BH53 JHFRAT & BTB Flashcard

Front

When scoring your patient on seizure precautions with the JHFRAT, you notice the previous nurse scored the patient as a high fall risk per protocol. Do you agree with their assessment?

Back

No, because we do not have any protocols that would require a patient to be a fall risk.

Front

While receiving report, you are told that Ms. Everett is refusing the bed alarm. Upon your assessment of the patient, she is fully oriented and calls appropriately for assistance to the restroom. Do you agree that Ms. Everett is refusing the bed alarm?

Back

No, the patient does not meet the requirements needed to set the bed alarm.

Front

Which of the following medications are NOT considered as a high fall risk medication? Senna, Gabapentin, Benadryl, Ativan

Back

Benadryl

Front

You answer Mrs. Klein's call light & agree to help her to the bathroom. You remember that her primary nurse mentioned in huddle that Mrs. Klein has significant orthostatic hypotension. You help her to the restroom and attempt to stay within arm's reach while she is using the restroom. Mrs. Klein tells you that her orthostatic hypotension isn't real, and she would like to be alone. How do you respond?

Back

Your vitals show that your blood pressure drops when you move, which can make you fall. I would prefer to stay here to keep you safe.

Front

A few days later, you are assigned as Mrs. Klein's primary nurse. After some medication changes, her orthostatic hypotension has resolved. The aide finds you and tells you that the patient is refusing to have someone within arm's reach and that they were going to let the charge know. How do you respond?

Back

The patient does not need staff within arm's reach in the restroom anymore but thank you for trying to keep her safe. Let me show you where you can find her interventions.

Front

When BTB goes live, what will you do towards the end of every shift?

Back

Make sure the whiteboard is updated with interventions, Place a note detailing the patient's interventions, Evaluate your patient for any changes in the day that could impact their risk.

Front

You have just assisted Mrs. Benn to the restroom. While you are in the bathroom with the patient, the aide calls and tells you that your patient next door has breakfast and is asking for her insulin. Mrs. Benn is not orthostatic +, and she calls appropriately to get up. She does have an unsteady gait, which is why you assisted her to the bathroom. What should you do?

Back

Educate Mrs. Benn that you need to step out, to pull her bath light when she is finished, and to not get up without you.

Front

You have floated to another unit who has NOT implemented BTB. You have just assisted Mrs. Benn to the restroom. While you are in the bathroom with the patient, the aide calls and tells you that your patient next door has breakfast and is asking for her insulin. Mrs. Benn is not orthostatic +, and she calls appropriately to get up. She does have an unsteady gait, which is why you assisted her to the bathroom. What should you do?

Back

Let the aide know that you must remain with Mrs. Benn until she is finished.

Front

Which patient would NOT benefit from utilizing a gait belt? 77M who gets dizzy when transferring, 17M with a seizure history who has had multiple falls at home, 26F with a steady gait and no fall history, 87F who is impulsive and has difficulty following commands.

Back

26F with a steady gait and no fall history

Front

While you are charting, the charge nurse lets you know that they noticed your communication tool was not filled out on the patient's whiteboard and requests that you complete it. What is the best response?

Back

"Sorry, I forgot, I will go fill it out now. Would you be able to do this med pass for me while I do that?"