Fundamentals · Unit 1

🛡️ Unit 1

Safe & Effective Care Environment · 13 topics

My own notes. Rewritten from scratch — nothing here is copied from a review module.

Ch 1Health Care Delivery Systems

This topic covers where care happens, who pays for it, and how clients move between settings. Exam questions usually ask you to match a service (rehab, hospice, home health, urgent care) to the right client, or to label an intervention as primary, secondary, or tertiary prevention.

Three levels of preventionPrimary prevention stops disease before it starts (immunizations, seat belt teaching, prenatal vitamins). Secondary prevention detects existing disease early (mammogram, blood pressure screening, colonoscopy, PPD testing). Tertiary prevention limits damage from established disease (cardiac rehab, stroke physical therapy, diabetic foot care teaching).

Levels of care settingsPrimary care is the ongoing first-contact provider (clinic, provider office); secondary care is hospital-based acute treatment; tertiary care is highly specialized service such as burn centers, transplant units, and neonatal intensive care. Restorative care includes rehabilitation and skilled nursing facilities; continuing care includes long-term care and assisted living.

Home health criteriaInsurance coverage for home health typically requires a provider order, a skilled need (wound care, IV therapy, teaching, skilled assessment), and for Medicare that the client be essentially homebound. Home health is intermittent and time-limited, not custodial or around-the-clock care.

Hospice versus palliativeHospice serves clients with a terminal prognosis of roughly six months or less who choose comfort over curative treatment. Palliative care is symptom and quality-of-life management that can be given at any stage of illness and can run alongside aggressive treatment.

Medicare partsPart A covers inpatient hospital, skilled nursing facility, home health, and hospice; Part B covers outpatient services, provider visits, and durable medical equipment; Part C is a private managed-care alternative bundling A and B; Part D covers prescription drugs. Medicare is age 65 and older plus certain disabilities and end-stage renal disease.

Medicaid and prospective paymentMedicaid is jointly funded by federal and state government for low-income clients, and eligibility rules differ by state. Under prospective payment, facilities are reimbursed a preset amount based on diagnosis group rather than length of stay, which is why early discharge planning and preventing readmission matter financially.

Managed care structuresHealth maintenance organizations require use of in-network providers and a referral from a primary care gatekeeper for specialists. Preferred provider organizations allow out-of-network use at higher out-of-pocket cost and generally do not require referrals.

Case management roleA case manager coordinates services across settings, controls cost, monitors resource use, and arranges post-discharge referrals; the case manager does not provide hands-on bedside care. Utilization review evaluates whether the level of care is appropriate and justified.

Accreditation and qualityAccrediting bodies survey facilities against safety and quality standards, and facilities must demonstrate compliance to maintain reimbursement eligibility. Quality improvement is data-driven and system-focused; it examines processes and trends rather than blaming an individual staff member.

Classify prevention by where the client is in the disease process, not by the setting: no disease yet equals primary, screening a symptom-free client equals secondary, and managing or rehabilitating existing disease equals tertiary.

Never delay discharge planning until discharge day; planning begins at admission, because unmet home needs are a leading cause of readmission.

Ch 2The Interprofessional Team

This topic is about knowing which discipline to call for which problem and how to hand off information cleanly. Most questions describe a client need and ask which referral the nurse should initiate, or ask what belongs in a handoff report.

Nurse as coordinatorThe registered nurse assesses the client holistically, identifies needs that fall outside nursing, initiates referrals, and follows up to confirm the referral was completed. Coordination and continuity of care are nursing responsibilities that cannot be handed off.

Physical versus occupational therapyPhysical therapy addresses gross mobility: strength, gait training, transfers, balance, and assistive devices such as walkers and crutches. Occupational therapy addresses fine motor skill and activities of daily living such as dressing, bathing, eating, and adaptive equipment for the home and workplace.

Speech-language pathologyRefer to speech-language pathology for swallowing problems as well as speech and language deficits. Any client who coughs, chokes, or has a wet-sounding voice after swallowing, or who has had a stroke, needs a swallow evaluation before oral intake.

Dietitian referralsA registered dietitian calculates individualized calorie and nutrient needs, manages enteral and parenteral nutrition formulas, and teaches therapeutic diets. Refer for unintended weight loss, poor wound healing, low albumin or prealbumin, new diabetes, and new dialysis.

Respiratory therapyRespiratory therapists deliver nebulizer and inhaler treatments, manage ventilators and oxygen delivery devices, perform chest physiotherapy and suctioning, and obtain arterial blood gases. They also teach inhaler and incentive spirometry technique.

