Nclex Safety & Infection Control

Front 1

Who is at risk for falls?
 Older adult clients may be at an increased risk for falls due to decreased strength, impaired mobility and balance, and endurance limitation.
 Other clients who may be at increased risk include:  Clients with decreased visual acuity  Clients with generalized weakness  Clients with urinary frequency
 Clients with gait and balance problems
 Clients with cognitive dysfunction
 Clients who are taking medications whose side effects include orthostatic hypotension or drowsiness

Back 1

Nursing Responsibilities: Fall Prevention
Nurses are responsible for completing a fall risk assessment for each client upon admission and at regular intervals throughout hospitalization. All identified risks
should be documented in the health care record.
Other nursing responsibilities include:
 Providing client with non-skid footwear
 Keeping the floor free from clutter with a clear path to the bathroom
 Providing adequate lighting (including a night light)
 Orienting the client to the setting and making sure client understands how to use all assistive devices (such as grab bars and the call light)
 Keeping assistive devices nearby for client use.  Educating the client and family/caregivers on identified risks and the plan of care.

Front 2

Nursing Responsibilities, Cont.
 Call lights should be answered promptly to prevent the client from trying to ambulate independently.
 Clients who are determined to be at risk for falling should have a room close to the nurses’ station.
 Bed rails should be kept up with the bed in low position (sedated, unconscious, or high-risk clients).
 Wheels on beds, wheelchairs, and gurneys should be locked.  Bed or chair sensors should be utilized for clients at risk.

Back 2

Seizures
Seizures may include sudden onset and violent tonic- clonic movements that can result in injury. It is
important to prevent injury by implementing seizure precautions for a client with a history of seizures.

Front 3

Nursing Responsibilities: Seizure Precautions
The client who has a history of seizures should be assessed for:  Frequency of seizure activity  Type and date of last seizure  Medications
 Triggers of trends of seizures

Back 3

Nursing Responsibilities, Cont.
 Ensure rescue equipment is at the bedside. This includes oxygen, an oral airway, and suction equipment.
 Inspection of the client’s environment should be conducted. Items that may cause injury in the event of a seizure should be removed.
 Assist with ambulation and transfer for reduction of injury risk.
 Caregivers and family should be educated not to put anything in the client’s mouth in the event of a seizure.

Front 4

If a seizure occurs...
The client should not be restrained.
Caregivers and family members should be advised to:  Lower the client to the floor or bed  Protect the client’s head  Remove nearby furniture
 Provide privacy  Put the client on his side if possible  Loosen clothing to prevent injury and promote dignity

Back 4

Nursing Responsibilities After a Seizure
 Educate the client about what has occurred.  Provide comfort and understanding and a quiet environment for the
client to recover in.
 Document the seizure in the client’s record with any precipitating behaviors and a description of the event.
 Report the seizure to the Primary Care Provider.

Front 5

Nursing Responsibilities: Equipment Safety
 Equipment should only be used after a safety inspection (no frayed cords, loose, or missing parts) and instruction in its use.
 Electrical equipment must be grounded (three-pronged plug and grounded outlet) to decrease the risk for electrical shock.
 Disconnect all electrical equipment prior to cleaning.  JCAHO (2004) requires all pumps (general and PCA) to have free-
flow protection to prevent an overdose of fluids or medications
 Do not overcrowd outlets and use extension cords only when absolutely necessary.
 Malfunctioning equipment should be removed from the patient care area and reported to proper personnel.

Back 5

Nursing Responsibilities: Fire Safety
The fire response in the health care setting always follows this Sequence (RACE):
Rescue: Protect and evacuate clients in immediate danger.
Alarm: Report the fire. Contain: Contain the fire Extinguish: Extinguish the fire.

Front 6

NCLEX Challenge
An older female client who ambulates with a walker is taking diuretics. Nursing interventions for this client should include:
A. Keeping side rails up. B. Withholding diuretic medication. C. Leaving the bathroom light on. D. Providing a bedside commode.

Back 6

NCLEX Challenge
A: Incorrect. Rails up would increase the risk of falling for this client.
B: Incorrect. The nurse cannot withhold medication without consultation with the physician.
C: Incorrect. Leaving the light on would assist the client in locating the bathroom, but would not reduce the risk of falling as the client moves to the bathroom.
D: Correct. Providing a beside commode decreases the number of steps required to reach the toilet, thereby reducing the risk for falls.

Front 7

NCLEX Challenge
A client is admitted to the hospital following a seizure that occurred in her home. The client has no previous history of seizures. In planning the client’s nursing care, which of the following measures is most essential at the time of admission?
Select all that apply. 1. Place a padded tongue depressor at the head of the bed.
2. Pad the side rails. 3. Inform the client about the importance of wearing a medical
identification tag. 4. Teach the client about epilepsy. 5. Test oral suction equipment.

Back 7

1: Incorrect. Attempting to insert something into the client’s mouth during a seizure is likely to cause more injury.
2: Correct. Padding the side rails will help keep the client safe if another seizure occurs.
3: Incorrect. This step would be taken if it is likely that a seizure would reoccur. Since this is the client’s first seizure, more assessment is needed before this measure is deemed necessary.
4: Incorrect. This step would be taken if it is likely that a seizure would reoccur. Since this is the client’s first seizure, more assessment is needed before this measure is deemed necessary.
5: Correct. Maintaining oral suction equipment is appropriate and will keep the client safe in the event of another seizure.

Front 8

NCLEX Challenge
An older female client who ambulates with a walker is taking diuretics. Nursing interventions for this client should include:
A. Keeping side rails up. B. Withholding diuretic medication. C. Leaving the bathroom light on. D. Providing a bedside commode.

Back 8

NCLEX Challenge
A: Incorrect. Rails up would increase the risk of falling for this client.
B: Incorrect. The nurse cannot withhold medication without consultation with the physician.
C: Incorrect. Leaving the light on would assist the client in locating the bathroom, but would not reduce the risk of falling as the client moves to the bathroom.
D: Correct. Providing a beside commode decreases the number of steps required to reach the toilet, thereby reducing the risk for falls.

Front 9

NCLEX Challenge
A client is admitted to the hospital following a seizure that occurred in her home. The client has no previous history of seizures. In planning the client’s nursing care, which of the following measures is most essential at the time of admission?
Select all that apply. 1. Place a padded tongue depressor at the head of the bed.
2. Pad the side rails. 3. Inform the client about the importance of wearing a medical
identification tag. 4. Teach the client about epilepsy. 5. Test oral suction equipment.

Back 9

1: Incorrect. Attempting to insert something into the client’s mouth during a seizure is likely to cause more injury.
2: Correct. Padding the side rails will help keep the client safe if another seizure occurs.
3: Incorrect. This step would be taken if it is likely that a seizure would reoccur. Since this is the client’s first seizure, more assessment is needed before this measure is deemed necessary.
4: Incorrect. This step would be taken if it is likely that a seizure would reoccur. Since this is the client’s first seizure, more assessment is needed before this measure is deemed necessary.
5: Correct. Maintaining oral suction equipment is appropriate and will keep the client safe in the event of another seizure.