Nursing

Front 1

Who is at risk for Falls?

Back 1

Older adult
 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

Front 2

Nursing interventions to prevent falls are:

Back 2

Providing client with non-skid footwear
 Keeping the floor free from clutter
 Providing adequate lighting
 Orienting the client to the setting
 Keeping assistive devices nearby
 Educating the client and family/caregivers on identified risks and the plan of care.

Front 3

Safety: Seizure nursing interventions.

Back 3

Ensure rescue equipment is at the bedside. oxygen, an
oral airway, and suction equipment.
 Inspection of the client’s environment should be conducted.
 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: Interventions.

Back 4

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

Front 5

Nursing responsibilities after a seizure.

Back 5

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 6

Nursing Safety Responsibilities: Fire

Back 6

(RACE):
Rescue: Protect and evacuate clients in immediate danger.
Alarm: Report the fire.
Contain: Contain the fire
Extinguish: Extinguish the fire.

Front 7

What are the 3 classes of Fire?

Back 7

 Class A: Paper, wood, upholstery, rags, or other trash
 Class B: Flammable liquids and gases
 Class C: Electrical Fires

Front 8

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

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

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.

Front 10

Disaster

Back 10

an event that causes human suffering and demands more resources than are available in the community. It overwhelms, at least temporarily, the capacity of a hospital.

Front 11

Disaster Preparedness

Back 11

A type of management that includes preparedness for natural, man-made, or terrorist disasters.

Front 12

What does FEMA stand for?

Back 12

Federal Emergency Management Agency

Front 13

What should pre-disaster planning include?

Back 13

identification and assessment of population at risk.

Front 14

Pandemic

Back 14

A world-wide event that can be classified as a disaster.

Front 15

Mass Casualties

Back 15

Overwhelm the resources of the individual hospitals and possibly the resources of the community's health system

Front 16

Internal Emergencies

Back 16

loss of electric power or portable water and severe damage or casualties within the facility related to fire, severe weather, an explosion, or terrorist.

Front 17

External Emergencies

Back 17

Includes hurricanes, floods, volcano eruptions, earthquakes, pandemic flu, industrial accidents, and terrorist acts.

Front 18

Nursing Responsibilities during a disaster include:

Back 18

- Triage
- Prioritizing care of victims
- Transferring those requiring immediate attention.

Front 19

Prioritizing care: to make space, nurses are in charge of discharging hospitalized clients. The following types of clients are discharged:

Back 19

-clients who are hospitalized for diagnosis or observation and are not bedridden.
-clients already close to being discharged.
-postnatal clients and their babies after 24hrs.

Front 20

Triage: Highest priority care is given to:

Back 20

Clients with: life-threatening injuries but a high possibility of survival once stabilized.

Front 21

Triage Second highest priority of care if given to:

Back 21

clients who have injuries that involve systemic complications that are not yet life threatening and can usually wait 45-60 min. for treatment.

Front 22

Triage: Lowest priority of care is given to:

Back 22

clients who have local injuries with immediate complications and can usually wait several hours for treatment.

Front 23

Bioterrorism is classified into 3 categories.

Back 23

A. highest priority agents, risk to national security. Easily transmitted and high mortality rate. ex: smallpox, botulism, anthrax, plague.
B. Second highest priority. Easily disseminated with moderate morbidity and low mortality rates. EX: typhus and cholera.
C. Emerging pathogens that could be engineered in the future for mass dissemination. Easily reproduced + high morbidity and mortality rates. EX: hipha virus, hantavirus.
C.

Front 24

Bioterrorism Nursing primary Prevention:

Back 24

-preparation w/ bioterrorism drills, vaccines, and antibiotics for exposure prophylaxis.
Bioterrorism planning: Designing a response plan, assess for local facilities that have biosafety gear, identify chain of command for reporting attacks, setting up protocols for different biosafety levels of infection control and containment.

Front 25

Bioterrorism Secondary Prevention nursing interventions:

Back 25

-Early recognition
-Activation of response plan
-immediate implementation of infection control and containemnt measures, including decontamination environmental disinfection, protective equipment, and quarantines.
-screening the population for exposure, assessing rates of infection, administering vaccines as available.
-assisting, educating the population regarding symptom infection and management.
-monitoring mortality and morbidity.

Front 26

Bioterrorism Tertiary Prevention nursing interventions:

Back 26

-Rehabilitation of survivors.
-monitoring of medication regimens and referrals.
-evaluating the effectiveness and timeliness of the bioterrorism plan.

Front 27

Hazardous contamination if someone is contaminated nursing interventions for decontaminating:

Back 27

-Water is the universal antidote. For biological hazardous materials, use bleach.
-wear gloves, gown, mask + shoe covers. If clothing contaminated, remove it carefully and slowly.
-cleanse skin with gentle soap and water. Do not use an abrasive scrub or strong detergent, and do not shave hairy areas if there is redness or tenderness.