Social work and chaplaincySocial workers address financial barriers, insurance and housing problems, suspected abuse or neglect, substance use resources, and placement. Chaplains or spiritual care address spiritual distress, end-of-life meaning, and religious practice requests, and should be offered rather than assumed.

Structured handoff contentA handoff includes identity and code status, the current situation and reason for admission, relevant background, most recent assessment and vital signs, pending tests or treatments, and specific recommendations or watch items. Use a standardized format, allow the receiver to ask questions, and read back critical information.

Interprofessional conferenceAn interprofessional care conference brings disciplines together to set shared goals for a complex client; the client and family should be included whenever possible. The nurse contributes ongoing assessment data and the client's own stated priorities.

Conflict and closed loopAny team member may stop a process for a safety concern, and assertive communication about safety is expected regardless of hierarchy. Closed-loop communication means the receiver repeats back the order or message and the sender confirms it is correct.

Match the referral to the deficit: mobility and gait to physical therapy, activities of daily living and fine motor to occupational therapy, swallowing and communication to speech-language pathology, and resources or placement to social work.

Do not give a handoff report while distracted or without the receiver being able to ask questions; incomplete handoff is one of the most common root causes of preventable harm.

Ch 3Ethical Responsibilities

Ethics is about what a nurse should do when values conflict, as opposed to law, which is about what a nurse must do. Test items usually give a scenario and ask which ethical principle is being upheld or violated, so learn the principles by their one-word definitions.

AutonomyAutonomy is the client's right to make their own decisions, including decisions the team disagrees with, as long as the client is competent and informed. Supporting a client who refuses chemotherapy or blood products is autonomy in action.

Beneficence and nonmaleficenceBeneficence is acting to benefit the client, such as staying with a frightened client or advocating for better pain control. Nonmaleficence is avoiding harm, such as holding a medication when the client's vital signs make it unsafe or verifying a questionable dose.

JusticeJustice is fair and equal distribution of care and resources regardless of ability to pay, diagnosis, personal history, or social status. Assigning care by acuity rather than by insurance status is a justice example.

Fidelity and veracityFidelity is keeping promises and following through, such as returning at the time you told the client you would. Veracity is telling the truth, including not misleading a client about a diagnosis, prognosis, or the purpose of a medication.

ConfidentialityClient information may be shared only with those directly involved in that client's care and only to the extent needed. Discussing clients in elevators, hallways, or on social media violates confidentiality even when no name is used, if the client could be identified.

Dilemma versus legal issueAn ethical dilemma exists when two defensible options conflict and there is no clearly correct answer, such as honoring a do-not-resuscitate request the family opposes. A situation with a clear right answer defined by law or policy, such as a nurse diverting narcotics, is a legal problem, not a dilemma.

Ethics committee functionAn ethics committee provides education, policy guidance, and non-binding case consultation; it does not make the decision for the client or family. Any team member, and often the client or family, can request a consult.

Advocacy and personal valuesAdvocacy means supporting the client's expressed wishes and ensuring they have the information to decide, not steering them toward what the nurse would choose. Values clarification means recognizing your own beliefs so they do not intrude on care.

Conscientious objection limitsA nurse may decline to participate in a specific procedure that violates deeply held personal beliefs, but only through proper channels and only if a qualified replacement provides the care. Care cannot be abandoned or delayed in an emergency.

When a competent, informed client makes a choice the nurse or family dislikes, the correct action is to support the decision and notify the provider; autonomy outweighs the team's preference.

Never access or share a client record that you are not caring for, including your own family members or coworkers.

Ch 4Legal Responsibilities

This topic covers the laws that define nursing practice and the specific acts that create liability. Expect questions on the four elements of malpractice, on which intentional tort a scenario describes, and on who is responsible for each part of informed consent.

Nurse practice actEach state's nurse practice act is the law defining scope of practice, licensure requirements, and grounds for discipline, and the board of nursing enforces it. When facility policy conflicts with the practice act, the practice act controls, and the nurse is accountable for practicing within it.

Four elements of malpracticeTo prove nursing malpractice, all four must be present: a duty to the client, breach of that duty by failing to meet the standard of care, causation linking the breach to the outcome, and actual damages or harm. A mistake that causes no harm may still violate policy but generally fails the damages element.

Common negligence examplesFrequent liability sources include medication errors, failing to assess or reassess, failing to report a change in condition to the provider, failure to prevent falls, burns, retained objects, and inadequate documentation. Following an order the nurse knows to be unsafe does not transfer the liability away from the nurse.

Assault and batteryAssault is threatening a client with unwanted contact so they fear it will occur, such as threatening to force an injection. Battery is actually carrying out the contact without consent, including performing a procedure after the client refused.

