While working with a certified nursing assistant (CNA) in a local nursing home, the nurse knows that which of the following fall risk and prevention measures may be delegated to the CNA? Select all that apply
a. Remove clutter and spills in patient rooms.
b. Place nonskid slippers on all patients.
c. Answer call lights in a timely manner.
d. Assess each patient for fall risk.
A, B, C
The nurse should be sure that assistive personnel, such as CNAs, are aware of and follow all safety measures and institutional procedures. You can expect that a CNA can remove clutter and spills from a patient room, provide patients with nonskid slippers, lock beds and wheelchairs, and place a fall risk sign on a patient door. What cannot be delegated to assistive personnel is the assessment of a patient for fall risk. This is the responsibility of the nurse and is performed at the time of admission and throughout the length of stay.
You might also like to view...
Your hospitalized schizophrenic patient has been taking clozapine (Clozaril) for several months. You recognize this medication is effective by which of the following patient reports?
A. He no longer has a memory of past psychotic behavior. B. He is drowsier, so less bothered by the hallucinations. C. He no longer hears voices. D. He is more uncomfortable around others.
To examine the genitalia of a 2-year-old female, position her
a. in a froglike position on her caregiver's lap. b. in a semilithotomy position on the examining table without feet in stirrups. c. on her back with legs raised on her caregiver's lap. d. on her side on the examining table.
When diagnosing an MI on a 12-lead ECG, the nurse knows that the reciprocal leads may: Select all that apply
1. Reflect a mirror image of the changes or damage seen in the indicative leads. 2. Be a sign of ischemia in that area. 3. Indicate there is no ischemia in that area. 4. Reflect the same ST segment elevation seen in the indicative leads. 5. Indicate heart failure.
A nurse is looking to address teen gang violence in a nearby community using the principles of community organizing
The nurse has spent a great deal of time in the community performing a community assessment and getting to know residents and key stakeholders. What is the next step? A. Identify core leaders to organize the community around. B. Identify clear goals that relate to the over-arching goal of reducing teen gang violence. C. Identify available resources. D. Create a plan to evaluate their actions.