A client with end-stage lung cancer and metastasis to the brain has been admitted to the medicalsurgical unit. After trying all options to provide a safe
... [Show More] environment, the nursing staff is required
to apply restraints. Which nursing intervention is required for this client?
A.Checking the restraints every 1 to 2 hours
B.Releasing the restraints at least every 2 hours
C.Using chemical sedation instead of restraints
D.Using the most restrictive devices to prevent falls - CORRECT ANSWER B.Releasing the
restraints at least every 2 hours
Definition of Safety - CORRECT ANSWER Safety is the ability to keep the patient and staff
free from harm and minimize errors in care
Definition of The Scope of Safety - CORRECT ANSWER The scope of safety can be described
as:
1- unsafe: possible causing harm or even death
2- safe: to prevent harm or negative outcomes
Definition of The Attributes of Safety - CORRECT ANSWER Best safety practices reduce error
and harm through established protocols, memory checklists, and systems such as bar-code
medication administration
QSEN Competencies - CORRECT ANSWER Patient-Centered Care: the patient or designee as
the source of control and full partner in providing compassionate and coordinated care based on
respect for the patient's preferences, values, and needs
-cultural competence
-family-centered care
Teamwork and Collaboration: functioning effectively within nursing and inter-professional team,
fostering open communication, mutual respect, and shared decision-making to achieve quality
patient care
Evidence-Based Practice: the integration of the best current evidence and practices to make
decisions about patient care
Quality Improvement: a process in which nurses and the inter-professional health care team use
indicators (data) to monitor care outcomes and develop solutions to change and improve care.
Safety: the ability to keep the patient and staff free from harm and minimize errors in care
-critical rescue
-action alert
-drug alert
Informatics & Technology: the access and use of information and electronic technology to
communicate, manage knowledge, prevent error, and support decision-making
SBAR report - CORRECT ANSWER Introduce Yourself.
Situation: tell the "meat of the situation. Why are you calling?
Background: what lead to or relates to the situation
Assessment: assessment findings
Recommendation: state what is needed/desired outcome
Delegation - CORRECT ANSWER Process of transferring a selected nursing task or activity to a
competent UAP
The nurse is always accountable for the task/activity delegated
Supervision - CORRECT ANSWER Guidance or direction, evaluation, and follow-up by the
nurse to ensure a task/activity is performed appropriately
Five Rights of Delegation - CORRECT ANSWER 1- Right task: within the UAP's scope?
2-Right circumstances: patient care settings and resources are appropriate
3-Right Person: UAP competent?
4-Right communication: clear and concise communication
5-Right supervision: guide, direct, evaluate, and follow-up
Don't share your TEAACUP - CORRECT ANSWER Never delegate:
Teaching
Evaluation
Assessment
Advanced interventions
Collaboration
Unstable patients
Planning [Show Less]