False imprisonmentRestraining a client, physically or chemically, or confining them without an order, consent, or emergency justification is false imprisonment. Threatening to restrain a client who wants to leave against medical advice also qualifies.

Defamation and privacySlander is spoken and libel is written communication of false information that damages reputation, such as documenting that a client is an addict without clinical basis. Invasion of privacy includes photographing a client or exposing the body unnecessarily.

Informed consent rolesThe provider performing the procedure must explain the diagnosis, the nature and purpose of the procedure, the risks and benefits, alternatives, and the consequences of refusal. The nurse witnesses the signature, verifies it is voluntary and that the client appears to understand, and notifies the provider if the client cannot explain the procedure.

Advance directivesA living will states desired treatment if the client cannot speak; a durable power of attorney for health care names a decision-maker. Facilities must ask about advance directives at admission, the client may revoke one at any time, and a do-not-resuscitate order requires a provider order in the chart.

Mandatory reportingNurses are mandated reporters for suspected child and vulnerable adult abuse or neglect, certain communicable diseases, and gunshot and stab wounds; reporting requires reasonable suspicion, not proof. Good Samaritan laws provide limited protection for volunteer emergency aid given within one's skill level and without payment.

Incident reportsAn incident report is an internal quality document completed as soon as possible after an event, containing only objective facts and statements in quotation marks. Do not photocopy it, do not chart that one was filed, and do not place it in the client record; do chart the event itself and the client's condition.

For any liability question, run the four malpractice elements in order (duty, breach, causation, damages); if any element is missing, it is not malpractice.

Never carry out an order you believe is unsafe or that you do not understand; clarify with the provider first and document the clarification.

Ch 5Information Technology

This topic combines electronic record use, privacy safeguards, and documentation rules. Questions usually test what makes documentation legally defensible and which everyday behaviors breach protected health information.

Documentation timingChart as soon as possible after care and never before an intervention is performed; charting in advance is falsification. If an entry is added later, label it as a late entry with the current date and time and reference the time of the actual event.

Correcting an errorOn paper, draw a single line through the entry so it remains readable, write the word error or mistaken entry, and add your initials, date, and time. Never erase, use correction fluid, black out, or write over an entry; electronic systems keep an audit trail and require the built-in amendment function.

Objective and factual chartingRecord what you observed, measured, and did, plus the client's own words in quotation marks. Avoid conclusions such as appears intoxicated or seems anxious without supporting data, and never chart care that another person performed.

Abbreviation safetyAvoid abbreviations that are commonly misread, such as writing units rather than U, and writing daily rather than QD. Use a leading zero before a decimal, as in 0.5 mg, and never a trailing zero, as in 5.0 mg, which is easily read as 50.

Access and audit trailsElectronic records log every user's access by unique credentials, so record access is traceable and audited. Curiosity access to a celebrity, coworker, or family member record is a reportable violation and a common cause of termination even without disclosure.

Password and screen practicesNever share your login, log out or lock the screen before stepping away, position monitors away from public view, and use screen timeouts. Never let another staff member document under your credentials.

Minimum necessary ruleDisclose only the smallest amount of protected health information needed for the purpose at hand, and only to people involved in that client's care. Verify identity before releasing information by phone, and use only a facility-approved secure method for transmission.

Social media rulesDo not post client images, room views, or descriptive details, even in a private group and even without a name, because indirect identifiers can breach privacy. Photographs of clients require specific written consent and an approved device.

Clinical decision supportComputerized provider order entry reduces transcription and legibility errors, and alerts flag allergies, interactions, and duplicate therapy. Alerts support judgment but do not replace it; a nurse who overrides a warning is still accountable for verifying safety.

Downtime proceduresDuring system downtime, use paper downtime forms, then enter the documentation into the record once the system returns, labeled with the original date and time of care. Keep verifying orders and medications against the paper record until reconciliation is complete.

Documentation must be timely, accurate, objective, complete, and attributable to the person who provided the care; anything charted before care or under someone else's login is falsification.

Never share your electronic record password or leave a workstation logged in and unattended.

Ch 6Delegation and Supervision

Delegation questions ask which task can be given to whom, and they are answered by scope of practice, not by how busy the nurse is. Learn the tasks the registered nurse can never delegate, then sort the rest between licensed practical nurses and assistive personnel.

Five rights of delegationDelegate the right task, under the right circumstances, to the right person, with the right direction and communication, and with the right supervision and evaluation. All five must be satisfied; the nurse who delegates keeps accountability for the outcome.

Never delegated by the RNThe registered nurse retains initial assessment, analysis and nursing diagnosis, care planning, client and family teaching, evaluation of outcomes, and any task requiring nursing judgment. Unstable clients and unpredictable situations stay with the registered nurse.

