Fundamentals Chapter 13: Safety
CPR (Cardiopulmonary Resuscitation)
Primary Assessment: C-A-B-C sequence (trauma related, external uncontrolled bleeding), then A-B-C. •Airway •Breathing •Circulation
Factors contributing to an unsafe patient environment
•Age and ability to understand (children & elderly) •Impaired mobility (CVA, weakness, difficulty ambulating) •Communication (can't get words out d/t CVA, dementia, ALZ) •Pain and discomfort (patients can be angry, anxious, uncomfortable, irritable; in a hurry to get up leads to potential for fall)
Chest Thrusts and Back Blows (foreign body obstruction)
Adults: •Conscious: Heimlich Maneuver or J-thrusts (back blows) •Unconscious: CPR is no response, four abd thrusts thrusts on ground Child: •Conscious: 5 chest thrusts, 5 back blows •Unconscious: CPR Infant: •Conscious: 5 chest thrusts, 5 back blows •Unconscious: CPR
What is the preferred site to check a pulse on an infant while performing CPR? A) Carotid B) Brachial C) Popliteal D) Femoral
Answer: B) Brachial
The nurse is aware that The Joint Commission established the National Patient Safety Goals. Which method is used to monitor how the requirements are met? A) The Joint Commission reviews a written report submitted yearly by the facility. B) The National Patient Safety Goals reviews how the requirements are met. C) Each state monitors the number of safety violations occurring in facilities. D) Each facility determines the ways in which the requirements will be met.
Answer: D Rationale: The National Patient Safety Goals are developed to outline the safety requirements for hospitals. Each facility determines the ways in which requirements will be met.
The nurse is attending an education program about how to avoid back injury at work. Which factor is important for the nurse to apply? A) Recognize that the center of gravity runs midline from head to pelvis. B) The center of gravity will shift with age and weight changes. C) The base of support is strongest when the feet are positioned a foot apart. D) A wide base of support is considered adequate when the feet are shoulder distance apart.
Answer: D Rationale: The optimum distance between the feet is equal to the width of the shoulders.
Mass Casualty Event (MCE)
Bioterrorism: widespread biological released into water, air •anthrax, botulism, smallpox, bubonic plague •onset, location, number of affected, s/s, mortality Chemical: •pulmonary agents: mustard gas, cyanide, sarin •nerve agents: sarin, soman •vesicant agents: mustard, lewsite, phosgene oxime (these remain in an area longer) Nuclear: •"dirty bomb" •attack on nuclear facility
Minimizing Physical Hazards
Body Mechanics: center of gravity (middle point of body), base of support (feets and legs), avoid twisting, bend knees not back, hold weight close to your body, feet/knees at shoulder width; push, pull, or slide when able instead of lifting Adequate rest and appropriate focus: •avoid fatigue and unsafe practices; leads to injury and unnecessary mistakes •drugs and alcohol use
Fall Assessment rating scales
Gives a number rating for a patient's risk for fall. Higher the number, greater the risk.
PASS
P: Pull the pin A: Aim at the base S: Squeeze the trigger S: Sweep from side to side
RACE
Rescue: remove the patient from immediate danger Alarm: sound the fire alarm Confine: confine the fire to one room or area Extinguish: extinguish a small fire with fire extinguisher
Promoting Patient Safety
Strategies to prevent falls: •Place near nurse's station if possible •Offer assistance to bathroom or bathing •Keep bed in low position; mattress on floor may be needed •Provide distractions such as keeping them busy while in w/c, back rubs, reading material, games, word puzzles, rocking chair, clothes to fold •Offer regular, consistent assistance with bathroom visits •Assess falls risk frequently
Restraints
*Restraints are for when all other safety measures have failed* •Vests, jackets, or bands with connected straps that are tied to the bed, chair, or wheelchair •Protective devices •Safety reminder devices •Always use the least restrictive environment
Nurses are acutely aware of the biological hazards that risk the safety of health-care personnel. Which action is commonly performed to reduce the risk of biological hazards? A) The nurse remembering to not touch the face or eyes. B) Proper hand hygiene before and after touching patients. C) Always wearing personal protection equipment (PPE) D) Posting sign of infective agents on the patient's door
Answer: B Rationale: The first line of defense against contamination of both personnel and patients is performance of proper hand hygiene before and after touching patients.
