q24 hrs.)
OBRA’s essentials of SRD documentation:
reason for physical restraint
explanation given to pt and family
date and time of pt’s response to treatment
duration
frequency of observation and pt’s response
safety
release the SRD q2 hrs.
routine exercise of limbs + ROM
assessment for circulation and skin integrity
assessment for continued need for SRD
Pt outcome
Latex sensitivity
Question all pts regarding allergies and ask specifically about latex.
Inspect contents of pt care supply kits.
Levels of sensitivity:
Contact Dermatitis: nonallergic response with skin redness and itching.
Type IV hypersensitivity: delayed reaction including redness, itching, and hives for up to 48 hrs. localized swelling, red and itchy or runny eyes and nose, coughing.
Type I hypersensitivity: true latex allergy. Hives, generalized edema, itching, rash, wheezing, bronchospasm, difficulty breathing, laryngeal edema, diarrhea, nausea, hypotension, tachycardia, and respiratory/cardiac arrest.
Electrical hazards
Most equipment used in healthcare requires maintenance and needs to be properly grounded to reduce risk of hazards.
Teach pts: prevention of electrical shock, avoidance of use of electrical appliances near water, methods of grounding appliances and self, avoidance of operating unfamiliar equipment.
Radiation
Hospitals have strict guidelines on the care of radiation treatment and handling.
limit time spent near source, distance yourself, wear shielding devices, and track exposure levels with other devices.
If community is put at risk, specific agencies (EPA, NRC, DOE, DOT) institute measures to prevent exposure to vicinities, clean up the leaks asap, ensure everyone injured receives medical care.
Mercury spill clean up procedure
evacuate the room except for a housekeeping crew (if available)
ventilate the area, close interior doors and open outside windows
don’t vacuum the spill
mop the floor with specific cleanser
dispose of collected mercury according to local ordinances
(include broken thermometers or sphygmomanometers)
enters the body through inhalation and skin absorption, most likely affects kidney and brain.
Workplace violence
doesn’t always involve physical injury, refers to any extreme behavior used to frighten, intimidate, threaten, or injure a person or damage or destroy property.
behavior is sometimes physical, or verbal, or nonverbal.
assault occurs when threat or gesture causes person to fear of being hit; battery occurs when there is unwelcomed physical contact.
Guidelines to for violence identification and prevention is called: OSHA Workplace Violence Safety and Health Topics page.
Nurse’s responsibility in violence prevention programs
Understand and follow workplace violence prevention program.
Understand and follow facility security measures.
Voice safety and security concerns.
Report incidents promptly and accurately.
Take part in training programs.
Safety measures taken when dealing with agitated/aggressive people:
stand away from person, enough to not be hit or kicked.
position yourself close to the door, don’t get trapped.
note location of panic buttons, call bells, alarms, other security devices.
keep hands free.
stay calm, talk calmly.
don’t touch the person.
tell them that supervisor can come to talk.
leave the room as soon as it’s safe, and pt is safe.
notify supervisor/security officer.
complete incident report.
Fire safety
Keep the number for reporting visible fires on speed dial.
Know the agency’s fire drill and evacuation plan.
Know the location of all fire alarms, exits, and fire extinguishers.
Check for fire hazards on an ongoing basis.
Frayed or broken electrical cords or faulty equipment should never be used.
Notify the maintenance dept. of defects in equipment and report any shocks received from operating equipment.
Type A extinguishers— paper, wood, cloth
Type B extinguishers— flammable liquid fires, grease, anesthetics
Type C extinguishers— electrical fires
ABC type— acceptable for any type of fire
Accidental poisoning
Unintentional poisoning occurs when a person taking or giving too much of a substance did not mean to cause harm.
Affects a lot of 1 & 2 y.o., teens and adults has highest death rate.
91% of all unintentional poisonings are from drugs (OTC and Rx)
Syrup of ipecac no longer recommended for use.
Cleaning solutions and disinfectants must be labeled properly, don’t remove from original containers, and don’t use stuff from unmarked containers.