Licensed practical nurse scopeAn LPN or LVN typically cares for stable clients with predictable outcomes: administering most oral, subcutaneous, and intramuscular medications, sterile dressing changes, tracheostomy care, suctioning, enteral feedings, urinary catheter insertion, and data collection reported to the registered nurse. Blood products, intravenous push medications, and total parenteral nutrition are generally outside LPN scope, and specifics vary by state.

Assistive personnel scopeAssistive personnel perform activities of daily living, bathing, feeding clients without swallowing risk, ambulation and transfers, repositioning, toileting, bed making, specimen collection, weights, intake and output, and vital signs on stable clients. They may report values but may not interpret them or decide what to do about them.

Direction that actually worksGive the specific task, the expected time frame, exactly what to report and when, and the limits of the task. Telling assistive personnel to report a systolic pressure below 100 or a heart rate above 110 immediately is adequate direction; telling them to let you know if anything seems off is not.

Supervision and follow-upAfter delegating, the nurse monitors performance, is available for questions, obtains the results, and evaluates the client outcome. If a task was done incorrectly, correct it privately and immediately and reassess the client.

Right to refuse an assignmentA nurse may refuse an assignment that is unsafe or outside their competence, but must notify the supervisor through the chain of command rather than simply leaving. Abandoning assigned clients after accepting report can result in licensure discipline.

Priority frameworksUse airway, breathing, circulation first, then Maslow's hierarchy with physiologic needs before safety, love and belonging, esteem, and self-actualization. Choose acute over chronic, actual over potential problems, and unexpected findings over expected ones.

Assignment versus delegationAssignment moves a task that is already within the receiver's scope and job description; delegation transfers a task from the nurse's own scope to another person. Either way, the registered nurse remains accountable for supervision and for the client's outcome.

If a task requires assessment, teaching, evaluation, or judgment, or if the client is unstable, the registered nurse keeps it; everything else is sorted by license and job description.

Never delegate the care of an unstable client or a client whose response to an intervention cannot be predicted.

Five rights of delegation: right task, circumstance, person, direction, supervision.

Ch 7Nursing Process

The nursing process is the five-step problem-solving framework that structures nearly every exam question: assessment, analysis or diagnosis, planning, implementation, and evaluation. When a question asks what to do first, the answer is usually to gather more assessment data unless the client is in immediate danger.

Assessment stepCollect subjective data (what the client reports, such as pain or nausea) and objective data (what you can measure or observe, such as blood pressure, a wound appearance, or laboratory values). Validate questionable data and get information from the client first when possible before secondary sources.

Analysis and diagnosisCluster related data, identify the problem, and state it as a client problem the nurse can treat, distinct from the medical diagnosis. A complete statement includes the problem, the related cause or etiology, and the supporting evidence, for example impaired skin integrity related to prolonged immobility as evidenced by a stage 2 sacral pressure injury.

Actual, risk, and health promotionAn actual problem has present signs and symptoms; a risk problem has no signs yet but identifiable risk factors and therefore no as-evidenced-by clause. A health promotion problem reflects a client's readiness to improve an already adequate behavior.

Planning and goal writingGoals must be client-centered, measurable, realistic, and time-limited: the client will ambulate 20 feet with a walker twice daily by postoperative day two. Goals describe what the client will do, not what the nurse will do, and short-term goals are met within days while long-term goals extend over weeks.

Priority settingRank problems using airway, breathing, and circulation first, then safety, then physiologic needs, then psychosocial. Life-threatening and unstable problems always precede important but non-urgent teaching or comfort needs.

ImplementationInterventions may be independent (nurse-initiated, such as repositioning or teaching pursed-lip breathing), dependent (require a provider order, such as medications), or collaborative (carried out with other disciplines). Reassess the client immediately before performing the intervention to confirm it is still appropriate.

EvaluationCompare the client's actual response with the measurable goal and state whether it was met, partially met, or not met. If the goal was not met, return to assessment to determine why, then revise the diagnosis, goal, or interventions rather than simply repeating them.

Types of assessmentA comprehensive assessment is done at admission and establishes a baseline; a focused assessment targets one system or problem; an ongoing assessment tracks change over time; an emergency assessment is a rapid airway, breathing, circulation check. Match the type to the situation the question describes.

Concept mapping and continuityThe nursing process is cyclical and continuous, not a one-time sequence, and the plan of care is revised whenever the client's status changes. All disciplines and shifts work from the same current plan, which is why documentation of revisions matters.

When a question asks what the nurse does first and no life-threatening problem is present, choose the assessment option; you cannot intervene correctly on data you have not collected.

Never write a nursing diagnosis that names a medical condition or blames a provider, and never carry out a planned intervention without first confirming the client's current status.

ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation.

Ch 9Admissions, Transfers, and Discharge

This topic covers the nurse's specific duties at each transition point in a client's stay. Questions focus on what must be done at admission, what belongs in a transfer report, and who has authority to discharge a client.

Admission essentialsOn admission, verify identity with two identifiers, apply the identification and allergy bands, obtain baseline vital signs, height, and weight, complete a comprehensive history and physical assessment, and review advance directives. Orient the client to the room, call light, bed controls, bathroom, and unit routines, and document that orientation.

Medication reconciliationObtain a full list of home medications including doses, times, over-the-counter products, herbals, and supplements, and compare it with the admission orders. Reconciliation is repeated at every transfer and again at discharge to prevent omissions and duplications.

Valuables and belongingsEncourage the client to send valuables home. Anything kept must be listed on an inventory form describing items in neutral terms (yellow metal ring rather than gold ring), signed by the nurse and the client, and secured per policy; document dentures, glasses, hearing aids, and prosthetics.

Reducing admission anxietyIntroduce yourself and the staff by name and role, explain what will happen and when, allow the client to keep a personal item, and answer questions before starting paperwork. Relocation stress is common in older adults and can present as confusion, withdrawal, or agitation.

Transfer report contentGive the receiving unit or facility the client's name, age, provider, diagnosis and surgical history, code status, allergies, current status and recent vital signs, medications with the last doses given, treatments, devices such as lines and drains, isolation status, and functional and cognitive baseline. Send the record, medication administration record, and belongings, and document the time, method of transport, and who received the client.

Discharge planning starts at admissionAssess the home environment, caregiver availability, financial and transportation barriers, and self-care ability from day one, and make referrals early. Late planning is the most common reason for failed discharge and readmission.

Discharge order authorityOnly the provider can write the discharge order; the nurse assesses readiness, completes teaching, removes devices per order, and arranges follow-up. Facility policy commonly requires escort to the exit, and the client should not drive after sedation or anesthesia.

Teaching and teach-backDischarge teaching covers medications with purpose, dose, and side effects, activity and diet limits, wound or device care, follow-up appointments, and specific signs that require calling the provider or emergency services. Provide written instructions at an appropriate reading level and confirm understanding by having the client explain or demonstrate it back.

Leaving against medical adviceA competent client may leave at any time, and preventing them is false imprisonment. Notify the provider, explain the risks, ask the client to sign the against-medical-advice form, document the refusal if they will not sign, and still provide prescriptions, instructions, and safe transportation guidance.

Discharge planning is a continuous process that begins at admission, and only a provider's order actually discharges the client.

Never physically prevent a competent adult from leaving the facility, even against medical advice.

Ch 11Infection Control

This topic is about breaking the chain of infection and choosing the correct precautions and personal protective equipment for a given organism. Expect questions on which isolation category a disease requires, on the order of putting on and taking off equipment, and on hand hygiene exceptions.

Chain of infectionThe six links are infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host. Hand hygiene interrupts the mode of transmission and is the single most effective control measure; immunization protects the susceptible host.

Hand hygiene rulesAlcohol-based rub is acceptable for routine decontamination when hands are not visibly soiled; rub all surfaces until fully dry. Wash with soap and running water for at least 20 seconds when hands are visibly soiled, before eating, after using the restroom, and always after caring for a client with Clostridioides difficile or suspected norovirus, because alcohol does not kill spores.

Standard precautionsApply to every client regardless of diagnosis: treat all blood, body fluids except sweat, non-intact skin, and mucous membranes as infectious. Wear gloves for anticipated contact, add gown, mask, and eye protection when splashing is possible, and never recap needles or reach into a sharps container.

Airborne precautionsUsed for organisms carried on small particles that stay suspended, including tuberculosis, measles, and varicella including disseminated herpes zoster. Place the client in a negative-pressure room with the door closed, wear a fit-tested N95 or higher respirator, and place a surgical mask on the client for necessary transport.

Droplet precautionsUsed for larger respiratory droplets that travel a short distance, including influenza, pertussis, mumps, rubella, meningococcal disease, and group A streptococcal pharyngitis. Use a private room when available, wear a surgical mask on entry, and mask the client during transport; a special air handling room is not required.

Contact precautionsUsed for organisms spread by direct or indirect contact, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Clostridioides difficile, respiratory syncytial virus, scabies, and draining wounds. Wear gown and gloves for all contact with the client or the environment, and dedicate equipment such as stethoscope, thermometer, and blood pressure cuff to that room.

Equipment orderPut on gown, then mask or respirator, then eye protection, then gloves. Remove gloves first, then eye protection, then gown, then mask or respirator, performing hand hygiene after removal; remove the respirator only after leaving the room and closing the door.