Which type of extinguisher should be used for fires ignited by combustible liquids and flammable gases? A) Type A B) Type B C) Type C D) Type D
Answer: B) Type B extinguisher
A nurse at a long-term care facility explores strategies to reduce the incidence of falls among the patient population. Which strategy can alert the staff of a patient's risk for falls while also maintaining confidentiality? Select all that apply. A) Putting a sign on the patient's door that says "Fall Risk" B) Placing a color-coded sticker on the patient's medical record C) Having the patient wear a color-coded armband D) Indicating the patient's fall risk on their Kardex or care plan E) Maintaining a list of fall risk patients on a bulletin board on the unit
Answer: B, C, D Rationale: A) This would break confidentiality by allowing anyone passing by to know that the patient is a fall risk. E) This would break confidentiality by allowing anyone passing by to know that the patient is a fall risk.
The nurse assigns patient care to an unlicensed assistive personnel (UAP). Which observed behavior by the UAP will warrant the nurse's interference? Select all that apply. A) The UAP is bathing a patient with the bed at the level of the UAP's knees. B) The UAP moves a patient from the bed to a chair with the assistance of one other person. C) The UAP places a food tray on a surface behind the UAP. D) The UAP is seen squatting to get supplies from the lower shelf in the supply room. E) The UAP is using a bath blanket to pull a patient across the bed for repositioning.
Answer: A & C Rationale: B) When moving a patient, it is safer to have more than one person helping to prevent injury to the patient or staff. D) The UAP is demonstrating proper body mechanics when items are retrieved from lower locations by squatting rather than bending from the waist. E) Whenever possible, heavy items should be pushed, pulled, or slid. Moving the patient in this manner is safe for both the patient and the UAP.
The nurse provides care for a patient with implanted radiotherapy on a medical floor. Which strategy will minimize the staff's radiation exposure? A) Check in with the patient via telephone hourly. B) Rotate hourly rounding duties with the nursing assistant. C) Wear regular gloves at all times when caring for the patient. D) Wear a film badge about the waist.
Answer: A) Check in with the patient via telephone hourly. Rationale: Checking in with the patient via telephone is a good way to minimize time in the room while also meeting the patient's needs.
The nurse works in a setting that requires a high level of physical care for disabled patients. Which action by the nurse will decrease the risk of the nurse experiencing physical injury? Select all that apply. A) Plan ahead how a task can be done safely. B) Turn the whole body instead of twisting. C) Raise the patient's bed to prevent bending over. D) Slide a heavy patient up in bed rather than lifting. E) Pull the patient's bed when moving the patient to another unit.
Answer: A, B, C Rationale: D) Sliding a patient up in bed will cause injury to the patient. Sliding causes skin shearing, which leads to tissure breakdown. E) Pulling a heavy object should be avoided when possible; it is safer to push objects like a patient's bed.
The newly hired nurse is being oriented to an acute care facility. Which facility policies regarding nurse safety will be shared with the nurse? Select all that apply. A) Proper body mechanics. B) Infection and disease control. C) Standard precautions. D) Attendance guidelines. E) Radiation therapies.
Answer: A, B, C, E Rationale: D) The policy that outlines attendance will be shared with the new nurse, but it is not a policy related to nurse safety.
The nurse in an acute care setting prepares to administer medications. Which is an acceptable method of safe patient identification? Select all that apply. A) Patient name B) Date of birth C) Social Security number D) Medical record number E) Picture
Answer: A, B, D, E Rationale: C) Acceptable forms of patient identification can be two of any of the following: patient name, date of birth, medical record number, or picture. Using two identifiers will reduce the risk of medical errors. Social Security number is not one of the acceptable forms.
The nurse is providing care for a patient who is extremely confused. The patient frequently gets out of bed alone and is a high fall risk. Which strategies can the nurse use to keep the patient safe from falls? Select all that may apply. A) Move the patient to a room close to the nurse's station. B) Remove medical equipment out of the patient's room. C) Place the patient's mattress on the floor of the room. D) Allow the patient to sit in a wheelchair near the nurse's station. E) Attempt to keep the patient distracted with music or the television.
