Ch. 26 Safety, Security, and Emergency Preparedness

A school nurse is aware of poisoning risks in the adolescent population. Poisoning in this age group is most often related to which of the following? A Experimentation with drugs and inhalants B The ingestion of substances in the home that contain lead C Exposure to toxic fumes in the home D Malfunction of a carbon monoxide monitor in the home

A Experimentation with drugs and inhalants

The acute care nurse is caring for a client who is at risk for falling. Which desired outcome is most appropriate for this client? A The client will not experience a fall and remains free of injury. B The client will stay in bed. C The client will avoid fall injury by using the call bell and wearing nonslip footwear. D The client will not ambulate without assistance.

A The client will not experience a fall and remains free of injury.

A new mother inquires about the use of a car seat for her infant. Which information provided by the nurse is most accurate regarding the use of a rear-facing safety seat for an infant? a) A rear-facing safety seat should be used for infants and toddlers younger than 2 years old and weighing less than 20 lb. b) A rear-facing safety seat should be used for infants younger than 1 year old or up to the maximum weight for the seat. c) A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat. d) A rear-facing safety seat should be used for infants younger than 1 year old and weighing more than 20 lb.

A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat. Explanation: The American Academy of Pediatrics (AAP) now recommends that infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) remain in a rear-facing safety seat.

A nurse making a home visit for a client living in a high-crime area observes that the apartment building does not have outside lighting. The nurse understands this is an important assessment for which reason? A This assessment finding will make the client less able to go to social gatherings. B Assessment includes risk factors in the home including individual risk and unsafe environment C Although important, this assessment is irrelevant to care. D Nurses in home healthcare are not concerned with safety.

B Assessment includes risk factors in the home including individual risk and unsafe environment

A team of inner city school nurses attends a community conference on child safety during the summer months. Which of the following would be the priority health outcome that these nurses would expect to achieve in summer school? A The students will only swim in the community pool when it hasn't rained for 2 days. B The students will demonstrate proper use of safety equipment while playing sports. C The students will sign up for Fall afterschool programs. D The students will read 400 pages from the summer booklist.

B The students will demonstrate proper use of safety equipment while playing sports.

A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out? A Place it in the client's medical record. B Take it home and keep it locked up. C Maintain it according to agency policy. D Include it with documentation of the error.

C Maintain it according to agency policy.

Bioterrorism has become a commonly used term. What is the definition of bioterrorism? A A verbal threat by those wishing to harm specific individuals B A written threat calculated to produce terror in a family C The deliberate spread of pathogens into a community D A worldwide plan to produce illness and injury

C The deliberate spread of pathogens into a community

Which level of health care provider may make the decision to apply physical restraints to a client? a) LPN team leader b) Nurse practitioner c) Senior personal care assistant d) RN nurse manager

Nurse practitioner Explanation: Current evidence-based research has shown that physical restraints should only be used as a last resort, and only used to prevent injury to staff, clients, or others. Federal and state guidelines, as well as accrediting bodies, such as The Joint Commission, require that restraints be applied only when ordered by a prescriber such as a physician, nurse practitioner, or physician assistant.

RACE

Rescue anyone in immediate danger. Activate the fire alarm and notify the appropriate person. Confine the fire by closing doors and windows. Evacuate patients and other people to a safe area.

The nurse is caring for an 80-year-old patient who was admitted to the hospital in a confused and dehydrated state. After the patient got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this patient? a) Leave the restraints on and talk with her, explaining that she must calm down. b) Take the restraints off, stay with her, and talk gently to her. c) Talk with the patient's family about taking her home because she is out of control. d) Sedate her with sleeping pills and leave the restraints on.

Take the restraints off, stay with her, and talk gently to her.

The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse? a) The 2-year-old helping mom to open the front door of the school. b) The 2-year-old and 6-year-old each holding the mother's hand. c) The 2-year-old leaning against the screen of a window in a classroom. d) The 6-year-old riding a bike on the playground with his friend.

The 2-year-old leaning against the screen of a window in a classroom. Explanation: Windows pose a serious risk to toddlers. Screens can easily give way to the weight of a toddler. This is an unsafe behavior. Toddlers thrive in exploration. The parent must be fastidious in monitoring and helping the toddler accomplish tasks. The buddy system is a great safety tool for school-age children.

When educating families on fire safety in the home, which information is important for the nurse to emphasize? a) Use extension cords to prevent shock. b) Account for all members and then exit together. c) Keep a fire extinguisher in a closet. d) Have a meeting place outside the home in case of fire.

d) Have a meeting place outside the home in case of fire.

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed, despite instructions to remain there. Which initial intervention is appropriate? a) Contact the physician for an order to apply a waist restraint. b) Administer a prescribed dose of lorazepam. c) Assess for the need to urinate. d) Raise the side rails.

Assess for the need to urinate. Explanation: Client needs should be assessed before considering physical or pharmacologic restraint.

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety? a) Run the electrical cord of the pump under the carpet. b) Use an extension cord to provide freedom of movement. c) Obtain a three-prong grounded plug adapter. d) Tape the electrical cord of the pump to the floor.