Protective environmentSeverely immunocompromised clients, such as those with neutropenia after transplant, need positive-pressure rooms with filtered air, no fresh flowers or standing water, no raw or undercooked foods per policy, and no visitors or staff with any infection. This protects the client from the environment rather than the reverse.

Sterile field principlesThe outer 1 inch of a sterile field is contaminated, anything below waist level or out of direct sight is contaminated, and moisture wicking through a field contaminates it. Hold sterile items above waist and in front of you, open the flap farthest from you first, do not reach across the field, and do not turn your back on it.

Signs and reportingLocalized infection shows redness, warmth, swelling, pain, and purulent drainage; systemic infection shows fever, chills, malaise, and an elevated white blood cell count, though older adults may present only with confusion or a low temperature. Obtain culture specimens before the first antibiotic dose whenever possible and report notifiable diseases per state law.

Match the precaution to the transmission route: airborne needs an N95 and a negative-pressure room, droplet needs a surgical mask within close range, and contact needs gown and gloves plus dedicated equipment.

Never use alcohol-based hand rub as the only hand hygiene after caring for a client with Clostridioides difficile; soap and water are required to remove spores.

Airborne: My Chicken Hez TB (measles, chickenpox/varicella, herpes zoster disseminated, tuberculosis).

Ch 12Client Safety

This topic covers falls, restraints, fire, and the routine verification steps that prevent errors. The most heavily tested content is restraint rules and the correct order of actions during a fire.

Two identifiersVerify the client with two identifiers, such as full name and date of birth, before every medication, treatment, procedure, specimen collection, and blood transfusion. The room number and bed number are never acceptable identifiers.

Fall risk factors and preventionThe strongest predictors are a history of falls, age over 65, altered mental status, impaired mobility or gait, and medications such as sedatives, opioids, antihypertensives, and diuretics. Keep the bed in the lowest position with wheels locked, call light and personal items in reach, adequate lighting, non-skid footwear, and offer toileting on a schedule rather than waiting for the client to call.

Restraint prerequisitesRestraints are a last resort after less restrictive measures fail, require a provider order specifying type, location, reason, and duration, and can never be ordered as needed or for staff convenience. In an emergency the nurse may apply a restraint first and must obtain the order within the time frame set by policy, typically about one hour.

Restraint time limitsFor violent or self-destructive behavior, orders are limited to 4 hours for adults 18 and older, 2 hours for ages 9 through 17, and 1 hour for children under 9, and must be renewed within those intervals. A provider face-to-face evaluation is required within 1 hour of initiating this type of restraint.

Restraint monitoringUse a quick-release knot, tie to the movable bed frame and never to a side rail, and keep two fingers of slack between the restraint and the skin. Check circulation, sensation, and skin frequently per policy, and at least every 2 hours release the restraint to provide range of motion, repositioning, toileting, food, and fluids; document all of it.

Side rails and seclusionRaising all four side rails on a bed is considered a restraint in most settings; two upper rails for mobility assistance is generally not. Seclusion is involuntary confinement alone in a room the client cannot leave and carries the same order and monitoring requirements as violent-behavior restraints.

Fire response orderFollow RACE: rescue anyone in immediate danger, activate the alarm and call the emergency number, contain the fire by closing doors and windows, then extinguish or evacuate. Rescue always comes before pulling the alarm, and ambulatory clients are moved before those requiring a stretcher.

Extinguisher useFollow PASS: pull the pin, aim at the base of the flames, squeeze the handle, and sweep side to side. Use an extinguisher only for a small contained fire when the exit route behind you is clear.

Seizure precautionsKeep the bed low with rails padded and up, suction and oxygen at the bedside, and never place anything in the mouth or restrain the client during a seizure. Turn the client to the side, protect the head, loosen tight clothing, time the seizure, and stay with them until they are fully oriented.

Equipment and event reportingDo not use frayed cords or ungrounded equipment, remove malfunctioning devices from service and label them, and never modify a device. Report near misses as well as actual events, since near-miss data drives system fixes before harm occurs.

Restraints always require a time-limited provider order for a specific behavior, are never ordered as needed, and require release with range of motion, toileting, and nutrition at least every 2 hours.

Never tie a restraint to a side rail, and never restrain or place anything in the mouth of a client who is actively seizing.

Fire: RACE (Rescue, Alarm, Contain, Extinguish) and extinguisher use PASS (Pull, Aim, Squeeze, Sweep).

Ch 13Home Safety

Home safety focuses on hazard assessment and teaching for clients living independently, especially older adults and families with young children. Questions typically describe a home visit and ask which finding needs correcting first or which teaching statement shows understanding.