Answer: A, C, D, & E. Rationale: B) It is not possible to remove all medical equipment out of the patient's room. However, the equipment should be kept out of the patient's pathway if possible.
The nurse is working in an extended care facility. In an effort to decrease patient falls, management is increasing the us of safety reminder devices. Which device does the nurse recognize as a safety reminder device? Select all that apply. A) A firm pillow to place across a patient's lap while in a wheelchair. B) A bed alarm placed under the mattress of a patient's bed. C) A call light button is placed at the patient's bedside. D) A wheelchair seat belt that prevents the patient from getting up. E) A pressure alarm placed beneath the cushion on a patient's bedside chair.
Answer: A, D, E Rationale: B) The bed alarm is designed to keep the patient safe by alerting the staff that a patient is out of bed. The patient is not likely to return to bed unassisted. C) The presence of a call light alone will not necessarily remind the patient to call for assistance.
The nurse manager is concerned about patient complaints related to the delay in response to call lights. Due to short staffing, which solution to the problem will the nurse implement? A) Assign each staff member an hour to monitor call lights. B) Ask the desk clerk to notify staff if call lights come on. C) Require nurses to check on patients every half-hour for needs. D) Request additional staff be hired to solve short staffing.
Answer: B) Ask the desk clerk to notify staff if call lights come on. Rationale: The desk clerk is likely to be the first person who is aware of a call light; it is practical for the desk clerk to notify staff that a patient is in need.
The nurse notices than an oxygen tank falls over, knocks the valve mechanism off, and gives off a spark. The escaping oxygen catches fire. Which fire extinguisher will the nurse use when attempting to put the fire out? A) Type A extinguisher B) Type B extinguisher C) Type C extinguisher D) Type D extinguisher
Answer: B) Type B extinguisher. Rationale: The B extinguisher is used on Class B fires that involve flammable gases and liquids.
The nurse is involved in caring for victims of a mass casualty event (MCE). Which conditions reflect a shift in normal standards of care by the nurse? A) Victims will be treated in the order they arrive at the care location. B) Victims who are likely to die will be eliminated from the care list. C) Victims with minor injuries will be treated first and sent home. D) Victims with serious injuries will be treated in the order they arrive.
Answer: B) Victims who are likely to die will be eliminated from the care list. Rationale: During a MCE, patients who are likely to die are not treated. Supplies and medical attention are provided to those who are likely to live.
The nurse comes across an unresponsive patient while making routine rounds. Which are the correct actions by the nurse? Select all that apply. A) Begin taking notes about the incident and continue until the code is complete. B) Initiate a Code Blue after the patient is identified as being in cardiac and/or respiratory arrest. C) Continue to assess the patient's condition until the code team arrives. D) Ask a staff member to escort the family members to a private room. E) Immediately review the patient's medial record for indicators of a Code Blue.
Answer: B, D Rationale: A) The nurse may very well begin to take notes about the code after the code team arrives and takes over the CPR activities. Later, the code details will need to be documented in the patient's medical record. C) The nurse should begin CPR as soon as the code is called. The nurse will continue CPR until the code team arrives or the patient responds. E) An immediate review of the patient's medical record for indicators of a pending Code Blue is not needed. The code team may want information about the immediate status of the patient and conditions that warranted a code being called.
The nurse is providing care for a patient who is confused and constantly pulls at an indwelling catheter and nasogastric (NG) tube. The nurse has tried multiple alternatives to restraints, none of which have been effective. Which does the nurse consider before calling the health-care provider for a restraint order? A) "Will the patient become worse if restraints are applied?" B) Is placing the patients in restraints the last resort?" C) "Are restraints necessary to maintain tube placement?" D) "How will we convince the patient that this is needed?"
Answer: C) "Are the restraints necessary to maintain tube placement?" Rationale: If the patient is left to pull on the urinary catheter and the NG tube, it is probable that one or the other will eventually be pulled out.
