PHARMACOLOGY 02 FUNDAMENTALS 06A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for
... [Show More] falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention?
1. UAP has attached a bed alarm to the client's gown and bed
2. UAP has been making hourly rounds on the client
3. UAP has lowered the bed and raised all 4 side rails
4. UAP has placed a fall risk ID bracelet on the client's wrist
Explanation:
Placing the client's bed in the lowest position is appropriate, but raising all 4 side rails is considered a form of restraint. Having all 4 side rails up may actually increase clients' risk for falls as they may try to climb up and over the rails. Raising 2-3 side rails is appropriate. The nurse should lower at least one side rail and communicate to the UAP that having all 4 up is inappropriate.
(Option 1) Placing a bed alarm would be an appropriate intervention for this client.
(Option 2) Making rounds at least hourly is appropriate for this client. The nurse should assess if more frequent rounds are warranted.
(Option 4) Placing a fall risk ID band will help communicate to other members of the interdisciplinary team that the client is at risk for falls.
Educational objective:
The nurse should ensure that multiple interventions are put in place for the client at high risk for falls. These include placing the bed in the lowest position with 2-3 side rails up, identifying the client with a fall risk ID band, using bed alarms, and making frequent rounds on the client.
2-Unlicensed assistive personnel report 4 situations to the registered nurse. Which situation warrants the nurse's intervention first?
1. Room 1: Client on a 24-hour urine collection had a specimen discarded by mistake
2. Room 2: Client and family request clergy to administer last rites
3. Room 3: Puncture-resistant sharps disposal container on the wall is full
4. Room 4: Client with diabetes mellitus has an 8 AM fingerstick glucose of 80 mg/dL (4.4 mmol/L)
Explanation:
Health care workers are required to abide by Occupational Safety and Health Administration standards and regulations to reduce work-related injuries (eg, sharps) and exposure to bloodborne pathogens (eg, HIV, hepatitis B and C). A sharps disposal container should not be overfilled and should be replaced on a regular basis to reduce the risk for a needle stick during disposal.
(Option 1) If any urine is discarded by accident during a 24-hour collection test, the procedure must be restarted. A new container will need to be labeled with the appropriate times and date, but immediate intervention is not required.
(Option 2) The nurse will arrange for a visit from clergy to administer the last rites (Sacrament of the Sick), a religious ceremony for Roman Catholic clients who are extremely or terminally ill. Although the situation requires prompt intervention, it does not involve a safety hazard.
(Option 4) A fingerstick glucose of 80 mg/dL (4.4 mmol/L) is normal (70-110 mg/dL [3.9-6.1 mmol/L]) and requires no intervention unless the client received insulin and refuses or is unable to eat.
Educational objective:
Prevention of injury and safety in the workplace should be a priority when the nurse is delegating, planning, or providing nursing care.
3-A comatose client in the intensive care unit has an indwelling urinary catheter. Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections (UTIs)? Select all that apply.
1. Cleanse periurethral area with antiseptics every shift
2. Ensure each client has a separate container to empty collection bag
3. Keep catheter bag below the level of the bladder
4. Routinely irrigate the catheter with antimicrobial solution
5. Use sterile technique when collecting a urine specimen
Explanation:
Health care catheter-associated UTIs are prevalent among hospitalized clients with indwelling urinary catheters. Steps to prevent infections in clients with urinary catheters include the following:
• Wash hands thoroughly and regularly
• Perform routine perineal hygiene with soap and water each shift and after bowel movements
• Keep drainage system off the floor or contaminated surfaces
• Keep the catheter bag below the level of the bladder
• Ensure each client has a separate, clean container to empty collection bag and measure urine
• Use sterile technique when collecting a urine specimen
• Facilitate drainage of urine from tube to bag to prevent pooling of urine in the tube or backflow into the bladder
• Avoid prolonged kinking, clamping, or obstruction of the catheter tubing
• Encourage oral fluid intake in clients who are awake and if not contraindicated
• Secure the catheter in accordance with hospital policy (tape or Velcro device)
• Inspect the catheter and tubing for integrity, secure connections, and possible kinks
(Option 1) Perineal hygiene is performed using soap and water only every shift and as needed. Routine use of antiseptic cleansers is not shown to prevent infection and may lead to the development of drug-resistant bacteria.
(Option 4) Routine irrigation with antimicrobial solution or systemic administration of antimicrobials is not recommended for routine catheter care and infection prevention.
Educational objective:
Routine catheter care to prevent health care catheter-associated UTIs includes routine hand hygiene [Show Less]