Fall hazards in the homeRemove throw rugs and clutter from walkways, secure electrical cords along walls, add non-skid strips and grab bars in the tub and next to the toilet, use a raised toilet seat and shower chair as needed, and install handrails on both sides of stairs. Provide bright, glare-free lighting with night lights along the path from bed to bathroom.

Water temperatureSet the water heater to no higher than 120 degrees Fahrenheit, about 49 degrees Celsius, to prevent scald burns in children and older adults with reduced sensation. Test bath water before the client enters, and teach never to leave a child unattended in a tub.

Smoke and carbon monoxide alarmsPlace smoke alarms on every level and near sleeping areas, test them monthly, and replace batteries at least annually. Install carbon monoxide detectors near sleeping areas; headache, dizziness, nausea, and confusion in multiple household members at once suggests carbon monoxide exposure, and the response is to get everyone into fresh air and call for help.

Home oxygen safetyPost no-smoking signs, keep the source at least 5 to 10 feet from open flame, gas stoves, candles, and space heaters, and avoid petroleum-based lubricants, wool, and synthetic fabrics that create static. Secure cylinders upright so they cannot fall, and keep a fire extinguisher in the home.

Medication and poison safetyStore medications and household chemicals in original labeled containers, up high and locked, away from food, and never transfer chemicals into drink bottles. Post the poison control number, and for an ingestion, call poison control before giving anything; do not induce vomiting.

Food safetyKeep the refrigerator at or below 40 degrees Fahrenheit and the freezer at 0 degrees, refrigerate leftovers within 2 hours (1 hour if above 90 degrees), and thaw food in the refrigerator rather than on the counter. Wash hands and surfaces between raw and ready-to-eat foods, and cook poultry to an internal temperature of 165 degrees Fahrenheit.

Child-specific hazardsUse cabinet latches and outlet covers, keep small objects, latex balloons, nuts, grapes, and hot dogs away from children under 4, and set crib slats no more than about 2 and 3 eighths inches apart with no soft bedding. Place infants on their back to sleep, and never leave an infant unattended on an elevated surface.

Car and firearm safetyRear-facing car seats belong in the back seat, never in front of an active airbag, and children remain rear-facing until they exceed the seat's height and weight limits. Firearms should be stored unloaded and locked with ammunition locked separately.

Cognitive impairment adaptationsFor a client with dementia, remove stove knobs or install an automatic shutoff, lower water temperature, secure exterior doors with alarms, remove or lock car keys, and use identification jewelry in case of wandering. Simplify the environment and keep furniture arrangement consistent.

Emergency preparedness at homeKeep an accessible list of medications, allergies, and emergency contacts, a working phone, and a plan with at least two exit routes and a meeting place. Teach clients on life-sustaining equipment to register with the utility company and to have a backup power plan.

In a home safety scenario, address the hazard with the highest chance of immediate serious injury first, which is usually fire, scald, fall, or poisoning risk rather than a general clutter or nutrition concern.

Never allow smoking or open flame near home oxygen equipment.

Ch 14Ergonomic Principles

Ergonomics is about moving clients and objects without injuring the client or yourself. Questions test body mechanics rules, correct fitting and use of canes, walkers, and crutches, and safe transfer sequences.

Core body mechanicsKeep feet apart at shoulder width to widen the base of support, bend at the hips and knees rather than the waist, keep the back straight, and lift with the large leg muscles. Hold the object close to your center of gravity and pivot with your feet instead of twisting your spine.

Push, pull, and slidePushing, pulling, rolling, and sliding require less force than lifting, so use them whenever possible. Raise the bed to your waist height before care, lower the near side rail, and move toward yourself rather than reaching across the bed.

Get help and use equipmentUse mechanical lifts, friction-reducing slide sheets, and transfer boards for clients who cannot bear weight, and get adequate staff for the client's weight and level of assistance. Assess weight-bearing ability and cooperation before every transfer, and never let a client hold onto your neck.

Gait belt and transfer sequenceApply a gait belt snugly around the waist over clothing, grasp it underhand, and stand facing the client with your knees blocking theirs. Position the chair on the client's stronger side at a slight angle, lock all wheels, dangle the client at the bedside first, and let them rise on a count while pushing from the bed rather than pulling on you.

Orthostatic precautionsHave the client sit on the edge of the bed for a few minutes before standing and ask about dizziness. If the client becomes weak or begins to fall during a transfer, ease them to the floor while protecting the head, using your body and a wide stance rather than trying to hold them upright.

Cane techniqueHold the cane on the stronger side, with the top at hip or greater trochanter level and the elbow flexed roughly 15 to 30 degrees, and place the tip about 6 inches to the side and slightly forward. Advance the cane and the weaker leg together, then step through with the stronger leg.

