The nurse is performing the Timed Get Up and Go (TUG) assessment. ...

[natalie2426]

The nurse is performing the Timed Get Up and Go (TUG) assessment. Which actions will the nurse take? (Select all that apply.)
 
  a. Ranks a patient as high risk for falls after patients takes 18 seconds to complete
  b. Teaches patient to rise from straight back chair using arms for support
  c. Instructs the patient to walk 10 feet as quickly and safely as possible
  d. Observes for unsteadiness in patient's gait
  e. Begins counting after the instructions
  f. Allows the patient a practice trial

Question 2

A patient requires restraints after alternatives are not successful. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care? (Select all that apply.)
 
  a. Health care provider orders restraints prn (as needed).
  b. Health care provider writes the type and location of the restraint.
  c. Health care provider renews orders for restraints every 24 hours.
  d. Health care provider performs a face-to-face assessment prior to the order.
  e. Health care provider specifies the duration and circumstances under which the restraint will be used.

[bimper21]

Answer to Question 1

ANS: C, D, F
The nurse instructs the patient to walk 10 feet (3 m) as quickly and safely as possible and observes for unsteadiness in the patient's gait. For accuracy, a patient should have one practice trial that is not included in the score. Patient taking less than 20 seconds to complete TUG is adequate for independent mobility. Score over 30 seconds is dependent and at risk for fall. Counting does not begin after instructions. The patient rises from a straight back chair without using arms for support.

Answer to Question 2

ANS: B, D, E
A physician's/health care provider's order is required, based on a face-to-face assessment of the patient. The order must be current, state the type and location of restraint, and specify the duration and circumstances under which it will be used. These orders need to be renewed within a specific time frame according to the policy of the agency. In hospital settings each original restraint order and renewal is limited to 8 hours for adults, 2 hours for ages 9 through 17, and 1 hour for children under age 9. Restraints are not to be ordered prn (as needed).