Safety

The parent of a 2½-year-old child arrives at the hospital emergency department and reports to the nurse that the child has been complaining of a "tummy ache." The parent also reports that the child has been irritable and that it has been difficult to awaken the child. On further assessment, the nurse suspects lead poisoning. Which assessment question would elicit specific data related to this condition? 1. "Does your child chew on pencils or crayons?" 2. "Do you live in a house that is more than 25 years old?" 3. "Have you noticed a sweet and fruity odor on the child's breath?" 4. "Has your child been breathing very fast or sweating profusely?"

2. "Do you live in a house that is more than 25 years old?" **Homes that are older than 25 years may have lead paint and will most likely have lead pipes, which can contribute to lead poisoning. **Pencil lead is made of graphite, so it does not present a hazard to the child. Crayons are not toxic. A sweet and fruity odor to the breath is a symptom of ketoacidosis. Rapid breathing and diaphoresis are highs of salicylate poisoning.

An adolescent is admitted to the hospital after an accidental self-inflicted gunshot wound to the foot. The nurse would plan to take which action as a first step for the prevention of future injury? 1. Explore the client's knowledge of gun safety. 2. Assess the client for a history of risk-taking behaviors. 3. Refer the client to a firearm safety class sponsored by the hospital. 4. Have the client watch a video on the tragedies of improper firearm use.

1. Explore the client's knowledge of gun safety. **A leading cause of accidental death in the adolescent population is improper use of firearms. Before implementing firearm safety goals, the nurse needs to obtain baseline data through a firearm safety history, which is described in the correct option. Option 2 may be indicated because of the relationships among accidents, impulsivity, and risk-taking behaviors, but assessing past risk-taking behaviors would not be the first step directed at prevention. Option 3 may be effective, but referral to a firearm safety course would not come before assessing the client's knowledge of gun safety. Option 4 may or may not be effective, at some point, for this client.

The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse would implement which action next? 1. Reassess the client. 2. Conduct a staff meeting to describe the fall. 3. Document in the nurse's notes that an incident report was completed. 4. Contact the nursing supervisor to update information regarding the fall.

1. Reassess the client. **After a patients fall, the nurse must frequently reassess the patient because potential complications do not always appear immediately after the fall. The patients fall would be treated as private information and shared on a "need to know" basis. Communication regarding the event would involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary.

The community health nurse is providing a session on childhood poisoning and has instructed a group of parents of preschoolers about home safety measures. Which statement by one of the parents would the nurse identify as something that requires the need for reinforcement of the instructions? 1. Refers to medication as "candy for when you are sick" 2. Says they will store medications in child-proof containers 3. Keeps the poison control center telephone number readily available 4. States the intention to label all toxic substances and place them in a locked area

1. Refers to medication as "candy for when you are sick" **Medicine would not be referred to as candy. Home safety measures are simple but important. Medications need to be stored in child proof containers. The number of tablets in a container needs to be limited. The poison control center telephone number needs to be visible near all telephones. Toxic substances need to be labeled with poison stickers and placed in a locked area out of reach of children.

The nurse provides instructions to the parents of an infant regarding car travel and safety seats. Which is the appropriate information related to the safety of the infant? 1. Restrain in a car seat in the back seat in a semireclined rear-facing position. 2. Restrain in a car seat in the front seat in a semireclined rear-facing position. 3. Restrain in a car seat in the back seat in a semireclined forward-facing position. 4. Restrain in a car seat in the front seat in a semireclined forward-facing position.

1. Restrain in a car seat in the back seat in a semireclined rear-facing position. **Infants need to be restrained in a car seat or infant only seat in a semi reclined rear facing position in the back seat of the car. The infant is not placed in the front seat or in the forward facing position.

The home care nurse is performing an environmental assessment in the home of an older client. Which observation by the nurse requires intervention? 1. Unsecured scatter rugs 2. Clear exit passageways 3. An operable smoke detector 4. A prefilled medication cassette

1. Unsecured scatter rugs **Trauma to the older patient in the home may be caused by a variety of factors. These include an unsteady gait, the presence of unsecured scatter rugs, cluttered passageways, inoperable smoke detectors, and a history of previous falls. Any assessment findings that could lead to injury or trauma in the home would be addressed immediately.