Walker techniqueWith the client standing inside the walker and elbows flexed about 15 to 30 degrees, move the walker forward a comfortable step, then step in with the weaker leg, then the stronger leg. All four points must be in contact before stepping, and the client should never pull up on the walker to stand.

Crutch fitting and gaitsFit crutches so there are 2 to 3 finger widths between the axilla and the underarm pad, with elbows flexed about 20 to 30 degrees; weight is borne on the hands, not the axillae, to prevent nerve damage. Tripod position places the crutch tips about 6 inches in front and to the side of the feet.

Stairs ruleGoing up, the stronger leg leads, followed by the weaker leg and the device. Going down, the device and the weaker leg go first, followed by the stronger leg; remember up with the good, down with the bad.

Positioning and pressure reliefReposition an immobile client at least every 2 hours in bed and encourage shifting every 15 minutes when seated. Keep the head of bed at or below 30 degrees when possible to reduce shear, use a 30-degree side-lying position rather than direct pressure on the hip, float the heels off the mattress, and lift rather than drag when moving a client up in bed.

Weight-bearing rule for devices: the assistive device always moves with or before the weaker leg, and the cane is held on the stronger side.

Never bear weight in the axillae on crutches, and never twist your torso while lifting a client.

Stairs: up with the good, down with the bad.

Ch 15Security and Disaster Plans

This topic covers facility security threats such as infant abduction and workplace violence, plus how nurses respond to internal and external disasters. The most tested concept is mass casualty triage, which prioritizes differently than everyday emergency care.

Mass casualty triage logicIn a disaster, the goal shifts from doing everything for the sickest client to doing the greatest good for the greatest number. Clients with survivable injuries who need limited resources are treated first, while those with catastrophic injuries and minimal survival chance receive comfort measures.

Triage color tagsRed or immediate means life-threatening but survivable with rapid intervention, such as an airway obstruction or uncontrolled bleeding. Yellow or delayed means serious injuries that can wait a short time, such as a stable open fracture; green or minimal means walking wounded; black or expectant means injuries incompatible with survival given available resources.

Internal versus external disasterAn internal disaster occurs within the facility, such as fire, loss of power or water, a chemical spill, or a violent intruder, and may require evacuation or lockdown. An external disaster occurs in the community and floods the facility with casualties, activating the surge plan, staff callback, and discharge of stable clients to open beds.

Evacuation priorityEvacuate ambulatory clients first, then those who need assistance such as wheelchair users, then non-ambulatory or critical clients who require carries or stretcher transport. Move horizontally to a safe compartment beyond fire doors before moving vertically down stairs, and never use elevators during a fire.

Infant and child abductionTransport newborns only in a bassinet, never carried in arms, and release an infant only to a person whose facility photo identification and matching band you verify. Teach parents never to hand the infant to anyone without proper identification, and during an abduction alert, staff monitor all exits, stairwells, and anyone carrying bags or packages.

Workplace violence and de-escalationWatch for escalating cues such as pacing, clenched fists, loud or rapid speech, and invasion of personal space. Maintain a calm voice and open posture, keep an arm's length or more of distance, position yourself between the client and the exit without blocking their way, remove objects that could be thrown, and call for help early.

Active threat responseThe general priority sequence is to escape if a safe route exists, hide behind a locked or barricaded door with lights off and phones silenced if escape is impossible, and confront the threat only as an absolute last resort. Move only the clients you safely can and follow the facility lockdown protocol.

Bioterrorism basicsAnthrax is not spread person to person and is treated with antibiotics after decontamination; smallpox is highly contagious and requires airborne plus contact precautions with a negative-pressure room. Report any suspected exposure cluster to public health immediately.

Chemical and radiation exposureFor chemical exposure, staff don protective equipment and decontaminate the client, usually by removing clothing and irrigating with copious water, before bringing the client into the treatment area. For radiation, limit time near the source, maximize distance, and use shielding, and handle contaminated clothing and dressings as radioactive waste.

Nurse's role in the planKnow your facility's alert codes, your assigned role in the emergency operations plan, the location of emergency supplies and shutoff valves, and the chain of command; disaster response uses a defined incident command structure rather than usual reporting lines. Personal preparedness, including a family plan, is expected so staff can report when called in.

In mass casualty triage, the client tagged for immediate care is the one with a life-threatening but reversible problem, not the one with the most severe injuries overall.

Never carry a newborn in your arms through a unit hallway or release an infant to anyone whose identification you have not verified.

Triage tags: Red = now, Yellow = wait, Green = walk, Black = expectant.