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A comprehensive overview of patient safety and delegation in nursing, covering key concepts, responsibilities, and best practices. It includes a series of questions and answers that address common challenges and scenarios encountered in clinical settings. Particularly useful for nursing students and professionals seeking to enhance their knowledge and skills in patient safety and delegation.
Typology: Exams
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Describe nurse responsibilities for patient safety - ANS>-Use risk assessment tools
When is it not okay to delegate? - ANS>-thinking, complex assessment, and judgment are required
Describe physical restraints - ANS>appropriate only for a short term situation or procedure, uses physical strength to restrain (ex. swaddle wrap for insertion of IV in pediatric client) Describe mechanical restraints - ANS>physical device applied such as straps, mittens, jackets, vests, belts, fabric around wrist or ankles typically tied to bed frame using quick release knot Describe chemical restraints - ANS>administration of medications to reduce client movement/behavior (ex. benzos) Describe barrier restraints - ANS>limit movement within a setting (ex. bed enclosures, concave mattresses, lapboards, cribs for pediatrics) Describe seclusion - ANS>environmental restraint involving placement of client alone in a securely locked room without their consent, typically used for clients who are very combative and pose a risk to other clients and staff When is it appropriate to obtain an order for restraints? - ANS>-client must be exhibiting unnecessary or unwanted movement that is considered unsafe
Describe safety concerns for infants/toddlers - ANS>burn injuries related to hot liquids or steam, accidental poisonings/choking, drowning, properly fitting car seats (rear-facing) Describe safety concerns for school aged children - ANS>vehicle safety (sit in backseat), safe participation in sports (helmets, eye protection, etc.), water safety, Internet safety (bullying), firearm safety (not toys), stranger danger Describe safety concerns for adolescents - ANS>risks involving fire, water, sports, firearms, vehicles, bullying, intimate-partner violence, substance abuse, speeding, unprotected sex, suicide, nutrition Describe safety concerns for adults under 65y/o - ANS>stress, poorly developed coping strategies, alcohol consumption, mental disorders, obesity, workplace accidents/violence Describe safety concerns for older adults over 65y/o - ANS>chronic illnesses, less physical activity, impaired mobility, cognitive/sensory deficits, FALLS, frailty Describe home safety risks for an older adult (bathroom, bedroom, kitchen, general) - ANS>Bathroom: slipping in shower/tub/tile, toilets too low to ground, step in showers/tubs, use of non-electric razors, water temperature too hot, toxic cleaning supplies, accidental
electrocution in the event client's wet hand or body part comes into contact with outlet Bedroom: bed is too high and client could roll out of bed, no use of mat/bed/motion alarm for clients who have mobility/cognitive issues, no use of hospital beds for clients with mobility difficulty Kitchen: commonly used items out of reach, step stools without rubber grippers to prevent sliding, stoves without automatic shut off mechanisms, toxic cleaning supplies, accidental burns from knocking/pulling over pot handles on the stove, accidental electrocution in the event client's wet hand or body part comes into contact with outlet General: dim lights, rounded traditional door knobs, animals and animal food/water bowls (tripping hazard), swivel/chairs with wheels, loose rugs, unsecured electrical cords, multicolored painted walls, medications not organized into pill dispenser, lack of use of chair lift, lack of handrails, uneven flooring, no emergency numbers in phone or nearby What are Standards of Compliance? - ANS>former National Safety Goals (NSG) that have been routinely adopted by healthcare professional and are now retired, but still must be continually met (medical error prevention, verification of qualifications and competency of health care staff procedures, rights and education of clients, infection control, management of medications, emergency preparedness)
Joint Commission Patient Safety Goals: Use alarms safely - ANS>-Clinical safety alarms both warn of potentially serious event that is occurring and if the machine is malfunctioning
Describe some basic fire safety guidelines - ANS>-Installation of fire alarms and CO detectors
Describe seizure safety measures - ANS>Pre Seizure: ensure suction and oxygen equipment is set up at bedside, check baseline vital signs, establish two IV sites, nsure side rails are padded and that restrictive clothing/jewelry is removed During seizure: call for immediate assistance, assume client to side-lying position, protect head from injury, remove dangerous objects around client, do not hold client down, determine if seizure activity was or was not bilateral, determine eye activity, administer medication per provider prescription, monitor ABCs, assess vitals and skin, assess bowel or bladder incontinence, obtain blood glucose if needed, and provide verbal reassurance help is on the way Post Seizure: obtain lab toxicology screen if prescribed, blood drug level of anticonvulsant if prescribed, assess gag reflex, assess swallowing, and explain to client what occurred and provide reassurance that client is safe What are ALL of the rights of medication administration? - ANS>-Right client: two identifiers
Additional rights:
extremity can be slightly cooler if it is immobilized in a cast or if a client has a circulation problem to an extremity Unexpected: hyper/hypothermia Describe expected vs unexpected findings for skin integrity - ANS>Expected: skin should be smooth and intact Unexpected: primary vs. secondary lesions, ABCDE assessment, infestation Describe expected vs unexpected findings for skin moisture/texture/turgor - ANS>Expected: wrinkling, acne, scars from trauma/procedures, should rise easily when pinched and return rapidly to flat position when released but this can be delayed in older clients due to decreased skin elasticity Unexpected: profound dryness, rough, flaking, velvet texture, diaphoresis, tenting, edema Describe expected vs unexpected findings for hair/nails - ANS>Expected: hair evenly distributed, quantity, and good hygiene; nails are symmetrical, smooth, slightly curved/flat, color similar to client's skin tone, not pale, and quick capillary refill <2sec
Unexpected: hair loss (alopecia); nails broken/missing, clubbing (spongy to touch, spoon-like), delayed capillary refill, loosely attached, pale(anemia)/brown(melanoma)/blue(cyanosis) color, linear depressions (Raynauds), not smooth What is the difference between primary vs secondary lesions? - ANS>Primary lesions are the direct result of an underlying condition Secondary lesions are the result of primary lesions What is edema? Causes? Manifestations? Measurement scales? - ANS>accumulation of fluid in interstitial spaces, most commonly found in lower extremities, sacrum increased risk for pressure injury skin will appear shiny and tight pitting vs. non-pitting (1+ = trace(rapid response), 2+ = mild (10-15sec response), 3+ = moderate (prolonged), 4+ = severe (prolonged)) if edema is bilateral the cause is a central problem like heart failure, if it is unilateral or localized the cause is likely not central; edema could mask signs of jaundice or cyanosis