Safety
The nurse is caring for a client that requires lifting. What techniques should the nurse utilize to prevent injury to self and potentially the client? You answered this question Incorrectly 1. Tighten stomach muscles. 2. Keep the knees straight. 3. Keep weight to be lifted close to body. 4. Bend at the waist. 5. Avoid twisting the body.
1., 3., & 5. Correct: Tightening the stomach muscles provides stability for the movement. Keeping the weight close to the body provides additional support and reduces the risk of a stretching type injury. When the body is in alignment, it is considered to be balanced. Therefore, twisting motions cause the body to be off balanced and make the nurse more susceptible to injury. 2. Incorrect: The trunk should be kept straight, and the knees should be bent. This provides an upright posture to maximize stability and reduce risk of injury. 4. Incorrect: The trunk should be kept straight, and the knees should be bent. This provides an upright posture to maximize stability and reduce risk of injury. Bending at the knees helps prevent back injuries.
A community health nurse is planning to discuss how to prevent pesticide ingestion at a local health fair. What should the nurse include in this teaching session? You answered this question Incorrectly 1. Discard the outer leaves of lettuce. 2. Wash fruits and vegetables with dish soap. 3. Buy organic produce. 4. Peel fruits prior to eating. 5. Dry produce thoroughly with disposable paper towels after washing. 6. Use a scrub brush when washing fresh fruits and vegetables.
1., 3., 4., 5., & 6. Correct: The outer leaves of green, leafy vegetables, such as lettuce and cabbage, should be discarded as pesticide residue likely remains there. Another great idea to reduce overall exposure to pesticides is to buy organic or unsprayed produce. If you can't buy organic, peel fruits and vegetables prior to eating. Washing your fruits and veggies is not enough if you want to reduce the pesticide load you expose yourself to, as it is very important to thoroughly dry them with disposable paper towels as well. This will remove all the remaining pesticide residue and make the produce safer to eat. A scrub brush is very effective in cleaning the crevices and areas around the stem. 2. Incorrect: One of the most common mistakes people make in their attempt to remove all pesticide residue from their produce is that they wash their fruits and vegetables with soap or, even worse, dish soap. Never use detergents, special rinses or soaps of any kind, as this will only do more harm than good. Unless the soap is entirely made of natural and organic materials, it tends to contain harmful compounds that easily penetrate the skin of the fruits, thus doing more harm than the actual pesticides after you ingest them. Simply wash with tap water.
The charge nurse is reviewing multiple events reported by staff during morning shift. The nurse is aware which event requires a written incident report? You answered this question Incorrectly 1. A client yells loudly throughout the night shift. 2. A nurse discusses client's prognosis with family. 3. An unlicensed assistive personnel (UAP) spills water pitcher onto client. 4. A nurse tears sterile gloves and applies new gloves.
.2 CORRECT: The purpose of an incident report is to document any incident or unusual event inconsistent with routine operations of hospital or staff routine and resulting in injury, or potential liability, for clients, family, or staff. The nurse has violated HIPPA regulations by discussing a client's medical prognosis with family members. The primary healthcare provider is responsible to discuss prognosis with client and only those individuals designated by the client. 1. INCORRECT: Although this client may disturb other clients at night, this event does not meet the criteria for an incident report. 3. INCORRECT: This event requires the UAP to intervene, providing clean clothes for the client. However, while an unfortunate occurrence, this incident would not require an incident report. 4. INCORRECT: Damaged sterile gloves must be removed and replaced immediately to prevent contamination of the field. The nurse followed the correct procedure and no report is needed.
The nurse is teaching the parents of a child with impetigo about care. Which statement by the parents indicate further teaching is needed? You answered this question Incorrectly 1. "We will not allow bathing until the scabs are healed." 2. "The skin and crusts will be washed daily with soap and water." 3. "Lotions should not be applied to the lesions, so they remain dry." 4. "We will apply the antibiotic ointment to the lesions after removing the crusts."
1. Correct: The parents need further teaching. The crusts and debris should be washed at least daily. 2. Incorrect: The parents understand teaching and do not need further teaching. The crusts and debris should be washed with soap and water at least daily. 3. Incorrect: The parents understand teaching and do not need further teaching. Antibiotic ointment should be applied to the lesions. 4. Incorrect: The parents understand teaching and do not need further teaching. The crusts should be removed so the antibiotic cream can reach the infected site.
