Client Safety

b

A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. 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 his medications." D. "I will prepare to insert an airway."

c

A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire. B. Activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit.

d

A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses' station? A. A middle adult who is postoperative following a laparoscopic cholecystectomy. B. A middle adult requires telemetry for a possible myocardial infarction. C. A young adult who is postoperative following an open reduction internal fixation of the ankle. D. An older adult who is postoperative following a below-the-knee invitation.

c d e (A = By restraining the client, the nurse risks liability for false imprisonment.)

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) A. Place a belt restraint on a client when he is sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call right is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment.

a (A = The first action the nurse should take using the nursing process is to assess or collect data from the client. Therefore, the priority action is to determine the client's fall risk. This will guide the nurse in implementing appropriate safety measures.)

The nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment. B. Educate the client and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in his possession.