Ch. 12 - Client Safety
5. A nurse is caring for a newly admitted client who has a documented history of falls. Which of the following is the priority action by the nurse? A. Complete a fall-risk assessment. B. Educate the client and family on fall risks. C. Complete a physical assessment. D. Survey the client's belongings.
A. CORRECT: The greatest risk to this client is injury due to a fall. Therefore, the priority action is to determine the client's fall risk. This will guide the nurse in implementing appropriate safety measures. B. INCORRECT: It is important for family members to be aware of the client's risk for falls. Providing instruction to the client and family is an appropriate nursing action, but this is not the priority action. C. INCORRECT: Completing a physical assessment will help to identify further risk for injury and provide baseline physical data, but this is not the priority action. D. INCORRECT: Surveying the client's belongings (glasses, medications, hearing aids, canes, walkers) may provide clues to potential fall risks. However, this is not the priority action.
3. A nurse observes smoke coming from under the door of the staff lounge. Which of the following is the priority action by the nurse? A. Extinguish the fire. B. Pull the fire alarm. C. Evacuate the clients. D. Close all open doors on the unit.
A. INCORRECT: Although extinguishing the fire is part of the fire response, it is not the priority action. B. INCORRECT: Although pulling the fire alarm is part of the fire response, it is not the priority action. C. CORRECT: Rescue is the first action in the fire response. Protecting and evacuating clients in close proximity to the fire is the priority action. D. INCORRECT: Although containing the fire by closing doors is part of the fire response, it is not the priority action.
4. A charge nurse is designating room assignments for clients who will be admitted to the unit. Based on the nurse's knowledge of fall prevention, which of the following clients should be assigned to the room closest to the nurses' station? A. A 43-year-old client who is postoperative following a laparoscopic cholecystectomy B. A 61-year-old client being admitted for telemetry to rule out a myocardial infarction C. A 50-year-old client who is postoperative following an open reduction internal fixation of the ankle D. A 79-year-old client who is postoperative following a below-the-knee amputation
A. INCORRECT: Although this client just had surgery, risk factors for falls are low based on the client's age and type of surgery. B. INCORRECT: Although this client is on telemetry, this client does not display as many risk factors as another client who is to be admitted. C. INCORRECT: Although this client just had surgery, this client does not display as many risk factors as another client who is to be admitted. D. CORRECT: This client should be assigned to a room near the nurses' station due to risk factors that include client's age, mobility, and balance issues related to the surgery, and potential side effects, such as drowsiness, as a result of analgesic medication.
1. A nurse is caring for a client who was just admitted to the unit after falling at a nursing home. This client is oriented to person, place, and time and can follow directions. Which of the following actions by the nurse are appropriate to decrease the risk of a fall? (Select all that apply.) A. Place a belt restraint on the client when he is sitting on the bedside commode. B. Keep the bed in low position with full side rails up. C. Ensure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment.
A. INCORRECT: It is inappropriate to restrain this client and could be considered false imprisonment. B. INCORRECT: Full side rails for this client may put the client at greater risk for a fall because he may attempt to climb over the bed rails to get out of bed. C. CORRECT: Ensuring that the call light is within reach enables the client to contact the nursing staff to ask for assistance and prevents the client from falling out of bed while reaching for the call light. D. CORRECT: Nonskid footwear may keep the client from slipping. E. CORRECT: A fall-risk assessment serves as the basis for an individualized plan of care.
2. A nurse manager is reviewing care of a client who has had a seizure with nurses on the unit. Which of the following statements by a nurse requires further instruction? A. "I will place the client on his side." B. "I will go to the nurses' station for assistance." C. "I will administer medications as prescribed." D. "I will be prepared to insert an airway."
A. INCORRECT: When a seizure occurs, the client should be placed in a side-lying position to allow for drainage of secretions and to prevent the tongue from occluding the airway. B. CORRECT: During a seizure, the client should not be left alone. The nurse remains with the client and calls for assistance using the call light. C. INCORRECT: Administering medications is an appropriate action by the nurse. D. INCORRECT: Nothing should be placed in the client's mouth except an airway, if needed. A tongue blade can cause injury and airway obstruction.
6. A nurse educator is teaching about the safe use of seclusion and restraints to a group of newly licensed nurses. What should be included in the teaching? Use the ATI Active Learning Template: Basic Concept to complete this item. Under Nursing Interventions, describe six nursing responsibilities when caring for a client in either seclusion or restraints.
Nursing Interventions ◯ Nursing responsibilities include knowing how often the client should be Assessed - Including neurosensory checks of affected extremities (circulation, sensation, mobility). These checks are usually done at least every 2 hr. Offered food and fluid. Provided with means for hygiene and elimination. Monitored for vital signs. Offered range of motion of extremities. ◯ Frequency of client assessments in regard to food, fluids, comfort, and safety should be performed and documented every 15 to 30 min. ◯ Other responsibilities include the following: Explaining the need for the restraint to the client and family, emphasizing that the restraint is needed to ensure the safety of the client and will be used only as long as it is necessary. Obtaining signed consent from client or guardian, if required. Reviewing the manufacturer's instructions for correct application. Removing or replacing restraints frequently to ensure adequate circulation to the area and allowing for full range of motion to the restricted limb. Padding bony prominences. Using a quick-release knot to tie the restraint to the bed frame where it will not tighten when the bed is raised or lowered. Ensuring that the restraint is loose enough for range of motion and with enough room to fit two fingers between the device and the client to prevent injury. Regularly assessing the need for continued use of the restraints to allow for discontinuation of the restraint or limiting the restraint at the earliest possible time. Never leaving the client unattended without the restraint. Completing documentation to include the following: Precipitating events and behavior of the client prior to seclusion or restraint Alternative actions taken to avoid seclusion or restraint The time restraints were applied and removed (if discontinued) Type of restraint used and location Client's behavior while restrained Type and frequency of care (range of motion, neurosensory checks, removal, integumentary checks) Condition of the body part being restrained Client's response when the restraint is removed Medication administration