When disposing of waste in a client's room, the nurse would place which item(s) in a biohazard red bag? You answered this question Incorrectly 1. Chest drainage unit 2. Doxorubicin IV bag and tubing 3. Staples removed from an abdominal incision 4. Tramadol 50 mg tablet prescribed but refused by client 5. Soiled dressing 6. Paper trash with identifying client information
1., & 5. CORRECT. Chest drainage units should be capped and placed in a large red biohazard bag for disposal. Dressings soiled with human waste, blood or body fluids should be disposed of in a red biohazard bag. 2. INCORRECT. Doxorubicin is an intravenous antineoplastic chemotherapy agent. IV bags and tubing used to administer chemotherapy medications should be disposed of intact and placed in a yellow or purple chemotherapy waste container with a lid. 3. INCORRECT. Client staples are considered a "sharp" and should be disposed of in a red biohazard sharps container. 4. INCORRECT. Tramadol is a non-hazardous waste medication, but it is also a Schedule IV narcotic. Narcotics should be disposed of in an irretrievable medicinal waste container or sharps container according to hospital policy. No matter the type of container used, for narcotics, it should be irretrievable. 6. INCORRECT. Paper trash containing client information should be disposed of in a manner that it is no longer readable, cannot be reconstructed and cannot be retrieved.
Which finding by the nurse would need to be reported to the primary healthcare provider immediately when caring for an infant who was born with a myelomeningocele? You answered this question Incorrectly 1. High pitched cry 2. Eyes fixed downward 3. Increasing head circumference 4. Decrease in a feeding by 30 mL 5. Projectile vomiting
1., 2., 3., & 5. Correct: Infants with myelomeningoceles can have problems with the normal flow of the cerebral spinal fluid around the defect. These are all signs of increasing intracranial pressure and development of hydrocephalus and should, therefore, be reported to the primary healthcare provider immediately. 4. Incorrect: Although a pattern of poor feeding would need to be reported to the primary healthcare provider, a one-time decrease in feeding is not something that would warrant immediate notification.
A client diagnosed with a brain injury continues to attempt to get out of the bed without assistance. Which nursing interventions would the nurse implement? You answered this question Incorrectly 1. Ask a familiar person to stay with the client. 2. Apply position change sensor to the bed. 3. Move client closer to the nursing station. 4. Reinstruct the client to not get out of the bed. 5. Provide positive and negative reinforcement.
1.,2. & 3: Correct: Having a person directly monitor the client will decrease the possibility of the client getting out of the bed. In addition, a familiar person in the room can have a calming effect on the client. Bed alerts will notify the healthcare team that the client is moving in the bed. This will result in a quicker response time to evaluate, if the client is trying to get out of bed. The intervention of moving the client closer to the nursing station will increase the observation of the client. This increased visualization can allow the healthcare team to intervene if the client tries to get out of the bed. 4. Incorrect: Due to the brain injury, the client's ability to process information, including instructions is limited. The client may become agitated and exhibit restless behaviors. Reinstructing the client will not be effective if the client is having difficulty processing the initial instructions. 5. Incorrect: Due to the brain injury, cognitive deficits occur resulting in the decreased ability for the client to interpret information. The client will not have the ability to recognize positive reinforcement messages. The client should not be subjected to any negative reinforcement actions.
Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Which actions should be instituted by each unit's charge nurse? You answered this question Incorrectly 1. Turn on local news for up-to-date information on the train derailment. 2. Prepare a list of clients who could quickly be discharged or transferred. 3. Determine which personnel could be sent to the command center. 4. Notify clients that the disaster plan has been put into effect. 5. Alert all off-duty personnel to stand by in case of call- in.
2., 3. & 5. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. However, there are some basic points which are standard among all facilities. This situation is considered an external disaster which means the hospital will be expecting multiple victims. The charge nurse on each unit needs to prepare a list of possible discharges or transfers to be given to the appropriate primary healthcare providers for further action. When handling any disaster, a facility must have a "command center" that is operated by outside personnel such as a Fire chief, Police, Swat or other outside emergency persons. This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. However, each unit must have one designated representative to send to the command center, when requested, to receive and then relay, pertinent information back to the unit. These individuals are selected by the charge nurse, and do not have to be nurses. Additionally, off-duty personnel may be needed and should be alerted to stand by; however, the command center alone makes the determination whether extra personnel should be called in, or if it would put more individuals in jeopardy. 1. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. 4. Incorrect: This would unnecessarily alarm the clients. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client.
A client with recurrent angina and hypertension has been started on new medications. When reviewing the admission forms, the nurse should immediately question which prescription? Exhibit You answered this question Incorrectly 1. 2 gm sodium diet 2. Metoprolol 25 mg PO once daily 3. Potassium 10 meq PO once daily 4. Diltiazem 120 mg PO once dail
3. Correct: This client is being treated for recurrent angina with hypertension. The admission prescription includes spironolactone daily, which is a potassium-sparing diuretic; therefore, the client should NOT be taking a daily dose of potassium. 1. Incorrect: A 2 gram sodium diet is considered a low salt diet, which would be appropriate for a client with hypertension. Excessive dietary salt leads to water retention and increased blood pressure. This prescription is appropriate for the client and does not need to be questioned. 2. Incorrect: Metoprolol is a beta-blocker used to decrease preload, which will also decrease pulse and blood pressure. The dose is appropriate for this client and does not need to be questioned. 4. Incorrect: Diltiazem is a calcium channel blocker which vasodilates the arterial system and reduces recurrent angina by decreasing afterload. Additionally, calcium channel blockers help to decrease blood pressure. This medication and dose are appropriate for this client.
