PrepU #9 ch.27

The nurse is caring for a client who scored 3 on the Hendrich II Fall Risk Model. Which intervention(s) is appropriate? Select all that apply.

-Document the finding in the electronic health record (EHR) -Implement normal fall prevention measures

A client is brought to the emergency department after inhaling a substance suspected to be anthrax from the contents of an envelope. What symptoms experienced by the client would the nurse correlate with this substance?

Cough, dyspnea, and fatigue

An anxious adult child asks the nurse how to keep an older adult parent safe in the home. The client tells the nurse that the parent lives alone, has chronic illnesses, and also has sensory-perceptual alterations. What is the nurse's first action in forming an intervention plan?

Identify the hazards in the home.

During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of:

mass trauma terrorism.

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?

"Always provide close supervision for young children when they are in or around pools and bathtubs."

The nurse is discussing car safety with the mother of a 6-year-old child. The child's mother questions the need for the use of special car seats for her child. What information can be provided to her?

"At the age of 6 your child should be using a booster seat."

The poison control nurse receives a call from the caregiver of a young school-age child who may have ingested a poisonous substance. Which is the priority response by the nurse?

"Check breathing and heart rate."

A large health care organization has committed to promoting a just culture when adverse events and near misses take place. Which question will guide the organization's response when a nurse commits an error?

"How did the nurse's actions contribute to this error?"

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective?

"I will rescue clients from harm before doing anything else."

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

"Is your child breathing at this time?"

A school nurse is conducting a safety seminar with students in 6th grade. Which teaching point is most important?

"Make sure that you have smoke detectors in your house and that they're in working order."

A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety?

"Parents are effective role models for children when they also wear helmets while riding."

The nurse is teaching a nursing student about proper latex glove use. Which nursing student action requires intervention by the nurse? Select all that apply.

-"snapping" the gloves when applying them to ensure proper fit -wearing gloves for long periods of time after procedure ends

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.

-Client-centered care -Teamwork and collaboration -Quality improvement (QI)

The nurse is caring for a client that is disoriented. The nurse places the client in soft wrist restraints to discourage pulling at a nasogastric tube. Which nursing action(s) is appropriate? Select all that apply.

-Obtain order from a licensed provider within minutes of restraint application -Check circulation and skin condition every 2 hours -Offer regular, frequent opportunities for toileting

The older adult client is confused and wanders at night at home. The caregiver is seeking assistance with this problem. The caregiver states, "I am so worried about my family member. What can I do and still get some rest at night?" What instruction(s) would the nurse provide to the caregiver? Select all that apply.

-Reduce stimulation, noise, and light a few hours prior to bedtime. -Provide low lights in the rooms in which the client may wander -Encourage the client to toilet prior to bedtime Place locks on any doors to the outside that the client would be able to open

The nurse is performing an assessment on an older adult. From which data does the nurse deduce that the client is at high risk for falls in the home? Select all that apply.

-Takes furosemide daily -Admits to drinking wine through the evening -Has history of diabetic neuropathy

The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use?

19-year-old male college student majoring in physics

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address?

A hair dryer is placed next to the sink.

Which nurse would be at the highest risk of causing a hazardous situation?

A nurse who has worked 32 hours of overtime this week

The nurse has just admitted a client with a latex allergy to the medical-surgical nursing floor. Which is the priority nursing intervention?

Apply an allergy-alert identification bracelet on the client.

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

Ask to examine the client alone in order to speak to her privately.

A school-age child is admitted to the emergency room with a possible 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 client?

Assessment of vital signs and respiratory status

When educating parents about the safety of preschool-aged children, which is most important for the nurse to include in the presentation?

At home chemicals should be kept in a locked cabinet.

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

Avoid unattended baths for the toddler.

Which item would alert the home care nurse to a safety hazard threatening a young child?

Dangling blind cords

A caregiver of a toddler has called the poison control nurse to report that the child licked a small amount of petroleum jelly. The caregiver states that the toddler is sitting on the floor, watching a cartoon, and playing with a toy. Which information will the poison control nurse provide?

Dilute with water or milk.

The nurse is providing education to a group of healthy older adults. Which nursing recommendation best promotes client safety in an independent living environment?

Encourage exercise that improves balance and muscle strength

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure?

Extremity restraint

What teaching will the community health nurse include for parents of toddlers?

Household cleaners must be kept out of reach.

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home?

Most people who die in house fires die of smoke inhalation rather than burns.

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?

Obtain a three-prong grounded plug adapter.