The nurse is preparing to administer an intramuscular (IM) injection to a client receiving a continuous heparin infusion. Which action would the nurse prepare to do? 1. Use a ⅝-inch needle for the injection. 2. Apply prolonged pressure to the IM site after the injection. 3. Apply a 4 × 4 pressure dressing at the IM site after the injection. 4. Decrease the rate of the heparin infusion for 1 hour before and 1 hour after the injection.

2. Apply prolonged pressure to the IM site after the injection. **Heparin is an anticoagulant that increases the risk of bleeding. Prolonged pressure over the site of an IM injection will lessen the chance of having an increase of bleeding into the tissue. It is not necessary to apply pressure dressing to the IM site injection. A ⅝-inch needle is not an appropriate size needle for an IM injection. The heparin infusion is not decreased before an injection, and the rate is not adjusted unless specifically prescribed by a HCP.

The nurse purchases a cup of coffee, a bottle of water, and a bagel in the hospital cafeteria and then returns to the nursing unit to take a morning break in the staff lounge. On entering the lounge, the nurse notes that the cushion of a chair is on fire. What would the nurse's first action be? 1. Activate the fire alarm. 2. Quickly pour the coffee on the fire. 3. Open the bottle of water and throw it on the fire. 4. Grab a fire extinguisher and attempt to put out the fire.

1. Activate the fire alarm. **The initial nursing action in the event of a fire would be to remove any patients from the vicinity of the fire. The next step would be to activate the fire alarm. The nurse would then contain the fire, followed by extinguishing the fire. In the situation described in the question, the initial nursing action would be to activate the fire alarm. **Pouring water or coffee onto the fire or attempting to extinguish the fire with the use of a fire extinguisher can delay obtaining lifesaving assistance from the fire department.

The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride and plans to use an IV infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse would take which action? 1. Initiate the IV line without the use of a pump. 2. Contact the electrical maintenance department for assistance. 3. Plug in the pump cord in the available plug above the room sink. 4. Use an extension cord from the nurses' lounge for the pump plug.

2. Contact the electrical maintenance department for assistance. **Electrical equipment must be maintained in good working order and needs to be grounded; otherwise, it presents a physical hazard. An IV line that contains a dose of potassium chloride needs to be administered by an infusion pump. The nurse needs to use hospital resources for assistance **A regular extension cord would not be used because it poses a risk for fire. Use of electrical appliances near a sink also presents a hazard.

The nurse is administering ear drops to a 2-year-old child. To follow the correct administration procedure, the nurse would perform which action? 1. Pulls the pinna of the ear back and up. 2. Pulls the pinna of the ear back and down. 3. Places the child in a prone position with the ear to receive the drop facing downward. 4. Places the child in a side-lying position with the ear to receive the drop facing downward.

2. Pulls the pinna of the ear back and down. **Because of the internal anatomy of the ear, if the child is 3 years of age or younger, the pinna of the ear is pulled back and down. If the child is older than 3 years, the pinna of the ear is pulled back and up. The child needs to lie on the unaffected side with the ear to receive the drop facing upward.

The nurse is preparing to administer an intramuscular injection to a 4-year-old child. The nurse plans to administer the injection in the ventral gluteal muscle, knowing that which indicates the maximum amount of medication volume that can be safely injected? 1. 0.5 mL 2. 1.0 mL 3. 1.5 mL 4. 2.0 mL

3. 1.5 mL **In a young child, ages 3 to 6 years, the maximum volume of medication that can be tolerated into the ventral gluteal muscle is 1.5 mL.

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan? 1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a lead apron when providing direct care to the client 4. Placing the client in a semiprivate room at the end of the hallway

4. Placing the client in a semiprivate room at the end of the hallway **A private room with a private bath is essential if a patient. has an internal radiation implant This is necessary to prevent accidental exposure of other patients to radiation.