The nurse is working at the hospital when a blizzard occurs in the area. The state issued a state of emergency requiring all traffic remain off the roads unless it is an emergency. Which crisis does the nurse anticipate? A) An inability to get necessary shipments of medications. B) Lack of space for the existing staff to sleep or rest. C) A shortage of staff that can get to the hospital. D) A risk that the hospital will lose electrical service.
Answer: C) A shortage of staff that can get to the hospital. Rationale: The real crisis is related to the limited number of staff that can get to the hospital. The existing staff will be scheduled for rest and sleep periods, which will put fewer staff members in the units.
The nurse works on a pediatric unit and is caring for a young school-age patient. Which nursing action will help the nurse keep the patient safe? A) Request that a parent stay at the bedside. B) Instruct the patient to use the call button for help. C) Visit the patient's room on a regular basis. D) Tell the patient to stay in bed and watch telvesion.
Answer: C) Visit the patient's room on a regular basis. Rationale: Visiting the patient's room on a regular basis will let the patient know that is someone is near. The nurse should assess the patient for needs, answer questions, and offer reassurance during the visit. The nurse-patient interaction will help keep the patient safe.
The nurse is caring for a confused patient. What should the nurse do to prevent this patient from falling? A) Encourage patient to use handrails B) Place patient in a room near the nurse's station C) Reinforce how to use the call light on the bed D) Maintain close supervision
Answer: D) Maintain close supervision
What is an appropriate goal for a patient who is at risk for falling? The patient will be: A) taught how to call for help B) kept on bedrest while dizzy C) restrained when agitated D) free from trauma
Answer: D) free from trauma
Which type of restraint might be used to prevent a patient with a severe skin disorder from scratching? A) vest restraint B) waist restraint C) extremity restraint D) mitt
Answer: D) mitt
The nurse notices smoke coming from a patient's room and discovers a small fire in the waste can. In which order should the nurse perform fire safety? Place the options in the correct order. All options must be used. 1) Squeeze the handles together to release the contents 2) Pull the pin found between the handles 3) Aim the nozzle of the extinguisher at the base of the fire 4) Sweep the nozzle back and forth at the base of the flames
Answer: 2, 3, 1, 4 Rationale: PASS
The nurse manager in an extended care facility is concerned about an increase in patient falls. Which situation is most likely contributing to the increase? A) Call lights are not being answered promptly. B) Pain medications are not being administered. C) Toileting schedules are set for every 2 hours. D) There is a high use of ambulatory devices on the unit.
Answer: A Rationale: Delay in assistance is a major contribution to the incidences of falling. Patients with urgent needs will not wait long for assistance, and may fall in attempt to meet their needs without help.
The nurse continues to work after an older patient with dementia moved into the nurse's home. The nurse manager notes that the nurse made three medication errors in the past week. The nurse manager expects which cause for the nurse's behavior most likely? A) A lack of sleep because of the parent's night wandering and confusion. B) Financial obligations to provide health care for the nurse's parent. C) Concern about strangers in the nurse's home to care for the parent. D) Worry about the nurse's own personal safety.
Answer: A Rationale: The most likely cause of the nurse's medication errors is the lack of sleep. Nurses who are exhausted cannot think clearly and are prone to errors.
In two-rescuer CPR of the adult victim, the standard ratio of compressions to breaths is? A) 15:2 B) 30:2 C) 15:1 D) 30:1
Answer: A) 15:2
What is the preferred site to check a pulse on a child while performing CPR? A) Carotid B) Brachial C) Popliteal D) Femoral
Answer: A) Carotid
A victim is using the universal sign for choking. The rescuer: A) asks, "Are you choking?" B) sweeps the mouth with two fingers C) places the victim flat and uses the jaw thrust maneuver to open the airway D) asks, "Are you OK?"
Answer: A) asks, "Are you choking?"
The nurse assigns the unlicensed assistive personnel (UAP) to perform the 2-hour check on a patient in restraints. Which specific tasks will the nurse instruct the UAP to perform? Select all that apply. A) Offer the patient fluids B) Check the pressure points for redness and chafing C) Assess extremities for capillary refill and sensation D) Assist with ambulation if appropriate E) Help with toileting as needed
Answer: A, D, E Rationale: B) The nurse, not the UAP, should be sure to assess the patient for redness and chafing. C) The nurse, not the UAP, should be sure to assess the patient's extremities.