Obtain a three-prong grounded plug adapter. Explanation: The nurse should obtain a three-prong grounded plug adapter, as it carries any stray electricity back to the ground. Using an extension cord may be an electrical hazard. Taping the electrical cord to the ground and running the electrical cord under the carpet are not appropriate actions for electrical safety.

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which of the following measures would be a high priority recommendation for this client? a) Raising all the side rails of the bed b) Placing the client in a bed with a bed alarm c) Using restraints on the client to prevent a fall d) Providing a bed that is elevated from the floor

Placing the client in a bed with a bed alarm Explanation: Raising all side rails on the bed would be a restraint, and may increase the client's risk of a fall if he or she climbs out of bed. Providing a bed that is elevated would put the client at a greater risk for a fall. Using restraints are not an option at this time, but placing the client in a bed with a bed alarm would help to prevent a fall.

What is the primary role of the nurse in the care of clients that experience domestic violence? a) Identifying health education and counseling measures for the family b) Serving as a witness in court c) Calling the police d) Providing prompt recognition of the potential or actual threat to safety

Providing prompt recognition of the potential or actual threat to safety Explanation: The nurse is often the initial health care provider in contact with an abused child or a battered woman or man. Prompt recognition of the potential or actual threat to safety is crucial, and the nursing assessment may play a vital role in identifying a harmful environment.

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take? a) Evacuate the unit. b) Confine the fire. c) Extinguish the fire. d) Pull the fire alarm lever.

Pull the fire alarm lever. Explanation: The nurse should pull the fire alarm lever. As per the RACE principle of fire management, the flow of activities should be rescue, alarm, confine, and extinguish. The client had already been evacuated by another nurse, so the next action should be to pull the fire alarm lever, followed by confinement of the fire and extinguishing.

What is the most appropriate outcome for the client that has a nursing diagnosis of "Risk for injury related to the use of assistive mobility devices in an unfamiliar environment?" a) The client will identify resources for safety information. b) The client will demonstrate safety measures to prevent falls. c) The client will identify unsafe situations in his or her environment. d) The client will establish safety priorities with family members.

The client will demonstrate safety measures to prevent falls. Explanation: Because this client has been assigned a nursing diagnosis of "Risk for injury related to the use of assistive mobility devices in an unfamiliar environment," the nurse should determine that the client is at risk for falls and, therefore, a good outcome would be to prevent falls.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report? a) The nurse should await results of the x-ray before filing the report. b) The nurse should make a copy of the safety event report and place it in the client's medical record. c) The nurse should record the incident in the client's medical record and fill out a safety event report separately. d) The nurse should include a note on the client's chart that mentions the report.

The nurse should record the incident in the client's medical record and fill out a safety event report separately. Explanation: The nurse completes the safety event report immediately after an unintentional injury and is responsible for recording the incident and its effect on the client in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation.

A school-aged child is admitted to the Emergency Room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the patient? a) Evaluation of all of his cranial nerves b) Initiation of a peripheral intravenous (IV) line for fluid administration c) Assessment of head circumference d) Assessment of vital signs and respiratory status

d) Assessment of vital signs and respiratory status

The nurse needs to plan the interventions necessary to reduce fall risks for the older adult clients at her facility. Which is the strongest indicator that a client is at risk for falls? a) The client uses a rolling walker. b) The client is forgetful. c) The client is on beta blockers and antihypertensive medication. d) The client has fallen before.

d) The client has fallen before.

Ava is a 5-year-old girl admitted to the ICU status post head trauma from a bike injury. She is awake but confused, and continues to pull at her IV tubing and catheter. A restraint is ordered. Which of the following might be appropriate for Ava? Select all that apply. a) A sedating medication b) Isolation c) Four-point soft restraints d) Four side rails up

• A sedating medication • Four side rails up Explanation: The use of four-point restraints and isolation would likely increase her agitation. These would be appropriate if her behavior was violent or if her behavior posed an immediate threat to herself or others, such as trying to climb out of the bed.

Choice Multiple question - Select all answer choices that apply. A nurse is using the DAME acronym to perform fall assessments on older adults in a home health care setting. Which examples of nursing actions follow this guideline? (Select all that apply.) a) D—A nurse decreases the amount of pain killers administered to patients. b) D—A nurse assesses drug and alcohol use of the patients. c) E—A nurse assesses the energy level of patients prior to scheduling activities. d) M—A nurse reviews patient charts for medical problems affecting falls. e) A—A nurse assesses the age-related physiologic status of the patients. f) M—A nurse manages the amount of time patients spend alone.

• D—A nurse assesses drug and alcohol use of the patients. • A—A nurse assesses the age-related physiologic status of the patients. • M—A nurse reviews patient charts for medical problems affecting falls. Explanation: Home health care nurses frequently use the acronym DAME to assess the risk for falling in older adults at home. The D stands for drug and alcohol use; the A stands for age-related physiologic status; the M is for medical problems; and the E represents environment.