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WorksheetsGU, Falls, & Restraints
Total questions: 10
Worksheet time: 10mins
What is a possible complication of a catheter associated urinary tract infection (CAUTI)?
dysuria
pyelonephritis
bacteremia
foul-smelling urine
sepsis
You respond to a client's room for a chair alarm that has been triggered. The patient is noticably frustrated and asks you why they require an alarm on their chair. The following is the best response.
"You are at a high risk for falls."
"The alarm is required because you are not allowed to get out of your chair."
"We need to make sure that you do not get out of the chair by yourself."
"The alarm reminds you to call for help before you get out of your chair."
The American Hospital Association issued a recommendation to standardize the colors of wrist bands in hospitals. Choose the correct wrist band colors.
yellow for allergies, red for fall risk, and purple for DNR
yellow for DNR, red for allergies, and purple for fall risk
yellow for fall risk, red for allergies, and purple for DNR
yellow for allergies, red for DNR, and purple for fall risk
The most common causative pathogen for urinary tract infections is
Klebsiella pneumoniae
Escherichia coli (E. Coli)
Staphylococcus saprophyticus
Proteus mirabilis
The following would be included in a nursing care bundle to prevent Catheter Associated Urinary Tract Infections: (Select all that apply)
Maintain a closed drainage system
Keep the drainage bag below the level of the bladder
Draw urine samples from the drainage spigot on the urinary drainage bag.
Before transferring the client, empty the drainage tube in the drainage bag and empty the bag.
Perform perineal hygiene daily and after a bowel movement.
When catheterizing a male patient the client is noticeably nervous and clinching his abdominal muscles. The following is the best response by the nurse.
"Relax, this will be over in a few seconds"
"Would you like me to come back and try this later?"
"Take deep breaths, and exhale slowly"
"Can you please tell me your name and date of birth?"
You have successfully placed a urinary catheter on a 75 year-old male patient. As you are inflating the balloon after insertion the patient begins to complain of pressure in his lower abdomen. The best course of action is to
Deflate the balloon and slowly advance the catheter. Re-inflate the balloon.
Deflate the balloon and remove the catheter. Dispose of the catheter and re-start the procedure.
Deflate the balloon and slowly retract the catheter. Re-inflate the balloon.
Advance the catheter and assess the client for pain.
The following are fall prevention interventions for low risk clients except for
Client given fall education upon admission.
Chair alarm pad in use when sitting in chair.
Oriented to call light.
Bed in low and locked position.
Environment cleared of hazards.
According to the Agency for Healthcare Research and Quality's (AHRQ) Intervention Bundle to reduce the risk of falls, which of the following is to occur after a fall or near fall?
Hourly comfort care and safety rounds
Patient education through teach-back
Placing a mat on the floor next to the clients bed
Safety huddle
Which of the following is an objective for the proper use and application of a client restraint?
Reduce the risk of patient injury from falls.
Prevent interruption of therapy such as traction, IV infusions, nasogastric tube feeding, or Foley catheterization.
Prevent patients who are confused or combative from removing life-support equipment.
Reduce the risk of injury to others by the patient.