Have closest poison control center’s number on speed dial for yourself and pt.
Disaster planning
e.g. earthquakes, hurricanes, floods, tornados. (facilities are expected to receive victims and survivors)
factors that affect response:
time of day
scope and duration of event
readiness of facility and staff, equipment, etc.
preparations for appropriate procedures
extent of collaboration with various community agencies and institutions
Terrorism
possibility of terrorist attack is viewed as an environmental health threat.
Dept of Homeland Security responsible for overseeing approaches to domestic incidents. (concerned with preventing and managing potential attacks)
Bioterrorism
use of biological agents to create fear and threaten.
facility’s emergency management plan provides details on how to respond to a terrorist attack: e.g. determining agent used, determining time and location of attack and of affected population, obtaining and delivering supplies, providing treatment.
OSHA has health safety and info on biological agents like: plague, ricin, anthrax, tularemia, smallpox, and viral hemorrhagic fever (VHF).
The nurse is caring for a patient on a ventilator and reads the order "restrain prn." The nurse considers which factor when caring for this patient? (Select all that apply.)
SRDs often decrease anxiety because the patient feels safer.
All older adult patients need some type of SRD at night.
Allow as much freedom of movement as possible when applying SRDs.
When using soft SRDs to prevent pulling of the ventilator tubing, tie them to the side rail.
Ensure that the nurse's two fingers can be inserted between the SRD and the patient's skin.
Assign confused or disoriented patients to rooms near the nurses' station.
Release the physical restraint at least every 4 hours.
Ensure an order is renewed a minimum of every 48 hours while the restraints are necessary.
3, 5
Allow as much freedom of movement as possible when applying SRDs.
Ensure that the nurse’s two fingers can be inserted between the SRD and the patient’s skin.
The LPN/LVN is reviewing the care plan of the patient who has an SRD applied for personal safety. Which is the highest priority goal for this patient?
Patient will remain free of injury.
Patient will allow SRDs to be used.
Nurse will check SRD every 30 minutes.
Use least restrictive form of SRD possible.
1
Patient will remain free of injury.
The nurse is documenting on a patient with an SRD. What information must the nurse include in this documentation?
The nurse's feelings about having used the SRD.
The specific type of SRD used and an assessment of the patient.
Confirmation of a pin order for use of the SRD.
Evidence that the patient was assessed every 8 hours.
2
The specific type of SRD used and an assessment of the patient.
When caring for the patient who requires the use of an SRD, what should be included in the patient's plan of care? (Select all that apply.)
Monitor the skin for signs of impairment.
Remove the SRD once every 2 hours.
Secure the ends of the ties to the side rails.
Ensure that the SRD is in place at all times.
Reevaluate the need for the SRD frequently.
1, 5
Monitor the skin for signs of impairment.
Reevaluate the need for the SRD frequently.
The nurse discovers smoke in a soiled utility room across the hall from a patient's room. What should the nurse's initial action be?
Sound the fire alarm.
Disconnect the oxygen supply.
Use any extinguisher on the fire.
Remove the patient from the area.
1
Sound the fire alarm.
The nurse is observing the UAP who is assisting a resident in a long-term care facility to ambulate with a gait belt. Which action by the UAP indicates to the nurse that further instruction is necessary? (Select all that apply.)
The UAP loosely fastens the gait belt around the patient's waist.
The UAP places the gait belt on the resident before assisting the resident to a standing position.
The UAP grasps the gait belt while assisting the resident out of bed.
The UAP fastens the belt around the arm of the chair to prevent the resident from slipping out of the chair.
The UAP explains to the resident that the gait belt is used to prevent injury to the resident and the UAP when assisting with ambulation.
1, 4
The UAP loosely fastens the gait belt around the patient’s waist.
The UAP fastens the belt around the arm of the chair to prevent the resident from slipping out of the chair.
A type C fire extinguisher is required for which type of fire?
Paper
Cloth
Grease
Electrical
4
Electrical
Note 
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