Two cognitively impaired siblings are clients in the same hospital room. During rounds, the nurse notes they have removed identification bracelets. Because of similar appearance, the nurse is unable to identify the correct client for blood work. What would be the most reliable method for the nurse to use to properly identify these clients? You answered this question Incorrectly 1. Draw blood to type and crossmatch and compare with chart. 2. Call the primary healthcare provider to identify each client. 3. Ask nurses on the next shift to try to identify the clients. 4. Notify family to come in and identify clients in person.
4. CORRECT: The only way to definitely identify a client with no identification bracelet who is unable to identify self is to have immediate family verify the client in person. When the family member arrives and verifies the client, the hospital must apply a new ID bracelet in the presence of the family for added security. 1. INCORRECT: Even typing and cross-matching to determine the blood type does not guarantee a correct identification. Additionally, both clients may have the same type blood since they are siblings. 2. INCORRECT: A primary healthcare provider would not necessarily be able to identify a specific client. Having hundreds of clients would make it more difficult to remember individuals correctly. It is unlikely that the healthcare provider could correctly indicate which client needed blood work. 3. INCORRECT: This is the least effective approach to properly identify the clients. Certainly, nurses spend more time with clients than other healthcare individuals, but asking another nurse to make this type of identification is still extremely risky and unreliable.
During night time rounds, the nurse finds a client has cigarettes in bed and the room is filled with smoke. In what order should the nurse perform the following actions? You answered this question Incorrectly The Correct Order Remove client from room. Pull the fire alarm handle. Notify hospital operator. Close the client's door. Get the fire extinguisher.
CORRECT. Anytime an internal disaster is suspected, client safety is always the first concern. National Fire Safety codes refer to the pneumonic "R-A-C-E" (rescue -alarm-contain-extinguish). If the area is safe for the nurse to enter, removing the client from that environment would be the first action. Secondly the nurse must activate the EMS alarm system so that emergency personnel are en route. Additionally, the hospital must be alerted by contacting the hospital operator to activate appropriate internal alarm systems. Closing the client's door will help contain any fire or smoke. Finally, the nurse should obtain the closest fire extinguisher appropriate for the type of fire.
The homecare nurse is providing family teaching on safety issues for a client diagnosed with Parkinson's disease. What adaptations should the nurse instruct the family to initiate? You answered this question Incorrectly 1. Install grab bars on tub walls. 2. Place nightlights in hallways. 3. Add bran and fiber to daily diet. 4. Remove scatter rugs or loose cords. 5. Keep bedroom dark, cool and quiet. 6. Put tennis balls on wheels of walker.
1., 2., 3., 4., & 5. Correct: Parkinson's disease causes deterioration of the basal ganglia, ultimately impacting motor control and function. As muscles become stiff and rigid, mobility slows, resulting in poor coordination and loss of balance. Safety is a chief concern in all ADLs, requiring modifications in activity, nutrition, and the client's environment. Because Parkinson's disease affects mobility, modification such as grab bars and night lights are essential. Clients develop constipation because of decreased peristalsis, so adding bran and fiber can address impending bowel issues. Scatter, or throw, rugs along with loose extension cords on the floor create a fall risk because the client is unable to pick up feet during ambulation. The shuffling gait that develops increases the risk for falls. These clients also have problems with insomnia along with poor REM sleep, leading to daytime drowsiness. Making the bedroom conducive to sleep may help alleviate symptoms for a period of time. A dark, cool room with no distractions is the most appropriate sleep environment. 6. Incorrect: The proper method of utilizing a walker is to step into the walker, pause and then move it forward before stepping again. Even though clients with Parkinson's disease have a shuffling gait and stooped posture, sliding a walker with tennis balls on the wheels presents a serious safety issue. The client would not have the ability to control the speed or hold the walker steady while stepping into it.
A school-aged child is being assessed in the emergency room for probable viral meningitis. The nurse contacts the pediatric unit to determine if an appropriate room is available in case of admission. The pediatric charge nurse knows the most appropriate placement for this client would be what? You answered this question Incorrectly 1. Private room. 2. Negative air-flow room. 3. Will not need hospitalization. 4. Needs standard precautions only.
4. CORRECT. Viral meningitis is caused by a group of enteroviruses, such as those that also cause mumps or measles. School-aged clients generally fare better than very young children or infants. The Center for Disease (CDC) has determined that standard precautions are adequate for older children and adults. 1. INCORRECT. A private room would be appropriate for bacterial meningitis and other highly contagious illnesses. This is not needed in the case of viral meningitis. 2. INCORRECT. Negative air-flow is needed for serious illnesses such as active tuberculosis, SARS, Ebola or even certain types of chickenpox. Such a room would not be necessary for viral meningitis. 3. INCORRECT. While it is true that many cases of viral meningitis are managed at home, some clients may require supportive therapies provided in a hospital. Note the emergency nurse is only inquiring about a possible room placement. Admission for this client has not yet been determined.