MM - Care/Safety and Hematologic

Any pressure injury that opened in the hospital after admission is consider ?

• Hospital acquired Pressure Injury

• Community Acquired Pressure Injury

• Unit acquired Pressure Injury

• Secondary acquired Pressure Injury

Once a fall risk assessment is completed, you should then:

• Educate the patient and/or family regarding their fall risk

• Effectively communicate high risk patient’s to the care team

• Follow your hospital’s falls prevention policy

• All of the above

You are caring for a patient with a Foley catheter. Which of the following orders from your provider would you question?

• 'Make sure there are no dependent loops or kinks in the tubing.'

• 'Wash your hands before handling the Foley drainage bag.'

• 'Use chlorhexidine wipes to clean around the Foley during each shift.'

• 'Keep the Foley in place for urinary incontinence.

Under what circumstances is it considered acceptable practice for the nurse to document a nursing activity before it is carried out?

• When the activity is routine (e.g., raising the bed rails)

• When the activity occurs at regular intervals (e.g., turning the client in bed)

• When the activity is to be carried out immediately (e.g., a stat medication)

• It is never acceptable

Answer explanation

Rationale: It is never acceptable practice for the nurse to document a nursing activity before it is carried out. This would be very unsafe because many things can cause an activity to be postponed or canceled and prior charting would be inaccurate, misleading, and potentially dangerous. In a few situations, it may be permissible to chart frequent or routine activities some time following the activities such as at the end of a shift or after a particular interval (e.g., every 4 hours) rather than immediately following the activity.

The client has a high-priority nursing diagnosis of Risk for Impaired Skin Integrity related to the need for several weeks of imposed bed rest. The nurse evaluates the client after 1 week and finds the skin integrity is not impaired. When the care plan is reviewed, the nurse should perform which of the following?

• Delete the diagnosis since the problem has not occurred

• Keep the diagnosis since the risk factors are still present

• Modify the nursing diagnosis to Impaired Mobility

• Demote the nursing diagnosis to a lower priority

Answer explanation

Rationale: There is no reason to delete (option 1) or modify (option 3) the nursing diagnosis or demote its priority (option 4) because the risk factors that prompted it are still present.

An element of quality improvement, rather than quality assurance, is which of the following?

• Focus is on individual outcomes

• Evaluates organizational structures

• Aims to confirm that quality exists

• Plans corrective actions for problems

Answer explanation

Rationale: Quality improvement (QI) plans corrective actions for problems.

EBP generally includes careful review of research findings according to guidelines that nurse scholars have used to measure the merit of a study or group of studies.

• True

• False

Many nurses are concerned that too much attention to EBP will draw attention away from the art of nursing care—that nursing will become lost in the science.

• True

• False

Implementation of EBP in nursing is still evolving, as often, nursing interventions are based on experience, tradition, intuition, common sense, and untested theories.

• True

• False

environmental safety

• summary of information about an incident

• An accident that occurs in a health care facility

• adaptation of the environment to prevent incidents & injuries