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1

safety precautions

- lock wheels of the wheelchair to prevent it from moving on the client when sitting down
- call bell should be within reach @ all times, teach client to use call bell
- keep clients bed in low position
- put fall risk id on clients wrist

2

dirty linen

- all linen that touches floor should get put in linen bag

3

location of pt

pt at risk for fall should be near the nursing station

4

history of falls precuations for showers

put a bath seat in it

5

gait belt

helps support the client while walking. gait belt keeps the client center of gravity stable and helps prevents falls

6

precautions

- 95 mask is required for airbone precautions
- gloves are required when coming in contact with bodily fluids
- hand hygiene should be preformed in between every glove use

7

hippa

- when complying with hippa remember that documentation provides info to facilitate communication amoung members of the health care team and plan appropriate therapies when evaulating progress

8

insurance

- health care facilites hvae insurance that covers all employees
- recommended that nurses obtain their own professional liability insurance

9

violations of hippa

- sharing a computer password with coworkers would violate hippa
- sharing lab findings with a client family would be a violation of hippa unless the family is considered an authorized person

10

documentation provides

info to facilitate communication among all members of the healthcare team

11

interprofessional team

- an occupational therapist can assist with clients who have physical challenges with adaptive devices to help with self care activities

12

applying critical thinking skills

helps pt focus on their values and beliefs within their mangement of care

13

what does a nurse consider whom is critically thinking

immediate action with a pt condition worsens

14

a nurse who improves plan of care....

while thinking back on interventions and their effectiveness is critically thinking

15

what does concept map promote

clinical decisions and critical thinking -

16

nursing process and exploring other option for pt care

promote critical thinking

17

cane

- instruct client to move a cane an advance their weak leg forward to the cane followed by the advancing strong leg past the cane

- provides clients body weight to be distributed between the cane and the stronger leg

18

where should height of the cane be

equal distance between the floor and the hip

19

which side should the cane be on

strong side of pt. body

20

how should the elbows be when holding cane

keep their elbow slightly flexed when they use their cane

21

walker

client should lift the walker in advance it and then set it down
- nurse should walk slightly behind client who is using a walker in case they need assistance

22

how should the client move feet with walker?

the client should move one foot up to the walker and move the walker first

23

where should the walker land on a person body

below the level of the clients waste

24

nursing process first step

assessment

includes:
- organizing clients data
- nurse should assess the client's date first and then analyze the data to determine what is a priority

25

steps of nursing process

assessment
analysis
planning
implementation
evaluation

26

nursing plan of care

comes after implementation of care
- plan following by evaluation to determine the effectiveness of the interventions that the nurse has done

27

sterile field

-open package over a sterile package over the middle of sterile field
- pull flaps of the package away from body, grasping it from side to side to avoid reaching over the sterile field and contaminating
- label into palm of hand so that the solution doe snot drip down the label in ruin it

28

restraints

- use a quick release tie fro easy removal in emergency
- two fingers should fit under restraint
- padding should be applied against bony promises with restraints to prevent friction and potential skin breakdown

29

how often should restraints be removed

remove every two hours according to facilities policy
- assess skin and whether or not the restraint is too tight

30

where should restraints be secured to

an area of the bed frame that moves with the client when repositioning
- not to the siderail
- head of bed is okay