Which car safety device would be used for a child who is 8 years old and 4 feet tall? 1. Seat belt 2. Booster seat 3. Rear-facing convertible seat 4. Front-facing convertible seat

2. Booster seat **All children whose weight or height is above the forward facing limit for their car safety seat need to use a belt positioning booster seat until the vehicle seat belt fits properly, typically when they have reached a height of 4 ft, 9 in and are between 8-12 years old. Infants would ride in a car in a semi reclined, rear facing position in an infant only seat or a convertible seat until they weight at least 20 lb and are at least 1 year of age. The transition point for switching to the forward facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 20 lb (9 kg) and 1 year of age.

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which action would the nurse take first? 1. Check for medication interactions. 2. Determine whether there are medication duplications. 3. Call the prescribing primary health care provider (PHCP) and report polypharmacy. 4. Determine whether a family member supervises medication administration.

2. Determine whether there are medication duplications. **Polypharmacy is a concern in the older patient. Duplication of medications needs to be identified before medication interactions can be determined because the nurse needs to know what the patient is taking. Asking about medication administration supervision may be part of the assessment but is not a first action. The phone call to the HCP is the intervention after all other information has been collected.

A client has a prescription for an injection to be administered by the intradermal route. The nurse would avoid which action when administering this medication? 1. Injecting the medication slowly 2. Massaging the area after removing the needle 3. Inserting the needle at a 10- to 15-degree angle 4. Making a circular mark around the injection site

2. Massaging the area after removing the needle **An intradermal injection is administered with the needle bevel facing upward at a 10-15 degree angle. The medication is injected slowly, and a bleb would form under the skin with injection. After withdrawal of the needle, the area may be patted dry with a 2 X 2 sterile gauze. The area would not be rubbed, to prevent the spread of the medication beyond the area of injection. All equipment is then disposed of, and the area of injection is outlined (circled) for later reference.

The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the AP? 1. Placing a safety knot in the safety device straps 2. Safely securing the safety device straps to the side rails 3. Applying safety device straps that do not tighten when force is applied against them 4. Securing so that two fingers can slide easily between the safety device and the client's skin

2. Safely securing the safety device straps to the side rails **The safety straps are secured to the bed frame and never to the side rails to avoid accidental injury in the event that the side rails are released. A half bow or safety knot or device with a quick release buckle would be used to apply a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in care of an emergency. The safety device needs to be secure, and one or two fingers would slide easily between the safety device and the patients skin.

The home health nurse performs an assessment on a client who had cardiac surgery 10 days ago. The client states, "I get dizzy in the shower." On the basis of the client's statement, which would the nurse assess first? 1. The bathroom environment in the home 2. The temperature of the water of the client's shower 3. The client's insurance plan for reimbursement of medical equipment 4. The client's insurance plan regarding coverage for home health assistive personnel care

2. The temperature of the water of the client's shower **The patient may be taking hot showers, which can cause vasodilation with a consequent decrease in venous return to the heart. Decreased venous return decreases cerebral blood flow, leading to symptoms of dizziness. By assessing the temperature of the shower first, the nurse may identify the problem and instruct the client to decrease the water temperature or defer hot showers or baths until the healing process has occurred. The client's complaint is dizziness. Factors that increase dizziness would be the first assessment. Options 1, 3, and 4 do not directly relate to the client's complaint.

The nurse is caring for an older client who had a hip pinned after being fractured. Which would the nurse do to prevent further injury? 1. Respond to the call light within 10 minutes. 2. Use a night-light in the hospital room and the bathroom. 3. Medicate the client with a sleeping pill to encourage the client to sleep through the night. 4. Keep all four side rails in the up position, preventing the client from getting out of bed.

2. Use a night-light in the hospital room and the bathroom. **The use of a night light may help with orientation as well as fall prevention. Option 1 is not appropriate because 10 minutes is a long time for someone to have to wait after pressing the call light. Responding promptly to the client's use of the call light minimizes the chance that the client will try to get up alone, which could result in a fall. A sleeping pill may increase the fall risk of a client who tries to get up during the night. Having full side rails (or four side rails) could increase the level of injury when a client tries to get out of bed in spite of the side rails. In addition, agency policy is always followed with regard to the use of side rails.

