Client Safety Questions ATI

A 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 clients environment D. Make sure the client uses assistive aids in his possession

A. Complete a fall-risk assessment 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.

A nurse manager us 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

B. I will go to the nurses station for assistance During a seizure, the nurse should stay with the client and use the call light to summon assistance

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 the 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 clients call light is within reach D. Provide the Client with nonskid footwear E. Complete a fall-risk assessment

C. Make sure that the clients call light is within reach D. Provide the client with nonskid footwear E. Complete a fall-risk assessment making sure that the call light is within reach enables the client to contact the nursing staff to ask for assistance and events the client from falling out of bed while reaching for the call light. Nonskid footwear keeps the client from slipping A fall-risk assessment serves as the basis for a plan of care the nurse can then individualize for the client

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. Extinguishing the fire B. Activate the Fire alarm C. Move all clients that are nearby D. Close all open doors on the unit

C. Move all clients that are nearby The greatest risk to this client is injury from the fire. Therefore, the priority intervention is to rescue the clients. The nurse should protect and move clients in close proximity to the fire

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 who 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 amputation

D. An older Adult who is postoperative following a below-the-knew amputation The nurse should assign this client to a room near the nurses' station due to risk factors that include the client's age plus the immobility and balance issues that result from this type of surgery