Nursing Care and Safety: Seizures, Fall Prevention, and Nutrition

What is the priority action during a seizure?

Stay with patient and note time

What position should a patient be placed in during a seizure?

Side-lying position

What should the nurse NOT do during a seizure?

Do not restrain or place anything in mouth

A patient is on oxygen therapy. What is the priority safety teaching?

No smoking and keep away from heat sources

What causes carbon monoxide poisoning?

Inhalation of gas that binds to hemoglobin

What are symptoms of carbon monoxide poisoning?

Headache, dizziness, fatigue, nausea

What is the priority action for a chemical spill?

Check the MSDS sheet

What is the priority intervention to reduce fall risk?

Perform fall risk assessment first

What are common fall risk factors?

Poor mobility, medications, unsafe environment, vision issues

What is the nurse's priority before using restraints?

Attempt alternatives first

What is friction?

Skin rubbing against surface

What is shear?

Skin stays while deeper tissues move

What is Virchow's triad?

Venous stasis, endothelial injury, hypercoagulability

What is the priority prevention for DVT?

Early ambulation and antiembolism devices

What exercises prevent DVT?

Ankle pumps, foot circles

What is the correct way to go up stairs with crutches?

Good leg first, then weak leg and crutches

What is the correct way to go down stairs with crutches?

Crutches first, then weak leg, then strong leg

What is proprioception?

Awareness of body position and movement

What is the greatest risk of immobility?

Multiple system complications (DVT, skin breakdown, pneumonia)

What respiratory complication occurs with immobility?

Atelectasis

What musculoskeletal complication occurs with immobility?

Muscle atrophy and contractures

What cardiovascular complication occurs with immobility?

Orthostatic hypotension and DVT

What should the nurse assess during hygiene care?

Skin, ROM, IV sites, self-care ability

What is the priority when providing hygiene?

Maintain safety, privacy, and dignity

What is the correct order for CHG wipes?

Neck/chest → arms → abdomen/perineum → legs → back

What is important about CHG wipes?

Do not rinse off

How is female perineal care performed?

Front to back

How is male perineal care performed?

Clean in circular motion from meatus outward

How is catheter care performed?

Clean outward from insertion site

What is key teaching for diabetic foot care?

Inspect daily, no soaking, lotion not between toes

What should diabetic patients avoid?

Soaking feet

How many kcal per gram do carbohydrates provide?

4 kcal

How many kcal per gram do protein provide?

4 kcal

How many kcal per gram do fats provide?

9 kcal

What is the body's preferred energy source?

Carbohydrates

What is basal metabolic rate (BMR)?

Energy required to maintain life at rest

What is the best indicator of long-term nutrition status?

Albumin

What is the best indicator of short-term nutrition status?

Prealbumin

What is BMI used for?

Assess body weight relative to height

What BMI indicates obesity?

30 or greater

What is a priority nursing action for cultural nutrition?

Respect and incorporate food preferences

What is dysphagia?

Difficulty swallowing

What is the priority intervention for dysphagia?

Consult speech therapy and use aspiration precautions

What position reduces aspiration risk when feeding?

Upright or high Fowler's

What is the first step after inserting a feeding tube?

Verify placement

What is the BEST method to verify feeding tube placement?

X-ray

How is NG tube length measured?

Nose to ear to xiphoid

What is the correct order for enteral feeding?

Elevate HOB → verify placement → check residual → flush → feed

What is the priority complication of enteral feeding?

Aspiration

How can the nurse prevent tube clogging?

Use liquid medications and flush tube

What should the nurse do if patient has cramping during feeding?

Slow the feeding rate

What type of tube is used for long-term feeding?

PEG or jejunostomy tube

What type is used for short-term feeding?

NG or NJ tube

What is TPN?

Total parenteral nutrition given through central line

What are complications of TPN?

Infection and hyperglycemia

What should the nurse do if TPN is stopped suddenly?

Taper to prevent hypoglycemia

What is a full liquid diet?

Liquids such as milk, pudding, ice cream

What is NOT included in a full liquid diet?

Solid foods like mashed potatoes

What is the priority for food safety?

Prevent contamination and proper storage

Who is most at risk for foodborne illness?

Immunocompromised patients

What is an eating disorder characterized by starvation?

Anorexia nervosa

What is an eating disorder with binge and purge behavior?

Bulimia nervosa

What is an open wound?

Skin is broken and exposed

What is a closed wound?

Skin intact with underlying damage

What is a partial-thickness wound?

Involves epidermis and part of dermis; painful and moist

What is a full-thickness wound?

Involves entire dermis; requires scar formation

What is primary intention healing?

Edges closed; low infection risk

What is secondary intention healing?

Wound left open; heals by scar tissue

What is tertiary intention healing?

Delayed closure due to infection risk

What happens in the inflammatory phase?

Redness, swelling, pain, WBC migration

How long does the inflammatory phase last?

About 4 days

What happens if wound stays in inflammatory phase?

Becomes chronic

What happens in proliferative phase?

Granulation tissue and new tissue formation

What is granulation tissue?

Red, vascular healing tissue

When should healing ridge be present?

Day 5-9

What happens in maturation phase?

Collagen reorganizes and scar strengthens

Is scar tissue as strong as original tissue?

No

What are signs of wound infection?

Redness, warmth, swelling, purulent drainage

What type of drainage is clear?

Serous

What type is pink?

Serosanguineous

What type is bloody?

Sanguineous

What type indicates infection?

Purulent

What is a pressure injury?

Damage from pressure over bony areas

What is Stage 1 pressure injury?

Non-blanchable redness

What is Stage 2 pressure injury?

Blister or partial-thickness loss

What is Stage 3 pressure injury?

Full-thickness with fat visible

What is Stage 4 pressure injury?

Bone, muscle, or tendon exposed

What is unstageable wound?

Covered with slough or eschar

What is the Braden Scale used for?

Assess risk for pressure injury

What does a low Braden score indicate?

High risk

What is the priority intervention to prevent pressure injuries?

Turn patient every 2 hours

What is dehiscence?

Wound edges separate

What is evisceration?

Organs protrude from wound

What is the priority action for evisceration?

Cover with sterile saline dressing and call provider

What is the most important factor for wound healing?

Adequate oxygenation

What diet promotes wound healing?

High protein and high calorie

A nurse assesses a patient with reddened skin over the sacrum that does not blanch when pressed. What stage is this?

Stage 1

A nurse notes a blister on a patient's heel. What stage pressure injury is this?

Stage 2

A patient has a shallow open ulcer with a red-pink wound bed. What stage is this?

Stage 2

A nurse observes a wound with visible adipose (fat) tissue. What stage is this?

Stage 3