The home care nurse visits a client who has been started on oxygen therapy. The nurse provides instructions to the client regarding safety measures for the use of oxygen in the home. Which statement, if made by the client, indicates a need for further instruction? 1. "I need to be sure that no one smokes in my home." 2. "I need to be sure that I stay at least 10 feet away from any burning candles." 3. "It is all right to use an electric razor for shaving if I leave it plugged in for only a short time." 4. "I need to be sure that there is space between the oxygen concentrator and the wall in the room."

3. "It is all right to use an electric razor for shaving if I leave it plugged in for only a short time." **The use of small electric items, tools, or other equipment could emit sparks; these items need to be avoided while oxygen is in use. The use of this equipment could result in fire and injury to the patient. The patient also would be instructed not to allow smoking in the home and to stay at least 10 feet away from any type of flame. The oxygen concentrator is kept away from walls and corners to permit adequate airflow.

The nurse is administering an acetaminophen suppository to a child with a fever. The nurse inserts the suppository into the rectum a distance of no more than how many centimeters? 1. 0.5 2. 1 3. 2 4. 2.5

3. 2 **The childs rectal vault is not as long as that of an adult, the distance required to place medications is approximately 1 to 2 cm. After insertion, the buttocks would be held together until the urge to expel the suppository has passed.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? 1. Call for help. 2. Extinguish the fire. 3. Activate the fire alarm. 4. Confine the fire by closing the room door.

3. Activate the fire alarm. **The order of priority in the event of a fire is RACE. R: rescue the patient A: activate the fire alarm C: contain the fire E: extinguish the fire

The pediatric nurse educator provides a teaching session to parents regarding the substances that cause lead poisoning. Which item, if identified by a parent as a known environmental substance that can cause lead poisoning, indicates a need for further education? 1. Paint chips 2. Vinyl blinds 3. Properly glazed pottery 4. Solder used in plumbing

3. Properly glazed pottery **Paint chips, soil contaminated with lead, lead solder used in plumbing, vinyl blinds, and improperly glazed pottery can be the source of toxic exposure in lead poisoning.

What action would the nurse take as a priority after administering an opioid analgesic to a client experiencing pain? 1. Dim the lights in the room. 2. Take the client to the bathroom to void. 3. Provide safety measures per agency protocol. 4. Perform range-of-motion exercises to the injection site to promote medication absorption.

3. Provide safety measures per agency protocol. **The nurse would ensure client safety after administering an opioid analgesic to prevent injury once the medication has taken effect. The nurse needs to provide safety measures per agency protocol, such as raising side rails, ensuring that the client understands the use of the call bell, and ensuring that the nurse would be called before the client gets out of bed. Dimming the light in the room is the next most helpful action. The client would have been asked about the need to urinate before the medication was administered. It is unnecessary to do range-of-motion exercises to the injection site.

The nurse is caring for an older client with dysphagia who is at risk for aspiration. When preparing the client for eating, the nurse would place the client in which position to minimize the risk for aspiration? 1. Low-Fowler's 2. On the left side 3. Upright in a chair 4. On the right side

3. Upright in a chair **It is best to assist the patient who is at risk for aspiration and is dysphagic to fit upright in a chair for meals. This position facilitates chewing and swallowing and prevents reflux of stomach contents.

An unconscious client has an impaired corneal reflex on one side. The nurse would demonstrate the best understanding of how to protect the client's eye by performing which action? 1. Placing an eye patch 2. Taping the eye shut during the day 3. Using sterile saline drops every few hours to keep the eye moist 4. Wiping inside the lower eyelid with a cotton-tipped applicator 3 times a day

3. Using sterile saline drops every few hours to keep the eye moist **With loss of the corneal reflex, the patient is at risk for eye dryness and also for corneal abrasions if foreign matter comes in contact with the eye. Use of sterile saline drops is indicated to keep the eyes lubricated. An eye patch would have to be used carefully because corneal abrasion could result if the cornea comes in contact with the patch. Taping the eye shut is inappropriate and could impair the conscious client's vision, putting the client at risk for other injury, such as from falls. Introduction of a cotton-tipped applicator (foreign object) inside the lower eyelid also risks corneal abrasion.