The nurse is caring for a patient who has wrist restraints applied to protect tubing inserted for medical treatments. Which guidelines will the nurse follow while the patient is restrained? Select all that apply. A) Check the patient's skin and circulation every hour B) Remove the restraints completely every 2 hours C) Allow the patient to move about independently when restraints are off D) Document all interventions on the restraint flow sheet E) Tell the patient the restraints can be removed if tubes are left alone
Answer: B, D Rationale: A) The patient's skin and circulation are checked every 30 minutes C) The patient may or may not be able to move about independently. In this scenario, the patient has tubes, which may prevent unlimited movement. E) It is inappropriate to tell the patient that the patient's behavior is the reason for being restrained. The nurse should explain that the restraints are to keep the patient safe.
The nurse works in a facility that developed a new policy regarding the use of restraints. The goal is to improve patient safety. Which type of safety equipment does the nurse expect to be used to decrease the use of restraints? A) Vests equipped with quick-release belts. B) Side rails that are lower in height. C) Chair and bed monitors sensitive to pressure. D) Jackets that attach to wheelchair backs and the patient.
Answer: C Rationale: Chair and bed monitors that are pressure sensitive will alarm when the patient gets up, alerting staff that the patient is at risk. The nurse can expect the use of monitoring devices instead of restraints.
The nurse becomes aware of a mass casualty event from a bioterrorism attack in the form of a highly contagious disease. Which clue is likely to be the first indicator of this kind of attack? A) The water supply is tested and noted to be contaminated. B) A terrorist group makes a public announcement of involvement. C) People begin presenting at various hospitals with similar symptoms. D) The fresh food supply is positive for infectious types of bacteria.
Answer: C Rationale: The first clue may occur days after the initial exposure and be noticed when people begin presenting at various hospitals with similar symptoms.
The nurse works in an acute care setting. When reviewing safety factors, the nurse becomes aware of many conditions that can contribute to patient safety. Which factor will the nurse identify as a contributing factor to an unsafe patient environment? A) The patient is required to wear a hospital gown and slippers. B) The patient feels confined to a room that is unfamiliar. C) The patient finds the environment like a maze within a maze. D) The patient may feel that privacy is compromised.
Answer: C Rationale: The overall arrangement of a hospital unit can be very confusing and overwhelming to a patient in the hospital. The reality of not knowing where one is can contribute to an unsafe environment.
The nurse is preparing to clean up a chemical spill in the medication room. Which action will the nurse take first? A) Use paper towels to soak up the spill. B) Alert housekeeping about the spill. C) Close the door and access the SDS book. D) Place soaked up paper towels in a biohazard bag.
Answer: C Rationale: When dealing with a chemical, cleanup should occur according to the SDS. The nurse will first close the door to control exposure and follow the SDS guidelines for managing the spill.
Profuse smoking is coming out of the heating unit in the patient's room. What should you do first? A) Open a window B) Activate the fire alarm C) Move the patient out of the room D) Close the door to the patient's room
Answer: C) Move the patient out of the room
The nurse is checking on a patient after a chest restraint is applied by the unlicensed assistive personnel (UAP). Which finding will prompt the nurse to review restraint procedure with the UAP? A) The nurse can slip two fingers between the patient's body and the restraint. B) The restraint has the label "back" located on the posterior of the patient's body. C) The nurse can validate the size of the vest with the patient's body. D) The restraint straps are double-knotted to the frame of the patient's bed.
Answer: D Rationale: The restraint straps that are connected to the frame of the patient's bed are not an issue. However, all restraints should be tied with a quick-release knot. No other knot is ever acceptable.