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 measure would be a priority recommendation for this client?

Placing the client in a bed with a bed alarm

An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse's best action for reducing the client's risk of falls?

Provide a bedside commode and ensure adequate lighting.

What is the primary role of the nurse in the care of clients who experience domestic violence?

Providing prompt recognition of the potential or actual threat to safety

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?

Pull the fire alarm lever.

An older adult is admitted to the hospital with a fractured hip. The client suddenly develops acute onset of confusion and hallucinations. Which action should the nurse implement first?

Reduce distressing environmental stimuli to maximize client safety

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?

Refrain from using extension cords.

There is a fire in the trashcan in the client's room. What is the nurse's first priority?

Remove the client from the room.

The nurse has received a medication order over the telephone from a provider. What is the next appropriate nursing action?

Repeat or read back the order.

The nurse is admitting a client to a medical-surgical unit who states, "If someone brings balloons to me, I might have trouble breathing." What is the appropriate nursing action

Replace common health care items with latex-free equipment.

A nurse is preparing discharge education for a client with a newborn infant. What is the highest priority item that must be included in the education plan?

Restrain the infant in a car seat.

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care?

Risk for Injury Related to Agitation

The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care?

Risk for Poisoning related to poor eyesight and the inability to read medication labels

A father asks the nurse who is caring for his 13-year-old daughter why his daughter could be performing poorly in school lately, and why she is distancing herself from friends and family. Which of these possibilities would the nurse consider as the priority risk?

She may be the victim of cyber-bullying.

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?

Social Pressure

The nurse is reading another nurse's notes that were recorded in the electronic health record (EHR) during the previous shift. What is the appropriate nursing action when numerous unapproved abbreviations are noticed in the previous nurse's notes?

Suggest to the nurse manager that an in-service on abbreviation use would be helpful.

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client 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 client?

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

The acute care nurse is caring for a client who is at risk for falling. Which desired outcome is most appropriate for this client?

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

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation?

The hospital must bear any costs incurred for treating the client's injury.

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

The nurse details the client's response and the examination and treatment of the client after the incident.

A nurse follows the universal client compact principles for partnership when providing care for clients. Which nursing action reflects this philosophy?

The nurse includes the client as a member of the health care team.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

The nurse should question the client about the source of the bruises.

A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate?

The report provides a detailed and objective account of the circumstances before, during, and after the event.

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow?

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

The nurse is teaching a nursing student about proper latex glove use. Which teaching will the nurse include?

Wash hands thoroughly after removing gloves with a pH-balanced soap.

A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint?

a dose of an antipsychotic

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?

administration of an antipsychotic agent to alter the client's behavior

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should:

fill out an incident report, with the goal of preventing a similar event in the future.

The nurses on a critical care unit can utilize the safety strategy of redundancy by:

having two nurses independently check the dosage of high-risk medications.

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized?

identifying systemic factors on the unit that may have contributed to the event

Which level of health care provider may make the decision to apply physical restraints to a client?

nurse practitioner

The occupational health nurse is planning a safety in-service for a group of clerical workers. Which topic would be most beneficial?

principles of body alignment

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply.

-drowsiness -headache -vomiting

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?

the 2-year-old leaning against the screen of a window in a classroom

A nurse is assessing fire safety in a home in which a single parent and young children live. What information would the nurse include in teaching the parent on how to prevent injury from fires and burns? Select all that apply.

-Cook on back burners on the stove, and keep handles turned toward the back. -Practice with the children what to do if there is a fire in the home. -Teach your children to stop, drop, and roll if clothing catches on fire. -Set the temperature of the water heater to 120°F (49°C) or less.

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.)

-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.

A nurse makes a medication error and reports it to the nurse manager, requesting assistance filling out the incident report. What should the nurse manager educate the nurse about regarding the incident report? Select all that apply.

-It should provide a clear, concise recording of the situation -It should provide a clear, concise recording of the situation

A nurse is teaching parents about Internet safety for children. Which action(s) is a recommended guideline for Internet use? Select all that apply.

-Use filtering software to block objectionable information. -Investigate any public chat rooms used by the children -Be alert for downloaded files with suffixes that indicate images or pictures.

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

Ensure that two fingers can be inserted between the restraint and the client's extremity.

A hospital is introducing a program that has the goal of aligning practices more closely with the Quality and Safety Education for Nurses (QSEN) project. What initiative best exemplifies QSEN competencies?

New systems are introduced to increase communication between nurses and the members of other health disciplines.