A nursing student is assigned to administer an intramuscular iron injection to a client. The coassigned nurse asks the student about the technique for administration of this medication. The student indicates understanding of the administration procedure by identifying what as the correct injection site and method? 1. Anterolateral thigh using an air lock 2. Deltoid muscle using a 1-inch needle 3. Ventrogluteal muscle using Z-track technique 4. Subcutaneous tissue of the abdomen using a 1-inch needle

3. Ventrogluteal muscle using Z-track technique **The correct technique for administering intramuscular iron is deep in the ventrogluteal muscle using Z-track technique. This method minimizes the possibility that the injection will strain the skin a dark color. The medication is not given in the thighs, arms, or abdomen or by the subcutaneous route.

The nurse is providing instructions to the assistive personnel (AP) who will be caring for a client with hand restraints. The nurse asks the AP to repeat the instructions to ensure that the AP understands the care. Which statement, if made by the AP, indicates an understanding of the care for this client? 1. "I need to remove the restraints every 4 hours." 2. "I need to make sure that the restraints are securely tied to the side rails." 3. "If the family comes in to visit, I can tell them to take the restraints off if they want to." 4. "I need to remove the restraints at least every 2 hours to perform range-of-motion exercises."

4. "I need to remove the restraints at least every 2 hours to perform range-of-motion exercises." **The nurse would instruct the AP to check restraints, circulatory status, and skin integrity every 30 minutes. Additionally, restraints need to be removed at least every 2 hours to permit muscle exercise and promote circulation. **Restraints are not to be secured to the bed rails because this could cause injury to the patient if the rails are lowered. The responsibility of the patient would not be placed on the family members. Agency guidelines regarding the use of restraints would always be followed.

The nurse has administered an injection to a client. After the injection, the nurse accidentally drops the syringe on the floor. What is the safe nursing action in this situation? 1. Obtain a dustpan and mop to sweep up the syringe. 2. Call the housekeeping department to pick up the syringe. 3. Carefully pick up the syringe from the floor and gently recap the needle. 4. Carefully pick up the syringe from the floor and dispose of it in a sharps container.

4. Carefully pick up the syringe from the floor and dispose of it in a sharps container. **Used syringes would always be placed in a sharps container immediately after use to avoid injury to anyone. A syringe would not be swept up because this action poses an additional risk of needlestick. It is not the responsibility of the housekeeping department to pick up the syringe. Syringes would not be recapped because of the risk of getting pricked with a contaminated needle.

A home care nurse provides medication instructions to a client. What is the appropriate nursing action to ensure safe administration of medication in the home? 1. Conduct pill counts on each home visit. 2. Demonstrate the proper procedure to take prescribed medications. 3. Instruct the client to double up on medications if a dose has been missed. 4. Have the client verbalize and demonstrate the correct administration procedures.

4. Have the client verbalize and demonstrate the correct administration procedures. **To ensure safe administration of medication, the nurse allows the patient to verbalize and demonstrate correct procedure and administration of medications. Demonstrating the proper procedure for the client does not ensure that the client can safely perform this procedure. It is not acceptable to double up on medication, and conducting a pill count on each visit is not realistic or appropriate.

The community health nurse is performing a safety assessment in the home of a parent with two children, ages 1 and 3 years. Which, if noted during the assessment, presents the greatest hazard to the children? 1. Small dog as a house pet 2. Hot water heater set above 120° F 3. Gate placed at the stairs of the second floor 4. Toys with small loose parts in the playroom

4. Toys with small loose parts in the playroom **Toys with small loose parts would be the priority concern. Children at this age are likely to place the small toy parts in their mouths, which could lead to aspiration and choking. **A small dog as a house pet is not necessarily a hazard. The water temperature of the hot water heater is a concern but is not the greatest hazard. The mother needs to be aware of and taught safety measures related to safe water temperatures for bathing the children. A gate placed at the stairs of the second floor is a safety measure.