Unit 1 - Hand Hygiene, Infection Control, PPE, Restraints, Safety, HIPAA, Delegation, SBAR, Basic Care, Transfers, ROM

When should hand hygiene be performed?

Before and after patient contact, before aseptic tasks, after body fluid exposure, after touching patient surroundings.

When must soap and water be used instead of alcohol gel?

When hands are visibly soiled or after caring for a patient with C. difficile.

What type of precautions apply to all patients?

Standard precautions.

What PPE is required for contact precautions?

Gloves and gown.

What diseases require droplet precautions?

Influenza, meningitis.

What PPE is required for airborne precautions?

N95 respirator and negative pressure room.

What is the correct order for donning PPE?

Gown, mask/respirator, goggles/face shield, gloves.

What is the correct order for doffing PPE?

Gloves, goggles, gown, mask.

What must a nurse do immediately after a needlestick exposure?

Stop procedure, wash area, notify instructor/charge nurse, complete incident report, go to employee health.

When are restraints used?

As a last resort when the patient is a danger to self/others or to protect medical devices.

What type of knot is used for restraints?

Quick-release knot.

Where should restraints be tied?

To the bed frame, never to side rails.

How often should a restrained patient be checked?

Circulation checks every 15 minutes and restraint removal every 2 hours.

What are high fall-risk factors?

History of falls, confusion, weakness, sedatives, orthostatic hypotension, incontinence.

What fall prevention measures should be implemented?

Bed in low position, call light within reach, non-skid socks, bed alarm, clear pathways.

What is subjective data?

Information the patient reports, such as pain or nausea.

What is objective data?

Information the nurse observes or measures, such as vital signs or wound appearance.

What are key principles of HIPAA?

Only access patient information you need, protect passwords, avoid discussing patient info in public areas, dispose of papers properly.

What tasks can an RN NOT delegate?

Assessment, nursing judgment, evaluation, and patient teaching.

What tasks can be delegated to a UAP?

ADLs, feeding, bathing, toileting, vital signs on stable patients, I&O, positioning.

What tasks can be delegated to an LPN?

PO medications, wound care, Foley catheter insertion, monitoring findings (RN interprets).

What does SBAR stand for?

Situation, Background, Assessment, Recommendation.

What type of patient should be seen first during prioritization?

Unstable patients with airway, breathing, or circulation problems.

What counts as intake in I&O?

PO fluids, IV fluids, tube feeds, liquid medications.

What counts as output in I&O?

Urine, emesis, liquid stool, wound drainage.

When should urine output be reported to the provider?

When output is less than 30 mL/hr.

What is included in basic hygiene for a bedbound client?

Privacy, warm water, clean from clean to dirty, oral care every 2 hours if NPO, perineal care last.

What is the purpose of range of motion (ROM)?

To prevent contractures, maintain mobility, and improve circulation.

What is active ROM?

The patient performs movements independently.

What is passive ROM?

The nurse assists with movements for the patient.

What is the first safety step in transferring a patient?

Lock bed and wheelchair wheels.

What device should be used during transfers?

A gait belt.

When is logrolling used?

For patients with spinal precautions.