Responding to Disasters
External disasters: •bomb threat, shooting, bad weather •originates outside health-care facility; results in casualties to be brought to facility Internal disasters: •originates inside facility; casualties are already within the facility
Morse Fall Scale
Potential increased risk of falls include: •History of falls within 3 months •Bedrest, Nurse assistance •Cane, crutches, walker use •Furniture (objects in the way) •Impaired mobility •Weakness •Forgets limitations •Altered LOC
Pediatric/Infant CPR
•Airway: -not breathing, begin the C-A-B-C sequence -perform CPR for 1 minute before calling for help or 911 (unless at hospital) •Breathing: -give two breaths (one second per breath) -smaller amounts of air is needed for pediatrics and infants -use the amount of air for the infant that a rescuer is able to hold in their cheeks Circulation: -rate of 100-120 times per minute -ratio of compressions to ventilation is 30:2
Pediatric/Infant CPR
•Assess carotoid artery: child •Assess brachial artery: infant •If no pulse or pulse less than 60 beats per minute, begin CPR
Medical Terminology
•CVA: stroke •S/S: signs and symptoms •Vertigo: dizzy •paralysis: loss is sensation; asthenia -quad: all 4 -para: half of the body (upper or lower), (superior or inferior) -hemi: half of the body (left or right) •paresis: weakness
Restraints Guidelines for Nurses
•Check on patient every 30 minutes •Remove restraints every 2 hours •Offer free fluids •Assist with toileting •Change positions regularly (turn q2, every 2 hours) •Assessment of extremities- edema, perfusion, cap refill time, sensation, and function •Assess skin over pressure points •Assess wrist and leg pulses •Assist with ambulation; if restraints are off, stay with patient *Document all actions on the appropriate flow sheet* *CNA/UAP may perform checks and releases, but it is ultimately LPN's responsibility*
Radiation Hazards
•Lead aprons are available if exposure risk is high •If pregnant, the priority is to ask for another assignment. If unable, utilize lead apron •Material Safety Data Sheet (MSDS) in each department of hospital
Restraint Alternatives
•Monitors: chair, leg, or bed monitors that alarm •Soft devices: bolsters placed in the bed on either side of the patient •Strategies
Safe O2 Use at Home
•No flames near O2 source •No candles, smoking, open-flame heater use near source •No wool blankets or sweaters (generates static electricity) •Long oxygen tubing is useful for getting around home, but encourage patient to follow safety precautions
Chemical Hazards
•Safety Data Sheet (SDS) •Cleaning supplies, or mixing cleaning supplies can pose risk; eyes, skin, mouth •O2 is combustible
Types of Extinguishers
•Type A: paper, wood, fabric, and trash (solids) •Type B: combustible liquids such as oil, gasoline, and other petroleum-based products, and flammable gases (petroleum-based products) •Type C: electrical fires such as short-circuits in wires, motor, or equipment fires (liquids, gases) •Type D: powders, flakes, or shavings of combustible metals (debris) •Type K: kitchen fires due to combustible cooking fluids such as oils and fats (kitchen)
Waist Restraints
•Used to protect a patient in danger of getting out of a bed or chair •Placed around the patient's waist, then the straps are tied to the moveable portion of the bed frame or to the lower portion of the back of the wheelchair
Vest Restraints
•Used to protect a patient in danger of getting out of bed or out of a wheelchair or chair. •Placed on the patient with the crossover in front and the straps tied to the lower portion of the back of the wheelchair. •If used with the patient in bed, the straps are tied to the moveable portion of the bed frame, not to the bed rails
Mitt Restraints
•Used to protect a patient in danger of pulling out tubes or interfering with treatments. Sometimes used to prevent scratching in patients with severe skin disorders. •The patient's hand is placed within the mitt, and the mitt is secured around the wrist •The straps can also be tied to the moveable portion of the bed frame but not the bed rails
Extremity Restraints
•Used to protect a patient in danger of pulling out tubes or taking off monitoring devices •Placed around the patient's wrist, then tied to the moveable portion of the bed frame and not the bed rails •Be able to insert 2-3 fingers between restraints and patient's skin
Foreign Body Airway Obstruction Management
•Weak, ineffective cough •High-pitched, "crowing" noise while inhaling •Increased respiratory difficulty •Cyanosis (pale, blue) •Complete airway obstruction: cannot speak, breathe, or cough and may clutch the neck •Ask the victim, "Are you choking?"
